Revision Total Knee Arthroplasty (rTKA) is predicted to increase by more than 600% between 2005 and 2030. The survivorship of primary TKA has been extensively investigated, however more granular information on the risks of rTKA is needed. The aim of the study was to investigate the incidence of re-revision TKA, with explanatory variables of time from primary to revision, and indication (aseptic vs septic). Secondary aim was to investigate mortality. This is an analysis of the Scottish Arthroplasty Project data set, a national audit prospectively recording data on all joint replacements performed in Scotland. The period from 2000 to 2019 was studied. 4723 patients underwent revision TKA. The relationship between time from primary to revision TKA and 2nd revision was significant (p<0.001), with increasing time lowering probability of re-revision (OR 0.99 95% CI 0.987 to 0.993). There was no significant association in time to first revision on time from 1st revision to re-revision (p>0.05). Overall mortality for all patients was 32% at 10 years (95% CI 31-34), Time from primary TKA to revision TKA had a significant effect on mortality: p=0.004 OR 1.03 (1.01-1.05). Septic revisions had a reduced mortality compared to aseptic, OR 0.95 (0.71-1.25) however this was not significant (p=0.69). This is the first study to demonstrate time from primary TKA to revision TKA having a significant effect on probability of re-revision TKA. Furthermore the study suggests mortality is increased with increasing time from primary procedure to revision, however decreased if the indication is septic rather than aseptic

Aims. The aim of this study was to evaluate the diagnostic value of preoperative serum CRP, white blood cell count (WBC), percentage of neutrophils (%N), and neutrophil to lymphocyte ratio (NLR) when using the fracture-related infection (FRI) consensus definition. Methods. A cohort of 106 patients having surgery for suspected septic nonunion after failed fracture fixation were studied. Blood samples were collected preoperatively, and the concentration of serum CRP, WBC, and differential cell count were analyzed. The areas under the curve (AUCs) of diagnostic tests were compared using the z-test. Regression trees were constructed and internally cross-validated to derive a simple diagnostic decision tree. Results. Using the FRI consensus definition, 46 patients (43%) were identified as infected. Sensitivity, specificity, and AUC of CRP were 67% (95% confidence interval (CI) 52% to 80%), 61% (95% CI 47% to 74%), and 0.64 (95% CI 0.54 to 0.74); of WBC count were 17% (95% CI 9% to 31%), 95% (95% CI 86% to 99%), and 0.57 (95% CI 0.50 to 0.62); of %N 13% (95% CI 6% to 26%), 87% (95% CI 76% to 93%), and 0.50 (95% CI 0.43 to 0.56); and of NLR 28% (95% CI 17% to 43%), 80% (95% CI 68% to 88%), and 0.54 (95% CI 0.46 to 0.63), respectively. A better performance of serum CRP was shown in comparison to the leucocyte count (p = 0.006), %N (p < 0.001), and NLR (p = 0.001). A statistically lower serum CRP level was shown in patients with an infection caused by a low virulence microorganism in comparison to high virulence bacteria (p = 0.008). We found that a simple decision tree approach using only low serum neutrophils (< 3.615 × 10. 9. /l) and low CRP (< 2.45 mg/l) may allow better identification of aseptic cases. Conclusion. The evaluated serum inflammatory markers showed limited diagnostic value in the preoperative diagnosis of FRI when using the uniform FRI Consensus Definition. Therefore, they should remain as suggestive criteria in diagnosing FRI. Although CRP showed a higher performance in comparison to the other serum markers, it is insufficiently accurate to diagnose a septic nonunion, especially when caused by low virulence microorganisms. Cite this article: Bone Joint J 2020;102-B(7):904–911

Aim. The aim of this study was to determine whether the absence of periosteal reaction on plain radiographs was predictive of exchange nail failure in lower limb diaphyseal fracture non-unions. Methods. A consecutive cohort of 20 femora and 35 tibiae undergoing exchange nailing for diaphyseal aseptic (n=39) and septic (n=16) fracture non-union at a single centre from 2003 to 2010. Multiple causes of non-union were found in 29 patients (53%) with infection present in 16 cases (29.1%). Of this cohort 49 fracture non-unions had complete radiographic records (19 femora and 30 tibiae) allowing evaluation of the periosteal callus. The primary outcome was the number of number of revision procedures required to achieve union. Failure was defined was as the requirement of >two revision procedures to achieve union. Results. The absence of periosteal callus from the fracture site on all four cortices conferred a relative risk ratio (RRR) 5.00 (p=0.006) of exchange nail failure in septic fracture non-unions. Receiver operator characteristic curve analysis of number of cortices with periosteal reaction for predicting exchange nail (>two exchange nail procedures) failure in both septic and aseptic cases found an area under the curve of 0.79 (95% confidence interval 0.675–0.904, p<0.0001). The complete absence of callus within 5 mm of the fracture site had a 75% chance of requiring 3 or more exchange nails to obtain union. Conversely the presence periosteal callus on at least one cortex within 5mm of the fracture site had a 100% chance the fracture would unite following 1 or 2 exchange nail procedures. Conclusion. Careful radiographic analysis of lower limb diaphyseal non-union should be undertaken before exchange nailing. The absence of periosteal reaction on plain radiographs in septic fracture non-union is predictive of exchange nail failure

We report the outcome of 84 nonunions involving long bones which were treated with rhBMP-7, in 84 patients (60 men: 24 women) with a mean age 46 years (18 to 81) between 2003 and 2011. The patients had undergone a mean of three previous operations (one to 11) for nonunion which had been present for a mean of 17 months (4 months to 20 years). The nonunions involved the lower limb in 71 patients and the remainder involved the upper limb. A total of 30 nonunions were septic. Treatment was considered successful when the nonunion healed without additional procedures. The relationship between successful union and the time to union was investigated and various factors including age and gender, the nature of the nonunion (location, size, type, chronicity, previous procedures, infection, the condition of the soft tissues) and type of index procedure (revision of fixation, type of graft, amount of rhBMP-7) were analysed. The improvement of the patients’ quality of life was estimated using the Short Form (SF) 12 score. A total of 68 nonunions (80.9%) healed with no need for further procedures at a mean of 5.4 months (3 to 10) post-operatively. Multivariate logistic regression analysis of the factors affecting union suggested that only infection significantly affected the rate of union (p = 0.004).Time to union was only affected by the number of previous failed procedures (p = 0.006). An improvement of 79% and 32.2% in SF-12 physical and mental score, respectively, was noted within the first post-operative year. Rh-BMP-7 combined with bone grafts, enabled healing of the nonunion and improved quality of life in about 80% of patients. Aseptic nonunions were much more likely to unite than septic ones. The number of previous failed operations significantly delayed the time to union. Cite this article: Bone Joint J 2015;97-B:997–1003

Aims

The aim of this study was to evaluate the radiological outcome of patients with large bone defects in the femur and tibia who were treated according to the guidelines of the diamond concept in our department (Centre for Orthopedics, Trauma Surgery, and Paraplegiology).

Aims. This study aimed to investigate the role of quantitative histological analysis in the diagnosis of fracture-related infection (FRI). Patients and Methods. The clinical features, microbiology culture results, and histological analysis in 156 surgically treated nonunions were used to stratify the likelihood of associated infection. There were 64 confirmed infected nonunions (one or more confirmatory criteria: pus, sinus, and bacterial growth in two or more samples), 66 aseptic nonunions (no confirmatory criteria), and 26 possibly infected nonunions (pathogen identified from a single specimen and no confirmatory criteria). The histological inflammatory response was assessed by average neutrophil polymorph (NPs) counts per high-power field (HPF) and compared with the established diagnosis. Results. Assuming a cut-off of over five neutrophils per high-power field to diagnose septic nonunion, there was 80% sensitivity and 100% specificity (accuracy 90%). Using a cut-off of no neutrophils seen in any high-power field to diagnose aseptic nonunion, there was a sensitivity of 85% and a specificity of 98% (accuracy 92%). Conclusion. Histology can be used in a bimodal fashion as a diagnostic test for FRI. The presence of more than five NPs/HPF had a positive predictive value for infected nonunion of 100%, while the complete absence of any NPs is almost always indicative of an aseptic nonunion (positive predictive value of 98%). Cite this article: Bone Joint J 2018;100-B:966–72

Aims

Musculoskeletal infection is a devastating complication in both trauma and elective orthopaedic surgeries that can result in significant morbidity. Aim of this study was to assess the effectiveness and complications of local antibiotic impregnated dissolvable synthetic calcium sulphate beads (Stimulan Rapid Cure) in the hands of different surgeons from multiple centres in surgically managed bone and joint infections.

Aims

This study aimed to investigate the clinical characteristics and outcomes associated with culture-negative limb osteomyelitis patients.

Aims

This is a multicentre, prospective assessment of a proportion of the overall orthopaedic trauma caseload of the UK. It investigates theatre capacity, cancellations, and time to surgery in a group of hospitals that is representative of the wider population. It identifies barriers to effective practice and will inform system improvements.

Understanding the cause of failure of total knee arthroplasties (TKA) is essential in guiding clinical decision making and adjusting treatment concepts for revision surgery. The purpose of the study was to determine current mechanisms of failure of TKA and to describe changes and trends in revision surgery over the last 10 years. A retrospective review was done on all patients who had revision total knee arthroplasty during a 10-year period (2000–2009) at one institution. The preoperative evaluation in conjunction with the intraoperative findings was used to determine causes of failure. All procedures were categorizes as Sharkey et al. described previously. The data was analyzed regarding the cause of failure and displaying the incidence and trends over the last 10 years. 1225 surgeries were done in the time period with a steady increase of procedures per year (34 procedures in 2000 to 196 in 2009). The most common cause of revision TKA was aseptic failure in 65% and septic failure in 31% of the reviewed cases. However, we could observe a steady proportional increase of the septic classified revisions over the time. Both categories could be subdivided to specific causes of failure including aseptic loosening (24%), anterior knee pain (20%), instability (6,4%), arthrofibrosis (4,9%), PE wear (3,6%), malpositioning/malrotation (2,7%) periprosthetic fracture (2,0%) and other (4,6%), or in early (12,9%), late (15,4%) or low-grade infection (3,3%), respectively. Complementary to the classification Sharkey et al. described in 2002 we identified new subcategories of failure: malrotation (since 2003), Low-Grade-Infection (since 2006), allergic failure/loosening (since 2006), Mid-Flexion-Instability (since 2007), soft tissue impingement (since 2009). The incidence of the classic aseptic loosening due to PE wear shows a clear decrease in the last 10 years whereas we could observe an increase of the new diagnosis of instability, malrotation or low-grade-infection as determined cause of failure. The detailed analysis of the failure mechanism in total knee arthroplasty is important to understand the clinical problem and to adjust treatment strategies. We were able to complement present classifications and give a first overview on the incidence for specific causes of failure. Our data shows changes in the indication for surgery over the time and compared to the collective of Sharkey et al. from 1997–2000. This might be due to new diagnostic methods and better implant materials as well as to a generally increased awareness of the specific mechanism of TKA failure

Objective. Ankle fractures are frequent and seem to be easy to handle in most cases. Of course, also these easy fractures can cause infections that must be carefully managed. What risk factors do we find? What options do we have in treating these complications? What are the consequences and what will the result for the patient be like, compared to non-infected cases?. In a retrospective study we included 82 patients treated with an osteosynthesis in ankle fractures (AO 44 B or C fractures). Average age was 52.4 years (range 20–84 years, median 51.0). Results. In 9 (10.9%) patients there were septic complications. Concerning risk factors, we found 4 (44.4%) patients with nicotine abuse, 2 (22.2%) with additional alcohol abuse. Average stay in hospital was 39.6 days (range 9–95 days). In 4 (44.4%) cases local infection was treated with antibiotics and rest alone. 5 (55.5%) of the patients had additional operations due to infection, in average 5.4 per patient (range 1–10). Early implant removal was done in 3 (33.3%) cases, in average after 3 months. We found 2 (22.2%) infections due to Staphylococcus aureus, 1 (11.1%) due to MRSA and one infection with MRSA and Proteus mirabilis. In one case vacuum dressing had been applied for 44 days. In another case infection could only be healed with an intramedullary vancomycin augmented spacer and finally a screw arthodesis of the ankle, this was a patient with proven arteriosclerosis of the lower extremities. All other fractures finally showed bony healing in xrays. No plastic surgery (e.g. flaps) was needed to close a wound definitely. In follow up (in average after 33 months, range 17–42), the average AOFAS of these patients was 76.5 (range 35–100, median 81.5), compared to an average AOFAS of 89.4 (range 35–100, median 98.0) of all patients. No patient developed a septic syndrom, no ICU stay occurred because of the infection. Conclusions. In spite of most cases of ankle fractures having good outcomes without complications, once infected an ankle osteosynthesis can be a serious problem for both surgeon and patient. Consequent surgical therapy at the right time including early hardware removal, spacers or vacuum dressing if necessary as well as an antibiotic regime addressing problematic pathogens like MRSA are needed to control infections. Problems remaining are functional outcome and wound closure in this sensitive area. Plastic surgery might be needed

A review of current literature describes varying 10-year survival rates for the Oxford Unicompartmental Knee Replacement (Biomet Orthopedics Inc, Warsaw, Ind). Application of rigorous indications and meticulous surgical technique are two factors considered to reduce revision rates. A retrospective case-note review was conducted for 96 patients (128 knees) aged 42–89 (mean 57) who had an Oxford unicompartmental knee replacement for medial compartment osteoarthritis between January 2000 and January 2011. All procedures were performed, or directly supervised, by one 5 surgeons. The aim of the study was to ascertain the rate of revision to bicompartmental knee replacement and any associated contributory factors. Of the 128 unicompartmental knees, 10.9% were revised to either mobile- or fixed-bearing total knee replacements due to septic (0.5%) and aseptic (1.5%) loosening, patello-femoral pain (3.9%), periprosthetic fracture (0.8%) and bearing dislocation (3.1%). Of those knees requiring revision, mean patient age was 73 years, 50% had wound complications and 42% were performed by senior trainees. All patients had intact ACL and medial osteoarthritis. Mean time to revision was 2.7 years. In conclusion, revision of the unicompartmental knee was related to patient age > 65 years and early post-operative complications; grade of operating surgeon had little apparent effect

Introduction. Alternative bearings – metal-on-metal and ceramic-on-ceramic bearings have been introduced in the last decade with the aim to diminish wear and, subsequently, aseptic loosening and osteolysis. These bearings were aimed for younger, more active patients. Clinical results which would compare the performance of various alternative and traditional bearings are scarce. Methods. Between January 2000 and December 2002, we performed 487 total hip replacements in 474 patients using three types of bearings: metal-on-metal (MOM), metal-on-polyethylene (MOP), and ceramic-on-ceramic (COC). All patients received the same type of acetabular cup (Bicon-Plus, Plus Orthopedics) and same type of femoral component (SL-Plus, Plus Orthopedics). We used the hospital computer database for the evaluation of patient data and data on revision operations. Results. At a mean follow-up of 8.5 years (range, 6.8 to 9.9 years), eighteen hips were revised. Seventeen revisions were aseptic, and one was septic. The percentage of revision in the whole group was 3.7%. The percentage of revisions for individual groups of bearings varied and ranged from 1.5% in the MOP group, 4.1% in the COC group to 8.7% in the MOM group. Reasons for revisions were analyzed in details. We noticed that the percentage of aseptic loosening differed among the groups, with the MOM group having the highest percentage of revisions due to aseptic loosening. Conclusions. The results obtained for this large series of THRs with the same type of acetabular and femoral components, and differing only in the type of bearing, indicate that the combination of material of acetabular cup and femoral head affect the performance of the hip prosthesis

We aimed to investigate the effect of Seprafilm®, a synthetic biomembran, on the intra-articular adhesion formation in an experimental arthrofibrosis model. Twenty male white rabbits were randomly allocated into two groups of 10 animals in each. A standard surgical procedure aiming at the development of arthrofibrosis and including medial parapatellar arthrotomy, lateral eversion of the patella, partial synovectomy and debridement of anterior of supracondylar area and patella joint surface by scalpel was performed on all rabbits' right knees. Group 1 rabbits served as controls, and in Group 2 rabbits a Seprafilm®, barrier placed into the described area. In both groups, after surgery, knee joint was immobilized by a no.5 wire suture passing from the ankle and groin and keeping the joint in 140° of flexion. At 6th week, all animals were sacrificed and adhesion formation was evaluated both macroscopically and histo-pathologically. All data were semi-quantified and analyzed statistically by Fisher's exact test. While all rabbits in control group displayed different rates of adhesion macroscopically (62.5% severe, 25% moderate, 12.5% mild), none in the study group had it. The average macroscopic adhesion score was 2.5 ± 0.75 in control group, and 0 in Seprafilm® group. Histopathologic evaluation also revealed microscopic adhesion in all rabbits in control group, but none in Seprafilm® group. Fibroblast proliferation in Seprafilm® group (100% mild) was significantly lower than in control group (62.5% severe, 37.5% moderate) (p<0.05). In conclusion, use of Seprafilm® as a mechanical barrier may be of value against the formation of arthrofibrosis in risky knees such as septic and traumatic ones

Background. A lot of discussion persists whether obesity negatively influences the outcome of hip arthroplasty. Current literature does not answer this question, since manuscripts showing a worse outcome and those showing a similar outcome can both be found. We performed a meta-analysis with the primary research question whether obesity has a negative influence on short and long term outcome of total hip arthroplasty. Methods. A search of the literature was performed and studies comparing the outcome of hip arthroplasty in different weight groups were included. Methodology of the included studies was scored according to the Cochrane guidelines. Data extraction and pooling of the data was performed. For continuous data a weighted mean difference and for dichotomous variables a weighted Odds ratio was calculated. Heterogeneity was calculated using I2 statistics. Results. A total of 15 studies were available for data-extraction. Dislocation occurred more often in obese with an Odds ratio of 0.54 (95%CI: 0.38–0.75) (10 studies, n = 8634). Aseptic loosening occured more often in obese with an Odds ratio of 0.64 (95% CI 0.43–0.96)(6 studies, n = 5137). Infection occured more often in obese with an Odds Ratio of 0.3 (95%CI: 0.19–0.49) (10 studies, n = 7500). Venous thromboembolism occured more often in obese with an Odds Ratio of 0.56 (95%CI: 0.32–0.98) (7 studies, n = 3716). For septic loosening and intraoperative fractures no difference was found, probably due to low power. Subjective outcome measurements did not allow Pooling due to high heterogeneity (I2 = 68%). Conclusions. We conclude that being obese; ergo having a BMI of more than 30 certainly has a negative influence on total hip replacement

The use of a total hip arthroplasty with alumina on alumina bearing couple should limit the risk of wear and secondary osteolysis. From June 1999 to December 2002, we have realised a continuous series of 265 ABGII cementless THA with Alumina bearing. The average age was 58 years (22–78 years). The main causes were osteoarthritis (81%) and osteonecrosis (13%). The operation was performed through a posterior standard approach. In all cases, an anatomic cementless ABG II stem and an acetabular cementless ABG II cup were implanted. The bearing couple was always Alumina Biolox Forte with a 28 mm femoral head in 99% of cases. To date, 12 patients died and 17 patients were lost to follow up (6.4%). 224 patients (232 hips) had a regular clinical and radiological follow-up. The mean follow up was 8.5 years (5–11 years). 9 patients were revised for septic loosening (4cases), femoral fracture (4 cases) and inveterate dislocation (1 case). There was no aseptic loosening. The overall survival rate at more than 10 years is 96.6%. We deplore 2 cases of postoperative dislocation. In this series, we did not observe any breakage of ceramic implant. The clinical and functional outcome is good and stable over time with an average PMA score at 17.6 and an average Harris score at 97.3. 16 patients reported at least one or more episode of abnormal noise “Squeaking” type (6%). It is most often a mild noise and it occurs in a static bending position. This noise disappeared with time in 10 cases. It never necessitated a prosthetic revision. The radiological control does not show any wear. There is no evidence of acetabular or femoral osteolysis. The radiological implant fixation according to the Engh and ARA criteria was good and stable in all cases. This series demonstrate that the implantation of an anatomic cementless HA arthroplasty with an alumina bearing in a young and active patient prevents the risk of wear and osteolysis and improves durability over time. The use of a 28 mm head does not increase the risk of instability and we did not observe failure of the ceramic implants

INTRODUCTION. Management of neglected residually displaced acetabular fractures is a big challenge. ORIF is often doomed to failure so a primary total hip replacement is usually kept in mind as a method of choice. However THR is a technically difficult and results are quiet unpredictable. OBJECTIVE. To present our experience with THR in maltreated grossly displaced acetabular fractures and to discuss operative technique and prognostic factors in that complicated surgery. MATERIAL. THR was applied in 14 patients (11 males and 3 females, mean age 51 years) with at least three-months old and significantly displaced acetabular fractures. In 12 cases preceding treatment was conservative, and in 2 it was operative. Fracture nonunion was recognized in 5 cases, old hip dislocation in 4 and protusion in 3. Large interfragmentary gaps and local bone defect were detected in almost all cases. METHOD. THR was performed 3–31 months after injury. Extensile iliofemoral or Y-shaped approach with trochanteric osteothomy was used in most cases. Depending of particular situation a variety of techniques were applied to provide adequate bone stock for the cup, such as an approximate ORIF, periacetabular osteotomy, structural or morcelised bone grafting. Reinforcement ring was used in 6 cases. The cup fixation was cemented in 12 procedures and uncemented in 2. Cemented stem was introduced in 10 cases and uncemented in 4. Preoperative selective embolisation of superior gluteal artery was carried out in 1 patient. RESULTS. The operative duration was 3–7 hours and blood loss was 850–2200 ml. The only intraoperative accidentwas jatrogenic lesion of superior gluteal artery required embolisation. The follow up was a 16–94 months. Average postoperative Harris Hip Score was 78, compared with 54 before surgery (P<0.01). There was 2 aceptic and 1 septic loosenings with subsequent revisions (21.4%). In 2 cases sight asymptomatic migration of the cap was noted. DISCUSSION. The most difficult but most important stage of operation is a creating of sufficiently stable bone stock for the acetabular cap, impeded by by fragment displacement, nonunion or prolonged hip dislocation. If nonuion the achievement of bone healing is essential. Any instability should be overcomed by stable osteosynthesis. The gaps should be filled by ORIF or bone grafting. We consider cemented fixation possibly with reinforcement ring as a most secure way to provide strong cup anchorage. Uncemented pess-fit cup may be used in cases with lesser initial displacement. In spite of all late results are considerable worse than in conventional hip replacement. CONCLUSION. THR after neglected acetabular fractures is a challenging and demanding procedure. Successful outcome may be only expected if a solid bone stock is made using various surgical techniques

Cemented total hip arthroplasty yields reliable results in short to medium term studies, but aseptic loosening remains a problem in long-term follow up, especially in young and active patients. Aseptic loosening has been related to wear, and in order to minimize wear various alternatives to the traditional metal on polyethylene have been proposed. Both ceramic on polyethylene (COP) and metal on metal (MOM) have been shown to produce less wear than metal on polyethylene (MOP). In order to study the effect of the bearing, we have utilized identical stems and cups while comparing the different bearings. Methods and material. 396 hips were randomized to MOP, COP or MOM using a cemented triple tapered polished stem (MS-30; Sulzer Orthopedics) with a cemented polyethylene cup (Weber; Sulzer, Orthopedics) and a 28 millimeter head. For the MOP and COP articulations, a all-polyethylene cup was used with a Protasul™ metal head or a Sulox™ alumina head, whereas a polyethylene cup with metal insert was used for the MOM articulations (Weber Polyethylene Cup with Metasul™ Insert) with a Metasul™ metal head. Harris Hip Score (HHS) and radiological evaluation was performed after two, five and seven years. Ethical approval was obtained. Results. HHS was available for 338 hips after seven years. The HHS in the MOP group (116 hips) was 93.7 (SD 9.0), 93.5 in the COP group (112 hips) (SD 8.8), and 91.0 (SD 13.4) in the MOM group (110 hips). Radiographic evaluation was available for 335 hips. Radiolucencies around the stem larger than one millimeter were found in five of 115 MOP hips, seven of 111 COP hips and in seven of 110 MOM hips. Periacetabular radiolucencies identified as larger than one millimeter were found in none of the 116 MOP hips, five of the 112 COP hips and in 19 of the 110 MOM hips. Ten revisions were performed. In the MOP group there were three revisions (infection, dislocation, pain); one in the COM group (infection), and six in the MOM group (three infections, two aseptic loosening and one septic loosening). Discussion. Clinically, the three bearing types perform equally well at seven years, and there are few signs of impending failure for the stem. However, there are an alarmingly high proportion of cups showing signs of loosening. Two hips have been revised in the MOM group for aseptic loosening as opposed to none in the two other groups, which adds to the concern. The MOM articulation used in this study should be monitored closely for signs of aseptic loosening

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

The aim of this study was to describe implant and patient-reported outcome in patients with a unilateral transfemoral amputation (TFA) treated with a bone-anchored, transcutaneous prosthesis.