Sub-muscular plating is an established technique in the management of long-bone fractures and reconstruction. In the femur, the presence of the vascular structures medially favours the lateral approach and as such, the technique of medial femoral sub-muscular plating has not, to the authors knowledge, been previously described. We report a series of 5 patients employing the medial approach to femoral sub-muscular plating. The indications and limitations of the technique are discussed with particular reference to reducing external fixation times, avoidance of stress risers and areas of previously traumatised or infected tissues. The surgical technique for medial femoral sub-muscular plating with emphasis on the role of vastus medialis in the protection of the vascular structures, together with cross sectional anatomy is described. Medial femoral sub-muscular plating is a useful technique in specific indications and can be performed safely with an understanding of the relevant anatomy

We describe the technique and results of medial submuscular plating of the femur in paediatric patients and discuss its indications and limitations. Specifically, the technique is used as part of a plate-after-lengthening strategy, where the period of external fixation is reduced and the plate introduced by avoiding direct contact with the lateral entry wounds of the external fixator pins. The technique emphasises that vastus medialis is interposed between the plate and the vascular structures.

A total of 16 patients (11 male and five female, mean age 9.6 years (5 to 17)), had medial submuscular plating of the femur. All underwent distraction osteogenesis of the femur with a mean lengthening of 4.99 cm (3.2 to 12) prior to plating. All patients achieved consolidation of the regenerate without deformity. The mean follow-up was 10.5 months (7 to 15) after plating for those with plates still in situ, and 16.3 months (1 to 39) for those who subsequently had their plates removed. None developed a deep infection. In two patients a proximal screw fractured without loss of alignment; one patient sustained a traumatic fracture six months after removal of the plate.

Placing the plate on the medial side is advantageous when the external fixator is present on the lateral side, and is biomechanically optimal in the presence of a femoral defect. We conclude that medial femoral submuscular plating is a useful technique for specific indications and can be performed safely with a prior understanding of the regional anatomy.

Cite this article: Bone Joint J 2014;96-B:137–42.

Purpose: Autologous bone grafting is considered the gold standard for multiple orthopaedic indications, including non-union of fractures and other bone defects. Previously autograft was most commonly harvested from the iliac crest, with an estimated complication rate of greater than 10%. New technology, the RIA system, allows harvest of graft material from the medullary canal of the femur. The purpose of this study is to examine the osteo-inductive properties of this human femoral bone graft obtained using the RIA system and the RIA filtrate combined with chronOS (Tricalcium Phosphate). This study will examine whether these materials will induce bone growth when implanted in a rat sub-muscular pouch model. Method: Three samples were collected from each human subject. These included:. femoral bone graft obtained using the RIA {n=10}. chronOS washed with RIA filtrate {n=10}and. a mixture of these two materials {n=10}. chronOS (alone) was used as control {n=10}. These materials were implanted into a sub-muscular pouch in athymic rats (to eliminate rejection of the xenograft). Rat serum levels of BMP-2, VEG-F, TGF-β and IL-10 were obtained at days 7, 14, 21 and 28. Rats were sacrificed at day 28 and radiographic and histologic examinations and histomorphometric analyses were performed. Results: Overall, there were no significant differences in BMP-2, VEG-F, TGF-β and IL-10 levels either between groups or between time points. Average serum values for BMP-2 decreased over time for all groups. Histologically and radiographically, all four materials induced new bone production. chronOS alone produced the greatest volume of new bone while RIA reamings alone produced the least. Histological analysis demonstrated formation of normal bone. Conclusion: The RIA system allowed for harvest of femoral bone graft. This graft induced bone formation and increased osteogenic protein levels when implanted in the rat model. The RIA filtrate, when combined with Tricalcium Phosphate, is equally osteoinductive. Combining reamings with filtrate material may allow large volumes of graft to be produced using this system. This new technology may allow the collection of large volume, osteoinductive grafts without the complications previously described for iliac crest bone graft harvesting

Aims. In order to limit the amount of both medial and lateral dissection, the MIPO technique was developed for extraarticular fractures of the femur. In this prospective study we have evaluated the outcome of 34 cases of supracondylar or subtrochanteric fractures of the femur treated by MIPO technique via exclusive proximal and distal incisions, using a DCS. Material and methods. Between July 2000 and March 2003, 34 acute fractures (14 supracondylar and 20 subtrochanteric) in 33 patients were included in this study. The technique consisted of 5 major steps: 1. the insertion of the condylar screw using minimal incision; 2. the selection of DCS-plate by fluoroscopy; 3. the insertion of the DCS-plate beneath the vastus lateralis; 4. an additional minimal proximal or distal incision allows plate positioning and its slipping onto the condylar screw; 5. after the limb axis, length and rotation are confirmed by reliable clinical and radiological techniques, the plate was fixed to the shaft with 3 or 4 screws placed divergently. Results. All fractures healed within a mean time of 14 weeks (range 8–24 weeks). 1 late implant failure (plate screw breakage) in an extremely cominutive fracture did not required repeat fixation. At follow-up, there were 5 varus-valgus deformities above 5°, 4 leg length discrepancies over 15 mm and 1 malrotation of 20°. According to the Neer score there were 22 excellent, 10 satisfactory and 2 unsatisfactory results. Discussion. The key to MIPO is the use of 2-part and 2-plane alignment achieved by a DCS inserted in a sub-muscular fashion. Conclusions. The MIPO technique with proximal and distal incisions minimizes surgical trauma and has the advantages of a faster rate of union, with no need for bone grafting. Care should be taken to ensure adequate axial and rotational alignment

The treatment of fractures has evolved from extensive open reduction and internal fixation to minimally invasive surgery and biological fixation. High energy bicondylar tibial plateau fractures pose a treatment challenge to most orthopaedic Surgeons. This study evaluates the results of biologic plating of bicondylar tibial plateau fractures. Between January 2005 and January 2006 we treated 25 closed bicondylar tibial plateau fractures with minimally invasive surgery using locking plates and screws. Routine tomograms and CT scans were performed after a detailed history and physical examination were performed. Pre-operative planning and templating was performed in all cases. Surgery was carried out by the same surgical team using a tourniquet and an anterolateral or medial surgical approach. Bone grafting was also performed in some cases. The implants used were pre-contoured locking plates (Synthes, Smith & Nephew). The rehabilitative programme was commenced on day 2 by the same Physiotherapist and non weight bearing for 12 weeks. Four patients refused to be part of the study and two were lost to follow up. Nineteen patients were available for follow up with a mean follow up of 10 months. There were 10 males with mean age of 35 years. Two patients were treated for early superficial wound sepsis which healed. Eight patients needed a bone graft at the time of surgery. The average range of movement was 5–110 degrees of flexion. There were no implant failures or non unions. At six months all patients walked unaided with no deformity and were satisfied with the operation. As an alternative to external fixation of these difficult fractures we recommend a less invasive precontoured plate with locking screws. The advantages include sub-muscular, extraperiostal plate application through a relatively small incision, percutaneous screw placement through a guide, the fixed angle of the plate obviating the necessity of medial plate fixation, and plate lengths are available to span the metadiaphysis. The results suggest that biologic plating with a precontoured locking plate of bicondylar tibial plateau fractures may give better short term results with excellent function

The outcome of surgery in patients with medial epicondylitis of the elbow is less favourable in those with co-existent symptoms from the ulnar nerve. We wanted to know whether we could successfully treat such patients by using musculofascial lengthening of the flexor-pronator origin with simultaneous deep transposition of the ulnar nerve. We retrospectively reviewed 19 patients who were treated in this way. Seven had grade I and 12 had grade IIa ulnar neuropathy. At a mean follow-up of 38 months (24 to 48), the mean visual analogue scale pain scores improved from 3.7 to 0.3 at rest, from 6.6 to 2.1 with activities of daily living, and from 7.9 to 2.3 at work or sports, and the mean disabilities of the arm, shoulder and hand scores improved from 42.2 to 23.5.

These results suggest that this technique can be effective in treating patients with medial epicondylitis and coexistent ulnar nerve symptoms.