Despite the current trend favoring surgical treatment of displaced intra-articular calcaneal fractures (DIACFs), studies have not been able to demonstrate superior functional outcomes when compared to non-operative treatment. These fractures are notoriously difficult to reduce. Studies investigating surgical fixation often lack information about the quality of reduction even though it may play an important role in the success of this procedure. We wanted to establish if, amongst surgically treated DIACF, an anatomic reduction led to improved functional outcomes at 12 months. From July 2011 to December 2020, at a level I trauma center, 84 patients with an isolated DIACF scheduled for surgical fixation with plate and screws using a lateral extensile approach were enrolled in this prospective cohort study and followed over a 12-month period. Post-operative computed tomography (CT) imaging of bilateral feet was obtained to assess surgical reduction using a combination of pre-determined parameters: Böhler's angle, calcaneal height, congruence and articular step-off of the posterior facet and calcaneocuboid (CC) joint. Reduction was judged anatomic when Böhler's angle and calcaneal height were within 20% of the contralateral foot while the posterior facet and CC joint had to be congruent with a step-off less than 2 mm. Several functional scores related to foot and ankle pathology were used to evaluate functional outcomes (American Orthopedic Foot and Ankle Score - AOFAS, Lower Extremity Functional Score - LEFS, Olerud and Molander Ankle Score - OMAS, Calcaneal Functional Scoring System - CFSS, Visual Analog Scale for pain - VAS) and were compared between anatomic and nonanatomic DIAFCs using Student's t-test. Demographic data and information about injury severity were collected for each patient. Among the 84 enrolled patients, 6 were excluded while 11 were lost to follow-up. Thirty-nine patients had a nonanatomic reduction while 35 patients had an anatomic reduction (47%). Baseline characteristics were similar in both groups. When we compared the injury severity as defined by the Sanders’ Classification, we did not find a significant difference. In other words, the nonanatomic group did not have a greater proportion of complex fractures. Anatomically reduced DIACFs showed significantly superior results at 12 months for all but one scoring system (mean difference at 12 months: AOFAS 3.97, p = 0.12; LEFS 7.46, p = 0.003; OMAS 13.6, p = 0.002, CFSS 7.5, p = 0.037; VAS −1.53, p = 0.005). Univariate analyses did not show that smoking status, worker's compensation or body mass index were associated with functional outcomes. Moreover, fracture severity could not predict functional outcomes at 12 months. This study showed superior functional outcomes in patients with a DIACF when an anatomic reduction is achieved regardless of the injury severity

Despite the current trend favoring surgical treatment of displaced intra-articular calcaneal fractures (DIACFs), studies have not been able to demonstrate superior functional outcomes when compared to non-operative treatment. These fractures are notoriously difficult to reduce. Studies investigating surgical fixation often lack information about the quality of reduction even though it may play an important role in the success of this procedure. We wanted to establish if, amongst surgically treated DIACF, an anatomic reduction led to improved functional outcomes at 12 months. From July 2011 to December 2020, at a level I trauma center, 84 patients with an isolated DIACF scheduled for surgical fixation with plate and screws using a lateral extensile approach were enrolled in this prospective cohort study and followed over a 12-month period. Post-operative computed tomography (CT) imaging of bilateral feet was obtained to assess surgical reduction using a combination of pre-determined parameters: Böhler's angle, calcaneal height, congruence and articular step-off of the posterior facet and calcaneocuboid (CC) joint. Reduction was judged anatomic when Böhler's angle and calcaneal height were within 20% of the contralateral foot while the posterior facet and CC joint had to be congruent with a step-off less than 2 mm. Several functional scores related to foot and ankle pathology were used to evaluate functional outcomes (American Orthopedic Foot and Ankle Score - AOFAS, Lower Extremity Functional Score - LEFS, Olerud and Molander Ankle Score - OMAS, Calcaneal Functional Scoring System - CFSS, Visual Analog Scale for pain – VAS) and were compared between anatomic and nonanatomic DIAFCs using Student's t-test. Demographic data and information about injury severity were collected for each patient. Among the 84 enrolled patients, 6 were excluded while 11 were lost to follow-up. Thirty-nine patients had a nonanatomic reduction while 35 patients had an anatomic reduction (47%). Baseline characteristics were similar in both groups. When we compared the injury severity as defined by the Sanders’ Classification, we did not find a significant difference. In other words, the nonanatomic group did not have a greater proportion of complex fractures. Anatomically reduced DIACFs showed significantly superior results at 12 months for all but one scoring system (mean difference at 12 months: AOFAS 3.97, p = 0.12; LEFS 7.46, p = 0.003; OMAS 13.6, p = 0.002, CFSS 7.5, p = 0.037; VAS −1.53, p = 0.005). Univariate analyses did not show that smoking status, worker's compensation or body mass index were associated with functional outcomes. Moreover, fracture severity could not predict functional outcomes at 12 months. This study showed superior functional outcomes in patients with a DIACF when an anatomic reduction is achieved regardless of the injury severity

Introduction. The condition of the soft tissues surrounding an ankle fracture influences timing and treatment of injuries. Conventional treatment used an open approach to facilitate anatomical reduction and rigid internal fixation. Intramedullary devices for fibular fractures provide a safe alternative in patients in which the condition of the soft tissue envelope or the patient's co-morbidities may benefit from a less invasive approach. We compared outcomes for patients treated with open reduction internal fixation (ORIF) with those undergoing treatment with fibular nails (FN). Methods. 13 consecutive patients treated with fibular nails (FN) were compared with 13 age-matched patients that underwent open reduction and internal fixation (ORIF). All patients were followed to union. Study outcomes were time from admission to surgery, length of stay, wound failure, implant failure, revision surgery, OMAS and SF-36. Results. There was no difference in age or sex distribution between groups. There was no difference in OMAS at 1 year (83 ± 9 in FN group; 80± 21 in ORIF group) and SF-36 (94 ± 11 and 90 ± 20). There were 2 implant failures in the ORIF group and none in the FN group. There was one wound failure in the ORIF group and none in the FN group. Patients treated with FN had a shorter time to surgery (1 day ± 24 hours vs 3 days ± 24 hours) and shorter length of stay (1 day ± 24 hours vs 4 days ± 96 hours). Conclusion. FN is a safe method to treat patients with displaced distal fibular fractures that may have a poor soft tissue envelope and risk factors for wound healing. FN reduces the time to surgery and overall length of stay compared with similar patients treated with conventional ORIF

The risk of AVN is high in Unstable Slipped Capital Femoral Epiphysis (SCFE) and the optimal surgical treatment remains controversial. Our AVN rates in severe, unstable SCFE remained unchanged following the introduction of the Modified Dunn Procedure (MDP) and as a result, our practice evolved towards performing an Anterior Open Reduction and Decompression (AOR) in an attempt to potentially reduce the “second hit” phenomenon that may contribute. The aim of this study was to determine the early surgical outcomes in Unstable SCFE following AOR compared to the MDP. All moderate to severe, Loder unstable SCFEs between 2008 and 2022 undergoing either an AOR or MDP were included. AVN was defined as a non-viable post-operative SPECT-CT scan. Eighteen patients who underwent AOR and 100 who underwent MPD were included. There was no significant difference in severity (mean PSA 64 vs 66 degrees, p = 0.641), or delay to surgery (p = 0.973) between each group. There was no significant difference in the AVN rate at 27.8% compared to 24% in the AOR and MDP groups respectively (p = 0.732). The mean operative time in the AOR group was 24 minutes less, however this was not statistically significant (p = 0.084). The post-reduction PSA was 26 degrees (range, 13–39) in the AOR group and 9 degrees (range, -7 to 29) in the MDP group (p<0.001). Intra-operative femoral head monitoring had a lower positive predictive value in the AOR group (71% compared to 90%). Preliminary results suggest the AVN rate is not significantly different following AOR. There is less of an associated learning curve with the AOR, but as anticipated, a less anatomical reduction was achieved in this group. We still feel that there is a role for the MDP in unstable slips with a larger remodelling component

Acromioclavicular joint (ACJ) dislocations is a common disorder amongst our population for which numerous techniques have been described. It is thought that by using this novel technique combining a CC and AC repair with a reconstruction will result in high maintenance of anatomical reduction and functional results. 12 consecutive patients ACJ dislocations were included. An open superior clavicular approach is used. Firstly, the CC ligaments are repaired after which a CC reconstruction is performed using a tendon allograft. Secondly, the AC ligaments are repaired using an internal brace construct combined with a tendon allograft reconstruction (Figure 1). The acute:chronic ratio was 6:6. Only IIIB, IV and V AC-joint dislocations were included. The Constant-Murley Score improved from 27.6 (8.0 – 56.5) up to 61.5 (42.0 – 92.0) at 12 months of follow up. Besides one frozen shoulder from which the patient recovered spontaneously no complications were observed with this technique. The CCD was reduced from 18.7 mm (13.0 – 24.0) to 10.0 mm (6.0 – 16.0) and 10.5 mm (8.0 – 14.0) respectively 12 weeks and 12 months postoperatively. There is some evidence, suggesting to address as well as the vertical (coracoclavicular (CC) ligaments) as the horizontal (acromioclavicular (AC) ligaments) direction of instability. This study supports addressing both entities however comparative studies discriminating chronic as acute cases should be conducted to further clarify this ongoing debate on treating ACJ instability. This study describes a novel technique to treat acute and chronic Rockwood stage IIIB – IV ACJ dislocations with promising short-term clinical and radiological results. This suggests that the combined repair and reconstruction of the AC and CC ligaments is a safe procedure with low complication risk in experienced hands. Addressing the vertical as well as horizontal stability in ACJ dislocation is considered key to accomplish optimal long-term results

Management of acetabular fractures in the elderly population remains somewhat controversial in regards to when to consider is open reduction internal fixation (ORIF) versus acute primary total hip. study aims to (1) describe outcome of this complex problem and investigate predictors of successful outcome. This retrospective study analyzes all acetabular fractures in patients over the age of 60, managed by ORIF at a tertiary trauma care centre between 2007 and 2018 with a minimum follow up of one year. Of the 117 patients reviewed, 85 patients undergoing ORIF for treatment of their acetabular fracture were included in the analysis. The remainder were excluded based management option including acute ORIF with THA (n=10), two-stage ORIF (n=2), external fixator only (n=1), acute THA (n=1), and conservative management (n=1). The remainder were excluded based on inaccessible medical records (n=6), mislabelled diagnosis (n=6), associated femoral injuries (n=4), acetabular fracture following hemiarthroplasty (n=1). The mean age of the cohort is 70±7 years old with 74% (n=62) of patients being male. Data collected included: demographics, mechanism of injury, Charlson Comorbidity Index (CCI), ASA Grade, smoking status and reoperations. Pre-Operative Radiographs were analyzed to determine the Judet and Letournel fracture pattern, presence of comminution and posterior wall marginal impaction. Postoperative radiographs were used to determine Matta Grade of Reduction. Outcome measures included morbidity-, mortality- rates, joint survival, radiographic evidence of osteoarthritis and patient reported outcome measures (PROMs) using the Oxford Hip Score (OHS) at follow-up. A poor outcome in ORIF was defined as one of the following: 1) conversion to THA or 2) the presence of radiographic OA, combined with an OHS less than 34 (findings consistent with a hip that would benefit from a hip replacement). The data was analyzed step-wise to create a regression model predictive of outcome following ORIF. Following ORIF, 31% (n=26) of the cohort had anatomic reduction, while 64% (n=54) had imperfect or poor reduction. 4 patients did not have adequate postoperative radiographs to assess the reduction. 31 of 84 patients undergoing ORIF had a complication of which 22.6% (n=19) required reoperation. The most common reason being conversion to THA (n=14), which occurred an average of 1.6±1.9 years post-ORIF. The remainder required reoperation for infection (n=5). Including those converted to THA, 43% (n=36) developed radiographic OA following acetabular fracture management. The mean OHS in patients undergoing ORIF was 36 ± 10; 13(16%) had an OHS less than 34. The results of the logistic regression demonstrate that Matta grade of reduction (p=0.017), to be predictive of a poor outcome in acetabular fracture management. With non-anatomic alignment following fixation, patients had a 3 times greater risk of a poor outcome. No other variables were found to be predictive of ORIF outcome. The ability to achieve anatomic reduction of fracture fragments as determined by the Matta grade, is predictive of the ability to retain the native hip with acceptable outcome following acetabular fracture in the elderly. Further research must be conducted to determine predictors of adequate reduction in order to identify candidates for ORIF

The syndesmosis ligament complex stabilizes the distal tibiofibular joint, while allowing for the subtle fibular motion that is essential for ankle congruity. Flexible fixation with anatomic syndesmosis reduction results in substantial improvements in functional outcomes. New dynamic CT technology allows real-time imaging, as the ankle moves through a range of motion. The aim of this study was to determine if dynamic CT analysis is a feasible method for evaluating syndesmosis reduction and motion following static and flexible syndesmosis fixation. This is a subgroup analysis of a larger multicenter randomized clinical trial, in which patients with AO 44-C injuries were randomized to either Tightrope (one knotless Tightrope, Group T) or screw fixation (two 3.5-mm cortical screws, Group S). Surgical techniques and rehabilitation were standardized. Bilateral ankle CT scans were performed at one year post-injury, while patients moved from maximal dorsiflexion (DF) to maximal plantar flexion (PF). Three measurements were taken at one cm proximal to the ankle joint line in maximal DF and maximal PF: anterior, midpoint, and posterior tibiofibular distances. T-tests compared Group T and Group S, and injured and uninjured ankles in each group. Fifteen patients (six Group T [three male], nine Group S [eight male]) were included. There was no difference for mean age (T = 42.8 ± 14.1 years, S = 37 ± 12.6, P = 0.4) or time between injury and CT scan (T = 13 ± 1.8 months, S = 13.2 ± 1.8, P = 0.8). Of note in Group S, seven of nine patients had at least one broken screw and one additional patient had screws removed by the time of their dynamic CT. There was no significant difference between treatment groups for tibiofibular distance measurements in maximal PF or DF. Group T showed no significant difference between the injured and uninjured side for tibiofibular measurements in maximal PF and DF, suggesting anatomic reduction. For Group S, however, there was a significantly larger distance for all three measurements at maximal PF compared to the uninjured ankle (all P < 0 .05). In all but one Group S patient, screws were broken or removed prior to their dynamic CT, allowing possible increased syndesmotic motion, similar to Group T. Despite this, dynamic CT analysis detected increased tibiofibular distance in Group S as ankles moved into maximal PF when compared with the uninjured ankle. Given the importance of anatomic syndesmosis reduction, dynamic ankle CT technology may provide valuable physiologic information warranting further investigation

Few will disagree that the best femoral head that a young patient can have is his or her own, native femoral head. In the active, healthy patient under age 60 with a displaced femoral neck fracture, well-done, timely ORIF presents the best chance of preserving the patient's native femoral head. Arthroplasty is generally reserved for older patients, over age 60, where attempts at ORIF in this setting have demonstrated failure rates over 40%. “Physiologic age” is a somewhat nebulous term that takes into account the health and ambulatory status of the patient. For example, a 52-year-old with end-stage renal failure, severe osteoporosis, and a displaced femoral neck fracture may best be treated with arthroplasty. However, in reality, such situations are quite rare. Recent studies have documented that approximately 80% of young patients with displaced femoral neck fractures treated with ORIF will keep their own femoral head for 10 years after injury. The variables under the surgeon's control include timing of fixation, quality of reduction, accurate implant placement and implant selection, and capsulotomy. All of these variables potentially affect outcomes. Fractures in this young age group are frequently high shear angle (vertical) Pauwels type 3 fractures, and benefit from fixed angle fixation. The author prefers anatomic reduction and stabilization with a sliding hip screw and a superiorly placed derotation screw. Careful attention to detail is important to obtain an anatomic reduction, which is the most important variable in the outcome of these challenging injuries

The purpose of this study is to determine the re-operation rate following plate fixation of the olecranon with contoured anatomic plates. Plate fixation of the olecranon allows for management of different fracture patterns as well as osteotomies with anatomic reduction and stable fixation for early elbow mobilization. However, olecranon hardware prominence can be troublesome. Our hypothesis was with the newer generation of low profile contoured anatomic plates, the rate of hardware removal should be lower compared to previously described literature. Retrospective review for patients treated with operative fixation of the olecranon between 2010 and 2015 in the Edmonton zone was identified using population level administrative data. Radiographic screening of these patients was then carried out to identify those who received plate fixation. Fracture patterns were also characterized. Chart reviews followed to determine the indications for re-operation and other post-operative complications. Main outcome measures were re-operation rate and their indications, including hardware prominence. During the screening process, 600 surgically treated olecranon patients were identified and 321 patients were found to have plate fixation of the olecranon. Chart review determined 90 patients had re-operations demonstrating a 28% re-operation rate. Re-operation due to hardware prominence was found to be 15.6%. Other indications included hardware failure (5.3%), infection (2.8%), or contracture (2.8%). Compared to patients that did not require re-operation, the re-operation group had a higher incidence of Type III olecranon fractures (17.4% vs 8.4%, p = 0.036) and Monteggia pattern injuries (13.5% vs 4.9%, p = 0.008). Recent heteregenous data suggests the hardware removal rate related to implant prominence is between 17–54%. Compared to the literature, this study demonstrated a lower rate at 15.6% with contoured anatomic plating. Also, those with more complex fracture patterns were more likely to require re-operation

Few will disagree that the best femoral head that a young patient can have is his or her own, native femoral head. In the active, healthy patient under age 60 with a displaced femoral neck fracture, well-done, timely ORIF presents the best chance of preserving the patient's native femoral head. Arthroplasty is generally reserved for older patients, over age 60, where attempts at ORIF in this setting have demonstrated failure rates over 40%. “Physiologic age” is a somewhat nebulous term that takes into account the health and ambulatory status of the patient. For example, a 52-year-old with end stage renal failure, severe osteoporosis, and a displaced femoral neck fracture may best be treated with arthroplasty. However, in reality, such situations are quite rare. Recent studies have documented that approximately 80% of young patients with displaced femoral neck fractures treated with ORIF will keep their own femoral head for 10 years after injury. The variables under the surgeon's control include timing of fixation, quality of reduction, accurate implant placement and implant selection, and capsulotomy. All of these variables potentially affect outcomes. Fractures in this young age group are frequently high shear angle (vertical) Pauwels Type 3 fractures, and benefit from fixed angle fixation. The author prefers anatomic reduction and stabilisation with a sliding hip screw and a superiorly placed derotation screw. Careful attention to detail is important to obtain an anatomic reduction, which is the most important variable in the outcome of these challenging injuries

Nearly one quarter of ankle fractures have a recognized syndesmosis injury. An intact syndesmosis ligament complex stabilizes the distal tibio-fibular joint while allowing small, physiologic amounts of relative motion. When injured, malreduction of the syndesmosis has been found to be the most important independent factor that contributes to inferior functional outcomes. Despite this, significant variability in surgical treatment remains. This may be due to a poor understanding of normal dynamic syndesmosis motion and the resultant impact of static and dynamic fixation on post-injury syndesmosis kinematics. As the syndesmosis is a dynamic structure, conventional CT static images do not provide a complete picture of syndesmosis position, giving potentially misleading results. Dynamic CT technology has the ability to image joints in real time, as they are moved through a range-of-motion (ROM). The aim of this study was to determine if syndesmosis position changes significantly throughout ankle range of motion, thus warranting further investigation with dynamic CT. This is an a priori planned subgroup analysis of a larger multicentre randomized clinical trial, in which patients with AO-OTA 44-C injuries were randomized to either Tightrope or screw fixation. Bilateral ankle CT scans were performed at 1 year post-injury, while patients moved from maximal dorsiflexion (DF) to maximal plantar flexion (PF). In the uninjured ankles, three measurements were taken at one cm proximal to the ankle joint line in maximal DF and maximal PF: Anterior (ASD), middle (MSD), and posterior (PSD) syndesmosis distance, in order to determine normal syndesmosis position. Paired samples t-tests compared measurements taken at maximal DF and maximal PF. Twelve patients (eight male, six female) were included, with a mean age of 44 years (±13years). The mean maximal DF achieved was 1-degree (± 7-degrees), whereas the mean maximal PF was 47-degrees (± 8-degrees). The ASD in DF was 3.0mm (± 1.1mm) versus 1.9mm (± 0.8mm) in PF (p<0.01). The MSD in DF was 3.3mm (±1.1mm) versus 2.3mm (±0.9mm) in PF (p<0.01). The PSD in DF was 5.3mm (±1.5mm) versus 4.6mm (±1.9mm) in PF (p<0.01). These values are consistent with the range of normal parameters previously reported in the literature, however this is the first study to report the ankle position at which these measurements are acquired and that there is a significant change in syndesmosis measurements based on ankle position. Normal syndesmosis position changes in uninjured ankles significantly throughout range of motion. This motion may contribute to the variation in normal anatomy previously reported and controversies surrounding quantifying anatomic reduction after injury, as the ankle position is not routinely standardized, but rather static measurements are taken at patient-selected ankle positions. Dynamic CT is a promising modality to quantify normal ankle kinematics, in order to better understand normal syndesmosis motion. This information will help optimize assessment of reduction methods and potentially improve patient outcomes. Future directions include side-to-side comparison using dynamic CT analysis in healthy volunteers

Few will disagree that the best femoral head that a young patient can have is his or her own, native femoral head. In the active, healthy patient under age 60 with a displaced femoral neck fracture, well-done, timely ORIF presents the best chance of preserving the patient's native femoral head. Arthroplasty is generally reserved for older patients, over age 60, where attempts at ORIF in this setting have demonstrated failure rates over 40%. “Physiologic age” is a somewhat nebulous term that takes into account the health and ambulatory status of the patient. For example, a 52-year-old with end stage renal failure, severe osteoporosis, and a displaced femoral neck fracture may best be treated with arthroplasty. However, in reality, such situations are quite rare. Recent studies have documented that approximately 80% of young patients with displaced femoral neck fractures treated with ORIF will keep their own femoral head for 10 years after injury. The variables under the surgeon's control include timing of fixation, quality of reduction, accurate implant placement and implant selection, and capsulotomy. All of these variables potentially affect outcomes. Fractures in this young age group are frequently high shear angle (vertical) Pauwels type 3 fractures, and benefit from fixed angle fixation. The author prefers anatomic reduction and stabilization with a sliding hip screw and a superiorly placed derotation screw. Careful attention to detail is important to obtain an anatomic reduction, which is the most important variable in the outcome of these challenging injuries

Few will disagree that the best femoral head that a young patient can have is his or her own, native femoral head. In the active, healthy patient under age 60 with a displaced femoral neck fracture, well-done, timely ORIF presents the best chance of preserving the patient's native femoral head. Arthroplasty is generally reserved for older patients, over age 60, where attempts at ORIF in this setting have demonstrated failure rates over 40%. Recent studies have documented that approximately 80% of young patients with displaced femoral neck fractures treated with ORIF will keep their own femoral head for 10 years after injury. The variables under the surgeon's control include timing of fixation, quality of reduction, accurate implant placement and implant selection, and capsulotomy. All of these variables potentially affect outcomes. Fractures in this young age group are frequently high shear angle (vertical) Pauwels type 3 fractures, and benefit from fixed angle fixation. The author prefers anatomic reduction and stabilization with a sliding hip screw and a superiorly placed derotation screw. Careful attention to detail is important to obtain an anatomic reduction, which is the most important variable in the outcome of these challenging injuries

Few will disagree that the best femoral head that a young patient can have is his or her own, native femoral head. In the active, healthy patient under age 60 with a displaced femoral neck fracture, well-done, timely ORIF presents the best chance of preserving the patient's native femoral head. Arthroplasty is generally reserved for older patients, over age 60, where attempts at ORIF in this setting have demonstrated failure rates over 40%. “Physiologic age” is a somewhat nebulous term that takes into account the health and ambulatory status of the patient. For example, a 52-year-old with end stage renal failure, severe osteoporosis, and a displaced femoral neck fracture may best be treated with arthroplasty. However, in reality, such situations are quite rare. Recent studies have documented that approximately 80% of young patients with displaced femoral neck fractures treated with ORIF will keep their own femoral head for 10 years after injury. The variables under the surgeon's control include timing of fixation, quality of reduction, accurate implant placement and implant selection, and capsulotomy. All of these variables potentially affect outcomes. Fractures in this young age group are frequently high shear angle (vertical) Pauwels type 3 fractures, and benefit from fixed angle fixation. The author prefers anatomic reduction and stabilization with a sliding hip screw and a superiorly placed derotation screw. Careful attention to detail is important to obtain an anatomic reduction, which is the most important variable in the outcome of these challenging injuries

Background. Referral to centres with a pelvic service is standard practice for the management of displaced acetabular fractures. Hypothesis. The time to surgery: (1) is a predictor of radiological and functional outcome and (2) this varies with the fracture pattern. Methods. A retrospective case review of 254 patients over a ten year period with a minimum follow-up of two years. Patients were divided into two groups based on fracture pattern: elementary or associated. ‘Time to surgery’ was analysed as a continuous and a stratified variable. The primary outcome measures were the quality of reduction and functional outcome. Logistic regression analysis was used to test our hypothesis, while controlling for potential confounding variables. Results. For elementary fractures, an increase in the time to surgery on one day reduced the odds of an excellent/good functional result by 15% (p = 0.001) and of an anatomical reduction by 18% (p = 0.0001). For associated fractures, the odds of obtaining an excellent/good result were reduced by 19% (p = 0.0001) and an anatomical reduction by 18% (p = 0.0001) per day. When ‘time’ was measured as a categorical variable, an anatomical reduction was more likely if surgery was performed within 15 days (elementary) and five days (associated). An excellent/good functional outcome was more likely when surgery was performed within 15 days (elementary) and ten days (associated). Conclusion. The time to surgery is a significant predictor of radiological and functional outcome for both elementary and associated displaced acetabular fractures. The organisation of regional trauma systems must be capable of satisfying these time-critical targets to achieve optimal patient outcome

Few will disagree that the best femoral head that a young patient can have is his or her own, native femoral head. In the active, healthy patient under age 60 with a displaced femoral neck fracture, well-done, timely ORIF presents the best chance of preserving the patient's native femoral head. Arthroplasty is generally reserved for older patients, over age 60, where attempts at ORIF in this setting have demonstrated failure rates over 40%. Recent studies have documented that approximately 80% of young patients with displaced femoral neck fractures treated with ORIF will keep their own femoral head for 10 years after injury. The variables under the surgeon's control include timing of fixation, quality of reduction, accurate implant placement and implant selection, and capsulotomy. All of these variables potentially affect outcomes. Fractures in this young age group are frequently high shear angle (vertical) Pauwels type 3 fractures, and benefit from fixed angle fixation. The author prefers anatomic reduction and stabilization with a sliding hip screw and a superiorly placed derotation screw. Careful attention to detail is important to obtain an anatomic reduction, which is the most important variable in the outcome of these challenging injuries

Distal radius fractures are the most common osteoporotic fractures among women. The treatment of these fractures has been shifting from a traditional non-operative approach to surgery, using volar locking plate (VLP) technology. Surgery, however, is not without risk, complications including failure to restore an anatomic reduction, fracture re-displacement, and tendon rupture. The VLP implant is also marked by bone loss due to stress-shielding related to its high stiffness relative to adjacent bone. Recently, a novel internal, composite-based implant, with a stiffness less than the VLP, was designed to eradicate the shortcomings associated with the VLP implant. It is unclear, however, what effect this less-stiff implant will have upon adjacent bone density distributions long-term. The objective of this study was to evaluate the long-term effects of the two implants (the novel surgical implant and the gold-standard VLP) by using subject-specific finite element (FE) models integrated with an adaptive bone formation/resorption algorithm. Specimen: One fresh-frozen human forearm specimen (female, age = 84 years old) was imaged using CT and was used to create a subject-specific FE model of the radius. Finite element modeling: In order to simulate a clinically relevant (unstable) fracture of the distal radius, a wedge of bone was removed from the model, which was approximately 10 mm wide and centered 20 mm proximal to the tip of the radial styloid. Bone remodeling algorithm: A strain-energy density (SED) based bone remodeling theory was used to account for bone remodeling. With this approach, bone density decreased linearly when SED per bone density was less than 67.5 µJ/g and increased when it was more than 232.5 µJ/g. When it was in the lazy zone (67.5 to 232.5 µJ/g), no changes in density occurred. Boundary conditions: A 180 N quasi-static force representing the scaphoid, and a 120 N quasi-static force representing the lunate was applied to the radius. The midshaft of the radius was constrained. FE outcomes: To examine the effects of stress shielding associated with each implant, the long-term changes of bone density within proximal transverse cross-sections of radius were inspected. The regional density analysis focused on three transverse cross-sections. The transverse cross-sections were positioned proximal to the subchondral plate, and were distanced 50 (cross-section A), 57 (cross-section B), and 64 mm (cross-section C) from the subchondral endplate. For both implants in all three cross-sections, cortical bone was reserved completely at the volar side. On the dorsal side, the cortical bone was completely resorbed in the VLP model. In all cross-sections, the averaged resultant density was higher for the “novel implant”. The difference ranged from 33% (cross-section A) to 36% (cross-section C) in favor of the “novel implant”. On average, the density values of the novel implant were 34% higher in transverse cross-sections (A, B, and C). This study showed that the novel implant offered higher density distributions compared to the VLP, which suggests that the novel implant may be superior to the VLP in terms of avoiding stress shielding

Purpose. Isolated fractures of femoral condyle in the coronal plane (Hoffa fracture) is rare and is surgically challenging to treat. 44 patients were operated between 2004–2014. The aim was to retrospectively assess the fracture patterns, fixation done and functional outcome. Methods. All injuries resulted from direct trauma to the knee out of which 36 were due to road traffic accidents.38 were closed injuries and the rest open.35 involved lateral condyle, 8 involved medial condyle and one was bicondylar type. All were anatomically reduced with fixation decided based on preoperative radiographs, CT scan and intra-op observation. Early passive motion and isometric exercises were started but kept non-weight bearing for 6–8 weeks. The mean follow up period was five years. Outcomes were measured using Neer's scoring system and International Knee Society Documentation Committee (IKDC) Functional Score. Results. 26 patients had excellent outcome, 14 had satisfactory and 4 had unsatisfactory outcome which corresponded with the specified fracture severity pattern. Uniformly excellent results were obtained in all simple pattern fractures, whereas comminuted fracture patterns were more challenging to treat with variable outcomes. Conclusion. In our retrospective observational study, we found that each fracture had specific pattern which dictated the treatment plan and the prognosis. Subsequently we grouped the fractures and proposed a classification system that would specify the pattern of fracture and dictate the type of fixation preferred. We conclude that therapeutic outcome is significantly affected by the amount of articular surface comminution, posterior cortex comminution, attainment of anatomical reduction and stable fixation

We would like to present this case series of 10 adolescent patients with displaced, closed diaphyseal tibial fractures managed using the Taylor Spatial Frame. Management options for these injuries include non-operative treatment, antegrade nailing, flexible nailing systems, plating and external circular fixation. External circular fixation allows anatomical reduction avoiding potential complications such as growth arrest associated with antegrade nailing and retained metal work with plating. Flexible nailing system and cast immobilisation are unreliable for precise anatomical reduction. With limited evidence as to the extent of post-traumatic deformity that is acceptable, combined with the limited remodeling potential that this patient group possess, the precision of percutaneous fixation with the Taylor Spatial Frame system has clear advantages. This is a retrospective analysis of 10 adolescent patients with a mean age of 14.5 years (range 13 to 16 years). Data collected includes fracture configuration, deformity both pre and post operatively compared to post frame removal, length of time in frame and complications. The data was gathered using the patient case notes and the Picture Archiving and Communications System. The mean time in frame was 15.5 weeks (range 11 to 22 weeks). One non-union in a cigarette smoker was successfully managed with a second Taylor Spatial Frame episode. Our conclusion was that with careful patient selection the Taylor Spatial Frame allows successful treatment of closed tibial fractures in adolescents, avoiding complications such as growth arrest and post-traumatic deformity as well as avoiding retained metalwork

Trans-articular coronal shear fractures of the distal humerus pose a significant challenge to the surgeon in obtaining an anatomical reduction and rigid fixation and thereby return of good function. A variety of approaches have been described which include the extended lateral and anterolateral approaches and arthroscopically-assisted fixation for non-comminuted fractures. Fixation methods include open or percutaneous cannulated screws and headless compression screws directed either anterior to posterior or posterior to anterior. We describe an illustrated, novel approach to this fracture which is minimally invasive but enables an anatomical reduction to be achieved. A 15 year old male presented with a Bryan and Morrey type 4 fracture as described by McKee involving the left distal humerus. He was placed in a lateral position with the elbow over a support. A posterior longitudinal incision and a 6cm triceps split from the tip of the olecranon was made. The olecranon fossa was exposed and a fenestration made with a 2.5mm drill and nibblers as in the OK (Outerbridge-Kashiwagi) procedure. A bone lever was then passed though the fenestration and used to reduce the capitellar and trochlear fracture fragments into an anatomical position with use of an image intensifier to confirm reduction. The fracture was then fixed with two headless compression screws from posterior to anterior into the capitellar and trochlear fragments (see images). Early mobilisation and rehabilitation were commenced. Follow-up clinical examination and radiographs at six weeks revealed excellent range-of-motion and function with anatomical bony union. We believe that this novel approach to this fracture reduces the amount of soft tissue dissection associated with conventional approaches and their associated risks and also enables earlier return to function with restoration of anatomy