Aims. Posterior column plating through the single anterior approach reduces the morbidity in acetabular fractures that require stabilization of both the columns. The aim of this study is to assess the effectiveness of posterior column plating through the anterior intrapelvic approach (AIP) in the management of acetabular fractures. Methods. We retrospectively reviewed the data from R G Kar Medical College, Kolkata, India, from June 2018 to April 2023. Overall, there were 34 acetabulum fractures involving both columns managed by medial buttress plating of posterior column. The posterior column of the acetabular fracture was fixed through the AIP approach with buttress plate on medial surface of posterior column. Mean follow-up was 25 months (13 to 58). Accuracy of reduction and effectiveness of this technique were measured by assessing the Merle d’Aubigné score and Matta’s radiological grading at one year and at latest follow-up. Results. Immediate postoperative radiological Matta’s reduction accuracy showed anatomical reduction (0 to 1 mm) in 23 cases (67.6%), satisfactory (2 to 3 mm) in nine (26.4%), and unsatisfactory (> 3 mm) in two (6%). Merle d’Aubigné score at the end of one year was calculated to be excellent in 18 cases (52.9%), good in 11 (32.3%), fair in three (8.8%), and poor in two (5.9%). Matta’s radiological grading at the end of one year was calculated to be excellent in 16 cases (47%), good in nine (26.4%), six in fair (17.6%), and three in poor (8.8%). Merle d’Aubigné score at latest follow-up deteriorated by one point in some cases, but the grading remained the same; Matta’s radiological grading at latest follow-up also remained unchanged. Conclusion. Stabilization of posterior column through AIP by medial surface plate along the sciatic notch gives good stability to posterior column, and at the same time can avoid morbidity of the additional lateral window. Cite this article: Bone Jt Open 2024;5(2):147–153

The June 2023 Trauma Roundup³⁶⁰ looks at: Aspirin or low-molecular-weight heparin for thromboprophylaxis?; Lateral plating or retrograde nailing for distal femur fractures?; Sciatic nerve palsy after acetabular fixation: what about patient position?; How reliable is the new OTA/AO classification for trochanteric hip fractures?; Young hip fractures: is a medial buttress the answer?; When is the best time to ‘flap’ an open fracture?; The mortality burden of nonoperatively managed hip fractures.

Introduction. Posterolateral tibial plateau fractures account for 7 % of all proximal tibial fractures. Their fixation often requires posterolateral buttress plating. Approaches for the posterolateral corner are not extensile beyond the perforation of the anterior tibial artery through the interosseous membrane. This study aims to provide accurate data about the inferior limit of dissection by providing measurements of the anterior tibial artery from the lateral joint line as it pierces the interosseous membrane. Materials and Methods. Forty unpaired adult lower limbs cadavers were used. The posterolateral approach to the proximal tibia was performed as described by Frosch et al. Perpendicular measurements were made from the posterior limit of the articular surface of the lateral tibial plateau and fibula head to the perforation of the anterior tibial artery through the interosseous membrane. Results. The anterior tibial artery coursed through the interosseous membrane at 46.3 +/− 9.0 mm (range 27–62 mm) distal to the lateral tibial plateau and 35.7 +/− 9.0 mm (range 17–50 mm) distal to the fibula head. There was no significant difference between right or left sided knees. Discussion. This cadaveric study demonstrates the safe zone (min 27 mm, mean 45mm) up to which distal exposure can be performed for fracture manipulation and safe application of a buttress plate for displaced posterorlateral tibial plateau fractures. Evidence demonstrates quality of reduction correlates with clinical outcome and the surgeon can expect to be able to use a small fragment buttress plate of up to 45mm as this is the mean

This paper highlights the fact that full length labral tears are a cause of instability in posterior fracture-dislocations of the hip. From July 1994 to March 2001, 133 consecutive posterior fracture-dislocations of the hip were surgically treated. On admission, all patients were initially subjected to closed reduction, and in some cases skeletal or skin traction was applied. Pelvic radiographs were taken to confirm relocation, and CT done to look for intra-articular bone fragments. Intra-operative findings and surgical technique were recorded. Redislocation occurred in eight patients, whose surgical notes were reviewed to determine the cause. Despite 9 kg of skeletal traction, one patients’s hip redislocated the day after closed reduction. In the other seven, redislocation occurred postoperatively. The time to redislocation varied from one day to 16 weeks, and because redislocation was sometimes painless, not all patients reported it immediately. Two patients, whose radiographs showed very small fragments at the superior-posterior position, would normally have been treated conservatively. On one, surgery was performed because the fragment was lodged at the weight-bearing area of the joint. The hip of the other redislocated on skeletal traction the day after closed reduction. At surgery, it was noted that both patients had extensive soft tissue stripping and full length tears of the labrum. The other six patients had clear posterior wall fractures requiring surgical reconstruction. The fragments were often attached to the capsule but were too small to fix with screws, so buttress plating was used alone. Full-length labral tears in posterior dislocations of the hip cause instability, and failure to address this adequately at surgery may result in redislocation

A carbonated apatite cement with a high compressive strength was used in the treatment of tibial plateau fractures. There were 41 patients (20 male; 21 female; mean age 59 years). All patients had isolated tibial plateau fractures. There were 15 B2.2, 23 B3.1 and 3 B2.3 fractures. Fractures were fixed with limited internal fixation using a short anterior parapatellar incision. Reduction and fixation were initially achieved. Once this was carried out the void under the elevated plateau was filled using calcium phosphate cement. A buttress plate was used in one case, screws or K-wires in 33 cases and calcium phosphate cement alone in 7 cases. Patients were mobilised partially weight bearing in a hinged knee brace and allowed full weight bearing at 6 weeks. Reductions were anatomic (< 2mm displacement in 32 (78%) cases, satisfactory (3-5mm displacement) in 7 (17%) cases and imperfect (> 5mm) in 2 (5%) patients. Extrusion of some calcium phosphate cement into surrounding soft tissue occurred in one case. This material resorbed with no adverse effects. Loss of reduction was observed in 6 (15%) cases. There were no other significant complications. Thirty-seven patients (90%) had more than 120 degrees of knee flexion at 6 months. Calcium phosphate cement is an alternative to the use of bone grafting in any area of cancellous subject to compressive load. It is ideal for use in tibial plateau fractures with compressed subchondral bone after elevation. It obviates the need for buttress plating and bone grafting and there is no bone graft donor site morbidity. Patients are able to mobilise more rapidly and early discharge is facilitated. Calcium phosphate cement is a promising development in the management of tibial plateau fractures and initial results suggest it may be more effective in maintaining reduction that standard methods of fixation and grafting

Background: The stability of fracture fixation is influenced by the type of fixation, densitometric and geometric structure of the bone. DXA measures the integral mass of trabecular and cortical bone mineral but cannot discriminate between the structurally and mechanically separate constitutes. Distribution and organisation of bone mass (the geometric structure) has the final determination of the mechanical properties of bone. Pq CT scan is able to measure densitometric and geometric parameters of bone structure. However, there are no reports in the literature on the relationship between these measurements and the strength of fracture fixation. Our aim is to study the correlation between geometric and densitometric measurements of Pq CT scan, with the strength of fixation of bicondylar tibial plateau fractures and to assess the role of both trabecular and cancellous bone in that strength. Method: Eight Fresh frozen human cadaveric tibias were collected from subjects without a medical history of skeletal pathology. The proximal 10% of the tibia was scanned in a peripheral quantitative computer tomography scanner 1mm thick transverse slides, the cancellous and cortical bone mineral density of the proximal tibia were measured. The geometrical parameters: cortical area, trabecular area, bone strength index (BSI) and the Stress strain index (SSI) as non invasive indicators of the mechanical strength of the bone, were also calculated. A bicondylar tibial plateau fracture was simulated, stabilised, and then tested. All tibias were fixed with Dual buttress plating using a standard AO technique. Cyclic axial compression tests were performed. Inter-fragmentary shear displacements were measured using four extensometers. Failure was defined as over 3mm displacement. Results: Except for the cortical density, there was a strong correlation between failure load and geometric and densitometric parameters. The trabecular density was the best predictor of fixation strength of tibial plateau fracture. Discussion: Trabecular density is a more reliable parameter to measure than the cortical density. Therefore, the fixation strength of tibial plateau fracture is dominantly influenced by the mechanical properties of cancelous bone. Cortical bone has a secondary role. These results highlight the importance of fixation techniques that rely on cancellous bone anchoring such as tensioned fine wire fixation in tibial plateau fractures

Aims

Surgical treatment of young femoral neck fractures often requires an open approach to achieve an anatomical reduction. The application of a calcar plate has recently been described to aid in femoral neck fracture reduction and to augment fixation. However, application of a plate may potentially compromise the regional vascularity of the femoral head and neck. The purpose of this study was to investigate the effect of calcar femoral neck plating on the vascularity of the femoral head and neck.

Abstract

The medial malleolus, once believed to be the primary stabilizer of the ankle, has been the topic of conflicting clinical and biomechanical data for many decades. Despite the relevant surgical anatomy being understood for almost 40 years, the optimal treatment of medial malleolar fractures remains unclear, whether the injury occurs in isolation or as part of an unstable bi- or trimalleolar fracture configuration. Traditional teaching recommends open reduction and fixation of medial malleolar fractures that are part of an unstable injury. However, there is recent evidence to suggest that nonoperative management of well-reduced fractures may result in equivalent outcomes, but without the morbidity associated with surgery. This review gives an update on the relevant anatomy and classification systems for medial malleolar fractures and an overview of the current literature regarding their management, including surgical approaches and the choice of implants.

Cite this article: Bone Joint J 2019;101-B:512–521.

The operative treatment of displaced fractures of the tibial plateau is challenging. Recent developments in the techniques of internal fixation, including the development of locked plating and minimal invasive techniques have changed the treatment of these fractures. We review current surgical approaches and techniques, improved devices for internal fixation and the clinical outcome after utilisation of new methods for locked plating.

The October 2014 Foot & Ankle Roundup360 looks at: multilayer compression bandaging superior for post-traumatic ankle oedema; compression stockings for ankle fractures; weight bearing ok in Achilles tendon ruptures; MRI findings can predict ankle sprain symptoms; salvage for malreduced ankle fractures; locking fibular plates are more expensive; is fixation better early or late in pilon fractures?; and calcaneal fracture fixation not for subtalar arthropathy

The October 2014 Trauma Roundup³⁶⁰ looks at: proximal humeral fractures in children; quadrilateral surface plates in transverse acetabular fractures; sleep deprivation and poor outcomes in trauma; bipolar hemiarthroplasty; skeletal traction; forefoot fractures; telemedicine in trauma; ketamine infusion for orthopaedic injuries; and improved functional outcomes seen with trauma networks.

Coronal plane fractures of the posterior femoral condyle, also known as Hoffa fractures, are rare. Lateral fractures are three times more common than medial fractures, although the reason for this is not clear. The exact mechanism of injury is likely to be a vertical shear force on the posterior femoral condyle with varying degrees of knee flexion. These fractures are commonly associated with high-energy trauma and are a diagnostic and surgical challenge. Hoffa fractures are often associated with inter- or supracondylar distal femoral fractures and CT scans are useful in delineating the coronal shear component, which can easily be missed. There are few recommendations in the literature regarding the surgical approach and methods of fixation that may be used for this injury. Non-operative treatment has been associated with poor outcomes. The goals of treatment are anatomical reduction of the articular surface with rigid, stable fixation to allow early mobilisation in order to restore function. A surgical approach that allows access to the posterior aspect of the femoral condyle is described and the use of postero-anterior lag screws with or without an additional buttress plate for fixation of these difficult fractures.

Cite this article: Bone Joint J 2013;95-B:1165–71.

We reviewed 59 bone graft substitutes marketed by 17 companies currently available for implantation in the United Kingdom, with the aim of assessing the peer-reviewed literature to facilitate informed decision-making regarding their use in clinical practice. After critical analysis of the literature, only 22 products (37%) had any clinical data. Norian SRS (Synthes), Vitoss (Orthovita), Cortoss (Orthovita) and Alpha-BSM (Etex) had Level I evidence. We question the need for so many different products, especially with limited published clinical evidence for their efficacy, and conclude that there is a considerable need for further prospective randomised trials to facilitate informed decision-making with regard to the use of current and future bone graft substitutes in clinical practice.

Cite this article: Bone Joint J 2013;95-B:583–97.

Open reduction and internal fixation of high-energy pilon fractures are often associated with serious complications. Various methods have been used to treat these injuries, with variable results. A total of 17 consecutive patients with pilon fractures of AO/OTA type 43-B3 (n = 1), type C2 (n = 12) and type C3 (n = 4) were treated by indirect reduction by capsuloligamentotaxis and stabilisation using an ankle-spanning Ilizarov fixator. The calcaneal ring was removed at a mean of 3.7 weeks (3 to 6). A total of 16 patients were available for follow-up at a mean of 29 months (23 to 43). The mean time to healing was 15.8 weeks (13 to 23). Nine patients had pin-track infections but none had deep infection or osteomyelitis. Four patients (25%) had malunion. Fair, good or excellent ankle scores were found in 14 patients. External fixation with a ring fixator achieves stable reduction of the fractured fragments without additional trauma to soft tissues.

With minimum complications and good healing results, the Ilizarov apparatus is particularly useful for high-energy pilon fractures.

The recent development of locking-plate technology has led to a potential revolution in the management of fractures of the distal radius. This review examines the evidence for pursuing anatomical restoration of the distal radius and the possible advantages and pitfalls of using volar locking plates to achieve this goal. The available evidence for adopting volar locking plates is presented and a number of important and, as yet unanswered, questions are highlighted.

Between June 1999 and May 2003 we undertook direct primary closure of the skin wounds of 173 patients with Gustilo and Anderson grade-IIIA and grade-IIIB open fractures. These patients were selected from a consecutive group of 557 with type-III injuries presenting during this time. Strict criteria for inclusion in the study included debridement within 12 hours of injury, no sewage or organic contamination, no skin loss either primarily or secondarily during debridement, a Ganga Hospital open injury skin score of 1 or 2 with a total score of ten or less, the presence of bleeding skin margins, the ability to approximate wound edges without tension and the absence of peripheral vascular disease. In addition, patients with polytrauma were excluded.

At a mean follow-up of 6.2 years (5 to 7), the outcome was excellent in 150 (86.7%), good in 11 (6.4%) and poor in 12 (6.9%). A total of 33 complications occurred in 23 patients including superficial infection in 11, deep infection in five and the requirement for a secondary skin flap in three. Six patients developed nonunion requiring further surgery, one of whom declined additional measures to treat an established infected nonunion.

Immediate skin closure when performed selectively with the above indications proved to be a safe procedure.

We have evaluated the functional, clinical and radiological outcome of patients with simple and complex acetabular fractures involving the posterior wall, and identified factors associated with an adverse outcome.

We reviewed 128 patients treated operatively for a fracture involving the posterior wall of the acetabulum between 1982 and 1999. The Musculoskeletal Functional Assessment and Short-Form 36 scores, the presence of radiological arthritis and complications were assessed as a function of injury, treatment and clinical variables.

The patients had profound functional deficits compared with the normal population. Anatomical reduction alone was not sufficient to restore function. The fracture pattern, marginal impaction and residual displacement of > 2 mm were associated with the development of arthritis, which related to poor function and the need for hip replacement. It may be appropriate to consider immediate total hip replacement for patients aged > 50 years with marginal impaction and comminution of the wall, since 7 of 13 (54%) of these required early hip replacement.