Ankle fractures represent the third most common fragility fracture seen in elderly patients following hip and distal radius fractures. Non-operative management of these see complication rates as high as 70%. Open reduction and internal fixation (ORIF) has complication rates of up to 40%. With either option, patients tend to be managed with a non-weight bearing period of six weeks or longer. An alternative is the use of a tibiotalocalcaneal (TTC) nail. This provides a percutaneous treatment that enables the patient to mobilise immediately. This case-series explores the efficacy of this device in a broad population, including the highly comorbid and cognitively impaired. We reviewed patients treated with TTC nail for acute ankle fractures between 2019 and 2022. Baseline and surgical data were collected. Clinical records were reviewed to record any post-operative complication, and post-operative mobility status and domicile. 24 patients had their ankle fracture managed with TTC nailing. No intra-operative complications were noted. There were six (27%) post-operative complications; four patients had loosening of a distal locking screw, one significant wound infection necessitating exchange of nail, and one pressure area from an underlying displaced fracture fragment. All except three patients returned to their previous domicile. Just over two thirds of patients returned to their baseline level of mobility. This case-series is one of the largest and is also one of the first to include cognitively impaired patients. Our results are consistent with other case-series with a favourable complication rate when compared with ORIF in similar patient groups. The use of a TTC nail in the context of acute, geriatric ankle trauma is a simple and effective treatment modality. This series shows acceptable complication rates and the majority of patients are able to return to their baseline level of mobility and domicile

The PFNA is used routinely at the RUH for unstable peri-trochanteric and femoral fractures. Failure of operative treatment is associated with increased morbidity and financial burden. We analysed surgical and fracture factors, aiming to identify those associated with fixation failure. Retrospective analysis of 76 consecutive patients treated with a PFNA between 2009–2012 was performed. Patient demographics were assessed, along with fracture classification, adequacy of reduction, tip apex distance (TAD) and grade of surgeon. Failure was defined as metal work failure, non-union or need for repeat procedure. The mean age was 78.9 years (25.9–97.4). 21 were male and 49 female. There were 17 failures (24.3%) (7 required further surgery). 10 failures were per-trochanteric, 2 sub-trochanteric and 5 mid-shaft fractures. Complications included 4 broken and 6 backed-out distal locking screws, 2 blade cut-outs, 1 nail fracture and 4 non-unions. All per-trochanteric were adequately reduced with a TAD <25 mm. 11/17 had consultant supervision. A high rate of backed-out distal locking screws was identified. We found no concerns with adequacy of reduction, TAD or consultant supervision

We reported the outcomes of patients with Charcot neuropathy who underwent hind foot deformity correction using retrograde intramedullary nail arthrodesis. Twenty one feet in 20 patients, aged 45 to 83 years, with a mean BMI of 32.7 and a median ASA score of 3, were included in this study. All patients presented with severe hindfoot deformities and 15 had recurrent ulceration. All patients were treated with hindfoot corrective fusion and seven patients also underwent simultaneous mid foot fusion using a bolt or locking plate. After a mean follow up of 26 months, none of the cases required any form of amputation. Eighty percent of patients with ulceration achieved healing and all but one patient returned to independent ambulation. One nail fracture and three mid foot metal work failure resulted in fixation failure requiring revision surgery. Distal locking screw displacement occurred only with standard screws but not with hydroxyapatite-coated screws. The AAOS-FAO score improved from 50.7 to 65.2 (p=0.015). The EQ-5D-5L improved from 0.63 to 0.67 (p=0.012) and the SF-36 PCS from 25.2 to 29.8 (p=0.003). Single stage deformity correction with intramedullary hindfoot arthrodesis nail is a viable treatment option for severe Charcot hindfoot deformity with ulceration and instability

Techniques for fixation of the lateral malleolus have remained essentially unchanged since the 1960s, but are associated with complication rates of up to 30%. The fibular nail is an alternative method of fixation requiring a minimal incision and tissue dissection, and has the potential to reduce complications. We reviewed the results of 105 patients with unstable fractures of the ankle that were fixed between 2002 and 2010 using the Acumed fibular nail. The mean age of the patients was 64.8 years (22 to 95), and 80 (76%) had significant systemic medical comorbidities. Various different configurations of locking screw were assessed over the study period as experience was gained with the device. Nailing without the use of locking screws gave satisfactory stability in only 66% of cases (4 of 6). Initial locking screw constructs rendered between 91% (10 of 11) and 96% (23 of 24) of ankles stable. Overall, seven patients had loss of fixation of the fracture and there were five post-operative wound infections related to the distal fibula. This lead to the development of the current technique with a screw across the syndesmosis in addition to a distal locking screw. In 21 patients treated with this technique there have been no significant complications and only one superficial wound infection. Good fracture reduction was achieved in all of these patients. The mean physical component Short-Form 12, Olerud and Molander score, and AAOS Foot and Ankle outcome scores at a mean of six years post-injury were 46 (28 to 61), 65 (35 to 100) and 83 (52 to 99), respectively. There have been no cases of fibular nonunion. Nailing of the fibula using our current technique gives good radiological and functional outcomes with minimal complications, and should be considered in the management of patients with an unstable ankle fracture

The ITS volar radial plate (Implant Technology Systems, Graz/Austria) is a fixation device that allows for the distal locking screws to be fixed at variable angles (70°-110°). This occurs by the different material properties, with the screws (titanium alloy) cutting a thread through the plate holes (titanium). We present our experience with the ITS plate. We retrospectively studied 26 patients who underwent ITS plate fixation for unstable multifragmentary distal radial fractures (AO types A3, B2, B3, C2, C3). The surgery was performed either by a consultant orthopaedic hand surgeon or senior registrar. A volar approach was used every time and 10 cases required synthetic bone grafting. Post-operatively they were immobilised for an average of 2.5 weeks. The 26 patients had a mean age of 58 and the dominant side was affected in 46% of cases. 5 cases were open fractures and 10 cases followed failed manipulation under general anaesthesia. The average interval between injury and surgery was 7 days. Union was achieved in all cases. No implant infections, failure or tendon rupture/irritation occurred. There were two fractures which loss reduction, of which one required revision surgery. There was one case of CRPS. The six month average DASH score was 27.5. We consider the ITS plate a technically easy plate to use and a reliable implant at early follow-up. We value the versatility of its variable angle screw fixation ability for complex intra-articular distal radial fractures

Aim. The purpose of the study was to evaluate the results of Expert tibial nailing for distal tibial fractures. Methods. All patients who had a distal third or distal end fracture of the tibia treated with the Expert tibial nail over a three year period at our institution were included in the study. A total of 44 distal tibial fractures in the same number of patients were treated with the nailing system. One patient died in the immediate post operative period from complications not directly related to the procedure and 3 were lost to follow up leaving a cohort of 40 patients for evaluation. 31 of the fractures were closed while the remaining 9 were open. The average age group of the cohort was 46.8 years with 26 males and 14 females. Results. All 40 patients were followed up to full radiological union of their tibia fractures. The average time to radiological union was 12.5 weeks for the closed fracture group and 15.1 weeks for the open fractures. The difference in time to union between the two groups was not statistically significant. There was infection around a distal locking screw in a closed fracture which settled with screw removal. Three patients in the closed fracture group required dynamisation to hasten union while none required dynamisation in the open fracture group. No bone grafting was performed on any of the patients. One patient had non union of a distal fibula fracture which required plating of as an additional procedure. On follow-up none of the patients reported knee pain or had limitation of ankle movements. Conclusion. The Expert tibial nail is an effective implant for the treatment of both open and closed distal tibial fractures with a low complication rate

Purpose of study. The addition of interlocking screws to intramedullary nails adds greatly to the stability of these constructs, yet the placement of distal screws accounts for a significant proportion of the total fluoroscopy and operative times. The Sureshot® (Smith and Nephew™) is a computerised system that allows placement of distal screws without fluoroscopy by using electromagnetic guided imagery. The purpose of this study is to compare traditional free-hand technique to the Sureshot® technique in terms of operating time, radiation dose and accuracy. Methods. Between September 2011 and March 2012 we prospectively randomised 66 consecutive patients presenting to us with femur shaft fractures requiring intramedullary nails to either free-hand (n=33) or Sureshot® assisted (n=28) distal locking. Fractures warranting only one distal locking screw, or those requiring retrograde or cephalo-medullary nailing, were excluded. Five patients' data was not suitable for analysis. The two groups were assessed for distal locking time, distal locking radiation and accuracy of distal locking. Results. The average total operative time was 51 minutes (range 25–88) for the free-hand group and 59 minutes (range 40–103) for the Sureshot® group. The average time for distal locking time was 10 minutes (range 4–16) with free-hand and 11 minutes (range 6–28) with Sureshot®. The average radiation dose for distal locking was 746.27 μGy (range 200–2310) for the free-hand group and 262.54 μGy (range 51–660) for the Sureshot® group. There were 2 misplaced drill bits in the free-hand group and 3 in the SureShot® group. Conclusion. SureShot® assisted distal locking reduces radiation exposure, but in a high-volume institution like ours it didn't reduce operative time or improve our accuracy. The benefits of this reduction in radiation still need to be quantified. The slightly higher number of misplaced drill bits and screws may represent our learning curve with SureShot®. NO DISCLOSURES

Background. The management of non-unions of subtrochanteric femoral fractures with associated implant failure is challenging. This study assessed the outcome of a cohort of patients treated according to the diamond concept. Methods. Between 2005–2010 all patients with subtrochanteric aseptic non-unions presented post implant failure (Gamma Nail breakage) were eligible in the absence of severe systemic pathologies and comorbidities. Demographics, initial fracture pattern, method of stabilisation, mode of failure of metal work, time to revision of fixation, complications, time to union, and functional outcome were recorded over a minimum period of follow-up of 12 months. The revision strategy was based on the “diamond concept;” optimising the mechanical and biological environment (revision of fixation, osteoinduction/BMP-7, osteoconduction/RIA harvested graft, and osteogenicity/concentrate of bone marrow aspirate). Results. Out of 280 nailing procedures 12 (4.3%) cases met the inclusion criteria. A consistent mode of metalwork failure was recorded with initial breakage of the proximal distal locking screw followed by nail breakage at the lag screw level. Biomechanical SEM analysis of the nails revealed no structural damage besides the standard fatigue striation. Varus mal-reduction was present in all cases, with an average of 7.3 degrees (5–11). The average time to screw failure was 4.3 months (2–6) and nail failure was 5.9 months (4–10). All but one of the cases were revised to a 95 degrees blade plate and one to an Affixus nail. Time to union was 6.5 months (5–10). All but one of the cases by 12 months have returned to their preinjury level of mobilisation. Conclusion. Varus mal-reduction must be avoided in the initial stabilisation of subtrochanteric fractures. Proximal distal screw failure is predictive of future fracture non-union and subsequent nail breakage. The diamond concept for optimising mechanics and bone biology is a successful method for managing complex sub-trochanteric non-unions with failed metalwork

Introduction. Getting the distal locking screw lengths right in volar locking plate fixation of distal radius is crucial. Long screws can lead to extensor tendon ruptures whereas short screws can lead to failure of fixation, especially if there is dorsal comminution of the fracture. The aim of our study was to determine the distal radius anatomy in relation to sagittal lengths and distance between dorsal bone edge and extensor tendons based on MRI scan. Method. One hundred consecutive MRI scans of wrist were reviewed by two of the authors on two occasions. All MRI scans were performed for different wrist pathologies except distal radius fractures or tumours. An axial image, two cuts proximal to the last visible articular surface, was selected. Sagittal length at 5 different widths, maximum volar width, radial overhang over distal radio-ulnar joint and the distance between dorsal bone edge and extensor tendons were measured. Results. A total of 120 MRI scans were included of which 74 were women and 46 were men. Mean volar width was 32mm and longest sagittal length was 22 mm (at Lister's tubercle). Length radial to Lister's tubercle was the shortest (17mm) and ulnar sides were 21mm and 29mm. Male measurements were mean 3mm longer than females. Mean radial overhang over DRUJ was 4mm. Distance from bone to tendons was within 2mm of dorsal radius edge. Conclusion. The study provides a reference guide to average screw lengths at different widths of distal radius in males and females. EPL tendon is closest to bone although all the extensor tendons are within 2mm of bone edge and carry a risk of injury from drill and screw placement. DRUJ is also at risk of injury if screws are placed within 4mm of ulnar edge of distal radius

The common practice for insertion of distal locking screws of intramedullary (IM) nails is a freehand technique under fluoroscopic control. The process is technically demanding, time-consuming and afflicted to considerable radiation exposure to patient and surgical personnel. A new technique is introduced which guides the surgeon by landmarks on the X-ray projection. 18 fresh frozen human below-knee specimens (incl. soft tissue) were used. Each specimen was instrumented with an Expert Tibial Nail (Synthes GmbH, Switzerland) and was mounted on an OR-table. Two distal interlocking techniques were performed in random order using a Siemens ARCADIS C-arm system (Siemens AG, Munich, Germany). The newly developed guided technique, guides the surgeon by visible landmarks projected onto the fluoroscopy image. A computer program plans the drilling trajectory by 2D-3D conversion and provides said guiding landmarks for drilling in real-time. No additional tracking or navigation equipment is needed. All four distal screws (2 mediolateral, 2 anteroposterior) were placed in each procedure. Operating time, number of taken X-rays and radiation time were recorded per procedure and for each single screw. 8 procedures were performed with the freehand technique and 10 with the guided technique. A 58% reduction in number of fluoroscopy shots per screw was found for the guided technique (7.4±3.4 vs. 17.6±10.3; p < 0.001). Total radiation time was 55% lower for the guided technique (17.1 ± 3.7s vs. 37.9 ± 9.1s) (p = 0.001). Operating time was shorter by 22% in the guided technique (3.2±1.2 min vs. 4.1±2.1 min p = 0.018). In an experimental setting, the newly developed guided freehand technique has proven to markedly reduce radiation exposure when compared to the conventional freehand technique. The method enhances established clinical workflows and does not require cost intensive add-on devices or extensive training. A newly developed simple navigated technique has proven to markedly reduce radiation exposure and time for distal locking of intramedullary nails

Aims

The aim of this study was to present the first retrieval analysis findings of PRECICE STRYDE intermedullary nails removed from patients, providing useful information in the post-market surveillance of these recently introduced devices.

Femoral lengthening using the Intramedullary Skeletal Kinetic Distractor is a new technique. However, with intramedullary distraction the surgeon has less control over the lengthening process. Therefore, 33 femora lengthened with this device were assessed to evaluate the effect of operative variables under the surgeon’s control on the course of lengthening. The desired lengthening was achieved in 32 of 33 limbs. Problems encountered included difficulty in achieving length in eight femora (24%) and uncontrolled lengthening in seven (21%). Uncontrolled lengthening was more likely if the osteotomy was placed with less than 80 mm of the thick portion of the nail in the distal fragment (p = 0.052), and a failure to lengthen was more likely if there was over 125 mm in the distal fragment (p = 0.008). The latter problem was reduced with over-reaming by 2.5 mm to 3 mm. Previous intramedullary nailing also predisposed to uncontrolled lengthening (p = 0.042), and these patients required less reaming.

Using the Intramedullary Skeletal Kinetic Distractor, good outcomes were obtained; problems were minimised by optimising the position of the osteotomy and the amount of over-reaming performed.