Aims. Dual plating of distal femoral fractures with medial and lateral implants has been performed to improve construct mechanics and alignment, in cases where isolated lateral plating would be insufficient. This may potentially compromise vascularity, paradoxically impairing healing. This study investigates effects of single versus dual plating on distal femoral vascularity. Methods. A total of eight cadaveric lower limb pairs were arbitrarily assigned to either 1) isolated lateral plating, or 2) lateral and medial plating of the distal femur, with four specimens per group. Contralateral limbs served as matched controls. Pre- and post-contrast MRI was performed to quantify signal intensity enhancement in the distal femur. Further evaluation of intraosseous vascularity was done with barium sulphate infusion with CT scan imaging. Specimens were then injected with latex medium and dissection was completed to assess extraosseous vasculature. Results. Quantitative MRI revealed a mean reduction of 21.2% (SD 1.3%) of arterial contribution in the lateral plating group and 25.4% (SD 3.2%) in the dual plating group (p = 0.051); representing a mean decrease in arterial contribution of 4.2%. The only significant difference found between both experimental groups was regionally, at the lateral aspect of the distal femur with a mean drop in arterial contribution in the lateral plating group of 18.9% (SD 2.6%) versus 24.0% (SD 3.2%) in the dual plating group (p = 0.048), representing a mean decrease in arterial contribution of 5.1%. Gross dissection revealed complete destruction of periosteal vessels underneath either medial or lateral plates in both groups. The network of genicular branches contributing to the posterior and distal femoral condyles was preserved in all specimens. A medial vascular pedicle was found dividing from the superficial femoral artery at a mean 12.7 cm (SD 1.7) proximal to the medial epicondyle and was undisrupted in the dual plating group. Conclusion. Lateral locking-plate application resulted in mean 21.2% reduction in distal femur vascularity. Addition of medial plates did not further markedly decrease vascularity. As such, the majority of the vascular insult occurred with lateral plating alone. Supplemental medially based fixation did not lead to marked devascularization of the distal femur, and should therefore be considered in the setting of comminution and poor bone stock in distal femoral fractures. Further clinical research is required to confirm the results of this study. Cite this article: Bone Joint J 2020;102-B(4):530–538

The extended lateral L-shaped approach for the treatment of displaced intra-articular fractures of the calcaneum may be complicated by wound infection, haematoma, dehiscence and injury to the sural nerve. In an effort to reduce the risk of problems with wound healing a technique was developed that combined open reduction and fixation of the joint fragments and of the anterior process with percutaneous reduction and screw fixation of the tuberosity. A group of 24 patients with unilateral isolated closed Sanders type II and III fractures was treated using this technique and compared to a similar group of 26 patients managed by the extended approach and lateral plating. The operation was significantly shorter (p < 0.001) in the first group, but more minor secondary procedures and removal of heel screws were necessary. There were no wound complications in this group, whereas four minor complications occurred in the second group. The accuracy and maintenance of reduction, and ultimate function were equivalent

Background. To establish relative fixation strengths of a single lateral locking plate, a double locking plate, and a tibial nail in treatment of proximal tibial extra-articular fractures. Methods. Three groups of composite tibial synthetic bones consisting of 5 specimens per group were included; lateral plating (LP) using a LCP-PLT (locking compression plate-proximal lateral tibia), double plating (DP) using a LCP-PLT and a LCP-MPT (locking compression plate-medial proximal tibia), and intramedullary nailing (IN) using an ETN (expert tibial nail). To simulate a comminuted fracture model, a gap osteotomy measuring 1 cm was cut 8 cm below the joint. For each tibia, a minimal preload of 100N was applied before loading to failure. A vertical load was applied at 25mm/min until tibia failure. Results. For axial loading, fixation strength of DP (14387.3N, SD=1852.1) was 17.5% greater than that of LP (12249.3N, SD=1371.6), and 60% less than that of IN (22879.6N, SD=1578.8) (p<0.001). For ultimate displacement in axial loading, similar results were observed for LP (5.74mm, SD=1.01) and DP (4.45mm, SD=0.96), with a larger displacement for IN (5.84mm, SD=0.99). Conclusion. In biomechanical testing of a comminuted proximal tibial fracture model, DP proved stronger than LP in terms of ultimate strength. IN proved strongest; however, DP may be an acceptable alternative for minimally invasive osteosynthesis, which may be technically difficult to fix using a nail

Lateral malleolar plating is associated with complication rates of up to 30%. The fibular nail is an alternative fixation technique, requiring a minimal incision and tissue dissection, with the potential to reduce the incidence of complications. We reviewed our results of 105 unstable ankle fractures fixed with the Acumed fibular nail between 2002 and 2010. The mean age was 65 years and 72% of patients had significant systemic medical comorbidities. A number of different locking screw configurations were assessed over the study period. A proximal blocking screw resulted in satisfactory stability in 93%, single locking screws in 86%, but nailing without locking in only 66%, leading to the development of our current technique. Of the twenty-one patients treated with this technique there have been no significant complications, and only two superficial wound infections. Good fracture reduction was achieved in all of these patients. The mean physical component SF12, Olerud and Molander and Foot and Ankle Outcome scores were 46, 65 and 83 respectively. The outcomes of unstable ankle fractures managed with the fibular nail are encouraging, with good radiographic and functional outcomes and minimal complications. This technique should be considered in the management of debilitated patients with unstable ankle fractures

Aims

Tibial plateau fractures are serious injuries about the knee that have the potential to affect patients’ long-term function. To our knowledge, this is the first study to use patient-reported outcomes (PROs) with a musculoskeletal focus to assess the long-term outcome, as compared to a short-term outcome baseline, of tibial plateau fractures treated using modern techniques.

Techniques for fixation of fractures 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 the incidence of 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 American Academy of Orthopaedic Surgeons 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.

We investigated the stability of seven Schatzker type II fractures of the lateral tibial plateau treated by subchondral screws and a buttress plate followed by immediate partial weight-bearing. In order to assess the stability of the fracture, weight-bearing inducible displacements of the fracture fragments and their migration over a one-year period were measured by differentially loaded radiostereometric analysis and standard radiostereometric analysis, respectively. The mean inducible craniocaudal fracture fragment displacements measured −0.30 mm (−0.73 to 0.02) at two weeks and 0.00 mm (−0.12 to 0.15) at 52 weeks. All inducible displacements were elastic in nature under all loads at each examination during follow-up. At one year, the mean craniocaudal migration of the fracture fragments was −0.34 mm (−1.64 to 1.51).

Using radiostereometric methods, this case series has shown that in the Schatzker type II fractures investigated, internal fixation with subchondral screws and a buttress plate provided adequate stability to allow immediate post-operative partial weight-bearing, without harmful consequences.

Heterotopic ossification occurring after the use of commercially available bone morphogenetic proteins has not been widely reported. We describe four cases of heterotopic ossification in patients treated with either recombinant bone morphogenetic protein 2 or recombinant bone morphogenetic protein 7. We found that while some patients were asymptomatic, heterotopic ossification which had occurred around a joint often required operative excision with good results.