Fragility ankle fractures are traditionally managed conservatively or with open reduction internal fixation (ORIF). Tibiotalocalcaneal (TTC) fusion is an alternative option for the geriatric patient. This systematic review and meta-analysis provides a detailed analysis of the functional and clinical outcomes of hindfoot nailing for fragility ankle fractures presented so far in the literature. A systematic search was performed on MEDLINE, EMBASE, Cochrane Library, Scopus, Web of Science, identifying fourteen studies for inclusion. Studies including patients over 60 with a fragility ankle fracture, treated with TTC nail were included. Patients with a previous fracture of the ipsilateral limb, fibular nails, and pathological fractures were excluded. Subgroup analyses were performed according to (1) open vs closed fractures, (2) immediate post-operative FWB vs post-operative NWB, (3) majority of cohort are diabetics vs minority of cohort are diabetics. Meta-regression analyses were done to explore sources of heterogeneity, and publication bias was assessed using Egger's test. The pooled proportion of superficial infection, deep infection, implant failure, malunion, and all-cause mortality was 0.10 (95%CI:0.06-0.16; I2=44%), 0.08 (95%CI:0.06-0.11, I2=0%), 0.11 (95%CI:0.07-0.15, I2=0%), 0.11 (95%CI:0.06-0.18; I2=51%), and 0.27 (95%CI:0.20-0.34; I2=11%), respectively. The pooled mean post-operative OMAS score was 54.07 (95%CI:48.98-59.16; I2=85%). The best-fitting meta-regression model included age and percentage of male patients as covariates (p=0.0263), and were inversely correlated with higher OMAS scores. Subgroup analyses showed that studies with a majority of diabetics had a higher proportion of implant failure (p=0.0340) and surgical infection (p=0.0096), and a lower chance of returning to pre-injury mobility than studies with a minority of diabetics (p=0.0385). Egger's test (p=0.56) showed no significant publication bias. TTC nailing is an adequate alternative option for fragility ankle fractures. However, current evidence includes mainly case series with inconsistent outcome measures reported and post-operative rehabilitation protocols. Prospective RCTs with long follow-up times and large cohort sizes are needed to clearly guide the use of TTC nailing for ankle fractures

Background. Distal radius fractures are among the most common fractures encountered in the clinical setting, with a reported incidence of 17%. Of these common fractures, it has been said 60% are intra-articular in nature. Intra-articular or unstable and comminuted fractures represent severe, high energy injuries. There is a considerable amount of controversy as to which fixation method is superior. Even the OA concludes; “comparing external fixation (EF) with open reduction and internal fixation (ORIF) for the treatment of intra-articular distal radius fractures described no consistent benefit of one treatment over another”. There are only a few randomised control trials that go beyond one year to cover the long-term follow up (over two years). There has yet to be a meta-analysis of the long-term outcomes of open reduction internal fixation (ORIF) versus external fixation. We aim to show from this meta-analysis if there is any significant difference in the outcomes of either fixation method in the long-term. Method. We pooled the data of all available randomised control trials that compare the long-term outcomes of ORIF against external fixation of distal radius fractures. We completed a systematic review of PubMed, embase, MEDLINE and the Cochrane Library, from inception to December 2014. We then preformed our meta-analysis using RevMan 5.3 software. Results. We did not determine any significant difference in long-term outcomes when comparing ORIF with external fixation. However 6 of the 11 outcomes supported ORIF. Conclusion. There is no significant difference in the long-term outcomes between ORIF and external fixation. No meta analysis to date, short or long term, has been able to determine which is the superior, yet the future treatment of these fractures looks to be ORIF in the form of volar plating. We recommend before this becomes universal, further research must be carried out. Level of Evidence. Level 1. Disclosures. this was the first author's, Dr CJC Gouk, Masters dissertation at the University of Edinburgh. No financial support was received

Abstract. Objectives. Current literature on pilon fracture includes a range of different management strategies, however there is no universal treatment algorithm. We aim to determine clinical outcomes in patients with open and closed pilon fractures, managed using a treatment algorithm applied consistently over the span of this study. Methods. 135 patients over a 6-year period were included. Primary outcome was AOFAS score at 3, 6, 12-months post-injury. Secondary outcomes include time to partial weight-bear (PWB), full weight-bear (FWB), bone union time, follow-up time. AO/OTA classification was used (43A: n=23, 43B: n=30, 43C: n=82). Treatment algorithm consisted of fine wire fixator (FWF) for severely comminuted closed fractures (AO/OTA type 43C3), or open fractures with severe soft tissue injury (GA type 3). Otherwise, open reduction internal fixation (ORIF) was performed. When required, minimally invasive osteosynthesis was performed in combination with FWF to improve joint congruency. Results. Mean AOFAS score 3, 6, and 12 months post-treatment for open and closed fracture patients were 44.12 and 53.99 (p=0.007), 62.38 and 67.68 (p=0.203), 78.44 and 84.06 (p=0.256), respectively. 119 of 141 fractures healed without further intervention (84.4%). Average time to union was 51.46 and 36.48 weeks for open and closed fractures, respectively (p=0.019). On average, open, and closed fracture patients took 12.29 and 10.76 weeks to PWB (p=0.361); 24.04 and 20.31 weeks to FWB (p=0.235), respectively. Common complications for open fractures were non-union (24%), post-traumatic arthritis (16%); for closed fractures they were post-traumatic arthritis (25%), superficial infection (22%). Open fracture was a risk factor for non-union (p=0.042;OR=2.558,95% CI 1.016–6.441), bone defect (p=0.001;OR=5.973,95% CI 1.986–17.967), and superficial infection (p<0.001;OR=4.167,95% CI 1.978–8.781). Conclusions. FWF with minimally invasive osteosynthesis, where required for severely comminuted closed fractures, and FWF for open fractures with severe soft tissue injury, are safe methods achieving low complication rates and good functional recovery

Introduction and Objective. Despite the low incidence of pilon fractures among lower limb injuries, their high-impact nature presents difficulties in surgical management and recovery. Current literature includes a wide range of different management strategies, however there is no universal treatment algorithm. We aim to determine clinical outcomes in patients with open and closed pilon fractures, managed using a treatment algorithm that was applied consistently over the span of this study. Materials and Methods. This retrospective study was conducted at a single institution, including 141 pilon fractures in 135 patients, from August 2014 to January 2021. AO/OTA classification was used to classify fractures. Among closed fractures, 12 had type 43A, 18 had type 43B, 61 had type 43C. Among open fractures, 11 had type 43A, 12 had type 43B, 27 had type 43C. Open fractures were further classified with Gustilo-Anderson (GA); type 1: n=8, type 2: n=10, type 3A: n=12, type 3B: n=20. Our treatment algorithm consisted of fine wire fixator (FWF) for severely comminuted closed fractures (AO/OTA type 43C3), or open fractures with severe soft tissue injury (GA type 3). Otherwise, open reduction internal fixation (ORIF) was performed. When required, minimally invasive osteosynthesis (MIO) was performed in combination with FWF to improve joint congruency. All open fractures, and closed fractures with severe soft tissue injury (skin contusion, fracture blister, severe oedema) were initially treated with temporary ankle-spanning external fixation. For all open fracture patients, surgical debridement, soft tissue cover with a free or pedicled flap were performed. For GA types 1 and 2, this was done with ORIF in the same operating session. Those with severe soft tissue injury (GA type 3) were treated with FWF four to six weeks after soft tissue management was completed. Primary outcome was AOFAS Ankle-Hindfoot score at 3, 6 and 12-months post-treatment. Secondary outcomes include time to partial weight-bear (PWB) and full weight-bear (FWB), bone union time. All complications were recorded. Results. Mean AOFAS score 3, 6, and 12 months post-treatment for open and closed fracture patients were 44.12 and 53.99 (p=0.007), 62.38 and 67.68 (p=0.203), 78.44 and 84.06 (p=0.256), respectively. 119 of the 141 fractures healed without further intervention (84.4%). Average time to bone union was 51.46 and 36.48 weeks for open and closed fractures, respectively (p=0.019). Union took longer in closed fracture patients treated with FWF than ORIF (p=0.025). On average, open and closed fracture patients took 12.29 and 10.76 weeks to PWB (p=0.361); 24.04 and 20.31 weeks to FWB (p=0.235), respectively. Common complications for open fractures were non-union (24%), post-traumatic arthritis (16%); for closed fractures they were post-traumatic arthritis (25%), superficial infection (22%). Open fracture was a risk factor for non-union (p=0.042; OR=2.558, 95% CI 1.016–6.441), bone defect (p=0.001; OR=5.973, 95% CI 1.986–17.967), and superficial infection (p<0.001; OR=4.167, 95% CI 1.978–8.781). Conclusions. The use of a two-staged approach involving temporary external fixation followed by definitive fixation, provides a stable milieu for soft tissue recovery. FWF combined with MIO, where required for severely comminuted closed fractures, and FWF for open fractures with severe soft tissue injury, are safe methods achieving low complication rates and good functional recovery

With increasing numbers of total joint arthroplasties being performed, peri-prosthetic fracture incidence is rising, and operative management remains the gold standard. Short-term survivorship up to 12 months has been well-documented but medium to long-term is almost unknown. We present survivorship review from a district general hospital, undertaking 800 primary hip and knee arthroplasties per year. Patients with peri-prosthetic fractures and background total knee replacements were identified using our computer database between 2006–2011. All patients were operated on our site; methods used include open reduction, internal fixation (ORIF) using Axsos (Stryker Newbury) locking plates (28), intra-medullary nailing (1) or complex revision (6) depending on fracture and patient factors and surgeon's preference. Mortality was assessed at 30 days, 12 months and 5 years. Thirty-four patients were identified with a 7:1 female to male ratio and mean age of 76. 75% of patients had their primary arthrodesis at our hospital. There was only 1 plate failure noted requiring revision plating. Mortality at 30 days, 12 months and 5 years were 3.2, 12.5% and 50% respectively. When compared to the literature our time interval from index surgery to fracture is considerably longer (115 vs 42 months). Further multi-centre reviews are required to further asses this unexpected finding. Overall mortality is better than our hip fracture cohort, suggesting that good results can be achieved in District Hospital. The longer-term results are encouraging and can act as a guide for patients with this injury. We recommend that patients are managed in consultant-led, multi-disciplinary teams

Standard fixation for intra-articular distal humerus fracture is open reduction and internal fixation (ORIF). However, high energy fractures of the distal humerus are often accompanied with soft tissue injuries and or vascular injuries which limits the use of internal fixation. In our report, we describe a highly complex distal humerus fracture that showed promising healing via a ring external fixator. A 26-year-old man sustained a Gustillo Anderson Grade IIIB intra-articular distal humerus fracture of the non-dominant limb with bone loss at the lateral column. The injury was managed with aggressive wound debridement and cross elbow stabilization via a hinged ring external fixator. Post operative wound managed with foam dressing. Post-operatively, early controlled mobilization of elbow commenced. Fracture union achieved by 9 weeks and frame removed once fracture united. No surgical site infection or non-union observed throughout follow up. At 2 years follow up, flexion - extension of elbow is 20°- 100°, forearm supination 65°, forearm pronation 60° with no significant valgus or varus deformity. The extent of normal anatomic restoration in elbow fracture fixation determines the quality of elbow function with most common complication being elbow stiffness. Ring fixator is a non-invasive external device which provides firm stabilization of fracture while allowing for adequate soft tissue management. It provides continuous axial micro-movements in the frame which promotes callus formation while avoiding translation or angulation between the fragments. In appropriate frame design, they allow for early rehabilitation of joint where normal range of motion can be allowed in controlled manner immediately post-fixation. Functional outcome of elbow fracture from ring external fixation is comparable to ORIF due to better rehabilitation and lower complications. Ring external fixator in our patient achieved acceptable functional outcome and fracture alignment meanwhile the fracture was not complicated with common complications seen in ORIF. In conclusion, ring external fixator is as effective as ORIF in treating complex distal humeral fractures and should be considered for definitive fixation in such fractures

Abstract. Objectives. The outcomes from patella fracture have remained dissatisfactory despite advances in treatment, especially from operative fixation1. Frequently, reoperation is required following open reduction and internal fixation (ORIF) of the patella due to prominent hardware since the standard technique for patella ORIF is tension band wiring (TBW) which inevitably leaves a bulky knot and irritates soft tissue given the patella's superficial position2. We performed a systematic review to determine the optimal treatment of patella fractures in the poor host. Methods. Three databases (EMBASE/Medline, ProQuest and PubMed) and one register (Cochrane CENTRAL) were searched. 476 records were identified and duplicates removed. 88 records progressed to abstract screening and 73 were excluded. Following review of complete references, 8 studies were deemed eligible. Results. Complication rates were shown to be high in our systematic review. Over one-fifth of patients require re-operation, predominantly for removal of symptomatic for failed hardware. Average infection rate was 11.95% which is higher than rates reported in the literature for better hosts. Nevertheless, reported mortality was low at 0.8% and thromboembolic events only occurred in 2% of patients. Average range of movement achieved following operative fixation was approximately 124 degrees. Upon further literature review, novel non-operative treatment options have shown acceptable results in low-demand patients, including abandoning weight-bearing restrictions altogether and non-operatively treating patients with fracture gaps greater than 1cm. Regarding operative management, suture/cable TBW has been investigated as a viable option with good results in recent years since the materials used show comparable biomechanics to stainless steel. Additionally, ORIF with locking plates have shown favourable results and have enabled aggressive post-operative rehabilitation protocols. TBW with metallic implants has shown higher complication rates, especially for anterior knee pain, reoperation and poor functional outcomes. Conclusion. There is sparse literature regarding patella fracture in the poor host. Nevertheless, it is clear that ORIF produces better outcomes than conservative treatment but the optimal technique for patella ORIF remains unclear. TBW with metallic implants should not remain the standard technique for ORIF; low-profile plates of suture TBW are more attractive solutions. Non-operative treatment may be considered for low-demand individuals however any form of patellectomy should be avoided if possible. Declaration of Interest. (b) declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported:I declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research project

Abstract. Objectives. Currently, the golden standard for the management of ankle fractures is open reduction and internal fixation (ORIF), a procedure which preserves joint anatomy and function. However, ORIF is associated with high risk of infection, especially in the elderly population, who tend to suffer from osteoporosis and vascular disease. Studies recommend hindfoot nailing (HFN) as a safe and efficient management alternative for this demographic. Unlike ORIF, HFN allows immediate weight-bearing, which has been linked to a lower rate of complications. This study aims to evaluate the outcomes of hindfoot nailing in ankle fractures using a case series of 43 patients. Methods. This is a retrospective study with a sample size of 43 patients, that have a mean age of 77.3 years and several medical conditions. These patients experienced ankle fractures that were treated with HFN. Data collected included injury patterns, operative complications, rate of radiological union, comorbidities and changes in mobility and housing before and after surgery. Results. Before their fracture, 62.8% of patients mobilised using a walking stick or a wheeled frame. Following surgery, 52.4% experienced decreased level of mobility. 50% of patients achieved radiological union at the time of data analysis, whereas 52.4% of patients reported a post-operative complication, most commonly soft tissue or bone infection. Conclusions. Our study has a large sample size compared to previous research. The follow-up period varies depending on patient attendance to follow-up clinical appointments. Our patient cohort exhibits significantly lower rates of radiological union, higher incidence of complications and poor post-operative functional outcomes associated with HFN. These data contradict previous studies suggesting HFN for the surgical management of ankle fractures in the elderly and frail population and demonstrate that a more thorough evaluation of HFN is needed

Introduction and Objective. Lower limb fractures are amongst the most common surgically managed orthopaedic injuries, with open reduction and internal fixation (ORIF) as the conventional method of treatment of the fibula. In recent years, dedicated intramedullary implants have emerged for fibula fixation in tandem with the move towards minimally invasive surgery in high-risk patients. This is the largest multicentre review to date with the aim of establishing the clinical outcomes following intramedullary nail (IMN) fixation of the fibula and to identify the absolute indication for fibula IMN fixation. Materials and Methods. A retrospective study of adult patients in all UK hospitals, who underwent fibula nail fixation between 01/01/2018 and 31/10/2020 was performed. Primary outcome measures included time to union, infection rate, other post-operative complications associated with the fixation and length of hospital stay. The secondary outcome measure was to identify the indication for fibula nailing. Data tabulation was performed using Microsoft Excel and analysis was performed using SPSS Version 23 (SPSS Statistics). Results. 2 Major Trauma Centres (MTCs) and 9 Trauma Units (TUs) were eligible for inclusion. 102 patients were included and 91% were classified as ankle fractures of 68% (n=69) were Weber B, 24% (n=24) Weber C and 8% (n=9) were either distal tibial fractures with an associated fibula fracture or pilon fractures. The mean age was 64 years of which 45 were male patients and 57 were female. The average BMI was 30.03kg/m. 2. and 44% of patients were ASA 3. 74% of patients had poor pre-op skin condition including swelling and open wounds. The calculated infection rate for fibula nail was 4.9% and metal-work complication rate was 4.9%. The average time to union was 13 weeks and length of inpatient stay was 15 days (SD +/− 12 days). Conclusions. MEFNO has demonstrated that fibula nail is an ideal implant in patients who have a physiologically higher risk of surgery, poor skin condition and a complex fracture pattern. The time to union, complication and infection risks are lower than that reported in literature for ankle ORIFs

Introduction. Intraarticular calcaneal fractures often need open reduction and internal fixation (ORIF) with plate osteosynthesis. The wound complication is one of the common problems encountered following this and affects the outcome adversely. Our study was done to assess how far postoperative slab/cast can avert wound complications. Methods. Out of 42 patients with unilateral intraarticular calcaneal fractures, 20 were offered postoperative slab/cast and this was continued for six weeks. The remaining 22 patients were not offered any plaster. All patients were followed-up for two years. Results. The incidence of wound dehiscence was 2 in the plaster group as well as 8 in the non-plaster group and this was statistically significant (p = 0.02). Also, significantly lower heel widening was reported in the plaster group (p = 0.03). Although, there was no significant difference in the patient-reported outcome (Maryland Foot Score) and the incidence of pain between the two groups, the occurrence of neurological deficit following surgery and the postoperative range of movements were comparable in these two groups. Conclusion. Thus, it may be concluded that postoperative plaster application for the initial six weeks could be a low-cost yet effective way to reduce wound complications following plate osteosynthesis in intraarticular calcaneal fractures

Lisfranc injuries are uncommon and can be challenging to manage. There is considerable variation in opinion regarding the mode of operative treatment of these injuries, with some studies preferring primary arthrodesis over traditional open reduction and internal fixation (ORIF). We aim to assess the clinical and radiological outcomes of the patients treated with ORIF in our unit. This is a retrospective study, in which all 27 consecutive patients treated with ORIF between June 2013 and October 2018 by one surgeon were included with an average follow-up of 2.4 years. All patients underwent ORIF with joint-sparing surgery by a dorsal bridging plate (DBP) for the second and third tarsometatarsal (TMT) joint, and the first TMT joint was fixed with trans-articular screws. Patients had clinical examination and radiological assessment, and completed American Orthopaedic Foot and Ankle Society (AOFAS) midfoot score and Foot Function Index (FFI) questionnaires. Our early results of 22 patients (5 lost to follow-up) showed that 16 (72%) patients were pain free, walking normally without aids, and wearing normal shoes and 68% were able to run or play sports. The mean AOFAS midfoot score was 78.1 (63–100) and the average FFI was 19.5 (0.6–34). Radiological assessment confirmed that only three patients had progression to posttraumatic arthritis at the TMT joints though only one of these was clinically symptomatic. Good clinical and radiological outcomes can be achieved by ORIF in Lisfranc injuries with joint-sparing surgery using DBP

Introduction and Objective. Joint malleolar fractures have been estimated around 9% of all fractures. They are characterized by different both early and late complications. Among the latter, arthrofibrosis and early secondary arthrosis represent the two most common ones. Moreover, these two complications could be considered related to each other. Their real cause is still under investigation, even if residual post-operative hematoma and acute post-traumatic synovitis appear to be the most accredited. Supporting this hypothesis, joint debridement and the evacuation of the post-operative hematoma could represent a possible solution. The aim of this prospective study is to evaluate the role of arthroscopic lavage and debridement during internal fixation in order to prevent late joint complications. Materials and Methods. Sixty consecutive patients who reported dislocated articular ankle fractures with surgical indication of open reduction and internal fixation (ORIF) have been included in this study. 27 patients underwent ORIF surgery associated with arthroscopic washout and debridement, while 33 patients, representing the control group, underwent just internal reduction and osteosynthesis. Patients with pure dislocations, non-articular fractures, polytrauma, previous local trauma, metabolic and connective pathologies were excluded. Follow-up was performed at 40 days (T1), 3 (T2) and 6 months (T3) after trauma for all patients. If necessary, some have been re-evaluated 12 months after the trauma. Efficacy of the treatment was evaluated through the VAS scale, Maryland scale, search for local complications such as dehiscence or infections, and finally radiographic evaluation. T-Student was estimated in order to individuate statistical significance. Results. VAS scale showed higher values for the case group than the control group with mean values of 2.7 and 4.2 at T1 and 2.1 and 3.8 at T2, respectively. At 6 months follow-up, the VAS values resulted similar with 2.6 for the case group and 2.8 for the control group. The same projections were found for the Maryland scale, with values of 61.5 and 40.7 at T1, 80.8 and 68.0 at T2 and 87.8 and 85.0 with no significant differences at T3 respectively. No significant differences were detected for complications or radiographic evaluation. Conclusions. Our study has shown significance differences in terms of pain and time for recovery only in the very short term follow up. Although our study, due to the specific limits, cannot be considered diriment, on the basis of the data, we could hypothesize that the aforementioned hypothesis may remain valid for the non-acute hematoma or that the cause of the arthrofibrosis should be sought somewhere else. However, evidence is low, and further research is needed

Abstract. Objective. To compare the clinical and radiological outcome between less invasive stabilization system (LISS, Synthes, Paoli, PA.) and open reduction with internal fixation (ORIF) for the treatment of extraarticular proximal tibia fractures through the lateral approach. Background. Proximal tibial fractures present a difficult treatment challenge with historically high complication rates. ORIF has been in vogue for long time with good outcome. But these are associated with problems especially overlying skin conditions, delayed recovery and rehabilitation with limited functional outcome. LISS is an emerging procedure for the treatment of proximal tibial fractures. It preserves soft tissue and the periosteal circulation, which promotes fracture healing. Patients and methods. Thirty patients with closed proximal tibial fractures were included in this study. They were randomly divided into 2 groups. Group I (n=15) patients were treated by LISS and group II (n=15) by ORIF. Major characteristics of the two groups were similar in terms of age, sex, mode of injury, fracture location, and associated injuries. All patients were followed up at least 6 months. Results. In each group, 12 patients were united, 2 patients were non- united and one patient showed delayed union. The mean operative time in LISS patients was 79.3 min, while in ORIF patients; it was 122 min. All patients of LISS group were exposed to radiation, while only 40% of ORIF group were exposed. The mean time of union of LISS patients was 10.87weeks. While in ORIF patients, the mean time of union was 21.13 weeks. There was no significant difference between both groups regarding the postoperative complications. Functional outcome was satisfactory in both groups. Conclusion. LISS achieves comparable results with ORIF in extraarticular fractures of the proximal tibia. Although LISS potentially has the radiation hazard, it reduces the perioperative complications with a shortened operation time and minimal soft tissue dissection. Declaration of Interest. (b) declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported:I declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research project

Objectives. Pilon fractures represent one of the most surgically challenging fractures in orthopaedics. Different techniques exist for their management, with open reduction and internal fixation (ORIF) and External fixation (Ex-Fix) the most widely used. Whilst there is a plethora of data regarding these strategies for Pilon fractures as a whole, very limited data exists solely on the management of open Pilon fractures. This study aimed to elucidate how surgical management options can influence postoperative complications, and if this can influence future management protocols. Materials and methods. We conducted a search in PubMed, EMBASE and CENTRAL for postoperative complications and functional outcomes in open pilon fractures in those treated with Ex-Fix vs ORIF (PROSPERO-CRD42020184213). The postoperative complications measured included non-union, mal-union, delayed union, bone grafting, amputation, osteoarthritis, deep infection and superficial infection. Functional outcomes in the form of the AOFAS score was also measured where possible. We were able to carry out a meta-analysis for both deep infections and non-unions. Results. The search yielded 309 results and a total of 18 studies consisting of 484 patients were included. All fractures included were open, and consisted of 64 Gustilo-Anderson Type I, 148 Type II, 103 Type IIIa, 90 Type IIIb and 9 Type IIIc. 60 Type III fractures could not be further separated and 12 were ungraded. Both ORIF and Ex-Fix were found to have statistically similar AOFAS scores (p=0.682). For all included studies, the Ex-Fix group had significantly higher rates of superficial infections (p=0.001), non-unions (p=0.001), osteoarthritis (p=0.001) and bone grafting (p=0.001). The meta-analysis found no significant difference in non-union (pooled OR=0.25, 95% CI: 0.03 to 2.24, p = 0.44) or deep infection rates (pooled OR=1.35, 95% CI: 0.11 to 16.69, p = 0.12) between the ORIF and Ex-fix groups. Conclusion. Based on our study, while Ex-Fix and ORIF have similar functional outcomes, Ex-Fix appears to have a significantly higher risk of postoperative complications which must be considered by surgeons when choosing surgical management options. Further research, ideally in a randomised control trial format, is required to definitively demonstrate ORIF superiority in the management of open pilon fractures

Distal radial fractures are amongst the most common trauma referrals, however controversy remains regarding their optimum management. We undertook a retrospective review of the management of distal radial fractures in our department. The prospectively maintained trauma database was used to identify patients admitted for operative management of a dorsally displaced distal radial fracture between June 2008 and June 2009. Only extra-articular or simple intra-articular fractures were included (AO classification A2/A3/C1/C2). Operation notes were reviewed to determine the method of fixation. Patients were contacted by post and asked to complete a functional outcome score - Disabilities of the Arm, Shoulder and Hand (DASH). A further 12 patients with similar fractures who had been managed conservatively were also asked to complete a DASH score to provide a comparison between operative and non-operative management. 98 patients were identified - 67 female, 31 male. Mean age was 51 years, range 15-85 years. All patients were at least 1 year post-op. 26 patients had manipulation under anaesthesia (MUA). 48 patients had MUA and K-wire fixation, which was supplemented with synthetic bone substitute in 16 cases. 3 patients had MUA and bone graft and 21 patients had open reduction and internal fixation (ORIF) with a volar plate. 34 correctly completed DASH scores were returned. A lower score equates to a better functional outcome. Mean DASH scores were: MUA 14.8; MUA+K-wire 13.1; ORIF 13.6; conservative 47.1. This data would indicate that patients with a significantly displaced distal radial fracture have a better functional outcome with operative management to improve the fracture alignment. However, all of the methods of fixation used resulted in similar functional outcomes at one year