Aims

The aim of this study was to describe services available to patients with periprosthetic femoral fracture (PPFF) in England and Wales, with focus on variation between centres and areas for care improvement.

The COVID-19 pandemic presented a significant impact on orthopaedic surgical operating. This multi-centre study aimed to ascertain what factors contributed to delays to theatre in patients with shoulder and elbow trauma. A retrospective cohort study of 621 upper limb (shoulder and elbow) trauma patients between 16/03/2020 and 16/09/2021 (18-months) was extracted from trauma lists in NHS Tayside, Highland and Grampian and Picture Archiving and Communication Systems (PACS). Median patient age =51 years (range 2-98), 298 (48%) were male and 323 (52%) female. The commonest operation was olecranon open reduction internal fixation (ORIF) 106/621 cases (17.1%), followed by distal humerus ORIF − 63/621 (10.1%). Median time to surgery was 2 days (range 0-263). 281/621 (45.2%) of patients underwent surgical intervention within 0-1 days and 555/621 patients (89.9%) had an operation within 14 days of sustaining their injury. 66/621 (10.6%) patients waited >14 days for surgery. There were 325/621 (52.3%) patients with documented evidence of delay to surgery; of these 55.6% (181/325) were due to amendable causes. 66/325 (20.3%) of these patients suffered complications; the most common being post-operative stiffness in 48.6% of cases (n=32/66). To our knowledge, this is the first study to specifically explore effect of COVID-19 pandemic on upper limb trauma patients. We suggest delays to theatre may have contributed to higher rates of post-operative stiffness and require more physiotherapy during the rehabilitation phase. In future pandemic planning, we propose dedicated upper-limb trauma lists to prevent delays to theatre and optimise patients’ post-operative outcomes

Aims. We report the long-term outcomes of the UK Heel Fracture Trial (HeFT), a pragmatic, multicentre, two-arm, assessor-blinded, randomized controlled trial. Methods. HeFT recruited 151 patients aged over 16 years with closed displaced, intra-articular fractures of the calcaneus. Patients with significant deformity causing fibular impingement, peripheral vascular disease, or other significant limb injuries were excluded. Participants were randomly allocated to open reduction and internal fixation (ORIF) or nonoperative treatment. We report Kerr-Atkins scores, self-reported difficulty walking and fitting shoes, and additional surgical procedures at 36, 48, and 60 months. Results. Overall, 60-month outcome data were available for 118 patients (78%; 52 ORIF, 66 nonoperative). After 60 months, mean Kerr-Atkins scores were 79.2 (SD 21.5) for ORIF and 76.4 (SD 22.5) for nonoperative. Mixed effects regression analysis gave an estimated effect size of -0.14 points (95% confidence interval -8.87 to 8.59; p = 0.975) in favour of ORIF. There were no between group differences in difficulty walking (p = 0.175), or on the type of shoes worn (p = 0.432) at 60 months. Additional surgical procedures were conducted on ten participants allocated ORIF, compared to four in the nonoperative group (p = 0.043). Conclusion. ORIF of displaced intra-articular calcaneal fractures, not causing fibular impingement, showed no difference in outcomes at 60 months compared to nonoperative treatment, but with an increased risk of additional surgery. Cite this article: Bone Joint J 2021;103-B(6):1040–1046

Aims. Displaced, comminuted acetabular fractures in the elderly are increasingly common, but there is no consensus on whether they should be treated non-surgically, surgically with open reduction and internal fixation (ORIF), or with acute total hip arthroplasty (THA). A combination of ORIF and acute THA, an approach called ’combined hip procedure’ (CHP), has been advocated and our aim was to compare the outcome after CHP or ORIF alone. Patients and Methods. A total of 27 patients with similar acetabular fractures (severe acetabular impaction with or without concomitant femoral head injury) with a mean age of 72.2 years (50 to 89) were prospectively followed for a minimum of two years. In all, 14 were treated with ORIF alone and 13 were treated with a CHP. Hip joint and patient survival were estimated. Operating times, blood loss, radiological outcomes, and patient-reported outcomes were assessed. Results. No patient in the CHP group required further hip surgery, giving THA a survival rate of 100% (95% confidence interval (CI) 100 to 100) after three years, compared with 28.6% hip joint survival in the ORIF group (95% CI 12.5 to 65.4; p = 0.001). No dislocations or deep infections occurred in the CHP group. No patient died within the first year after index surgery, but patient survival was lower in the CHP group after three years. There were no relevant differences in patient-reported outcomes. Conclusion. The CHP confers a considerably reduced need of further surgery when compared with ORIF alone in elderly patients with complex acetabular fractures. These findings encourage both further use of, and larger prospective studies on, the CHP. Cite this article: Bone Joint J 2019;101-B:478–483

The aim of the study was to report the survival of open reduction and internal fixation (ORIF) of Vancouver B fractures associated with the Exeter Stem (ES) at a minimum of 5 years. This retrospective cohort study assessed 129 consecutive patients with Vancouver B type fractures treated with ORIF from 2008-2016 at a minimum of 5 years. Patient records were examined, and the following recorded: details of primary prosthesis, details of injury, Vancouver classification, details of operative management, complications, and requirement for reoperation. Data was analysed using SPSS. Survival analysis was undertaken using the endpoint ‘reoperation for any reason’. Mean age at fracture was 78.2 (SD10.6, 46-96) and 54 (43%) were female. Vancouver subclassifications were: 24% B1, 70.5% B2 and 5.5% B3. For all Vancouver B fractures, Kaplan Meier analysis demonstrated a 5 year survival free from reoperation of 88.8% (82.0-94.7 95%CI). Fourteen patients required reoperation, most commonly within the first year for non-union and plate fracture (5.4%). Five-year survival for any reoperation differed significantly according to fracture type (p=0.016) and was worst in B1s: B1 76.6% (61.3-91.9); B2 92.6% 986.9-98.3); and 100% of B3. Univariate analysis identified B1 type (p=0.008) and a transverse fracture pattern (p=0.003) to be significantly associated with the need for reoperation. Adopting a strategy of fixation of all Vancouver B fractures involving the ES where the fracture was anatomically reducible and the bone cement interface was well-fixed was associated with a 5 year survival, free from reoperation of 88.8%

Acetabular fractures present a challenge. Anatomical reduction can be achieved by open reduction and internal fixation (ORIF). However, in elderly patients with complex fracture patterns and osteoporotic bone stock, “fix and replace” has become an option in the management of these injuries. This involves ORIF of the acetabulum to enable insertion of a press fit cup and subsequent cemented femoral stem at the index surgery. A Retrospective analysis of all operatively managed acetabular fractures by a regional Pelvic and Acetabular Trauma service (01/01/2018-30/05/2023) STATA used for analysis. 34 patients undergoing “fix and replace” surgery. Of the 133 patients managed with ORIF, 21 subsequently required Total Hip Arthroplasty (THA). Mean follow up was 2.7 years versus 5.1. There was no statistical significance between the two groups with regards to BMI or sex. Mean age in the “fix and replace” group was 68 compared to 48 in the ORIF and subsequent THA group. This reached statistical significance between the two groups (p=0.001).ASA and Charlson Comorbidity Index (3 and 3 in “fix and replace” and 2 and 1.2 in ORIF to THA group) and Charlson Comorbidity Index both were statistically significantly different (p=0.006 and p=0.027, respectively). High energy mechanism of injury accounted for 56% of the “fix and replace” group compared to 48% in the ORIF to THA. 74% of “fix and replace” were associated fractures compared to 53% of ORIF to THA. Wait to surgery was 3 days for “fix and replace” while 186 days was the mean wait time from listing to THA for the ORIF to THA group. Complication rate was 41% versus 43% in the two groups. 14% in the ORIF to THA group developed PJI versus 6% in “fix and replace”. Fix and replace allows early mobilisation in frailer, elderly patients. Our results show fewer returns to theatre and less PJI in patients having arthroplasty as part of “fix and replace” than subsequent to Open reduction internal fixation

The aim of this study was to document the outcome following either early or delayed fixation for complex (AO-OTA type 43.C) fractures of the tibial plafond. From our trauma database we identified all patients who sustained a complex intra-articular fracture of the distal tibia over an 11-year period. Demographic data, fracture classification, management, complications and subsequent surgeries were recorded. The primary outcome measure was the development of early complications following surgery. The secondary outcome measure was the long-term patient reported outcome. There were 102 type C pilon fractures in 99 patients with a mean age of 42yrs (16–86) and 75.5% (n=77) were male. 73 (71.6%) patients underwent primary open reduction internal fixation (ORIF), with 20 (19.6%) undergoing primary external fixation with delayed ORIF. 34 complications were recorded in 28 (27.5%) patients. There were 18 (17.6%) infections, with a deep wound infection in 9 (8.8%) patients and a superficial wound infection in 9 (8.8%). Risk factors for developing infection were multiple co-morbidities (p=0.008), an open fracture (p=0.008), and primary external fixation with delayed ORIF (p=0.023). At a mean of 6 years (0.3–13; n=53) post injury the mean FAOS score was 76.2 (0–100), the mean FADI score was 75.7 (0–100), and 72% (n=38) of patients were satisfied. This is the largest series in the literature documenting the outcome following fixation for type C tibial pilon fractures. Despite the severity of these injuries, we have demonstrated a satisfactory outcome using primary early fixation in the vast majority of cases

The primary aim of this study was to identify risk factors for developing neuritis and its impact on outcome following open reduction internal fixation (ORIF) of distal humerus fractures. Patients were identified from a prospective trauma database (1995–2010). All fractures of the distal humerus (OA-OTA Type A, B, C) managed with ORIF were included. Prospective long-term follow up was collected by telephone. Demographic data, fracture classification, intraoperative details (time to surgery, tourniquet, approach, fixation technique, nerve transposition), subsequent surgeries, presence of postoperative nerve palsy, complications and range of motion were collected. The Broberg and Morrey Elbow Score and DASH score were used as functional outcome measures. Eighty-two patients, mean age 50(range, 13–93) were included. 16% (13/82) developed post-operative ulnar neuritis, 7% (6/82) radial neuritis and 5% (4/82) longterm nonspecific dysaesthesia. Short-term (mean 10 months, range 1–120, collected in 82 patients) and long-term (mean 6 years, range 4–18, collected in 45%, 34/75, of living patients) was completed. In patients with nerve complication: average Broberg and Morrey score was 86 (76% good/excellent), average DASH was 24.7(range, 3.3–100) and Oxford Elbow Score was 39.5(range, 18–48). Compared to: 94 (96% good/excellent), 17.7(range, 0–73.3) and 43.8(range, 17–48) in patients without. Mean pain score was 3.7 in patients with nerve complication compared to 2 without. Nerve complications were seen with increased frequency in young, male patients with high energy and Type C injuries. Nerve complication following ORIF of distal humerus fractures is relatively common. They have detrimental impact on functional outcome. Certain groups appear to be at increased risk

Background. Distal radial fractures in the elderly population have been traditionally managed by closed techniques, primarily due to their poor bone quality and low functional demands. Since the introduction of the volar locking plate (VLP), which provides a good fixation in osteoporotic bones, there maybe an increased use of open reduction and internal fixation (ORIF) in the elderly population. Aim. We aimed to determine the changes in the management of these fractures in Scotland, and whether this differs between specialist regional centres and district general centres. Patients and Methods. We retrospectively analysed distal radius fractures, in patients aged over 70 years in the period between 1989 and 2008. Data were obtained from the national statistical centre based on admission code and from discharge summaries. Data included patient demographics and treatment method; either open reduction and internal fixation (ORIF), Kirschner wire, or manipulation under anaesthetic (MUA). Results. Incidence of distal radius fractures has increased by 75% from 1989 to 2008. In 2003 there were 94 (13.6%) ORIF, 109 (15.1%) K-wire and 492 (71.3%) MUA. In 2008 there were 131 (22.5%) ORIF, 81 (14.2%) K-wire and 361 (63.3%) MUA. There has been a 34% increase in the number of ORIF and a 26% decrease in K-wire procedures. There is a difference in the proportion treated by ORIF in university hospital and district general hospital trusts; 11.8% more fractures are treated by ORIF in university hospitals (p<0.5). Conclusion. There has been an increasing tend to use VLP in the place of K wire fixation. However a vast majority of elderly patients are still treated primarily with MUA. There is an increased tendency to use VLP in university hospital trusts than in distict general hospitals. This may be a reflection of the availability and preferences of specialist orthopaedic hand surgeons

Aims and objectives. The aim of this study was to assess the radiographic outcome by using Lindstrom grading for the management of Malone 2A and 2B fractures by 3 different methods of treatment. The three different methods included manipulation under anaesthesia, k-wire fixation and open reduction internal fixation. Methods and materials. Between March 2006 and February 2007, 62 intra-articular distal radius fractures were retrospectively selected. 31 patients including 21 females and 9 males with an average age of 62 years were classified as Malone 2A fractures and 32 patients including 18 females and 14 males with an average age of 64.5 years were classified as Malone 2B fractures. 18 patients had manipulation under anaesthetic (MUA) and immobilisation in a plaster of paris (POP) cast, 27 patients had manipulation and k-wire fixation and 17 patients had open reduction internal fixation (ORIF) of the fractures. All the patients had radiographic assessment at 6 weeks post op using Lindstrom grading. Grade 1 and 2 were considered acceptable, grade 3 and 4 were considered unacceptable. Results. In Malone 2A fractures the acceptable number of fractures were as follows −5/10 (50%) of the MUA group, 6/13(46.1%) in the k wire fixation group and 6/7 (85.7%) in the ORIF group. In Malone 2B fractures, the acceptable numbers were - nil in MUA group, 4/14 (28.6%) in k wire fixation group and 8/10 (80%) in the ORIF group. Conclusion. MUA and k wire fixation were not a good option for Malone 2B fractures as these fractures showed the best outcome with 80% acceptable results after ORIF. Malone classification can be used as a reliable predictor for deciding the treatment method for intra articular distal radius fractures as seen by the high acceptable results after ORIF for both type 2A and 2B fractures

The primary aim was to determine the rate of complications and re-intervention rate in a consecutive series of operatively managed distal radius fractures. Data was retrospectively collected on 304 adult distal radius fractures treated at our institution in a year. Acute unstable displaced distal radius fractures surgically managed within 28 days of injury were included. Demographic and injury data, as well as details of complications and their subsequent management were recorded. There were 304 fractures in 297 patients. The mean age was 57yrs and 74% were female. Most patients were managed with open reduction and internal fixation (ORIF) (n=278, 91%), with 6% (n=17) managed with manipulation and Kirschner wires and 3% (n=9) with bridging external fixation. Twenty-seven percent (n=81) encountered a post-operative complication. Complex regional pain syndrome was most common (5%, n=14), followed by loss of reduction (4%). Ten patients (3%) had a superficial wound infection managed with oral antibiotics. Deep infection occurred in one patient. Fourteen percent (n=42) required re-operation. The most common indication was removal of metalwork (n=27), followed by carpal tunnel decompression (n=4) and revision ORIF (n=4). Increasing age (p=0.02), male gender (p=0.02) and high energy mechanism of injury (p<0.001) were associated with developing a complication. High energy mechanism was the only factor associated with re-operation (p<0.001). This study has documented the complication and re-intervention rates following distal radius fracture fixation. Given the increased risk of complications and the positive outcomes reported in the literature, non-operative management of displaced fractures should be considered in older patients

Aims. Acetabular fractures in older adults lead to a high risk of mortality and morbidity. However, only limited data have been published documenting functional outcomes in such patients. The aims of this study were to describe outcomes in patients aged 60 years and older with operatively managed acetabular fractures, and to establish predictors of conversion to total hip arthroplasty (THA). Methods. We conducted a retrospective, registry-based study of 80 patients aged 60 years and older with acetabular fractures treated surgically at The Alfred and Royal Melbourne Hospital. We reviewed charts and radiological investigations and performed patient interviews/examinations and functional outcome scoring. Data were provided by the Victorian Orthopaedic Trauma Outcomes Registry (VOTOR). Survival analysis was used to describe conversion to THA in the group of patients who initially underwent open reduction and internal fixation (ORIF). Multivariate regression analyses were performed to identify factors associated with conversion to THA. Results. Seven patients (8.8%) had died at a median follow-up of 18 months (interquartile range (IQR) 12 to 25), of whom four were in the acute THA group. Eight patients (10%) underwent acute THA. Of the patients who underwent ORIF, 17/72 (23.6%) required conversion to THA at a median of 10.5 months (IQR 4.0 to 32.0) . After controlling for other factors, transport-related cases had an 88% lower rate of conversion to THA (hazard ratio (HR) 0.12, 95% confidence interval (CI) 0.02 to 0.91). Mean standardized Physical Component Summary Score (PCS-12) of the 12-Item Short Form Health Survey (SF-12) was comparable with the general population (age-/sex-matched) by 12 to 24 months. Over half of patients working prior to injury (14/26) returned to work by six months and two-thirds of patients (19/27) by 12 months. Conclusion. Patients over 60 years of age managed operatively for displaced acetabular fractures had a relatively high mortality rate and a high conversion rate to THA in the ORIF group but, overall, patients who survived had mean PCS-12 scores that improved over two years and were comparable with controls. Cite this article: Bone Joint J 2020;102-B(12):1735–1742

Introduction. There is a need for a standardised guideline to assist in optimal decision-making in diabetics who have acquired an ankle fracture. Through a critical analysis of the literature, a diagnostic and management algorithm that incorporates a quantitative scoring system is proposed and presented for consideration. Methods. Publications were identified by conducting a comprehensive keyword search of Medline, EMBASE and CINAHL databases. Search terms included “diabetes,” “ankle,” and “fracture”. Articles published in the English language that were pertinent to the topic were included. Manual search of the references in these relevant papers were also completed to further identify publications for potential inclusion. Publications and conferences not published in the English language or not pertinent to the topic in the above databases were excluded. Duplicate results that occurred in different databases were truncated to a single result. Results. A total of 352 results were revealed using the above methods. Of these, 59 articles met our inclusion criteria. 293 articles met our exclusion criteria. A further 9 articles were included after reviewing the included articles and their respective references. From these results, we propose a detailed diagnostic algorithm that may provide a systematic approach to a diabetic patient who presents with acute ankle pain, swelling, warmth, and/or redness. If a fracture is noted on plain radiographs, a proposed management algorithm and scoring system can be used to assist in deciding whether to proceed with primary open reduction, internal fixation (ORIF) or primary arthrodesis/rigid fixation. This scoring system is based on factors acquired through history and examination. Major factors have been allocated a score of 2, which include: previous or coinciding history of Charcot arthropathy, peripheral neuropathy, insulin dependence with poor compliance, and a diabetic history of greater than 20 years. Minor factors have been allocated a score of 1, which include: age > 50, nephropathy, retinopathy, osteoporosis, vasculopathy, and presence of nutrition/diet deficiency. A score of greater than 7 suggests a primary limb-salvage arthrodesis/rigid fixation because of the likely poor outcome in a primary ORIF. A score of less than 7 suggests that an acceptable outcome will likely result with a primary ORIF. Discussion. Through the use of the AFDA algorithm and score, it will hopefully provide a standardised approach to diabetic ankle fractures and; a method of quantifying risks for both the patient and affected ankle joint, thus, allowing the surgeon to have confidence in achieving the best possible outcome. Although this score is based on a critical analysis of the current literature, further validation of both this algorithm and score is recommended. Once validated, the AFDA score in particular, can also potentially be used as a research tool for further follow-up and outcome studies on diabetic ankle fractures

Open reduction and internal fixation (ORIF) with trans-articular screws or dorsal plating is the standard surgical technique for displaced Lisfranc injuries. This aim of this study is to compare the clinical outcomes of percutaneous reduction and internal fixation (PRIF) of low energy Lisfranc injuries with a matched, control group of patients treated with ORIF. Over a seven-year period (2012–2019), 16 consecutive patients with a low energy Myerson B2-type injury were treated with PRIF. Patient demographics were recorded within a prospectively maintained database at the institution. This study sample was matched for age, sex and mechanism of injury to a control group of 16 patients with similar Myerson B2-type injuries treated with ORIF. Clinical outcome was compared using the American Orthopaedic Foot and Ankle Society (AOFAS) midfoot score and Manchester Oxford Foot Questionnaire (MOXFQ). At a mean follow up of 43.0 months (95% CI 35.6 – 50.4), both the AOFAS and MOXFQ scores were significantly higher in the PRIF group compared to the control ORIF group (AOFAS 89.1vs 76.4, p=0.03; MOXFQ 10.0 vs 27.6, p=0.03). There were no immediate postoperative complications in either group. At final follow up, there was no radiological evidence of midfoot osteoarthritis in any patient in the PRIF group. Three patients in the ORIF group developed midfoot osteoarthritis, one of whom required midfoot fusion. PRIF is a technically simple, less invasive method of operative stabilisation of low energy Lisfranc injures which also appears to be associated with better mid-term clinical outcomes compared to ORIF

Aims. The aim of this study was to determine the trajectory of recovery following fixation of tibial plateau fractures up to five-year follow-up, including simple (Schatzker I-IV) versus complex (Schatzker V-VI) fractures. Patients and Methods. Patients undergoing open reduction and internal fixation (ORIF) for tibial plateau fractures were enrolled into a prospective database. Functional outcome, using the 36-Item Short Form Health Survey Physical Component Summary (SF-36 PCS), was collected at baseline, six months, one year, and five years. The trajectory of recovery for complex fractures (Schatzker V and VI) was compared with simple fractures (Schatzker I to IV). Minimal clinically important difference (MCID) was calculated between timepoints. In all, 182 patients were enrolled: 136 (74.7%) in simple and 46 (25.3%) in complex. There were 103 female patients and 79 male patients with a mean age of 45.8 years (15 to 86). Results. Mean SF-36 PCS improved significantly in both groups from six to 12 months (p < 0.001) and one to five years (simple, p = 0.008; complex, p = 0.007). In both groups, the baseline scores were not reached at five years. The SF-36 PCS was significantly higher in the simple group compared with the complex group at both six months (p = 0.007) and 12 months (p = 0.01), but not at five years (p = 0.17). Between each timepoint, approximately 50% or more of the patients in each group achieved an MCID in their score change, indicating a significant clinical change in condition. The complex group had a much larger drop off in the first six months, with comparable proportions achieving MCID at the subsequent time intervals. Conclusion. Tibial plateau fracture recovery was characterized overall by an initial decline in functional outcome from baseline, followed by a steep improvement from six to 12 months, and ongoing recovery up to five years. In simple patterns, patients tended to achieve a higher functional score by six months compared with the complex patterns. However, comparable functional scores between the groups achieved only at the five-year point suggest later recovery in the complex group. Function does not improve to baseline by five years in either group. This information is useful in counselling patients about the course of prospective recovery. Cite this article: Bone Joint J 2019;101-B:1009–1014

Background:. Pilon fractures are complex intra-articular fractures of the tibial plafond associated with significant short and long morbidity. Minimising surgical complications is essential. Methods:. Clinical and radiological outcomes in 49 patients with AO type 43B and 43C fractures were evaluated retrospectively. Definitive management depended on patient factors, soft tissue injury and fracture pattern. Results:. The majority of fractures (n=26, 53%) were C3 type. 9 fractures were open (18%), grade 3A or 3B. 34 patients (69%) were definitively managed with open reduction and internal fixation (ORIF) predominantly through an anterior approach. 15 (31%) had mini-open or percutaneous plafond reduction and external fixation. No medial plates were used. There were no deep infections. Complications occurred in 5 (10%) patients, all relating to metaphyseal delayed or non-union. At last review, 18 patients (36%) had radiographic evidence of post-traumatic arthritis. Discussion:. Surgeons treating pilon fractures should be familiar with external and internal fixation techniques in order to minimise surgical complications. An algorithm for treatment planning is suggested. Conclusion:. It is possible to achieve low surgical complication rates through careful management according to the nature of the fracture and patient characteristics. For plating, the antero-lateral distal tibial Peri-Loc plate is an effective and safe implant

Objective. The development of surgical site infection in the early weeks following open reduction and internal fixation (ORIF) is a challenging problem. There are no evidence-based guidelines to direct the number of surgical debridements prior to definitive wound closure. The purpose of this study was to assess the success of infection resolution, and to identify risk factors for failure, in post-operative infections treated with a single debridement and primary wound closure. Methods. We retrospectively reviewed 61 postoperative infections (60 patients) that developed following fracture ORIF that were treated with a single debridement and primary closure. Data was collected from a review of the patients’ medical record. Variables were compared between the two groups using univariate and multivariate logistic regression analysis. Results. Twenty nine cases (48%) in 28 patients achieved successful outcome following a single debridement and primary closure without hardware removal. Risk factors for treatment failure, identified by multivariate analysis, were AO/OTA classification B and C type fractures (odds ratio = 2.539; 95% confidence interval = 1.110, 5.807; p = 0.027) and elevated C-reactive protein at admission (odds ratio = 1.017; 95% confidence interval = 1.002, 1.032; p = 0.026). Conclusions. Acute postoperative infection following ORIF treated by a single debridement and primary closure with hardware retention is successful in only half of the cases

Open reduction and internal fixation (ORIF) of ankle fractures is associated with well known complications including wound dehiscence and infection, construct failure and symptomatic metalwork. A technique of intramedullary fibular nailing has been developed that requires only minimal incisions, is biomechanically stronger than ORIF and has low-profile hardware. We hypothesized that fibular nailing would result in a rate of reduction and union comparable to ORIF, with a reduced rate of wound and hardware problems. 100 patients over the age of 65 years with unstable ankle fractures requiring fixation were randomised to undergo fibular nailing or ORIF. Outcome measures assessed over the 12 postoperative months were wound complications, accuracy of reduction, Olerud and Molander score (OMS), and total cost of treatment. The mean age was 74 years (range 65–93) and 75 patients were women, all had some form of comorbidity. Significantly fewer wound infections occurred in the fibular nail group (p=0.002). Eight patients (16%) in the ORIF group developed lateral-sided wound infections, two of these developed a wound dehiscence requiring further surgical intervention. No infections or wound problems occurred in the fibular nail group and at 1 year patients were significantly happier with the condition of their scar (p=0.02), and had slightly better OMS scores (p=ns). The overall cost of treatment in the fibular nail group was less despite the higher initial cost of the implant. The fibular nail allows accurate reduction and secure fixation of ankle fractures with a significantly reduced rate of soft-tissue complications when compared with ORIF

Aims

Ankle fractures are common injuries and the third most common fragility fracture. In all, 40% of ankle fractures in the frail are open and represent a complex clinical scenario, with morbidity and mortality rates similar to hip fracture patients. They have a higher risk of complications, such as wound infections, malunion, hospital-acquired infections, pressure sores, veno-thromboembolic events, and significant sarcopaenia from prolonged bed rest.

Aims

Pneumatic tourniquets are often used during the surgical treatment of unstable traumatic ankle fractures. The aim of this study was to assess the risk of reoperation after open reduction and internal fixation of ankle fractures with and without the use of pneumatic tourniquets.