The aim was to report operative complications, radiographic and patient-reported outcomes following lateral tibial plateau fracture fixation augmented with calcium phosphate cement (CPC). From 2007–2018, 187 patients (median age 57yrs [range 22–88], 63% female [n=118/187]) with a Schatzker II/III fracture were retrospectively identified. There were 103 (55%) ORIF and 84 (45%) percutaneous fixation procedures. Complications and radiographic outcomes were determined from outpatient records and radiographs. Long-term follow-up was via telephone interview. At a median of 6 months (range 0.1–138) postoperatively, complications included superficial peroneal nerve injury (0.5%, n=1/187), infection (6.4%, n=12/187), prominent metalwork (10.2%, n=19/187) and post-traumatic osteoarthritis (PTOA; 5.3%, n=10/187). The median postoperative medial proximal tibial angle was 89o (range 82–107) and posterior proximal tibial angle 82o (range 45–95). Three patients (1.6%) underwent debridement for infection and 27 (14.4%) required metalwork removal. Seven patients (4.2%) underwent total knee replacement for PTOA. Sixty percent of available patients (n=97/163) completed telephone follow-up at a median of 6yrs (range 1–13). The median Oxford Knee Score was 42 (range 3–48), Knee injury and Osteoarthritis Outcome Score 88 (range 10–100), EuroQol 5-Dimension score 0.812 (range −0.349–1.000) and Visual Analogue Scale 75 (range 10–100). There were no significant differences between ORIF and percutaneous fixation in patient-reported outcome (all p>0.05). Fixation augmented with CPC is safe and effective for lateral tibial plateau fractures, with a low complication rate and good long-term knee function and health-related quality of life. Percutaneous fixation offers a viable alternative to ORIF with no detriment to patient-reported outcome

Background. Although gradual bone transport may provide a large-diameter bone, complications are common with the long duration of external fixation. To reduce such complications, a new technique of bone transport with a locking plate has been done for tibial bone defect. Methods. In 13 patients (mean age, 38.9 years) of chronic osteomyelitis or traumatic bone defect, segmental transport was done using external fixator with a locking plate. In surgical technique, a locking plate was fixed submuscularly, holding the proximal and distal segments. Then, the external fixator for transport was fixed without contact of the locking plate. After docking, 2 or 3 screws were fixed at the transported segment through the plate holes. At the same time, the external fixator was removed. Results. The mean transported amount was 5.8cm, and the mean external fixation index was 13.3 days/cm. The primary union at the docking site was achieved in all cases. No patients showed angular deformity over 5 degrees. There were 2 patients of leg length discrepancy with less than 1.5cm. Deep infection or recurrence of osteomyelitis was not developed. Except for two patients with pre-existed peroneal nerve injury, all had excellent or good functions according to the criteria of Mekhail. Conclusion. In tibial reconstruction, transport with a locking plate may be a successful method with reducing external fixation time. It may allow patients to return to daily life earlier with relatively few complications

We reviewed the outcome of Agility total ankle replacements carried out in our institution between 2002 and 2006. Follow-up consisted of clinical and radiological review pre-operatively, at 6 weeks, 6 and 12 months, and annually until 10 years post-op. Clinical review included the American Orthopaedic Foot and Ankle Score, satisfaction and pain scores. 30 arthroplasties were performed in 30 consecutive patients. Pre-operative diagnosis was rheumatoid arthritis (16), primary osteoarthritis (12) and post-traumatic osteoarthritis (2). After a mean follow up of 6.2 years (1.4–10.1), 4 patients had died, and 20 out of the remaining 24 were available for follow-up. Complications included lateral malleoli fracture (3), superficial peroneal nerve injury (2), one early death, unrelated to the surgical procedure, delayed syndesmotic union (1), non-union (6) and deep infection (2), of which one underwent removal of the implant; the other receives long-term oral antibiotics. AOFAS scores improved from mean 40.4 pre-op to 83.5 post-op (p<0.001). Radiological assessment revealed 25 (93%) patients had lucency in at least one zone in the AP radiograph. We found a relatively high level of re-surgery and complications following Agility total ankle replacement. A 7% revision rate is much higher than would be tolerated in knee or hip arthroplasty, but compares favourably to other studies of TAR. Despite radiological loosening, and the high rate of re-surgery and complications; patients are generally satisfied with the procedure, reporting lower levels of pain and improved function. Overall, we feel that the Agility ankle is an acceptable alternative to arthrodesis, however patients should be warned of the risk of re-surgery

Introduction. Debate remains which surgical technique should be used for ankle arthrodesis. Several open approaches have been described, as well as the arthroscopic method, using a variety of fixation devices. Both arthroscopic and open procedures have good results with union rates of 93–95%, 3% malunion rate and patient satisfaction of 70–90%, although some report complication rates as high as 40%. Aims. To identify union, complication and patient satisfaction rates with open ankle fusions (using the plane between EHL and tibialis anterior). Method. A retrospective review of all isolated primary fusions performed between 2005 and 2009. Patient records were reviewed and patients were recalled for clinical evaluation and AOFAS scoring. Follow up range was 7 months–8.3 years (mean 4 years). Results. 82 ankles were identified in 73 patients. Medical notes were reviewed for all patients. Fifty five patients were clinically reviewed (75% response rate), a further 3 contacted by telephone (79% response rate). Fifeteen were not contactable. Male 47: 35 female, age range at surgery 18–75 years (mean 56.1), left 37: 45 right, 8 were smokers. Causes leading to fusion were: Trauma 52 (63%), OA 17, Rh.A 7, CMT 3, CTEV 2, Talar AVN 1. All fusions were performed with 2 (78) or 3 (4) medial tibiotalar screws. Length of stay range: 1–12 days (mean 3.1). All patients were placed in plaster post operatively for a minimum 12 weeks. Time to union ranged from 8 to 39 weeks (mean 13.3) with a union rate of 100%. Major complications were 14.6%: 7 (8.5%) malalignment, 3 (3.7%) wound problems, 2 (2.4%) complex regional pain syndrome. There were no non unions, DVT, PE, stress fractures or deep infections. There were 2 (2.4%) delayed unions (> 6 months, both smokers), 6 (7%) asymptomatic superficial peroneal nerve injuries and one saphenous nerve injury. Four (4.8%) required screw removal. Subsequent fusions were performed in 7.3%, 4 subtalar, 1 triple and 1 chopart. The AOFAS range was 8–89 (mean 66). 79% were either ‘very satisfied’ or ‘satisfied’ and 8% were ‘very disatisfied’ or ‘disatisfied’. Patients played a variety of sports including golf, squash, badmington and sky diving. Conclusion. These results show excellent union rates (100%) in part related to the strong no smoking policy and meticulous surgical technique. Two delayed unions (union at 39 and 31 weeks) were smokers. There were high satisfaction rates, however varus malalignment and persistent pain (particularly CRPS) resulted in dissatisfaction. Many patients remained highly active. These results exceed the current reported union rates and compare favourable with complications and patient satisfaction and we therefore advocate this technique

Unstable bicondylar tibial plateau fractures are rare and there is little guidance in the literature as to the best form of treatment. We examined the short- to medium-term outcome of this injury in a consecutive series of patients presenting to two trauma centres. Between December 2005 and May 2010, a total of 55 fractures in 54 patients were treated by fixation, 34 with peri-articular locking plates and 21 with limited access direct internal fixation in combination with circular external fixation using a Taylor Spatial Frame (TSF). At a minimum of one year post-operatively, patient-reported outcome measures including the WOMAC index and SF-36 scores showed functional deficits, although there was no significant difference between the two forms of treatment. Despite low outcome scores, patients were generally satisfied with the outcome. We achieved good clinical and radiological outcomes, with low rates of complication. In total, only three patients (5%) had collapse of the joint of > 4 mm, and metaphysis to diaphysis angulation of greater than 5º, and five patients (9%) with displacement of > 4 mm. All patients in our study went on to achieve full union.

This study highlights the serious nature of this injury and generally poor patient-reported outcome measures following surgery, despite treatment by experienced surgeons using modern surgical techniques. Our findings suggest that treatment of complex bicondylar tibial plateau fractures with either a locking plate or a TSF gives similar clinical and radiological outcomes.

Cite this article: Bone Joint J 2014;96-B:956–62.

The outcomes of 261 nerve injuries in 100 patients were graded good in 173 cases (66%), fair in 70 (26.8%) and poor in 18 (6.9%) at the final review (median 28.4 months (1.3 to 64.2)). The initial grades for the 42 sutures and graft were 11 good, 14 fair and 17 poor. After subsequent revision repairs in seven, neurolyses in 11 and free vascularised fasciocutaneous flaps in 11, the final grades were 15 good, 18 fair and nine poor. Pain was relieved in 30 of 36 patients by nerve repair, revision of repair or neurolysis, and flaps when indicated. The difference in outcome between penetrating missile wounds and those caused by explosions was not statistically significant; in the latter group the onset of recovery from focal conduction block was delayed (mean 4.7 months (2.5 to 10.2) vs 3.8 months (0.6 to 6); p = 0.0001). A total of 42 patients (47 lower limbs) presented with an insensate foot. By final review (mean 27.4 months (20 to 36)) plantar sensation was good in 26 limbs (55%), fair in 16 (34%) and poor in five (11%). Nine patients returned to full military duties, 18 to restricted duties, 30 to sedentary work, and 43 were discharged from military service. Effective rehabilitation must be early, integrated and vigorous. The responsible surgeons must be firmly embedded in the process, at times exerting leadership.