Traditionally, unstable anterior pelvic ring injuries have been stabilised with an external fixator or by internal fixation. Recently, a new percutaneous technique of placement of bilateral supraacetabular polyaxial screws and subcutaneous connecting bar to assemble an “internal fixator” has been described.

We present the surgical technique and early clinical results of using this technique in twenty-five consecutive patients with a rotationally unstable pelvic ring injury and no diastasis of the symphysis pubis treated between April 2010 and December 2013. Additional posterior pelvic stabilisation with percutaneous iliosacral screws was used in 23 of these patients. The anterior device was routinely removed after three months.

Radiological evidence of union of the anterior pelvic ring was seen in 24 of 25 patients at a minimum 6 month follow-up. Thirteen patients developed sensory deficits in the lateral femoral cutaneous nerve (five bilateral) and only one fully recovered.

The anterior pelvic internal fixator is a reliable, safe and easy percutaneous technique for the treatment of anterior pelvic ring injuries, facilitating the reduction and stabilisation of rotational displacement. However, lateral femoral cutaneous nerve dysfunction is common. The technique is recommended in cases with bilateral or unilateral pubic rami fractures and no diastasis of the symphysis pubis.

Stable, anatomical fixation of acetabular fractures gives the best chance of a good outcome. We performed a biomechanical study to compare fracture stability and construct stiffness of three methods of fixation of posterior wall acetabular fractures.

Two-dimensional motion analysis was used to measure fracture fragment displacement and the construct stiffness for each fixation method was calculated from the force / displacement data.

Following 2 cyclic loading protocols of 6000 cycles, to a maximum 1.5kN, the mean fracture displacement was 0.154mm for the rim plate model, 0.326mm for the buttress plate and 0.254mm for the spring plate model. Mean maximum displacement was significantly less for the rim plate fixation than the buttress plate (p=0.015) and spring plate fixation (p=0.02).

The rim plate was the stiffest construct 10962N/mm (SD 3351.8), followed by the spring plate model 5637N/mm (SD 832.6) and the buttress plate model 4882N/mm (SD 387.3).

Where possible a rim plate with inter-fragmentary lag screws should be used for isolated posterior wall fracture fixation as this is the most stable and stiffest construct. However, when this method is not possible, spring plate fixation is a safe and superior alternative to a posterior buttress plate method.

Introduction

Pelvic and acetabular injuries are relatively rare and surgical reconstruction usually occurs only in specialist centres. As part of their work up there is a local protocol for radiological investigations including Judet oblique views for acetabular fractures, pelvic inlet and outlet for pelvic ring fractures and urethrograms for sustaining anterior pelvic injury. The aim of this service evaluation was to assess whether patients had these radiological investigations prior to transfer.

This multi-centre single-blind randomised control trial compared outcomes in patients with acute displaced mid-shaft clavicle fractures treated either by primary open reduction and plate fixation (ORPF), or non-operative treatment (NT).

Two-hundred patients were randomised to receive either ORPF or NT. Functional assessment was conducted up to one-year using DASH, SF-12 and Constant scores (CS). Union was evaluated using radiographs and CT.

Rate of non-union was significantly reduced after ORPF (1 following ORPF, 16 following NT, odds ratio=0.07, 95% CI=0.01–0.50, p=0.0006). 7 patients had delayed-union after NT. Group allocation to ORPF was independently predictive of development of non-union. DASH and CS were significantly better in the ORPF group 3-months post-surgery, but not at one-year (mean DASH = 6.2 after NT versus 3.7 after ORPF, p=0.09; mean CS = 86.1 after NT versus 90.7 after ORPF, p=0.05). Group allocation was not predictive of one-year outcome. Non-union was the only factor independently predictive of one-year functional outcome. There were no significant differences in time off work or subjective scores. Five patients underwent revision for complications after ORPF. 10 patients underwent metalwork removal. Treatment cost was significantly greater after ORPF (p=0.001). ORPF reduces rate of non-union compared with NT and is associated with better early functional outcomes. Improved outcomes are not sustained at one-year. Differences in functional outcome appear to be mediated by prevention of non-union from ORPF. ORPF is more expensive and associated with implant-related complications not seen with NT. Our results do not support routine primary ORPF for displaced mid-shaft clavicle fractures.

Aim

Evaluate the outcome and complications of anterior pubic symphysis plating in the stabilisation of traumatic anterior pelvic ring injuries.

Controversy exists whether to treat unstable pertrochanteric hip fractures with either intra-medullary or extra-medullary devices. A prospective randomised control trial was performed to compare the outcome of unstable pertrochanteric hip fractures stabilised with either a sliding hip screw or long Gamma Nail. The hypothesis was that there is no difference in outcome between the two modes of treatment.

Over a four year period, 210 patients presenting with an unstable pertrochanteric hip fracture (AO/OTA 31 A2) were recruited into the study. Eligible patients were randomised on admission to either long Gamma Nail or sliding hip screw. Follow-up was arranged for three, six, and twelve months. Primary outcome measures were implant failure or ‘cut-out’. Secondary measures included mortality, length of hospital stay, transfusion rate, change in mobility and residence, and EuroQol outcome score.

Five patients required revision surgery for implant cut-out (2.5%), of which three were long Gamma Nails and two were sliding hip screws (no significant difference). There were no incidences of implant failure or deep infection. Tip apex distance was found to correlate with implant cut-out. There was no statistically significant difference in either the EuroQol outcome scores or mortality rates between the two groups when corrected for mini mental score. There was no difference in transfusion rates, length of hospital stay, and change in mobility or residence. There was a clear cost difference between the implants.

The sliding hip screw remains the gold standard in the treatment of unstable pertrochanteric fractures of the proximal femur.

Background

Tightrope fixation has been suggested as an alternative to screw stabilisation for distal tibiofibular joint diastasis that provides stability but avoids the problems of rigid screws across the joint. Recent case series (of 6 and 16 patients) have however, reported soft tissue problems and infections in 19–33% of patients. This study aims to review treatment and complications of distal tibiofibular diastasis fixation in our unit with the use of Tightrope or diastasis screws.

There is controversy regarding the optimum method of stabilising traumatic anterior pelvic ring injuries. This study aimed to evaluate the role of pubic symphysis plating.

Controversy exists whether a single proximal lateral tibia (PLT) locked plate is adequate for bicondylar fractures and whether the use of integral raft screws makes the use of bone graft less important.

57 consecutive patients who underwent reconstruction with a locked PLT plate were retrospectively reviewed. Radiographs were examined for operative reduction and subsequent loss of reduction.

55 patients were followed-up for an average of 27 weeks. Fractures were divided into unicondylar (Group 1, n=33) and bicondylar (Group 2, n=22). Union occurred in all patients, with no revisions or removal of metalwork at final follow-up. In 50 patients (88%), the fracture was reduced to within 2mm of anatomical. Articular surface collapse of >2mm occurred in three patients. Nine patients underwent bone grafting with no difference in outcome. A supplementary medial plate was used in three patients with a separate posteromedial fragment.

Except for a separate posteromedial fragment, the use of a single locked PLT plate for bicondylar fractures allows union to occur without failure. With the use of integral raft screws, the need for bone graft is questionable. The short-term radiological results and complication rate of PLT locked plating is excellent.

The purpose of this study was to assess the clinical and radiological outcome following spring plate fixation of posterior wall fractures.

Spring plates are fashioned from a one third tubular plate cutting through one of the holes in the plate and bending the sharp edges through 90 degrees allowing screw fixation of small acetabular margin fragments well away from the joint reducing the risk of joint penetration.

From July 1993 to August 2004, 89 patients with displaced posterior wall fractures underwent posterior wall fixation with one or more spring plates. Patients were assessed post-operatively with a CT scan and annually for up to 5 years for a clinical and radiological assessment. Clinically patients were graded according to the Epstein modification of Merle d'Aubigné/Postel Hip Score. The radiographs were graded using the Roentographic Grade criteria used by Matta.

Patients were reviewed at a mean 55 month follow-up. There were 12 post-operative complications. Clinically excellent or good results were seen in 70% and radiologically in 70%. There were 15 revisions for osteonecrosis, infection and osteoarthritis. 91% (20/22) of fractures had excellent/good clinical results if reduced anatomically compared with 66% (24/36) of those reduced to within 2mm as assessed by the post-operative CT scan. Only 44% (8/18) of those reduced leaving a gap of greater than 2mm had an excellent/good clinical result.

Posterior wall fractures can be treated successfully by the use of spring plates. Clinical results correspond closely with radiological appearance. The accuracy of reduction correlates highly with the subsequent prognosis and we recommend routine post-operative CT scanning to identify misplaced metalwork and the accuracy of reduction to help predict prognosis.

Aims: To determine the incidence and pattern of pain in patients with displaced pelvic ring injuries treated surgically. To investigate the link between pain and neurological injury.

Methods: All patients with pelvic ring fractures treated surgically were contacted by a postal questionnaire. Assessment was made from validated pain scores, pain maps, a Visual Analog Scale (VAS) and correlated with outcome scores including SF36 and Euroqol. Injuries were classified using the Young and Burgess (YB) classification.

Results: There was a response rate of 85% (151 of 178 patients). Average age at injury was 40 yrs (16–74 yrs). Average follow up was 5.3yrs (1–12 yrs). 72% were male. There were 31% Antero-Posterior Compression (APC) injuries, 37% Lateral Compression (LC) injuries and 32% Vertical Shear (VS) injuries. 76% of all patients reported activity related pain; 70% of APC, 73% of LC and 86% of VS injuries (p=0.05, Chi-squared test). These results correlated directly with the pain domain of the Euroqol tool. There were however no statistically significant differences in the interference of pain with work (SF36) or the VAS between injury classes. There was a 15% prevalence of neurological injury in the cohort (9% of APC, 11% of LC and 27% of VS injuries; p=0.03 Chi-squared test). There were no statistically significant differences in the prevalence of moderate to severe pain (Euroqol) or the VAS between those with and without significant neurological injury. The presence of neurological injury significantly affected return to employment but not return to sports or social activities.

Conclusions: These results illustrate the prevalence of significant morbidity in patients with surgically treated pelvic ring fractures. Presence of pain could be linked to injury category but a link with neurological injury was not obvious. This can help give prognostic information to patients suffering displaced pelvic ring injuries requiring surgical reconstruction.

Aims: To determine the incidence and pattern of sexual dysfunction in patients with displaced pelvic ring injuries treated surgically. To investigate a link between sexual and urological dysfunction.

Methods: All patients with pelvic ring fractures treated surgically were contacted by a postal questionnaire. Sexual function was assessed using elements of the validated Sexual Function Questionnaire. Patients were also asked specifically about new-onset sexual and urological dysfunction. Injuries were classified using the Young and Burgess (YB) classification.

Results: There was a response rate of 85% (151 of 178 patients). Average age at injury was 40 yrs (16–74 yrs). Average follow up was 5.3yrs (1–12 yrs). 72% were male.

31% were Antero-Posterior Compression (APC) injuries, 37% Lateral Compression (LC) injuries and 32% Vertical Shear (VS) injuries.

32% of all patients reported significant new sexual problems (36% of males and 24% of females). Of the males, 31% reported erectile dysfunction (12% absolute impotence), 32% reported decreased arousal and 21% reported ejaculatory problems. Of the females, 16% reported decreased arousal, 5% reported anorgasmia and 3% reported painful orgasms. There were no reported cases of dyspareunia in the female patients.

41% of APC, 15% of LC and 39% of VS injuries reported significant new sexual problems (p=0.02, Chi-squared test).

There was a 12% prevalence of significant new urological dysfunction in the entire cohort, with 27% of those with sexual dysfunction also reporting urological dysfunction. This compares with a 5% prevalence of urological dysfunction in patients without sexual dysfunction (p< 0.0001, Chi-squared test).

Conclusions: This large outcome study of UK patients illustrates the significant prevalence of new onset sexual dysfunction in patients with surgically treated pelvic ring fractures. The results also suggest an association between sexual and urological dysfunction. This can help give prognostic information to patients and plan service provision.

The aims of this study were to review the management of open tibial fractures in our specialist ortho-plastic centre and to assess whether our practice concurred with the BAO/BAPS guidelines. A retrospective note review of patients with open tibial fractures was undertaken. Data was collected on time to referral to the plastic surgery unit and time to definitive soft tissue cover. Return of limb function was assessed using the Enneking score.

Forty five consecutive patients (27M vs. 18F), with an age range of 11–86 yrs (median age of 42 years), were treated using strict protocols. Seventeen cases were referred by the on-site orthopaedic unit, and 28 patients were from 7 neighbouring units. Time from injury to initial plastic surgery assessment ranged from 0 to 19 days, with a median of 4 days. Time from injury to definitive soft tissue cover ranged from 0 to 21, with a median of 5 days. 41/45 cases had definitive surgery within 5 days of initial plastics assessment. 5 patients with definitive treatment at days 4, 4, 7, 7, 12 developed superficial wound infection.

Patients referred from neighbouring units underwent on average 1 extra operation. We failed to detect any significant difference in return of function between the 2 groups indicating that referral to a specialist centre may produce equivalent functional return even if there is a delay in definitive treatment.

Open tibial fractures should be managed in a specialist centre, manned with dedicated lower limb plastic and orthopaedic reconstructive surgeons and followed up in a combined ortho-plastic clinic. However, more emphasis should be put on improved communication between referring units and the specialist centre.

We aimed to determine multi-modality outcomes in surgically treated patients with high energy pelvic ring injuries. A retrospective cohort study of all patients with pelvic ring fractures treated surgically within our specialist tertiary referral unit was undertaken between 1994 and 2007. Case-notes and radiographs were reviewed and patients were contacted by postal questionnaire. Outcome measures were return to work, return to pre-injury sports and social activities, and the Short Form-36 (SF-36) outcome tool. Injuries were classified using the Young and Burgess (YB) classifications.

There was a response rate of 70% (145 of 209 patients), 74% of the study subjects were male. Average age at injury was 40 yrs (16–74 yrs). Average follow up was 5.3 yrs (1–12 yrs). There were 45 Antero-Posterior Compression (APC) injuries, 51 Lateral Compression (LC) injuries and 49 Vertical Shear (VS) injuries. 58% of the APC injuries had returned to work (including changed roles at work), compared with 68% of the LC injuries and 51% of the VS injuries. 27% of the APC injuries had returned to their pre-injury sports, compared with 39% of the LC and 33% of the VS injuries. 64% of the APC injuries had returned to their pre-injury social activities compared with 77% of the LC and 49% of the VS injuries.

The SF-36 average Physical Functioning Score was better for the LC group (73.2) than the APC (61.7) and VS (63.3) groups. This general trend was repeated when the General Health and Social Functioning scores were reviewed.

These results illustrate the long-term morbidity associated with pelvic ring injuries and relationship with injury subtypes. The LC injuries appear to have better outcomes with all outcome measures than APC and VS injuries. Further studies are underway to look at other factors and their relationship to outcomes.

Controversy exists whether to treat unstable pertrochanteric hip fractures with either intramedullary or extramedullary devices. A prospective randomised control trial was performed to compare the outcome of unstable pertrochanteric hip fractures stabilised with either a sliding hip screw (SHS) or Long Gamma Nail (LGN). The hypothesis was that there is no difference in outcome between the two modes of treatment.

Over a four year period, 210 patients presenting with an unstable pertrochanteric hip fracture (AO/OTA 31 A2.1/A2.2/A2.3) were recruited into the study. Eligible patients were randomised on admission to either LGN or SHS. Follow-up was arranged for three, six, and twelve months. Primary outcome measures were implant failure and implant ‘cut-out’. Secondary measures included mortality, length of hospital stay, and EuroQol outcome score.

Five patients required revision surgery for implant cutout, of which three were LGNs and two were SHSs (no significant difference). There was a significant correlation between tip apex distance and the need for revision surgery. There were no incidences of implant failure or deep infection. Mortality rates between the two groups were similar when corrected for mini mental score. There was no difference between the two groups with respect to tip apex distance, hospital length of stay, blood transfusion requirement, and EuroQol outcome score.

The sliding hip screw remains the gold standard in the treatment of unstable pertrochanteric fractures of the proximal femur.

In January 2005, NICE published their guidelines on secondary prevention of osteoporotic fractures. This audit aims to assess our compliance with these in the outpatient setting.

The records of all new patients attending fracture clinic in a large teaching hospital, over a one month period, were reviewed. All patients who required screening or treatment for osteoporosis (females greater than 50 years old sustaining a fragility fracture) were reviewed at one year to assess compliance with the guidelines.

Of the 454 patients reviewed, 90 females over the age of 50 (19%) were identified. These were further subdivided into females between the age of 50 to 75 years (Group A, n=62) and those over 75 (Group B, n=28). The inclusion criteria was presence of a fragility fracture (Group A, n=30 and Group B, n=15). Group A was investigated with DEXA scans in only 26.7% (n=8). Of these, only six were managed as per NICE guidelines and compliant at one-year. Seven patients in Group B were subsequently treated with medical therapies, but only three were managed as per NICE guidelines and compliant. Therefore of the 45 patients included in the audit, only nine were managed appropriately at one-year (20%). One patient suffered a further fracture – who had been fully compliant with treatment.

NICE guidelines have been introduced to help the nation’s health using evidence based criteria. There has been no specific extra funding to enable the setting up of additional pathways and investigations for the targeted population. Even in a busy department where systems were implemented to follow the guidelines, the overall compliance with the pathway is less than a quarter. When new guidance is produced for healthcare, there should be advice, support and funding for their implementation.

Introduction: Injuries to the bony pelvis are a significant group of injuries with often serious implications. The close proximity of the bony pelvis to vital organs, it’s involvement in weight bearing and ambulation, and the high energy mechanisms usually required to produce these injuries produces a variety of injury patterns, associated injuries and possible outcomes.

Aims: To determine the long-term functional outcomes of displaced pelvic ring injuries treated surgically in the United Kingdom

Methods: All patients with pelvic ring fractures treated surgically were contacted by postal questionnaire. Outcomes were measured using the SF-36, as well as ad-hoc tools including return to work and sporting activities. Injuries were classified using the Young and Burgess (YB) classification system.

Results: There was a response rate of 70% (145 of 209 patients). Average age at injury was 40 yrs (16–74 yrs). Average follow up was 5.3yrs (1–12 yrs).

There were 45 Antero-Posterior Compression (APC) injuries, 51 Lateral Compression (LC) injuries and 49 Vertical Shear (VS) injuries.

69% of the LC injuries had returned to some form of employment, compared with 58% of the APC injuries and 51% of the VS. 39% of the LC injuries had returned to their pre-injury sporting activities, compared with 27% of the APC and 33% of the VS.

The average Physical Functioning Score of the SF-36 outcome tool was 73.2 for the LC injuries, 61.7 for the APC injuries and 63.3 for the VS injuries (scale 0–100, 100 representing best status). These trends were mirrored in the other outcome domains of the SF-36 tool.

Conclusions: These results illustrate the long-term morbidity associated with pelvic ring injuries and relationship with injury subtypes. LC injuries appeared to perform better than APC and VS injuries in all outcome measures utilized. These findings may aid in determining the prognosis and provision of services for patients with pelvic ring injuries.

Introduction: Posterior wall acetabular fractures are potentially difficult fractures to treat due to difficulties associated with the types of approach, reduction and fixation required. Spring plates are a method of maintaining such fractures reduced.

Aims: To assess the clinical and radiological outcome with spring plate fixation of posterior wall fractures.

Materials and Methods: From July 1993 to August 2004, 91 patients with 92 displaced posterior wall fractures underwent posterior wall fixation with one or more spring plates.

All patients were assessed postoperatively with a CT scan and annually for up to 5 years for a clinical and radiological assessment. Clinically patients were graded according to the Epstein modification of Merle D’Aubigne/ Postel Hip Score. The radiographs were graded using the Roentographic Grade criteria used by Matta.

Results: Patients were reviewed at a mean 44 month follow up.

At the time of operation 40% of fractures were reduced anatomically. There were 12 post operative complications.

Clinically excellent or good results were seen in 70% and radiologically in 68%. There were 11 revisions for osteonecrosis, infection and osteoarthritis.

There was a high correlation between the accuracy of the reduction and the subsequent prognosis.

Conclusion: Posterior wall fractures can be treated successfully by the use of spring plates. Clinical results correspond closely with radiological appearance. The accuracy of reduction correlates highly with the subsequent prognosis and we recommend routine postoperative CT scanning to identify misplaced metalwork and the accuracy of reduction to help predict prognosis.

We report the results of the use of the Long Gamma Nail in the treatment of complex proximal femoral fractures in our hospital.

All patients at one hospital treated with the Long Gamma Nail were reviewed. Information collected included the age, sex, type of injury, fracture classification, intra-operative complications, post-operative complications, and survival of the implant and patient.

One hundred nails were reviewed which were inserted in 97 patients. 70 patients were followed up for 1 month or more and their mean follow up was 8 months (range 3 months to 6 years). The mean age was 74 (range 16–98). Twenty were inserted into femurs with metastatic malignancy and four patients were victims of poly-trauma. The average length of the operation was 2 hours 22 minutes. Blood transfusion was required in 74% and on average was 2.5 units. There were 7 significant complications. Five patients underwent revision, 2 to Total Hip Arthroplasty after proximal screw migration and 2 patients required exchange nailing. There was one broken nail and two peri-prosthetic fractures at the tip of the nail.

Success was defined as achievement of stability of fracture until union or death; this was achieved in 15% of cases. The mortality was 7% at 30 days and 17% at one year. One death was directly related to the nail and the rest due to medical co-morbidities. Complication rate fell with increasing experience in the unit. The training of surgeons had no detrimental effect on outcome.

Complex proximal femoral fractures including pathological lesions, subtrochanteric fractures and pertrochanteric fractures with subtrochanteric extensions are difficult to treat, with all implants having high failure rates. The long gamma nail allows early weight bearing and seems effective in treating these difficult fractures. Furthermore the majority of these unstable fractures tend to occur in the very elderly with osteoporosis and other medical co-morbidity. Care should be taken to avoid malpositioning of the implant, as this was the major cause of failure and revision. The length of time surgery may take and the anticipated blood loss should not be underestimated especially when dealing with challenging fractures in frail and elderly patients or those with medical co-morbidity.

The Stoppa approach was originally conceived to deal with difficult abdominal hernia surgery. Its use has been modified to deal with Acetabular and Pelvic surgery. We report on our use of the Stoppa approach in 26 cases from 1998–2003 to fix Pelvic, Acetabular, and combined Pelvic/Acetabular fractures.

The Stoppa approach was used in combination with other approaches to afford the best access for fixation. 11 of the cases were Acetabular fractures with no pelvic ring disruption (42.3%), 4 cases (15.3%) were pelvic ring disruptions without an Acetabular component. The other 11 cases (42.3%) were combined Pelvic and Ace-tabular fractures where this approach came into its own. In particular it is to be noted that the Corona Mortis was easily identifiable in 5 (19.2%) of the cases to allow its safe ligation.

The anatomy of the approach and the access afforded are considered, along with the plating techniques that can be achieved because of its use.

Patients were followed up for an average of 17.39 months with one lost to follow up. Clinical results were excellent in 20 cases, good in 2, fair in 2, and poor in 1.

Complications were lateral femoral cutaneous nerve palsy in 11 patients, 1 bladder rupture, 2 superficial wound infections, one lateral incisional hernia related to an ilioinguinal approach, and 1 deep vein thrombosis. Heterotopic Ossification occurred in 3 patients in whom the Kocher-Langenbeck approach was used. One revision for screw proximity to the joint was undertaken.

The Stoppa approach allows safe access and ease of reduction and fixation in these complex fractures, in combination with other approaches, particularly in combined pelvic and Acetabular fractures. We outline our recommendations for its use in this paper and outline a series of fracture patterns where it is most helpful.