Purpose: Displaced acetabular fractures require operative intervention for optimal results. Obesity and morbid obesity is becoming more prevalent. Morbid obesity is defined as a body-mass index (BMI) > 40. The purpose of this investigation is to evaluate the early results of operative treatment of acetabular fractures in morbidly obese patients.

Method: A prospectively gathered database demonstrated 349 patients who underwent ORIF for acetabular fractures over a 60 month period. Of those patients, 39 were morbidly obese. Patient weights were collected from anesthesia records. There were 15 posterior wall, 10 transverse/posterior wall, 5 T-type, 3 transverse, 3 anterior column/posterior hemi-transverse, 1 anterior column, 1 posterior column/posterior wall, and 1 both column fractures. Early results of morbidly obese patients (Group 1) were reviewed. Perioperative complications were compared to patients with BMI < 40 (Group 2). Factors evaluated were: estimated blood loss, operative time, length of hospital stay, and overall complication rate (as defined by wound complications or heterotopic ossification requiring subsequent surgery, failure of fixation, nerve palsy, death).

Results: Follow up ranged from 6–48 months. Fracture reductions were perfect in 23, imperfect in 10, and poor in 6. Fixation failure was noted in 9 patients and typically associated with comminuted posterior wall fractures. Eight patients developed deep infections necessitating debridements. Nine patients required secondary surgery for wound healing problems. Of those, 6 required one additional surgery, three required 2, two required 3, one required 5, and one required 12 additional surgeries. Six patients proceeded to THA and two of those required revisions. The average EBL was 903cc in group 1 versus 630cc in group 2 (p < 0.044). Operative time averaged 293 minutes in group 1 versus 250 in group 2 (p< 0.008). Hospital stay for group 1 averaged 26 days versus 15 days in group 2 (p< 0.008). Complication rate for group 1 was 67% versus 16% in group 2.

Conclusion: This data shows that there is a significant increase in estimated blood loss, operative time, and length of hospital stay. Moreover, the risk of complications should be heavily weighed prior to operative intervention

Purpose: Treatment of complex diaphyseal malunions is challenging. It requires extensive preoperative planning and precise operative technique. A single technique has not been generalizable secondary to the limitations of each type of osteotomy. A simpler method was developed to manage these deformities.

Method: Ten patients with complex diaphyseal mal-unions (4 femoral, 6 tibial) underwent a clamshell osteotomy. Indications for surgery included pain at adjacent joints and deformity. Preoperative evaluation included deformity characterization. The malunited segment was identified on biplanar radiographs. After exposure the malunited segment was transected perpendicular to the normal diaphysis proximally and distally. The transected segment was again osteotomized about its long axis and wedged open with a lamina spreader, similar to opening a clamshell. The surgical approach was sealed to retain the subsequent reamings. The proximal and distal segments of the diaphysis were aligned using the intramedullary nail as an anatomic axis template and the opposite extremity as a length and rotation template. Partial weight-bearing mobilization with crutches began immediately and progressed based on clinical and radiographic evaluation. Followup ranged from 6–52 months.

Results: Radiographic angular corrections were complete in each case and ranged from 2–20 degrees in the coronal plane, 0–32 degrees in the sagittal plane, and 0–25 degrees in the axial plane (rotation). Correction of length ranged from 0–5 centimeters, restoring leg length to within 2 centimeters in all cases. All osteotomies were healed both clinically and radiographically by 6 months. All patients were ambulatory without assistive devices by the time of the most recent followup.

Conclusion: The proposed osteotomy provides a generalizable way to correct many forms of diaphyseal mal-unions by acting as a bypass in realigning the anatomic axis of the long bone using a reamed intramedullary nail as a template.

Of 110 consecutive open tibial fractures 90 were reviewed and analysed retrospectively with particular reference to wound closure, method of stabilisation, infection rate and the incidence of non-union. There were 41% Gustilo type I, 39% type II and 20% type III injuries. The incidence of deep infection was 20% after primary wound closure compared with 3% after delayed closure, and eight of the nine non-unions followed primary closure. We conclude that primary wound closure should be avoided in the treatment of open tibial fractures.

1. The phosphonates are simple chemical compounds containing P-C-P bonds which are resistant to the action of naturally occurring phosphatases and pyrophosphatases. They inhibit the formation and dissolution of apatite crystals in vitro and prevent ectopic mineralisation and bone resorption in animals.

2. In man one diphosphonate (EHDP) has been shown to reduce the excessive turnover of bone in Paget's disease and also appears to slow the mineralisation of ectopic bone matrix in myositis ossificans progressiva.

3. The possible uses of the diphosphonates in bone disorders with excessive resorption and in ectopic mineralisation are being further investigated.