Aims. Fractures of the distal femur are an important cause of morbidity. Their optimal management remains controversial. Contemporary implants include angular-stable anatomical locking plates and locked intramedullary nails (IMNs). We compared the long-term patient-reported functional outcome of fixation of fractures of the distal femur using these two methods of treatment. Patients and Methods. A total of 297 patients were retrospectively identified from a State-wide trauma registry in Australia: 195 had been treated with a locking plate and 102 with an IMN. Baseline characteristics of the patients and their fractures were recorded. Health-related quality-of-life, functional and radiographic outcomes were compared using mixed effects regression models at six months and one year. Results. There was a clinically relevant and significant difference in quality-of-life at six months in favour of fixation with an IMN (mean difference in EuroQol-5 Dimensions Score (EQ-5D) = 0.12; 95% CI 0.02 to 0.22; p = 0.025). There was weak evidence that this trend continued to one year (mean difference EQ-5D = 0.09; 95% CI -0.01 to 0.19; p = 0.073). There was a significant although very small reduction in angular deformity using an IMN (mean difference -1.02; 95% CI -1.99 to -0.06; p = 0.073). There was no evidence that there was a difference in any other outcomes at any time point. Take home message: IMN may be a superior treatment compared with anatomical locking plates for fractures of the distal femur. These findings are concordant with other data from pilot randomised studies which favour treatment of these fractures with an IMN. This study strongly supports the need for a definitive randomised trial. Cite this article: Bone Joint J 2016;98-B:846–50

Aims. This study reviews the use of a titanium mesh cage (TMC) as an adjunct to intramedullary nail or plate reconstruction of an extra-articular segmental long bone defect. Patients and Methods. A total of 17 patients (aged 17 to 61 years) treated for a segmental long bone defect by nail or plate fixation and an adjunctive TMC were included. The bone defects treated were in the tibia (nine), femur (six), radius (one), and humerus (one). The mean length of the segmental bone defect was 8.4 cm (2.2 to 13); the mean length of the titanium mesh cage was 8.3 cm (2.6 to 13). The clinical and radiological records of the patients were analyzed retrospectively. Results. The mean time to follow-up was 55 months (12 to 126). Overall, 16 (94%) of the patients achieved radiological filling of their bony defect and united to the native bone ends proximally and distally, resulting in a functioning limb. Complications included device failure in two patients (12%), infection in two (12%), and wound dehiscence in one (6%). Four patients (24%) required secondary surgery, four (24%) had a residual limb-length discrepancy, and one (6%) had a residual angular limb deformity. Conclusion. A titanium mesh cage is a useful adjunct in the treatment of an extra-articular segmental defect in a long bone. Cite this article: Bone Joint J 2018;100-B:646–51

Aims

The aim of this study was to assess the safety and clinical outcome of patients with a femoral shaft fracture and a previous complex post-traumatic femoral malunion who were treated with a clamshell osteotomy and fixation with an intramedullary nail (IMN).

We re-examined clinically and radiologically 88 patients with a fracture of the lower leg at a mean follow-up of 15 years. Forty-three fractures (49%) had healed with malalignment of at least 5°. More arthritis was found in the knee and ankle adjacent to the fracture than in the comparable joints of the uninjured leg. Malaligned fractures showed significantly more degenerative changes. Eighteen patients (20%) had symptoms in the fractured leg. There was a significant correlation between symptoms in the knee and arthritis but not between symptoms and ankle arthritis or malalignment. We conclude that fractures of the lower leg should be managed so that the possibility of angular deformity and thereby late arthritis is minimised

Aims

Open reduction and plate fixation (ORPF) for displaced proximal humerus fractures can achieve reliably good long-term outcomes. However, a minority of patients have persistent pain and stiffness after surgery and may benefit from open arthrolysis, subacromial decompression, and removal of metalwork (ADROM). The long-term results of ADROM remain unknown; we aimed to assess outcomes of patients undergoing this procedure for stiffness following ORPF, and assess predictors of poor outcome.

Aims

Fractures of the distal femur can be challenging to manage and are on the increase in the elderly osteoporotic population. Management with casting or bracing can unacceptably limit a patient’s ability to bear weight, but historically, operative fixation has been associated with a high rate of re-operation. In this study, we describe the outcomes of fixation using modern implants within a strategy of early return to function.

We report on the use of the Ilizarov method to treat 40 consecutive fractures of the tibial shaft (35 AO 42C fractures and five AO 42B3 fractures) in adults. There were 28 men and 12 women with a mean age of 43 years (19 to 81). The series included 19 open fractures (six Gustilo grade 3A and 13 grade 3B) and 21 closed injuries. The mean time from injury to application of definitive Ilizarov frame was eight days (0 to 35) with 36 fractures successfully uniting without the need for any bone-stimulating procedure. The four remaining patients with nonunion healed with a second frame. There were no amputations and no deep infections. None required intervention for malunion. The total time to healing was calculated from date of injury to removal of the frame, with a median of 166 days (mean 187, (87 to 370)). Minor complications included snapped wires in two patients and minor pin-site infections treated with oral antibiotics in nine patients (23%). Clinical scores were available for 32 of the 40 patients at a median of 55 months (mean 62, (26 to 99)) post-injury, with ‘good’ Olerud and Molander ankle scores (median 80, mean 75, (10 to 100)), ‘excellent’ Lysholm knee scores (median 97, mean 88, (29 to 100)), a median Tegner activity score of 4 (mean 4, (0 to 9)) (comparable to ‘moderately heavy labour / cycling and jogging’) and Short Form-12 scores that exceeded the mean of the population as a whole (median physical component score 55 (mean 51, (20 to 64)), median mental component score 57 (mean 53, (21 to 62)). In conclusion, the Ilizarov method is a safe and reliable way of treating complex tibial shaft fractures with a high rate of primary union.

We reviewed the clinical details and radiographs of 52 patients with ballistic fractures of the femur admitted to the International Committee of the Red Cross Hospital in Kenya (Lopiding), who had sustained injuries in neighbouring Sudan. In all cases there had been a significant delay in the initial surgery (> 24 hours), and all patients were managed without stabilisation of the fracture by internal or external fixation.

Of the 52 patients, three required an amputation for persisting infection of the fracture site despite multiple debridements. A further patient was treated by an excision arthroplasty of the hip, but this was carried out at the initial operation as a part of the required debridement.

All of the remaining 48 fractures healed. Four patients needed permanent shoe adaptation because of limb shortening of functional significance.

Although we do not advocate delaying treatment or using traction instead of internal or external fixation, we have demonstrated that open femoral fractures can heal despite limited resources.

Recent reports have suggested that a delay in the management of type-III supracondylar fractures of the humerus does not affect the outcome. In this retrospective study we examined whether the timing of surgery affected peri-operative complications, or the need for open reduction. There were 171 children with a closed type-III supracondylar fracture of the humerus and no vascular compromise in our study. They were divided into two groups: those treated less than eight hours from presentation to the Accident and Emergency Department (126 children), and those treated more than eight hours from presentation (45 children). There were no differences in the rate of complications between the groups, but children waiting more than eight hours for reduction were more likely to undergo an open reduction (33.3% vs 11.2%, p < 0.05) and there was a weak correlation (p = 0.062) between delay in surgery and length of operating time. Consequently, we would still recommend treating these injuries at the earliest opportunity.

As there is little information on the factors that influence fracture union following intramedullary nailing of the tibia we retrospectively investigated patient-, injury- and treatment-related factors in 161 patients with closed or grade I open fractures of the tibial diaphysis. The patients were reviewed until clinical and radiological evidence of union at a mean of 13.3 months (4 to 60). Multivariate statistical analysis using a Cox proportional hazards model showed that the risk of failure of union increased by 2.38 times for highly comminuted fractures, by 3.14 times when nail dynamisation was applied, and by 1.65 times when the locking screws failed. In fractures with no or only minimal comminution the risk of nonunion increased if the post-reduction gap was ≥ 3 mm.

Fractures of the distal radius occurring in young adults are treated increasingly by open surgical techniques, partly because of concern that failure to restore the alignment of the fracture accurately may cause symptomatic post-traumatic osteoarthritis in future years. We reviewed 106 adults who had sustained a fracture of the distal radius between 1960 and 1968 and who were below the age of 40 years at the time of injury. We carried out a clinical and radiological assessment at a mean follow-up of 38 years (33 to 42).

No patient had required a salvage procedure. While there was radiological evidence of post-traumatic osteoarthritis after an intra-articular fracture in 68% of patients (27 of 40), the disabilities of the arm, shoulder and hand (DASH) scores were not different from population norms, and function, as assessed by the Patient Evaluation Measure, was impaired by less than 10%. Ordinal logistic regression analysis showed a significant relationship between narrowing of the joint space and extra-articular malunion (dorsal angulation and radial shortening) as well as intra-articular injury. Multivariate analysis revealed that grip strength had fallen to 89% of that of the uninjured side in the presence of dorsal malunion, but no measure of extra-articular malunion was significantly related to either the Patient Evaluation Measure or DASH scores.

While anatomical reduction is the principal aim of treatment, imperfect reduction of these fractures may not result in symptomatic arthritis in the long term, and this should be considered when counselling patients on the risks and benefits of the many treatment options available.

A total of 179 adult patients with displaced intra-articular fractures of the distal radius was randomised to receive indirect percutaneous reduction and external fixation (n = 88) or open reduction and internal fixation (n = 91). Patients were followed up for two years. During the first year the upper limb musculoskeletal function assessment score, the SF-36 bodily pain sub-scale score, the overall Jebsen score, pinch strength and grip strength improved significantly in all patients. There was no statistically significant difference in the radiological restoration of anatomical features or the range of movement between the groups.

During the period of two years, patients who underwent indirect reduction and percutaneous fixation had a more rapid return of function and a better functional outcome than those who underwent open reduction and internal fixation, provided that the intra-articular step and gap deformity were minimised.