Aims. Minimally invasive fixation of pelvic fragility fractures is recommended to reduce pain and allow early mobilization. The purpose of this study was to evaluate the outcome of two different stabilization techniques in bilateral fragility fractures of the sacrum (BFFS). Methods. A non-randomized, prospective study was carried out in a level 1 trauma centre. BFFS in 61 patients (mean age 80 years (SD 10); four male, 57 female) were treated surgically with bisegmental transsacral stablization (BTS; n = 41) versus spinopelvic fixation (SP; n = 20). Postoperative full weightbearing was allowed. The outcome was evaluated at two timepoints: discharge from inpatient treatment (TP1; Fitbit tracking, Zebris stance analysis), and ≥ six months (TP2; Fitbit tracking, Zebris analysis, based on modified Oswestry Disability Index (ODI), Majeed Score (MS), and the 12-Item Short Form Survey 12 (SF-12). Fracture healing was assessed by CT. The primary outcome parameter of functional recovery was the per-day step count; the secondary parameter was the subjective outcome assessed by questionnaires. Results. Overall, no baseline differences were observed between the BTS and SP cohorts. In total, 58 (BTS = 19; SP = 39) and 37 patients (BTS = 14; SP = 23) could be recruited at TP1 and TP2, respectively. Mean steps per day at TP1 were median 308 (248 to 434) in the BTS group and 254 (196 to 446) in the SP group. At TP2, median steps per day were 3,759 (2,551 to 3,926) in the BTS group and 3,191 (2,872 to 3,679) in the SP group, each with no significant difference. A significant improvement was observed in each group (p < 0.001) between timepoints. BTS patients obtained better results than SP patients in ODI (p < 0.030), MS (p = 0.007), and SF-12 physical status (p = 0.006). In all cases, CT showed sufficient fracture healing of the posterior ring. Conclusion. Both groups showed significant outcome improvement and sufficient fracture healing. Both techniques can be recommended for BFFS, although BTS was superior with respect to subjective outcome. Step-count tracking represents a reliable method to evaluate the mobility level. Cite this article: Bone Joint J 2021;103-B(3):462–468

Coronal plane fractures of the posterior femoral condyle, also known as Hoffa fractures, are rare. Lateral fractures are three times more common than medial fractures, although the reason for this is not clear. The exact mechanism of injury is likely to be a vertical shear force on the posterior femoral condyle with varying degrees of knee flexion. These fractures are commonly associated with high-energy trauma and are a diagnostic and surgical challenge. Hoffa fractures are often associated with inter- or supracondylar distal femoral fractures and CT scans are useful in delineating the coronal shear component, which can easily be missed. There are few recommendations in the literature regarding the surgical approach and methods of fixation that may be used for this injury. Non-operative treatment has been associated with poor outcomes. The goals of treatment are anatomical reduction of the articular surface with rigid, stable fixation to allow early mobilisation in order to restore function. A surgical approach that allows access to the posterior aspect of the femoral condyle is described and the use of postero-anterior lag screws with or without an additional buttress plate for fixation of these difficult fractures.

Cite this article: Bone Joint J 2013;95-B:1165–71.

Techniques for fixation of fractures of the lateral malleolus have remained essentially unchanged since the 1960s, but are associated with complication rates of up to 30%. The fibular nail is an alternative method of fixation requiring a minimal incision and tissue dissection, and has the potential to reduce the incidence of complications.

We reviewed the results of 105 patients with unstable fractures of the ankle that were fixed between 2002 and 2010 using the Acumed fibular nail. The mean age of the patients was 64.8 years (22 to 95), and 80 (76%) had significant systemic medical comorbidities. Various different configurations of locking screw were assessed over the study period as experience was gained with the device. Nailing without the use of locking screws gave satisfactory stability in only 66% of cases (4 of 6). Initial locking screw constructs rendered between 91% (10 of 11) and 96% (23 of 24) of ankles stable. Overall, seven patients had loss of fixation of the fracture and there were five post-operative wound infections related to the distal fibula. This lead to the development of the current technique with a screw across the syndesmosis in addition to a distal locking screw. In 21 patients treated with this technique there have been no significant complications and only one superficial wound infection. Good fracture reduction was achieved in all of these patients. The mean physical component Short-Form 12, Olerud and Molander score, and American Academy of Orthopaedic Surgeons Foot and Ankle outcome scores at a mean of six years post-injury were 46 (28 to 61), 65 (35 to 100) and 83 (52 to 99), respectively. There have been no cases of fibular nonunion.

Nailing of the fibula using our current technique gives good radiological and functional outcomes with minimal complications, and should be considered in the management of patients with an unstable ankle fracture.

We carried out a retrospective review of 47 intra-articular fractures of the calcaneum treated by open reduction and internal fixation in 45 patients by a single surgeon between 1993 and 2001. The fractures were evaluated before operation by plain radiographs and a CT scan using Sanders’ classification. Osteosynthesis involved a lateral approach and the use of the AO calcaneal plate. The mean follow-up was for ten years (7 to 15). Clinical assessment included the American Orthopaedic Foot and Ankle Society Score (AOFAS), the Creighton-Nebraska Score, the Kerr, Prothero, Atkins Score and the SF-36 Health Questionnaire. The radiological evaluation consisted of lateral and axial views of the os calcis. Arthritic changes in the subtalar joint were assessed with an internal oblique view and were graded using the Morrey and Wiedeman scale.

There were 18 excellent (38.3%), 17 good (36.2%), three fair (6.3%) and nine poor (19.2%) results. Five patients had a superficial wound infection and five others eventually had a subtalar arthrodesis because of continuing pain. Restoration of Böhler’s angle was associated with a better outcome. The degree of arthritic change in the subtalar joint did not correlate with the outcome scores or Sanders’ classification. Prompt osteosynthesis should be considered for intra-articular fractures of the calcaneum in order to restore the shape of the hindfoot and Böhler’s angle.