Objectives. The aim of this study was to compare the biomechanical stability and clinical outcome of external fixator combined with limited internal fixation (EFLIF) and open reduction and internal fixation (ORIF) in treating Sanders type 2 calcaneal fractures. Methods. Two types of fixation systems were selected for finite element analysis and a dual cohort study. Two fixation systems were simulated to fix the fracture in a finite element model. The relative displacement and stress distribution were analysed and compared. A total of 71 consecutive patients with closed Sanders type 2 calcaneal fractures were enrolled and divided into two groups according to the treatment to which they chose: the EFLIF group and the ORIF group. The radiological and clinical outcomes were evaluated and compared. Results. The relative displacement of the EFLIF was less than that of the plate (0.1363 mm to 0.1808 mm). The highest von Mises stress value on the plate was 33% higher than that on the EFLIF. A normal restoration of the Böhler angle was achieved in both groups. No significant difference was found in the clinical outcome on the American Orthopedic Foot and Ankle Society Ankle Hindfoot Scale, or on the Visual Analogue Scale between the two groups (p > 0.05). Wound complications were more common in those who were treated with ORIF (p = 0.028). Conclusions. Both EFLIF and ORIF systems were tested to 160 N without failure, showing the new construct to be mechanically safe to use. Both EFLIF and ORIF could be effective in treating Sanders type 2 calcaneal fractures. The EFLIF may be superior to ORIF in achieving biomechanical stability and less blood loss, shorter surgical time and hospital stay, and fewer wound complications. Cite this article: M. Pan, L. Chai, F. Xue, L. Ding, G. Tang, B. Lv. Comparisons of external fixator combined with limited internal fixation and open reduction and internal fixation for Sanders type 2 calcaneal fractures: Finite element analysis and clinical outcome. Bone Joint Res 2017;6:433–438. DOI: 10.1302/2046-3758.67.2000640

Introduction. There is no doubt that the future of limb lengthening lies with internal lengthening. Complication rates are reduced and patient satisfaction is increased. The evolution of internal lengthening peaked with the dual direction, easily inserted and externally controlled PRECICE Nail. It has excelled in performance in accuracy and satisfaction. Its versatility increased with smaller sizes and increased excursion. A field safety notice was issued was issued in October 2021 by the parent company NuVasive. The advice was monitoring of current cases and a hold on implantation until after a review of process. At the National Orthopaedic Hospital Cappagh we elected to remove all implanted nails and assess the nail integrity and physiological changes associated with implantation. Materials & Methods. All patients in who a retained Precice nail at the time of the field safety notice were identified. Patients and families were contacted to explain the issued safety notice from the company and explain that we would be scheduling them for nail removal. This was part of our standard care but we prioritised this group on our waiting list. Consent was obtained for nail removal but also for histological assessment of canal scrapings, blood ion level analysis and independent assessment of the retrieved nail by our academic collaborators at University College Dublin. Ion levels were then repeated at an interval post removal with consent. Results. We identified 7 Precice nails in 5 patients still implanted. All patients had consolidated after lengthening and were ready for nail removal. Elevated Titanium blood ion levels were identified at the time of retrieval. Histological abnormalities consistent with metalosis were identified. In all cases the nail was grossly intact and examination of the motor showed no evidence of wear or failure. Follow up ion levels obtained post retrieval showed persistent elevation. Conclusions. Our retrieval audit shows persistent elevation of Titanium ion levels and abnormal histology despite apparent nail integrity. These findings require further evaluation in a larger retrieval series to determine if there is a high incidence of this phenomenon and if ion levels have a clinical effect

Implant manufacturers develop new products to improve existing fracture fixation methods or to approach new fracture challenges. New implants are commonly tested and approved with respect to their corresponding predecessor products, because the knowledge about the internal forces and moments acting on implants in the human body is unclear. The aim of this study was to evaluate and validate implant internal forces and moments of a complex physiological loading case and translate this to a standard medical device approval test. A finite elements model for a transverse femur shaft fracture (AO/OTA type 32-B2) treated with a locked plate system (AxSOS 3 Ti Waisted Compression Plate Broad, Stryker, Kalamazoo, USA) was developed and experimentally validated. The fractured construct was physiologically loaded by resulting forces on the hip joint from previously measured in-vivo loading experiments (Bergmann et. al). The forces were reduced to a level where the material response in the construct remained linear elastic. Resulting forces, moments and stresses in the implant of the fractured model were analysed and compared to the manufacturers’ approval data. The FE-model accurately predicted the behaviour of the whole construct and the micro motion of the working length of the osteosynthesis. The resulting moment reaction in the working length was 24 Nm at a load of 400 N on the hip. The maximum principle strains on the locking plate were predicted well and did not exceed 1 %. In this study we presented a protocol by the example of locked plated femur shaft fracture to calculate and validate implant internal loading using finite element analysis of a complex loading. This might be a first step to move the basis of development of new implants from experience from previous products to calculation of mechanical behaviour of the implants and therefore, promote further optimization of the implants’ design

Poor availability of allografts in South Africa has led to an increased use of synthetic augmentation to stabilize knee joints in the treatment of knee dislocations. This study aims to evaluate multiligament knee injuries treated with a posterior cruciate ligament internal brace. The study included patients with knee dislocations who were treated with a PCL internal brace. The internal brace involved the insertion of a synthetic suture tape, which was drilled into the femoral and tibial footprint. Chronic injuries were excluded. Patient-reported outcome scores (PROMs), range of motion, stress X-Rays, and MRI scans were reviewed to assess outcomes. Acceptable outcomes were defined as a Lysholm score of 84 or more, with grade II laxity in no more than one ligament and a range of motion from full extension to 90° or more. The study included eight patients, with a median age of 42, of which five were female. None of the patients had knee flexion less than 90° or an extension deficit of more than 20°. PROMs indicated acceptable outcomes (EQ5D, Tegner Lysholm). Stress radiographs showed less than 7mm (Grade I) of posterior translation laxity in all patients. Four patients underwent MRI scans 1–2 years after the initial surgery, which revealed healing of the PCL in all patients. However, increased signal in a continuous ligament suggested only partial healing in two patients. Tunnel widening of 200% and 250% was noted around the tibial and femoral PCL footprints, respectively. All patients demonstrated stable knees and acceptable PROMs. Tunnel widening was observed in all patients who had MRI scans. Factors such as suspensory fixation, anisometric tunnel position, and the absence of PCL tear repair may have contributed to the tunnel widening

Aims. Lower limb fractures are common in low- and middle-income countries (LMICs) and represent a significant burden to the existing orthopaedic surgical infrastructure. In high income country (HIC) settings, internal fixation is the standard of care due to its superior outcomes. In LMICs, external fixation is often the surgical treatment of choice due to limited supplies, cost considerations, and its perceived lower complication rate. The aim of this systematic review protocol is identifying differences in rates of infection, nonunion, and malunion of extra-articular femoral and tibial shaft fractures in LMICs treated with either internal or external fixation. Methods. This systematic review protocol describes a broad search of multiple databases to identify eligible papers. Studies must be published after 2000, include at least five patients, patients must be aged > 16 years or treated as skeletally mature, and the paper must describe a fracture of interest and at least one of our primary outcomes of interest. We did not place restrictions on language or journal. All abstracts and full texts will be screened and extracted by two independent reviewers. Risk of bias and quality of evidence will be analyzed using standardized appraisal tools. A random-effects meta-analysis followed by a subgroup analysis will be performed, given the anticipated heterogeneity among studies, if sufficient data are available. Conclusion. The lack of easily accessible LMIC outcome data, combined with international clinical guidelines that are often developed by HIC surgeons for use in HIC environments, makes the clinical decision-making process infinitely more difficult for surgeons in LMICs. This protocol will guide research on surgical management, outcomes, and complications of lower limb shaft fractures in LMICs, and can help guide policy development for better surgical intervention delivery and improve global surgical care. Cite this article: Bone Jt Open 2024;5(11):1020–1026

The management of femoral bone loss is challenging during revision hip arthroplasty. In patients with Paprosky grade IIIB and IV defects, obtaining fixation and rotational stability using traditional surgical constructs is difficult. The use of a custom-made internal proximal femoral replacement prostheses has been proposed as a solution in patients, with severe femoral bone stock loss. However, there is a paucity in the literature on their use and long-term outcomes. We report on the clinical and radiological results of our cohort. We retrospectively reviewed all patients who underwent internal proximal femoral replacement for revision hip arthroplasty between April 1996 and April 2019. All patients had at least 2 years of follow-up time. 160 patients underwent limb salvage at our institution using internal proximal femoral replacement. The mean follow-up was 79.7 months (S.D 41.3). Indications for revision included periprosthetic fractures, aseptic loosening, and deep infection. The mean Oxford hip score increased from 13.8 (0–22) to 31.5 (18–43) (paired t-test, p < 0.001). Kaplan-Meier prosthesis survival analysis with revision as the endpoint was 87% at 5 years. None required revision of the femoral stem. There were four dislocations (5%) and there was failure to eradicate the deep infection in four. This technique allows instant distal fixation, allowing for early mobilisation. Long-term clinical and radiological outcomes are encouraging and the complication rates are acceptable for this patient group

Shoulder movements from neutral into flexion, extension, abduction, adduction and external rotation are easily measured with a goniometer. In the neutral position, the glenohumeral ligaments, which act as the reins of the joint, limit movement and are symmetrically relaxed. The torso obstructs internal rotation with the arm adducted at the side and the full range of movement cannot be attained. The torso is cleared when the shoulder is abducted, usually to 90°. However, this degree of abduction places the shoulder within the painful arc of impingement and may influence the degree of internal rotation. Further, owing to shoulder joint stiffness, some patients may not be able to abduct the shoulder to 90°. Because of these problems, it has become internationally accepted to measure internal rotation in the near-neutral position by determining the vertebral level behind the back to which the thumb can reach. We assessed 200 symptomatic and asymptomatic shoulders to determine the correlation between the ‘hand behind back’ and angular measurements of internal rotation at 90° or 30° of abduction

Introduction. Circular external fixators are fundamental to lower limb reconstruction, primarily in situations with a high risk of infection such as open fractures. During the Covid-19 pandemic, use of circular frames in our unit decreased, following departmental approval, due to resource management and in keeping with BOA guidelines as we opted to “consider alternative techniques for patients who require soft tissue reconstruction to avoid multiple operations”. These alternatives included the use of internal fixation (plate osteosynthesis and intramedullary nailing) as a measure to reduce the number of hospital attendances for patients and to conserve resources. This change in practice has continued in part following the pandemic with the increased use of internal fixation in cases previously deemed unsuitable for such techniques. We present our experience of this treatment strategy in the management of complex lower limb injuries, focusing on outcomes and consider the lessons learnt. Materials & Methods. Data of patients with complex lower limb injuries treated before, during and after the pandemic were collected from our in-house trauma database, theatre records and follow up clinics. The rationale for choosing other techniques over a circular frame, the type of alternative technique used, the cost of such alternatives, the need for soft tissue reconstruction, time to recovery, complications and amputation rates were compared among groups. Results. These data suggest comparable outcomes between circular frames and alternative techniques can be achieved. A notable reduction in the number of circular frames applied during the review period was observed. Furthermore, frame fixation was associated with more frequent outpatient review and the associated implications for resource management. Conclusions. Conclusion: The Covid-19 pandemic has posed great challenges to the Trauma and Orthopaedic community, forcing us to be flexible by adopting alternative treatment methods to traditional circular external fixation. These alternatives have proven feasible and potentially more cost effective, prompting their adoption in the post pandemic era. However, this change of practice is not without potential consequences and continued investigation is warranted

Introduction. Acute ankle injuries are commonly seen in musculoskeletal practice. Surgical management is the gold standard for lateral ligament injury in those with failed conservative treatment for a minimum of six months. Several studies have shown good functional outcome and early rehabilitation after MBG repair with an internal brace augmentation which is a braided ultrahigh molecular weight polyethylene ligament used to enhance the repair that acts as a secondary stabiliser. Hence the aim of the study was to compare the results with and without augmentation. Methods. A single centre retrospective review conducted between November 2017 and October 2019 and this included 172 patients with symptomatic chronic lateral ligament instability with failed conservative management. The diagnosis was confirmed by MRI. All patients had an ankle arthroscopy followed by open ligament repair. Patients were grouped into isolated MBG and internal brace groups for analyses and all had dedicated rehabilitation. Results. A total of 148 patients were available for final follow up with 87 patients in the MBG group and 61 patients in the IBA group. Mean Age was 38 years and mean follow up was 22 months. The internal brace group showed better Manchester Oxford foot and ankle score (19.7 vs 18.2) and more patients returning to preinjury activity levels (73 vs 55) as compared to isolated repair. Conclusion. Internal brace augmentation with MBG repair facilitated early rehabilitation and return to pre injury activity level in majority of patients compared to isolated MBG repair

Aims. In contrast to operations performed for other fractures, there is a high incidence rate of surgical site infection (SSI) post-open reduction and internal fixation (ORIF) done for tibial plateau fractures (TPFs). This study investigates the effect of induced membrane technique combined with internal fixation for managing SSI in TPF patients who underwent ORIF. Methods. From April 2013 to May 2017, 46 consecutive patients with SSI post-ORIF for TPFs were managed in our centre with an induced membrane technique. Of these, 35 patients were included for this study, with data analyzed in a retrospective manner. Results. All participants were monitored for a mean of 36 months (24 to 62). None were subjected to amputations. A total of 21 patients underwent two-stage surgeries (Group A), with 14 patients who did not receive second-stage surgery (Group B). Group A did not experience infection recurrence, and no implant or cement spacer loosening was noted in Group B for at least 24 months of follow-up. No significant difference was noted in the Lower Extremity Functional Scale (LEFS) and the Hospital for Special Surgery Knee Score (HSS) between the two groups. The clinical healing time was significantly shorter in Group B (p＜0.001). Those with longer duration of infection had poorer functional status (p＜0.001). Conclusion. Management of SSI post-ORIF for TPF with induced membrane technique combined with internal fixation represents a feasible mode of treatment with satisfactory outcomes in terms of infection control and functional recovery. Cite this article: Bone Joint Res 2021;10(7):380–387

The incidence of hip fractures in the elderly is increasing. Minimally displaced and un-displaced hip fractures can be treated with either internal fixation or hemiarthroplasty. The aim was identifying the revision rate of internal fixation and hemiarthroplasty in patients 60 years or older with Garden I or II hip fractures and to identify risk factors associated with each method. A retrospective analysis was conducted from 2 Major Trauma Centres and 9 Trauma Units between 01/01/2015 and 31/12/2020. Patients managed conservatively, treated with a total hip replacement and missing data were excluded from the study. 1273 patients were included of which 26.2% (n=334) had cannulated hip fixation (CHF), 19.4% (n=247) had a dynamic hip screw (DHS) and 54.7% (n=692) had a hemiarthroplasty. 66 patients in total (5.2%) required revision surgery. The revision rates for CHF, DHS and hemiarthroplasty were 14.4%, 4%, 1.2% (p<0.001) respectively. Failed fixation was the most common reason for revision with the incidence increasing by 7-fold in the CHF group [45.8% (n=23) vs. 33.3% (n=3) in DHS; p<0.01]. The risk factors identified for CHF revision were age >80 (p<0.05), female gender (p<0.05) and smoking (p<0.05). The average length of hospital stay was decreased when using CHF compared to DHS and hemiarthroplasty (12.6 days vs 14.9 days vs 18.1 days respectively, p<0.001) and the 1 year mortality rate for CHF, DHS and hemiarthroplasty was 2.5%, 2% and 9% respectively. Fixation methods for Garden I and II hip fractures in elderly patients are associated with a higher revision rate than hemiarthroplasty. CHF has the highest revision rate at 14.4% followed by DHS and hemiarthroplasty. Female patients, patients over the age of 80 and patients with poor bone quality are considered high risk for fixation failure with CHF. When considering a fixation method in such patients, DHS is more robust than a screw construct, followed by hemiarthroplasty

Introduction. Ankle fractures in the elderly have been increasing with an ageing but active population and bring with them specific challenges. Medical co-morbidities, a poor soft tissue envelope and a requirement for early mobilisation to prevent morbidity and mortality, all create potential pitfalls to successful treatment. As a result, different techniques have been employed to try and improve outcomes. Total contact casting, both standard and enhanced open reduction internal fixation, external fixation and most recently tibiotalocalcaneal (TTC) nailing have all been proposed as suitable treatment modalities. Over the past five years popular literature has begun to herald TTC nailing as an appropriate and contemporary solution to the complex problem of high-risk ankle fragility fractures. We sought to assess whether, within our patient cohort, the outcomes seen supported the statement that TTC has equal outcomes to more traditional open reduction internal fixation (ORIF) when used to treat the high-risk ankle fragility fracture. Materials & Methods. Results of ORIF versus TTC nailing without joint preparation for treatment of fragility ankle fractures were evaluated via retrospective cohort study of 64 patients with high-risk fragility ankle fractures without our trauma centre. We aimed to assess whether results within our unit were equal to those seen within other published studies. Patients were matched 1:1 based on gender, age, Charlson Comorbidity Index (CCI) and ASA score. Patient demographics, AO/OTA fracture classification, intra-operative and post-operative complications, discharge destination, union rates, FADI scores and patient mobility were recorded. Results. There were 32 patients within each arm. Mean age was 78.4 (TTC) and 78.3 (ORIF). The CCI was 5.9 in each group respectively with mean ASA 2.9 (TTC) and 2.8 (ORIF). There were two open fractures within each group. Median follow up duration was 26 months. Time to theatre from injury was 8.0 days (TTC) versus 3.3 days (ORIF). There was no statistically significant difference in 30-day, one year or overall mortality at final follow up. Kaplan-Meier survivorship analysis did however demonstrate that of those patients who died post-operatively the mean time to mortality was significantly shorter in those treated with TTC nailing versus ORIF (20.3 months versus 38.2 months, p=0.013). There was no statistical difference in the overall complication rate between the two groups (46.9% versus 25%, p=0.12). The re-operation rate was twice as high in patients treated with TTC nailing however this was not statistically significant. There was no statistical difference in the FADI scores at final follow up, 72.1±12.9 (TTC) versus 67.9±13.9 (ORIF) nor post-operative mobility status. Conclusions. Within our study TTC nailing with an unprepared joint demonstrated broadly equivalent results to ORIF in the management of high-risk ankle fragility fractures; this replicates findings of previous studies. We did however observe that mean survival was significantly shorter in the TTC group than those treated with ORIF. We believe this may have been contributed to by a delay to theatre due to TTC stabilisation being treated as a sub-specialist operation in our unit at the time. We propose that both TTC and ORIF are satisfactory techniques to stabilise the frail ankle fracture however, similarly to the other fragility fractures, the priority should be on an emergent operation in a timely fashion in order to minimise the associated morbidity and mortality. Further randomised control studies are needed within the area to establish definitive results and a working consensus

Introduction and Objective. Postoperative management regimes vary following open reduction and internal fixation of unstable ankle fractures. There is an evolving understanding that poorer outcomes could be associated with non-weight bearing protocols and immobilisation. Traditional non-weight bearing cast immobilisation may prevent loss of fixation, and this practice continues in many centres. The aim of this systematic review and meta-analysis is to compare the complication rate and functional outcomes of early weight-bearing (EWB) versus late weight-bearing (LWB) following open reduction and internal fixation of ankle fractures. Materials and Methods. We performed a systematic review with a meta-analysis of controlled trials and comparative cohort studies. MEDLINE (via PubMed), Embase and the Cochrane Library electronic databases were searched inclusive of all date up to the search time. We included all studies that investigated the effect of weight-bearing following adults ankle fracture fixation by any means. All ankle fracture types, including isolated lateral malleolus fractures, isolated medial malleolus fractures, bi-malleolar fractures, tri-malleolar fractures and Syndesmosis injuries, were included. All weight-bearing protocols were considered in this review, i.e. immediate weight-bearing (IMW) within 24 hours of surgery, early weight-bearing (EWB) within three weeks of surgery, non-weight-bearing for 4 to 6 weeks from the surgery date (or late weight-bearing LWB). Studies that investigated mobilisation but not weight-bearing, non-English language publications and tibial Plafond fractures were excluded from this systematic review. We assessed the risk of bias using ROB 2 tools for randomised controlled trials and ROBINS-1 for cohort studies. Data extraction was performed using Covidence online software and meta-analysis by using RevMan 5.3. Results. After full-text review, fourteen studies (871 patients with a mean age ranged from 35 to 57 years) were deemed eligible for this systematic review; ten randomised controlled trials and four comparative cohort studies. Most of the included studies were rated as having some concern with regard to the risk of bias. There is no important difference in the infection rate between protected EWB and LWB groups (696 patients in 12 studies). The risk ratio (RR) is 1.30, [95% CI 0.74 to 2.30], I. 2. = 0%, P = 0.36). Other complications were rare. The Olerud-Molander Ankle Score (OMAS) was the widely used patient-reported outcome measure after ankle fracture fixation among the studies. The result of the six weeks OMAS analysis (three RCTs) was markedly in favour of the early weight-bearing group (MD = 10.08 [95% CI 5.13 to 15.02], I. 2. = 0%P = <0.0001). Conclusions. The risk of postoperative complications is an essential factor when considering EWB. We found that the overall incidence of surgical site infection was 6%. When comparing the two groups, the incidence was 5.2% and 6.8% for the LWB and EWB groups. This difference is not clinically important. On the other hand, significantly better early functional outcome scores were detected in the EWB group. These results are not without limitations. Protected early weight-bearing following open reduction and internal fixation of ankle fractures is potentially safe and improve short-term functional outcome. Further good-quality randomised controlled trials would be needed before we could draw a more precise conclusion

Abstract. Background. The incidence of periprosthetic fractures of the femur around a total knee arthroplasty (TKA) is rising and this is owed to the increased longevity that today's TKA implants allow for, as well as an aging population. These injuries are significant as they are related to increased morbidity and mortality. Methods. We retrospectively reviewed all periprosthetic fractures around a TKA that presented to our NHS Trust between 2011 to 2020. Medical records were reviewed. Treatment, complications and mortality were noted. Results. 37 patients (34 females) with an average age of 84 (range 65–99) met the inclusion criteria for this study. 17 patients (45.9%) underwent open reduction and internal fixation (ORIF), eight patients (21.6%) underwent revision arthroplasty to a distal femoral replacement (DFR) and 12 patients (32.4%) were treated non-operatively. 10 (58.8%) of the 17 patients that were treated with ORIF were discharged from hospital to a rehabilitation facility rather than their usual residence. In comparison, 3 (37.5%) of the patients that were treated with a DFR were discharged to a rehabilitation facility. one-year mortality rate in the ORIF group was 29.4 compared to 12.5% in those that had a DFR. Conclusion. Revision arthroplasty using a DFR should be considered in patients with periprosthetic fractures around a TKR, as it is associated with lower mortality rates and higher immediate post-operative function

Introduction. We demonstrate the preliminary results with a novel technique to solve large bone defects using two lengthening nails, working together and aligned in a custom made device. An illustrative case that successfully produced 17 cm bone in 3.5 months, is presented. Materials and Methods. A 28 year old healthy male presented with a slowly growing mass in the left femur. No general symptoms were reported, no weight loss, no previous illness. Histopathology, CT and MRI scans revealed a malignant diaphyseal bone tumor. A three-stage trifocal bone transport was projected and conducted based on a 3D model test. Results. Trifocal bone transport using two lengthening nails in a custom made device, reduced the 17 cm bone defect in 3.5 months. Follow up was 9 months. Conclusions. The presented technique successfully solved the clinical problem and is a showcase for further developments of internal devices for complex and large bone losses and lengthenings

Background. Studies have compared open reduction internal fixation (ORIF) with fibular nail fixation (FNF) and shown reduced wound complications with minimal difference to PROMS in the short term. Our aim is to compare long-term outcomes for unstable ankle fractures at 10 year follow up. Methods. Patients from a previously conducted RCT were contacted at a minimum of 10 years post intervention at a single study centre. Case notes were reviewed, and patient reported outcome measures acquired at 10 years. Results. Ninety-nine patients were included (48 FNF and 51 ORIF). After 10 years 75% (33/44) of patients in the FNF group required no further follow up versus 81% (39/48) in the ORIF group. Radiographically at 2 years post-injury, there was no statistically significant difference between groups for development of osteoarthritis (p=0.851). There was one tibio-talar fusion in each group secondary to osteoarthritis, but no statistically significant difference in overall re-operation rate (p=0.518). Fifty-one percent (n=50) of patients have so far returned patient reported outcome measures at a minimum of 10 years (Fibular nail n=23, plate fixation n=27). No significant difference was found between groups for the mean scores of Olerud and Molander Ankle Score (FNF 84.78 vs ORIF 84.07; p=0.883), the Manchester-Oxford Foot Questionnaire (MOXFQ) (FNF 89.54 vs ORIF 96.47; p=0.112), Euroqol-5D Index (FNF 0.88 vs ORIF 0.87; p=0.701) and Euroqol-5D Visual Analogue Score (FNF 77.30 vs ORIF 77.52; p=0.859). Conclusion. The current study illustrates that both methods of treatment result in a satisfactory long-term outcome with no difference in late complications or PROM scores at up to 10 years in patients under 65 years old, although the study is currently under powered

Introduction. Femoral shaft fractures in children is a serious injury that needs hospitalization, with a high prevalence in the age group 6–8 years old. Various treatment options are available and with a comparable weight of evidence. Submuscular plating provides a dependable solution, especially in length-unstable fractures and heavier kids. We present a novel technique to facilitate and control the reduction intraoperatively, which would allow for easier submuscular plate application. Materials and Methods. We have retrospectively reviewed four boys and three girls; all were operated in one centre. Polyaxial clamps and rods were applied to the sagittally-oriented bone screws, the reduction was done manually, and the clamps were tightened after achieving the proper alignment in the anteroposterior and lateral fluoroscopy views. The submuscular plate was applied as described, then clamps and bone screws were removed. Results. The mean age at surgery was 13 years (range, 9–14). The mean body weight was 43.3 kg (range, 30–66). There were five mid-shaft fractures, one proximal third and one distal third. There were Four type A fractures, two type B and one type C. Four patients had road traffic accidents while three had direct trauma. The mean preoperative haemoglobin concentration 12.5 g/dl (range 11.3–13 g/dl). No blood transfusion was needed intraoperatively or postoperatively. The operative time averaged 122 minutes, and the mean hospital stay was one (range 1–4 days). The patients reported no pain at a mean of 1.5 weeks (range, one-three weeks). All fractures united at a mean of 8.7 weeks (range 6–12 weeks). No wound healing problems nor deep infections happened. The knee joint range of motion was full in all patients at six weeks postoperatively. There was no mechanical irritation from the inserted plate. At the final follow-up, all fractures united without malalignment nor length discrepancy. Conclusions. External fixator-assisted internal fixation of pediatric femoral fractures would facilitate the accuracy and control of fracture reduction and allow minimally invasive percutaneous osteosynthesis. Our study has shown a decrease in operative time, and an accompanying reduction in length of inpatient stay, prolonged need for analgesia and post-operative rehabilitation

Introduction. Stiffness postTotal Knee Replacement (TKR) is a common, complex and multifactorial problem. Many reports claim that component mal-rotation plays an important role in this problem. Internal mal-rotation of the tibial component is underestimated among surgeons when compared to femoral internal mal-rotation. We believe the internal mal- rotation of thetibial component can negatively affect the full extension of Knee. We performed an in-vivo study of the impact of tibial internal mal-rotation on knee extension in 31 cases. Method. During TKR, once all bony cuts were completed and flexion/extension gaps balanced, we assessed the degree of knee extension using the trial component in the setting of normaltibial rotation and with varying degrees of internal rotation (13–33°, mean 21.2±4.6°). Intra-operative lateral knee X-ray was done to measure the degree of flexion contracture in both groups. We also compared the degree of flexion contracture between CR and PS spacers. Results. The average degree of knee flexion contracture with normal rotation of the tibial component was 0.7±4.1° (range:-9 to 10), whereas after tibial internal rotation was 7.3±4.6° (range:-1 to 23)(P – value:0.001). The increase in the flexion contracture deformity was higher with PS spacer (7.18±2.61) than with CR spacers (5.22±2.05). Conclusion. The internal mal-rotation of the tibial component limits the ability of the tibia to externally rotate on the femur, thereby limiting full knee extension and leading to flexion contracture

Internal fixation remains the treatment of choice for non-displaced femoral neck fractures in elderly patients, whereas, arthroplasty is preferred for displaced fracture patterns. Given technological advancements in implant design and excellent long-term outcomes, arthroplasty may provide improved outcomes for the treatment of non-displaced femoral neck fractures. The aim of our study was to conduct a systematic review of the orthopaedic literature (1) to investigate the outcomes of internal fixation for the treatment of non-displaced and minimally displaced femoral neck fractures in elderly patients and (2) to compare the outcomes of patients treated with internal fixation to arthroplasty in this patient population. Relevant articles were identified using PubMed, Embase, and CENTRAL databases. Manuscripts were included only if they contained (1) patients 60 years or older with (2) nondisplaced or minimally displaced (Garden I or II) femoral neck fractures (3) treated with internal fixation or arthroplasty or (4) separately reported outcomes in this patient population. The primary outcome was reoperation. Secondary outcomes included mortality, patient reported outcomes, length of hospital stay, infection, and transfusions. An a priori decision was made to classify studies into comparative or non-comparative groups. Comparative studies directly compared arthroplasty to internal fixation in the specific study population while the non-comparative studies included separate cohorts of patients treated with arthroplasty or internal fixation. A fixed-effects model was used to quantitatively pool study outcomes. Twenty-five non-comparative studies were identified with a total of 22,020 patients, all of which were treated with internal fixation. The pooled incidence of reoperation after internal fixation was 14.4% (95% CI: 10.8 – 18.8). The incidence of mortality within one-year of injury was 14.4% (95% CI: 6.7 – 28.3), based on the reporting in 14 studies. Three comparative studies were identified with a total of 360 patients (128 treated with arthroplasty and 232 treated with internal fixation). All three studies reported reoperation rates. The overall risk of reoperation was 3.1% in the arthroplasty group compared to 9.5% in the internal fixation group (relative risk: 0.30, 95% CI: 0.10 – 0.84, p= 0.02). Only two studies reported mortality. The relative risk of mortality in patients treated with arthroplasty compared to internal fixation was 2.54 (95% CI: 1.38 – 4.70, p= 0.003). Internal fixation of minimally displaced femoral neck fractures in the elderly is associated with a risk of reoperation and mortality that exceeds 14%. Treatment with arthroplasty may reduce the risk of reoperation by 70%. However, this benefit maybe tempered by a potential increased risk of mortality associated with arthroplasty in this patient population

Introduction. Osteoarthritis (OA), a painful, debilitating joint disease, often caused by excessive joint stress, is a leading cause of disability (World Health Organisation, 2003) and increases with age and obesity. A 5° varus malalignment increases loading in the medial knee compartment from 70% to 90% (Tetsworth and Paley, 1994). Internal unloading implants, placed subcutaneously upon the medial aspect of the knee joint, are designed to offload the medial compartment of the knee without violating natural joint tissues. The aim of this study is to investigate the effect of an unloading implant, such as the Atlas™ knee system, on stress within the tibiofemoral joint with different grades of cartilage defects. Methods. To simulate surgical treatment of medial knee OA, a three-dimensional computer-aided design of an Atlas™ knee system was virtually fixed to the medial aspect of a validated finite element knee model (Mootanah, 2014), using CATIA v5 software (Dassault Systèmes, Velizy Villacoublay, France). The construct was meshed and assigned material properties and boundary conditions, using Abaqus finite element software (Dassault Systèmes, Velizy Villacoublay, France). A cartilage defect was simulated by removing elements corresponding to 4.7 mm. 2. The international cartilage repair society (ICRS) Grade II and III damage were simulated by normalized defect depth of 33% and 67%, respectively. The femur was mechanically grounded and the tibia was subjected to loading conditions corresponding to the stance phase of walking of a healthy 50-year-old 68-Kg male with anthropometrics that matched those of the cadaver. Finite element analyses were run for peak shear and von Mises stress in the medial and lateral tibiofemoral compartments. Results. Von Mises stress distribution in the tibial cartilage, with ICRS Grade II and III defects, without the unloading implant, at the end of weight acceptance (15% of the gait cycle) were analysed. The internal unloading implant reduces peak von Mises stress by 40% and 43% for Grade II and Grade III cartilage defects, respectively. The corresponding reductions in shear stress are 36% and 40%. Consistent reduction in peak von Mises stress values in the medial cartilage-cartilage and cartilage-meniscus contact areas were predicted throughout the stance phase of the gait cycle for ICRS Grade II defect. Similar results were obtained for Grade III defect and for peak shear stress values. There were no overall increases in peak von Mises stress values in the lateral tibial cartilage. Discussion and Conclusions. The internal unloading implant is capable of reducing von Mises and shear stress values in the medial tibial cartilage with ICRS Grade II and III defects at the cartilage-cartilage and cartilage-meniscus interfaces throughout the stance phase of the gait cycle. This did not result in increased stress values in the lateral tibial cartilage. Our model did not account for the viscoelastic effects of the cartilage and meniscus. Results of this study are based on only one knee specimen. The internal unloading implant may protect the cartilage in individuals with medial knee osteoarthritis, thereby delaying the need for knee replacements