Vancouver B type peri-prosthetic hip fractures are increasingly common and represent a very complex and challenging problem in terms of management. Plate fixation has not always succeeded, and revision hip arthroplasty on a suboptimal trauma list can be a daunting prospect. Our technique is to use the opposite sided distal femoral LISS plate, inserted from proximally to distally in an inverted manner. Vastus lateralis is elevated off the trochanteric ridge, and a small amount of bone is removed from the ridge to get the plate to sit snugly. The fracture is opened only enough to achieve reduction, and fixation with locking screws are placed percutaneously distal to the fracture. Bone grafting or cable fixation can also be applied at the fracture site. 20 consecutive patients with Vancouver B peri-prosthetic hip fractures were reviewed. The average patient age was 78 yrs. 14 fractures occurred in cemented and 6 in uncemented femoral stems. 12 fractures occurred in primary THR and 8 in bipolar hip hemiarthroplasty. Six were managed using the inverted LISS plate, 6 using other methods of fixation, and 8 with revision THR. In terms of mortality at 12 months, there was no difference between the treatment arms, with 1 death in the LISS and other fixation group respectively and 0 deaths in the revision THR group. From a morbidity perspective there was no difference with respect to post-op medical complications, weight bearing status and length of hospital stay. There was, however, a difference between the inverted LISS plate group and other fixation methods group compared with the revision THR group in terms of average transfusion requirement (2 units and 3 units vs 8 units) and average operative time (80 mins and 100 mins vs 465 mins). 1 LISS plate failed in the 12 month period, with 1 Revision THR and 2 from the other fixation group. This study suggests that it is a stable method of fixation, particularly in the type B1 and B2 subtypes. It may also be used in patients with multiple co-morbidities who cannot undergo a revision procedure and in patients who are minimally/non ambulant. In one patient, we used it to stabilize the fracture before progressing to a later, more controlled, revision hip replacement situation. LISS fixation has a short operative time, low transfusion requirement, low failure rate and is technically easier to perform than revision surgery

The distal femur fracture is a difficult injury that affects young men andelderly women. The tissue stripping that occurs with the traditional approach has been a factor in the development of complications like infection and nonunion. This study addresses the issue of minimally invasive approach. Does the LISS system really improve the results of such fracture?. Fifty-two patients were included in the trial from six academic trauma centres. Twenty-eight fractures had been randomised to be fixed with the LISS device, while twenty-four had the DCS implant. Type C3 fractures were excluded as they were not amenable for fixation with DCS system. All procedures were performed via minimally invasive technique. The LISS system had the targeter that helped with plate insertion and distal diaphyseal screws placement. Radiography was utilised in the case of the DCS distal screws insertion. All fractures went onto union, except two participants in LISS group who had to be revised due to loss of reduction, in the early post-operative peroid. There were three nonunions in the same group. These required a re-operation. Further more, a LISS participant who had re-injured his distal femur (unrelated to LISS plate), was fixed with different implant. There was a single nonunion with the DCS group that needed revision surgery. There was one participant from each group who had drifted into varus. Neither required a re-operation. This translated into a 21% re-operation rate in the LISS system compared to 4% with the DCS device. Our data supports the use of the DCS system in the fixation of distal femur fractures (except Type C3} via a minimally invasive approach. The LISS implant seems to be technique dependent. In our centre, the LISS plate had been discontinued in favour of the DCP and LCP systems

Massive segmental bone defects in long bones remain a considerable clinical challenge and are a source for significant morbidity and prolonged dysfunction for the patient. We demonstrate the successful use of resorbable polylactide membranes as a scaffold for autologous bone graft in the treatment of a 10cm traumatic femoral bone defect. A 28-year-old male was involved in a motorcycle accident vs. tree at 140k/hr. He sustained a Gustillo grade 3b intercondylar fracture of his right femur, and a 10cm piece of his femoral bone found at the scene was brought to Emergency in a sterile container. He was taken to theatre for debridement and ORIF of the intercondylar fracture, with vacuum dressing cover. Day 5 post injury the patient returned to theatre and the LISS plate was revised to correct the rotation and 3cm shortening. The 10cm cortical defect now present was filled with antibiotic cement (Palacos) and delayed primary closure was performed. Day 21 post injury the cement spacer was removed and replaced with two polylactide membrane tubes, one within the medullary canal and the other around the outside of the bone. The “neocortical” space thus produced was grafted with cancellous autograft mixed with bone morphogenic protein (OP1, Stryker). The remainder of the post-operative course was uncomplicated and the patient was discharged home 5 days later. The patient was reviewed at the 6 week and 3 month mark post injury. The femoral defect demonstrated both radiological and clinical union at the 3 month mark and full weight bearing was permitted. His range of motion at that stage was 5 to 95 degrees with no sign of infection. The use of polylactide membranes as a scaffold in the treatment of segmental long bone defects is an excellent and relatively straightforward technique. Forming a space between the 2 tubes controls cancellous graft to the site of the cortical area where it is required and the polylactide membrane then resorbs over years producing CO2 and water. This case demonstrates that the use of polylactide membranes is safe and effective in the management of segmental long bone defects

Aims

Computer hexapod assisted orthopaedic surgery (CHAOS), is a method to achieve the intra-operative correction of long bone deformities using a hexapod external fixator before definitive internal fixation with minimally invasive stabilisation techniques.

The aims of this study were to determine the reliability of this method in a consecutive case series of patients undergoing femoral deformity correction, with a minimum six-month follow-up, to assess the complications and to define the ideal group of patients for whom this treatment is appropriate.