Introduction. Osteochondral defects of the knee may occur following patella dislocation or following direct trauma or twisting injuries to the knee in adolescents. Often a diagnostic and therapeutic challenge, if these lesions are left, posttraumatic osteoarthritis may occur. This retrospective single centre study presents the short-term results following operative fixation of osteochondral fragments of the knee using Omnitech ® screws. Method. All skeletally immature patients presenting with an osteochondral fracture of their femur or patella confirmed on xray and MRI were identified. Arthroscopic evaluation of the osteochondral defect was performed followed by open reduction and internal fixation of the osteochondral fragment using Omnitech ® screws. A standard postoperative rehabilitation protocol was followed. Patients were evaluated at follow-up using a Knee Injury and Osteoarthritis Outcome Score (KOOS). Results. Eight patients were identified. The mean age at time of injury was 15 years (range 14–16) for two girls and 14.4 years (range 13–16) for six boys. The lateral femoral condyle was involved in six cases and patella in two cases. At mean follow up of 14 months (range 1–38) there was no revision for failure and no postoperative complications. The KOOS score (out of 100) at final follow up was subdivided as follows; Pain, 93 (range 81–100), other symptoms, 77 (range 36–100), function in daily living (ADL), 97 (range 84–100), function in sport and recreation, 84 (range 55–100) and knee related quality of life, 79 (range 44–100). Discussion. The short-term results of using Omnitech® screws are promising. Subchondral screw placement with adequate compression of the osteochondral fragment is achievable with Omnitech ® screws. Seven patients are back to their pre-injury sporting activity and one patient is currently undergoing postoperative rehabilitation, one month following surgery

Purpose

There is increasing evidence that primary fixation of displaced mid-shaft fractures of the clavicle results in superior short-term outcomes when compared to traditional non-operative methods. However, the results from published studies are limited to relatively short-term (one year or less) follow-up. Accurate data of longer follow-up is important for a number of reasons, including patient prognostication, counseling and care, the design of future trials, and the economic analysis of treatment. The purpose of this paper was to examine the results of the two year follow up of patients enrolled in a previously published randomized clinical trial of operative versus non-operative treatment of displaced fractures of the clavicle.

Fractures of the distal radius are common, and form a considerable proportion of the trauma workload. We conducted a study to examine the patterns of injury and treatment for adult patients presenting with distal radius fractures to a major trauma centre serving an urban population. We undertook a retrospective cohort study to identify all patients treated at our major trauma centre for a distal radius fracture between 1 June 2018 and 1 May 2021. We reviewed the medical records and imaging for each patient to examine patterns of injury and treatment. We undertook a binomial logistic regression to produce a predictive model for operative fixation or inpatient admission. Overall, 571 fractures of the distal radius were treated at our centre during the study period. A total of 146 (26%) patients required an inpatient admission, and 385 surgical procedures for fractures of the distal radius were recorded between June 2018 and May 2021. The most common mechanism of injury was a fall from a height of one metre or less. Of the total fractures, 59% (n = 337) were treated nonoperatively, and of those patients treated with surgery, locked anterior-plate fixation was the preferred technique (79%; n = 180). The epidemiology of distal radius fractures treated at our major trauma centre replicated the classical bimodal distribution described in the literature. Patient age, open fractures, and fracture classification were factors correlated with the decision to treat the fracture operatively. While most fractures were

There is conjecture on the optimal timing to administer bisphosphonate therapy following operative fixation of low- trauma hip fractures. Factors include recommendations for early opportunistic commencement of osteoporosis treatment, and clinician concern regarding the effect of bisphosphonates on fracture healing. We performed a systematic review and meta-analysis to determine if early administration of bisphosphonate therapy within the first month post-operatively following proximal femur fracture fixation is associated with delay in fracture healing or rates of delayed or non-union. We included randomised controlled trials examining fracture healing and union rates in adults with proximal femoral fractures undergoing osteosynthesis fixation methods and administered bisphosphonates within one month of operation with a control group. Data was pooled in meta-analyses where possible. The Cochrane Risk of Bias Tool and the GRADE approach were used to assess validity. For the outcome of time to fracture union, meta-analysis of three studies (n= 233) found evidence for earlier average time to union for patients receiving early bisphosphonate intervention (MD = −1.06 weeks, 95% CI −2.01 – −0.12, I. 2. = 8%). There was no evidence from two included studies comprising 718 patients of any difference in rates of delayed union (RR 0.61, 95% CI 0.25–1.46). Meta-analyses did not demonstrate a difference in outcomes of mortality, function, or pain. We provide low-level evidence that there is no reduction in time to healing or delay in bony union for patients receiving bisphosphonates within one month of proximal femur fixation

Sacral fractures are often underdiagnosed, but are frequent in the setting of pelvic ring injuries. They are mostly caused by high velocity injuries or they can be pathological in aetiology. We sought to assess the clinical outcomes of the surgically treated unstable sacral fractures, with or without neurological deficits. unstable sacral fractures were included in the study. Single centre, prospectively collected data, retrospective review of patients who sustained vertically unstable fractures of the sacrum who underwent surgical fixation. out of a total of 432 patients with pelvis and acetabulum injuries. fifty six patients met the inclusion criteria. 18 patients had sustained zone one injuries. 14 patients had zone 2 injuries and 10 patients had zone 3 injurie. Operative fixation was performed percutaneously using cannulated screws in 18 patients.. Open fixation of the sacrum using the anterior approach in 6 patients. Posterior approach was indicates in all 10 of the zone 3 injuries of the sacrum. While in 4 patients, combined approaches were used. 3 patients had decompression and spinopelvic fixation. Neurological deficits were present in 16% of the patients. 2 patients presented with neurgenic bladder. Of the 4 patients who had neurological fall out, 3 resolved with posterior decompression and posterior fixation. All 4 neurological deficits were due to taction or compression of the nerve roots. No hardware failures or non unions observed. The rate of neurological deficit was related more to the degree of pelvic ring instability than to a particular fracture pattern. Low rates of complications and successful surgical treatment of sacral fractures is achiavable. Timeous accurate diagnosis mandatory

The rate of arterial injury in trauma patients with pelvic ring fractures has been cited as high as 15%. Addressing this source of hemorrhage is essential in the management of these patients as mortality rates are reported as 50%. Percutaneous techniques to control arterial bleeding, such as embolization and REBOA, are being employed with increasing frequency due to their assumed lower morbidity and invasiveness than open exploration or cross clamping of the aorta. There are promising results with regards to the mortality benefits of angioembolization. However, there are concerns with regards to morbidity associated with embolization of the internal iliac vessels and its branches including surgical wound infection, gluteal muscle necrosis, nerve injury, bowel infarction, and thigh / buttock claudication. The primary aim of this study is to determine whether pelvic arterial embolization is associated with surgical site infection (SSI) in trauma patients undergoing pelvic ring fixation. This observational cohort study was conducted using US trauma registry data from the American College of Surgeons (ACS) National Trauma Database for the year of 2018. Patients over the age of 18 who were transported through emergency health services to an ACS Level 1 or 2 trauma hospital and sustained a pelvic ring fracture treated with surgical fixation were included. Patients who were transferred between facilities, presented to the emergency department with no signs of life, presented with isolated penetrating trauma, and pregnant patients were excluded from the study. The primary study outcome was surgical site infection. Multivariable logistic regression was performed to estimate treatment effects of angioembolization of pelvic vessels on surgical site infection, adjusting for known risk factors for infection. Study analysis included 6562 trauma patients, of which 508 (7.7%) of patients underwent pelvic angioembolization. Overall, 148 (2.2%) of patients had a surgical site infection, with a higher risk (7.1%) in patients undergoing angioembolization (unadjusted odds ratio (OR) 4.0; 95% CI 2.7, 6.0; p < 0 .0001). Controlling for potential confounding, including patient demographics, vitals on hospital arrival, open fracture, ISS, and select patient comorbidities, pelvic angioembolization was still significantly associated with increased odds for surgical site infection (adjusted OR 2.0; 95% CI 1.3, 3.2; p=0.003). This study demonstrates that trauma patients who undergo pelvic angioembolization and operative fixation of pelvic ring injuries have a higher surgical site infection risk. As the use of percutaneous hemorrhage control techniques increase, it is important to remain judicious in patient selection

Aim. To conduct a systematic review and meta-analysis comparing the development of early and late fracture-related infections (FRI) following closed and open fractures in HIV-positive and HIV-negative patients. Method. A systematic literature search was conducted using MEDLINE through the OVID interface, ProQuest, Web of Science, The Cochrane Library and Scopus. Only studies involving HIV-positive who underwent operative fixation (internal or external) of open or closed fractures, with a HIV-negative control group, were considered eligible. Following eligibility assessment, studies were included with the main outcome of interest being the development of either early or late fracture-related infection at the site of surgery in patients with open and closed fractures. Results. Eleven studies were included (n = 2634). The studies’ follow-up periods were between one and 39 months with an average of 11 months. Three studies were conducted before the introduction of ARV (anti-retroviral) therapy (1994) and two did not involve any patients on ARV's. Across the entire group, for both open and closed fractures, the risk of a fracture-related infection was greater in HIV-positive patients (Odds ratio (OR) = 1.61; 95% CI = 0.93–2.79, p = 0.04). When looking at closed fractures treated operatively, an OR = 4.59 was found in HIV-positive patients in terms of the risk of fracture-related infection (95% CI = 0.30–68.99, p < 0.001). Open fractures showed similar results with an OR of 3.48 in HIV-positive patients (95% CI = 0.55 – 21.99, p < 0.001). Studies performed prior to the widespread introduction of anti-retroviral therapy and/or did not have any patients on antiretroviral therapy showed a greater infection risk in patients living with HIV infection with OR 3.53 (95% CI = 1.85 – 6.74, p = 0.36). However, studies performed in the era after the introduction of antiretroviral therapy showed no increase of infection risk for HIV-positive patients with an OR = 0.91 (95% CI = 0.58 – 1.43, p = 0.76). Conclusions. The assumption that HIV infection increases the risk for fracture-related infection remains unsubstantiated. The introduction of anti-retroviral therapy may have confounded the issue and we noted an apparent decrease in the risk in later studies. More data is required from well-designed larger studies to inform future analysis

The purpose of this study is to determine the re-operation rate following plate fixation of the olecranon with contoured anatomic plates. Plate fixation of the olecranon allows for management of different fracture patterns as well as osteotomies with anatomic reduction and stable fixation for early elbow mobilization. However, olecranon hardware prominence can be troublesome. Our hypothesis was with the newer generation of low profile contoured anatomic plates, the rate of hardware removal should be lower compared to previously described literature. Retrospective review for patients treated with operative fixation of the olecranon between 2010 and 2015 in the Edmonton zone was identified using population level administrative data. Radiographic screening of these patients was then carried out to identify those who received plate fixation. Fracture patterns were also characterized. Chart reviews followed to determine the indications for re-operation and other post-operative complications. Main outcome measures were re-operation rate and their indications, including hardware prominence. During the screening process, 600 surgically treated olecranon patients were identified and 321 patients were found to have plate fixation of the olecranon. Chart review determined 90 patients had re-operations demonstrating a 28% re-operation rate. Re-operation due to hardware prominence was found to be 15.6%. Other indications included hardware failure (5.3%), infection (2.8%), or contracture (2.8%). Compared to patients that did not require re-operation, the re-operation group had a higher incidence of Type III olecranon fractures (17.4% vs 8.4%, p = 0.036) and Monteggia pattern injuries (13.5% vs 4.9%, p = 0.008). Recent heteregenous data suggests the hardware removal rate related to implant prominence is between 17–54%. Compared to the literature, this study demonstrated a lower rate at 15.6% with contoured anatomic plating. Also, those with more complex fracture patterns were more likely to require re-operation

Distal radius fractures are among the most common fractures seen in the emergency department. Closed reduction can provide definitive management when acceptable radiographic parameters are met. Repeated attempts of closed reduction are often performed to improve the alignment and avoid operative management. However, multiple reduction attempts may worsen dorsal comminution and lead to eventual loss of reduction, resulting in no demonstrable benefit. We hypothesize that compared to one closed reduction attempt, repeated closed reduction of extra-articular, dorsally angulated, displaced distal radius fractures has a low success rate in the prevention of operative fixation and improvement of radiographic parameters. Initial and post reduction radiographs for all distal radius fractures managed at Vancouver General Hospital between 2015 and 2018 were reviewed. Inclusion criteria were based on the AO fracture classification and included types 23-A2.1, 23-A2.2 and 23-A3. Exclusion criteria included age less than 18, intra-articular involvement with more than two millimeters of displacement, volar or dorsal Barton fractures, fracture-dislocations, open fractures and volar angulation of the distal segment. Distal radius fractures that met study criteria and underwent two or more attempts of closed reduction were matched by age and gender with fractures that underwent one closed reduction. Radiographic parameters including radial height and inclination, ulnar variance and volar tilt were compared between groups. Sixty-eight distal radius fractures that met study criteria and underwent multiple closed reduction attempts were identified. A repeated closed reduction initially improved the radial height (p = 0.03) and volar tilt (p < 0.001). However, by six to eight weeks the improvement in radial height had been lost (p = 0.001). Comparison of radiographic parameters between the single reduction and multiple reduction groups revealed no difference in any of the radiographic parameters at one week of follow up. By six to eight weeks, the single reduction group had greater radial height (p = 0.01) ulnar variance (p = 0.05) and volar tilt (p = 0.02) compared to the multiple reduction group. With respect to definitive management, 38% of patients who underwent a repeated closed reduction subsequently received surgery, compared to 13% in the single reduction group (p = 0.001). Repeated closed reduction of extra-articular, dorsally angulated, displaced distal radius fractures did not improve alignment compared to a single closed reduction and was associated with increased frequency of surgical fixation. The benefit of repeating a closed reduction should be carefully considered when managing distal radius fractures of this nature

Distal radius fractures are among the most common fractures seen in the emergency department. Closed reduction can provide definitive management when acceptable radiographic parameters are met. Repeated attempts of closed reduction are often performed to improve the alignment and avoid operative management. However, multiple reduction attempts may worsen dorsal comminution and lead to eventual loss of reduction, resulting in no demonstrable benefit. We hypothesize that compared to one closed reduction attempt, repeated closed reduction of extra-articular, dorsally angulated, displaced distal radius fractures has a low success rate in the prevention of operative fixation and improvement of radiographic parameters. Initial and post reduction radiographs for all distal radius fractures managed at Vancouver General Hospital between 2015 and 2018 were reviewed. Inclusion criteria were based on the AO fracture classification and included types 23-A2.1, 23-A2.2 and 23-A3. Exclusion criteria included age less than 18, intra-articular involvement with more than two millimeters of displacement, volar or dorsal Barton fractures, fracture-dislocations, open fractures and volar angulation of the distal segment. Distal radius fractures that met study criteria and underwent two or more attempts of closed reduction were matched by age and gender with fractures that underwent one closed reduction. Radiographic parameters including radial height and inclination, ulnar variance and volar tilt were compared between groups. Sixty-eight distal radius fractures that met study criteria and underwent multiple closed reduction attempts were identified. A repeated closed reduction initially improved the radial height (p = 0.03) and volar tilt (p < 0.001). However, by six to eight weeks the improvement in radial height had been lost (p = 0.001). Comparison of radiographic parameters between the single reduction and multiple reduction groups revealed no difference in any of the radiographic parameters at one week of follow up. By six to eight weeks, the single reduction group had greater radial height (p = 0.01) ulnar variance (p = 0.05) and volar tilt (p = 0.02) compared to the multiple reduction group. With respect to definitive management, 38% of patients who underwent a repeated closed reduction subsequently received surgery, compared to 13% in the single reduction group (p = 0.001). Repeated closed reduction of extra-articular, dorsally angulated, displaced distal radius fractures did not improve alignment compared to a single closed reduction and was associated with increased frequency of surgical fixation. The benefit of repeating a closed reduction should be carefully considered when managing distal radius fractures of this nature

Femoral neck stress fractures (FNSF) are uncommon, representing 3.5% to 8% of all stress fractures in military recruits. The majority of displaced FNSF undergo operative fixation and are at risk of avascular necrosis (AVN) and non union with a 40–100% medical discharge rate. We aimed to review the incidence and outcome of displaced FNSF in Royal Marine Recruits. Retrospective review identified 6 Royal Marine recruits, aged 17 to 25, who had suffered a displaced FNSF over a 6 and a half year period. Incidence was 0.93 per 1000 recruits. Patients were treated urgently by operative fixation with a 2 hole dynamic hip screw device, in 3 cases supplemented with an anti-rotation screw. There were no cases of AVN, no surgical complications and no further procedures were required. All united with a mean time to union of 11 months. 50% had a union time greater than 1 year. 2 completed training, 2 are still in rehabilitation and 2 (33%) were discharged before completion of training. These fractures are slow to unite compared to other fractures at this site or stress fractures elsewhere. With urgent surgical intervention and stable fixation all however went onto successful union with time and all returned to rehabilitation or training with minimal complications. Awareness of the length of time to union has been invaluable in guiding treatment and rehabilitation. It can help avoid the risks of unnecessary secondary interventions for delay to union

Recruits undergoing arduous training at Commando Training Centre Royal Marines (CTCRM) carry a higher risk of femoral neck stress fractures than many other military populations. This injury has serious sequelae and requires urgent operative fixation if it is displaced. Existing literature advocates a low threshold for imaging patients where this injury is suspected, due to the prognostic advantage conferred by early intervention. CTCRM uses a locally produced scoring system based on history and clinical assessment, to guide the requirement for imaging. Since 2015 access to MRI has been possible through a fast track provider. Between 2012 and 2015, 3522 Royal Marine Recruits entered training. Over the period, 95 MRI scans of the hip were performed, of which 12 utilised private pathways. 13 stress fractures of the femoral neck were identified; 23% (n=3) were displaced and required fixation. The overall incidence rate for this injury is therefore 37 per 10,000, with a displaced incidence rate of 9 per 10,000. We compare these data with previous studies, discuss the use and efficacy of the scoring tool, and assess the benefit conferred by the local private MRI agreement

Background. This is a continued assessment of the effectiveness of a locked intramedullary device in the treatment of acute clavicle shaft fractures. Results of patients treated thus far were assessed, including patients reported on previously. Description of methods. Patients admitted with midshaft clavicle fractures were assessed to determine whether operative fixation of the fracture was required. Indications for surgery were midshaft clavicle fractures with 100% displacement; more than 1.5 cm of shortening, presence of a displaced butterfly segment, bilateral clavicle fractures, ipsilateral displaced glenoid neck fractures, skin and neurovascular compromise. Patients that matched the criteria for surgery were treated operatively with an intramedullary locked device by the author. Post-operatively, patients were kept in a shoulder immobilizer for a period of 6 weeks. Patients were invited to attend a scheduled follow-up visit where the data was collected that comprised the review. All patients were assessed by the surgeon, a radiologist, a physiotherapist and an occupational therapist. Scar size and quality, Dash score, Constant Shoulder score, complications and the radiological picture were assessed. Summary of results. 50 patients (52 clavicle fractures – 2 patients sustained bilateral fractures), 28 males and 22 females with a mean age of 30 attended the schedule data collection visit and were included in the study. 48 clavicles achieved complete union with the remaining 4 fractures progressing normally to union at 10 and 12 weeks post surgery. No additional complications than those reported on previously were encountered. Conclusion. Locked intramedullary fixation of clavicle shaft fractures that match the criteria for operative fixation continues to give good results. No non-unions were found and a high level of patient satisfaction was achieved. The operative technique continues to be refined leading to less fixation related complications. MULTIPLE DISCLOSURES

Purpose. In a previously published multicenter randomized clinical trial it was shown that young patients (16–60 years-old) with displaced mid-shaft clavicle fractures had superior limb specific outcomes when they were treated with primary plate fixation versus non operative treatment at one year follow-up. This study examines the general health status of this cohort of patients at two-years post injury. Method. We evaluated the general health of a cohort of patients with displaced mid-shaft clavicle fractures comparing non-operative versus plate fixation at two-years after injury. At the conclusion of our study, eighty-nine patients (fifty-four from the operative group and thirty-five from the non-operative group) completed the two-year follow-up. Outcome analysis included the standard clinical follow-up and SF-36 scores. Results. SF-36 scores were significantly improved in the operative fixation group at all time-points: 6 weeks, 3, 6, 12, 24 months (P<0.01). At two-years after the injury, the patients in the operative group had better patient oriented outcome scores, especially in the physical performance component of the SF-36 scores (Physical component (PCS) 57.1 versus 51.0, P<0.05). Conclusion. Operative treatment more reliably restored pre-operative levels of general health status compared to non-operative treatment. Operative fixation of a displaced mid-shaft clavicle fracture in young active patients resulted in improved patient oriented general health status at two-year follow-up. The improvement is especially pronounced in the physical component of the SF-36 scores. These findings support primary plate fixation of displaced mid-shaft clavicle fractures in young active adults

Patella fractures constitute 1% of all fractures and may disrupt the extensor mechanism of the knee. The mainstay of treatment for most patella fractures is operative fixation; however, patients with intact extensor mechanisms may be treated with splinting. We describe a series of patients with patella fractures managed non- operatively, without restricted weight bearing or splinting. A consecutive series of 21 patients presenting with a patella fracture to two metropolitan hospitals were included in this study. All patients had an intact extensor mechanism but no distinction was made on age or fracture type. All patients were treated non-operatively with analgesia, were allowed to fully weight-bear and were not splinted. A retrospective review of the case notes was performed and data was collected with phone interview. The main outcome measure was the Western Ontario and McMaster Universities. Osteoarthritis (WOMAC) index, which has a maximum (worst) possible score of 240, and which provides an aggregate score of pain, stiffness and function. Mean time at follow up was 24 months (range 5–49 months). WOMAC scores were excellent (mean=18 of possible maximum 240; range 0–84). Only one patient had a significant complication related to their fracture (deep venous thrombosis), which was detected during hospital admission. Most patients had returned to usual work (9/14). No patients required operative fixation. There was no association between adjusted WOMAC score and age, sex, compensation status, time of follow up, or whether the patient had a significant ipsilateral injury. Patients who had returned to work (p=0.02) or who had lower levels of education (p=0.03) had better WOMAC scores. Management of patella fractures with an intact extensor mechanism does not require restricted weight bearing or splinting

Fractures of the shaft of the humerus are often treated conservatively in a hanging cast or a humeral brace. The conservative management of this fracture is often prolonged and quite uncomfortable for the patient. Some of the patients will need an operative fixation after a trial of conservative management. We retrospectively looked at 72 consecutive patients with fractures of the shaft of the humerus that presented in our institution over a period of two years. The fracture pattern, treatment modality time to union and the number that needed operative fixation following a trial of conservative treatment was analysed. Of the 72 patients 4 were lost to follow-up. 45 patients had a 1.2.B or 1.2.C type of fracture and 23 had a 1.2.A type of fracture. 29 (41%) were successfully treated conservatively, 11 (16%) patients were operated as the primary procedure and 15 (22%) patients were operated due to delayed or non union. 13 (19%) patients were operated within 4 weeks of the fracture as their alignment was not acceptable on their weekly follow-up. The average time to union in the patients treated conservatively was 22 weeks, while that of the patients treated primarily by open reduction and plating was 14 weeks (p-value<0.05). Patients who needed operation after initial conservative management required prolonged period of rehabilitation and union time was 32.2 weeks. At the time of fracture union 72% of the patients who had been treated conservatively had joint stiffness requiring physiotherapy, while only 18% of those who had an open reduction and internal fixation had stiffness and required physiotherapy. (p-value < 0.05). In conclusion careful consideration should be given before it is decided to treat this fracture conservatively especially in the case of 1.2.A fracture pattern

Diabetes is a poor prognostic indicator after an acute ankle fracture. Many surgeons avoid essential surgery due to their concerns regarding complications. We performed a retrospective analysis of complication rates for acute ankle fractures in diabetics with a control non-diabetic patient treated by all surgeons in our unit and assessed factors for success including long-segment fixation methodologies. Patient records were cross-referenced with departmental databases and a retrospective review of all ankle fractures managed in our department was conducted from 2014. All patients subjected to a retrospective review of their notes and assessment of their follow up for at least 6 months. Radiographs were assessed of the ankle before and at completion of treatment were reviewed independently (RA and FR). We identified all patients with a diabetic ankle fracture their HB1Ac (for diabetic control) and systematic co-morbidities. Fractures were classified into unimalleolar, bi malleolar and trimalleolar and surgery grouped into standard or long-segment-rigid fixation. Statistical analysis was conducted using absolute/relative risk (RR); numbers needed to treat (NNT) were calculated. We compared a control-group, a diabetic group managed conservatively, and undergoing surgery; comparing the concept of rigid fixation. Further sub-analysis conducted to assess differences between diabetic neuropathy, retinopathy and nephropathy. Ethics approval was granted as per our institutional policy by our governance lead. We identified 64 patients with a diabetic ankle fractures, their fracture pattern and a control group. Thirty-one had conservative treatment; 33 had operative fixation of which 13 had rigid fixation. Compared to the control (n=32) both diabetic groups had a higher risk of possible complication. The relative risk was between 3.1–3.4 (P<0.002) and linked to systematic complications of diabetes e.g. neuropathy 5.9 (P<0.003); HBA1c 4.6 P<0.004); and neuropathy and retinopathy 6.2 P<0.0003). We observed RR is reduced for a complication occurring following surgery with prolonged immobilization (0.86) and rigid fixation (0.65) and NNT required to see a benefit from rigid fixation was 7. The overall RR for a complication was similar between conservative and surgical management (4.6 vs.5.1). We agree diabetics have a higher risk for complications than non-diabetics, however the risk is not as great as previously reported. There is little difference in surgical or conservative treatment but strong evidence indicating rigid long-segment-fixation with prolonged-immobilization could improve the risk benefit ratio when compared to non- operative management alone but further evaluation is required

Acute scaphoid fractures are commonly treated with cast for 8–12 weeks. With this prolonged period of immobilisation patients can encounter joint stiffness and muscle wasting requiring extensive physiotherapy. Despite best practice, these fractures also pose a risk of non-union and suboptimal function. Fracture location, duration of time lost from work and impairment in activities of daily living are key factors in scaphoid fracture management. The aim of our study was to compare percutaneous screw fixation of the scaphoid with other operative fixation techniques. Parameters documented were length of conservative treatment, mechanism of injury, post-op complications and patient satisfaction levels with each technique using a standardised questionnaire. Economic benefit was also measured by examining time to return to work, number of x-rays and outpatient visits required per treatment group. In this study, 76 patients requiring operative scaphoid fixation were evaluated. 27 patients underwent percutaneous fixation. Waist fractures accounted for 66% (n= 18), proximal pole fractures 33% (n=8) and distal pole fractures 4% (n=1). There were 16 non-displaced fractures (59%) and 11 displaced fractures (41%). The average length of conservative treatment was 77 days (range: 2–256 days). Within the percutaneous group 2 patients developed non-union. We did not encounter any wound infection or superficial radial nerve damage. Patients treated with early percutaneous fixation had highest satisfaction levels, returned to work earlier and required less follow-up (P< 0.001). In conclusion percutaneous screw fixation provides earlier bone union and avoids the need for prolonged immobilisation when compared to other treatment modalities. The economic benefit of early percutaneous fixation must also be considered when managing patients with scaphoid fractures

Background. Operative fixation of acute tendo-achilles ruptures remains controversial. Standard surgical exposure is associated with and increased risk of wound breakdown and infections. The mini-open technique was developed to minimise these risks and provide anatomical reduction/apposition of the tendon rupture. Methods. We present a retrospective case series of 27 patients who were treated operatively for acute Achilles tendon rupture in the hands of 1 surgeon, between 4–6 years post operatively, using Achillon instrumentation. Post operatively they were treated with an air cast boot and 3 wedges, bringing the foot into neutral by 6 weeks followed by a rehabilitation programme. The patients were contacted via telephone and consent was obtained. The complications, Leppilahti score and ATRS score were then calculated. Results. 2 patients underwent a further operation (one for a retained suture and another for a re-rupture in an uncompliant patient), in total there were 2 re-ruptures (another patient sustained a partial rupture which was treated conservatively). There were no patients who sustained a wound problem or infection (other than the patient already mentioned). There were 3 patients who complained of ongoing altered sensation in the sural nerve distribution, and 4 who had paraesthesia post operativeley that completely resolved within 3 months. There were no DVT/PE reported and the average Leppilahti score was 85.7/100 (excellent outcome) and ATRS 93.3/100 (excellent outcome). Conclusion. This study shows that the mini-open technique can be used successfully to treat acute tendo-Achilles ruptures with excellent long term outcome

Prevention: Many periprosthetic femur fractures may be prevented by: good patient follow-up; timely reoperation of lytic lesions if radiographs suggest fracture risk; prophylactic use of longer stemmed implants or strut grafts to bypass cortical defects at revision surgery. Treatment: Periprosthetic fractures can be treated using an algorithmic approach based on the Vancouver classification system. Fractures of greater or lesser trochanter (Type A): nonoperative treatment if displacement acceptable and if not associated with lysis; operative treatment if displacement unacceptable or associated with progressive lysis. Fractures of distal femur well distal to implant (Type C): treat as any other femur fracture, usually operatively; fixation options: plate/retrograde nails. Fractures around the implant or at its tip (Type B): these fractures almost always require surgery. Nonoperative treatment is associated with high rate of malunion, nonunion, poor results. Treatment is according to fixation status of implant and bone quality. Well-fixed stem (Type B1): ORIF with cable plate and/or strut grafts; or with locking plate and minimally invasive biologic technique. Loose stem (Type B2 and Type B3): revise implant to long stem; usually use uncemented distally-fixed implant; occasionally long cemented stem (avoid cement extrusion). In most cases we favor use of a modular fluted tapered stem which provides axial and rotational stability by fixation distal to the fracture. Principles: obtain fracture stability, implant stability, and optimise conditions for bone healing (use bone grafts, don't strip periosteum)