This randomised study compared outcomes in patients with displaced fractures of the clavicle treated by open reduction and fixation by a reconstruction plate which was placed either superiorly or three-dimensionally. Between 2003 and 2006, 133 consecutive patients with a mean age of 44.2 years (18 to 60) with displaced midshaft fractures of the clavicle were allocated randomly to a three-dimensional (3D) (67 patients) or superior group (66). Outcome measures included the peri-operative outcome index, delayed union, revision surgery and symptoms beyond 16 weeks. CT was used to reconstruct an image of each affected clavicle and Photoshop 7.0 software employed to calculate the percentage of the clavicular cortical area in the sagittal plane. The patients were reviewed clinically and radiographically at four and 12 months after the operation. The superior plate group had a higher rate of delayed union and had more symptomatic patients than the 3D group (p < 0.05). The percentage comparisons of cortical bone area showed that cortical bone in the superior distal segment is thicker than in the inferior segment, it is also thicker in the anterior mid-section than in the posterior (p < 0.05). If fixation of midshaft fractures of the clavicle with a plate is indicated, a 3D reconstruction plate is better than one placed superiorly, because it is consistent with the stress distribution and shape of the clavicle

MATERIAL AND METHODS. From 1986 to 2002, among 195 fractures treated with this plate, 181 were evaluated. A first series of 116 cases analysed in 1997 (follow up 22 months) was enlarged by a recent series of 65 cases (follow up 29 months). According to Duparc, there were 5(2.7%) type II, 69(36.9%) type III, 103(55.1%) type IV, 10(5.3%) type V. According to Sanders there were 67(37%) type 2, 65(36.9%) type 3, 49(27.1%) type 4. The protocol was as follows: fractures were investigated with standard views (including Broden’s views) and CT scans. The average delay before surgery was 5.5 days. Blisters were not a contraindication to surgery, if not obviously infected. Reduction was performed by an extended lateral approach, and checked under fluoroscopy. Joint reduction was fixed by screws. The reconstruction plate, bent in a standard way, was then placed laterally, from above the tuberosity towards the inferolateral part of the anterior process. All but one or two posterior screws ideally converge to the sustentaculum tali (ST), building a strong support below the posterior facet. Postoperatively partial weight bearing below the threshold of pain was allowed in the majority of cases. Clinical results were assessed using the French Orthopaedic Society (SOFCOT) functional score for both series, and AOFAS (American Foot and Ankle Society) score, and Mary-land Foot Score (MFS) for the recent series. RESULTS. According to the SOFCOT, there were 74% good and excellent results. The average MFS was 87/100, the average AOFAS score, 82/100. The average beginning of walking without crutches was 10 weeks. In the second series of 65 cases, 78.4% of active patients went back to their previous job at the same level. Reduction was assessed anatomic on the postoperative Broden view in 90.5% of cases. The average Böhler’s angle remained stable. Secondary fusion of the subtalar joint was required only in 4 cases (2.1%). Wound healing was delayed in 19.7%, but generally, it was spontaneously obtained in a few weeks. Three deep late infections (1.6%) healed after plate removal. DISCUSSION. ORIF of displaced articular calcaneal fractures using a contoured lateral plate has yet become a routine in our institution. The concept of screws converging from the plate to the ST, which is the strongest part of the broken bone, provides both optimal fixation of the primary fracture line (separation fracture), and a solid support below the reduced posterior facet. In most of cases early partial weight bearing did not jeopardize articular reduction, except the 4 (2.2%) significant secondary displacements. Therefore, in very comminuted fractures involving the tuberosity, we rather use of the new AO locked Plate. Conclusion: Because the reconstruction plate was always modelled in the same standardized shape, we developed a specific precontoured thinner plate

Aims

Posterior column plating through the single anterior approach reduces the morbidity in acetabular fractures that require stabilization of both the columns. The aim of this study is to assess the effectiveness of posterior column plating through the anterior intrapelvic approach (AIP) in the management of acetabular fractures.

Purpose: The purpose of this biomechanical study is to compare the double reconstruction plate osteosynthesis versus double tension band osteosynthesis in the fixation of osteoporotic supracondylar humeral fractures. Materials and Methods: Sixteen fresh cadavers (mean age: 75, range:70–80) were randomized into two experimental groups. Same supracondylar transverse humeral fractures were formed in both groups. Fractures in the first group, were fixed with double tension band technique using 2mm in diameter Kirschner wires and 1mm in diameter tension wires. Fractures in the second group, were fixed with double reconstruction plate osteosynthesis using 3,5mm reconstruction plates each fixing medial and lateral columns. Distal fragment was fixed with only one screw. Axial loading, maximum load, failure load and failure patterns were analysed. Statistical analysis was performed with SPSS 13.90 soft ware program. Groups were compared with Mann Whitney U test. Results: Minimum load reqired for fracture displacement was statistically higher in double reconstruction plate osteosynthesis group (p< 0.005). Minumum load reqired for fixation failure was statistically higher in double reconstrution plate osteosynthesis group (p< 0,020). Conclusion: Fracture healing mainly depends on a stable fracture fixation. Double plate ostesynthesis should be preferred over double tension band technique in osteoporotic supracondylar humeral fractures as it provides more stability

Introduction. Plate fixations have been recommended for dislocated clavicle fractures. However, existing plates are inadequate for morphological compatibility with the clavicle. The aim of this study is to measure the anatomical shape of the clavicle and to compare the radiographical and clinical outcomes of our tree-dimensional (3D) reconstruction plate with conventional straight plate. Methods. Chest CT image of 15 patients with normal clavicle were analyzed. Their clavicles were reconstructed and measured their anatomical variables. A hospital-based case-control study was conducted, including a consecutive series of 52 patients with displaced midshaft clavicle fractures. 3D reconstruction plate was used for 26 patients and another 26 patients were treated with conventional straight plate. Outcome measures included the period of bone union, revision surgery, operating times and clinical symptoms using DASH score. Results. The result indicated that plates applying to any shape of the clavicle require a strong curve on the distal part and a twist on the proximal part. A case-control study demonstrated that the conventional straight plate group had higher rate of delayed union and had more symptomatic than the 3D group. Conclusion. The plates with a strong curve on the distal end and a twist on the proximal end exhibit better compatibility with the clavicle. Our 3D reconstruction plate showed superiority in both radiographical and clinical outcome than conventional straight ones

3D printing techniques have attracted a lot of curiosity in various surgical specialties and the applications of the 3D technology have been explored in many ways including fracture models for education, customized jigs, custom implants, prosthetics etc. Often the 3D printing technology remains underutilized in potential areas due to costs and technological expertise being the perceived barriers. We have applied 3D printing technology for acetabular fracture surgeries with in-house, surgeon made models of mirrored contralateral unaffected acetabulum based on the patients’ trauma CT Scans in 9 patients. The CT Scans are processed to the print with all free-ware modeling software and relatively inexpensive printer by the surgeon and the resulting model is used as a ‘reduced fracture template’ for pre-contouring the standard pelvic reconstruction plates. This allows use of the standard surgical implants, saves time on intra-operative plate contouring, and also aids in reduction to an extent. We share through this presentation the workflow of the freeware softwares to use in order to use this surgical planning and implant preparation that may remove the perceived barriers of cost and technology from surgeons that wish to explore using 3D printing technology for acetabular fracture management and may extend applications to other regions

Dual plating of the medial and lateral distal femur has been proposed to reduce angular malunion and hardware failure secondary to delayed union or nonunion. This strategy improves the strength and alignment of the construct, but it may compromise the vascularity of the distal femur paradoxically impairing healing. This study investigates the effect of dual plating versus single plating on the perfusion of the distal femur. Ten matched pairs of fresh-frozen cadaveric lower extremities were assigned to either isolated lateral plating or dual plating of a single limb. The contralateral lower extremity was used as a matched control. A distal femoral locking plate was applied to the lateral side of ten legs using a standard sub-vastus approach. Five femurs had an additional 3.5mm reconstruction plate applied to the medial aspect of the distal femur using a medial sub-vastus approach. The superficial femoral artery and the profunda femoris were cannulated at the level of the femoral head. Gadolinium MRI contrast solution (3:1 gadolinium to saline ration) was injected through the arterial cannula. High resolution fat-suppressed 3D gradient echo sequences were completed both with and without gadolinium contrast. Intra-osseous contributions were quantified within a standardized region of interest (ROI) using customized IDL 6.4 software (Exelis, Boulder, CO). Perfusion of the distal femur was assessed in six different zones. The signal intensity on MRI was then quantified in the distal femur and comparison was made between the experimental plated limb and the contralateral, control limb. Following completion of the MRI protocol, the specimens were injected with latex medium and the extra-osseous vasculature was dissected. Quantitative MRI revealed that application of the lateral distal femoral locking plate reduced the perfusion of the distal femur by 21.7%. Within the dual plating group there was a reduction in perfusion by 24%. There was no significant difference in the perfusion between the isolated lateral plate and the dual plating groups. There were no regional differences in perfusion between the epiphyseal, metaphyseal or meta-diaphyseal regions. Specimen dissection in both plating groups revealed complete destruction of any periosteal vessels that ran underneath either the medial or lateral plates. Multiple small vessels enter the posterior condyles off both superior medial and lateral geniculate arteries and were preserved in all specimens. Furthermore, there was retrograde flow to the distal most aspect of the condyles medially and laterally via the inferior geniculate arteries. The medial vascular pedicle was proximal to the medial plate in all the dual plated specimens and was not disrupted by the medial sub-vastus approach in any specimens. Fixation of the distal femur via a lateral sub-vastus approach and application of a lateral locking plate results in a 21% reduction in perfusion to the distal femur. The addition of a medial 3.5mm reconstruction plate does not significantly compromise the vascularity of the distal femur. The majority of the vascular insult secondary to open reduction, internal fixation of the distal femur occurs with application of the lateral locking plate

Aims. Osseointegrated prosthetic limbs allow better mobility than socket-mounted prosthetics for lower limb amputees. Fractures, however, can occur in the residual limb, but they have rarely been reported. Approximately 2% to 3% of amputees with socket-mounted prostheses may fracture within five years. This is the first study which directly addresses the risks and management of periprosthetic osseointegration fractures in amputees. Methods. A retrospective review identified 518 osseointegration procedures which were undertaken in 458 patients between 2010 and 2018 for whom complete medical records were available. Potential risk factors including time since amputation, age at osseointegration, bone density, weight, uni/bilateral implantation and sex were evaluated with multiple logistic regression. The mechanism of injury, technique and implant that was used for fixation of the fracture, pre-osseointegration and post fracture mobility (assessed using the K-level) and the time that the prosthesis was worn for in hours/day were also assessed. Results. There were 22 periprosthetic fractures; they occurred exclusively in the femur: two in the femoral neck, 14 intertrochanteric and six subtrochanteric, representing 4.2% of 518 osseointegration operations and 6.3% of 347 femoral implants. The vast majority (19/22, 86.4%) occurred within 2 cm of the proximal tip of the implant and after a fall. No fractures occurred spontaneously. Fixation most commonly involved dynamic hip screws (10) and reconstruction plates (9). No osseointegration implants required removal, the K-level was not reduced after fixation of the fracture in any patient, and all retained a K-level of ≥ 2. All fractures united, 21 out of 22 patients (95.5%) wear their osseointegration-mounted prosthetic limb longer daily than when using a socket, with 18 out of 22 (81.8%) reporting using it for ≥ 16 hours daily. Regression analysis identified a 3.89-fold increased risk of fracture for females (p = 0.007) and a 1.02-fold increased risk of fracture per kg above a mean of 80.4 kg (p = 0.046). No increased risk was identified for bilateral implants (p = 0.083), time from amputation to osseointegration (p = 0.974), age at osseointegration (p = 0.331), or bone density (g/cm2, p = 0.560; T-score, p = 0.247; Z-score, p = 0.312). Conclusion. The risks and sequelae of periprosthetic fracture after press-fit osseointegration for amputation should not deter patients or clinicians from considering this procedure. Females and heavier patients are likely to have an increased risk of fracture. Age, years since amputation, and bone density do not appear influential. Cite this article: Bone Joint J 2020;102-B(2):162–169

Background. Open reduction and internal fixation using plate osteosynthesis for midshaft clavicle fractures is often associated with hardware prominance. Although clinical studies have suggested a role for the use of thinner 2.7mm plates as a means of increasing cosmetic acceptability this still remains an area of controversy. We investigated the effect of plate size (2.7mm vs. 3.5mm), plate treatment (annealed vs. cold worked) and number of screws on the stiffness and yield point. Methods. Twenty-four synthetic clavicles were randomly divided into four treatment groups - Synthes (Synthes, Paoli, PA) 2.7mm cold-worked calcaneal reconstruction plate with six or eight bicortical screws; 3.5mm LCP reconstruction plate (RP) and 3.5mm LCP pre-contoured superior-anterior clavicle plate (PCSA). After measuring the baseline stiffness of the intact specimens, all clavicles were plated, a wedge-shaped inferior defect was created and testing performed using a cantilever-bending model. Statistical analysis was performed using one-way ANOVA with Tukey's multiple comparison test with significance set at a P value <0.05. Results. The 3.5mm RP construct was significantly stiffer than both of the 2.7mm CR constructs (P < 0.0001). The yield point for the 3.5mm PCSA construct was greater than the other three constructs (P < 0.0001), while the yield point for the 2.7mm CR plate with 6 screws and with 8 screws was higher than the 3.5mm RP construct (P = 0.0002 and P = 0.0023 respectively). The amount of displacement required to reach the yield point was highest for the 2.7mm CR plate with six screws and this was significantly higher than the values for the other three constructs. Conclusion. The 3.5mm plates demonstrated increased bending stiffness compared to the 2.7mm plates. Despite the lower resistance to bending forces, the cold worked 2.7mm plate exhibited a significantly higher yield point and required significantly more superior to inferior displacement to deform

Aim: To compare and evaluate results following fixation of displaced clavicle fracture using three different plates. Methods: Between 1994 and 2001, forty patients with displaced midclavicular fracture were plated with three different type of implants. The mean age of the patients was thirty-four years. Reconstruction Plate was used in twenty, 3.5 mm DCP in ten and 3.5mm LCDCP in ten. Twenty-eight fractures were multifragmentary. The interfragmentary screw technique was used in fifteen cases and one patient required bone grafting. Evaluation: In this retrospective study, the patients’ shoulder function, rate of fracture union, and complications between the three different types of plate were evaluated and compared. Results: Patients whose fracture was treated with DCP or LCDCP all achieved union within three months. One LCDCP lifted laterally after the patient went back to manual work within two weeks. Of the patients whose fracture was treated with reconstruction plate (20), only twelve united uneventfully within three months. Eight complications were recorded. Delayed union occurred in three, loss of fixation in two and the plate bent in the remaining three. All the complications were observed in multifragmentary fractures. Conclusion: The more malleable reconstruction plate appeared to deform under load when used in the fixation of displaced multifragmentary clavicular fracture. We recommend the stronger LCDCP in this situation

We report the case of a 74-year-old woman who sustained an intertrochanteric fracture of the femoral neck in a previously arthrodesed hip. The hip arthrodesis had been performed 53 years earlier to treat septic arthritis. The fracture was treated successfully using a double-plating technique with 4.5 mm titanium reconstruction plates

Purpose of the study: Because of the difficulty of maintaining anatomic reconstruction, plate fixation is limited for complex fractures of the calcaneum. Implants with angular stability can broaden classical indications and improve outcome. Material and method: From February 2004 to February 2008 we treated 35 articular fractures of the calcaneum: 26 male, 6 female, 3 bilateral cases, mean age 41.46±15.99 years, age range 17–71, ≥ 3 displace fragments [Duparc IV:16; Duparc V: 16], preoperative CT [Sanders III: 22; IV: 13]. The surgical procedure was performed by one operator on days 4 to 7: lateral wide-L incision; articular and extra-articular reduction; lateral fixation using an AO-LCP. ®. plate with locking screws. Intra- and postoperative X-rays (Boehler angle, talo- and cubocalcaneal congruence), postoperative CT. Rehabilitation: mobilisation of the talocalcaneal joint on day 21; partial weight bearing after 2 months; complete weight bearing after 3 months. Radiological and clinical (Kitaoka) follow-up every 60 months. Results: Anatomic joint reduction was achieved and maintained by osteosynthesis (35/35). Late healing (smoking) (6/35). Healing: 2 months (21/35), 3 (14/35). Plate failure at 3 months without displacement (2/35). Anatomic joint reduction sustained ≥12 months (35/35). Gait without crutches after three months (35/35). Infection at 12 months (1/35). Mean follow-up (40 months, range 12–60). Discussion: The purpose of surgical treatment is to achieve anatomic reconstruction of all joint surfaces and restore calcaneal height, length, width and alignment until bone healing. Complex joint fractures with a high risk of loss of correction or secondary nonunion have limited the use of conventional reduction-osteo-synthesis methods in favour of first-line reconstruction-arthrodesis. These complex fractures require plates with multiple fixations to maintain stability. Optimal recover of function can be achieved if the anatomic reduction of the joint surface and extra-articular elements can be maintained stable from the start and sustained to healing, demonstrating the usefulness of reconstruction. No series has reported this innovating therapeutic concept. Conclusion: The reconstruction plate with locked screws enabled osteosynthesis of the most complex calcaneal joint fractures for which the discussion remains open concerning the role of osteosynthesis. The resistant fixation of all the fragments using screws with angular stability enabled stable reconstruction without loss of primary reduction, either secondarily or late, and allowed rapid rehabilitation. The long-term stability of the anatomic reconstruction guarantees good functional outcome which persists over time

Aims

Large bone defects resulting from osteolysis, fractures, osteomyelitis, or metastases pose significant challenges in acetabular reconstruction for total hip arthroplasty. This study aimed to evaluate the survival and radiological outcomes of an acetabular reconstruction technique in patients at high risk of reconstruction failure (i.e. periprosthetic joint infection (PJI), poor bone stock, immunosuppressed patients), referred to as Hip Reconstruction In Situ with Screws and Cement (HiRISC). This involves a polyethylene liner embedded in cement-filled bone defects reinforced with screws and/or plates for enhanced fixation.

Non operative treatment of supracondylar fractures of the humerus has almost always resulted in failure. Closed reduction followed by prolonged immobilization until union, may be associated with an acceptable X-ray but with unacceptable function because of marked stiffness. Traction and early motion preserves movement but the incongruity of the joint leads to instability, early post-traumatic arthritis and pain. Traction also requires prolonged hospital admission which is not possible in modern health care settings. Attempts at early motion without reduction, the so called “bag of bones treatment” leads to gross malunions, non-unions and poor function. In order to function normally an elbow requires stability, a congruent articulation, freedom from pain, and a functional range of motion. After fracture one can achieve a normal elbow only after anatomic reduction fracture which is combined with absolutely stable fixation and early motion. These fractures are classified according to the Comprehensive Classification into Types: A, B, and C, with their respective groups and subgroups, all arranged in an ascending order of severity. Once a surgeon classifies a fracture he gains insight into the associated problems in treating it. Classification thus helps in proper decision making. In young patients these fractures are usually the result of a high energy trauma. Although multifragmentary and at times open, these are fractures of normal bone and are therefore often amenable to secure fixation. In the elderly the commonest mechanism is a slip and fall on to the point of the elbow. The olecranon is driven into the trochlea and splits the osteoporotic condyle of the humerus into a multitude of fragments. The resultant fractures are multifragmentary, displaced and often defy attempts at reduction and fixation. When one is deciding on treatment the factors which must be considered are patient factors, the fracture factors, and the treatment factors. The most important factors are: the patients age and the degree of osteoporosis, the comminution and displacement of the fractures, the association of neurovascular injuries, and whether the fracture is open or closed. An open reduction and internal fixation is best performed with the patient on the side with the injured elbow uppermost, or with the patient prone. The best surgical approach is posterior. Once the skin is incised one must isolate and protect the ulnar nerve. The facture is exposed by carrying out an osteotomy of the olecranon. In elderly patients in whom a prostheses might become the salvage, one should consider using a triceps splitting approach or a triceps peal as for an elbow arthroplasty. Commence fixation with an anatomic reduction of the trochlear fragment to the capitellar fragment. If bone is missing than instead of lag screws one uses fully threaded screws to prevent the narrowing of the distal articulation. Once securely fixed, the articular complex is fixed to the metaphysis and shaft. The fixation is carried out with two plates which should be positioned at 90 degrees to each other to achieve the strongest biomechanical construct. The plates commonly used are the 3.5mm LCDCP plates or the 3.5mm reconstruction plates. The choice of one or the other plate depends on the fracture pattern and on the necessary contouring of the plates. The usual choice are two reconstruction plates one medially and one posteriorly contoured to fit the posterior aspect of the capitellum which is devoid of articular cartilage. Such fixation is particularly useful in distal fractures. If there is metaphyseal bone loss one should use at least one LCDCP since these are stronger than the reconstruction plates. Post-operatively the elbow is immobilized in 120–150 degrees of extension and is elevated for 24–48 hours. Early active motion should commence no later than day three in order to regain a range of motion. Delay in internal fixation beyond day 5 often leads to the formation of heterotopic bone with marked stiffness. If surgery is delayed the patient should receive Indocid to prevent heterotopic bone formation. If heterotopic bone develops and blocks motion it should be resected early. One should not delay until the alkaline phosphatase and the bone scans return to normal. Supracondular fractures in the elderly present special problems since they defy attempts at reduction and stable fixation. As a result many elderly patients, whether operated or not, end up with poor and painful elbow function. To prevent these therapeutic disasters recently primary total elbow arthroplasty has been used as a primary form of treatment. Bernard Morrey published encouraging early results of elderly patients with supracondylar fractures treated primarily with the semi-constrained Coonrad Morrey prosthesis. Since then this rationale has been adopted by a number of trauma centers and there are numerous multicenter trials underway to evaluate this form of treatment and place it in its proper perspective. Open supracondylar fractures present a special problem. If they occur in young patients with good bone and if they are reconstructible, then after a thorough irrigation and debridement a primary open reduction and internal fixation should be carried out. If stable fixation is not possible one should carry out an open reduction and fixation of the articular component, and span the elbow with an external fixator. Once a stable and closed soft tissue envelope has been achieved one can carry out a delayed reconstruction of the metaphyseal component. This greatly reduced risks of infection. In elderly patients with osteoporotic bone this may not be possible as indicated. Every open fracture must be irrigated and debrided. Stable internal fixation greatly lessens the risk of infection. Because of poor bone mobilization of the joint in these patients must be delayed and the internal fixation often supplemented with external fixation to prevent fixation failure. A primary arthroplasty should not be considered because of the risk of sepsis. In young patients with good bone with Type C1 and C2 fractures 80–90% of good functional results are to be expected. C3 fractures particularly if open and fractures in the elderly, except those treated with primary arthroplsty, lead to unsatisfactory outcomes

Aims

The aim of this study was to evaluate the outcome of complex radial head fractures at mid-term follow-up, and determine whether open reduction and internal fixation (ORIF) or radial head arthroplasty (RHA) should be recommended for surgical treatment.

Aims

The aims of this network meta-analysis (NMA) were to examine nonunion rates and functional outcomes following various operative and nonoperative treatments for displaced mid-shaft clavicle fractures.

Aim. Evaluate the outcome and complications of anterior pubic symphysis plating in the stabilisation of traumatic anterior pelvic ring injuries. Methods. All patients who underwent pubic symphysis plating in a tertiary referral unit were studied. Fracture classification, type of fixation, complications, and incidence of metalwork failure were recorded. Results. Out of 178 consecutive patients, 159 (89%) were studied for a mean of 41 months. There were 121 males and 38 females (mean age 38 years). Symphysis pubic fixation was performed in 105 AO-OTA type B and 54 type C injuries using a Matta symphyseal plate (n = 92), reconstruction plate (n = 65), or DCP (n = 2). Supplementary posterior pelvic fixation was performed in 103 patients. 6 patients required revision for failure of fixation or symptomatic instability of the pubic symphysis. A further 7 patients had metalwork removed for other reasons. Metalwork breakage occurred in 66 patients (42%), at a mean of 17 months. 64 of these 66 patients were asymptomatic and metalwork was left in situ. Conclusions. Plate fixation of the symphysis pubis is an effective method of stabilising anterior pelvic ring injuries with a low complication rate. There is a high rate of late metalwork breakage, but this is not clinically significant

There is controversy regarding the optimum method of stabilising traumatic anterior pelvic ring injuries. This study aimed to evaluate the role of pubic symphysis plating. Methods. All patients who underwent pubic symphysis plating in a regional pelvic and acetabular unit were studied. Fracture classification, type of fixation, complications, and incidence of metalwork failure were recorded. Results. Out of 178 consecutive patients, 159 (89%) were studied for a mean of 37.6 months. There were 121 males and 38 females (mean age 43 years). Symphysis pubic fixation was performed in 100 AO-OTA type B and 59 type C injuries using a Matta symphyseal plate (n=92), reconstruction plate (n=65), or DCP (n=2). Supplementary posterior pelvic fixation was performed in 102 patients. 5 patients required revision for failure of fixation or symptomatic instability of the pubic symphysis. A further 7 patients had metalwork removed for other reasons. Metalwork breakage occurred in 63 patients (40%). 62 of these 63 patients were asymptomatic and metalwork was left in situ. Conclusions. Plate fixation of the symphysis pubis is an effective method of stabilising anterior pelvic ring injuries with a low complication rate. There is a high rate of late metalwork breakage, but this is not clinically significant

This report reviews the long-term results of treating acetabula with unusually severe problems, such as pelvic discontinuity or major column loss after failed total hip arthroplasty (THA) and reconstruction problems. Loss of acetabular bone stock results from removal of bone during the original procedure, prosthetic failure, and osteolysis. In massive structural failure, the acetabular rim, quadrilateral plate, and associated columns become deficient. At worst, this may be combined with pelvic discontinuity and disruption of the ilium and ischium. Prosthetic protrusio may result from fixation loss and be associated with scarring of the femoral vessels, femoral nerve, ureter and bowel. A variety of implants has been used to in ace-tabular reconstruction. The results are often poor because of insufficient bone stock to support the implant. In a consecutive series of 251 THA revisions done between 1988 and 1996, 17 patients were treated for major pelvic column loss, pelvic discontinuity or both. In five patients, a posterolateral approach without trochanteric osteotomy was used. The extensile triradiate approach with ilioinguinal extension was used in 12 patients in whom severe prosthetic protrusio increased the risk of intrapelvic iatrogenic injury. A long anterior column pelvic plate was applied. A posteriorly placed AO 4.5-mm pelvic reconstruction plate with 10 to 12 holes was used in nine cases of pelvic discontinuity and in five cases of posterior column bone loss. This plate extended from the most inferior extent of the ischium across the wall of the posterior column to a point high on the ilium. Anterior column fixation was done in eight of nine cases of pelvic discontinuity and all three cases of anterior column deficiency. This called for an 8 to 12-hole 3.5-mm AO pelvic reconstruction plate that extended from the pubic symphysis across the pelvic rim. This spanned the anterior column defect, ranging from 4 cm to 8 cm, to the medial wall of the ilium. Bulk allograft was used in 16 of the 17 patients. The patient in whom allograft was not used had pelvic discontinuity following pelvic irradiation. Whole pelvic acetabular transplants were used in seven with severe bone loss or following resection for chondrosarcoma and the other for pigmented or villonodular synovitis. Posterior segmental acetabular allograft was used in two cases of posterior column absence. Femoral heads were used in two posterior column defects, three pelvic discontinuities with anterior column defect, and two anterior column defects. Acetabular components were cemented in six of seven whole bulk ace-tabular transplants, six of nine pelvic discontinuities and two anterior column defects. Cemented implants were classified as loose if there was a complete radiolucent line at the bone cement interface, measurable component migration or measurable change in position. Uncemented acetabular components were considered loose if component migration had occurred or screws had broken. Pelvic plates were considered loose if there was measurable migration or change in plate position or if fixation screws had backed out or broken. Radiographic union was considered present when bridging callus or trabecular bone was visible across the discontinuity site. Junctional healing was considered probable when radiographs did not show obvious signs of failure. Grafts were considered unhealed if there was obvious displacement, bone gaps or hardware breakage. Seven of the nine patients with pelvic discontinuity had late evidence of healing of the fracture and allograft consolidation. One underwent removal of the graft at three weeks after developing acute postoperative infection: early junctional healing of a whole bulk acetabular allograft required an osteotomy to break up the interface. Another patient, who underwent removal of the graft and implant at three months for chronic infection, had consolidation of a whole bulk ace-tabular allograft. One patient underwent revision of a pressfitted acetabular component at 60 months, and the pelvic discontinuity was solidly united. In a fourth patient, explored at 124 months for loosening of a cemented cup, there was near complete dissolution of the graft posterior acetabular wall and a loose posterior pelvic plate. In a patient with pelvic discontinuity after radiation therapy for uterine carcinoma, satisfactory healing of the pelvic discontinuity was confirmed at 32 months, when excisional arthroplasty for late chronic infection followed urinary sepsis. Seven patients had major column loss with severe cavitary defects. Consolidation of the allograft was noted in all seven within the first 12 months of follow-up. Revision (47%) was required for infection in three patients, implant loosening in four, and recurrent implant dislocation in one. The four loose cups were revised to a cemented all-polyethylene component. All four implants had been placed on less than 50% host bone. None of the four has required subsequent revision. Dislocation postoperatively occurred in eight patients. In six, the extensile triradiate approach had been used. This approach led to dislocation in 50%. The main reasons for using the extensile triradiate approach were to avoid catastrophic injuries by direct exposure of vital structures and to allow stable anterior column plate fixation. In that no neurovascular injuries occurred and stable durable allograft consolidation and healing of pelvic discontinuity took place, these goals were largely met. Three patients developed late sciatic palsy. In one, plaster immobilisation had possibly caused direct pressure over the fibular head and led to chronic peroneal palsy. The other two underwent additional exploration of the sciatic nerve for late entrapment caused by migration of screws from the posterior column plate. Two patients developed bladder infections postoperatively. Another developed superficial phlebitis of the lower leg. Acetabular revision for loosening was necessary in three of seven cementless implants, while only two of 10 cemented implants failed. The acetabular component should be cemented into the allograft when more than 50% of the prosthetic interface is non-viable. Virtually all graft material, including dense cortical grafts, may ultimately fail if used for implant fixation. Patients should be told about the inevitable risks. However, techniques used led to stable healing of the pelvic discontinuity in most cases. Long pelvic plates that securely stabilise the pelvis and allografts carefully opposed to host bone may explain the relative success in this series