The treatment of calcaneal malunion.

The surgical treatment of calcaneal malunion is technically very demanding and requires a careful assessment of the exact cause of the problem. A number of different surgeries are available depending on the precise cause of symptoms. The results are reasonable and justify surgery in an otherwise disabled group of patients. Calcaneal malunion surgery should not be performed by the occasional surgeon, as the price of error is usually amputation.

Interobserver and intraobserver reliability assessment of calcaneal fracture classification systems.

The aim of the present study was to assess the reliability of commonly used intra-articular calcaneal fracture classification systems and to compare them with the newer AO Integral Classification of Injuries (ICI) system. Forty computed tomography and radiographic images of 40 intra-articular calcaneal fractures were reviewed independently by 3 reviewers on 2 separate occasions and classified according to the Essex-Lopresti, Atkins, Zwipp and Tscherne, Sanders, and AO-ICI classification systems. The reviewers were unaware of the patients' identity and all aspects of clinical care. The data were analyzed using kappa (κ) statistics to assess the intra- and interobserver reliability. The κ values were calculated for Essex-Lopresti (κ = 0.85 intraobserver, κ = 0.78 interobserver), Atkins (κ = 0.42 intraobserver, κ = 0.73 interobserver), Zwipp and Tscherne (κ = 0.40 intraobserver, κ = 0.47 interobserver), Sanders (κ = 0.31 intraobserver, κ = 0.35 interobserver), and AO-ICI (κ = 0.41 intraobserver, κ = 0.33 interobserver). The AO-ICI classification system had levels of reproducibility similar to that of the Sanders classification, currently the most widely used system. The Essex-Lopresti classification demonstrated improved reliability compared with that reported in previous studies. This can be attributed to using sagittal computed tomography images, in addition to the originally described plain radiographs, for assessment. This improvement is relevant because of its accepted prognostic predictability.

Intra-operative correction of Taylor Spatial Frame without a computer.

The Taylor Spatial Frame (TSF) is a circular external fixator used to treat complex fractures and skeletal deformities. The device consists of 2 rings attached to bone by wires or half pins, connected by universal hinge joints to 6 independent telescopic struts, creating a hexapod. The output piece is defined as the movable ring, which has 6 degree of freedom relative to the other ring, which is the base. With 6 degree of freedom, the movable platform is capable of moving in 3 linear directions and 3 angular directions singularly or in any combination. These hexapod devices require complex mathematical software programs to accurately control the output piece. In the case of the TSF, the deformity and positional frame parameters can be indentified on postoperative radiographs. They are then input into internet-based software to calculate strut adjustments required to achieve deformity correction. When treating fractures with the TSF, the rings can be connected using FastFx struts. These struts can be locked in position or left in a sliding mode (unlocked) allowing manual manipulation of the frame to acutely correct the position of the fracture fragments. This reduction is rarely perfect however and often requires further postoperative frame adjustments using software calculations. We describe an intra-operative method for accurately adjusting the frame in its locked mode without the need for software input.

Complications of definitive open reduction and internal fixation of pilon fractures of the distal tibia.

A series of 49 pilon fractures in a tertiary referral centre treated definitively by open reduction and internal fixation have been assessed and the complications of such injuries examined. A retrospective analysis of case notes, radiographs and computerised tomographs over a seven-year period from 1999-2006 was performed. Infection was the most common postoperative problem. There were seven cases of superficial infection. There was a single case of deep infection requiring intravenous antibiotics and removal of metalwork. Other notable complications were those of secondary osteoarthritis (three cases) and malunion (one case). The key finding of this paper is the 2% incidence of deep infection following the direct operative approach to these fractures. The traditional operative approach to such injuries (initially advocated by Rüedi and Allgöwer in Injury 2:92-99, 1969) consisted of extensive soft tissue dissection to gain access to the distal tibia. Our preferred method is to access the tibia via the "direct approach" which involves direct access to the fracture site with minimal disturbance of the soft tissue envelope. We therefore believe that open reduction and internal fixation of pilon fractures via the direct approach to be a safe technique in the treatment of such devastating injuries.

Computer hexapod assisted orthopaedic surgery (CHAOS) in the correction of long bone fracture and deformity.

SUMMARY: We describe a surgical technique using the Taylor Spatial Frame intraoperatively to correct complex multiplanar deformities of the distal femur prior to definitive internal fixation using minimally invasive stabilization techniques. Eight procedures were done in 7 patients. All deformities were complex oblique plane deformities, often with a rotational component, and ranged from 10 degrees valgus to 35 degrees varus; up to 45 degrees of external rotation; 10 mm of translation and in 1 case, 100 mm of shortening. All patients underwent acute intraoperative deformity correction mediated by the Taylor Spatial Frame prior to definitive internal fixation using either a percutaneous locking plate or locked intramedullary nail. Deformity correction and restoration of the mechanical axis were achieved in all cases. There were no cases of wound breakdown, infection, nerve palsy or compartment syndrome. We believe the Taylor Spatial Frame can be effectively and safely used to assist the acute correction and subsequent internal fixation of limb deformity.

Dermal traction on the Ilizarov frame.

We report a technique of skin traction, which harnesses the biological and mechanical properties of skin. We have used this technique in open fractures to close or reduce the size of the wound, thereby avoiding the use of split skin grafts or free flaps and their resultant additional morbidity. This report summarises our early experience with this technique in seven patients. We describe the technique and the results so far.

Fine wire frame-assisted intramedullary nailing of the tibia.

Intramedullary nailing is accepted as the technique of choice for treatment of unstable tibial diaphyseal fractures. Indirect closed reduction must first be obtained to allow passage of the guide wire and reamers. We describe the use of a simple frame that allows precise reduction, control of rotation and easy imaging access, without increasing operating or screening time.