Malreduction of tibial articular width in bicondylar tibial plateau fractures treated with circular external fixation is associated with post-traumatic osteoarthritis.

OBJECTIVES: We aimed to report outcomes of Bicondylar Tibial Plateau (BTP) fractures treated using Ilizarov fixation, and identify risk factors for developing post-traumatic radiographic osteoarthritis (ROA). METHODS: Retrospective study of 80 BTP fractures managed with Ilizarov fixation. RESULTS: All fractures united, with only 3 cases of deep infection. ROA was evident in 12.5% at average 13 months post-injury. Increased tibial articular-widening associated with risk of developing ROA (p = 0.02). CONCLUSION: Ilizarov fixation is safe and reliable in the management of BTP fractures. Restoration of tibial articular-width at fixation associated with reduced risk of developing radiographic OA.

Transverse debridement and acute shortening followed by distraction histogenesis in the treatment of open tibial fractures with bone and soft tissue loss.

This retrospective case series evaluates the technique of transverse debridement, acute shortening and subsequent distraction histogenesis in the management of open tibial fractures with bone and soft tissue loss, thereby avoiding the need for a soft tissue flap to cover the wound. Thirty-one patients with Gustilo grade III open tibial fractures between 2001 and 2011 were initially managed with transverse wound extensions, debridement and shortening to provide bony apposition and allowing primary wound closure without tension, or coverage with mobilization of soft tissue and split skin graft. Temporary monolateral external fixation was used to allow soft tissues resuscitation, followed by Ilizarov frame for definitive fracture stabilization. Leg length discrepancy was corrected by corticotomy and distraction histogenesis. Union was evaluated radiologically and clinically. Patients' mean age was 37.3 years (18.3-59.3). Mean bone defect was 3.2 cm (1-8 cm). Mean time to union was 40.1 weeks (12.6-80.7 weeks), and median frame index was 75 days/cm. Median lengthening index (time in frame after corticotomy for lengthening) was 63 days/cm. Mean clinic follow-up was 79 weeks (23-174). Six patients had a total of seven complications. Four patients re-fractured after frame removal, one of whom required a second frame. Two patients required a second frame for correction of residual deformity, and one patient developed a stiff non-union which united following a second frame. There were no cases of deep infection. Acute shortening followed by distraction histogenesis is a safe method for the acute treatment of open tibial fractures with bone and soft tissue loss. This method also avoids the cost, logistical issues and morbidity associated with the use of local or free-tissue transfer flaps and has a low rate of serious complications despite the injury severity.

Closed Tibial shaft fractures treated with the Ilizarov method: A ten year case series.

OBJECTIVES: To review the outcomes of patients treated with the Ilizarov method for an isolated, closed, simple diaphyseal, Tibial fracture at our institution over the last decade. METHODS: The Ilizarov frame database was used to identify 76 skeletally mature patients who sustained an isolated, closed, extra-articular, simple, diaphyseal Tibial fracture; the injury also known as a "nail-able Tibial fracture." RESULTS: The average age of the patient was 38 (17-70). All 76 patients progressed to union. The average time until union was 148 (55-398) days. The coronal and sagittal alignment was 3° (0-17°) and 4° (0-14°) respectively. No patient suffered from compartment syndrome. No patient developed septic arthritis. No patient had documented anterior knee pain or secondary knee specialist input post frame removal. On average, there were 9(4-29) follow up appointments and 10(5-26) radiographs post frame application. There is a 59% chance of a patient having a difficulty post frame application. The malunion rate was 5%. Persisting pinsite infection post frame removal occurred in 5 patients (6.5%). Drilling of the pinsite sequestrum resolved the infection in four of these patients, giving a deep infection rate of 1.3%. CONCLUSIONS: The Ilizarov method has a role to play in the treatment of simple closed Tibial shaft fractures in patients who need to kneel. Patient education is a priority however; the patient must be made aware of the difficulty rate associated with the Ilizarov method when compared to the complication profile of alternative treatments.

Distal radial fractures: the significance of the number of instability markers in management and outcome.

INTRODUCTION: Distal radial fractures are one of the most common orthopaedic injuries. An effective treatment strategy is needed to ensure good outcome and better resource usage. AIM: To identify the significance of the number of instability markers in distal radial fractures in predicting outcome and proposing a standardized management strategy. METHODS: Data was collected retrospectively over three months at the Northern General Hospital, Sheffield. All patients who had a distal radius fracture in the defined time period and matched our criteria were included. Relevant instability markers identified through a literature review were: age >60 years, dorsal angulation >20°, intra-articular fracture, ulna fracture, dorsal comminution, radial shortening and osteoporosis. The number of instability markers, management and outcome were recorded for each patient. The strategy of management was subdivided into: plaster cast immobilisation with subsequent rehabilitation, manipulation with subsequent cast immobilization and surgery (locked volar plating). Outcomes were graded as "good" or "poor" based on the complications and the function achieved at discharge from follow-up. RESULTS: Two hundred and seven patients were included in our study. One hundred and nineteen patients had <3 instability markers (Group A) and 88 had >4 (Group B). One hundred and sixty-two were female and 45 were male. The average age was 60 years and the age range was 19 to 96 years. In Group A, 91% achieved "good" outcome regardless of management strategy, versus 66% in Group B (p<0.001). In Group B, amongst patients who had surgery (29), 79% achieved "good" outcome, however those with manipulation alone (38), only 58% achieved "good" outcome (p > 0.03 (one tailed), p > 0.06 (double tailed)). CONCLUSIONS: We have found that four or more instability markers are globally associated with a poorer outcome. Patients with four or more markers who underwent surgery did uniformly better than those with manipulation alone. However, in patients with three or fewer markers, non-operative management yielded equally good outcomes. We plan to use this as a pilot study for future primary research.