Treatment of posterior malleolar (PM) ankle fractures remain controversial. Despite increasing recommendation for small PM fragment fixation, high quality evidence demonstrating improved clinical outcomes over the unfixated PM is limited. We describe the medium-to-long term clinical and radiographical outcomes in younger adult patients with PM ankle fractures managed without PM fragment fixation.

A retrospective cohort study of patients aged 18-55 years old admitted under our orthopaedic unit between 1st of April 2009 and 31st of October 2013 with PM ankle fractures was performed. Inclusion criteria were that all patients must mobilise independently pre-trauma, have no pre-existing ankle pathologies, and had satisfactory bimalleolar and syndesmotic stabilisation. Open fractures, talar fractures, calcaneal fractures, pilon fractures, subsequent re-injury and major complications were excluded. All PM fragments were unfixated. Clinical outcomes were evaluated using Foot and Ankle Ability Measure (FAAM) with activities of daily living (ADL) and sports subscale, visual analogue scale (VAS) and patient satisfaction ratings. Osteoarthrosis was assessed using modified Kellgren-Lawrence scale on updated weightbearing ankle radiographs.

61 participants were included. Mean follow-up was 10.26 years. Average PM size was 16.19±7.39%. All participants were evaluated for clinical outcomes, demonstrating good functional outcomes (FAAM-ADL 95.48±7.13; FAAM-Sports 86.39±15.52) and patient satisfaction (86.16±14.42%), with minimal pain (VAS 1.13±1.65). Radiographical outcomes were evaluated in 52 participants, showing no-to-minimal osteoarthrosis in 36/52 (69.23%), mild osteoarthrosis in 14/52 (26.92%) and moderate osteoarthrosis in 2/52 (3.85%). Clinical outcomes were not associated with PM fragment size, post-reduction step-off, dislocation, malleoli fractured or syndesmotic injury. PM step-off and dislocation were associated with worse radiographical osteoarthrosis. Other published medium-to-long term studies reported overall good outcomes, with no differences after small fragment fixation.

The unfixated smaller posterior malleolus fragment demonstrated overall satisfactory clinical and radiographical outcomes at 10-year follow-up and may be considered a valid treatment strategy.

Objectives

“Virtual fracture clinics” have been reported as a safe and effective alternative to the traditional fracture clinic. Robust protocols are used to identify cases that do not require further review, with the remainder triaged to the most appropriate subspecialist at the optimum time for review. The objective of this study was to perform a “top-down” analysis of the cost effectiveness of this virtual fracture clinic pathway.

Intramedullary nailing is acknowledged as a safe and effective mode of treatment for many tibial fractures. Implant removal is frequently indicated either as an elective procedure following union or because of problems such as infection or delayed fracture union. It is therefore essential that intramedullary rod removal should be reasonably straightforward and atraumatic.

We describe three cases in which bony growth into the implant has made rod removal either difficult or impossible. We include photographs of two removed implants with clearly visible areas of osseo-integration with bony growth into the cannulation through the interlocking holes as well as radiographs demonstrating the same phenomenon.

The average time between insertion and removal was 16 months. In all cases an end cap had been used such that insertion of the extraction device was straightforward but for two patients nail removal was extremely difficult due to bone ingrowth and in the third patient the nail had to be left in-situ. All three implants were made of titanium and the patients were all active young males. The authors have never encountered this problem with steel rods and speculate that the osteointegrative property of titanium is the major causative factor.

We suggest that unremoved intramedullary rods represent a major risk in fracture management and that close monitoring of these implants should be undertaken.

Aim: To report the early results of the Elite Hylamer hip with Zirconium femoral heads in patients younger than 60 years. Methods: 29 hips were implanted in 26 patients by a single surgeon with a specialist interest in hip arthroplasty. Third generation cementing techniques were used for all implants. All patients have been followed up. There has been one death. Results have been analysed using the life table method using the Peto method for 95% confidence intervals. Results: Mean age 49.2 years (range 31–57). 12 Females and 17 Males.15 of 29 hips (53.3%) have been revised or are currently on the waiting list for revision surgery. These failures have occurred in 7 Females and 8 Males. Mean time to failure 35.4 months (range 18 to 68 months). All failures have been as a result of aseptic loosening. Survivorship analysis reveals a 32.42% survival at 5 to 6 years (6.9% standard error). Conclusions: At the time of its introduction, Hylamer was thought to represent a significant step forward in the reduction of the problem of osteolysis. This however has not been our experience. In the light of the catastrophic failure rate in this series of patients, all postoperative X-rays were critically reviewed. We were unable to observe any dramatic technical errors by way of implant malpositioning and cement mantle deficiencies to account for the observed failures. We have also seen that statistically there is no difference in the hip scores for the patients whose hips have failed and those who have not yet met the criteria for failure. In view of this it is imperative that patients with this implant should be reviewed both clinically and radiologically. We feel that these results should be published earlier rather than later to ensure that others remain vigilant in the follow up of their patients