The purpose of this study was to identify factors that predict implant cut-out after cephalomedullary nailing of intertrochanteric and subtrochanteric hip fractures, and to test the significance of calcar referenced tip-apex distance (CalTAD) as a predictor for cut-out.

We retrospectively reviewed 170 consecutive fractures that had undergone cephalomedullary nailing. Of these, 77 met the inclusion criteria of a non-pathological fracture with a minimum of 80 days radiological follow-up (mean 408 days; 81 days to 4.9 years). The overall cut-out rate was 13% (10/77).

The significant parameters in the univariate analysis were tip-apex distance (TAD) (p <  0.001), CalTAD (p = 0.001), cervical angle difference (p = 0.004), and lag screw placement in the anteroposterior (AP) view (Parker’s ratio index) (p = 0.003). Non-significant parameters were age (p = 0.325), gender (p = 1.000), fracture side (p = 0.507), fracture type (AO classification) (p = 0.381), Singh Osteoporosis Index (p = 0.575), lag screw placement in the lateral view (p = 0.123), and reduction quality (modified Baumgaertner’s method) (p = 0.575). In the multivariate analysis, CalTAD was the only significant measurement (p = 0.001). CalTAD had almost perfect inter-observer reliability (interclass correlation coefficient (ICC) 0.901).

Our data provide the first reported clinical evidence that CalTAD is a predictor of cut-out. The finding of CalTAD as the only significant parameter in the multivariate analysis, along with the univariate significance of Parker’s ratio index in the AP view, suggest that inferior placement of the lag screw is preferable to reduce the rate of cut-out.

Cite this article: Bone Joint J 2014; 96-B:1029–34.

High energy chest trauma resulting in flail chest injury is associated with increased rates of patient morbidity. Operative fixation of acute rib fractures is thought to reduce morbidity by reducing pain and improving chest mechanics enabling earlier ventilator weaning.

A variety of operative techniques have been described and we report on our unit's experience of acute rib fracture fixation. Over 18 months, 10 patients have undergone acute rib fracture fixation. Outcome measures included; patient demographics, time ventilated pre-operatively, time ventilated post-operatively and time spent on ITU/HDU post operatively.

The mean time from presentation to surgery was 5 days (range 2–12 days). The mean time ventilated post operatively was 2 days (range 1–4 days) and the mean number of days spent on ITU/HDU post-operatively was 6 days (range 2–11 days).

Our results appear positive in terms of time spent ventilated post-operatively but no conclusion can be drawn as we have no comparable non-operative group. We have however shown, that rib fracture fixation can be carried out successfully and safely in a trauma centre. Further evidence on rib fracture fixation is required from a large, multi-centre randomised controlled trial.

The aim of this study was to evaluate the results of a consecutive series of distal tibial fractures treated by percutaneous plating.

85 patients with distal tibial fractures were treated using minimally invasive medial plate fixation. 18 patients had open fractures. Eight had displaced intra-articular fractures (AO type 43C). The majority had extra-articular fractures (AO type 42 or 43A). Patients ranged in age from 16–89 years. All were followed to union with a minimum follow-up period of 6 months (average 47 months). Outcome measures assessed retrospectively were alignment, time to full weight bearing and complications including infection, delayed or non-union and secondary surgery.

The mean time to surgery after injury was 5 days (range 0–22). 51 patients had unlocked pre-contoured plates and the remaining 34 had locking plates. The fibula was plated in 41 cases. Post-operative mal-alignment greater than 5 degrees varus or valgus occurred in 3 cases (3.5%). The average time to full weight bearing was 11 weeks. Superficial infection occurred in 6 patients (7%) and deep infections in 4 cases (4.7%). There was one case of plate fracture. 4 patients, including this case, required further surgery to achieve union. There was a high rate of metalware symptoms that prompted plate removal.

Percutaneous plate fixation of distal tibial fractures is a reliable method of treatment with complication rates lower than reported for open techniques.

Deterioration in knee joint proprioception has been postulated to occur following injury, resulting in further instability due to disruption of receptors and feedback mechanisms. Surgical reconstruction techniques may also influence post-operative proprioceptive ability (PA). We hypothesised that anterior cruciate ligament (ACL) reconstruction techniques which disrupt the knee capsule would result in a decrease in PA.

Following ethical approval, a total of 48 subjects (mean age: 28.1 ± 10.5, 34 male, 14 female) undergoing ACL reconstruction surgery were included in the study. Fifteen subjects underwent “open” capsule ACL surgery and patellar tendon graft, whereas 33 subjects had “closed” capsule surgery with a hamstring tendon graft. Knee proprioception was measured on a custom-designed test apparatus incorporating electromagnetic position sensors (Polhemus Fastrack) located on femoral and tibial landmarks to accurately track knee angle during flexion-extension (no load). Leg flexion-extension under partial weight-bearing (5kg) was also evaluated. Pre-operative PA was assessed bilaterally, and then again on operated joints at three, six and twelve months post-op. Proprioceptive ability was measured as the cumulative absolute error in knee angle (°) between five repeat measurements and a target angle.

We observed no significant difference in PA between injured and contralateral knees prior to ACL reconstruction. Post-operatively, no significant difference in PA was observed between “open” versus “closed” ACL techniques, irrespective of loading conditions. While trends indicated that PA during knee extension (no load) and leg flexion (partial weight-bearing) improved over the 12 months compared to pre-operative values in closed ACL surgery, these were not significantly different to open ACL results.

The proportion of subjects whose PA improved in at least two out of the three post-op evaluations was also similar (approx 50%) across all groups, irrespective of joint loading. The only difference was PA during leg flexion under partial weight bearing, where 27% of open ACL surgery patients showed improvement in two or more follow-up tests, as opposed to 58% of closed ACL surgery patients.

We present a method to determine pre- and postoperative PA during knee flexion/extension under no load as well as under partial weight-bearing. We saw no significant difference in PA of the knee under no-load versus load. We also saw no significant difference in postoperative PA following open capsule, patellar tendon graft versus closed capsule, hamstring tendon graft ACL reconstruction technique after 1 year follow-up.

The purpose of this study was to evaluate the results of LISS fixation of distal femur fractures

This is a single-centre review of 64 consecutive LISS plates used for distal femoral fractures over 5.5 years. No patients were excluded and all were followed for a minimum of one year (mean 37 months). Primary outcomes were time to union, knee ROM, Knee Outcome Survey Activities of Daily Living Scale and SF-36 scores. Secondary outcomes were fracture alignment, additional surgery and complications.

Sixty-four fractures were followed in 62 patients with a bimodal distribution of age (mean 66 yrs, 14–98 years). Two major subgroups were young patients (55 and under) with high-energy fractures, most common in men (12:4) and elderly patients with insufficiency or peri-prosthetic fractures, more common in women (11:35). Twenty-two patients died prior to clinical follow-up in the study, but only eight of these died prior to radiological and clinical bony union. No other patients were lost to follow-up. Ninety-four percent of patients achieved within 10 degrees of full knee extension (mean 1.4 degrees), whilst 74% achieved knee flexion > 100 degrees and all achieved 90 degrees. Mean union time was 6.8 months and there was one infected non-union. There were 28 re-operations in 17 patients. Ten were for removal of metal-ware, four required bone grafting and two had revision of fixation.

LISS fixation is a reproducible technique, producing reliable union, low re-operation rates (other than metal-ware removal) and good restoration of knee function. LISS is good for both high and low energy injury patterns and works well in the presence of both knee and hip replacements. We recommend bi-cortical proximal fixation in osteoporotic bone.

This paper presents the experience of a tertiary referral centre for pelvic and acetabular trauma.

From August 1999 a tertiary referral centre was established in Christchurch to provide management for pelvic and acetabular trauma for the South Island. The experience of unit was reviewed.

One hundred and twenty four unstable pelvic and acetabular fractures were treated between August 1999 and March 2005. Ninety two percent of fractures were treated by one or both of two fellowship trained trauma surgeons. While the rate of complications was low, there were 6 significant infections, 3 nerve injuries, and 2 non-unions. The experience of the unit is presented.

A tertiary referral centre for pelvic and acetabular trauma has been able to provide a successful service to the South Island with satisfactory results.

The aim of the study was to evaluate the results of the LISS system for distal femur fractures.

Eighteen consecutive patients with fractures of the distal femur treated with the LISS system were followed until fracture union. This group included intra-articular, extra-articular and periprosthetic fractures occurring from both high and low energy trauma.

Fractures united in 17 out of 18 cases and only 1 patient required bone grafting. The patient with the fracture that didn’t unite had an early above knee amputation for major pressure areas and peripheral vascular disease. There were no infections but 2 cases of plate failure proximally.

The LISS system is a good treatment option for fractures of the distal femur in both the osteoporotic patient and the patient with high energy trauma.

Introduction: Unstable, extra-articular, proximal, tibia fractures are difficult clinical problems often complicated by mal-alignment and soft-tissue breakdown.

Aim: To evaluate the biomechanical properties of a traditional double plating (DP) technique, the Less Invasive Stabilization System (LISS) and hybrid external fixation. Secondarily, the clinical outcomes of an initial series of 20 fractures treated with the LISS system were to be evaluated.

Methods: The axial stiffness and biaxial tilt (varus/valgus and anterior/posterior) of the three systems were tested. Five synthetic tibiae per system were loaded in sequence under the following conditions of instability:

1)Intact.

2)1 cm medial wedge osteotomy (proximal metaphysis).

3)1 cm gap osteotomy.

Twenty proximal tibial fractures treated with the LISS system were reviewed to assess union rates, complications, knee motion and secondary procedures.

Results: There were no significant differences between the different systems when they were used on the intact specimens. The DP system was significantly stiffer axially and in varus tilt than the LISS and the hybrid systems for the wedge osteotomy for all loads. The LISS was significantly stiffer in varus tilt than the hybrid with the wedge at maximal loading. With the gap osteotomy, all three systems were significantly different from each other in both stiffness aspects (DP> LISS> hybrid). The hybrid exhibited axial gap closure at approximately one third of the force of the other systems. No implant failed or exhibited plastic deformation. In the clinical review all fractures united and only three required bone grafting. No fixation failed but there were three deep infections. Over 80% of the cases had knee motion of 90 degrees or better.

Conclusions: The DP was significantly stiffer than both the LISS and the hybrid system for axial displacement and varus tilt at comparable loads for the wedge and gap models. The LISS was significantly stiffer than the hybrid in the completely unstable gap model. The tibial LISS system gave encouraging initial clinical results.

Introduction: Complex acetabular fractures often require an extensile exposure to visualise the fracture adequately. Such extensile exposures have been associated with increased morbidity. Simultaneous iliofemoral and Kocher-Langenbeck approaches offer an alternative to such exposures and do not involve sectioning of the abductor tendons or a trochanteric osteotomy. We have used simultaneous anterior and posterior exposures for complex fractures in which the transverse component is transtectal and for selected both-column fractures. This study reports on the technique and reviews 51 cases performed between 1990 and 1998.

Methods: Combined anterior and posterior surgical approaches were used in 51 of 397 acetabular fracture between 1990 and 1998. A retrospective review of the case notes of all 51 patients was performed and operative times, blood loss and complications were recorded. Pre-operative, post-operative and 12-month follow-up radiographs were assessed for fracture classification, adequacy of reduction and the development of heterotopic ossification. The presence of avascular necrosis and post-traumatic osteoarthritis were also noted.

Results: The average duration of surgery was 4 hours and 40 minutes and the average blood loss was 1735ml. A reduction within 1mm of the anatomic position was achieved in 71% of cases and within 3mm of the anatomic position in 92% of cases. There were two deep infections and two post-operative sciatic nerve palsies. There were two patients who developed Brooker grade IV heterotopic ossification.

Conclusions: Planned simultaneous iliofemoral and Kocher-Langenbeck exposures were performed with operation time, blood loss, fracture reduction and complications comparable with or better than other reported series using extensile exposures. We consider this approach a useful alternative particularly for complex fracture patterns of the acetabulum, which involve a displaced transtectal transverse component.

We report three cases of spontaneous healing of aneurysmal bone cysts (ABC). In one case histological material was obtained after resection of the already ossified expansile mass discovered as a lytic lesion seven months previously. In the two other patients, spontaneous ossification of a radiologically presumed ABC in the lytic and expansile phase was observed after nine and seven months respectively. The healed lesions have remained stable at 12, 32, and 36 months respectively. These findings suggest that when the diagnosis can be made with confidence, and the lesion is in a location and at a stage that does not entail any risk of fracture or compression, expectant management should be considered. Our three patients were aged 22, 19 and 18 years, older than usual for developing ABC. This is also true for many of the few other reported cases of spontaneous or almost spontaneous healing and suggests that ABC has a greater tendency to stabilise in older patients.