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Abstract: Introduction and aim: Tibial plateau fractures (TPFs) are an independent, non-modifiable risk factor for surgical site infections (SSIs). Current antero-lateral approaches to the knee dissect through the anterior tibial angiosome (ATA), which may contribute to a higher rate of SSIs. The aim of this study was to develop an angiosome-sparing antero-lateral approach to allow reduction and fixation of lateral TPFs and to investigate its feasibility in a consecutive cohort. Methods: Twenty cadaveric knees were dissected to define the position of the vessels supplying the ATA from the lateral tibial condyle to the skin perforators. Based on these results, an angiosome-sparing surgical approach to treat lateral TPFs was developed. Fifteen consecutive patients were subsequently treated through this approach. Clinical outcomes included assessment of SSI and Lysholm score. Fracture healing and stability were assessed using the Rasmussen score and radiostereometric analysis (RSA). Results: At the latest follow-up between 1 and 4 years, there was no report of SSI. Nine patients (60%) had good or excellent Lysholm scores. The mean Rasmussen score at final follow-up was 17 (median 18, range 14–18) with 10 patients (66%) graded as excellent. Fracture fragment migration measured using RSA was below 2mm in all cases. Discussion: This study has demonstrated that an angiosome-sparing antero-lateral approach to the lateral tibial plateau is feasible. Adequate stability of these fracture types was achieved by positioning a buttress plate away from the bone and superficial to the regional fascial layer as an ‘internal–external fixator’. Conclusion: The angiosome-sparing approach developed was able to be used in a prospective cohort and the clinical results to date are encouraging. Future clinical studies need to investigate the potential benefits of this surgical approach when compared with the previously described antero-lateral approaches. [Copyright &y& Elsevier]

Abstract: Background: It has been suggested that platelet-rich plasma (PRP) might enhance bone formation. The aim of this study was to quantify the effect of PRP administered in the early phases of distraction osteogenesis in an ovine femur model. Methods: Twenty sheep aged 4months underwent osteotomy of the femoral diaphysis followed by distraction osteogenesis. The sheep were divided into two groups of 10. One group received three injections of PRP on days 0, 10, and 20 of the procedure (PRP group) and the other received no additional treatment (control group). The results were evaluated by computed tomography (CT) and histology on completion of distraction osteogenesis (day 40). CT evaluation included measurement of the callus and bone density. Femur size was also measured proximally and distally. Histological evaluation was used to quantify osteoblasts, osteoclasts, vascular lumens, and trabecular maturity by zones and to calculate trabecular bone, fibrous tissue, and cartilage ratios. Results: Radiological and histological evaluation of the regenerate bone showed no significant differences between the PRP group and the control group for any of the variables analysed. The only significant difference detected was a wider femur (increased diaphyseal thickness) at the proximal and distal levels in the PRP group. Conclusion: We found no radiological or histological evidence that the administration of PRP in the early phases of distraction osteogenesis enhances bone formation. [Copyright &y& Elsevier]

Abstract: Aim: The aim of the present study was to compare the primary fixation stability and initial fixation stiffness of two established fixation techniques, the tension band wiring technique and interfragmentary screw fixation, with a mini-screw fragment fixation system in a model of transverse patella fracture. It was hypothesised that the biomechanical loading performance of the fragment fixation system would not significantly differ from the loading characteristics of the two established methods currently investigated. Materials and methods: Ninety-six calf patellae were used in this biomechanical model. A standardized transverse patella fracture was induced and three different fixation methods, including the modified tension band wiring technique, interfragmentary screw fixation, and the mini-screw fragment fixation system, were used for fragment fixation. Specimens were mounted to a loading rig which was secured within a material testing machine. In each fixation group, eight specimens were loaded to failure at a simulated knee angle of either 0° or 45°. Another eight specimens were submitted to a polycyclic loading protocol consisting of 30 cycles between 20N and 300N at a simulated knee angle of 0° or 45°. The residual displacement between the first and the last cycle was recorded. Differences in the biomechanical performance between the three fixation groups were evaluated. Results: No significant differences between the three fixation groups were observed in the parameters maximum load to failure and linear fixation stiffness with monocyclic loading. Specimens being loaded at 45° showed significantly lower maximum failure loads and linear stiffness when compared with 0°. During polycyclic loading, no significant differences in the residual displacement were observed between the groups at 0° loading angle, while at 45°, residual displacement was significantly higher with tension band fixation when compared with interfragmentary screw fixation or the fragment fixation system. Conclusion: The biomechanical performance of the fragment fixation system was comparable to interfragmentary screw fixation and superior to the tension band wiring technique. Given the advantages of a system which provides interfragmentary compression and which simplifies fracture fixation after open or closed reduction, we believe the fragment fixation system to be an adequate alternative in the osteosynthesis of transverse patella fractures. [Copyright &y& Elsevier]

Abstract: Aims and objectives: To measure long-term functional outcome and health-related quality of life following tibial fracture in association with the full spectrum of soft tissue injury. Methods: One hundred and thirty patients with different types of tibial injury were selected from our trauma database. This included 33 patients with compartment syndrome (no underlying fracture), 30 with closed diaphyseal tibial fractures, 45 with grade IIIB/IIIC open fractures and 22 requiring below knee amputation. Mean time to final follow-up was 37.4 months. The EQ-5D (EuroQol) questionnaire was used to assess these patients at this point. Patients had been treated according to standard unit protocols. Open fractures were jointly managed under the care of local plastic and orthopaedic surgeons using a policy of obtaining early soft tissue cover. Results: Patients with reconstructed IIIB fractures reported problems with pain and carrying out their normal activities more frequently than amputees whilst still reporting problems with mobility just as frequently. Anxiety and depression were more common in the patients with open fractures and amputees as were problems with self-care, though the latter were unusual overall. Stepwise logistic regression revealed that tibial injury type was significantly predictive of all measured outcomes except self-care (p <0.0001). Age, ISS, sex and time to follow-up were not significant predictors of response. Conclusions: These results show that patients with these injuries still report long-term problems with their health-related quality of life, though to varying degrees. This information is useful when determining the treatment options for these patients and it is important that it is shared with the patient prior to surgery where possible. [Copyright &y& Elsevier]

Summary: Objective: To evaluate and present our current clinical experience in the treatment of closed and open tibial shaft fractures using the expandable intramedullary nailing system. Design: Prospective study. Setting: One level-1 trauma centre. Participants: Twenty-six patients with acute tibial shaft fractures with at least 10cm of intact cortex on both sides of the fracture. Intervention: Internal fixation using the Fixion expandable intramedullary nail (Disc-O-Tech Medical Technologies Ltd., Herzliya, Israel). Main outcome measurements: Operative and fluoroscopy time, healing time and perioperative complications were recorded. Results: Twenty-six tibial fractures were treated (OTA classification: 3 type A1, 8 A2, 8 A3, 3 B1, 3 B2, and 1 B3), six of which were open. All fractures healed by week 18.5 with an mean of 12.8±3.8 weeks. The operating time ranged from 20 to 50min with an mean of 40±12.17min. The fluoroscopy time ranged from 6 to 22s with a mean of 10±5s. In one case the nail failed to expand, as detected by X-ray control, and had to be exchanged intraoperatively. Two patients reported anterior knee pain during the follow up, but did not wish any further treatment. In a low demanding patient rotational malalignment was noted and no further action needed. Conclusion: According to the results of this study, the use of the Fixion nailing system, where indicated, is associated with minimal complications and very good functional outcomes in fractures OTA types A and B. The advantages of the expandable nail include the decrease in the operating and fluoroscopy time and the simplicity of its application. [Copyright &y& Elsevier]

Summary: A retrograde femoral nail was designed to slide over the tip of the femoral stem. Eighteen patients (4 ♂, 14 ♀) were treated with this retrograde nail between 1995 and 2003. The mean age was 81.4 years (range 61–96) with a mean follow-up of 21 months (range 4–61 months). Eight patients suffered from severe comorbidity. Mean surgical time was 91min. Fourteen patients regained their preoperative functional level. Six patients died within the first post-operative year of natural causes. Their knee- and hip-function were reasonable considering the age group and co-morbidity. One revision was required and one patient had a protruding nail. In all patients radiological union of the fracture was seen between 4 and 12 months after surgery. Retrograde bridging nailing of the periprosthetic fractured femur is a therapeutic option in geriatric or impaired patients and can serve as a definitive implant. [Copyright &y& Elsevier]

Summary: Between April 1996 and May 2002, 22 people (18 men, 4 women) were treated for neglected fractures of the patella at our hospital. The median patient age was 43 (range 22–55) years. The majority of the fractures were caused by a direct fall on the knee. In all they comprised 18 transverse, 2 comminuted and 2 lower pole fractures, most of which had been treated by traditional methods initially. The median time between injury and surgery was 3 (range 2–6.5) months. Treatment methods in the orthopaedic department included tension band wiring in 16 cases, tension band wiring with cerclage in 3 cases and patellectomy in 3 cases. Results were evaluated after a median follow-up period of 5.5 (range 2–9) years and were based on Bostman criteria. Excellent results were achieved in 5 and good results in 15 cases. The poor results in two cases were due to infection and implant failure. Surgical treatment of neglected fractures of patella can thus lead to favourable outcomes. [Copyright &y& Elsevier]

Summary: Background: Studies have shown that women are at higher risk of sustaining noncontact anterior cruciate ligament (ACL) injuries in specific sports. Recent gait studies of athletic tasks have documented that gender differences in knee movement, muscle activation, and external loading patterns exist. The objective of this study was to determine in a knee cadaver model if application of female-specific loading and movement patterns characterised in vivo for a stop-jump task cause higher ACL strains than male patterns. Methods: Gender-specific loading patterns of the landing phase of the vertical stop-jump task were applied to seven cadaver knees using published kinetic/kinematic results for recreational athletes. Loads applied consecutively included: tibial compression, quadriceps, hamstrings, external posterior tibial shear, and tibial torque. Knee flexion was fixed based on the kinematic data. Strain of the ACL was monitored by means of a differential variable reluctance transducer installed on the anterior-medial bundle of the ACL. Findings: The ACL strain was significantly increased (P <0.05) for the female loading pattern relative to the male loading pattern after the posterior tibial shear force was applied, and showed a similar trend (P =0.1) to be increased after the final tibial torque was applied. Interpretation: This study suggests that female motor control strategies used during the stop-jump task may place higher strains on the ACL than male strategies, thus putting females at greater risk of ACL injury. We believe these results suggest the potential effectiveness of using training programs to modify motor control strategies and thus modify the risk of injury. [Copyright &y& Elsevier]

Summary: The vast majority of tibial plateau fractures heal uneventfully, and no case series on intraarticular tibial plateau nonunions exists. The purpose of the present study was to evaluate the radiographic and clinical outcome of these nonunions following surgical treatment in a single surgeon series. Five patients with tibial plateau nonunions were treated at our institution using a specific treatment protocol consisting of open reduction and debridement, deformity correction, internal fixation including lag screws, bone graft augmentation, and selective knee joint arthrolysis. Patient outcomes were assessed using radiographs and the Knee Society questionnaire scores. Following surgical treatment of the nonunion, all healed at an average of 12.8 weeks, and average follow-up was 44 months. Preoperative coronal plane deformity was corrected in all patients. The final knee motion arc averaged 120° postoperatively. Both the pain and function subscales of the Knee Society Rating scale improved significantly. Four of the five returned to their normal pre-injury activities, but two patients required total knee arthroplasty which was performed successfully after healing of the nonunion. With meticulous surgical technique and a standard protocol, healing may be reliably achieved. Arthrosis occurs frequently, and may occur primarily at the time of injury or from chronic alteration of intraarticular contact forces secondary to development of a nonunion. [Copyright &y& Elsevier]

Summary: Background: The diagnosis of posterolateral instability of the knee is often based on a typical indirect mechanism of injury, a history of “giving way” and a positive dial test. Our search of the English literature revealed no mention of including the valgus stress test in the diagnostic protocol for posterolateral instability. Hypothesis: Based on our experience, we hypothesised that a medial collateral ligament (MCL) tear will also produce a positive dial test and that a valgus stress test would provide differential diagnostic information. Methods: The MCL''s of 14 fresh cadaveric knees (7 cadavers) were cut to simulate a grade 3 tear, taking care not to damage the medial retinaculum or the posteromedial stabilisersrs of the knee. The amount of tibial external rotation (the dial test) was measured for each knee before and after transection of the MCL. Results: The results of the dial test after transection of the MCL were similar to those stemming from a solitary injury to the posterolateral corner. There was a significant increase in external rotation of the knee in 30° and 90° of flexion. More over, external rotation in 30° was significantly greater than external rotation in 90° of knee flexion. Conclusions: Whenever suspecting a posterolateral complex injury, one has to carefully perform a valgus stress test in 0° and 30°. Although the support of a clinical study is needed in order to make a definite conclusion, the dial test is probably not reliable in the presence of medial instability, and alternative diagnostic measures should be used. [Copyright &y& Elsevier]

Summary: Study design:: Experimental evaluation of intracompartmental pressures in a fresh above knee amputated human leg. Objectives:: To determine what effect raised pressure in one compartment of the lower leg had upon its neighbour. Summary of background data:: There has been no previous reports of isolated compartment pathology, following low velocity trauma, causing a compartment syndrome in all four compartments of the lower leg. Methods:: Immediately after leg amputation, the intracompartmental pressure in the deep posterior compartment was artificially raised to 100mmHg with infused 0.9% sodium chloride solution. The resultant pressure changes in remaining compartments were recorded over 30min. Results:: Five legs were evaluated. After 30min, the mean maximum intracompartmental pressure increase found in the superficial posterior, anterior and peroneal compartments was 78.4mmHg (range 65–94mmHg), 25.2mmHg (range 14–31mmHg) and 24.8mmHg (range 15–31mmHg), respectively. Conclusions:: This experimental data and case reports show that a compartment in which there is raised pressure may exert external pressure on a neighbouring compartment that can result in physiological changes to induce a compartment syndrome within that neighbour. The importance of assessing all compartments within a limb segment, even when associated with low velocity trauma, remains paramount. [Copyright &y& Elsevier]

Summary: The purpose of this study was to use multivariate analysis to evaluate contributing factors affecting deep infection and nonunion of open femoral fractures treated with locked intramedullary nailing (IMN). We examined 89 open femoral fractures (88 patients) treated with immediate or delayed locked IMN in static fashion at the Kitasato University Hospital from 1988 to 2001. Multiple regression models were derived to determine predictors of deep infection and nonunion. The following predictive variables of deep infection were selected for analysis: age, sex, Gustilo type (I+II or III), fracture grade by AO type (A or B+C), fracture site (proximal site+distal site or middle site), timing or method of IMN, reamed or unreamed nailing (R versus UR), debridement time (≤6h or >6h), existence of polytrauma (ISS&#60;18 or ISS≥18), and existence of floating knee injury (+ or −). The predictive variables of nonunion selected for analysis were the same as those for deep infection, with the addition of deep infection (+ or −). Five fractures (5.6%) developed deep infections: one Gustilo type II and four type III. Multivariate analysis revealed that only Gustilo type significantly correlated with occurrence of deep infection (p &#60;0.05). Nonunion occurred in 12 fractures (14.1%). Multivariate analysis revealed that only fracture grade by AO type significantly correlated with occurrence of nonunion (p &#60;0.02). [Copyright &y& Elsevier]

Summary: Categories of displaced and undisplaced stable ankle fracture are well recognised. We report on a further group of ankle fractures which are undisplaced at presentation, but do not fulfil criteria for stable injuries, and therefore, may be at risk of displacement. The Blackburn Foot and Ankle Service operates evidence-based guidelines for ankle fractures, introduced in 1998. These were prospectively applied to 306 skeletally mature patients (308 fractures) following classification of the ankle fracture based upon clinical examination and radiography (mortise and lateral views). One hundred and forty-eight (48.4%) of fractures were stable, including 63 male and 85 women, median age 53 years (14–92). Eighty-eight (28.8%) of fractures were undisplaced but potentially unstable based on criteria, including 53 men and 35 women, median age 42 years (14–93). Seventy (22.9%) of fractures were displaced, including 41 men and 29 women, median age 44 years (16–94). Undisplaced, unstable fractures were treated mostly in below-knee casts with immediate weight-bearing and follow-up radiography. Two fractures in this group subsequently displaced requiring fixation according to AO principles. The risk of displacement in potentially unstable fractures is 2.3%. The unstable fracture groups, whether displaced or not, were similar in age/sex profile. [Copyright &y& Elsevier]

Summary: The aim of this analysis has been to evaluate the efficacy of retrograde nailing in the treatment of distal femur and femoral shaft fractures. Articles were extracted from the Pubmed database and the retrieved reports were included in the study only if pre-specified eligibility criteria were fulfiled. Moreover, a constructed questionnaire was administered, aimed at assessing the quality of the outcomes. Twenty-four articles were eligible for the final analysis, reviewing a total of 914 patients (mean age of 48.8 years) who sustained 963 distal and diaphyseal femoral fractures. The overall mortality rate was 5.3%. The incidence of infection was 1.1% and for septic arthritis of the knee was 0.18%. In patients with distal femoral fractures, the mean time to union and rate to union were 3.4 months and 96.9%, respectively. The mean range of knee motion was 104.6°. The rates of knee pain, malunion and re-operations were 16.5, 5.2 and 17%, respectively. Patients with femoral shaft fractures had a mean time to union 3.2 months, whilst the rate of union was 94.2%. The mean range of knee motion was 127.6°. The rates of knee pain, malunion and re-operations were 24.5, 7.4 and 17.7%, respectively. We concluded that retrograde intramedullary nailing appears to be a reliable treatment option, mainly for distal femoral fractures. However, in the management of diaphyseal fractures, retrograde intramedullary nailing is associated with high rates of knee pain and lower rates of fracture union. [Copyright &y& Elsevier]

Summary: Septic arthritis as a result of pin track infection, following application of external fixators in periarticular fractures of the lower limb, is a rare, but serious complication. Several studies, combining cadaver dissection and MRI scans or conventional X-ray measurements, have tried to define the exact anatomy of the capsular reflection in the major joints of the lower limb (hip, knee and ankle), in order to provide specific safe corridors for extra-capsular wire and pin placement. These studies are reviewed, their methods and results are presented, and their conclusions are evaluated as suggested guidelines for safe extra-capsular wire and pin insertion. [Copyright &y& Elsevier]

Hybrid external fixators are useful for the management of complex tibial plateau and plafond fractures, as they provide rigid fixation with relatively minimal soft tissue disruption. We reviewed the outcomes of patients with proximal (plateau) and distal (plafond) tibial fractures who were treated with hybrid frames at the Royal North Shore Hospital from 1998 to 2001. Twenty-four patients were identified from the hospital operating records and chart, X-ray and clinical reviews were performed. Follow-up periods averaged 13 months. Fractures were classified using the Ruedi classification for ankle fractures, and the Schatzker classification for the knee fractures. Clinical outcome was assessed using the Iowa knee score and the AOFAS ankle score. As one of the first Australian audits our outcomes were consistent with international standards. [ABSTRACT FROM AUTHOR]

Previous studies have suggested that the lower-extremities are among the most frequently injured body regions in polytrauma patients and have a major impact on the functional recovery following polytrauma. In particular, injuries to the distal part of the lower-extremity appear to be associated with a poor functional outcome. Therefore, the goal of this study was to evaluate the impact of injuries below the knee joint on the long-term functional outcome following polytrauma. Three hundred eighty-nine polytrauma patients with associated lower-extremity fractures and a minimum follow-up of 10 years were included in this study. All patients were examined by a doctor, using a patient questionnaire and a standardised physical examination. Significantly, inferior outcomes were seen in patients with fractures below the knee joint as measured by the modified Karlström–Olerud score, Lysholm score, range of motion, weight bearing status, Hannover score for polytrauma outcome (HASPOC), SF-12, Tegner activity score, and inability to work (P < 0.05). Fractures below the knee joint have a significant impact on the functional recovery following polytrauma. We suggest that delayed treatment, thin soft tissue envelope below the knee joint, high-energy trauma, unfavorable blood supply, and complex fracture patterns contribute to these unfavorable outcomes. [Copyright &y& Elsevier]

Background: Supracondylar fractures of the femur in the elderly are difficult to treat. Total knee replacement is often not considered. The aim of this study was to compare the short to medium term outcome of fixation and total knee replacement in medically fit active elderly patients with no pre-existing arthritis in order to determine whether total knee replacement can be an alternative to internal fixation. Patients and Methods: In this retrospective study, we included patients who were aged 75 or over with an ASA grade of two or less, walked independently before their injury, and sustained a type A or C supracondylar fracture. Four were treated with internal fixation and six with a cemented Stanmore knee replacement. Patients were reviewed clinically and radiographically a minimum of 6 months after surgery. Results: The advantages of total knee replacement were a greater proportion of patients returned to independent walking, rehabilitation was more rapid, and knee flexion was better. The advantages of internal fixation were a decreased need of blood transfusion, a smaller proportion of patients reported knee pain at follow up, and a better mean Oxford knee score at follow up. Anaesthetic time and level of patient satisfaction at follow up were similar. There were no peri-operative deaths. Conclusion: In this preliminary study, total knee replacement was a reasonable alternative to internal fixation for the treatment of supracondylar fractures of the distal femur in elderly. [ABSTRACT FROM AUTHOR]

As the first step in evaluation of the magnitude of the occupational injuries (OIs) in our community, we focused on hospital records of more than 8400 hospitalized trauma patients in six large university hospitals during 13 months of data gathering process.Fourteen percent of 8426 trauma patients had OIs (1180 cases) and 95% of them were male. Adults 19–39 years comprised 63% of the patients. Eleven percent of the patients were 18 years old or younger. Construction workers (26%), simple workers (26%), and industrial workers (17%) comprised nearly 70% of the OIs. Falls (39%) and striking by blunt objects (29%) were the most common mechanisms of injury. More than 60% of the patients did not have any type of insurance. A younger patient has a higher the probability of being uninsured. Head (49%) wrist and hand (46%) and knee and leg (36%) injuries were the most common regions injured. Additional community-based studies are needed to determine the risk of OIs among different occupational categories, as well as to identify the most vulnerable groups. [Copyright &y& Elsevier]

Summary: There is no published work addressing the safety of driving with a below knee cast. We assessed the effect of below knee casts on driving ability and therefore safety. The study gives doctors the evidence base on which to appropriately advise patients regarding driving safety in below knee plaster casts. With the help of the regional Police Force Training and Recruitment Centre, two subjects were assessed in a variety of below knee casts in both manual and automatic vehicles. One of the subjects was a highly trained police driver the other one of the medical authors. All assessments were carried out by a trained police advanced driver. With the exception of a left sided below knee cast in a automatic transmission vehicle all types of below knee casts were deemed a significant impairment and therefore unsafe to drive in. The DVLA has no guidelines regarding driving with a plaster cast. The decision of whether or not a patient can drive safely can now be taken out of the hands of the medical practitioner. [Copyright &y& Elsevier]

Summary: The purpose of this study was to evaluate the efficacy and safety of recombinant bone morphogenetic protein 7 (rhBMP-7 or OP-1) as a bone-stimulating agent in the treatment of persistent fracture non-unions. Twenty-five consecutive patients [19 males, mean age 39.4 years (range: 18–79)] with 26 fracture non-unions were treated with rhBMP-7. There were 10 tibial non-unions, eight femoral, three humeral, three ulnar, one patellar, and one clavicular non-union. The mean follow-up was 15.3 months. The mean number of operations performed prior to rhBMP-7 application was 3.2, with autologous bone graft and bone marrow injection being used in 10 cases (38.5%). Both clinical and radiological union occurred in 24 (92.3%) cases, within a mean time of 4.2 months and 5.6 months, respectively. Of the remaining two cases, one patient ultimately underwent a below knee amputation, secondary to recurrence of deep sepsis. The other patient with recalcitrant ulnar non-union although the radiological union was incomplete, declined further intervention, as he was asymptomatic. No complications or adverse effects from the use of rhBMP-7 were encountered. This study supports the view that the application of rhBMP-7 as a bone-stimulating agent is safe and a power adjunct to be considered in the surgeon''s armamentarium for the treatment of these challenging clinical conditions. [Copyright &y& Elsevier]