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There is a lack of consensus about the role of fibula fixation in these complex fractures, with only two clinical studies in the literature. We hypothesize that the fibula fracture need not be fixed in the tibial pilon fractures if primary stability can be achieved with tibial fixation alone.We reviewed 79 patients with operatively treated tibial pilon with associated fibula fractures from 2007 to 2017 and divided them into two groups; patients with fibula fracture fixation and those without fixation. The primary outcome measure was any mechanical complications. Secondary outcomes were wound complications and other morbidities.There were 54 (68.4%) patients with fibula fixation and 25 (31.6%) patients without fixation. There were no statistically significant differences in mechanical complications between the two groups. However, patients without fibula fixation were noted to have more wound complications (44% vs 25.9%, p = 0.108) although this was not statistically significant. In terms of removal of implant (ROI), there were no differences noted in patients with or without fibula fixation (33.3% vs 28%, p = 0.796). There were also no significant differences in ROI for those fixed with plate and screws when compared to those fixed with Rush rod and K wire within the group with fibula fixation.Fibula fixation in the treatment of tibial pilon fractures is not routinely necessary and does not result in decreased mechanical complications such as malunion, delayed union, nonunion and implant failure. Fibula fracture fixation should be reserved for cases where it may aid reduction or provide additional stability.

This study aims primarily to characterize the sequelae and morbidity associated with tibial pilon injuries from the patients' perspectives in terms of multiple surgical interventions, duration of hospital stay, downtime from work, loss of productivity and impact on patients' lives. The secondary aim is to review the associated risk factors for these morbidities.All patients with surgically treated tibial pilon fractures from 1st July 2007 to 30th June 2017 were included. The morbidities reviewed focused on delay to surgery, numbers of surgeries, limb amputation, length of stay (LOS), readmissions, duration of medical leave (ML), follow-up and number of outpatient visits.There were 102 patients included in the review and up to 70% of them had an average 7 days delay to definitive surgery. They also required an average hospital LOS of at least 2 weeks extending up to 3 more weeks if soft tissue reconstruction was necessitated. Up to a third of patients were readmitted with 15% of them needing further treatment. These patients required a notable period of downtime from work as shown in the long ML (mean 152.6 days [S.D. = 110.7]). Multiple conditional regression models showed AO/OTA classification (B and C) and open fracture as independent predictors of delay to surgery. Predictors for increased LOS were high velocity mechanism of injury at 4 days longer and patients who needed soft tissue reconstruction at 21 days longer. In terms of downtime from work, only work injury has been identified as an independent predictor of ML at 88.5 days longer.Tibial pilon fractures leads to significant morbidities with profound negative impact on patients' lives in terms of multiple surgical interventions required, prolonged hospital stay, need for readmissions and prolonged downtime from work. These morbidities from patients' perspective should be emphasized to patients and employers to manage their expectations and potential limitations.

Background: Calcaneal tuberosity avulsion fractures are challenging to treat because of the poor bone stock and high risk of fixation failure secondary to the strong Achilles tendon pull. The purpose of this study is to compare the tensile force to failure of 2 different types of screw fixation construct in a cadaveric model of calcaneal tuberosity avulsion fracture. Methods: An oblique osteotomy was created in the calcanei of 7 matched pairs of cadaveric specimens to simulate a tuberosity avulsion fracture and one specimen from each pair randomized into one of the 2 groups for comparison. Two cancellous screws were inserted perpendicular to the fracture line at the posteromedial and posterolateral corners of the avulsed fragment for the 2-screw construct. For the second group, an additional stab incision was made at the midline of the Achilles insertional region for a screw placed between the initial 2 screws with a trajectory toward the calcaneocuboid joint in the 3-screw construct. These specimens were then mounted and loaded to failure. Results: The mean force to a predefined failure at 3.0-mm gap for the 3-screw construct was 468.7 ± 267.9 N vs 278.9 ± 164.0 N for the 2-screw construct ( P < .001). The addition of a central nonparallel screw in the 3-screw construct significantly increased the force required for fracture gap displacement at all cut-off points (1.0-8.0 mm) when compared to the 2-screw construct ( P < .001). Notably, the mean peak tensile force for the 3-screw construct was 499.4 ± 255.4 N occurred at the gap displacement of 4.1 mm for the 3-screw construct whereas the mean peak tensile force for the 2-screw construct was 315.9 ± 162.4 N displacing the gap at 4.3 mm. Conclusion: This study showed that an additional central nonparallel screw in the 3-screw construct provided significant mechanical superiority compared to a 2-screw construct. Clinical Relevance: The present study supported the use of augmented fixation with an additional central off-axis screw to reduce risk of fixation failure in calcaneal tuberosity avulsion fractures.

Purpose To compare clinical outcomes of anterior cruciate ligament (ACL) reconstruction and investigate whether the clinical results of 4-strand hamstring tendon (HT) reconstruction are still inferior to that of the patellar tendon (PT). Methods We performed a comprehensive systematic review and meta-analysis of the English literature on PubMed, Scopus, Web of Science, and the Cochrane register for papers that compared clinical outcomes of PT versus HT for ACL reconstruction. Outcome measures analyzed included rate of rerupture, KT-1000, International Knee Documentation Committee grade, Lachman, pivot shift, Lysholm score, Tegner Activity Scale, anterior knee pain, and discomfort on kneeling. Results We included 19 studies from an initial 1,168 abstracts for the systematic review, and, eventually, 19 studies were included in the meta-analysis. The study population consisted of a total of 1784 patients. The average follow-up duration was 58.8 months. We found significant differences in favor of the HT technique in the domains of anterior knee pain, kneeling pain, and restriction in the range of active extension ("extension deficit"). We found no differences between the PT and HT technique in terms of rerupture rate. There were no clinically significant differences for the outcomes of Lysholm score and Tegner Activity Scale as well as the KT-1000 side-to-side at maximum manual force. Conclusions Contemporary 4-strand HT ACL reconstruction is comparable with the PT technique in terms of clinical stability and postoperative functional status across most parameters studied. The HT technique carries lower risk of postoperative complications such as anterior knee pain, kneeling discomfort, and extension deficit. Primary ACL reconstruction using the 4-strand HT technique achieves clinical results that are comparable with the PT technique with significantly less postoperative complications. Level of Evidence Level I, systemic review and meta-analysis of Level I studies.