Background: As a result of improper immobilization or operation in following distal radius fractures, rotation, and angulation malunion deformities can occur. That decreases the wrist function. This study is to evaluate the improvement of wrist function post arthroscopic intraarticular corrective osteotomy for malunion of distal radius.
Methods: From 2018 to 2021, there were 19 patients (15 male, 4 female) with intraarticular fractures of the distal radius and malalignment of the healing found. They all underwent arthroscopic intraarticular corrective osteotomy and reduction with internal fixation. Data were obtained through medical records and radiographic review. Intraoperative and immediate postoperative X-rays were compared with the final X-rays. healing, confirmed radiographically, was used to determine whether the device and internal fixation were adequate for fixation.
Results: All malunion of fractures were corrective and healed by an average of 7.5 weeks (range, 5–14 weeks) without loss of fixation or malunion again. All patients have regular follow-ups around 20-30 months (mean 25.2 m). Eighteen of nineteen patients improved wrist function to good or excellent by the scores of Modified Wrist Scores.
Conclusion: Prevention of these malunions by proper positioning at the time of primary treatment is emphasized. This is an effective method to correct the intraarticular malunion of the distal radius.

INTRODUCTION: Hip fractures constitute the most debilitating complication of osteoporosis with steadily increasing incidences in the aging population. In these cases intramedullary nailing can be challenging because of poor anchorage in the osteoporotic femoral head. Although numerous advances in implant designing and postoperative treatment methods have been achieved, complication rates around 16.5% have been reported, being mostly related to cut-out, varus deformation and rotation of femoral head fragment. Recently with the use of Trochanteric Femoral Nail Advanced System (TFNA) with cement augmentation ,these complications has been reduced. METHODS : A total of 100 cases have been done and more than 70 cases have completed one year follow up. The fracture was reduced in fracture table and TFNA nailing was done. The specifically designed blade tip has holes which permits the cement injection. We inject usually 5ml of cement. The Harris hip score was used for assessment of the functional outcome. The HHS was found to be statistically significant in first two weeks with cement augmentation. Patients were allowed full weight bearing mobilisation from Day 1. None of the patient had cut-out, back out of the blade or cement leakage. DISCUSSION : Cement augmentation into the femoral head really makes a stronger construct and effective enough to load immediately negating the fear of movement of the blade tip in the otherwise osteoporotic head. It is vitally important to mobilise the elderly to prevent systematic complications. Cement augmentation is really a valid option in such cases and aids in fast track mobilisation.

Introduction: Segmental bone defects (SBDs) of the distal femur present complex challenges in orthopedic surgery, with various reconstruction methods available, such as fibular flaps. We present two clinical cases of SBDs of the distal femur, each treated with a distinct reconstruction approach. Case Reports: Case 1: A 25-year-old man suffered a Gustillo-Anderson IIIA supra-intercondylar fracture with SBD of the distal femur from a motorcycle accident. Initial treatment included closed reduction and internal fixation with screws. Subsequently, he underwent minimally invasive osteosynthesis with a distal femur LCP plate. Reconstruction at 17 days post-injury involved a contralateral vascularized osteoseptocutaneous fibular free flap with allograft using the Capanna technique. However, early postoperative graft complications arose. Nevertheless at 7 months, he achieved 120° active-range-of-motion and full weight-bearing. Case 2: A 50-year-old man sustained a Gustillo-Anderson IIIB supra-intercondylar articular fracture of the distal femur from a motorcycle accident. He underwent surgery using a modified Olerud approach with allograft and anatomical plate osteosynthesis. At 6 months, he ambulated with one crutch and had active-range-of-motion of 15°. Discussion: Both cases underscore the complexity of managing SBDs of the distal femur. While fibular free flap reconstruction offers structural support and bone integration potential, it entails donor site morbidity and vascular complications. Conversely, allograft reconstruction presents a less invasive approach with favorable outcomes, avoiding additional vascularized tissue transfer. Conclusion: Managing SBDs of the distal femur requires a tailored approach. While allograft reconstruction remains valid, a stepwise fibular free flap reconstruction with allograft may offer comparable outcomes with specific advantages.

Septic metaphyseal nonunion of long bones is a rare entity. Seventeen adult patients were prospectively included in this study (SePseT Ilizarov, ISRCTN30905788) and followed-up for minimum 30 months after frame removal. The average number of failed previous operative procedures was 4.5. According to Paley classification there were 8 nonunions type A and 9 nonunions type B. The mean length of the bony defect was 4.3cm while fourteen patients had severely restricted movement of the knee. Radical surgical debridement, mono- or bifocal technique of osteosynthesis with Ilizarov method for a mean time of 200 days resulted to infection eradication and bone union for all the participants. According to the Paley’s grading system, thirteen patients had an excellent bone result, four good and one fair. The functional result was excellent in eleven patients, good in two and fair in four. All patients with nonunion type A according to Paley classification had excellent bone results. The external fixation time was increased when the initial fracture type was high-energy, the definitive treatment started ten months or more after the initial trauma, the patient had been subjected to more than four surgeries prior index treatment and in nonunions type B. Patient reported outcomes measurement scores were also at least good. The most common residual complications were knee and ankle stiffness (3 patients each) after bifocal osteosynthesis technique. The Ilizarov method seems to be a reliable treatment for this rare condition particularly in complicated cases with extensive bone defect, angular deformity or knee contracture.

Introduction:Infected big gap non-union of femur is difficult to treatment because of infection, bone loss, shortening, poor soft tissue covers and deformity.Materials & Methods:545 Infected big gap non-union of femur were treated from 1990 to 2023; 55 presented without active discharge and was treated with Ilizarov ring fixator, 200 presented with draining infection and were treated with debridement and Ilizarov bone transport, 200 had a bone transport to fill gap of 2.5 to 27 cm. Bifocal bone transport were done in 90 cases. None had bone grafting to achieve union.Results: All healed with the application of Ilizarov fixator, 5 needed reapplications of Ilizarov to achieve 100% union. Conclusion:A well plan step by step Ilizarov technique to cover infected gap nonunion of femur is an excellent method in challenging cases. Excellent results cannot be achieved with conventional methods but can be easily achieved with Ilizarov technique within 1-2 years.
This combined multiplanar type of deformity requires

Introduction: Distal femur fractures are challenging injuries, often occurring in osteoporotic patients yet requiring stable fixation for optimal recovery. Despite advancements like the nail-plate dual construct, no single fixation method has proven definitively superior. This audit evaluated fixation techniques utilized for distal femur fractures at our institution and their associated outcomes. Methods: A retrospective review of 217 patients who underwent operative fixation for distal femur fractures from 2013-2023 was conducted. Patient demographics, fracture patterns, fixation methods, operating room logistics, complications, and postoperative mortality were analysed. Results: The mean patient age was 74 years. Lateral plate fixation was most common (66%), followed by retrograde intramedullary nailing (20%), nail-plate constructs (4%), and two column plating (3%). Complications occurred in 20 patients (9%), including infections (2%), implant failures (2%), and non-union (1%), all stemming from lateral plate fixation. The average life expectancy post-operatively was approximately 2 years. Conclusion: Lateral plating remained the predominant fixation method at our institution, with a relatively low complication profile despite intramedullary nailing demonstrating lower non-union rates. Continued surgical expertise, judicious implant selection, and optimized rehabilitation are crucial for improving outcomes. A future audit incorporating patient-reported outcome measures at initial follow-up is planned.

Introduction: Determining the appropriate treatment strategy and timing of definitive fracture fixation is crucial and has a relevant impact on systemic outcomes. In this regard, this study aimed to provide recommendations for the timing and sequence of fracture fixation in multiple injured patients, with an emphasis on concurrent injuries to the head, chest, abdomen, spine (including spinal cord), vasculature, and multiple extremity fractures. Methods: We formed an international multidisciplinary expert panel and developed consensus statements using the Delphi method. Preliminary statements were drafted to define conditions for each type of associated injury under which fracture fixation can be recommended. These statements underwent repeated modifications by the consensus group members in preparation for an in-person meeting. During this meeting, the statements were discussed and finally voted. The process was supported by a systematic literature review. Results: A total of 20 consensus statements were prepare. Of these, five focused on traumatic brain injury, four on abdominal trauma, three each on thoracic trauma, multiple extremity fractures and on spinal injuries, and two focused on vascular injuries. The panel discussed the conditions and exceptions for definitive fracture fixation. Overall, 78 publications and every statement were reviewed, and overwhelming consensus was achieved for all 20 statements, with 15 of them reaching 100%. Conclusion: A total of 20 statements were developed on the timing of fracture fixation in patients with associated injuries. All statements agree that fracture fixation for major extremity injuries should be initiated within 24 hours of admission unless severe issues speak against it.

Introduction: Temporary external fixation is an established procedure in damage control. Yet, external fixation is also performed in patients that could also be cleared for early definitive fixation. MUST (MusculoSkeletal Temporary Surgery) describes injury patterns that should be considered for temporary fixation also in isolated musculoskeletal injuries. The impetus of our study was to identify characteristics that are predictive for external fixation in stable patients.
Methods: A retrospective database of patients admitted via trauma bay followed by surgical treatment from 2015 -2022 was analyzed. Only physiological compensated patients were included for further analysis. Standard statistics were performed to detect group differences and logistic regression was performed to identify predictive factors for external fixation. Subgroup analysis for patients with and without cerebral injuries was performed. Results: From 355 initial patients, 204 patients were considered as stable. 78 patients received temporary external fixation, 126 did not. Patients in the external fixation group presented significantly more open fractures, a higher ISS and AIS of the lower extremities. Adjusted logistic regression yielded the presence open fractures, elevated AIS of the lower extremities, extraarticular fractures and the presence of cerebral injuries as independent predictors for external fixation. Conclusion: The presence of intracranial injuries seems to influence the surgical decision making towards external fixation regardless of the injury severity and morphology. In addition, an open fracture constellation as well as the severity of lower extremity injuries seem to be able to predict external fixation. Further research regarding fracture fixation within concomitant intracranial lesions should be undertaken.

Introduction: Preoperative and post-operative mobility is frequently measured in patients with hip fractures in order to evaluate their surgical outcomes. Their preoperative mobility may impact their 1-year mortality rates. The Parker Mobility Score (PMS) is a validated and reliable method of quantifying a patient's mobility. The aim of this study is to investigate the correlation between preoperative PMS and 1-year mortality in patients presenting with hip fractures. We hypothesize that there is a correlation between preoperative PMS and 1-year mortality in a cohort of patients with hip fractures. Methods: A retrospective study was conducted on all hip fracture patients who underwent surgery in a single tertiary hospital between 2020-2021. Variables collected from the cohort include 1-year mortality, type of fracture, type of surgery, age, gender, and ethnicity. The effect of these variables on 1-year mortality was examined through binary logistic regression. Results: There were 588 patients. The mean age was 80.03±7.89 years(range 60–103) with a 1-year postoperative survival rate of 92.5% (544 patients). Preoperative PMS was found to be a strong predictor of 1-year mortality, and remained significant after adjusting for age, gender, ethnicity, type of surgery, and type of fracture in multivariable analysis (OR=1.22, 95% CI 1.08-1.38, p=0.001). 100% follow-up rates were achieved. Conclusion: We concluded that poorer preoperative PMS was associated with higher 1-year mortality rates in hip fracture patients. Thus, preoperative PMS is a useful predictor of 1-year mortality following hip fracture surgery.

Introduction: Physical component summary(PCS) is a component of Short Form 36(SF-36), which quantifies health-related quality of life. In order to evaluate surgical outcomes in hip fracture patients, preoperative and post-operative PCS is frequently measured. Their preoperative PCS may impact their length of stay(LOS). This study aims to investigate the correlation between pre-operative PCS and LOS in hip fracture patients. We hypothesize a correlation between pre-operative PCS and LOS in hip fracture patients. Methods: A retrospective study was conducted on all hip fracture patients who underwent surgery in a single tertiary hospital between 2020-2021. Variables collected from the cohort include LOS, type of fracture, type of surgery, age, gender, and ethnicity. The effect of these variables on LOS was examined through binary logistic regression. Results: There were 588 patients. The mean age was 80.03±7.89 years(range 60–103) with a median LOS of 13.60±4.24 days(range 3–104) and 1-year postoperative survival rate of 92.5%. Long stayers were defined as an LOS >10 days. Worse preoperative PCS was found to be a strong predictor of long stayers, and remained significant after adjusting for age, gender, ethnicity, type of surgery, and type of fracture in multivariable analysis (OR=1.03, 95% CI 1.01-1.05, p=0.001). Furthermore, PCS was also found to be a strong predictor of 1 year mortality (OR=1.03; 95% CI 1.00-1.06 ;p=0.04). 100% follow up rates were achieved. Conclusion: We concluded that poorer PCS was associated with higher LOS in hip fracture patients. Thus, preoperative PCS is a useful predictor of LOS following hip fracture surgery.

Comparative evaluation of Post-operative outcome of proximal femoral locking compression plate vs proximal femoral nail in unstable proximal femoral fractures

Authors:
Mr Arnab Sain, MRCS , Registrar Worthing Hospital(Ex Registrar Safdarjung Hospital, New Delhi)
Professor B.P Sharma, Safdarjung Hospital, New Delhi


Abstract:
Introduction:
Intertrochanteric fractures are of the commonest fractures of the hip. They occur mainly in elderly people with osteoporotic bone usually due to low energy trauma like simple fall. Their incidence is increasing day by day because of population aging.

Methodology:
The retrospective study was carried out in a tertiary care centre in India. 30 patients treated by proximal femoral locking compression plate(PF-LCP) and 30 patients treated by proximal femoral nailing(PFN) was selected for study.

Results:
Average operating time in PFN was 67(range 73.42-61.58 mins) and in PF-LCP is 81.5(range 90.71-72.29 mins). Out of 60 cases, radiological union was seen in 56(93.33%) cases and no radiological union was seen in 4 (6.67%) cases.

Conclusion:
The study found that PFN was a better implant as compared to PF-LCP in management of unstable proximal femur fractures.

Keywords: Femoral Fractures, Femoral locking compression plate and Proximal Femoral Nail

Introduction: The venous flap is one of the useful options for soft tissue reconstruction of the digits that is relatively thin and can be raised in any size and shape. However, the venous flap's hemodynamic characteristics are not physiological, which can sometimes lead to congestion. It is also difficult to determine whether the flaps will successfully survive in the early postoperative period. This study aims to investigate the outcome of the venous flap for digit reconstruction with blood flow monitoring using ultrasonography. Patients and methods: Seven patients who underwent soft tissue reconstruction with a venous flap were included in the study. The treatment course was investigated retrospectively. Results: The patients' mean age was 37.9 years, and venous flaps were harvested from the forearm in all patients. The mean size of the flaps was 24.6 cm2. The flaps were designed using a vein-fluorescent illumination device to confirm the vascular distribution. All patients had an A-V-V anastomosis. Six flaps were successfully survived, and one flap was totally necrotic due to infection at two weeks postoperatively. The mean postoperative follow-up was 15.1 months, and two patients underwent additional touch-up surgery. Discussion: Ultrasonographic monitoring facilitates the determination of stable intra flap blood flow and the evaluation of changes in blood flow over time, even when the flap is congested, and visual evaluation is difficult. Conclusion: The use of bedside ultrasonography to evaluate intra flap blood flow after venous flap surgery was a useful method for the postoperative evaluation of flaps.

Introduction: Isolated lateral malleolar fractures (ILMF) are common around the ankle joint, with varying post-operative rehabilitation practices, particularly regarding weight-bearing timing. This study examines the impact of early weight bearing (EWB) and late weight bearing (LWB) on clinical and radiological outcomes in ILMFs. Methods: Thirty-two patients operated on for ILMFs between 2022 and 2023 were assessed, divided into EWB and LWB groups based on weight-bearing times. All patients underwent open reduction and internal fixation using an anatomical locking compression plate with a lag screw. EWB patients initiated tolerable weight bearing on the first postoperative day, while LWB patients had complete restriction for 6 weeks post-surgery. Ankle exercises were allowed in both groups from the first postoperative day. Radiological, clinical (Foot and Ankle Outcome Score - FAOS), and complication assessments were conducted. Results: No significant differences were found between groups in outcomes or complications. Although LWB group had slightly higher complications, it was not statistically significant. EWB group showed significantly shorter hospital stays and return-to-work times compared to LWB group (2.4 vs. 4.1 days, p<0.05 and 6.2 vs. 8.5 weeks, p<0.05, respectively). Conclusion: Similar postoperative results between groups and shorter recovery times in EWB group support early weight bearing post-ILMF surgery. Consequently, early weight bearing should be considered in rehabilitation plans for ILMF patients with anatomical reduction and stable fixation using a plate.