Introduction: The operative treatment of distal tibial fractures are riddled with various complications , such as non-union, delayed union, infection & malunion. MIPPO plating was introduced to reduce these complications as it preserved the fracture haematoma and maintained the periosteal blood supply. In this study, the aim was to accentuate the benefits of ‘MIPPO plating with a super added intramedullary reaming ‘ proposed as “Dr.Shetty’s technique”. Materials and Methods: This is a hospital based randomised prospective comparative study analysing 60 patients, divided as 30 patients under group-1 -Treated by MIPPO+REAMING (Dr. Shetty’s technique) and 30 patients under group-2 -Treated by MIPPO alone (Conventional technique).Subjects included are skeletally mature patients with closed fracture of distal 1/3 of tibia/fibula without articular involvement. The patients were asked to follow up regularly in order to evaluate the union clinically and radiologically. X-rays were done at 6 weeks, 10 weeks, 14 weeks, 18 weeks, 6 months, 9 months and 12 months. Results: MIPPO + Reaming technique was found to be superior over MIPPO alone, as the fractures united 3.94 weeks earlier in Group 1 as compared to Group 2, as evident on radiological assessment , which was significant (P < 0.0001). Conclusion: Group-1 (MIPPO+Reaming) was associated with faster radiological and clinical union, early weight bearing, and lesser complication rate, which suggests that, this technique (“Dr.Shetty’s technique”) is a superior alternative to the standard MIPPO procedure as it probably obliviates the chances of non-union thus avoiding secondary interventions.

Introduction: We present a consecutive series of patients with tibia fractures in the presence of pre-existing implants. Methods: Using the prospectively completed limb reconstruction database, we identified 15 consecutive patients with periprosthetic tibial fractures between April 2013 and August 2019. Notes and scans were reviewed for diagnosis, investigations, treatment and follow-up. 15 patients were identified (6 female, 9 male). Mean age was 55.4 years (range 19-81 years). 11 were tertiary referrals from other centres. 4 patients had open fractures. Results: Mechanism of injury was fall from standing height in 9, road traffic collision in 3, sport in 2 and fall down stairs in 1. 2 patients had fractures distal to proximal tibial plates, 4 were distal to knee arthroplasty prostheses, 4 were around tibial nails, 1 proximal to a distal tibial plate, 3 proximal to ankle fracture metalware and 1 around an ACL reconstruction screw. All patients underwent Ilizarov frame treatment. One patient with IIIB open fracture received a free gracilis flap and another a local tibialis anterior flap. One patient with open fracture required bone transport. One patient required angioplasty for pre-existing peripheral vascular disease. Metalware was retained in 10 and removed in 5. 100% of patients achieved union after a single frame treatment. There were no deep infections. One patient sustained an early partial re-fracture after frame removal, treated successfully in cast. Conclusions: Ilizarov frame treatment is a safe method for the treatment of periprosthetic fractures of the tibia, reliably resulting in union, with or without metalware retention.

Introduction: This study describes the technique, outcomes and complication rate of tibiotalar arthrodesis (TTA) performed using a tibia intramedullary nail (IMN). Retrograde tibiotalocalcaneal (TTC) arthrodesis with a hindfoot nail has become an accepted technique for distal tibia fractures in high-risk, low demand patients. This procedure is an alternative to (TTC) arthrodesis which preserves the accommodative motion of the subtler joint. Methods: A retrospective review of patients at a level 1 MTC. Patient demographics, comorbidities, and 30-day complication were collected. Fractures were classified using the OTA/AO and modified Gustilo Anderson classification. Results: Seventeen patients, the median patient age was 79 years with a male:female ratio of 2:15. Six patients had an open fracture at presentation. Average time to TTA was 37 days. One patient developed a deep surgical site infection within 30-days of surgery and ultimately required further surgery. At final follow-up, 16 patients reported good functional outcomes and have been able to return to baseline activity. Conclusion: This technique may serve as a salvage procedure with indications similar to those for TTC arthrodesis in lower-demand patients including, complex distal tibial fractures, comminuted intra-articular fractures especially for patients with vulnerable soft-tissues. The added benefits of this technique over TTC arthrodesis is in preservation of the subtalar joint and motion thus avoiding the creation of a rigid lever arm from the calcaneus, terminating in the mid-tibia, and therefore risking peri-prosthetic fracture. The objective of this minimally invasive approach is to avoid disturbing soft tissue, bone vascularity, and thus minimize post-operative complication.

Background: Today there is no clear, gold standard in the treatment of an ankle fracture with syndesmotic injury. We aim to clinically compare Suture Button (SB) to Syndesmotic Screw (SS) fixation.

Method: We reviewed the cases of ninety patients, ages 18-77, who underwent SS (N-49) or SB (N-41) fixation for ankle fracture with syndesmotic injury at Soroka University Medical Center (SUMC), in the years 2014-2017. The primary outcome of the research was measured by the American Orthopedic Foot and Ankle Society (AOFAS) score. As for secondary outcomes, the Olerud-Malonder Score (OMS), visual analog scale (VAS), range of motion (ROM) and work status were assessed at one-year post-operation. All patients began full weight-bearing as tolerated at 6 weeks, and 42% (N-21) of the SS group had routine screw removal after 3 months.

Results: The AOFAS at one-year post-operation of the SS group was better by 5.7 points (CI: -10.48--0.92 Pv: 0.019) than the SB group. Working status had 20.5 points (CI: 15.39-25.67 Pv: <0.001) difference in the AOFAS score, between working and not working. For every increase of a year in age yields a 7% (CI: 0.88-0.97, PV: 0.002) decrease in the likelihood to be working at one-year post-operation, and after the SB procedure, there is a higher chance to be working at one-year post-operation by OR of 3.44.

Conclusion: This study sheds some light on the incorporation phase to a new technique in the institute, with emphasis on the social parameters that influence the choice of operation.

Background: Ankle fractures are one of the most common fractures in the elderly population, several factors contribute to difficulties in managing these injuries in this population, conventional open reduction and internal fixation has also been shown to have a significant rate of complications. Objectives: Exploring the role of retrograde tibiotalocalcaneal nail as a primary fixation modality in unstable ankle fractures. Methods: A retrospective review of the data of patients undergoing this procedure in a district general hospital from 2017 to 2020. The primary outcome was the rate of complications; other data included demographics, timing of surgery, mortality, length of follow up and discharge destination. At a later date, a telephone interview was conducted to assess patients using the Visual Analogue Score and the American Orthopaedic Foot and Ankle Society Ankle-Hindfoot score. Results: A total of 25 patients were identified from an online database, ages ranged from 58 - 93 years old. Follow up was from 11 to 28 weeks. There was one deep infection resulting in below knee amputation and one delayed wound healing, no other complications were noted. Twenty one patients were interviewed with VAS scores ranging from 1 - 4 and AOFAS scores from 57 - 70. Conclusions: Although Hindfoot retrograde nailing is reserved for a select subset of patients, it seems to provide an acceptable and reliable treatment option in this population. Given these findings, further comparative studies are required to explore the role of this modality further.

Distal metaphyseal tibial fractures are complex problems. These types of fractures occur typically as a result of axial and/or rotational forces on lower extremity. Both intramedullary nailing and plate fixations have been widely accepted to treat extra-articular distal tibia fractures. However, the ideal management is still controversial. The study consist of 72 patients of distal metaphyseal fracture of tibia surgically treated between August 2014 to August 2018 with either reamed intramedullary nailing or locked plating with open reduction method or minimally invasive technique. Patients in the age groups of 15-70yrs were included. Open fractures were excluded from the study. For intramedullary tibia nailing patellar tendon splitting approach was used in almost all patients. Biological plating was attempted in as many plating cases as possible. Patients treated by plating were observed to have marginally higher incidence of skin complications and delayed healing. Whereas IM nail appeared to have a higher rate of malunion and nonunion because it may involve reduction issues. The time of applying full weight bearing in the IM nailing group is lesser than the plating group. Our study results indicate a superiority of IM nail over plating in terms of lower rates of infections and statistically significant shorter time to union and full weight bearing. Whereas plate appered to be advantageous over IM nail in terms of leading to a better anatomical and fixed reductions of the fractures and a lower rate of union complications.

Significance: This article establishes an evidence-based update from the last decade on usage and efficacy of NPWT, specifically in orthopaedic practices, and highlights its role in managing diabetic foot wounds; thus, supplying the reader with a recommendation on in its usage in different clinical scenarios. Methods: The literature search performed identified 339 publications related to orthopaedics and diabetic foot practice and of these 22 met the inclusion criteria specified. These articles reviewed 4609 patients and yielded the following updates. Recent Advances: Recent evidence suggests that NPWT does not significantly improve overall outcomes, including quality of life and disability, when used for orthopaedic surgical wounds, and diabetic foot ulcers. Nevertheless, it has not been shown to be inferior to standard wound treatment. NPWT may improve some specific outcomes, including maximum wound depth and leucocyte count. Advances in NPWT have included the development of incisional NPWT (iNPWT) and adjuvant’s such as silver nitrate or polyhexanide. The latter having inherent advantages in the treatment of soft-tissue injuries without-bone involvement. NPWT may reduce dressing changes, however, has not been shown to be more cost effective. Future directions: Prospective controlled studies are necessary to determine the efficacy of NPWT/ iNPWT for more specific indications. NPWT combined with other advanced wound therapies should also be studied, to provide evidence on the benefit of these.

Background: Ankle injuries are one of the most common presentations to A&E. Radiological assessment of ankle injuries relies on adequate and good quality radiographs. The British Orthopaedic Association BOAST guidelines on management of ankle fractures recommend radiographs should be centred on the ankle and should include a true lateral and a mortise view. Also, additional radiographs of the whole leg are required when clinical examination suggests a more proximal fracture of the fibula (Maisonneuve injury). They also recommend separate radiographs of the foot and knee should be obtained if clinically indicated.
The aim of this audit is to assess the adequacy of AP (mortise view) and lateral ankle radiographs during assessment in the Emergency Department of patients with a suspected ankle fracture against the BOAST standard.
Methodology: PACS system interrogated and series of 100 patient records reviewed. Exclusion criteria: Children < 12 years old, Patients in casts, Evidence of, previous surgery, Calcaneal and weight bearing films.
Results: 56% and 100% compliance with proper mortise views and lateral views respectively in initial audit. Recommendations for more staff education discussed in Radiology audit meeting and implemented. Re-Audit showed improved uptake and significantly improved images.

Introduction: Extensile anterior approach when compared to other limited approaches provide adequate visualization for intra and extra articular surface of distal end tibia and thus play pivotal role in anatomical reconstruction and allow plate placement medially, laterally and anteriorly in single incision. Internal fixation using the extensile anterior approach for intra-articular distal tibia fractures is of interest as it is new entity and amount of literature to analyze functional outcomes and soft tissue complications is limited. Methods: Sixteen patients of distal tibia fractures were treated between 2017-2020 at Sunshine Hospital, Secundarabad by standard staged protocol with early external fixation with or without fibula fracture fixation followed by delayed definitive fixation through extensile anterior approach and were examined clinically at 2nd week and 6th week radiologically and for complications (if any); monthly thereafter. Results: Fractures were of AO/OTA type 43-C3 and 43-C2. All patients were followed up for minimum 12 months postoperatively for wound assessment and fracture healing. All patients except 1 had uneventful wound healing with no flap necrosis or infection without radiographic evidence of articular fragments avascular necrosis. The clinical outcome of these patients on AOFAS ankle hindfoot scale was 91-100/100. Conclusion: Extensile anterior approach provides the gateway for decent access of intra and extra articular distal end of tibia surface which is extremely essential for anatomical reconstruction and column-wise internal fixation permitting plate placement anteriorly, medially and laterally giving very low incidence of wound complications.

Background: Closed anterolateral talar dislocations are rare injuries that result in a dislocation of the talus from its surrounding articulations and typically occur in the context of a high energy trauma. Most cases reported are open talus dislocations, and only a handful of cases exist in the literature discussing the diagnosis and management of closed total talar dislocations.
Case Presentation: The authors report a case of a 52-years-old male patient who sustained a closed anterolateral total talar dislocation of the left talus associated with tarsal fractures after a fall from the 3rd floor onto his feet.
Outcomes: The talus could not be reduced by closed means making open reduction necessary. It was performed through an anterolateral approach and talocalcaneal transfixation completed with 3 Kirchner wires, under fluoroscopic control. At 6-month post operation follow-up, the talus didn’t show subluxation and avascular necrosis could not be detected.
Discussion: We report our experience and review the literature to discuss the recommended management.

Aims: The aim was to describe the epidemiology of Achilles tendon rupture (ATR) and its relationship with socioeconomic deprivation status (SEDS). Secondary aims were to determine variations in circumstances of injury between more and less deprived patients.
Methods: A retrospective review of consecutive patients with ATR was undertaken. Health-board population was defined using governmental population data and SEDS using the Scottish Index of Multiple Deprivation. The relationship between SEDS and patient and injury characteristics was assessed with univariate and binary logistic regression analyses.
Results: There were 783 patients (567 male;216 female) with ATR. Mean incidence for adults (≥18 years) was 18.75/100,000 per year (range 16.56-23.57) and for all ages was 15.26/100,000 per year (range 13.51 to 19.07). Incidence in the least deprived (LD) population quintiles (4th and 5th quintiles;18.07 per 100,000/year) was higher than the most deprived (MD) quintiles (1st and 2nd; 11.32/100,000 per year; OR=1.60, 95%CI=1.35-1.89;p<0.001).
When adjusting for confounding, LD patients were more likely to be >50 years old (OR=1.97;95%CI=1.24-3.12;p=0.004), to sustain ATR playing sports (OR=1.72, 95%CI=1.11-2.67;p=0.02) and in the spring (OR=1.65, 95%CI=1.01-2.70;p=0.045) and to have preceding tendinitis (OR=4.04, 95%CI=1.49-10.95;p=0.006). They were less likely to sustain low energy injuries (OR=0.44, 95%CI=0.23-0.87;p=0.02) and to be obese (OR=0.25-0.41, 95%CI=0.07-0.90;p≤0.03).
Conclusion: Incidence of ATR was higher in less socioeconomically deprived patients. Significant variations in patient and predisposing factors, mechanisms of injury and seasonality were demonstrated between MD and LD groups, suggesting that the circumstances and nature of ATR may vary with SEDS and these are not a homogenous group of injuries.