Background: As the more commonly used ilioinguinal approach is extensive and associated with complications arising from the dissection along the inguinal, we attempt to evaluate the efficacy of the modified Stoppa approach as an alternative in the operative management of acetabular fractures.
Methods: Forty-six patients with acetabular fractures, were operated by the modified Stoppa approach. Fractures were classified; operative time and blood loss was recorded; the radiological and clinical outcomes were prospectively analysed. We analysed the radiological results according to the criteria of Matta and the clinical results by the Merle d’Aubigne and Postel score with a minimum follow-up of 5-years.
Results: The clinical outcomes were excellent in 78.26%, good in 6.52%, fair in 6.52 % and poor in 8.69% cases. In 38 of our cases the reduction was anatomic, imperfect in 4 cases, and poor in two cases. The mean pre-operative displacements on axial, sagittal and coronal NCCT sections were 3.8, 3.1 and 3.6 mm, respectively; and mean post-operative displacements were 0.2, 0.3 and 0.2 mm, respectively. The mean pre-operative and post-operative fracture gap were 12.8 mm and 1.1 mm respectively.
Conclusions: Minimizing perioperative morbidity and simultaneously allowing access for anatomical reduction are the major benefits of the approach. The modified Stoppa approach can substitute the ilioinguinal approach for the surgical fixation of acetabular fractures.
Keywords: Modified Stoppa approach; Acetabular fractures; Anterior column; Acetabulum

The goal of this study was to investigate factors that predict treatment strategy by trauma surgeon.
Retrospective cohort study included polytrauma patients, primary admission and ICU requirement. Treatment strategies stratified into immediate definitive surgery (IDS), Safe definitive surgery (SDS), and delayed definitive surgery (DDS). Definitive surgery defined as fracture stabilization without secondary osteosynthesis. IDS with final definitive surgery within 12h, SDS had the first definitive surgery within 48hours, Group DDS included patients without surgery, or first definitive surgery after 48hours. Prediction of treatment strategy include abbreviated injury scale (AIS), and pathophysiologic parameters at admission.
Results
813 patients, 48 (5.9%) stratified into Group IDS, 362 (44.5%) into Group SDS and 403 (49.6%) into Group DDS. Mean age of patients 55.4 (SD 20.5) years, mean ISS 23.0 (SD 11.5), mortality 27.3%. Increased AIS spine was a risk factor for IDS strategy (OR 1.8, 95%CI 1.2 to 2.7, p < 0.001); increased AIS extremity was a risk factor for SDS strategy (Upper extremity: OR 2.3, 95%CI 1.5 to 3.4, p < 0.001, Lower extremity: 1.4, 95%CI 1.1 to 1.8, p = 0.002); increased AIShead was a risk factor for DDS strategy (OR 1.4, 95%CI 1.3 to 1.6). Prediction of SDS was highest when all physiologic parameters including hemorrhage, temperature, coagulation, and soft tissue were taken into consideration (AUC 0.8, 95%CI 0.7 to 0.9).
SDS represents a valid treatment strategy in polytrauma patients. The treating surgeon bases the decision of treatment protocol on injury distribution, injury severity, and on pathophysiologic response after trauma.

Introduction Pelvic ring fractures is not uncommon, and represented a challenge in their fixation. Anterior plating of sacroiliac joint seems to have less good outcome and low complications rate when compared to other approaches.

Aim of the work: The aim of this work is to assess the results of surgical treatment of unstable pelvic ring fractures with stabilization of sacroiliac joint with anterior plating, the results assessed clinically and radiologically.
Patients and methods: Fifteen patients with unstable pelvic ring fractures were included. All underwent full history taking, clinical and radiological evaluations and scheduled for anterior plating of sacroiliac joint. All were followed up for at least 15 months postoperatively.

Results: Radiologically, 53.3% had anatomic, 20.0% had moderate and 26.7% had nearly anatomic results. Clinically, satisfaction was reported by 80.0%. The union was achieved in 86.7% and no complications was reported among 80.0%.

Conclusion: Anterior pelvic plating combined with percutaneous sacroiliac joint screw fixation is effective treatment for unstable pelvic ring fractures with high success rate and low complications

Background: To compare the efficacy of the operative techniques, complications, reduction quality and functional recovery by using the modified iliofemoral approach and the modified Stoppa approach for the management of acetabular fractures.
Methods: A cohort of 60 patients from December 2016 to April 2022 with displaced acetabular fractures involving the were treated operatively with modified iliofemoral approach (group A) and modified Stoppa approach (group B), respectively. There were 30 patients in group A and 30 patients in group B. The surgical details, complications, radiographic and clinical results were recorded. The quality of reduction was assessed by measuring the residual step and gap displacement of postoperative CT with a standardized digital method.
Results: The complications, reduction quality (gaps and steps) and function recovery (modified Merle d’Abigne and Postel score) had no significant statistical difference in approaches. The mean operative time was shorter and the mean intraoperative haemorrhage was less in group A. There were statistical differences in the operative time (P = 0.024) and intraoperative haemorrhage (P = 0.006) between the modified iliofemoral approach and the modified Stoppa approach.
Conclusion: Compared to the modified Stoppa approach, the Modified ilio-femoral approach had a shorter operative time and the intraoperative haemorrhage was clearly less. It could be a better choice to deal with acetabular fractures involving the anterior column and anteriorly displaced transverse and T-shaped fractures. However, if the fracture line is distal, reduction and control of reduction can be difficult needing an additional Stoppa window.

Introduction: Acetabular fracture fixation surgery is associated with significant blood loss. Although Tranexamic acid (TXA) infusion effectively reduces perioperative blood loss and transfusion requirements in elective orthopedic surgery, its efficacy in major orthopedic trauma surgery is controversial.
Material and methods: Sixty-three patients undergoing acetabular fracture fixation surgery were randomized into either TXA (n=36) or placebo (n=27) group. TXA group received a bolus dose of TXA (10 mg/kg) 15 minutes prior to incision, followed by another similar dose after 3 hours of surgery. The placebo group received the same volume of normal saline similarly. All patients were operated on by a pelviacetabular surgeon with a uniform perioperative protocol. The intraoperative blood loss, drain output, the number of blood transfusions, postoperative hemoglobin (Hb) drop, and hematocrit (Hct) drop were calculated.
Results: Both groups were similar in relation to age, sex, BMI, preoperative Hb, the timing of surgery, fracture pattern, operative time, and surgical approaches. The mean postoperative Hb was 10.35 + 1.36 gm% in TXA group and 9.74 + 1.98 gm% in placebo group (p-value .158). There were no differences in intraoperative blood loss (438.11 ml vs. 442.81, p=.947), drain output (131.94 ml vs. 129.63, p=.870), and blood transfusion (8 patients vs. five patients, p=.719) between the groups. The drop in Hb and Hct in the postoperative period was also statistically not significant between the groups.
Conclusion: The use of intravenous Tranexamic acid in acetabular fracture fixation surgery did not show a reduction in blood loss and transfusion requirements compared to placebo.

In India, road traffic accident (RTA) is the leading cause for high velocity clavicle fractures. The fractures mostly occur in the midshaft region and are comminuted. The challenge faced by a surgeon is to restore the clavicle length to maintain the shoulder biomechanics of a patient. We studied the outcome of clavicle fractures that were comminuted with vertically displaced fracture fragments managed both surgically and conservatively. Methods: 285 patients with clavicle fractures were retrospectively analysed from 2015 to 2020. Data was collected based on the injury, fracture morphology, pre and post operative shortening, type of surgical management, shoulder strength and ROM and functional scoring from MRD. Results: A total of 182 patients were diagnosed with comminuted fractures. 76 patients had vertical displacement of the fragments. Of the 76 fractures the morphology of vertical displacement followed the ratio of 1:71:4 = Medial: Middle: Lateral third respectively. We had treated 16 such fractures conservatively and 61 fractures surgically. Fifty-six patients underwent superior plating with lag screw fixation while five patients underwent anterior plating with lag screw fixation. The mean follow up period was 3.2 years. Patients managed surgically had a residual shortening of 0.71cm. The post op functional scoring assessed using oxford shoulder score. Conclusion: Lag screw principle used to fix the vertical fragment to the butterfly fragment and then buttressing the clavicle with a plate, assures maximum restoration of the length. Conservatively managed fractures have a gross shortening due to collapse of fragments with cosmetic deformity and reduced shoulder strength.

Background: Combined open reduction and internal fixation (ORIF) of acetabular fractures with acute total hip replacement (THR) enables immediate full weight-bearing and rehabilitation, reducing complications associated with prolonged immobilisation. The aim of this study was to evaluate the functional and radiological outcomes of patients treated with this procedure at a major trauma centre and assess post-operative complications.
Methods: We retrospectively reviewed 77 patients (mean age: 72.2 years (37-94)) who underwent the fix-and-replace procedure for acetabular fractures between 2014-2021, with a minimum of 1 year follow-up.
Results: The most common mechanisms of injury were fall from standing (61%) and road traffic accident (19%); associated both column(ABC) was the most common fracture pattern (42%). Mean time to surgery was 11.3 days after injury (1-35). 92% of patients were ambulant with or without a walking aid at 6 weeks post-op. At 1 year, 84% had regained baseline pre-injury mobility status, and radiological outcomes were graded as excellent or good in all patients according to Matta’s grading system. The overall 1-year mortality rate was 9.1%. 23.4% of cases developed post-operative complications, of which infection (11/18) and iatrogenic sciatic nerve neuropraxia (8/18) were most common. Re-operative rate was 14.3%, including revision THR and/or washout with soft tissue debridement for infection, recurrent dislocation (36.3%), and septic acetabular cup loosening (9.1%).
Conclusion: The acute fix-and-replace strategy delivers good functional outcomes but complications are not uncommon, leading to increased mortality. Multidisciplinary management from both orthogeriatrics and specialist pelvic and acetabular surgeons are required for the best patient outcomes.

Background: Posterior wall fractures (PWFs) of the acetabulum represent approximately 20-30% of all acetabulum fractures. The aim of this study is to report the epidemiology of (PWFs), isolated or associated types, and analyze their pattern of injury. Methods: Retrospective review of patients' data with acetabular fractures obtained from the pelvic registry of the authors' institution, from 1st of January 2016 to 31st of December 2018. The data of 420 patients were available for review. Eighty patients with (PWFs), isolated or associated with other types according to Letournel classification, were included in the study. (PWFs) represented 19% of all reviewed acetabular fractures. Details of patients' data and fracture were reviewed. Results: Age ranged from 17 to 60 years (average =36.71±11.02). Sixty-five patients (81%) were males and 15 (19 %) were females. Motor car accident was the most common mechanism of injury (69%). Isolated posterior wall fracture (PWF) was reported in 36 patients (45%), transverse with (PWF) in 19 (24%), posterior column with (PWF) in 18 (22.5%), T-shaped with (PWF) in 4 (5%), and both-column with (PWF) in 3 (3.5%). Thirty-eight fractures (47.5%) were associated with posterior hip dislocation. Eight patients (10%) had associated sciatic nerve injury. Twenty-one (26%) were multifragmentary (PWFs), 37.5% had articular impactions (marginal impaction in 32.5% and roof impaction in 5%). Nineteen (24%) had femoral head lesions and twenty-two (27.5%) had retained bone fragment inside the hip joint. Conclusion: Posterior wall acetabular fracture is not that simple and is associated with many potentially bad predictors of functional outcome.

Background: The term “major fracture”, while widely used is not clearly defined. The aim of this systematic literature review was to identify all relevant articles on fractures that influence perioperative decision making in polytraumatized patients in regards to timing, sequence and strategy of fracture stabilization.

Methods: A systematic literature search was performed according to the PRISM guidelines in the Medline and EMBASE database on March 14, 2022. Mesh terms, EMTREE terms and regular search terms were combined with truncation and Boolean operators. Terms included “fracture”, “polytrauma”, “relevance”, “timing”, “decision” and “major” as well as alternative forms and spellings. Articles were identified, screened and tested for eligibility as per usual. Only original articles on clinical studies were included. Articles were stratified by fracture location and whether isolated or multiple fracture types were deemed relevant.

Results: In total, 4276 articles were identified through our systematic search. After screening and retrieval, 119 articles remained for full-text assessment and 75 articles met our criteria and were thus included. Femur fractures were by far most frequent with 60 articles (42 on femur exclusively). Fractures of Pelvis (n=21), Tibia (n=15) and Spine (n=14) were common as well, while articles on acetabulum (n=9) and upper extremity were (n=7) were more rare. Focus broadened over the years with more articles considering multiple fracture types as relevant.

Conclusion: Multiple fracture types are relevant for operative timing, sequence and strategy in polytraumatized patients. Our results offer a basis for the discussion of how to define the major fracture.

Objectives: to determine the factors affecting lower limbs amputation after fractures due to high velocity gunshots and ballistics injuries and to estimate the role of CT angiography in vascular cases associated with these injuries. Methods: a total of 214 patients with lower limbs fracture with vascular injury were involved in this study during a period from the 1st of January 2015 to the 31th December 2020. Result: out of 1176 patients with lower limbs fractures, 214 =18.2% has vascular injuries, 144/214=67.3% developed amputation. MESS was > 7 for (62=43%), primary Re / amputation done and MESS ≤ 7 for (82=57%). Severity of the injury, pump explosion (86=59.7%) and vascular injury with ischemia > 8hs (61=74.4%) are statistically significant (P< 0.05) associated with high rate of emergency amputation. Failure of vascular graft and reoperation (61=74.4%), nerve and tendons injuries (28=34.1%), infection (23=28%) and extensive bone loose (16=19.5%) are statistically significant (P< 0.05) associated with high rate of delayed amputation. Diagnosis of associated vascular injuries by physical examination (more than one hard or soft signs) were detected in all the patients, CT angiography requested for (82/152= 54%) patients, (78/82=95.1%) confirmed the injuries. Conclusion: severity of the injury and ischemia more than 8h are the main factors affecting amputation in lower limbs fractures in severe war related injuries and Failure of revascularization affects delayed amputation. There is no role for CT angiography in diagnosis of vascular injuries associated with these fractures. Instead, it may increase the time of ischemia and rate of amputation.

AIMS AND OBJECTIVES
The aim of our study is to explain and evaluate functional outcome of delayed distal femur fracture fixation. This study was conducted in the Department of Orthopaedics at tertiary care hospital from 2017-2020To evaluate distal femur fracture according to AO/OTA classification. To assess distal femur fracture according to closed or compound fractures.To assess bony union in delayed distal femur fracture fixation.To assess complications I in delayed distal femur fracture fixation. To assess knee range of motion and lower limb shortening in delayed distal femur fracture fixation.We have done retrospective study of 30 patients with distal femur fracture treated late (more than 1 month after trauma) with surgery during the period of 2017 to 2020.
Inclusion criteria:
open and closed distal femur fractures Age >16 years at presentation.Post traumatic distal femur fractures
Patients operated after 1 month
Exclusion criteria:Patients medically unfit for procedure.Patients not willing for procedure
Pathological fractures.Patients operated within 1 month.Patients with peri-prosthetic fracture
Functional grading was done according to pain, function, mobility and work while radiological grading was done according to varus / valgus deformity and status of union. OXFORD KNEE SCORE AND WOMAC KNEE SCORE are used as criteria for evaluation. the mean age was 44.9 years. majority of the patients were male. right sided fractures were seen . excellent results were seen in 3(10%) patients, good /satisfactory results were seen in 7(24%) patients, fair/unsatisfactory results were seen in 15(50%) patients and poor results were seen in 5(16%) patients.

The main objective of our study was to calculate mortality rates in elderly patients with low-energy distal femur fractures one year after surgery retrospective study. Estimate 1-year mortality rates in elderly patients who undergo operative treatment for distal femur fractures and identify potential risk factors for mortality. One year after surgery. Age of our 57 patients was on average 67 year with limits ranging from 58-91 years who sustained distal femur fractures at 2021.
Fracture fixation of the distal femur. ; Survival up to 1 year after surgery.
The 1-year mortality rate for distal femur fractures in elderly patients. There were no statistically significant differences in overall mortality between native bone and periprosthetic fractures, intramedullary nail or open reduction internal fixation, or across Orthopaedic Trauma Association fracture classifications. Overall patient mortality was significantly higher at 23 days : 5 patients, 1 month :15 patients lost view , three months 17 patients lost view ; six months 9 patients did not show up for consultation at 1 year 11 patients were reviewed at one year out of the 57, when surgery occurred more than 2 days from the injury. A time to surgery of more than 1 days, regardless of baseline illness, did not result in improved survivability at 1 year.
mortality for distal femur fractures in our series was 19,29% in the elderly population that’s half of our patients. A surgical treatment more than 1 day after injury was associated with increased patient mortality

Introduction: Fibula strut grafts play a vital role in treating fractures with extensive bone loss. However, morbidity associated with traditional methods of harvesting them outweighed the potential benefits.

Case Report: A Forty five year old Lady presented to with an closed comminuted fracture of Right Femur (Vinquist Type IV). She subsequently underwent intramedullary nailing of femur with an fibular strut graft obtained via minimally invasive technique.

Case Report: With patient in supine position, sites for distal osteotomy-10 cm from syndesmotic joint and Proximal osteotomy 5cm from fibular head were identified. Two separate three centimetre incisions were made and fibular diaphsyeal approach was used. Upon incising the crural fascia, the fibular is approached in the plane between soleus and peroneal muscles. Upon incision of the periosteum, soft tissue is detached from the sub-periosteum circumferentially around fibular. Multiple drill holes are made at the site of osteotomy and made complete with an osteotome. Intramedullary nailing of the femur was subsequently done and the graft held at fracture site with two 1.2 mm cerclage wires. Patient had no post operative complications and was discharged day three post-op. At 6 months post operation , patient was able to fully weight bear with radiographic evidence of union.

Conclusion; Post procedure graft site morbidity is often associated with traditional methods of harvesting. Minimally invasive method on the other hand has a number of benefits like the ability to harvest long grafts whilst reducing the operating time, decreasing intra and postoperative bleeding as well as scarring complications.