This study was performed to evaluate the results of operative treatment of ankle fractures in patients who required syndesmotic stabilization in addition to malleolar fracture fixation compared with patients who required malleolar fixation alone. The authors conducted a retrospective review of prospectively collected data. Academic medical center. Between October 2000 and November 2006, 347 patients who underwent surgical repair of an unstable ankle fracture were enrolled in a prospective database. Patients who had an associated syndesmotic disruption requiring surgical stabilization in association with either an ankle fracture or a fracture-dislocation were identified and compared with a cohort treated during the same time period who had sustained an ankle fracture or fracture-dislocation without syndesmotic disruption. All patients were followed and evaluated at 3, 6, and 12 months with clinical and radiographic examination as well as functional status (Short Musculoskeletal Functional Assessment, American Orthopaedic Foot and Ankle Society). Patient-reported pain and postoperative complications were recorded as well. Three hundred forty-seven patients met the inclusion criteria and had 1-year minimum follow up. Seventy-nine patients (23%) who had syndesmotic stabilization were identified and compared with 268 patients (77%) who did not. No differences were found between the two groups with respect to age or American Society of Anesthesiologists status; however, there was a greater percentage of men in the syndesmotic injury group (P = 0.04). There was a greater percentage of Type C fractures requiring syndesmosis stabilization, whereas Type B fractures were less likely to require syndesmosis stabilization (P = 0.001) At 6- and 12-month follow up, there was a clear difference in outcome based on American Orthopaedic Foot and Ankle Society and Short Musculoskeletal Functional Assessment scores; patients who underwent syndesmotic stabilization had worse American Orthopaedic Foot and Ankle Society scores with lower function ratings (P = 0.04) and worse pain ratings (P = 0.02). Short Musculoskeletal Functional Assessment scores were also worse at 12 months in patients who had syndesmotic stabilization because the dysfunction index was higher in the syndesmotic injury group (P = 0.009). Radiographically, 18 of 144 (13%) syndesmotic screws were noted to be broken on follow-up radiographs, eight of which were subsequently removed. There were no other differences in complication rates. Patients who required syndesmotic stabilization in addition to malleolar fracture fixation had poorer outcomes at 12 months compared with patients who required malleolar fracture fixation alone. This information is important for patient counseling to manage expectations regarding outcomes after injury.

To examine our incidence of early complications that occur using the Proximal Humeral Internal Locking System (PHILOS) and to determine the contributing factors. Academic medical center. Fifty-one consecutive patients treated with a proximal humerus locking plate. Development of an intraoperative, acute postoperative, or delayed postoperative complication. A retrospective analysis was undertaken of a consecutive series of proximal humerus fractures treated with a locking plate between February 2003 and January 2006 at our institution. Fifty-one fractures or fracture nonunions were identified in 18 male and 33 female patients with an average age of 61. All acute injuries were treated with a similar protocol of open reduction internal fixation with the PHILOS plate followed by early range of shoulder motion. Nonunions were treated in a similar manner with the addition of iliac crest bone graft placement. Patients were objectively assessed on their outcome by physical as well as radiological examination. All complications were recorded. Statistical analyses were performed to determine if patient age, fracture type, or number of screws placed in the humeral head contributed to complications. Fifty-one patients were available for minimum 6-month follow-up (mean, 16 months; range, 6 to 45 months). Radiographically, 92% of the cases united at 3 months after surgery, and 2 fractures had signs of osteonecrosis at latest follow-up. Sixteen complications were seen in 12 patients (24%). Eight shoulders in eight patients (16%) had screws that penetrated the humeral head. Two patients developed osteonecrosis at latest follow-up. One acute fracture and one nonunion failed to unite after index surgery. Significant heterotopic bone developed in 1 patient. Early implant failure occurred in 2 patients; one was revised to a longer plate, and one underwent resection arthroplasty. There was one acute postoperative infection. The major complication reported in this study was screw penetration, suggesting that exceptional vigilance must be taken in estimating the appropriate number and length of screws used to prevent articular penetration; although the device provides exceptional fixation stability, its indication must be scrutinized for each individual patient, taking the extent of trauma/fracture and age into consideration and carefully weighing it against other forms of treatment.

Background: There is much debate regarding the optimal treatment of displaced, unstable distal radial fractures in the elderly. The purpose of this retrospective review was to compare outcomes for elderly patients with a displaced distal radial fracture who were treated with or without surgical intervention. Methods: This case-control study examined ninety patients over the age of sixty-five who were treated with or without surgery for a displaced distal radial fracture. All fractures were initially treated with closed reduction and splinting. Patients who failed an acceptable closed reduction were offered surgical intervention. Patients who did not undergo surgery were treated until healing with cast immobilization. Patients who underwent surgery were treated with either plate-and-screw fixation or external fixation. Baseline radiographs and functional scores were obtained prior to treatment. Follow-up was conducted at two, six, twelve, twenty-four, and fifty-two weeks. Clinical and radiographic follow-up was completed at each visit, while functional scores were obtained at the twelve, twenty-four, and fifty-two-week follow-up evaluations. Outcomes at fixed time points were compared between groups with standard statistical methods. Results: Forty-six patients with a mean age of seventy-six years were treated nonoperatively, and forty-four patients with a mean age of seventy-three years were treated operatively. Other than age, there was no difference with respect to baseline demographics between the cohorts. At twenty-four weeks, patients who underwent surgery had better wrist extension (p = 0.04) than those who had not had surgery. At one year, this difference was not seen. No difference in functional status based on the Disabilities of the Arm, Shoulder and Hand scores and pain scores at any of the follow-up points was seen between the groups. Grip strength at one year was significantly better in the operative group. Radiographic outcome was superior for the patients in the operative group at each follow-up interval. There was no difference between the groups with regard to complications. Conclusions: Our findings suggest that minor limitations in the range of wrist motion and diminished grip strength, as seen with nonoperative care, do not seem to limit functional recovery at one year. Level of Evidence: Therapeutic Level III. See Instructions to Authors for a complete description of levels of evidence.

We performed a prospective, randomised trial to evaluate the outcome after surgery of displaced, unstable fractures of the distal radius. A total of 280 consecutive patients were enrolled in a prospective database and 88 identified who met the inclusion criteria for surgery. They were randomised to receive either bridging external fixation with supplementary Kirschner-wire fixation or volar-locked plating with screws. Both groups were similar in terms of age, gender, hand dominance, fracture pattern, socio-economic status and medical co-morbidities. Although the patients treated by volar plating had a statistically significant early improvement in the range of movement of the wrist, this advantage diminished with time and in absolute terms the difference in range of movement was clinically unimportant. Radiologically, there were no clinically significant differences in the reductions, although more patients with AO/OTA (Orthopaedic Trauma Association) type C fractures were allocated to the external fixation group. The function at one year was similar in the two groups. No clear advantage could be demonstrated with either treatment but fewer re-operations were required in the external fixation group.