Tibial plafond fractures are difficult to manage and may have serious complications. We identified more complications, more secondary procedures, and worse outcomes in patients with articular and metaphyseal comminution (type C3). ORIF was associated with fewer complications and less post-traumatic arthritis when compared to EF, possibly reflecting a selection bias for open injuries and more severely comminuted fractures to be managed with EF. ORIF with appropriate soft tissue handling resulted in acceptable results in most patients. Severely damaged soft tissues and highly comminuted C3 fractures may be safely treated with EF. Loss of function and progression to post-traumatic arthritis are common after tibial plafond fractures. Assessment of long-term results and the efficacy of additional reconstructive procedures will refine the treatment algorithms for these fractures.

he treatment of comminuted, intra-articular distal femoral fractures (Orthopaedic Trauma Association [OTA] classification 1 33-C3) is challenging. Many of these injuries are the result of high-energy trauma, which generates severe soft-tissue damage and articular and metaphyseal comminution. Bone loss resulting from open fracture and poor bone quality may decrease the stability of fixation. Traditional devices for internal fixation have included the 95° condylar blade-plate, the dynamic condylar screw with a 95° side-plate, and intramedullary nails. However, coronal fractures or extensive distal comminution may preclude the use of these devices. In such cases, a lateral buttress or neutralization plate may be used. The condylar buttress plate was the first implant designed to serve this function. Unfortunately, when this device is applied in the presence of medial comminution or bone loss, failure of fixation and varus collapse may eventually result 2,3 .Recent advances in technology for the treatment of distal femoral fractures include the Less Invasive Stabilization System (LISS; Synthes, Paoli, Pennsylvania) and the Locking Compression Plate (LCP) condylar plate (Synthes) 4-15 . Each of these implants offers multiple points of fixed-angle contact between the plate and screws in the distal part of the femur, theoretically reducing the tendency for varus collapse that is seen with traditional lateral plates. The LISS differs from the LCP condylar plate in composition, shape, and placement. Early clinical studies of the LISS have demonstrated a high frequency of fracture union with low rates of malalignment 7-9,15 . Few cases of failure of the LISS have been reported 11,12,16 . To our knowledge, there have been no published studies focusing specifically on the LCP condylar plate and no reported cases of failure of this implant in the distal part of the femur. The purposes of this report were to describe and critically examine six cases of failure of the LCP condylar plate and to discuss the limitations of this implant for the treatment of distal femoral fractures. The patients were informed that data concerning the cases would be submitted for publication. Materials and Methodse retrospectively reviewed the cases of all forty-six patients who had been treated primarily with the LCP condylar plate for a distal femoral fracture during a thirty-sixmonth period at our hospital, and we identified six implant failures. Fracture care was provided by fellowship-trained traumatologists at a level-I trauma center. Information on these patients can be found in Table I and the Appendix. Indications for the use of this implant included a coronal plane fracture, osteopenia, and/or extensive distal fracture comminution precluding insertion of a conventional 95° condylar blade-plate or a dynamic condylar screw. All forty-six patients underwent assessment and resuscitation according to Advanced Trauma Life Support (ATLS) guidelines 17 . Open wounds were inspected, and dressings were applied. Intravenous antibiotics and tetanus ...

Distraction osteogenesis in combination with free tissue transfer is a powerful technique that allows limb salvage, particularly when local and regional flaps are unavailable or inadequate. For infected nonunion of the tibia, it permits a staged approach that allows underlying osteomyelitis to declare itself and provides vascularized healthy soft-tissue coverage that facilitates repeated operations for the purpose of distraction.

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

A novel technique has been developed to salvage a transtibial amputation level with use of a rotational osteocutaneous flap from the hindfoot. In the absence of adequate tibial length and/or soft-tissue coverage to salvage the entire limb or to perform a conventional-length transtibial amputation, this technique is a highly functional alternative that does not require microvascular free tissue transfer.

Objective: To assess the outcomes of patients who sustained blunt trauma tibia fractures compared with tibia fractures from civilian gunshot injuries when treated with intramedullary fixation. Design: Retrospective chart review. Setting: Level I trauma center. Patients/Participants: Two hundred and seven patients underwent intramedullary nailing for 211 tibia fractures. Methods: A retrospective review of tibia fracture(s) treated with intramedullary fixation with comparison of closed, open, and gunshot wound (GSW) fracture outcomes. Main Outcome Measurements: Outcomes included infection and nonunion. Results: The infection rate in closed and GSW tibia fractures was significantly lower compared with the infection rate of open fractures (1% vs. 9% vs. 20%; P = 0.00005). Significantly lower rates of nonunion in closed fractures compared with open fractures and GSW fractures were appreciated (8% vs. 20% vs. 30%; P = 0.003). There was no difference in infection or nonunion between GSW fractures with small wounds, no exposed bone, and minimal comminution and closed injuries (P = 0.24, P = 0.60). Conversely, there was a significantly higher nonunion rate in GSW fractures with large wounds, exposed tibia, and comminution compared with blunt injuries (P = 0.0014). Conclusions: This study suggests that tibia fractures from civilian GSWs are heterogeneous injuries, and outcomes are dependent on the extent of soft-tissue injury, bone exposure, and bone loss. There are comparable infection rates in all fractures due to civilian GSWs and closed fractures, which are lower than high-grade open fractures. Tibia GSW fractures with exposed bone and comminution have higher complication rates and should be treated accordingly. Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

A global loss of scintillation in the femoral head as determined by SPECT scanning occurs in some patients with hip dislocations and fractures or dislocations of the acetabulum in the early injury period. Changes in blood flow occurred in patients with short (one hour) and long (twenty-four hours) dislocation times. However, the development of avascular necrosis could not be predicted by early SPECT scanning. Until further multicenter studies are performed, SPECT scanning cannot be recommended on an acute or routine basis to predict those patients who will develop avascular necrosis. Operative approaches for open reduction of the hip and internal fixation of acetabular fractures do not appear to affect blood flow to the femoral head. Although a golden time to relocation cannot be fully established from this study, early relocation is advised to decrease the potential risk of vascular spasm, scarring, and subsequent avascular necrosis.

In this case report, we describe a failure to lengthen with the PRECICE femoral nail and the subsequent steps taken to determine the root cause. We believe that this failure represents the first reported case of malfunction of the PRECICE femoral nail distraction mechanism since its 2013 redesign.