A series of 49 pilon fractures in a tertiary referral centre treated definitively by open reduction and internal fixation have been assessed and the complications of such injuries examined. A retrospective analysis of case notes, radiographs and computerised tomographs over a sevenyear period from 1999-2006 was performed. Infection was the most common postoperative problem. There were seven cases of superficial infection. There was a single case of deep infection requiring intravenous antibiotics and removal of metalwork. Other notable complications were those of secondary osteoarthritis (three cases) and malunion (one case). The key finding of this paper is the 2% incidence of deep infection following the direct operative approach to these fractures. The traditional operative approach to such injuries (initially advocated by Rüedi and Allgöwer in Injury 2:92-99, 1969) consisted of extensive soft tissue dissection to gain access to the distal tibia. Our preferred method is to access the tibia via the "direct approach" which involves direct access to the fracture site with minimal disturbance of the soft tissue envelope. We therefore believe that open reduction and internal fixation of pilon fractures via the direct approach to be a safe technique in the treatment of such devastating injuries.

We have recently described an extended lateral approach to the hindfoot for the operative treatment of displaced intra-articular fractures of the calcaneum. It has the advantage of avoiding damage to the sural nerve and preserving blood supply to allow prompt healing. We dissected 15 formalin-preserved cadavers, taking photographs to show the structures of the posterolateral aspect of the hindfoot and ankle. We describe a superficial and a deep triangle: the deep triangle contains a constant posterior peroneal artery which supplies the skin of the posterolateral heel. An approach designed to expose the sural nerve will divide this important artery and cause ischaemia of the posterior skin. The extended lateral approach elevates the sural nerve in a thick flap and preserves the blood supply of the skin. We have reviewed 150 consecutive patients after the use of this approach to study the indications for operation, the quality of wound healing, any damage to the sural nerve and other complications. We recommend the careful use of this approach. Our understanding of its anatomical basis has allowed us to widen the indications for its use.

PurposeIn the surgical treatment for lower-leg intra-articular fractures, the fragments have to be positioned and aligned to reconstruct the fractured bone as precisely as possible, to allow the joint to function correctly again. Standard procedures use 2D radiographs to estimate the desired reduction position of bone fragments. However, optimal correction in a 3D space requires 3D imaging. This paper introduces a new navigation system that uses pre-operative planning based on 3D CT data and intra-operative 3D guidance to virtually reduce lower-limb intra-articular fractures. Physical reduction in the fractures is then performed by our robotic system based on the virtual reduction.Methods3D models of bone fragments are segmented from CT scan. Fragments are pre-operatively visualized on the screen and virtually manipulated by the surgeon through a dedicated GUI to achieve the virtual reduction in the fracture. Intra-operatively, the actual position of the bone fragments is provided by an optical tracker enabling real-time 3D guidance. The motion commands for the robot connected to the bone fragment are generated, and the fracture physically reduced based on the surgeon’s virtual reduction. To test the system, four femur models were fractured to obtain four different distal femur fracture types. Each one of them was subsequently reduced 20 times by a surgeon using our system.ResultsThe navigation system allowed an orthopaedic surgeon to virtually reduce the fracture with a maximum residual positioning error of (translational) and (rotational). Correspondent physical reductions resulted in an accuracy of 1.03 ± 0.2 mm and , when the robot reduced the fracture.ConclusionsExperimental outcome demonstrates the accuracy and effectiveness of the proposed navigation system, presenting a fracture reduction accuracy of about 1 mm and , and meeting the clinical requirements for distal femur fracture reduction procedures.Electronic supplementary materialThe online version of this article (doi:10.1007/s11548-016-1418-z) contains supplementary material, which is available to authorized users.

We describe a surgical technique using the Taylor Spatial Frame intraoperatively to correct complex multiplanar deformities of the distal femur prior to definitive internal fixation using minimally invasive stabilization techniques. Eight procedures were done in 7 patients. All deformities were complex oblique plane deformities, often with a rotational component, and ranged from 10 degrees valgus to 35 degrees varus; up to 45 degrees of external rotation; 10 mm of translation and in 1 case, 100 mm of shortening. All patients underwent acute intraoperative deformity correction mediated by the Taylor Spatial Frame prior to definitive internal fixation using either a percutaneous locking plate or locked intramedullary nail. Deformity correction and restoration of the mechanical axis were achieved in all cases. There were no cases of wound breakdown, infection, nerve palsy or compartment syndrome. We believe the Taylor Spatial Frame can be effectively and safely used to assist the acute correction and subsequent internal fixation of limb deformity.

Quantitative immunophenotypic analysis of cell types present in peri-prosthetic tissue [pseudosynovial membrane (PSM)] from aseptically loose joint implants revealed considerable heterogeneity between tissues from different individuals. The monocyte/macrophage was the commonest leucocyte type; however, its proportion varied widely. T cells normally accounted for approximately 5% of cells, but in a few cases formed > 20% of cells. In all cases, there was a high ratio of CD4 to CD8 cells. PSM leucocytes were activated in most PSMs as judged by surface expression of CD23, CD25 and CD71. Analysis of the proportions of cell types in PSM, OA synovium and RA synovium revealed similarities between the different tissue types. The levels of IL-1, IL-6 and prostaglandin E produced by the PSM were correlated, but only IL-1 and IL-6 levels correlated with markers of the monocyte/macrophage lineage. This result suggests that prostaglandin E is produced in vivo by many PSM cell types.