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Alexandre Sitnik, Aleksander Beletsky, and Steven Schelkun

  • Results of the treatment of intra-articular fractures of the distal tibia have improved significantly during the last two decades.

  • Recognition of the role of soft tissues has led to the development of a staged treatment strategy. At the first stage, joint-bridging external fixation and fibular fixation are performed. This leads to partial reduction of the distal tibial fracture and allows time for the healing of soft tissues and detailed surgical planning.

  • Definitive open reduction and internal fixation of the tibial fracture is performed at a second stage, when the condition of the soft tissues is safe. The preferred surgical approach(es) is chosen based on the fracture morphology as determined from standard radiographic views and computed tomography.

  • Meticulous atraumatic soft-tissue handling and the use of modern fixation techniques for the metaphyseal component such as minimally invasive plate osteosynthesis further facilitate healing.

Cite this article: EFORT Open Rev 2017;2:352-361. DOI: 10.1302/2058-5241.2.150047

Ippokratis Pountos and Peter V. Giannoudis

  • The effective management of articular impacted fractures requires the successful elevation of the osteochondral fragment to eliminate joint incongruency and the stable fixation of the fragments providing structural support to the articular surface.

  • The anatomical restoration of the joint can be performed either with elevation through a cortical window, through balloon-guided osteoplasty or direct visualisation of the articular surface.

  • Structural support of the void created in the subchondral area can be achieved through the use of bone graft materials (autologous tricortical bone), or synthetic bone graft substitutes.

  • In the present study, we describe the available techniques and materials that can be used in treating impacted osteochondral fragments with special consideration of their epidemiology and treatment options.

Cite this article: EFORT Open Rev 2017;2. DOI: 10.1302/2058-5241.2.160072. Originally published online at

Antomio Capone, Marcella Peri, and Michele Mastio

  • We performed a systematic review of the literature involving a number of databases to identify studies that included outcomes of surgical treatment of acetabular fractures in patients aged > 55 years. An initial search identified 1564 studies. After exclusion by two independent reviewers, 15 studies met the inclusion criteria. All studies were case series and the mean Coleman Methodology score for methodological quality assessment was 43.7 (standard deviation 12.3). There were 354 patients with acetabular fractures. Pooled analysis revealed a mean age of 71.6 years (55 to 96) and a mean follow-up of 43 months (20 to 188). Complex fractures were reported in 70.1% of patients.

  • Seven studies presented the results of open reduction and internal fixation (ORIF); in eight other studies a total hip arthroplasty (THA), alone or combined with different internal fixation techniques, was the chosen treatment. In the ORIF sub-group, conversion to THA was performed at a mean of 25.5 months with anatomical reduction in 11.6% and imperfect and poor reduction in 22.3%. In the THA sub-group, an acetabular ring or cage with a cemented acetabular component was used in four studies (52 patients) and a cementless acetabular component was implanted in five studies (78 patients). Six patients (4.9%) underwent revision at a mean of 39 months after the index procedure.

  • The analysis of intra-operative and post-operative parameters showed a statistical difference between the two sub-groups with regards to the mean operating time (236 mins ORIF vs 178 mins THA), the mean blood loss (707 mL ORIF vs 974 mL THA) and the mean mortality rate at one year (22.6% ORIF vs 8.8% THA).

  • Based on the current data available, acute THA (alone or in combination with internal fixation) may have a role in the treatment of older patients with complex acetabular fractures. Despite the wide heterogenecity of fracture types and patient co-morbidities, THA procedures were associated with lower rates of mortality and further surgery when compared with the ORIF procedures.

Cite this article: EFORT Open Rev 2017;2:97-103. DOI: 10.1302/2058-5241.2.160036

Josep Muñoz Vives, Jean-Christophe Bel, Arantxa Capel Agundez, Francisco Chana Rodríguez, José Palomo Traver, Morten Schultz-Larsen, and Theodoros Tosounidis

  • In 1975, Blake and McBryde established the concept of ‘floating knee’ to describe ipsilateral fractures of the femur and tibia.1 This combination is much more than a bone lesion; the mechanism is usually a high-energy trauma in a patient with multiple injuries and a myriad of other lesions.

  • After initial evaluation patients should be categorised, and only stable patients should undergo immediate reduction and internal fixation with the rest receiving external fixation.

  • Definitive internal fixation of both bones yields the best results in almost all series.

  • Nailing of both bones is the optimal fixation when both fractures (femoral and tibial) are extra-articular.

  • Plates are the ‘standard of care’ in cases with articular fractures.

  • A combination of implants are required by 40% of floating knees.

  • Associated ligamentous and meniscal lesions are common, but may be irrelevant in the case of an intra-articular fracture which gives the worst prognosis for this type of lesion.

Cite this article: Muñoz Vives K, Bel J-C, Capel Agundez A, Chana Rodríguez F, Palomo Traver J, Schultz-Larsen M, Tosounidis, T. The floating knee. EFORT Open Rev 2016;1:375-382. DOI: 10.1302/2058-5241.1.000042.

Deepak Samson, Chye Yew Ng, and Dominic Power

  • Traumatic knee dislocation is a complex ligamentous injury that may be associated with simultaneous vascular and neurological injury.

  • Although orthopaedic surgeons may consider CPN exploration at the time of ligament reconstruction, there is no standardised approach to the management of this complex and debilitating complication.

  • This review focusses on published evidence of the outcomes of common peroneal nerve (CPN) injuries associated with knee dislocation, and proposes an algorithm for the management.

Cite this article: Deepak Samson, Chye Yew Ng, Dominic Power. An evidence-based algorithm for the management of common peroneal nerve injury associated with traumatic knee dislocation. EFORT Open Rev 2016;1:362-367. DOI: 10.1302/2058-5241.160012.

Jordi Tomás-Hernández

  • High-energy pilon fractures are challenging injuries. Multiple options are described for the definitive surgical management of these fractures, but there is no level I evidence for optimal management. The current management and recommendations for treatment will be reviewed in this article.

  • Anatomical reduction of the fracture, restoration of joint congruence and reconstruction of the posterior column with a correct limb axis minimising the soft-tissue insult are the key points to a good outcome when treating pilon fractures.

  • Even when these goals are achieved, there is no guarantee that results will be acceptable in the mid-term due to the frequent progression to post-traumatic arthritis.

  • In high-energy fractures with soft-tissue compromise, a staged treatment is generally accepted as the best way to take care of these devastating fractures and is considered a local ‘damage control’ strategy.

  • The axial cuts from the CT scan images are essential in order to define the location of the main fracture line, the fracture pattern (sagittal or coronal) and the number of fragments. All of this information is crucial for pre-operative planning, incision placement and articular surface reduction.

  • No single method of fixation is ideal for all pilon fractures, or suitable for all patients. Definitive decision making is mostly dependent on the fracture pattern, condition of the soft-tissues, the patient’s profile and surgical expertise.

Cite this article: Tomás-Hernández J. High-energy pilon fractures management: state of the art. EFORT Open Rev 2016;1:354-361. DOI: 10.1302/2058-5241.1.000016.

Luca Dei Giudici, Andrea Faini, Luca Garro, Agostino Tucciarone, and Antonio Gigante

  • The management of articular fractures is always a matter of concern. Each articular fracture is different from the other, whatever the classification system used and the surgical or non-surgical indications employed by the surgeon. The main goals remain anatomical reduction, stable fixation, loose body removal and minimal invasiveness.

  • Open procedures are a compromise. Unfortunately, it is not always possible to meet every treatment goal perfectly, since associated lesions can pass unnoticed or delay treatment, and even in a ‘best-case’ scenario there can be complications in the long term.

  • In the last few decades, arthroscopic joint surgery has undergone an exponential evolution, expanding its application in the trauma field with the development of arthroscopic and arthroscopically-assisted reduction and internal fixation (ARIF) techniques. The main advantages are an accurate diagnosis of the fracture and associated soft-tissue involvement, the potential for concomitant treatments, anatomical reduction and minimal invasiveness. ARIF techniques have been applied to treat fractures affecting several joints: shoulder, elbow, wrist, hip, knee and ankle.

  • The purpose of this paper is to provide a review of the most recent literature concerning arthroscopic and arthroscopically-assisted reduction and internal fixation for articular and peri-articular fractures of the upper limb, to analyse the results and suggest the best clinical applications.

  • ARIF is an approach with excellent results in treating upper-limb articular and peri-articular fractures; it can be used in every joint and allows treatment of both the bony structure and soft-tissues.

  • Post-operative outcomes are generally good or excellent. While under some circumstances ARIF is better than a conventional approach, the results are still beneficial due to the consistent range of movement recovery and shorter rehabilitation time.

  • The main limitation of this technique is the steep learning curve, but investing in ARIF reduces intra-operative morbidity, surgical errors, operative times and costs.

Cite this article: Dei Giudici L, Faini A, Garro L, Tucciarone A, Gigante A. Arthroscopic management of articular and peri-articular fractures of the upper limb. EFORT Open Rev 2016;1:325-331. DOI: 10.1302/2058-5241.1.160016.

Ioannis Ktistakis, Vasileios Giannoudis, and Peter V. Giannoudis

  • Hip fractures in the elderly population have become a ‘disease’ with increasing incidence.

  • Most of the geriatric patients are affected by a number of comorbidities.

  • Coagulopathies continue to be a special point of interest for the orthopaedic trauma surgeon, with the management of this high-risk group of patients a hot topic of debate among the orthopaedic community.

  • While a universal consensus on how to manage thromboprophylaxis for this special cohort of patients has not been reached, multiple attempts to define a widely accepted protocol have been published.

Cite this article: Ktistakis I, Giannoudis V, Giannoudis PV. Anticoagulation therapy and proximal femoral fracture treatment: an update. EFORT Open Rev 2016;1:310-315. DOI: 10.1302/2058-5241.1.160034.

Marko Bumbasirevic, Tomislav Palibrk, Aleksandar Lesic, and Henry DE Atkinson

  • As a result of its proximity to the humeral shaft, as well as its long and tortuous course, the radial nerve is the most frequently injured major nerve in the upper limb, with its close proximity to the bone making it vulnerable when fractures occur.

  • Injury is most frequently sustained during humeral fracture and gunshot injuries, but iatrogenic injuries are not unusual following surgical treatment of various other pathologies.

  • Treatment is usually non-operative, but surgery is sometimes necessary, using a variety of often imaginative procedures. Because radial nerve injuries are the least debilitating of the upper limb nerve injuries, results are usually satisfactory.

  • Conservative treatment certainly has a role, and one of the most important aspects of this treatment is to maintain a full passive range of motion in all the affected joints.

  • Surgical treatment is indicated in cases when nerve transection is obvious, as in open injuries or when there is no clinical improvement after a period of conservative treatment. Different techniques are used including direct suture or nerve grafting, vascularised nerve grafts, direct nerve transfer, tendon transfer, functional muscle transfer or the promising, newer treatment of biological therapy.

Cite this article: Bumbasirevic M, Palibrk T, Lesic A, Atkinson HDE. Radial nerve palsy. EFORT Open Rev 2016;1:286-294. DOI: 10.1302/2058-5241.1.000028.

Benedikt Johannes Braun, Jörg Holstein, Tobias Fritz, Nils Thomas Veith, Steven Herath, Philipp Mörsdorf, and Tim Pohlemann

  • Although the field of geriatric trauma is – ironically – young, care for the elderly trauma patient is increasingly recognised as an important challenge, considering the worldwide trend towards increasing longevity.

  • Increasing age is associated with physiological changes and resulting comorbidities that present multiple challenges to the treating physician.

  • Even though polytrauma is less likely with increasing age, lower-energy trauma can also result in life-threatening injuries due to the reduced physiological reserve.

  • Mechanisms of injury and resulting injury patterns are markedly changed in the elderly population and new management strategies are needed. From initial triage to long-term rehabilitation, these patients require care that differs from the everyday standard.

  • In the current review, the special requirements of this increasing patient population are reviewed and management options discussed. With the increase in orthogeriatrics as a speciality, the current status quo will almost certainly shift towards a more tailored treatment approach for the elderly patient. Further research expanding our current knowledge is needed to reduce the high morbidity and mortality rate.

Cite this article: Braun BJ, Holstein J, Fritz T, Veith NT, Herath S, Mörsdorf P, Pohlemann T. Polytrauma in the elderly: a review. EFORT Open Rev 2016;1:146-151. DOI: 10.1302/2058-5241.1.160002.