complications

Distal Tibial Fractures

Definition

Metaphyseal

Extra-articular

Intra-articular Extension

Indications

< 60 with good bone stock and preserved joint space

Reduction

Union rates increased with anatomical reduction

Options

- closed reduction

- open reduction / if closed reduction fails

Accept

- no varus

- < 15^o valgus

- < 10^o AP plane

Definition

Garden 1 / 2

Algorithm

ORIF

- ~ 15% displacement rate with non operative management

- increased risk of non union

- reduced hospital in patient stays

Options

Cannulated screws

DHS + derotation screw

3 cannulated screws

Indications

Patient > 70

Gjertsen et al JBJS Am 2010

- 4335 patients > 70 with displaced subcapital fractures

- minimum 1 year follow up

- 1 year mortality same in each group / 25%

- 22% reoperation in ORIF v 3% in hemiarthroplasty

- more pain / higher dissatisfaction / lower quality life in ORIF group

Options

Hemiarthroplasty

- unipolar monoblock

- unipolar modular

General

- haemarthrosis

- DVT

- infection

Septic Arthritis

Incidence

Issues

Femur

Multiplanar deformity

- worsend by previous surgery

- may require osteotomy

Acetabulum

Dysplasia often present

- not as severe as in DDH

LLD

Can be significant

Abductors

Have been short for long time

- difficult to restore length

Definition

Device that encircles a limb to occlude the vascular supply

Aim is to provide bloodless field

Contra-Indications

Local

- poor skin

- PVD

- DVT

- vascular bypass surgery

General

- sickle cell anaemia

Goal

Ultimate goal of blood management is to AVOID allogenic blood transfusion

Problems

Increased infection rate

- demonstrated in THR

- decreased killer T cells

Increased risk disease transmission

Increased risk transfusion reaction

Increased post-op fever and antibiotic requirements

Increased cost

Indications 

1. Significant functional impairment

2. PIPJ contracture

- originally thought to intervene early

- Macfarlane showed residual FFD always about 30^o

- may need to release  check rein ligaments / accessory collateral ligaments

3. MCPJ contracture >30^o

4. Trigger fingers

- must do limited fasciectomy 

Non-Operative

Education regarding shoe wear

- extra wide / large toe box

Insoles

- longitudinal arch support

- pre MT dome for metatarsalgia

- podiatry to attend to callosities

Toe spacers

Analgesia

Operative

Indications

1.  Continued pain and discomfort

2.  Difficulties with shoe wear