James A. Blair, MD, FAAOS, FACS

I think a 3.5mm screw with a 3-point bend maintains length. If it’s starting to shorten during screw insertion, I’ll perc a tenaculum clamp around the fibula and hold it out to length while inserting the screw.

If the fracture is length stable, then I’m not too worried about it. Oftentimes you still need to worry about malrotating the distal fragment. One tip is to put the screw on power on slow speed to avoid all the starts/stops. I have sheared off a screw shaft in the fibula before.

Looks great! Only thing I’d do different is an intramedullary screw up the fibula instead of a plate. I think it accomplished the same goal without the extra incision. Heck of a result at one year!

These almost always get ex-fixed acutely in our shop. I don’t have the mental fortitude during a call day running the acute trauma room to be definitively fixing pilons when there are other long bones and open fractures to manage. Ex-fix and schedule in an elective OR.

Maybe it’s just observation bias and all of my periprosthetic fractures are going to a different hospital (unlikely since most get transferred to us) or something like that.

I’ve had way more cement-related complications than press-fit complications in the last 3 years.

I think it’s easy to understand. Cementing takes longer. Sure, not much, but enough to matter. 10 min here and 10 min there can sometimes equate to another patient not getting surgery. Plus, we don’t do a ton of hemis where I’m at, so techs and reps are unfamiliar with cement.

:(

Joint is smashed in an open pilon in a poor host (smoker). In my hands, he either gets limited joint reduction/fixation and a static circular frame or a TTC nail.

I figured all the money they collect from JAAOS Global Res and Rev submissions fees would’ve paid for their social media team to create visuals. Or maybe it’s because they’re paying their reviewers too much. Oh wait…

Yup. Not impressed by this requirement. Place the onus on the author to increase JAAOS’s social media engagements.

If there is a fracture gap, then technically it’s a critical-sized segmental defect. That’s a whole other algorithm. R/o infection, correct Vit D deficiency, stop smoking (easier said than done). Exchange nail: correct malreduction with larger nail - compress the hell out of it.

Yes, I use an intramedullary screw in the fibula often. I think it’s ideal for these transverse tension failures of the fibula as they are length-stable. A 3.5mm cortical screw can take a bend and get good intramedullary osseous purchase.

Option 3: some combination thereof. Regardless, this is a bad injury and both hips have the potential to do very poorly.

Option 2: fix nothing. R hip gets THA and allow WBAT. L hip gets THA with a long diaphyseal stem to bypass shaft fx. Can also reduce and plate and maybe use primary THA components. Don’t have a good idea how far down the diaphysis the shaft fx is. WBAT LLE.

When ready for definitive fixation… Option 1: fix everything. Direct anterior approach for L femoral neck retrieval. Antegrade CMN (MetaTan for me) and get shaft reduced and stable. Then reduce & fix neck with MetaTan screws. R hip gets SHD for reduction and buried lag screws.

69 yo with that amount of impaction is unlikely to have a good result. 1st step is laying crepe and having patient understand how bad this is. Then take function into consideration for fix vs. fuse. Most likely: gross reduction of large fragments, prep joint, acute fusion.

This would be straightforward enough to nail.