Injury, Int. J. Care Injured 45 (2014) 725–731
Contents lists available at ScienceDirect
Injury journal homepage: www.elsevier.com/locate/injury
Comparative study of comminuted posterior acetabular wall fracture treated with the Acetabular Tridimensional Memory Fixation System Yuntong Zhang, Xue Zhao, Yang Tang, Chuncai Zhang, Shuogui Xu *, Yang Xie * Department of Orthopaedics, Changhai Hospital, Second Military Medical University, No. 168, Changhai Street, Shanghai 200433, China
A R T I C L E I N F O
A B S T R A C T
Article history: Accepted 11 November 2013
Background: Posterior wall fractures are one of the most common acetabular fractures. However, only 30% of these fractures involve a single large fragment, and comminuted acetabular posterior wall fractures pose a particular surgical challenge. The purpose of this study was to compare outcomes between patients who received fixation for comminuted posterior wall fracture using the Acetabular Tridimensional Memory Fixation System (ATMFS) and patients who underwent fixation with conventional screws and buttress plates (Plates group). Method: Between April 2003 and May 2007, 196 consecutive patients who sustained a comminuted posterior wall fracture of acetabulum were treated with ATMFS or conventional screws and buttress plates. Operative time, fluoroscopy time, blood loss, and any intra-operative complications were recorded. Plain AP and lateral radiographs were obtained at all visits (Matta’s criteria). Modified Merle d’ Aubigne-Postel score, and Mos SF-36 score were compared between groups. Results: Fifty patients were included in the analysis with 26 in the ATMFS group and 24 in the Plates group. The mean follow-up time was 57.5 months, ranging from 31 to 69 months. All patients had fully healed fractures at the final follow-up. There was no difference in clinical outcomes or radiological evaluations between groups. Conclusion: Patients with comminuted posterior wall fractures of the acetabulum treated with the ATMFS or conventional screws and buttress plate techniques achieve a good surgical result. Both techniques are safe, reliable, and practical. Use of the ATMFS technique may reduce blood loss and improve rigid support to marginal bone impaction. The use ATMFS may need additional support when fractures involve the superior roof. ß 2013 Elsevier Ltd. All rights reserved.
Keywords: Posterior wall fracture Acetabulum Treatment Shape-memory alloy
Introduction According to the Letournel and Judet’s study [1], the posterior wall fracture is one of the simpler acetabular fracture patterns and the most common type, accounting for approximately one quarter of all acetabular fractures. Over the past decade, surgical approaches and technique for repair of these fractures have advanced and most patients achieve excellent outcomes after anatomical reduction and rigid internal fixation with standard screws and buttress plates [2–5]. However, only 30% of these fractures involve a single large fragment and comminuted acetabular posterior wall fractures are a major surgical challenge [1,6–8]. Saterbak et al. [6] suggested that comminuted posterior wall fractures have a particularly high risk of failure, despite the straightforward operative approach and relatively easy fracture
* Corresponding authors. Tel.: +86 152 2128 8817; fax: +86 021 8187 8039. E-mail addresses: [email protected] (S. Xu), [email protected] (Y. Xie). 0020–1383/$ – see front matter ß 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.injury.2013.11.014
reduction. Zha et al. [9] found that comminuted posterior wall predicted poor outcomes, independent of the quality of the reduction. More recent studies have also shown that the involvement of the weight-bearing acetabular roof, marginal impaction, posterior dislocation of the hip, and injury to the femoral head are also risk factors for poor clinical outcome [9–16]. Acetabular tridimensional memory alloy-fixation system (ATMFS) have been developed and used for acetabular fractures for more than 15 years in China [17–19]. The new fixation system was designed according to the specific mechanical properties of biological memory material, nitinol alloy, and the anatomical and biomechanical features of the acetabulum. Detailed description of the technique, biomechanical analyses, and the results of a primary retrospective clinical study have been previously reported [19,20]. The purpose of this prospective study was to compare intraoperative metrics, radiographic parameters, functional outcomes and incidence of complications between patients treated for comminuted posterior wall fractures of acetabulum using either the ATMFS and conventional screw and buttress plate technique.
Y. Zhang et al. / Injury, Int. J. Care Injured 45 (2014) 725–731
726
Methods Between April 2003 and May 2007, 196 consecutive patients who sustained a comminuted posterior wall fracture of acetabulum (ASIF/OTA classification 62-A1) were evaluated for inclusion in this study. All procedures were approved by the ethics committee of the hospital. Written informed consent was obtained from the patients or from their relatives if the patients were incapable of consent. All the fractures in our series were comminuted, had at least three fragments including free and/or osteochondral marginally impacted fragments. Subjects were excluded if they presented with a pathologic acetabular fracture, ASA score V, were unable to walk before injury, or refused to participate. After screening and excluding subjects who did not meet study criteria, 56 subjects (23 males and 33 females) were enrolled into the study. Patients were randomized into one of two groups, ATMFS (n = 28) or conventional plates (n = 28), using consecutive numbers based on a computer generated list. All patients had the Dual Energy X-ray Absorptiometry (DEXA) for bone mineral density (BMD) in L1–L4 and were diagnosed according to the WHO criteria for osteoporosis (T < 2.5). The preoperative variables including patient age, gender, mechanism of injury, associated injuries, BMD, time to surgery, associated posterior dislocation or not, time to closed reduction, radiographic features, and ASA rating of operative risk were summarized in Table 1. Both treatment groups were comparable before the operation. The surgery was performed according to standard protocols for either the ATMFS or conventional plates, as recommended by the manufacturer [2,7,18]. The plates used in the study were standard 7 to 10-hole 3.5 mm locking reconstruction plates. The fractures were exposed using the Kocher–Langenbeck approach. In some cases, great trochanteric osteotomy was used to allow better access to superior (weight-bearing-dome) fracture fragments. Posterior wall marginal impaction was reconstructed with articular Table 1 Baseline data.
Patients (n) Mean age (SD; range) Sex (n, %) Female Male Mechanism of injury (n, %) Fall Vehicle accidents Others Associated injuries (n) Limb fracture Splenic rupture Pelvic ring fractures Spine fracture Head trauma Mean time to surgery (SD; range) Posterior dislocation of hip Closed reduction within 12 h Closed reduction after 12 h Radiographic feature (n) Posterior wall marginal impaction Superior roof involved Femoral head injury BMD (T value) ASA risk score 1 2 3 4
ATMFS
Plates
28 45 (7.4; 31–77)
28 49 (6.1; 30–76)
15 (53.6%) 13 (46.4%)
18 (64.3%) 10 (35.7%)
9 (32.2%) 14 (50%) 5 (17.8%)
11 (39.3%) 15 (35.6%) 2 (7.1%)
6 2 3 4 8 6.1 days (3.2; 2–18) 13 10 3
4 1 5 1 7 5.1 days (4.0; 2–15) 14 9 5
8
11
8 5
12 7 3.22 0.39
3.38 0.29 6 10 8 4
5 12 7 4
Fig. 1. The schematic diagram describes detailed technique of conventional screws and buttress plate.
fragment reduction and iliac bone grafting. The main difference between groups was the type of implant and the procedure of fixation. In the Plates group, thin Kirschner wires were used for the stabilization of comminuted posterior wall marginal acetabular fragments before applying interfragmentary lag screws or spring plates. A 3.5 mm locking reconstruction plate was used as a buttress plate to the main overlying posterior fragment (Fig. 1). In the ATMFS group, the B and C series of ATMFS device (Huzhou Swan Biological Memory Medical Devices Co., Ltd., Zhejiang, China), particularly designed for posterior wall fracture and comminuted fragments, were used after reduction and temporary fixation by the Kirschner wires (Figs. 2 and 3). All operations were performed by the senior author (Zhang CC). The duration of surgery, blood loss, post-surgery ICU time, quality of reduction, hospital stay time, and treatment cost, were recorded (Table 2). The drain was removed 2 days after surgery and patients were managed with antibiotics and prophylaxis against venous thrombosis. Antibiotics were used for 2 days and low-molecular-weight heparin was administered for 3 weeks after the surgery. No prophylaxis against heterotopic ossification was used. Three postoperative radiographic views (anterior–posterior pelvis, obturator oblique and iliac oblique views) were obtained in the first postoperative week. The patients were mobilized as soon as medically possible under the supervision of a qualified physiotherapist and encouraged to do progressive active exercises. In general, the patients were encouraged to sit up in bed and active functional exercises were initiated to strengthen the hip joint, as well as the quadriceps and hamstrings muscles on post-operative day 1. Patients were encouraged to walk with a walker between 2 and 6 weeks after surgery. Partial, toe-touch weight-bearing with crutches was allowed between 6 and 12 weeks. The patients were allowed to progress gradually to full weight-bearing after 12 weeks, depending on their tolerance and the stability of the fracture. Follow-up examinations were performed 1, 3, 6, and 12 months after surgery and then yearly thereafter. Plain AP and two oblique radiographs were obtained at each visit. Changes in implant position, complication rate, and fixation failures were recorded. Hip range of motion, hip pain, radiographic parameters and functional outcomes (Matta’s criteria, modified Merle
Y. Zhang et al. / Injury, Int. J. Care Injured 45 (2014) 725–731
727
Fig. 3. The Cadaveric model (The Second Military Medical University Anatomy Laboratory, Shanghai, China) of an acetabular posterior wall fracture and structure of the ATMFS device.
Fig. 2. The schematic diagram describes detailed technique of the Acetabular Tridimensional Memory Fixation System device. The principle of the new fixation system: the ATMFS should first be placed in cold water of 0–4 8C to allow the plastic deformation of the NiTi alloy. Then the arms of Ba should be unfolded using needle forceps, and a hole should be drilled to the intended fixed position, around the two sides of the fracture point, with the middle part of the arm aiming at the fracture fragment. At the edge of the acetabulum, we drilled one or more tunnels after the fixation of Ba, pointing to the anterior inferior part of the posterior column ridge line, making sure to avoid penetration of the tunnel into the joint. According to the length of the tunnel, we inserted Bb to suitable length, and hung the posterior fossa hook on the concave face of Ba in order to fix the bones of the acetabular posterior wall. The C series is used to fix single and small fragments separately in comminuted cases. Then we spray hot water on the memory alloy to allow morphological recovery.
d’Aubigne-Postel score, and Mos SF-36 scores) were determined at each evaluation. The relationship between clinical outcomes and radiological features, including posterior dislocation of hip, posterior wall marginal impaction, superior roof involvement, and femoral head injury, were also analyzed. Statistical analysis was performed using SPSS 10.0 software (SPSS Inc., Chicago, Illinois). Student t-tests were used to compare continuous variables between groups. Data were expressed as mean (standard deviation). Categorical variables were analyzed by the chi-square test or Fisher exact test where appropriate. The level of statistical significance was set at a two-sided p value of 0.05. Results There were no differences between groups for age, sex, mechanism of injury, mean time to surgery, BMD, associated
injuries, number of dislocations, time to closed reduction of the dislocation (categorized as less or more than 12 h), radiographic features, ASA score, and quality of initial reduction. The mean Tscore was 3.63 0.34 ( 2.5 to 4.1). Open reduction was performed in all 56 patients. There was a longer operative time in the Plates group compared to the ATMFS group, though the difference was not significant (p = 0.09). There was a significant difference between groups for intra-operative blood loss, with 710 (170) ml in the Plates group compared with 919 (190) ml in the ATMFS group (p = 0.03). The treatment cost was significantly lower in the ATMFS group with a mean value of 23,542 (2123) RMB compared to the Plates group with a mean value of 37,452 (3301) RMB (p = 0.03). The length of incision was significantly shorter in the ATMFS group (12.9 1.8 cm) than that in the Plates group (14.5 2.3 cm; p = 0.01). Blood transfusion, post-surgery ICU time, and length of hospital stay were not significantly different between groups. Perioperative variables were summarized in Table 2. Five subjects were lost to follow-up (2 in the ATMFS group and 3 in the Plates group) and 1 subject in the Plates group died within the follow-up period. Therefore, 50 patients were included for comparison at the final follow-up, 26 in the ATMFS group and 24 in the Plates group. The mean follow-up time was 57.5 months, ranging from 31 to 69 months. Post-operative complications are listed in Table 3. There was no significant difference between the two patient groups with regard to postoperative complications. Incomplete post-operative palsy of the sciatic nerve was noted in 3 patients, 2 in ATMFS group and 1 in Plates group. Those cases were successfully treated with conservative management and medication. Nerve function recovered in all subjects two weeks to one month after surgery. Three subjects developed superficial wound infection (2 in ATMFS and 1 in Plates),
Table 2 Peri-operative variables.
Duration of surgery (h) Blood loss (ml) Blood transfusion (ml) Length of incision (cm) Post surgery ICU time (day) Hospital stay time (day) Quality of reduction (n, %) Anatomical (
Contents lists available at ScienceDirect
Injury journal homepage: www.elsevier.com/locate/injury
Comparative study of comminuted posterior acetabular wall fracture treated with the Acetabular Tridimensional Memory Fixation System Yuntong Zhang, Xue Zhao, Yang Tang, Chuncai Zhang, Shuogui Xu *, Yang Xie * Department of Orthopaedics, Changhai Hospital, Second Military Medical University, No. 168, Changhai Street, Shanghai 200433, China
A R T I C L E I N F O
A B S T R A C T
Article history: Accepted 11 November 2013
Background: Posterior wall fractures are one of the most common acetabular fractures. However, only 30% of these fractures involve a single large fragment, and comminuted acetabular posterior wall fractures pose a particular surgical challenge. The purpose of this study was to compare outcomes between patients who received fixation for comminuted posterior wall fracture using the Acetabular Tridimensional Memory Fixation System (ATMFS) and patients who underwent fixation with conventional screws and buttress plates (Plates group). Method: Between April 2003 and May 2007, 196 consecutive patients who sustained a comminuted posterior wall fracture of acetabulum were treated with ATMFS or conventional screws and buttress plates. Operative time, fluoroscopy time, blood loss, and any intra-operative complications were recorded. Plain AP and lateral radiographs were obtained at all visits (Matta’s criteria). Modified Merle d’ Aubigne-Postel score, and Mos SF-36 score were compared between groups. Results: Fifty patients were included in the analysis with 26 in the ATMFS group and 24 in the Plates group. The mean follow-up time was 57.5 months, ranging from 31 to 69 months. All patients had fully healed fractures at the final follow-up. There was no difference in clinical outcomes or radiological evaluations between groups. Conclusion: Patients with comminuted posterior wall fractures of the acetabulum treated with the ATMFS or conventional screws and buttress plate techniques achieve a good surgical result. Both techniques are safe, reliable, and practical. Use of the ATMFS technique may reduce blood loss and improve rigid support to marginal bone impaction. The use ATMFS may need additional support when fractures involve the superior roof. ß 2013 Elsevier Ltd. All rights reserved.
Keywords: Posterior wall fracture Acetabulum Treatment Shape-memory alloy
Introduction According to the Letournel and Judet’s study [1], the posterior wall fracture is one of the simpler acetabular fracture patterns and the most common type, accounting for approximately one quarter of all acetabular fractures. Over the past decade, surgical approaches and technique for repair of these fractures have advanced and most patients achieve excellent outcomes after anatomical reduction and rigid internal fixation with standard screws and buttress plates [2–5]. However, only 30% of these fractures involve a single large fragment and comminuted acetabular posterior wall fractures are a major surgical challenge [1,6–8]. Saterbak et al. [6] suggested that comminuted posterior wall fractures have a particularly high risk of failure, despite the straightforward operative approach and relatively easy fracture
* Corresponding authors. Tel.: +86 152 2128 8817; fax: +86 021 8187 8039. E-mail addresses: [email protected] (S. Xu), [email protected] (Y. Xie). 0020–1383/$ – see front matter ß 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.injury.2013.11.014
reduction. Zha et al. [9] found that comminuted posterior wall predicted poor outcomes, independent of the quality of the reduction. More recent studies have also shown that the involvement of the weight-bearing acetabular roof, marginal impaction, posterior dislocation of the hip, and injury to the femoral head are also risk factors for poor clinical outcome [9–16]. Acetabular tridimensional memory alloy-fixation system (ATMFS) have been developed and used for acetabular fractures for more than 15 years in China [17–19]. The new fixation system was designed according to the specific mechanical properties of biological memory material, nitinol alloy, and the anatomical and biomechanical features of the acetabulum. Detailed description of the technique, biomechanical analyses, and the results of a primary retrospective clinical study have been previously reported [19,20]. The purpose of this prospective study was to compare intraoperative metrics, radiographic parameters, functional outcomes and incidence of complications between patients treated for comminuted posterior wall fractures of acetabulum using either the ATMFS and conventional screw and buttress plate technique.
Y. Zhang et al. / Injury, Int. J. Care Injured 45 (2014) 725–731
726
Methods Between April 2003 and May 2007, 196 consecutive patients who sustained a comminuted posterior wall fracture of acetabulum (ASIF/OTA classification 62-A1) were evaluated for inclusion in this study. All procedures were approved by the ethics committee of the hospital. Written informed consent was obtained from the patients or from their relatives if the patients were incapable of consent. All the fractures in our series were comminuted, had at least three fragments including free and/or osteochondral marginally impacted fragments. Subjects were excluded if they presented with a pathologic acetabular fracture, ASA score V, were unable to walk before injury, or refused to participate. After screening and excluding subjects who did not meet study criteria, 56 subjects (23 males and 33 females) were enrolled into the study. Patients were randomized into one of two groups, ATMFS (n = 28) or conventional plates (n = 28), using consecutive numbers based on a computer generated list. All patients had the Dual Energy X-ray Absorptiometry (DEXA) for bone mineral density (BMD) in L1–L4 and were diagnosed according to the WHO criteria for osteoporosis (T < 2.5). The preoperative variables including patient age, gender, mechanism of injury, associated injuries, BMD, time to surgery, associated posterior dislocation or not, time to closed reduction, radiographic features, and ASA rating of operative risk were summarized in Table 1. Both treatment groups were comparable before the operation. The surgery was performed according to standard protocols for either the ATMFS or conventional plates, as recommended by the manufacturer [2,7,18]. The plates used in the study were standard 7 to 10-hole 3.5 mm locking reconstruction plates. The fractures were exposed using the Kocher–Langenbeck approach. In some cases, great trochanteric osteotomy was used to allow better access to superior (weight-bearing-dome) fracture fragments. Posterior wall marginal impaction was reconstructed with articular Table 1 Baseline data.
Patients (n) Mean age (SD; range) Sex (n, %) Female Male Mechanism of injury (n, %) Fall Vehicle accidents Others Associated injuries (n) Limb fracture Splenic rupture Pelvic ring fractures Spine fracture Head trauma Mean time to surgery (SD; range) Posterior dislocation of hip Closed reduction within 12 h Closed reduction after 12 h Radiographic feature (n) Posterior wall marginal impaction Superior roof involved Femoral head injury BMD (T value) ASA risk score 1 2 3 4
ATMFS
Plates
28 45 (7.4; 31–77)
28 49 (6.1; 30–76)
15 (53.6%) 13 (46.4%)
18 (64.3%) 10 (35.7%)
9 (32.2%) 14 (50%) 5 (17.8%)
11 (39.3%) 15 (35.6%) 2 (7.1%)
6 2 3 4 8 6.1 days (3.2; 2–18) 13 10 3
4 1 5 1 7 5.1 days (4.0; 2–15) 14 9 5
8
11
8 5
12 7 3.22 0.39
3.38 0.29 6 10 8 4
5 12 7 4
Fig. 1. The schematic diagram describes detailed technique of conventional screws and buttress plate.
fragment reduction and iliac bone grafting. The main difference between groups was the type of implant and the procedure of fixation. In the Plates group, thin Kirschner wires were used for the stabilization of comminuted posterior wall marginal acetabular fragments before applying interfragmentary lag screws or spring plates. A 3.5 mm locking reconstruction plate was used as a buttress plate to the main overlying posterior fragment (Fig. 1). In the ATMFS group, the B and C series of ATMFS device (Huzhou Swan Biological Memory Medical Devices Co., Ltd., Zhejiang, China), particularly designed for posterior wall fracture and comminuted fragments, were used after reduction and temporary fixation by the Kirschner wires (Figs. 2 and 3). All operations were performed by the senior author (Zhang CC). The duration of surgery, blood loss, post-surgery ICU time, quality of reduction, hospital stay time, and treatment cost, were recorded (Table 2). The drain was removed 2 days after surgery and patients were managed with antibiotics and prophylaxis against venous thrombosis. Antibiotics were used for 2 days and low-molecular-weight heparin was administered for 3 weeks after the surgery. No prophylaxis against heterotopic ossification was used. Three postoperative radiographic views (anterior–posterior pelvis, obturator oblique and iliac oblique views) were obtained in the first postoperative week. The patients were mobilized as soon as medically possible under the supervision of a qualified physiotherapist and encouraged to do progressive active exercises. In general, the patients were encouraged to sit up in bed and active functional exercises were initiated to strengthen the hip joint, as well as the quadriceps and hamstrings muscles on post-operative day 1. Patients were encouraged to walk with a walker between 2 and 6 weeks after surgery. Partial, toe-touch weight-bearing with crutches was allowed between 6 and 12 weeks. The patients were allowed to progress gradually to full weight-bearing after 12 weeks, depending on their tolerance and the stability of the fracture. Follow-up examinations were performed 1, 3, 6, and 12 months after surgery and then yearly thereafter. Plain AP and two oblique radiographs were obtained at each visit. Changes in implant position, complication rate, and fixation failures were recorded. Hip range of motion, hip pain, radiographic parameters and functional outcomes (Matta’s criteria, modified Merle
Y. Zhang et al. / Injury, Int. J. Care Injured 45 (2014) 725–731
727
Fig. 3. The Cadaveric model (The Second Military Medical University Anatomy Laboratory, Shanghai, China) of an acetabular posterior wall fracture and structure of the ATMFS device.
Fig. 2. The schematic diagram describes detailed technique of the Acetabular Tridimensional Memory Fixation System device. The principle of the new fixation system: the ATMFS should first be placed in cold water of 0–4 8C to allow the plastic deformation of the NiTi alloy. Then the arms of Ba should be unfolded using needle forceps, and a hole should be drilled to the intended fixed position, around the two sides of the fracture point, with the middle part of the arm aiming at the fracture fragment. At the edge of the acetabulum, we drilled one or more tunnels after the fixation of Ba, pointing to the anterior inferior part of the posterior column ridge line, making sure to avoid penetration of the tunnel into the joint. According to the length of the tunnel, we inserted Bb to suitable length, and hung the posterior fossa hook on the concave face of Ba in order to fix the bones of the acetabular posterior wall. The C series is used to fix single and small fragments separately in comminuted cases. Then we spray hot water on the memory alloy to allow morphological recovery.
d’Aubigne-Postel score, and Mos SF-36 scores) were determined at each evaluation. The relationship between clinical outcomes and radiological features, including posterior dislocation of hip, posterior wall marginal impaction, superior roof involvement, and femoral head injury, were also analyzed. Statistical analysis was performed using SPSS 10.0 software (SPSS Inc., Chicago, Illinois). Student t-tests were used to compare continuous variables between groups. Data were expressed as mean (standard deviation). Categorical variables were analyzed by the chi-square test or Fisher exact test where appropriate. The level of statistical significance was set at a two-sided p value of 0.05. Results There were no differences between groups for age, sex, mechanism of injury, mean time to surgery, BMD, associated
injuries, number of dislocations, time to closed reduction of the dislocation (categorized as less or more than 12 h), radiographic features, ASA score, and quality of initial reduction. The mean Tscore was 3.63 0.34 ( 2.5 to 4.1). Open reduction was performed in all 56 patients. There was a longer operative time in the Plates group compared to the ATMFS group, though the difference was not significant (p = 0.09). There was a significant difference between groups for intra-operative blood loss, with 710 (170) ml in the Plates group compared with 919 (190) ml in the ATMFS group (p = 0.03). The treatment cost was significantly lower in the ATMFS group with a mean value of 23,542 (2123) RMB compared to the Plates group with a mean value of 37,452 (3301) RMB (p = 0.03). The length of incision was significantly shorter in the ATMFS group (12.9 1.8 cm) than that in the Plates group (14.5 2.3 cm; p = 0.01). Blood transfusion, post-surgery ICU time, and length of hospital stay were not significantly different between groups. Perioperative variables were summarized in Table 2. Five subjects were lost to follow-up (2 in the ATMFS group and 3 in the Plates group) and 1 subject in the Plates group died within the follow-up period. Therefore, 50 patients were included for comparison at the final follow-up, 26 in the ATMFS group and 24 in the Plates group. The mean follow-up time was 57.5 months, ranging from 31 to 69 months. Post-operative complications are listed in Table 3. There was no significant difference between the two patient groups with regard to postoperative complications. Incomplete post-operative palsy of the sciatic nerve was noted in 3 patients, 2 in ATMFS group and 1 in Plates group. Those cases were successfully treated with conservative management and medication. Nerve function recovered in all subjects two weeks to one month after surgery. Three subjects developed superficial wound infection (2 in ATMFS and 1 in Plates),
Table 2 Peri-operative variables.
Duration of surgery (h) Blood loss (ml) Blood transfusion (ml) Length of incision (cm) Post surgery ICU time (day) Hospital stay time (day) Quality of reduction (n, %) Anatomical (
