Janki Sharan Bhadani

Introduction Orthopedic trauma has witnessed enormous progress over the past few decades. Three-dimensional computed tomography (CT) reconstructions, patient-specific instrumentation, computer-assisted planning, navigation, robotics, and artificial intelligence are reshaping how surgeons understand and treat fractures. The concept of a constant fragment has remained timeless, despite the technological advances. Most surgeons use this concept every day, knowingly or unknowingly, without consciously naming it [1]. During fracture reduction, we first identify a fixed reference point, i.e., the fragment that has preserved its anatomical relationship through intact ligamentous or muscular attachments. Once this fragment is identified, every other displaced piece begins to make sense. Thus, reduce everything else to it. The constant fragment is therefore the anchor of fracture reconstruction [2].

Introduction: Open fractures remain among the most challenging injuries in trauma surgery. They involve contamination, soft-tissue disruption, skeletal instability, and often systemic injury. While traditionally defined by communication between the fracture and the external environment, an open fracture is better understood as a soft tissue injury in which the bone is broken [1]. Prognosis is determined not only by fracture pattern but also by contamination, vascularity, bone loss, host factors, and the quality of care delivered from the earliest hours. The goals of management remain consistent: prevent infection; preserve viable tissue; restore stability; facilitate reconstruction; and promote healing of soft tissue as well as bone to restore function. These objectives depend on the integration of sound principles across the entire pathway of care. The Gustilo-Anderson classification systems remain useful in guiding communication and treatment planning, but they do not replace judgement. [2] Injury severity is often best judged in the operating room, particularly after debridement [3]. Factors such as contamination, periosteal stripping, vascular injury, and bone loss frequently modify both prognosis and strategy. Understanding the Injury: The management of open fractures is often presented as algorithmic, but in reality, decision-making is frequently more nuanced. Some injuries are straightforward, where the path toward salvage or amputation is relatively clear from the outset. However, many injuries fall into a grey zone where the true extent of damage only becomes evident over time, with repeated assessment or during surgical exploration. This is particularly true when external appearance does not reflect the severity of underlying soft tissue damage, contamination, or tissue devitalisation [4]. An important example is the persistent misconception that an open fracture protects against compartment syndrome because the wound acts as a decompression. This is not always true. Compartment syndrome can still occur in open fractures, even within the same compartment that is open, and failure to recognize this can have serious consequences. Similarly, a seemingly small or benign wound may hide extensive muscle crushing, comminution, or associated degloving injury that fundamentally changes classification and management [5]. Delayed presentation adds another layer of complexity, as tissue viability may evolve and alter salvage potential. What appears salvageable at one point may become non-viable later, while other injuries that appear devastating may still be reconstructed successfully. These examples emphasise that classification systems are guides, not substitutes for judgement. Optimal management of complex open fractures depends on repeated reassessment, thoughtful interpretation of evolving findings, and experience. Much of the expertise in open fracture care lies in recognizing when the injury is not what it first appears to be (Fig. 1). Figure 1: Clinical scenarios illustrating evolving assessment in open fractures. Injury severity and management are not always apparent at presentation. (a, b) Severe Gustilo-Anderson type III B fracture injuries with preserved vascularity, where salvage remains feasible. (c) Delayed presentation of Gustilo-Anderson type III C fracture with a non-salvageable limb. (d) Low-grade open fracture complicated by compartment syndrome, showing that open fractures do not preclude this diagnosis, even in the same open compartment. (e) An apparently benign wound was upgraded to type III after exploration revealed extensive underlying soft tissue injury. (f) Open fracture associated with Morel-Lavallée lesion. These examples highlight the evolving nature of assessment and decision-making in open fractures. The First Hours Matter: Few concepts in trauma care have been as enduring as the 6-h rule. Although rooted in historical surgical principles, it is largely based on animal studies, with no clear consensus from human data [6]. Modern evidence has shifted the focus from rigid timing thresholds to the quality and sequence of care [7]. The emphasis is no longer on an arbitrary deadline for every open fracture but on ensuring that debridement is performed early with proper expertise, planning, and adequate facilities rather than hurriedly and inadequately. What truly matters is that antibiotics, debridement, and stabilisation are delivered promptly and appropriately. Early systemic antibiotics, ideally started within the 1st hour, remain a key determinant of infection prevention. Meticulous debridement and appropriate irrigation should be done by an experienced surgeon to continue to form the biological foundation of treatment [8]. The evolution in thinking has been away from dogma and toward evidence-informed judgement, where urgency is preserved, but rigid rules are replaced by thoughtful prioritisation. Initial skeletal stabilisation is central to this philosophy. It restores alignment, protects soft tissues, facilitates wound management, and supports both healing and staged reconstruction [7]. External fixation remains invaluable in severe soft tissue injury, contamination, vascular compromise, and damage control situations, while early definitive fixation may be appropriate in selected injuries [9] (Fig. 2). Figure 2: Integrated pathway in open fracture care. Integration of Infection Control, Stability, and Reconstruction: In selected high-risk injuries, local antibiotic strategies, including antibiotic beads or spacers to manage dead space, may complement systemic antibiotics. However, these adjuncts do not replace adequate debridement, removal of devitalised tissue, and stable fixation. Debridement, irrigation, and stabilisation remain complementary, not competing, priorities [10,11]. Our understanding of managing open fractures evolves over time (Table 1). Table 1: From traditional dogma to contemporary principles Fixation and soft-tissue coverage...

Introduction Tibial condyle fractures are often challenging to manage. These are frequently associated with complications, which can affect long-term knee function. This study aims to categorize these complications based on their timing and provide an overview of their prevention and management. Methods A narrative review was conducted by searching PubMed, Scopus, and Web of Science databases for studies published between January 2000 and March 2025. Relevant articles discussing complications following tibial condyle fractures were selected and analysed. Complications were grouped into early (within 2 weeks), intermediate (2 weeks to 3 months), and late (after 3 months) stages. Results Sixty-three studies were included on complications after tibial plateau fractures. Complications were categorized temporally as early (wound issues, compartment syndrome, infection), intermediate (persistent infection, fixation failure, stiffness), and late (malunion, nonunion, osteoarthritis). Management strategies varied by stage, emphasizing timely recognition, prevention, and appropriate intervention to optimize outcomes. Early complications included wound breakdown, compartment syndrome, and early infections. Intermediate complications involved persistent infection, implant-related issues, and arthrofibrosis. Late complications included nonunion, malunion, chronic osteomyelitis, stiffness, and post-traumatic arthritis. Advances in fracture classification, imaging, staged fixation strategies, and improved soft tissue management have contributed to reduced complication rates and better outcomes. Conclusion Management of tibial condyle fractures has evolved with a better understanding of soft tissue handling, fracture patterns, and the importance of early mobilization. Classifying complications by timing helps guide clinical decisions and improve patient outcomes. Despite advancements, complications remain a concern, especially in high-energy trauma or delayed presentations.

Introduction Incorporating data-driven technologies in orthopaedic surgery transforms clinical outcomes and enhances surgical precision. These advancements include predictive modelling, machine learning, Internet of Things (IoT)-enabled devices, and data visualization tools. This review aims to examine the current state of data-driven methods in orthopaedic surgery, highlight their clinical impact, and address existing challenges and future directions. Materials and Methods A comprehensive literature search was conducted across databases such as PubMed, Scopus, and Web of Science to identify relevant studies exploring data-driven technologies' applications in orthopaedic settings. The analysis focused on preoperative planning, intraoperative guidance, and postoperative monitoring while considering ethical concerns and implementation challenges in low and middle-income countries. Results The findings indicate that 3D imaging and patient-specific surgical guides enhance preoperative planning, improving accuracy and reducing surgical errors. Robot-assisted systems provide real-time intraoperative support, leading to better precision and reduced recovery times. Postoperative monitoring through wearable devices enables continuous patient tracking, allowing for early detection of complications and improved patient engagement. However, challenges related to data privacy, interoperability, and ethical considerations persist, potentially hindering broader adoption. Conclusions Integrating data-driven technologies is promising for advancing orthopaedic surgery by improving patient outcomes and surgical success rates. Addressing the identified challenges through ongoing research and interdisciplinary collaboration is essential for facilitating the effective implementation of these innovations in clinical practice. Future studies should focus on using data-driven technologies and ethical guidelines to improve orthopaedic outcomes and overcome challenges, particularly in low- and middle-income countries.

Background and Objective Calcaneal malunion, a frequent complication of calcaneal fractures, disrupts hindfoot anatomy, causing pain, deformity, stiffness, and gait abnormalities. While conservative management can be effective in selected cases, surgical intervention is often required. This study evaluates the efficacy of intraarticular osteotomy and osteosynthesis as a joint-preserving procedure to manage calcaneal malunion and prevent subtalar arthrodesis. Methods A retrospective analysis was conducted on ten male patients (aged 23–52 years) with symptomatic calcaneal malunion who underwent intraarticular osteotomy and osteosynthesis between March 2015 and March 2023. Functional outcomes were assessed using the Maryland Foot Score (MFS) and the American Orthopaedic Foot & Ankle Society (AOFAS) score. Clinical, radiological, and procedural parameters were analyzed. Results The average follow-up duration was 42.9 months (range 15–108 months). Type II malunion (60%) was the most common. Postoperative functional outcomes showed improvement, with a mean MFS of 92.4 and an AOFAS score of 84. Wound breakdown primarily in diabetic patients, was managed successfully with negative pressure wound therapy. Significant enhancements in radiological alignment and functional parameters were observed in all patients. Conclusion Intraarticular osteotomy and osteosynthesis are effective surgical options for managing calcaneal malunion, facilitating subtalar joint preservation and obviating the need for subtalar arthrodesis. This procedure optimizes functional recovery and preserves joint mobility in carefully selected patients.

Introduction Distal femur physeal fractures in children, particularly Hoffa fractures, are rare and prone to complications. This study aims to evaluate the outcomes of surgical intervention in children presenting with delayed intraarticular distal femur physeal fractures. Materials and Methods A multicentric retrospective study involving six pediatric patients with delayed presentation of distal femur physeal fractures was conducted. Five patients underwent surgical intervention involving osteotomy and anatomical refixation of the malunited fragments. One patient opted for conservative management. The age at presentation, time since injury, surgical procedures, and clinical and radiological outcomes were evaluated at the final follow-up. Fixation with lag screws was sufficient in three patients, while two required additional plate stabilization. Results The mean age of patients was 12.2 years, comprising four boys and two girls. The average delay in presentation was 30.8 months (ranging from 3 months to 8 years). For the surgical group (n = 5), the knee range of motion improved from an average of 16–66 degrees preoperatively to 6–128 degrees postoperatively at a mean follow-up of 60 months. The mean limb shortening was 3 cm (range 0.5–5 cm). Two patients required additional procedures for distal femur varus malalignment. The conservatively managed patient showed no improvement in knee movements at the 12 month follow-up, serving as a control. Conclusions Surgical intervention involving osteotomy and anatomical reduction for malunited intraarticular Salter–Harris type III and IV fractures of the distal femur in children yields good to excellent outcomes. Limb length discrepancy and malalignment, if present, can be addressed separately. Longer follow-up until skeletal maturity is necessary to evaluate final outcomes in these patients. Level of Evidence: Level IV (Case series). Therapeutic.