The incidence of periprosthetic distal femoral fractures after total knee replacement has been reported to be in the range of 0.3% to 2.5%. The treatment is technically challenging in fractures with small osteopenic distal fragment that might compromise stable fixation. Proper alignment and stabilization of the fracture is mandatory for early mobilization of the knee. Through the previous midline scar, knee is approached and with minimal soft tissue dissection a 7 or 9 mm supracondylar intramedullary nail is inserted retrograde achieving reduction and temporary stability. To augment the fixation, a distal femoral locking plate is slid submuscular by minimal invasive technique and held with screws. When possible, the nail locking screws are inserted through the plate, achieving stable reduction and adequate fixation to allow early mobilization during the postoperative period. Between 2009 and 2015, 13 patients with 14 type-2 periprosthetic supracondylar fractures were operated with the hybrid fixation technique. All the patients achieved union at 3 months with no loss of alignment or loss of range of motion. In type-2 supracondylar fractures with marked comminution, osteopenia, and small distal fragment, the hybrid fixation technique achieves satisfactory reduction and adequate stabilization that helps in early mobilization and fracture healing without additional periosteal damage to the distal fragment.

Background Although guidelines from multiple scientific studies decide the general trend in ACLR practice, there is often a variation between scientific guidelines and actual practice. Methods A 17-member committee comprised of sports surgeons with experience of a minimum of 10 years of arthroscopy surgery finalized a survey questionnaire consisting of concepts in ACL tear management and perioperative trends, intraoperative and post-operative practices regarding single-bundle anatomic ACLR. The survey questionnaire was mailed to 584 registered sports surgeons in six states of south India. A single, non-modifiable response was collected from each member and analyzed. Results 324 responses were received out of 584 members. A strong consensus was present regarding Hamstring tendons preference for ACLR, graft diameter ≥ 7.5 mm, viewing femoral footprint through the anterolateral portal, drilling femoral tunnel from anteromedial portal guided by ridges and remnants of femoral footprint using a freehand technique, suspensory devices to fix the graft in femur and interference screw in the tibia and post-operative bracing. A broad consensus was achieved in using a brace to minimize symptoms of instability of an ACL tear and antibiotic soaking of graft. There was no consensus regarding the timing of ACLR, preferred graft in athletes, pre-tensioning, extra-articular procedure, and return to sports. There was disagreement over hybrid tibial fixation and suture tapes to augment graft. Conclusion Diverse practices continue to prevail in the management of ACL injuries. However, some of the consensuses reached in this survey match global practices. Contrasting or inconclusive practices should be explored for potential future research.

Assigning Day's classification to a given case can be difficult in up to 33% patients with crescent fractures due to the obliquity of the iliac fracture line in axial sections. Sacroiliac articular alignment is the primary factor determining the surgical approach. Besides the fracture configuration, additional factors like delay in surgery, locking of the fracture fragments, comminution of the iliac or sacral fragment as well as access to the additional injuries contribute to the decision making.

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