Nikolaos Kanakaris

• MD, PhD
• Clinical Lead Major Trauma at Leeds Teaching Hospitals NHS Trust

Purpose Non-union is a significant complication following open diaphyseal tibia fractures. Management can be complex and unpredictable. Several principles must be addressed often in combination to achieve union. The aim of this study is to report on the characteristics, management and eventual outcome of non-united open tibial fractures over a 12-y...

Purpose To evaluate the clinical outcomes of the use of tibiotalocalcaneal nail for the treatment of complex distal tibia and ankle fractures in elderly people, in a major trauma centre. Methods Elderly patients (age > 65) with distal tibia or ankle fractures that underwent stabilization with a tibiotalocalcaneal nail were eligible to participate....

Introduction Management of complex fractures poses a significant challenge. Evolving research and changes to national guidelines suggest better outcomes are achieved by transfer to specialist centres. The development of Major Trauma Networks was accompanied by relevant financial arrangements. These do not apply to patients with closed fractures ref...

Failure of operative treatment of subtrochanteric femoral fractures may have various aetiologies. Subtrochanteric femur fractures are difficult to treat due to strong deforming forces at the fracture site, tenuous blood supply, and the immense load-bearing forces exerted through the peri-trochanteric region. Adequate reduction and stable fixation a...

Failure of operative treatment of acetabular posterior wall fractures may have a variety of aetiologies, with the most common being technical errors. Examples include intra-articular lag screw penetration, not recognizing fracture patterns that require either a spring or rim plate and inadequate use of bone graft for structural support in cases wit...

Objectives The purpose of this study was to investigate the safety and early clinical results from the use of a novel, noble metal-coated titanium tibial nail for the definite stabilization of tibial shaft fractures at risk of developing complications. Design This is a retrospective case series with prospectively collected data. Setting Level I T...

Purpose Obstetric outcomes in women following pelvic injuries requiring surgical fixation is not thoroughly known. We aimed to evaluate if radiographic measurements (RMs) can be used to provide information on delivery methods outcome after these injuries, and to evaluate if metal work removal is required prior to delivery. Method A retrospective s...

Segmental femoral fractures represent a rare but complex clinical challenge. They mostly result from high-energy mechanisms, dictate a careful initial assessment and are managed with various techniques. These often include an initial phase of damage control orthopaedics while the initial manoeuvres of patient and soft tissue resuscitation are emplo...

Purpose The aim of this study was to evaluate the results of distal femoral fracture fixation of two different methods, lateral locking plate (LP) or an Intra-medullary nail (IMN), in patients managed in our institution. More specifically, to assess: (a) if there was a difference in functional outcomes between the LP and IMN groups; (b) whether the...

Management of severely injured patients remains a challenge, characterised by a number of advances in clinical practice over the last decades. This evolution refers to all different phases of patient treatment from prehospital to the long-term rehabilitation of the survivors. The spectrum of injuries and their severity is quite extensive, which di...

The ability to enhance fracture healing is paramount in modern orthopaedic trauma, particularly in the management of challenging cases including peri-prosthetic fractures, non-union and acute bone loss. Materials utilised in enhancing fracture healing should ideally be osteogenic, osteoinductive, osteoconductive, and facilitate vascular in-growth....

The aim of this study was to assess the impact of Covid-19 measures on the rate of surgical site infections (SSI) and subsequent readmissions in orthopaedic patients. Retrospective, observational study in a level 1 major trauma center comparing rates of SSI in orthopaedic patients who underwent surgery prior to the Covid-19 lockdown versus that of...

Lately, the care of severely injured patients in the United Kingdom has undergone a significant transformation. The establishment of regional trauma networks (RTN) with designated Major Trauma Centers (MTCs) and satellite hospitals called Trauma Units (TUs) has centralized the care of severely injured patients in the MTCs. Pelvic fractures are noto...

Purpose The cost implications of limb reconstruction techniques have not been adequately investigated. Aim of this pilot study was to compare the direct medical cost of tibial bone defects managed with distraction osteogenesis–Ilizarov method (ILF), or with Masquelet technique (MIF). Methods Data of 20 random patients treated in a single centre we...

Background Our objective was to identify acetabular fractures in the elderly population (over 60 years of age), treated with open reduction and internal fixation (ORIF), and to examine their outcomes, primarily the risk for need for further surgery in the form of a total hip arthroplasty (THA), and factors associated with it. Additional outcomes su...

Purpose The 3-category rating of volar plate prominence in relation to the most volar edge of the distal radius (the watershed line) on lateral radiographs was reliable among a small group of surgeons and associated with the probability of flexor tendon irritation and potential rupture. Classifications are often less reliable when tested among a la...

Purpose The 3-category rating of volar plate prominence in relation to the most volar edge of the distal radius (the watershed line) on lateral radiographs was reliable among a small group of surgeons and associated with the probability of flexor tendon irritation and potential rupture. Classifications are often less reliable when tested among a la...

Aim Rate of surgical site infections (SSI) in orthopaedic surgery is low but can have disastrous consequences. The aim of this study was to assess the impact of Covid-19 measures on the rate of SSI and subsequent readmissions in orthopaedic patients. Method Retrospective, observational study comparing rates of SSI in orthopaedic patients who under...

Objectives: Hip fractures in the elderly are common injuries that need timely surgical management. Since the beginning of the pandemic, patients with a proximal femoral fracture (PFF) experienced a delay in time to surgery. The primary aim of this study was to evaluate a possible variation in mortality in patients with PFF when comparing COVID-19 n...

The acetabulum is considered as a complex three-dimensional structure with intricate nomenclature describing its anatomy, becoming even further intimidating when fractured. The dominant classification system for acetabular fractures (AFxs) remains the one Letournel introduced 40 years ago. The main features of the different types of this classifica...

PURPOSE Even though hip fracture care pathways have evolved, mortality rates have not improved during the last 20 years. This finding together with the increased frailty of hip fracture patients turned hip fractures into a major public health concern. The corresponding development of an indicator labyrinth for hip fractures and the ongoing practice...

Objectives:. To report our experience and clinical results of using the Masquelet technique for the treatment of tibial nonunions and acute traumatic tibial bone defects. Design:. Retrospective study of prospectively collected data (Level IV). Setting:. Level I trauma center in the UK. Patients/Participants:. Consecutive patients with tibial nonuni...

Posterior-wall acetabular fractures have been reported to be associated with marginal impaction characteristics in approximately 16% to 38% of cases1-3. Early recognition of this special entity of joint impaction is essential for effective preoperative planning, intraoperative execution, and favorable outcomes. The 2-level reconstruction technique...

Background Pulmonary embolism (PE) following trauma is a potentially preventable but highly lethal complication. We sought to investigate the incidence, risk factors and potential timing of occurrence of post-traumatic PE in a large cohort of trauma fatalities. Methods A case–control study on 9266 consecutive trauma fatalities (between 1996 and 20...

Objectives: To determine whether open reduction and internal fixation (ORIF) of periprosthetic Vancouver B2 fractures can lead to successful fracture healing in selected patients, when attention is given to the surgical exposure and the creation of a balanced extramedullary construct. Design: Retrospective. Setting: 2 level one trauma centers...

The Reamer-Irrigator-Aspirator (RIA-2) system has been established as a safe and reliable device to harvest large amounts of autograft. Nevertheless, hardware complications may occur. Breakage of the reamer head from the drive shaft with intramedullary retention of small metal debris has never been dealt with. The authors provide a technical trick...

Pelvic trauma typically results from high energy blunt trauma and these injuries are often associated with multiple other significant injuries. These injuries are associated with haemodynamic instability and can be potentially life threatening. They are associated with a high morbidity and disability. It is important in the management of these inju...

Introduction Data from clinical trials suggest that CT-confirmed nondisplaced scaphoid waist fractures heal with less than the conventional 8–12 weeks of immobilization. Barriers to adopting shorter immobilization times in clinical practice may include a strong influence of fracture tenderness and radiographic appearance on decision-making. This st...

Infected post-traumatic femoral defects are challenging to treat, and limited options exist. The case of a 20-year-old polytrauma male who sustained a segmental femur fracture involving the femoral neck, distal femur and an intermediate diaphyseal bone defect of 12 cm is presented. The patient declined a long-term frame in his femur. The 2-stage Ma...

Introduction The course of road traffic collision (RTC) victims with femoral fractures (FFx) from injury to death was reviewed. We sought to correlate the presence of femoral fractures with the overall severity of injury from RTCs using objective indices and to identify statistically significant associations with injuries in other organs. Patients...

Biofilm represents an organized multicellular community of bacteria having a complex 3D structure, formed by bacterial cells and their self-produced extracellular matrix. It usually attaches to any foreign body or fixation implant. It acts as a physical protective barrier of the bacteria from the penetration of antibodies, bacteriophages, granulocy...

Purpose To evaluate the available tibial fracture non-union prediction scores and to analyse their strengths, weaknesses, and limitations. Methods The first part consisted of a systematic method of locating the currently available clinico-radiological non-union prediction scores. The second part of the investigation consisted of comparing the vali...

Introduction : Periprosthetic femoral fractures (PPFs) represent a challenging clinical problem with a fast-rising incidence. Interprosthetic fractures (IPFs) represent one of its most difficult variants. There is a paucity of data regarding the financial burden of PPFs, and none for IPFs. This study aims to estimate the direct medical cost of the...

Purpose To identify the incidence, risk factors, and treatment course of patients who developed deep infection following fixation of pelvic fractures. Methods Over a period of 8 years patients who underwent pelvic reconstruction in our institution and developed postoperative infection were included. Exclusion criteria were pathological fractures a...

Nonunion remains a major complication of the management of long bone fractures. The primary aim of the present study was to investigate whether raised levels of C-reactive protein (CRP) and white blood cell count (WBC), in the absence of clinical signs, are correlated with positive intraoperative tissue cultures in presumptive aseptic long-bone non...

The Vancouver classification is still a useful tool of communication and stratification of periprosthetic fractures, but besides the three parameters it considers, clinicians should also assess additional factors. Combined advanced trauma and arthroplasty skills must be available in departments managing these complex injuries. Preoperative confirma...

Pelvic girdle pain (PGP) refers specifically to musculoskeletal pain localised to the pelvic ring and can be present at its anterior and/or posterior aspects. Causes such as trauma, infection and pregnancy have been well-established, while patients with hypermobile joints are at greater risk of developing PGP. Research exploring this association is...

Aims To analyse the learning points from the first 30 days of the COVID-19 lockdown at our institution. Patients & methods Following ethical approval, data were collected prospectively on all patients admitted under orthopaedics between March 23, 2020, and April 22, 2020. This included baseline demographics (sex, age), biochemical (blood tests), ra...

Sacral fractures are a heterogeneous group of fractures occurring in young people following road traffic accidents and falls from height, or in the elderly with osteoporosis following trivial trauma. This heterogeneity, combined with the low incidence of sacral fractures, determines a lack of experience amongst physicians, often leading to misdiagn...

Background: Open pelvic fractures remain challenging in terms of their management. The purpose of this narrative review was to evaluate the latest advances made in the management of these injuries and report on their clinical outcome. Patients and methods: A literature review was undertaken focusing on studies that have been published on the man...

Fractures of the pelvic ring defined as lateral compression (LC) injuries, according to the Young and Burgess classification system, represent the most common patterns of pelvic trauma (especially the LC1s) as well as the subtype with the widest variability of fracture configuration.

The optimal time for the second stage is between 4 and 8 weeks. ➤ Multiple tissue biopsy specimens must be sent for microbiological analysis during both stages of the procedure. ➤ Recurrence of infection requires debridement of the membrane and surrounding soft tissues and reinitiation of the technique (return to first stage). ➤ The bone graft util...

Introduction: We hypothesised that the use of a polyaxial locking plate design offers the same clinical benefits as a monoaxial locking plate system following distal femoral osteoporotic/periprosthetic fracture fixation. Method: A multicentre prospective randomised pilot trial was conducted. Inclusion criteria were patients over 60 years with a...

Introduction: The Kocher-Langenbeck approach is the workhorse for the reduction and fixation of hip fractures that require fixation via a posterior approach1,2. Indications & contraindications: Step 1 preoperative planning: Review the patient's general condition and imaging studies, plan the sequence of reduction and fixation, and make sure th...

Introduction: The ilioinguinal approach is the standard approach for the open reduction and internal fixation of the majority of displaced, anteriorly based acetabular fractures as it offers wide access to the acetabulum, is extensile, and has been associated with enhanced recovery. Indications & contraindications: Step 1 preoperative planning:...

Background: Radiographic fracture classification helps with research on prognosis and treatment. AO/OTA classification into fracture type has shown to be reliable, but further classification of fractures into subgroups reduces the interobserver agreement and takes a considerable amount of practice and experience in order to master. Questions/purp...

Background: Surgical site infection remains a significant concern in treating patients with open fractures. In prevention of such, current guidelines support the immediate administration of antibiotic agents. The duration of antibiotic treatment is still controversial. A maximum of 72 hours, even in the absence of definitive soft tissue coverage,...

Purpose: The incidence of low energy pelvic fractures (FPFs) in the elderly is increasing. Comorbidities, decreased bone-quality, problematic fracture fixation and poor compliance represent some of their specific difficulties. In the absence of uniform management, a standard operating procedure (SOP) was introduced to our unit, aiming to improve t...

Purpose: Surgical costs are under scrutiny and surgeons are being held increasingly responsible for cost containment. In some instances, implants are the largest component of total procedure cost, yet previous studies reveal that surgeons' knowledge of implant prices is poor. Our study aims to (1) understand drivers behind implant selection and (2...

Over the last 50 years the concept of inducing bone formation, using biologically active signalling molecules, has evolved significantly. The most potent of these osteoinductive molecules remain the Bone Morphogenetic Proteins, with established role on the chemotaxis, proliferation and differentiation of mesenchymal progenitor cells to form cartila...

Objectives: To analyse the complications and outcomes (functional/radiographic) of Pelvic External Fixators applied as part of the definitive fixation in polytrauma patients. Design: A single center retrospective chart review. Setting: A level-1 trauma center. Patients and methods: We reviewed all the polytrauma patients (ISS>16) between 200...

This prospective study was undertaken at a regional tertiary referral centre to evaluate the results of treatment of bone defects managed with the induced membrane (IM) technique. Inclusion criteria were patients with bone defects secondary to septic non-union, chronic osteomyelitis and acute fracture with bone loss. Pathological fractures with bon...

The aim of this retrospective study with prospectively documented data was to report the clinical results of treatment of long bone non-unions using the "diamond concept". Over a 4-year period, patients that presented with a long bone non-union and were managed with the diamond conceptual framework of bone repair were evaluated. Exclusion criteria...

Anterior cruciate ligament is one of the most important stabilizing factors of the knee. Most injuries occur with the knee is in an almost fully extended position, and the tibia rotating on the femur. Such a force may be produced by opposition of an object or opponent, or body weight distribution during non-contact physical activity such as landing...

Acetabular deficiency may result from a number of causes the more common being congenital, post-traumatic or post arthroplasty loosening. The existing classifications are mainly associated with a previously placed acetabular cup since post-traumatic deficiency and congenital deficiencies are usually covered by other classifications (eg classificati...

In 1998 Walch et al. performed a clinical and radiographic analysis of 151 primary glenohumeral osteoarthritis. Based on this analysis they described a classification of the glenoid morphology in three types which are described in this chapter, as well as the treatment strategy and relevant evidence.

Although a widely accepted classification system for patellar fractures does not exist, most are based on an anatomic descriptive classification. Important factors include the location of fracture, direction of fracture lines, and the amount of comminution. In the AO/OTA classification which was firstly introduced in 1979, the patella is delineated...

The most commonly used classification system for Open fractures is that initially presented by Gustilo and Anderson and then further expanded by Gustilo, Mendoza, and Williams.

Many classifications apply to fracture of the fifth metatarsal. In general fractures of the proximal end of the fifth metatarsal are categorised as (1) those of the tuberosity and (2) those of the proximal metatarsal within 1.5 cm of the tuberosity. On this anatomical scheme are based some early classifications such as Lawrence’s (1993) and Dameron...

Fractures of the tibial intercondylar eminence (tibial spine) are observed mostly in children and adolescents, often after minimal trauma. Good results are expected with treatment by anatomic reduction.

The Enneking staging system presented in 1980 is suitable for staging mesenchymal lesions rather than non-mesenchymal ones (such as Ewing sarcoma, lymphoma, and leukaemia). The system has been designed for primary long-bone tumours but has also been adapted for use with spinal tumours [1].

Contemporary fixation of the proximal femur is performed utilising a number of implants adopting different concepts and techniques. Cephalomedullary nails in particular represent one of two main options, the other being dynamic hip screw (DHS). The aim of this cohort study is to present the early experience of two large units from different countri...

The objective of this study was to report on the safety, efficacy and clinical outcomes of the Polyax™ Locked Plating System (Biomet, Warsaw, IN, USA) in the management of acute (non-implant related and periprosthetic) distal femoral fractures. We retrospectively reviewed 71 patients with 73 distal femoral fractures. Thirty-three of the included fr...

Surgical management of hip fractures in elderly people is challenging and complications relating to surgery could be devastating. They often lead to reoperation and revision surgery and can be associated with significantly increased morbidity and mortality. The most common surgical complications after internal fixation of hip fractures include cut-...

To evaluate the management, clinical outcome and cost implications of three different treatment regimes for simple elbow dislocations. Following institutional board approval, we performed a retrospective review of all consecutive patients treated for simple elbow dislocations in a Level I trauma centre between January 2008 and December 2010. Based...

The primary aim of this study was to report on the mid-term outcomes after quadrilateral plate reconstruction of acetabular fractures using a buttress/spring plate through an ilioinguinal approach. Between 2003 and 2011, 30 adult patients (25 males) with mean age 54 years (range 17-80) who underwent surgical fixation for an acetabular fracture and...

Long antegrade cephalomedullary nailing is the standard of surgical care of atypical subtrochanteric fractures of the femur. Long nailing of such fractures is a technically demanding procedure. Our case report discusses the management of sequential bilateral atypical subtrochanteric fractures in an elderly female patient and the technical issues pe...

Background There is substantial unexplained geographical and surgeon-to-surgeon variation in rates of surgery. One would expect surgeons to treat patients and themselves similarly based on best evidence and accounting for patient preferences. Questions/purposes (1) Are surgeons more likely to recommend surgery when choosing for a patient than for t...

A large number of implants have been developed for intramedullary fixation of intertrochanteric fractures. This article attempts to summarize the contemporary understanding of the existing biomechanical and clinical evidence on intramedullary nailing of intertrochanteric fractures, as to whether they should be short or long nails, and the use or no...

In 1957, in a review article for the treatment of Grade IV Fracture-Dislocation of the Hip, Pipkin presented the following classification scheme which involves femoral head fractures. This type of fractures was named after his name thereafter.

In 1986 Bigliani et al. presented their work on the morphology of acromion and its relationship in rotator cuff tears. The acromion types were specified based on radiographic control and more specifically on the angled outlet Y view of the shoulder. Each acromion type is correlated with a percentage representing the risk for rotator cuff tears.

In a 1961 study Outerbridge presented the first true grading system for articular cartilage to describe the incidence of chondromalacia patellae at the time of meniscectomy. This macroscopic classification, as all early cartilage classification systems, uses both appearance and size of the lesion to assign a four grade staging. Outerbridge’s initia...

Posterior dislocations compose 80–90 % of all hip dislocations. For posterior dislocation of the hip to be created a large force needs to be applied to the flexed knee with the hip flexed adducted, and internally rotated. Based on the classification presented by Thompson and Epstein in 1951 posterior hip dislocations are classified based on the pre...

The avascular necrosis (AVN) or osteonecrosis of the femoral head is a pathologic process, with many etiological factors, that results from interruption of blood supply to the bone and if not managed timely it leads to the collapse of the femoral head. A number of different classification systems have been developed to evaluate patients with osteon...

The tarsometatarsal joint carries the eponym of Lisfranc, who described an amputation at this level. In 1909 Quenu and Kuss presented a classification for tarso-metatarsal joint injuries which was modified in 1982 by Hardcastle. In 1986 Myerson relabeled this classification presenting its final form. The patterns described by this classification ty...

The anatomic characteristics of fractures of the pelvic ring can be found as early as in the Homer's Iliad (rhapsody E 305-307) of the 7th century B.C. Duverney and Malgaigne have described, in 1751 and 1852 respectively, types of pelvic fractures that still bare their names. Multiple classification systems have been introduced to clinical practice...

In 1982 Oestern and Tscherne developed a classification for limb fractures. The classification focuses on soft tissue injuries and helps separate them into severity groups. The classification is subdivided to two main schemes referring to closed or open fractures relatively. The parameters that the Tscherne classification assesses include the follo...

Acute tibial tubercle avulsion fractures typically occur in adolescent boys involved in certain sports. It mainly happens by a strong quadriceps contraction during knee extension or by a rapid passive flexion of the knee against the contracting quadriceps. Ogden et al. described three histological zones in the tibial tubercle growth plate. There is...

The midtarsal joint includes the talonavicular and calcaneocuboid joints. It carries the eponym of Chopart, who described an amputation at this level. Main and Jowett in 1975 classified midtarsal injuries by the direction of the deforming force.

Open pelvic fractures have been classified into three zones [1]. Most recently another classification system was proposed [2]

The most common classification system for tibial plateau fractures is the one introduced by Schatzker in 1979.

Hip osteophyte formation consist late osteoarthritic changes. The changes involving the femoral head are usually more advanced than those seen in the acetabulum. Jeffery in 1973 performed a study describing the topography, morphology and growth of osteophytes in a series of femoral heads removed from patients presenting with advanced osteoarthritis...

As subtrochanteric fractures are defined those of which part of the fracture line lies within the zone between a horizontal line even with the inferior aspect of the lesser trochanter and another horizontal line 5 cm below it. The most useful classification system for subtrochanteric fractures is that proposed by Russell and Taylor which is based o...

The Evan's classification system for intertrochanteric fractures is described as well as the recommended treatment strategy, and relevant references as to their outcome.

Distal radial fractures, represent a group of the commonest injuries managed by the orthopedic trauma clinicians. Multiple classification systems have developed attempting to reflect fracture severity, define prognosis and guide treatment decision making. Four of the most commonly used classification systems are described to this chapter.

For distal femoral fractures, in the absence of a total knee arthroplasty implant, the classification introduced by the AO/ASIF organisation and later adopted by the OTA classification committee has been universally adopted by the clinicians.

The Gustilo-Anderson classification comprises the most commonly used classification for open fractures of usually mangled extremities. However there are many discussions regarding the inter-observer reliability of this classification system. Different studies show inter-observer reliability of approximately 60 % (ranging from 42 % to 92 %). Another...

In 1980, Winquist proposed a classification for femoral shaft fractures based on fracture comminution. The prognostic value of this classification scheme lies on the rationale that the more comminuted the fracture, the more injury the bone and the soft tissue sustain and the higher the likelihood for complications with healing.

The best method for measuring bone mass nowadays is the DEXA (dual energy X-ray absorptiometry) because of its high accuracy and low precision error. Nonetheless it is an expensive method. A less precise but more widely available and less expensive screening tool is conventional radiography. The Singh index describes the trabecular patterns in the...