Purpose. Failure resulting from a recurrent infection in total knee arthroplasty (TKA) is a challenging problem. Knee arthrodesis is one treatment option, however fusion is not always successful, as there is huge bone defect. The authors reports a new arthrodesis technique that uses a bundle of flexible intramedullary rods and an antibiotic-loaded cement spacer. Methods. There were 13 cases of arthrodesis due to recurrent periprosthetic joint infection, which were performed by the first author (WS Cho) at Asan Medical Center in Seoul from 2005 to 2014. All previous prosthetic components were removed and cement was thoroughly excised using a small osteotome. Two stage operation was done in most of cases. After thorough debridement, antibiotics loaded cement was inserted in first stage, flexible intramedullary rods were inserted retrogradely in the femoral side with the knee in flexion under fluoroscopy guidance. After filling the femoral intramedullary canal, the rods were then driven back securely into the tibial medullary canal. We aimed for as much rod length as possible to maximize stability. After 6 weeks of first stage operation, the rods of the femoral and tibial sides were arranged such that they overlapped and interdigitated to maximize mechanical strength, maintain the limb length and keep the rotational alignment. The interdigitating rod ends were tightly fixed using two (or three) cerclage wires. Antibiotic-loaded cement was filled into the knee joint space so that the cement is fit to the irregular contour of the femur and tibia, which was resulted from the severe bone loss. Postoperatively, patients were allowed to weight bear as tolerated. Results. The procedure was successful in every cases with no evidence of rod or cement failure at least 1 year follow up. Also there was no recurrence of infection. Conclusion. Although this simple method was not for bony union, the authors could achieve stable knee joint without recurrence of infection

High complication rates and technical difficulties of intramedullary fixation in children with osteogenesis imperfecta have prompted the modification of existing rod systems. The Sheffield telescoping intramedullary rod system was introduced to reduce the complications. It has a T-piece which is permanently fixed to prevent its separation and is expanded to reduce the migration. This study analyses the outcome of this rod system over a 12-year period in two specialist centres. Sixty rods were inserted in the lower limbs of 19 children with osteogenesis imperfecta. All children had multiple fractures of the bones before rod insertion. 39 rods were inserted into the femur, of which 3 were exchange and 4 revision procedures. 21 rods were inserted in the tibia. Eight children had intramedullary rodding of all the four lower limb long bones. The outcome was measured in terms of mobility status, incidence of refractures and rod-related complications. Our series demonstrates that there is significant reduction in refractures and improvement in the mobility status in children with osteogenesis imperfecta following intramedullary fixation. The frequent complication of T-piece separation and the need for reoperation has been overcome with the Sheffield modification of rod design. But the extracortical and metaphyseal migration of the rod continues to be a problem and further improvement in the design is desirable

High complication rates and technical difficulties of intramedullary fixation in children with osteogenesis imperfecta has prompted the modification of existing rod systems. The Sheffield telescoping intramedullary road has T-piece which is permanently fixed and is expanded to reduce metaphyseal migration. This study analyses the outcome of this rod system over an 11 year period in two tertiary referral hospitals. 60 rods were inserted in the lower limbs of 19 children with osteogenesis imperfecta. All children had multiple fractures of the bones before rod insertion. 39 rods were inserted into femur, of which 3 were exchange and 4 revision procedures. 21 rods were inserted into tibia. Eight children had intramedullary rodding of both femur and tibia bilaterally. The outcome was measured in terms of incidence of refractures, mobility status, functional improvement and rod related complications. Our series demonstrates that there is significant reduction in refractures and improvement in the functional status of children with osteogenesis imperfecta following intramedullary fixation. The frequent complication of T-piece separation and the need for re-operation has been overcome with Sheffield modification of rod design. But the incidence of the rod, particularly at the proximal end of femur remains high and further improvement in the design is desirable

Elongating rods have been used in the management of Osteogenesis Imperfecta (OI) for the last 50 years; complication rates have been high in many reviews of available techniques.

The functional outcomes and complications of a cohort of 22 Osteogenesis Imperfecta patients treated with 66 Sheffield Telescopic Intramedullary Rods at an average of 19 years post-initial surgery are analysed. The revision rate was 35% for any reason, 20% excluding revisions for rods separating due to growth. Re-operation other than revisions occurred in 10 rods (15%). Mobility was significantly better in the initial post-operative period (p=0.0015), this difference maintained in adulthood (p=0.0077). Back pain was the most frequent symptom. Symptoms related to the insertion technique across the knee and ankle were rare but those related to femoral trochanteric entry were common. Physeal damage following surgery was not experienced and all rods elongated.

All patients were satisfied with the outcome of their surgeries. SF-36 scores were significantly different for physical functioning domains, social functioning and vitality in comparison to normal population values, but comparable to other studies of OI.

The outcomes of this technique are satisfactory in adulthood; re-operation rates are high but related mainly to outgrowing the rods. Concerns regarding insertion with this fixed device at the knee and ankle are not founded, although proximal femoral fixation remains a problem.

From January 2003 to December 2004, 160 consecutive intertrochanteric hip fractures has been treated at the Orthopaedic Rizzoli Institute by a new short intra-medullary rod, which can be distally locked, combined with two sliding screws that insert into the femoral neck and head. The rod is an undersized, titan one. It can be inserted percutaneously.

Fractures were classified pre-operatively according to stability and post-operatively according to the type of operative reduction.

The failure rate and post-operative stability were then compared according to the type of fracture and to the quality of operative reduction.

Results indicate that the pre-operative fracture classification is a significant determinant of post-operative stability. The type of operative reduction was not as significant a determinant of post-operative stability, but an anatomical reduction gives better clinical results.

Overall results shows that stable fractures has always healed and only minor complications has been observed. Unstable fractures has a percentage of drawbacks of 1.5% (3 in 160 pts) due to a wrong screw positioning ( 2 proximal and 1 distal ).

Three patients died in the early post-operative period due to cardiac failure.

No intraoperative fracture, no displacement of the fracture site and no “cut out” were observed.

Aims. Congenital pseudarthrosis of the tibia (CPT) has traditionally been a difficult condition to treat, with high complication rates, including nonunion, refractures, malalignment, and leg length discrepancy. Surgical approaches to treatment of CPT include intramedullary rodding, external fixation, combined intramedullary rodding and external fixation, vascularized fibular graft, and most recently cross-union. The current study aims to compare the outcomes and complication rates of cross-union versus other surgical approaches as an index surgery for the management of CPT. Our hypothesis was that a good index surgery for CPT achieves union and minimizes complications such as refractures and limb length discrepancy. Methods. A multicentre study was conducted involving two institutions in Singapore and China. All patients with CPT who were surgically managed between January 2009 and December 2021 were included. The patients were divided based on their index surgery. Group 1 included patients who underwent excision of hamartoma, cross-union of the tibia and fibula, autogenic iliac bone grafting, and internal fixation for their index surgery. Group 2 included patients who underwent all other surgical procedures for their index surgery, including excision of hamartoma, intramedullary rodding, and/or external fixation, without cross-union of the tibia and fibula. Comparisons of the rates of union, refracture, limb length discrepancy, reoperations, and other complications were performed between the two groups. Results. A total of 36 patients were included in the study. Group 1 comprised 13 patients, while Group 2 comprised 23 patients. The mean age at index surgery was four years (1 to 13). The mean duration of follow-up was 4.85 years (1.75 to 14). All patients in Group 1 achieved bony union at a mean of three months (1.5 to 4), but ten of 23 patients in Group 2 had nonunion of the pseudarthrosis (p = 0.006). None of the patients in Group 1 had a refracture, while seven of 13 patients who achieved bony union in Group 2 suffered a refracture (p = 0.005). None of the patients in Group 1 had a limb length discrepancy of more than 2 cm, while ten of 23 patients in Group 2 have a limb length discrepancy of more than 2 cm (p = 0.006). In Group 1, four of 13 patients had a complication, while 16 of 23 patients in Group 2 had a complication (p = 0.004). Excluding removal of implants, four of 13 patients in Group 1 had to undergo additional surgery, while 18 of 23 patients in Group 2 had to undergo additional surgery following the index surgery (p = 0.011). Conclusion. A good index surgery of excision of hamartoma, cross-union of the tibia and fibula, autogenic iliac bone grafting, and internal fixation for CPT achieves union and minimizes complications such as refractures, limb length discrepancy, and need for additional surgeries

The cranial cup is now a standardised implant in acetabular revision surgery. In order to illustrate the positive results of a standardised implant in acetabular revision surgery in comparison to other possibilities of reconstruction, we analysed results of all data in our study group. Aseptic loosening of implants often causes segmental and cavitary acetabular deficiency. Experiences gained in radical tumour surgery with reconstruction by custommade endoprostheses induced the development of the cranial cup for revision total hip arthroplasty. This new cementless revision cup has an oval shape and a special cranial flap, as well as an intramedullary rod if necessary. This type of cranial cup has been used since 1993. From 9/97 to 1/99, we implanted 30 cranial cups in revision hip surgery and collected all data of these patients prospectively. Clinical and x-ray follow-up was documented on a regular basis. Acetabular deficiency occurred twice in type 1, five times in type 2, twenty-two times in type 3 and once in type 4. The AAOS D’Antonio score was used. Cranial cups were implanted without cranial flap in 10 cases, with cranial flap in 20 cases and once using the intramedullary rod additionally. Only 28 patients were included in our last examination because one patient had died and one was bedridden because of a reason other than the hip. The Harris hip score increased from an average of 32 points preoperatively to 63 points postoperatively. Twenty-one patients are satisfied or very satisfied with their surgery. Radiograph examinations showed an average inclination angle of 42.5° in all cranial cups. Up to now there have been complications in four patients who suffered luxations, but only one required a change of inlay. One intraoperative injury of the urinary bladder had to be revised later. Three implants showed a change of position in x-ray. One was the patient with the urinary bladder injury and possible septic loosening, the second was a patient with extreme osteoporosis, and the third was a patient who did not receive an intramedullary rod for a type 4 lesions. Currently, these three patients do not have any complaints. We have always achieved primary stability. Morselised bone autografts or bone substitute materials were used to fill remaining defects. An intramedullary rod should be used in pelvis discontinuity and is obligatory to achieve the necessary stability. Developed from the experiences of custom-made tumour endoprostheses, the cranial cup with all possible variations is an appropriate intraoperative variable implant in revision acetabular surgery

The aim of this study was to determine the effectiveness of intra-operative tranexamic acid in children with osteogenesis imperfecta, who have been shown to have increased bleeding tendency, in deformity correction surgery. We retrospectively reviewed all cases of lower limb intramedullary rodding in patients with osteogenesis imperfecta treated in our unit from 2000–2013 in whom a pre and post- operative full blood count was available (n=69). Case notes were reviewed and patients were grouped according to the use of tranexamic acid. Peri-operative change in haemoglobin (Hb), haematocrit (HCT) and requirement for blood transfusion was assessed. Of 69 operations performed, 62.3% were in female patients, 78.3% were femoral, and 43.5% were bilateral cases (19 femur, 11 tibia). In the non-tranexamic acid group there was a mean drop in Hb of 28.9 g/L (range 0–62), mean HCT drop of 8.8 (range 2.2–19.4) and 3 patients required red cell transfusion. In the tranexamic acid group there was a mean Hb drop of 22.5 g/L (range 1–49), mean HCT drop of 7.35 (range −0.8–16.7) and one patient required red cell transfusion. There was a significant decrease in Hb drop (p=0.0287) in the tranexamic acid group. Tranexamic acid seems to decrease the drop in haemoglobin during lower limb intramedullary rodding in patients with osteogenesis imperfecta, with little associated risk. Protocols should be established for future use a further review undertaken

Introduction and Purpose of Study. Osteogenesis imperfecta (OI) is a bone metabolic disorder that results in multiple fractures and deformities in children. The management of these patients should be in highly specialised units were multi-disciplinary management is mandatory. The aims of this study were twofold: 1. To determine the incidence and pattern of fractures in this population. 2. To determine the type, outcomes and complications of surgical treatment in the same population. Methods. A retrospective audit of patients treated for OI at a tertiary academic Hospital, from January 2002 to December 2011 was done. Results. Fifty three patients with OI were seen in the period under review. The patients came from six South African provinces including two other African countries. The male to female ratio was 1:1. The majority of patients were classified as type III and type IV, 19 (36%) and 14 (26%) respectively. Twelve patients (23%) had a first degree relative with OI. All patients received bisphosphonate therapy intravenously except two who were on oral medication. Seventeen patients (33%) had associated kyphoscoliosis – none were treated surgically. The most common long bone fractures were of the midshaft femur (61 fractures) and tibia (35 fractures). Seventeen patients (32%) received intramedullary rodding of either femur or tibia. Surgery had to be repeated due to rod migration in nine long bones (29%). The most common complication of surgery was rod migration and peri-implant fracture. Conclusion. Long bone fractures of the femur and tibia were most common cause of morbidity. Intramedullary rodding is a safe and effective means of long bone fracture management in patients with OI

Aim. To determine the preferable treatment for congenital pseudarthrosis of the tibia, we retrospectively reviewed 19 patients (20 limbs) treated consecutively over a 22 year period (1988–2007). Fifteen were followed up to maturity. The patients were assessed for union, leg length discrepancy (LLD), ankle valgus, range of ankle movement and distal tibial physeal injury. Results. The median age at surgery was 3 years. At surgery nineteen of the tibiae had a dysplastic constriction with a fracture (Crawford II-C or Boyd II) lesion. To obtain union in the 20 tibiae, 29 procedures were done. Nine failed primarily and required a second procedure to obtain union. Older patients (≥ 5 years) had a significantly higher success rate. Excision, intramedullary rodding and bone graft (IMR) was done in 14 tibiae: 10 (71.4%) were successful. Six of 10 primary operations and all 4 secondary operations after a previous failed procedure were successful. Ipsilateral vascularized fibula transfer (IVFT) was successful in 5 tibiae (3 primary and 2 secondary). Ilizarov with bone transport only, failed in two patients. Ilizarov with excision, intramedullary rodding and bone graft with lengthening was successful in 2 of 5 cases (40%); two sustained fractures at the proximal lengthening site. A median leg length discrepancy (LLD) of 3 cms occurred post surgery which was treated with contralateral epiphysiodesis. At maturity 3 patients had a LLD of ≥ 2cms. Six limbs had ankle valgus and were treated with stapling and tibio-fibular syndesmosis. Decreased range of movement of the ankle (< 50%) occurred in 7 patients. Distal tibial physeal injury occurred in 4 patients and was associated with repeated rodding. Conclusion. We concluded that surgery should be delayed as long as possible. If there is adequate tibial purchase for the rod distally, IMR is the best option. If purchase is inadequate, Ilizarov with rodding will avoid ankle stiffness. Epiphysiodesis is preferable to lengthening because of the risk of fracture above the rod. IVFT is a good option as a secondary procedure. NO DISCLOSURES

Intramedullary nailing is acknowledged as a safe and effective mode of treatment for many tibial fractures. Implant removal is frequently indicated either as an elective procedure following union or because of problems such as infection or delayed fracture union. It is therefore essential that intramedullary rod removal should be reasonably straightforward and atraumatic. We describe three cases in which bony growth into the implant has made rod removal either difficult or impossible. We include photographs of two removed implants with clearly visible areas of osseo-integration with bony growth into the cannulation through the interlocking holes as well as radiographs demonstrating the same phenomenon. The average time between insertion and removal was 16 months. In all cases an end cap had been used such that insertion of the extraction device was straightforward but for two patients nail removal was extremely difficult due to bone ingrowth and in the third patient the nail had to be left in-situ. All three implants were made of titanium and the patients were all active young males. The authors have never encountered this problem with steel rods and speculate that the osteointegrative property of titanium is the major causative factor. We suggest that unremoved intramedullary rods represent a major risk in fracture management and that close monitoring of these implants should be undertaken

A cadaveric study was done to determine the relationship of intramedullary axis of femur and the anatomical landmarks of proximal femur. The sharp tipped intramedullary rod was placed in the medullary canal from the isthmus to the proximal femur in 20 adult femoral specimens. The point of exit was measured in relationship to the piriformis fossa, tip of greater tuberosity, and mid lesser tuberosity. The center of the femoral canal axis is 1.23 ± 0.92 cm superior and medial to the pirifomis fossa, and is located 1.55 ± 0.66 cm from greater tuberority and 5.21 ± 1.28 cm from mid lesser tuberosity. The clinical relevance of this study is that the starting point for closed antegrade intramedullary rod of the femur should be 1.2 cm superior and medial to piriformis fossa in order to avoid the difficulty and complications in intramedullary nailing

High complication rates and technical difficulties of intra-medullary fixation in children with osteogenesis imperfecta has prompted the modification of existing rod systems. The Sheffield telescoping intramedullary rod has T-piece which is permanently fixed and is expanded to reduce metaphyseal migration. This study analyses the outcome of this rod system over an 11-year period. 32 rods were inserted in the lower limbs of 11 children with osteogenesis imperfecta. All children had multiple fractures of the bones before rod insertion.24 rods were inserted into femur, of which 3 were exchange procedures for complications. 8 rods were inserted into tibia. 4 children had intramedullary rodding of all the 4 lower limb bones. The outcome was measured in terms of mobility status, incidence of refractures and rod related complications. Complications encountered include 2-rod migrations, one instance each of broken rod, bent rod and valgus drift in the tibia.There was no instance of epiphyseal damage or growth arrest. Our series demonstrates that there is significant reduction in refractures and improvement in the mobility status in children with osteogenesis imperfecta following intramedullary fixation. The frequent complication of T-piece separation and the need for reoperation has been overcome with Sheffield modification of rod design. Though the incidence of rod related complications remain high, our study concludes that Sheffield rod system compares favourably with the existing intramedullary devices for osteogenesis imperfecta in the literature

This paper reviews the outcome of 13 children with congenital pseudarthrosis of the tibia after intramedullary rodding and autogenous bone grafting. The oldest patient was aged nine years at the time of surgery. The ages of the others ranged from 12 to 24 months. The oldest patient at follow-up was 18 years. All 13 had bone defect and angulation. Ten children had clinical features of neurofibromatosis. Ten had pseudarthrosis involving the distal third of the tibia, two the middle third and one the proximal third. Autogenous iliac crest chips were used following excision of fibrous tissue and dense and atrophic bone. Rodding was done across the ankle joint in 10 patients. Postoperatively an above-knee cast was applied for 6 to 12 months, after which an above-knee brace was used to protect the rodding. At follow-up, which ranged from 10 months to 16 years after surgery, all patients were fully weight-bearing and ambulant. Three patients were lost to follow-up after 2 to 4 years. Complications included refracture and rod breakage (two), rod migration (three), and growth retardation with shortening of up to 5 cm. Ten patients had ankle and subtalar joint stiffness and two had valgus deformities of the ankle. Three patients underwent repeat rodding and bone grafting. Radiological union was observed to be progressing in all patients. Intramedullary rodding of the tibia for congenital pseudarthrosis of the tibia is a simple procedure and can be repeated. It avoids prolonged hospital stay and permits early weight-bearing. Careful supervision is necessary, and until there are signs of good bony union, external support is mandatory

Introduction: The main features of osteogenesis imperfecta (OI) are excessive fragility and deformability of the long bones owing to poor bone quality and reduced bone mass, what leads to frequent fractures and residual deformity. Fractures in patients with OI usually heal rapidly, and conservative treatment is mostly successful. However, in displaced and unstable fractures surgical treatment is the only option. Aim: To present our experience in surgical treatment of fractures and deformities as a consequence of OI. Patients and methods: There are 41 individuals with OI in Croatian OI Register. We retrospectively analyzed 18 patients (12 males, 6 females) who were surgically treated from 1979 to June 2004 due to fractures and deformities of the long bones. At the time of the first surgical procedure in our Department, the youngest patient was 23 months old, and the oldest patient was 34 years old (average: 9.6 years). In two patients birth fractures were noticed, and in four patients fractures occurred in the first three months of their lives. In 9 patients severe form of OI was observed. There were 63 operative procedures in 18 patients, with the range from one to seven procedures per patient. We performed 36 reoperations mostly due to fractures of overgrown bone on solid intramedullary nail. Results: Different intramedullary rods were used on 34 occasions. We used solid intramedullary nails (Kuntchner’s nail, Rush’s nail) in 14 operations, Kirschner wires in 12 operations, and expandable intramedullary rod (Sheffield) in five operations. Elastic titanium nail (Nancy) was used in three operations. Other modes of fixation i.e. plates and screws, ASIF external fixator, and Ilizarov system (one patient) were used in total 29 operative procedures. None of the patients had infection related to operative procedure. Operations were mostly performed on femur (43 operations, 68%) and tibia (13 operations, 21%). There were 7 procedures (11%) on the upper extremities. We observed delayed union in three patients who were treated with bisphosphonates, and in two patients on proximal ulna. At the last follow-up ten patients were outdoor walkers, with or without one hand aid. Conclusion: Using correct indication, surgical technique and appropriate fixation device, surgical treatment can be safely performed in patients with OI. Surgery, rehabilitation, and medical treatment may significantly improve mobility and function in OI patients. The rarity of the disease, leading to small numbers of operations performed in a year, and the variable surgical findings, support centralization of surgery in OI patients with complex limb fractures and/or deformities

It is generally accepted that children treated for congenital pseudarthrosis of the tibia (CPT) should be followed-up until skeletal maturity, before drawing conclusions about the efficacy of treatment. We undertook this study in order to evaluate the long-term results of treatment of CPT by excision of the pseudarthrosis, intramedullary rodding and onlay cortical bone grafting. Among a total of 46 children with CPT treated by a single surgeon during a 20-year period, 38 had been treated by this technique and 11 of these children have reached skeletal maturity. These eleven cases (nine boys and two girls) formed the basis for this study. The mean age at presentation was 3.1 years (range 0.4–7 years); the mean age at index surgery was 3.2 years (range 0.7–7 years). The mean age at follow-up was 18.4 years (range 16–21.6 years) with a mean interval between surgery and final follow-up of 15.2 years (range 12.8–17.4 years). In all 11 children bone graft was harvested from the contralateral tibial diaphysis. Rods passed from the heel were used in nine children and in two Sheffield telescopic rods were passed from the ankle into the tibia. The fibula was divided in three children to ensure that the tibial fragments were in good contact before placing the graft astride them; the fibula was not touched in the remaining eight instances. To ensure that the intramedullary rod supported the pseudarthrosis site till skeletal maturity, revision rodding was performed as needed when the tip of the rod receded into the distal third. A thermoplastic clamshell orthosis was used till skeletal maturity. At final follow-up the union at the pseudarthrosis site was deemed to be ‘sound’ only if two independent observers concurred that there was definite bony continuity of the cortices on both the anteroposterior and lateral radiographs. Deformities of the tibia and ankle and ranges of motion of the knee, ankle and subtalar joints were noted. The limb lengths were measured with scanograms. The morbidity at the bone graft donor site was recorded. The function of the ankle was assessed by applying the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hind foot Score. Primary union of the tibial pseudarthrosis was achieved in nine of 11 cases with a mean time to union of 6.1 months. Secondary union was achieved in the remaining two cases following further intervention. At final follow-up sound union of the tibial pseudarthrosis was noted in all eleven patients but persistent pseudarthrosis of the fibula was present in 10 of 11 cases. The lateral malleolus was proximally situated in six cases. Ten of eleven children underwent a total of 21 secondary operations on an average of 2.6 years (range 0.5–5.1 years) after initial union was achieved. Six re-fractures were encountered in five patients at a mean of 6.1 years after index surgery. All the re-fractures united following the single episode of intervention. The overall mean shortening at final follow-up was 2.6 cm. At final follow-up, five patients had ankle valgus greater than 10 degrees. All the 11 patients walked without pain. Only two patients had significant motion at the ankle. Despite the ankle stiffness in the remaining children the AOFAS ankle-hindfoot scores ranged between 70 and 98 (mean 83.3). Our long-term results are comparable to the results of other studies in terms of the rate of union, the re-fracture rate, limb length discrepancy, residual deformity and the frequency of surgery

The aim of total knee arthroplasty (TKA) is to align both the femoral and tibial components perpendicular to the mechanical axis of the leg. Most instrument systems cut the femur and tibia independently. Accurate alignment of the femoral component is hampered by our inability to define precisely the centre of the hip in three-dimensional space. Femoral resection is therefore based on a number of assumptions, which unfortunately do not hold true all of the time. First, it assumes that an intramedullary rod follows a predictable path in the femur; secondly, that there is a fixed relationship between the rod and the mechanical axis of the leg, and thirdly that the shape of the distal femur is constant. Fourthly, even if the resection is correct, it assumes that the femoral component sits perfectly on cut surfaces. Further, there are inherent inaccuracies in the assessment of femoral component position, in that rotation of the limb with a 10° fixed-flexion deformity greatly affects apparent component position. The exact entry point into the femur also influences alignment in that an intramedullary rod placed through an entry point 10 mm anterior to the intercondylar notch of the femur gives a mean valgus angle of 8°. When the tibia is cut perpendicular to its long axis in the coronal plane, assuming 3° of tibial varus, the femur needs to be cut with the corresponding degree of valgus, i.e., 5°. Even this argument is based on a small number of cadavers and does not take account of variations in the anatomy of the distal femur. In particular, a valgus bow can result in valgus malposition of the component. Extramedullary alignment carries the problem of using only a surface representation of the centre of the hip in a single plane, which becomes inaccurate as the femoral jig is rotated. Malalignment of the tibial component increases the stress on the ultra-high molecular weight polyethylene insert, predisposing it to increased wear and subsidence. Studies comparing intramedullary and extramedullary guidance systems for cutting the proximal tibia have shown that 71% to 94% of prostheses inserted with an intramedullary guide, and 82% to 88% inserted with an extramedullary guide, are within 2° of being perpendicular to the long axis of the tibia. To set a benchmark for comparison with computer assisted and robotic techniques currently being developed, we felt that it was important to assess the accuracy of placement of both the tibial base plate and femoral component in the coronal plane using current guidance systems. We developed a series of radiographs allowing accurate independent assessment of femoral and tibial components. A long anteroposterior view of the distal femur with the patient prone was used to assess femoral placement. Coned views of the proximal and distal femur on the same plate were used to assess tibial placement. Correct rotational alignment of the radiograph was confirmed by the profile of the components. Using this technique, we radiologically assessed the varus/valgus alignment of the tibial components of 350 TKAs. All the tibial components were implanted using an extramedullary guide with no posterior slope. We implanted 96.3% of components within 2° of the perpendicular to the longitudinal axis of the tibia. In order to validate our radiological assessment, a subgroup of 40 knees was re-assessed on CT scan. Analysis of this subgroup showed a close correlation between the results using the two different methods (mean difference 0.88°, SD 0.75). We also assessed the position of the femoral component in 362 TKAs. A subgroup of 32 knees, 18 with perfect alignment and 14 with imperfect alignment, underwent CT scout scan of the femur from which the mechanical axis of the femur could be measured. Radiologically, 92% of all components were implanted within 3° of the target value and 83% were within 2° of target. There was close correlation between the CT and radiological measurements in the subgroup. Deviation from the mechanical axis was 1.16° (− 2.5° to +2°) in the perfectly aligned knees, validating both surgical technique and radiological assessment. Although the findings for the femoral components compared favourably with other studies, there was still room for improvement. We set out to achieve this through direct measurement of the mechanical axis of the femur. In a series of 80 TKAs, patients were subjected to a preoperative CT scout scan of the femur. We took care to eliminate rotational error. The angle between the slope of the distal femur and the mechanical axis of the femur was calculated. During surgery the distal cutting block (Wright Medical Medial Pivot Arthroplasty System) was applied directly to the distal femur without use of an intramedullary alignment rod and the angle corrected so as to be perpendicular to the mechanical axis. A right-angled jig resting on the anterior femoral cortex was used to assess the flexion/extension of the cut. Patients were scanned again postoperatively. In 76 knees (95%) the femoral component was within 2° of the mechanical axis. The remaining three were within 3°. We continue to evaluate the technique with the use of a new jig, which allows incremental 1°-correction of the distal femoral cut. In conclusion, accurate cutting of the tibia during knee arthroplasty is possible with careful use of extra-medullary instrumentation. The use of a simple pre-operative CT scan eliminates the errors inherent in intramedullary femoral systems and takes into account the femoral anatomy of each individual patient. Robotic-assisted surgery may offer the opportunity of accurate placement of components. It is, however, likely to be both time consuming and expensive. We should not yet abandon thoughts of improving the use of our current mechanical instruments. Robots have yet to prove their superiority

Minimally invasive plate osteosynthesis is a technically feasible surgical alternative to treat displaced diaphyseal fractures of the tibia. In recent years, this technique has evolved in response to the poor results following tibial fracture stabilization using the traditional open method of plate fixation. Devascularisation with periosteal stripping of bone fragments using open reduction and internal fixation to ensure adequate fracture visualisation led to a substantial percentage of complications including deep infection, delayed union or non union, and refractures after plate removal. Using the technique of minimally invasive plate osteosynthesis, fracture management is achieved with closed reduction followed by stabilisation using a subcutaneous epiperiosteal LC-DC-plate. Twenty-four patients with 25 tibial fractures were treated by minimally invasive plate osteosynthesis at the Kantonsspital, Fribourg, Switzerland, between 1997 and 1999. These cases were retrospectively reviewed. There were 11 male and 13 female patients with a mean age of 41 years (range 16 -64). Nineteen tibial diaphyseal fractures (7 type A, 11 type B, and 1 type C) and six tibial epiphyseal-metaphyseal fractures (4 type A, 1 type B, and 1 type C) were surgically treated. Three fractures were open (grade I). Twenty-four fractures were treated using a 4.5 mm titanium LC-DC-plate, and in one fracture a 4.5 mm stainless steel DC-plate was used for tibial fixation. Open reduction and internal fixation of the fibula was necessary in eleven fractures, nine of which were stabilized with a one-third tubular plate and two with a 3.5 mm LC-DC-plate. The postoperative regimen included partial weight bearing for eight weeks followed by progressive and protected weight bearing until fracture union was achieved. Fracture union was confirmed with radiographs obtained at six to eight weeks, twelve to sixteen weeks, and at final follow-up. The mean time to final follow-up was eighteen months. All fractures had solidly united within four months postoperatively. Radiographically, healing was characterised by callus formation located on the lateral and posterior aspects of the tibial diaphysis, and was similar to that which is usually seen after stabilisation of tibial fractures using an intramedullary rod. Both ankle and knee range of motion were similar to the uninjured side by final follow-up. There were eight cases of residual valgus malalignment of less than five degrees, and were associated with distal third tibial diaphyseal fractures with concomitant fibula fractures which were not rigidly stabilised. Postoperative complications included two deep wound infections and one postoperative compartment syndrome. Overall good results were obtained by using minimally invasive plate osteosynthesis of diaphyseal fractures of the tibia. Although this technique is more technically demanding than standard open reduction and internal fixation of tibial diaphyseal fractures, preservation of the soft tissue envelope and periosteal blood supply is beneficial for fracture healing. Surgical indications for minimally invasive plate osteosynthesis of the tibial diaphysis include a narrow tibial medullary canal as well as distal and proximal metaphyseal fractures not suitable for intramedullary rodding, and associated intra-articular tibial fractures. Minimally invasive plate osteosynthesis should be considered as a surgical alternative for the treatment of displaced diaphyseal fractures of the tibia

Children with osteogenesis imperfecta(OI) have multiple long bone fractures with subsequent deformities. The mainstay of treatment is correction with multiple osteotomies and intramedullary fixation. The Shefffield intramedullary telescoping rod system has been successful in the treament of long bone fractures and deformities (Wilkinson et al ,JBJS-B,1998) Bisphosphonates (Pamidronate -1- 1.5mg/kg/day)have been used as adjuvant therapy in the treatment of OI since the last five years. The perceived benefits include reduction in fracture frequency, improvement in bone density and a general feeling of well being. We present our experience of five cases of OI who developed infections around thier Sheffield telescoping rods while on Pamidronate therapy. There was only one case of sepsis over a ten year period(over eighty patients)in a previously reported series from our centre. The time interval between the start of Pamidronate therapy and the diagnosis of infection varied between 12–36 months ie. between 4–12 cycles of Pamidronate (parenteral administration over a three day period at three month intervals). All patients had their intramedullary rods in situ from anywhere between 2–7 years. The infections were low grade with a 2–3 month period of dull ache prior to actual presentation. Intrestigly though all patients had multiple rods in situ, only one of their femoral rods was affected and they did not have any other infective focus at the time of diagnosis. Three patients presented with thigh abcesses while the other two presented with ipsilateral knee pain and effusion. All had raised inflammatory markers, radiological signs of sepsis with Staph Aureus the commonest infecting organism. Those cases presenting with abcesses were treated by drainage and rod removal, however only antibiotics were sufficient in the rest. The relationship between Pamidronate therapy and these infections is not absolutely clear and has not been reported previously. The possible links are discussed and a high degree of suspicion is recommended for those cases of OI on bisphosphonate

Objective. To explore whether good postoperative alignment could be obtained through simple individual valgus resection angle using common instruments in total knee arthroplasty with lateral bowing femur. Methods. Data of 46 TKAs with lateral bowing femur were collected prospectively, the center of the femoral intercondylar notch was the fixed drilling hole whether preoperative planning or intraoperative implementing. The intramedullary rod was put into the femur as deep as possible, until completely entrance or the distal point of the rod contact with the lateral cortical bone of the femur, which prevent the further entrance of the rod. Individual valgus resection angle ranging from 7°to 9°was performed according to preoperative planning, followed by meticulous assessment of matching between cutting surface and valgus resection angle. Postoperative hip-knee-ankle (HKA) angle?medial tibial plate angle and position of lower extremity alignment passing through the tibial plate were measured. Results. The preoperative measurement valgus resection angle include 14 cases of 8°, 13 cases of 9°, 5 cases of 10°, 2 case of 11°. The postoperative mean medial tibial plate angle was 89.5°±0.5°, mean HKA angle was 179.3°±0.8°. 27(79.4%), 23(67.6%) and 16 (47.1%) cases had restoration of mechanical axis to ±3°, ±2°and ±1°of neutral respectively, and there were 7 (15.2%) outlier (±3°). Excluding 3 cases of actual performed 9°valgus resection angle while preoperative measurement larger than 9°, both components were aligned within 3° of neutral in 88.2% of the knees. 27 (79.4%) cases had lower extremity alignment passing through the middle third of tibial plate, 7 (20.6%) cases pass through the medial third of the tibial plate. Conclusions. Excellent postoperative alignment could be obtained through simple individual valgus resection angle using common instruments in total knee arthroplasty with lateral bowing femur