Aims

There is ambiguity surrounding the degree of scaphoid union required to safely allow mobilization following scaphoid waist fracture. Premature mobilization could lead to refracture, but late mobilization may cause stiffness and delay return to normal function. This study aims to explore the risk of refracture at different stages of scaphoid waist fracture union in three common fracture patterns, using a novel finite element method.

Introduction. Management of Vancouver type B1 and C periprosthetic fractures in elderly patients requires fixation and an aim for early mobilisation but many techniques restrict weightbearing due to re-fracture risk. We present the clinical and radiographic outcomes of our technique of total femoral plating (TFP) to allow early weightbearing whilst reducing risk of re-fracture. Methods. A single-centre retrospective cohort study was performed including twenty-two patients treated with TFP for fracture around either hip or knee replacements between May 2014 and December 2017. Follow-up data was compared at 6, 12 and 24 months. Primary outcomes were functional scores (Oxford Hip or Knee score (OHS/OKS)), Quality of Life (EQ-5D) and satisfaction at final follow-up (Visual Analogue Score (VAS)). Secondary outcomes were radiographic fracture union and complications. Results. Mean OHS and OKS was 50.25, EQ-5D score was >4 for all modalities, VAS was 64.4/100. Radiographs demonstrated bony union in 58% at 3 months and 76% at 6 months. We identified no case of re-fracture however non-union occurred in 4 patients. No other operative complications were identified. Conclusion. These results suggest that TFP may be a safe, viable option for management of periprosthetic fractures around stable implants allowing the benefit of early weightbearing, satisfactory outcomes and low re-fracture risk

Introduction. Retention and removal of children's orthopaedic metalwork is a contentious issue that has implications for current resource allocation, health economics, complication risks and can impact on future treatments. Understanding how to guide families make informed choices requires an overview of all the relevant evidence to date, and knowledge of where the evidence is lacking. Our aim was to systematically review the literature and provide a meta-analysis where possible, recommending either retention or removal. Materials and Methods. A search of the literature yielded 2420 articles, of which 22 papers were selected for the study analysis. Inclusion criteria: Any paper (evidence level I-IV) assessing the risks or benefits of retaining or removing orthopaedic metalwork in children. Exclusion criteria: Spinal implants; implant number < 40; < 75% recorded follow up; papers including implants in their analysis that always require removal; patients aged >18 years. Results. In total, 4988 patients (6412 implants) were included across all 22 studies. There was a significant amount of heterogenicity between studies. Overall the short term risks of metalwork retention and removal are low, with a few exceptions. In forearm plating re-fracture rates following removal were lower than those seen in studies looking at retained metalwork, provided removal occurred later than 12 months from the initial operation. Forearm re-fracture rates after removal of flexible nails significantly increased if removal was performed before 6 months. Major complications following routine metalwork removal from the proximal femur are relatively rare, with re-fracture rates of 1–5%. The majority of these re-fractures are seen in neuromuscular patients or in patients where removal occurs earlier than 6 months. Routine metalwork removal following SUFE had a complication rate of 30–60%. Conclusions. We found that there are certain subgroups of children that benefit from retention of metalwork and some that benefit from removal. There are several subgroups that we have identified which do not yet have sufficient long term evidence to make a balanced recommendation. We advise that families are made aware of what is known and what is unknown in order to allow for shared decision making

Aim. In previous small series, some authors have suggested a difference between re-fractures through immature callus and remodelled bone. We aimed to determine whether different fracture patterns occur in early and late re-fractures of paediatric forearm bones. Methods. Notes and radiographs of 77 forearm re-fractures from children aged 2–14 years were retrieved from our institution's radiographic database. Children treated surgically at initial presentation and re-fractures beyond one year were excluded. A control group of 100 forearm fractures without complication was used for comparison. Statistical analysis used chi-square and unpaired t-tests and statistically significant results were based on a two-tailed p-value <0.05. Results. Boys (76%), left laterality (78%), radius (69%), initial greenstick (66%) and diaphyseal fractures (62%) were most common. 60% of re-fractures were complete, 27% greenstick and 13% buckle. Median time to re-fracture was 93 days. Compared with buckle/greenstick configurations, complete re-fractures were more likely to occur if the re-fracture occurred within 50 days of initial injury (84% vs. 52%; p<0.05), if residual angulation was present on the radiograph at the time of last follow-up before re-fracture (74% vs. 46%; p<0.05) and resulted in a trend towards surgical management (25% vs 10%). A five-week period in cast was used to stratify children in both re-fracture and control groups. The re-fracture group was more likely to have been in cast for less than five weeks when compared to the control group (54% vs. 38%; p<0.05). Conclusions. Reduced length of cast immobilisation may be associated with an increased risk of re-fracture. Residual deformity before re-fracture and early re-fractures were more likely to result in complete re-fractures which may also mean a greater chance of surgical management

Background. A large proportion of the expense incurred due to hip fractures arises due to secondary factors such as duration of hospital stay and additional theatre time due to surgical complications. Studies have shown that the use of intramedullary (IM) nail fixation presents a statistically higher risk of re-fracture than plating, which has been attributed to the stress riser at the end of the nail. It is not clear, however, if this situation also applies to unstable fractures, for which plating has a higher fixation failure rate. Moreover, biomechanical studies to date have not considered newer designs of IM nails which have been specifically designed to better distribute weight-bearing loads. This aim of this experimental study was to evaluate the re-fracture risk produced by a newer type of nailing system compared to an equivalent plate. Methods. Experimental testing was conducted using fourth generation Sawbones composite femurs and X-Bolt IM hip nail (n=4) and fracture plate (n=4) implants. An unstable pertrochanteric fracture pattern was used (AO classification: 31-A1 / 31-A2). Loading was applied along the peak loading vector experienced during walking, up to a maximum load of 500N. The risk of re-fracture was evaluated from equivalent strains measured using four rosette strain gauges on the surface of the bone at known stress riser locations. Results. Strain gauge readings determined that the equivalent strains in the femoral diaphysis were approximately 25% larger for the nail than the plate (p < 0.005). The strain levels at the location coinciding with the end of the plate were also larger for the nail, but not significantly (p > 0.26). Conclusions. Although the risk of re-fracture for displaced tronchantaric fractures was found to be larger for nailing than plating, measured strains were substantially lower than the failure strain of cortical bone (even when scaled for full weight-bearing loads of 1800N). This indicates that fracture risk is not present in either implant for bone of healthy quality, but may still become problematic in highly osteoporotic patients. Level of Evidence. IIb - Evidence from at least one well designed experimental trial

Infection and re-fracture are well-described complications following open paediatric forearm fractures. The purpose of this paper is to determine if patient, injury, and treatment characteristics can be used to predict the occurrence of these complications following the surgical management of paediatric open forearm fractures. This is an IRB-approved retrospective review at a single-institution paediatric level 1 trauma centrefrom 2007–2013 of all open forearm fractures. Medical records were reviewed to determine the type of open fracture, time to administration of initial antibiotics, time from injury to surgery, type of fixation, length of immobilisation, and complications. Radiographs were studied to document fracture characteristics. 262 patients with an average age of 9.7 years were reviewed. There were 219 Gustillo-Anderson Type 1 open fractures, 39 Type 2 fractures, and 4 Type 3 fractures. There were 9 infections (3.4%) and 6 re-fractures (2.3%). Twenty-eight (10.7%) patients returned to the operating room for additional treatment; 21 of which were for removal of implants. Contaminated wounds, as documented within the medical record, had a greater chance of infection (21% vs 2.2%, p=0.002). No difference in infection rate was seen with regard to timing of antibiotics (p=0.87), timing to formal debridement (p=0.20), Type 1 versus Type 2 or 3 open fractures (3.4% vs 5.0%, p=0.64), 24 hours vs. 48 hours of post-operative IV antibiotics (5.2% vs 3.5%, p=0.53), or when comparing diaphyseal, distal, and Monteggia fracture patterns (3.6 vs 2.9% vs 5.9%, p=0.81). There was no difference in infection rate when comparing buried or exposed intramedullary implants (3.5% vs 4.2%, p>0.99). Rate of re-fracture was not increased based on type of open wound (p>0.99) or fracture type (0.4973), although 5 of the 6 re-fractures were in diaphyseal injuries. In this series of open paediatric both bone forearm fractures, initial wound contamination was a significant risk factor for subsequent infection. The rate of infection did not vary with timing of antibiotics or surgery, type of open fracture, or length of post-operative antibiotics. A trend to higher re-fracture rates in diaphyseal injuries was noted. Surgeons should consider planned repeat irrigation and debridement for open forearm fractures with obviously contaminated wounds to reduce the subsequent infection risk

Aim. Since 2008 we have been using third generation Fassier Duval (FD) telescopic rods for children with complex and severe osteogenesis imperfecta (sOI). We present our experience with the technique. Method. 8 children with sOI have undergone rodding of 16 lower limb long bones; 6 tibial, 10 femoral. 3 were revision procedures, exchanging previous Sheffield rods that had been implanted with the female portion only. Indications were recurrent fracture and/or progressive deformity. Age range and follow up are 2–12 and 0.4–4.75 years respectively. All but one of the procedures were performed by a single surgeon. Results. There have been 3 re-fractures at 3–5 years with bending of the implant at the rod-tip interface and one re-fracture around a well-positioned implant without bending, all requiring revision. Some female femoral rods have migrated distally (3/10) leading in one case to re-fracture above the implant, which was also revised. All rods have initially telescoped well but we have experienced high pull out rates of the threads in the distal tibia (3/6) at an average 18 months post implantation (range 14–20 months). None has yet required revision for this. Proximal migration of the femoral female component has not occurred except in one revision case, which responded well to interference wire fixation. We have one case of coxa vara that developed in a child whose femur was rodded at 2 years of age. Conclusion. The FD implants have functioned well and enabled us to avoid opening the ankle joint for tibial roddings. Nonetheless the re-fracture rates remain high in this group of severely affected children and are comparable to older generation implants. Proximal femoral and distal tibial anchoring points remain common sites of failure though rarely require early re-operation

Aim. The purpose of this study was to quantify the number of children treated with ESIN (elastic stable intra-medullary nails) at our institution and to determine what proportion of these nails have been removed and the time and difficulty taken to do so. Methods. Patients treated with ESIN between 2000 and 2005 were identified by database search. Their notes were reviewed to record patient and initial nailing details, and timing, difficulty and length of metalwork removal procedures. Complications leading to premature removal or following nail extraction were noted. Results. Eighty-seven patients were identified who fitted our study criteria (68% male, 32% female). Mean age was 10.9 years (4.7–15.9 years). Twelve of the procedures were for open fractures. Seventy-nine patients underwent nail removal at our institution. Four were followed up elsewhere and a decision to leave the nails in was made in another four patients (usually underlying bone pathology). Four patients had surgery earlier than planned to deal with implant problems: 3 to address prominent nails and 1 for re-fracture. The nails were removed at a mean of 8 months after insertion. Mean time taken to remove the metalwork was 25 minutes (10 to 75 minutes). Eight of the 79 removal procedures were graded as difficult, with one being extremely difficult: this was not predictable from pre-operative radiographs. There were 2 complications following metalwork removal. One was a re-fracture through a unicortical bone cyst 2 years after removal, which was successfully treated with ESIN again. The other was a superficial wound infection, which settled with antibiotics. Conclusion. It is routine policy at our institution to remove ESIN after fracture healing, but it should be noted that removal procedures can be difficult and lengthy. There is, however, a low complication rate following removal, and routine follow-up may not be necessary

Introduction. Ulnar shortening osteotomy has become an accepted treatment for a variety of ulnar sided wrist disorders. We have been performing ulnar shortening with an oblique osteotomy cut with the aid of a commercially available jig. The osteotomy is then fixed with a Dynamic Compression Plate. The aim of this study was to report the complications following ulnar shortening. Methods. We retrospectively analysed 56 consecutive ulnar shortening osteotomies. There were 36 female and 19 male patients. The mean age was 45 years. The mean follow-up was 399 days. 25 patients had pre-operative MRI scans and in 34 arthroscopy of the wrist had been performed. 22 tears of the triangular fibrocartilage complex were recorded on arthroscopy. In all cases shortening had been performed with the aid of a jig and bone resection performed in an oblique orientation. Dynamic Compression Plates were used for fixation and a lag screw was inserted through one of the plate-holes and across the osteotomy site. Radiographs were evaluated for pre-operative and post-operative ulnar variances and post-operatively for bony union. Results. The average post-operative ulna variance was 0.12mm. The average time for osteotomy union was 82 days. There were four delayed unions. There were three non-unions. The average time of revision surgery was ten months. All cases have gone onto radiographic union. 19 patients underwent a second operation to have their plates removed. Average time to plate removal was 494 days. There were two cases of re-fracture following plate removal. Conclusion. The rate of delayed and non-union following ulnar shortening osteotomy is higher in our series when compared to the literature. We also noted a higher incidence of plate removal and re-fracture through the osteotomy site. These complications are under-reported in the literature and more emphasis should be given when consent is taken for this procedure

Aim: Controversy remains regarding the complications/necessity for removal of metalwork used in the fixation of paediatric orthopaedic surgery owing to potential complications of removal. It was the aim of this study to review all cases of metalwork removal performed in a prescribed year in order to ascertain the reasons for removal and complications of these surgeries. Methods: All cases of metalwork removal performed under GA, from 1st January 2006 until 31st December 2006 in a regional paediatric orthopaedic unit, were reviewed. Data were obtained from case notes, computer and theatre records and radiographs. Details were obtained regarding demographic details, anatomic site, implant used, reasons for removal, problems of initial fixation and complications after removal. Results: 34 buried kirschner wires were removed under general anaesthetic. Of other metal work, 38 implants were removed; 22 in males and 16 in females. The commonest age distribution was the 11–15 age groups. The most common anatomic site for removal was the forearm (42%) followed by the femur (18%) and ankle (18%). The most common implant removed was plate (53%), followed by Nancy nails (18%). Problems following initial insertion were found in 4 patients (10.5%) including re-fracture distal to forearm plates (both in patients with co-existing osteopaenia), bowing of forearm and decreased sensation over the thumb. Metal work was removed for symptoms in 13 cases (34%) and the rest for patient request or clinical indications. Complications after metalwork removal occurred in 8 (21%) patients and included re-fracture of forearm (2), hypertrophic scar, abscess, skin reaction, wound breakdown, excessive bruising and discomfort. Conclusion: As routine removal of metalwork is generally considered not necessary, metalwork removal is often carried out for symptoms, at patient request as well as in patients with osteopaenia who have risk of fracture at the ends of metalwork. Parents need to be made aware of possible complications shown in the study, in order to give informed consent

Introduction. Fracture and deformity after frame removal is a known risk in 9–14.5% of patients after circular frame treatment. The aims of this study were to assess the effectiveness of our staged protocol for frame removal and risk factors for the protocol failure. Methods and materials. We identified 299 consecutive patients who underwent circular frame fixation for fracture or deformity correction in our unit from our prospective database. All 247 patients who followed the staged frame removal protocol were included in this study. We reviewed the electronic clinical record and radiographs of each patient to record demographics, risk factors for treatment failure and outcome following frame removal. We defined failure of the protocol as a re-fracture or change in bony alignment within 12 weeks of frame removal. Results underwent statistical analysis using Chi square analysis. Results. Of the 247 patients, 196 were trauma patients, of which 56 were open fractures and 48 were elective cases. There were 92 Ilizarov frames and 155 hexapods. 93 patients were smokers. The protocol failed to prevent mechanical failure after frame removal in 10 patients, of which four had refracture and six had an increase in deformity. The average increase in deformity was 7.7 in the frontal plane and 3.8 in the lateral plane. We identified risk factors for mechanical failure in eight of the ten; four were smokers, two were on steroids and two had hypophosphataemic rickets. Of the ten patients, four were for elective indications, six for trauma. Two of the six trauma patients had been treated for open fractures. ‘The type of frame and smoking history showed no statistical association with mechanical failure. Four patients went to have another frame, five were managed with plaster and one patient refused further treatment. Conclusion. Our staged reloading protocol may delay frame removal however it is a simple and effective way to confirm the timing of frame removal

Aims. Ilizarov described four methods of treating non-unions but gave little information on the specific indications for each technique. He claimed, ‘infection burns in the fire of regeneration’ and suggested distraction osteogenesis could effectively treat infected non-unions. This study investigated a treatment algorithm for described Ilizarov methods in managing infected tibial non-union, using non-union mobility and segmental defect size to govern treatment choice. Primary outcome measures were infection eradication, bone union and ASAMI bone and function scores. Patients and Methods. A consecutive series of 79 patients with confirmed, infected tibial non-union, were treated with one of four Ilizarov protocols, consisting of; monofocal distraction (26 cases), monofocal compression (19), bifocal compression/distraction (16) and bone transport (18). Median non-union duration was 10 months (range 2–168). All patients had undergone at least one previous operation (mean 2.2; range 1–5), 38 had associated limb deformity and 49 had non-viable non-unions. Twenty-six cases (33%) had a new simultaneous muscle flap reconstruction at the time of Ilizarov surgery and 25 had pre-existing flaps reused. Treatment algorithm based on assessment of bone gap and non-union stiffness, measured after resection of non-viable bone. Results. The treatment algorithm was easy to apply, being based on easily assessable criteria. Infection was eradicated in 76 cases (96.2%) at a mean follow-up of 40.8 months (range 6–131). All three cases of infection recurrence occurred in the monofocal compression group. They required repeat excision and Ilizarov distraction in two cases and below-knee amputation in one. Union was achieved in 68 cases (86.1%) with the initial Ilizarov methods alone. Union was highest amongst the monofocal distraction and bifocal compression/distraction groups, 96.2% and 93.8% respectively. Mean external fixator time was 7.5 months (range 3–17). Monofocal compression was successful in only 73.7% of mobile non-unions, with significantly lower ASAMI scores and a 26.3% re-fracture rate. Bone transport secured union in 77.8% (14/18) but with a 44.4% unplanned reoperation rate. However, after further treatment, infection-free union following bone transport was 100%. Conclusion. We cannot recommend Ilizarov monofocal compression in the treatment of infected, mobile non-unions. Distraction (monofocal or bifocal) was effective and is associated with higher rates of union and infection clearance

We report a case of fatal heart failure caused by cobalt intoxication after revision THR in the patient who successfully underwent re-revision THR. 53-year old male presented to emergency room in our hospital with progressive shortness of breath. Symptom was started about 6 months ago so he visited local hospital. He worked up for worsening dyspnea. Simple chest radiograph and enhanced heart MRI study were performed and they showed bilateral pericardial and pleural effusion. There was no evidence of ischemic change. Transthoracic echocardiogram showed the evidence of heart failure, left ventricular ejection fraction(EF) was 40%. He was admitted at local hospital and started on vasopressors but urine output was decreased and follow-up echocardiogram showed a 25% of EF. Patient recommended heart transplantation and transferred our hospital emergency room. He underwent sequential bilateral total hip arthroplasties using CoP bearing surfaces. At 12 years postoperatively, he presented to the other hospital with acute onset of left hip pain. He was diagnosed ceramic head fracture on his left hip. Head and liner change revision surgery was performed using Cobalt-Chrome alloy 28mm metal head and Protruded cross-linked polyethylene liners. In our hospital, the patient admitted cardiovascular department of internal medicine. Patient complained nonspecific fatigue and general weakness but had no other symptoms such as visual and hearing loss, cognitive dysfuction. During work-up, patient presented progressive left hip pain and complaint of discomfort for the mass on the left groin. He also complained Left leg weakness and numbness. Simple radiograph and enhanced CT study was done. Simple radiograph image shows radiodense area around the hip joint and radiologist suspected heterotopic ossification. The cardiovascular department consulted orthopedic department. In the image findings showed huge mass combined hemorrhagic component lining acetabular component extending psoas compartment and eccentric wear on cobalt-chrome alloy metal head. Also highly radiodense material was seen around neck inferor portion and severly deformed metal head was seen. It was highly suspected that metal related granuloma, which means severe metallosis. Performed heavy metals screen, cobalt levels were 397,800 μg/Land chrome levels were 236,000 μg/L suggesting cobalt toxicity. Hip joint aspiration was done for decompression as radiologic intervention and EDTA (ethylenediamine tetraacetate) chelation therapy started immediately. After 10 cycle chelating therapy, metal level was lowered cobalt levels by 255.2μg/L and chrome levels by 39.5 μg/L. When hospital day after 134, Medical condition of the patient was getting improved, we underwent revision surgery using ceramic on ceramic bearing surface. The patient discharged postoperative 79 days. Final heavy metals screen results were 27.79μg/L on cobalt and 22.17μg/L on chrome. Although there were also reported a good clinical result of revision surgery using MoP bearing, and some surgeons reluctant to use CoC articulation because of concerns about re-fracture of ceramic. But take into account like this devastating complication after cobalt-chrome wear caused by remained ceramic particles, we should carefully select which bearing is safer

Finite element modelling is being extensively used to evaluate the biomechanical behaviour of fractured bone treated with fixation devices. Appropriate modelling of the bone-implant interface is key to quality biomechanical prediction. The present study considers this interface modelling in the context of locking plates. A majority of previous studies assume the interface to be represented by a tied constraint or a fully bonded interface. Many other studies incorporate a frictional interface but ignore screw threads. This study compares the various interface modelling strategies. An interface with screw threads explicitly included is also considered. The study finds that interface modelling has significant impact on both the global and local behaviour. Globally, the load-deflection behaviour shows considerable difference depending on the interface model. Locally, the stress-strain environment within the bone close to the screws is significantly altered. The results show that the widely used tie constraint can overestimate stiffness of a construct which must be correctly predicted to avoid non-union or periprosthetic re-fracture, especially in osteoporotic bone. In addition, the predictions of screw loosening, bone damage and stress shielding are very different when screw threads are included in the model

Aim: To study a staged technique for the removal of the Ilizarov fixator following bony union. Method: A prospective case series of all fractures treated by the senior author between May 2005 and May 2007 were reviewed. When patients were able to weight bear pain free with radiological evidence of healing, the frames were dynamised initially by loosening the rods across the fracture site, then by removing all rods across the fracture site and finally the frame was removed under general anaesthetic. Patients were followed up for 6 months clinically and radiologically. Results: Of 39 fractures (38 patients) 37 underwent staged dynamisation. No patients required further, casting, bracing or walking aids after frame removal. There were no incidences of re-fracture, non-union or late mal-union at 6 months follow up. Conclusion: The proposed method of staged dynamisation is a safe and useful technique for confirming fracture union and guiding frame removal

The increasing rate of fragility fractures in the developed world is now well- documented and presents a significant challenge to Orthopaedics. Although guidelines exist for the management of osteoporosis, both before and after fracture events, little work has yet been done to measure the effect of interventions on reducing the rate of second fractures in the at-risk population. The longitudinal study, begun at The Canberra Hospital, aims to compare rates of second fractures in two populations of patients over 40 years who have sustained a low-impact, minor trauma fracture. A retrospective study of medical records provides baseline information on current intervention rates for osteoporosis. Secondly, a prospective study population is recruited from patients presenting to Fracture Clinic at The Canberra Hospital. Patients presenting to clinic will, after consent, undergo a screening process including blood test and DEXA scans, to confirm or reject a diagnosis of osteoporosis. Those diagnosed will be referred for medical management as well as non-pharmacological interventions. Follow-up will be conducted at 12 months with repeat testing for bone density to determine whether the interventions have produced measurable improvement and patients will be followed up for five years to establish the rate of re-fracture. A progress report will be presented to the conference advising on findings from the retrospective arm, scheduled for completion in September 2009, and results to date of the prospective arm. The study is a current work-in-progress, and will provide a basis for future research in this area

Presenters Position:. Purpose of Study:. To perform a retrospective audit of the spectrum of management of tibial pseudarthrosis by a single surgeon over a seven year time period. Description of Methods:. All discharge summaries and operation logs from 2004 to 2011 were reviewed to identify patients, and their case notes and x-rays were examined. Patients were contacted telephonically for follow-up examination. Summary of Results:. Eleven patients presented with pseudarthrosis or bowing of the tibia (six females, five males, age range 4 months–7 years). Three were being treated conservatively and two patients had undergone primary below-knee amputation for severe deformity and functional deficit. Six patients had undergone resection of the pseudarthrosis with intramedullary fixation with a Williams' rod. Three of these patients had Neurofibromatosis type 1. In all instances autogenous iliac crest bone graft was used. Fibular osteotomy was performed in five of these patients and the fibula was stabilised with a K-wire in four patients. All patients were discharged in an above knee cast. Mean follow-up from 1st surgery was 23.75 (1.5–72) months. In one patient, histology confirmed suspected fibrous dysplasia. One patient had had a revision procedure 12 months prior to last follow-up for re-fracture and rod displacement. Mean residual deformity was recorded as 4.2° (1° to 10°) valgus and 6.6° (−2° to 20°) anterior bowing. We had no instances of non-union or sepsis at latest follow-up in this small series. Conclusion:. Patients with tibial pseudarthrosis have a wide spectrum of presentation. Not every patient requires immediate surgery. Our treatment aim in the young patient is to maintain optimum ambulation, clinical union and alignment with radiographic appearance assuming secondary consideration. In our hands, internal fixation using a Williams' rod with autograft is safe and effective as the initial surgical procedure. Continued follow-up of these patients is mandatory as the risk of complications is high even after apparent union

We have treated 17 patients with bone defects of the tibia by internal bone transport using a stacked Taylor Spatial Frame. There were 12 cases of infected non unions, 2 cases of osteomyelitis, 1 case of acute traumatic bone loss, 1 case of non union in a patient with neurofibromatosis, and 1 case of pseudoarthrosis of the tibia. The mean bone defect was 51.8mm (range 10–100mm). Leg length has been restored to within 10mm in 16 cases and to within 15mm in one case. All patients have united. Residual deformity at the docking site or regenerate was negligible in 4 patients and less than 5 degrees in any plane in the remaining 13 patients. There have been two cases of re-fracture which have united with conservative treatment and 1 case of partial peroneal nerve palsy which is recovering. The use of a stacked Taylor Spatial Frame system is effective in mediating bone transport resulting in predictable regenerate, accurate docking and minimal induced bone deformity

Aim. To evaluate the results and complications of bone transport in the treatment of massive tibial bone defects, using the Ilizarov method. Methods. 15 patients underwent bone transport using the Ilizarov technique to treat massive tibial bone defects. The average age of the patients was 8.7 years (3–24 years) and the mean bone defect was 10.8 cms. Following a latent period of 1 week, distraction of the transport doughnut was commenced at 1mm/24 hours in 4 quarterly turns. A docking procedure was performed in 7 cases which involved freshening of the bone ends and autogenous bone grafting from the iliac crest. Following docking the fixator was removed once the regenerate had consolidated. Results. The fixators were removed after a mean 12.3 months (range 8–21 months). 1 patient required adjustment of the frame under anaesthetic due to translation of the docking doughnut and poor alignment. All patients had at least one superficial pin site infection successfully treated with oral antibiotics. Deep infection at the docking site was seen in 1 patient needing debridement and split skin grafting. There were no neuro-vascular complications. 1 patient had a recurvatum deformity at the regenerate due to early frame removal. There were no early fractures. Re-fracture of the docking site occurred in one patient, 17 months after the removal of the original frame. This needed open reduction and internal fixation. Non union at the docking site was seen in 3 patients, needing open reduction, internal fixation with bone grafting (1 case) and excision of non-union and compression with a further frame (2 cases). Conclusion. Massive bone transport in the tibia is an orthopaedic challenge. This paper highlights the complications of this procedure. It confirms the viability of this method but emphasises careful counselling of both the patient and parents prior to the commencement of such difficult treatment

Distal tibial bone loss involving the ankle is a devastating injury with few options for reconstruction. The purpose of our study was to look at the long term results of ilizarov technique used to achieve lengthening of tibia and fusion at the ankle. 17 cases (16 post traumatic and one post tumor resection) admitted to one institution between 1994 and 2003. 13 cases were done in bifocal and four in trifocal mode. The duration of follow up was 12 to 84 months The average age was 33 years (Range 7-71). The mean length of the defect was 4.5 cm (Range 1-12). Union of the fusion site occurred in 88 % (15/17) of the patients with mean duration to docking and union being 8 months. The mean time in fixator was 13 months (Range 5 to 29). Average number of surgeries per patient was 3.2. Five patients required free vascularised grafts before the index procedure and 4 patients required realignment at the docking site. Functional results – Fourteen (77.5%) of the patients could walk without support or bracing and twelve patients (71%) returned to same or modified occupation. Complications – Two non-union. Deformity – Fusion site equinus deformity occurred with non union after re-fracture in one case. There were 2 cases of residual fore-foot equinus. Residual low grade infection with discharging sinus was present in two patients. One patient needed change of wires for Pin tract infection. Our study showed 76% good and excellent scores on functional scoring but also demonstrates the high morbidity associated with this procedure. In spite of the steep learning curve and high complication rates the procedure can be undertaken in specialised centres for highly motivated patients to achieve good functional results