We aimed to assess whether using long stem femoral components, with cemented distal fixation and proximal impaction grafting allows early patient mobilisation, reconstitution of the proximal femur and long term stability of fixation in patients with aseptic loosening and proximal femoral analysis.

Over the past ten years 239 patients have been treated with an Elite Plus cemented long stem femoral implant, 33% with concomitant proximal impaction bone grafting. Many of the patients had co-morbidities. The average age at revision was 72 years (range 48 to 91). There was a slight female predominance. Fourteen percent of hips had been previously revised. Forty-eight patients were deceased and 22 were not available for follow-up; this left a cohort of 169 patients who were available for radiological and questionnaire review at an average of 4.5 years.

According to the Paprosky grading for pre-operative bone loss 40% had moderate to severe bone loss (grade IIIb or IV). The Barrack grading was used to assess the cement mantle post-operatively with 65% showing good cementation. The Harris and O'Neill grades were used at final review to assess probability of loosening with only 8% being probably or definitely loose. The average Oxford Hip Score was 29. Mesh ± cables were required in a third of cases to allow adequate containment and pressurisation. It was generally felt that the long stem needed to be at least one third longer than the initial component. The re-revision rate was 1.2 with a 10 year survivorship analysis of 94%. The complication rate of almost 6% included periprosthetic fractures, dislocations, infection and mesh breakage.

A long stem cemented femoral implant can be useful in bypassing proximal femoral deficiency in the appropriate patient.

Over 2 years, 14 patients with C1/2 instability underwent posterior transarticular screw fixation. Pathologies included atlanto-axial subluxation in five rheumatoid patients, atlanto-axial rotatory subluxation and an odontoid fracture in two patients with ankylosing spondylitis, nonunion of odontoid fractures in three patients, three transverse ligament injuries and one type-III odontoid fracture. This study aimed to assess the use of transarticular screw fixation in terms of technique, union rates and functional outcomes.

All operations were performed on a Relton-Hall frame with a Mayfield clamp and lateral fluoroscopy. The mean age of the eight men and six women was 48 years. The mean operation time was 112 minutes (65 to 225) and mean blood loss was 270 ml (150 to 700). Autologous posterior iliac crest bone graft was used in all patients. The procedure was aborted in one patient because of difficulty with reduction and screw angulation and in another because of excessive bleeding from the drill hole. Alternative fixation techniques were used in these two patients. All patients wore a Philadelphia collar postoperatively until stability was confirmed.

The time to radiological union was 8 to 10 weeks. Clinical outcomes revealed full ranges of flexion and extension in most patients, with a 50% decrease in cervical rotation. There were no neurological complications postoperatively. There was implant failure in one patient, with screw breakage evident at follow-up, but this patient went on to union without further intervention.

Transarticular screw fixation is an inexpensive, effective and safe technique for management of C1/2 instability.

We reviewed 16 metaphyseal-diaphyseal junction (MDJ) fractures treated over the four-year period 1997 to 2000. MDJ fractures occur in the area proximal to the supracondylar fossae and distal to the intersection of the metaphyseal flange and diaphysis of the humerus.

MDJ fractures are far less common than displaced classic supracondylar (SC) fractures: on average we see four MDJ and 80 SC fractures a year. The mean age of patients with MDJ fractures is 4.8 years, while the mean age of patients with SC fractures is 6.3 years. MDJ fractures are more often the result of a violent force: 56% occurred in falls and 38% in pedestrian traffic accidents, while 100% of SC fractures were due to falls. Only 1% of SC fractures were compound, while 13.5% of MDJ fractures were. MDJ fractures were of the extension type in 63% and of the flexion type in 37%. Only 3.7% of SC fractures were of the flexion type.

We treated four of the 16 MDJ fractures conservatively in a U-slab and 12 with percutaneous pinning (three with cross pinning, nine with one or both pins up the intramedullary shaft).

At a mean follow-up of two years (1 to 4) there were 11 satisfactory and five poor results. Three of the four patients managed conservatively had a poor result with varus malunion. The other two poor results were in percutaneously pinned fractures. One was pinned in varus and one refractured after the pins were removed at three weeks.

We conclude that MDJ fractures are distinct from SC fractures, and that percutaneous pinning is the best form of treatment. Because the fractures are more diaphyseal, immobilisation for four weeks rather than three is advised to prevent refracture.

Humeral shaft fractures, which make up about 3% of all fractures, can often be managed non-operatively, with outcomes ranging from good to excellent. Conservative management techniques include the hanging arm cast, U-slab coaptation splintage, thoracobrachial immobilisation, shoulder spica cast, skeletal traction and functional bracing. The outcomes of functional bracing and U-slab coaptation splint-age have been shown to be equally good, but Sarmiento et al reported that patients found functional bracing more acceptable. We compared the costs in time and money.

The U-slab coaptation splint is bulky and not uncommonly the slab slips or loosens, requiring repeated reapplication. We looked retrospectively at the frequency of U-slab reapplication in our outpatient setting, and multiplied the frequency of reapplication by the cost per unit and time per unit, comparing these parameters with those for functional braces.

Our study showed that in monetary terms U-slab coaptation was cheaper than functional bracing, but highlighted the hidden cost in terms of application time, additional imaging and rehabilitative physiotherapy. Functional bracing has the added advantages of single application, increased patient comfort and hygiene, more rapid rehabilitation of shoulder and elbow movements and ease of access for soft tissue dressing.