This paper reports our experience of revision open reduction, internal fixation and bone grafting of distal humeral fracture non-unions and in addition looks specifically at factors that may predispose to the development of non-union.

Between 1993 and 2003 18 patients with distal humeral fracture non-unions underwent revision surgery with bone grafting and rigid internal fixation. Two patients were lost to follow-up leaving a study group of 16 patients.

The patients’ age, sex, mechanism of injury, AO classification of the initial fracture and the primary treatment method were analysed with respect to possible factors predisposing to non-union.

All revision procedures were performed by the senior author. The non-union site was debrided, bone grafted and rigidly internally fixed.

Clinical assessment was performed using the Mayo Elbow Performance Score and radiographs were reviewed for evidence of bony union.

The Mayo elbow performance scores were excellent in 11, good in 2, fair in 2 and poor in 1.

Our results indicate that age, sex and mechanism of injury are not important in the development of non-union. Twelve patients (75%) however were considered to have undergone inadequate management of the original fracture.

Our experience would suggest that to reduce the risk of non-union following distal humeral fractures appropriate consideration must be given to the established and well proven surgical techniques.

If adequate fixation is considered beyond the experience of the treating surgeon we would strongly advise referral to a specialist unit.

Aim: To assess the intra- and inter-observer reliability of using pre-operative templates in selecting the appropriate prosthetic size of the unicompartmental knee system (Oxford Phase3, Biomet Merck, Bridgend) Methods: Ten observers estimated the size of the unicondylar knee prosthesis required for thirty randomly selected patients with osteoarthritis. Estimation of the size was gauged using templates pre-operatively. AP and lateral radiographs were taken of each patient. All observers were orthopaedic surgeons with a minimum of þve years experience in orthopaedic surgery and with a general interest in joint arthroplasty. The observations were recorded independently and repeated measurements were taken two weeks later. Results: Intra- and inter-observer discrepancies were evaluated using the weighted kappa (κ) coefþcient with signiþcant intra- and inter-observer variations. The results are shown in the table.

Conclusions: Pre-operative radiological templating is of questionable beneþt in patients undergoing Oxford Phase 3 knee arthroplasty.

The treatment of acetabular dysplasia in adolescents (age> 12) is difþcult and various complex pelvic osteotomies have been described. The aim of surgery being improvement in pain and to delay the onset of secondary osteoarthrosis. Methods: We present our experience of using the Tonnis triple pelvic osteotomy for treatment of acetabular dysplasia in the adolescent and adult age groups (range 13–27 years). This retrospective analysis includes 25 patients operated on over a nine year period (1991–2000) with an average followup of four years (range 2–8 years). More than 50% of the patients had had a previous open reduction or femoral osteotomy for CDH. Results: Radiographic analysis (pre & post op) included CE angle of Wiberg, Sharp-Ullmann index and the acetabular angle of the weight bearing zone. All parameters showed an improvement in the post operative analysis with an improvement in pain and range of movement in all patients. Discussion: The Tonnis triple pelvic osteotomy has the advantage of allowing the operator a direct þeld of view at all times and achieving a great deal of lateral rotation and medial displacement of the acetabulum due to the proximity of the osteotomy to the acetabulum. The ischial ramus and its ligaments to the sacrum are left intact, leading to greater stability of the pelvis and spine. Conclusion: Though technically difþcult and needing a long learning curve, it does improve acetabular alignment and symptoms in the early postoperative years. However long term studies are required to document its effect on the rate of secondary osteoarthrosis.

Introduction: Stabilization and bone grafting are the basic principles in the treatment of fracture non-union. Percutaneous bone marrow grafting has been suggested as an alternative source of osteogenic cells with an osteoindutive effect. Our aim is to assess prospectively, the efþcacy of percutanous bone marrow grafting in atrophic tibial non-union. Methods: 20 patients with established atrophic tibial non-union on the waiting list for surgical treatment were recruited. Under local anaesthesia bone marrow was aspirated from the iliac crest and injected into the fracture site. All patients were immobilized in above knee casts. A second injection was repeated at 6 weeks if there was no evidence of callous formation. The procedure was considered a failure if there was no union at six weeks following a third injection. Results: 19 patient were followed up clinically and radiologically until deþnite bone union or failure. Union occurred in 15 patients (75%), with an average time to union following the þrst injection of 14 weeks (range 6–22). Four patients showed no evidence of union. There were no cases of infection or complication at the donor or recipient site. Discussion: Percutanous bone marrow grafting is effective in inducing bone union. It is a minimally invasive technique and could be performed under local anaesthesia, with minimal cost and the potential to avoid a larger surgical procedure. All our patients were on the waiting list for open bone grafting but only 20% of them needed this. We recommend this technique for atrophic tibial non-unions with minimal deformity.

Aim: To report the results of supracondylar nailing of periprosthetic fractures of the distal femur above total knee replacement. Methods: Six displaced peri-prosthetic fractures of the distal femur in six female patients were treated with titanium supracondylar nail (Depuy ACE) between October 1997 and November 1999. The mean age was 68 years (42–92). Four patients had history of rheumatoid arthritis and two had previously undergone bilateral total hip replacement. None of the patients was reported to have anterior notching of the distal femur. Six fractures were equally distributed between right and left side. Low velocity trauma was the cause of fracture in all patients. The knee implants were in place for an average period of 36 months (3 wk to 48 months). The average follow up was 20 months (6–36). Results: All fractures healed in an average period of 14.6 weeks (12–18). One patient suffered another fall and sustained a fracture of the shaft of the femur above the nail. This was treated with exchange nailing using a long supracondylar nail with good result. All fractures healed in a satisfactory alignment. There were no cases of infection, loss of reduction and implant failure. All patients achieved their pre-injury functional status. The average ROM at the knee was 86.6 degrees (70–100). At latest follow up, none of the prostheses showed any signs of loosening and two patients had undergone total knee replacement on the contralateral side. Conclusion: Supracondylar nailing is a satisfactory method of managing periprosthetic fractures of the distal femur above a well-þxed implant.

The Copeland shoulder arthroplasty has been reported to give good results over a 5 to 10 year follow-up period. In this series all the humeral implants were inserted without cement. There was evidence of radiolucency in 30% of the humeral components.

In our unit since 1995 we have implanted the Copeland shoulder hemiarthroplasty using cement around the stem of the prosthesis. We radiologically reviewed 40 patients with a mean radiological follow-up of 4.5 years. There was radiological evidence of loosening in 5%.

Of this group, twenty-five patients had a minimum follow-up of 5 years, with a radiological loosening rate of 8%.

We would suggest that the use of a small amount of cement around the stem of the humeral component is beneficial in reducing the rate of loosening.

We also feel that, as the amount of cement is small and only around the stem, if revision is required it can be undertaken without the difficulties usually associated with cemented prostheses.

Between 1990 and 1996 we performed 20 consecutive ulnohumeral arthroplasties for primary osteoarthritis of the elbow.

The outcome was assessed using the Disabilities of Arm, Shoulder and Hand Score (DASH) and the Mayo Elbow Performance Score (MEPS) at a mean follow-up of 75 months (58 to 132). There were excellent or good results in 17 elbows (85%) using the DASH score and in 13 (65%) with the MEPS (correlation coefficient 0.79). The mean fixed flexion deformity had improved by 10° and the range of flexion by a mean of 20°.

In 16 elbows (80%) the benefits of surgery had been maintained, and of 16 patients working at the time of operation, 12 (75%) had returned to the same job.

There was no correlation between radiological recurrence of degenerative changes and the amount of fixed flexion deformity, the flexion arc, or the elbow scores.

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

Stabilization and bone grafting are the basic principles in the treatment of fracture non-union, however, infection is always a concern. Percutaneous bone marrow grafting has been suggested as an alternative, which provides a source of osteogenic cells with osteoinductive effect.

This prospective study evaluates the efficacy of percutanous bone marrow grafting in patients with tibial non-union while on the waiting list for open surgical procedures. 21 adult patients with established tibial non-union were recruited. The average age of fracture non-union was 12 months (range 6–36). Infected cases, deformed non-unions and gap non-unions were excluded. Eleven were hypertrophic and ten atrophic type of non-union.

Under local anaesthesia, bone marrow was aspirated from the iliac crests using a 16 G sternal puncture needle. 3–5ml marrow was aspirated and injected immediately into and about the non-union site. Subsequent aspirations were performed 1 cm posterior to the previous site until a maximum of 15 ml marrow was injected. Patients were immobilised in a plaster cast. Radiographs were repeated at 6 weeks interval. A second injection was repeated at 6 weeks if there was no evidence of callus formation.

The procedure was considered a failure, if there was no union at six weeks following the third injection. Bone marrow could not be aspirated in one patient. 19 patients were followed up clinically and radiologically until there was definite bone union or failure.

Bone union was achieved in 15 patients out of 20 (75%), with an average time to union following the first injection 14 weeks (range 6–22 ). Two of the patients needed only one injection, nine needed two injections, and four patients needed three injections to unite. 4 patients (20%) showed no evidence of union.

There were no complications at the donor or recipient site.

We conclude that percutanous bone marrow grafting is a safe, simple, and reliable method of treating tibial non-union with minimal deformity.

This study was designed to assess the standard of orthopaedic training of Senior House Officers in the U.K. and to determine the optimum time that should be spent in these posts before registrar training.

Two MCQ papers were constructed. One for the pre test and one for the post test. Questions covered all aspects of orthopaedics and trauma including operative surgery. The paper was firstly tested on controls including medical students, house officers, registrars of various grades and consultants. There was no statistical difference in the results for the two papers within the groups indicating that pre and post test papers were of similar standard. In addition the average scores in the tests increased proportionately to the experience and grade of the control.

129 SHOs from 25 hospitals in 10 different regions were tested by MCQ examination at the beginning of their 6-month post. They were again tested at the end of the job. The differences in score were compared. This difference was then correlated with the experience and career intention of the SHO.

There was no statistical difference between pre and post test results in all groups of SHOs in the study (student t test). The best improvement in scores during this six month period were seen in SHOs of 1–1.5 years orthopaedic experience. SHOs of more than 3 years experience demonstrated the smallest improvement in their score. There was a net loss of seven trainees with a career intention of orthopaedics to other disciplines.

In the vast majority of Senior House Officer posts in this country, very little seems to be learnt during a six-month attachment. This is especially so for those who are doing orthopaedics for the first time as well as very experienced SHOs.

To evaluate the effects of smoking on fracture healing in a non-union population.

A consecutive cohort of 104 patients with 107 non-unions managed by external fixation was reviewed. 75% were regular smokers compared to the regional average of 3 0%. 5 8 male and 20 female smokers, matched with the non-smoking group. Patients’ records and x-rays were evaluated; where information was missing patients were contacted by phone/post. Scoring was recorded from our own prospective database.

The smokers underwent 2. 6 procedures per segment with a mean treatment time of 17. 43 months (4–64) compared to 1. 9 and 10. 9 (2. 5–24) respectively in non-smoking group. The total hospital stay was 66% greater in the smoking group (41. 12 vs 27. 4 days).

102 non-unions healed, including seven who required revision surgery, six of whom were smokers. In smoking group five went on to amputation and three had residual infection. The entire non-smoking group healed after primary surgery except a 70 years old lady who was converted to intramedullary nailing.

The final assessment of the bony and functional results was performed by the method described by Paley and Catagni (JBJS 77A 1995).

When considered in the context of regional statistics for smoking there was a trend towards non-union in smokers [P< 0. 05].

We conclude that smoking adversely affects both primary fracture healing and non-union treatment.

Recurrent dislocation of the hip is a difficult management problem. We have chosen to tackle this in a minimal way and avoid complex revisions. All patients were late dislocators, and the majority were older than 75 years with 4 patients being octogenarians.

A 7cm incision is made in the skin at the trochanter, the fascia is opened and the hip dislocated posteriorly the head of the hip is felt under the external rotators and they are opened in a minimal way. The cup is inspected for gross wear, no abnormality has been found. The PLAD is applied and fixed posteriorly after removal of minimal capsular and scar tissue, simple closure takes place with no drain.

This procedure has been performed on nine occasions in our unit and all cases remain successful at a mean followup of 18 months (2–35 months). Operation times varied between 28 –42 minutes (mean 36 mins). Blood loss is minimal. The patient can be mobilised right away and early discharge can be achieved. This technique seems an ideal management solution in and elderly population with a good cup and stem with recurrent dislocation for unknown cause.

The long term results of the ulnohumeral arthroplasty have not previously been reported using a recognised elbow scoring system.

Kashiwagi reported his results in 1986 but no validated scoring system was used in the publication. Morrey in 1992 evaluated his results using the Mayo Elbow Performance Score but the mean follow-up interval was only 33 months.

Between 1990 and 1996 twenty consecutive ulnohumeral arthroplasties were performed for primary degenerative disease of the elbow.

Outcome assessment using the DASH questionnaire and the Mayo Elbow Performance Score was taken at a mean follow-up of 75 months (range 58 to 132). Excellent or good results were identified in 85% (17/20) using the DASH questionnaire, and 65% (13/20) on assessment with the Mayo Elbow Performance Score (correlation coefficient 0.79).

Eighty percent (16/20) felt that the benefits of surgery had been maintained, and of those working at the time of surgery, 75% (12/16) were still employed in the same vocation.

There was no correlation between radiographic recurrence and the degree of fixed flexion deformity, flexion arc or elbow scores.

Three and four part fractures of the proximal humerus can prove difficult to treat and results are generally poor. We used a Polarus Nail technique to treat seven consecutive patients who had sustained an isolated fracture to the proximal humerus. According to Neers classification, four patients had sustained a three-part fracture and three patients a four-part fracture. One patient had a fracture dislocation.

At review, six of the seven patients were assessed using the Constant and Dash scoring systems. One patient had died, but at last review had been discharged with a satisfactory result.

The average age of the patients reviewed was 62 years (range 48–79). The dominant hand was affected in 2 patients.

All six patients were followed up to fracture union and were happy with the result of treatment. All patients had mild or no pain. The average Constant score was 83 (range 59–98) and average Dash score was 131 (range 8–300)

When comparing our results to other methods of treatment already described, we found that fixation using a Polarus nail provided a satisfactory alternative method. In fact, our patients appeared to have less pain and a higher score to all elements of the Constant score.

We conclude therefore that the use of the Polarus Nail should be considered as a treatment option in this group of patients.