Background. Osteoarthritis of basal joint of the thumb represents one of the commonest degenerative diseases of the hand and wrist region. Depending on the severity of clinical symptoms surgical treatment is often recommended. Resection arthroplasty of the CMC joint with tendon interposition can be regarded as the gold standard. The aim of our study is to compare the Burton Pellegrini technique with a new modified technique of resection arthroplasty with interposition of local capsule tissue. Materials and Methods. We retrospectively evaluated 2 groups of patients. Two Consultant Surgeons took part in the study, one for each group, with each consultant performing trapeziectomies using only one of the techiniques for all his patients. The first group underwent trapeziectomy and local capsule interposition. It consists of 26 patients with a female/male ratio of 20/6, an average age of 64 years (range 53–88), an average follow up of 3.15 years (range 9–1) and a left/right ratio of 16/10. The second group underwent a standard Burton Pellegrini including flexor tendon interposition. It consists of 13 patients with a female/male ratio of 5/8, an average age of 68 years (range 58–85), an average follow up of 4.46 years (range 9–1) and a left/right ratio of 5/8. The outcomes were compared using the Michigan Hand Outcomes Questionnaire. A 2-tailed independent samples t-test was used for the statistical analysis of our data. Results. We found that there is significant difference between the two procedures only on the ability of working in present, t = 2.153 and p = 0.038. However, there is no significant difference between the other parameters we examined: overall hand function, t = 0.237 and p = 0.814; activities of daily living using the operated hand, t = 0.194 and p = 0.847; activities of daily living using both hands, t = 0.184 and p = 0.855; overall activities of daily living, t = 0.204 and p = 0.839; pain, t = 0.123 and p = 0.903; aesthetics, t = 1.063 and p = 0.295; satisfaction, t = 0.628 and p = 0.534; total score, t = 0.509 and p = 0.613. Furthermore, the overall score for the two procedures suggests that there is no significant difference between them. Conclusions. The new modified procedure is simpler and quicker than the traditional operation and avoids the morbidity of tendon harvesting. The overall outcome score for the two operations is equal, suggesting that there is no advantage to the more complex procedure. We have shown a difference between the two procedures in post op working ability, being better in the group with local capsule interposition

Introduction. Application of an external fixator for type B and C pelvic fractures can be life saving. Anteriorly the fixator half pins can be placed in the long and thick corridor of bone in the supra-acetabular region often referred to as the low anterior ex-fix. Pins in this location are favoured as they are more stable biomechanically. The bone tunnel for the low anterior ex-fix can be visualised with an iliac oblique projection intra-operatively. In some cases despite being outside the articular surface it may still be low enough to pass through the capsular attachment of the hip joint on the anterior inferior iliac spine. We aim to provide radiological markers for the most superior fibres of the capsule to help accurate extra-capsular pin placement within the supra-acetabular bone tunnel. Materials and Methods. Thirteen cadaveric pelves, embalmed with the method of Thiel, were used for this study. An image intensifier was positioned to acquire an iliac oblique outlet view, such that the supra acetabular bone tunnel was visualised. This was achieved by positioning the beam 30 degrees cephalad and 20 degrees medial. Both left and right hemipelves were examined in this way. A standard size metallic disc was included in all images with in the acetabulum to allow for image calibration. The proximal most fibres of the hip joint capsule were marked with a K-wire so that their relation to the bone tunnel could be clearly seen on the images. Once all images were acquired they were calibrated and analysed using ImageJ Software to estimate the height and maximum width of the bone tunnel as seen on the images and the vertical distance of the superior most fibres of the capsule from the dome of the acetabulum. Results. The mean height of the bone tunnel was 24.9 mm (SD 4.3 mm, Range 18.9–33.2 mm) and the maximum width of the tunnel was 11.7 mm (SD 2.6 mm, Range 7.6–16.3 mm). The inferior margin of the bone tunnel was on average 7.4 mm (SD 3.4 mm, Range 1.1–14.4 mm) superior to the acetabular dome and the most proximal fibres of the capsule were on average 9.2 mm (SD 2.4 mm, Range 4.7–16.1 mm) superior to the acetabular dome. This meant that on average 3.6 mm (SD 2.1 mm, Range 0.3–8.9 mm) of the inferior portion of the tunnel is within the joint. There was no statistically significant difference between the left and right sides. Conclusion. There is adequate space for two long external fixator pins within the described tunnel. These should be placed in the upper half of the anterior inferior iliac spine. Below this level there is risk of being intra-capsular which can lead to septic arthritis. For this reason we recommend that supra-acetabular pins should be placed at least 16 mm superior to the acetabular dome as visualised on the iliac oblique outlet view

Background. An increased incidence of periprosthetic osteolysis, resulting in loss of biologic fixation, has been recently reported in contemporary THAs with low-carbide metal-on-metal compared to metal-on-polyethylene couple bearings. A hypersensitivity reaction due to Co and Cr debris is reported as a potential cause for failure of THAs with high-carbide bearings, but there are no evidence-based data for this reaction in low-carbide metal-on-metal bearings. Questions/purposes. We investigated whether there were differences in immunologic hypersensitivity reactions in retrievals from revised THAs with COP versus MOM bearing couples. Patients and Methods. We compared newly formed capsule and periprosthetic interface membranes retrieved from revision surgery due to aseptic failure in 20 patients with low-carbide bearings and 13 patients with ceramic-on-polyethylene bearings. For control tissue we obtained samples from the hip capsule during the primary THA implantation in 13 patients with low-carbide bearings and seven with ceramic-on-polyethylene. We examined the tissues with conventional histologic and immunohistochemical methods. Results. Compared to the controls and the tissue from patients with ceramic-on-polyethylene bearings, the tissues from patients with low-carbide metal-on-metal bearings were associated with (1) extensive necrosis and fibrin exudation in the newly formed hip capsule and (2) diffuse and perivascular lymphocytic infiltration of a higher degree than in the ceramic-on-polyethylene hips in conventional histologic examination and (3) more T than B cells. Conclusions. The conventional histologic and immunohistochemical findings in tissues retrieved from failed THAs with low-carbide metal-on-metal bearings are consistent with a link between hypersensitivity and osteolysis with low-carbide bearing couple THA

Aim. Our goals were to minimize the invasiveness of the revision hip arthroplasty approach in order to accelerate the patient's rehabilitation, shorten the length of hospitalization and reduce the postoperative complications, especially the rate of joint dislocation. Our study aimed to prove whether and under which conditions the less invasive approach is preferable in revision arthroplasty. Material and Methods. The modified revision technique differs from the conventional approach in the following main aspects:. Oncologic: applying larger hip balls and inserts, after expanding the variety of the available articulating joint components in 4 mm steps (28–40 mm),. sparing and reconstructing the joint capsule, whereby the integrity of its acetabular origin is crucial. That procedure was combined with tissue dissection strictly parallel to the direction of the muscle fibers. The transgluteal approach after Bauer was applied. The small skin incision was closed by running subcuticular technique. The inpatient postoperative phase after revision total hip arthroplasty was evaluated in the last 6.5 years. All patients completed a questionnaire. Results. Less invasive revision hip arthroplasty was performed in 55 cases in a period of 6.5 years. No intraoperative method-specific complication was observed. Only one dislocation and one early infection, which needed surgical intervention, were recorded. The mean postoperative length of stay was 9.5 days after less invasive revision hip arthroplasty compared to an average of 20.5 days for all revisions. The duration of inpatient treatment was thus halved. This technique was mostly applied in the isolated stem exchange, followed by exchange of bearing components and complete joint exchange. The isolated socket exchange with stable stem is, however, difficult to be realized in the less invasive technique. Conclusion. The less invasive revision hip arthroplasty is associated with a low complication rate. It can be applied in about 30–50% of revision cases. Reconstructing the integrity of the capsule represents the most important modification of the operation's technique. The postoperative joint stability is on the midterm increased and the reconstruction of leg length is indirectly facilitated compared to resecting the joint capsule. Applying larger ball-insert pairs depending on the outer diameter of the socket allows a long-term increase in the joint stability and thus a reduction in the dislocation risk. Owing to its low complication rate and significant reduction of the length of stay, the less invasive revision hip arthroplasty approach is medically and economically recommended

Background:. Septic arthritis following intra-capsular penetration of the knee by external fixation devices is a complication of traction/fixation devices. This study aimed to demonstrate the capsular attachments and reflections of the distal femur to determine safe placements of wires. Methods:. The attachments of the capsule to the distal femur were measured in cadaveric knees. Medially and laterally measurements were expressed as percentages related to the maximal AP diameter of the distal femur. Results:. Mean distance of the anterior attachment was 79.5mm (Range 48.1–120.7mm). The medial capsular reflections were attached an average of 57% back from the anterior edge (Range 41–74%). Laterally the capsular reflections were attached an average of 48% from the anterior reference point (Range 33–57%). Discussion:. Capsular reflections varied. Medially the capsule attachment was up to 74% of diameter of distal femur at the level of the adductor tubercle. Therefore, the insertion of distal femoral traction pins or similar should be placed proximal to the adductor tubercle and no further than 25% of the distance to the anterior cortex. Care is needed to ensure pins do not travel to exit too anteriorly on the lateral side as capsular attachments were found to be up to a distance 48% of the diameter of the femur from anterior reference point

Introduction. Controversy exists as to whether the short external rotator tendons and capsule of the hip should be repaired after posterior approach primary total hip arthroplasty (THA). Recent studies using radiopaque markers have demonstrated that reimplantation of these muscle tendons fail early and may not prevent post operative dislocation. Methods. Using dynamic ultrasound examination we evaluated the patency of repair in 68 tendon groups (piriformis/conjoint tendon and obturator externus). We demonstrate short and medium term success in the reimplantation of these tendons using the double transosseous drill hole technique of reattaching the tendons and capsule to the greater trochanter. We followed up 21 of our total hip replacements and 13 hip resurfacings and undertook a dynamic ultrasound examination of the external rotators by an experienced musculoskeletal radiologist to assess their integrity at a minimum of 60 days and 100 days and an average of 213 days after the operation. Results. There were 34 hips assessed in 33 patients. 21 were total hip replacements and the rest were hip resurfacings. Each patient underwent a standard posterior approach by the senior surgeon. The piriformis and conjoint tendons (Group 1) and the obturator extenus (Group 2) were reattached with modified kessler sutures using a transosseous reimplantation technique. The capsule was reattached with a running suture using the same technique. The total hip replacement group had 16 out of 21 hips (76.2%) where both external rotator groups were intact at follow up, compared with 3 out of 13 hips (23.1%) for the hip resurfacing group (Chi-squared 9.188, p=0.002). Group 1 tendons were intact in 81% of the THR group while only in 53.8% in the rsurfaing group. We compared the hip replacement group with the hip resurfacing group using survival analysis techniques (log rank test), which take into account the different follow-up times. The hip replacement group showed a significantly longer time to the event of either rotator group not being intact at follow-up than the hip resurfacing group (log rank 5.568, p=0.018). Conclusions. Our results do appear to suggest that this technique may be of benefit in patients undergoing primary THA but may not be as successful after resurfacing procedures. We propose that the increased incidence of external rotator detachment seen in the resurfacing group may be due to the increased strain imparted on the tendons due to the greater distance to travel, as they wind around the large resurfaced femoral head and neck as compared to the relatively thinner THA femoral neck and smaller head component

Aims

Patients with A1 and A2 trochanteric hip fractures represent a substantial proportion of trauma caseload, and national guidelines recommend that sliding hip screws (SHS) should be used for these injuries. Despite this, intramedullary nails (IMNs) are routinely implanted in many hospitals, at extra cost and with unproven patient outcome benefit. We have used data from the National Hip Fracture Database (NHFD) to examine the use of SHS and IMN for A1 and A2 hip fractures at a national level, and to define the cost implications of management decisions that run counter to national guidelines.

Aims

Open reduction and plate fixation (ORPF) for displaced proximal humerus fractures can achieve reliably good long-term outcomes. However, a minority of patients have persistent pain and stiffness after surgery and may benefit from open arthrolysis, subacromial decompression, and removal of metalwork (ADROM). The long-term results of ADROM remain unknown; we aimed to assess outcomes of patients undergoing this procedure for stiffness following ORPF, and assess predictors of poor outcome.

Aims. Although infrequent, a fracture of the cuboid can lead to significant disruption of the integrity of the midfoot and its function. The purpose of this study was to classify the pattern of fractures of the cuboid, relate them to the mechanism of injury and suggest methods of managing them. Patients and Methods. We performed a retrospective review of patients with radiologically reported cuboid fractures. Fractures were grouped according to commonly occurring patterns of injury. A total of 192 fractures in 188 patients were included. They were classified into five patterns of injury. Results. Type 1 fractures (93 fractures, 48.4%) are simple avulsion injuries involving the capsule of the calcaneo-cuboid joint. Type 2 fractures (25 fractures, 13%) are isolated extra-articular injuries involving the body of the cuboid. Type 3 injuries (13 factures, 6.8%) are intra-articular fractures solely within the body of the cuboid. Type 4 fractures (35 fractures, 18.2%) are associated with disruption of the midfoot and tarsometatarsal injuries. Type 5 fractures (26 fractures, 13.5%) occur in conjunction with disruption of the mid-tarsal joint and either crushing of the lateral column alone or of both medial and lateral columns. Fractures with significant articular disruption or with loss of length of the lateral column underwent fixation. This involved either internal fixation to restore the anatomy of the cuboid and/or restoration of the length of the columns with bridging constructs using internal or external fixation. Conclusion. A classification system for fractures of the cuboid is proposed in relation to the mechanism of injury. The treatment of these fractures is described. Cite this article: Bone Joint J 2016;98-B:1003–8

INTRODUCTION. The TFCC injuries are usually diagnosed by a coronal MRI. We have described the Float image for the diagnosis of peripheral injuries of the TFCC. In a sagital image parallel to the ulnar diaphysis and placed lateral to the ulnar fovea, we can observe the radiocubital dorsal and volar ligaments of the TFCC. A distance of more than 4mm between the dorsal edge of the meniscus and the joint capsule suggests the presence of TFCC peripheral rupture. METHOD. 51 pacients were selected from all the patients who underwent wrist arthroscopy between 2006–2009. Inclusion criteria: MRI at our hospital, arthroscopy at our hospital, no presence of radial fracture. We assessed the correlation between the presence of the Float image and a TFCC injury confirmed by arthroscopy. RESULTS. The Float image for the diagnosis of peripheral TFCC injuries has a sensibility of 0.929 [0.774 to 0.98] and a specificity of 0,857 [0.654 to 0.95]. PPV: 0.897 [0.736 to 0.964] and NPV: 0.9 [0.699 to 0.972]. CONCLUSIONS. The Float MRI is a high sensibility and specificity method for the diagnosis of peripheral TFCC. The coronal MRI is useful for diagnosing central ruptures but has less sensibility for the peripheral injuries

The superficial anterior vasculature of the knee is variably described; most of our information comes from anatomical literature. Descriptions commonly emphasise medial-dominant genicular branches of the popliteal artery. Describing the relative contribution of medial and lateral vessels to the anastomotic network of the anterior knee may help provide grounds for selecting one of a number of popular incisions for arthrotomy. The aim of this study is to describe the relative contribution of vessels to anastomoses supplying the anterior knee. Cadaveric knees (n = 16) were used in two cohorts. The first cohort (n = 8) were injected at the popliteal artery with a single colour of latex, and then processed through a modified diaphanisation technique (chemical tissue clearance) before final dissection and analysis. This was repeated for the second cohort, but with initial dissection to identify potential source vessels at their origin. Each source vessel was injected with a different colour of latex. The dominant sources were determined in each specimen. The majority of the specimens (n = 13; 81%) demonstrated that an intramuscular branch though the vastus medialis muscle was the dominant vessel. Anastomoses were most common over the medial side of the knee, both superiorly and inferiorly (3-5 anastomoses in all cases). Anastomosis over the lateral knee was infrequent (1 anastomosis in 1 specimen). The results suggest that anterior vasculature of the knee is predominately medial in origin, but not from the genicular branches as previously described. This network of vessels found in the anterior knee is thought to be the main supply to the patella, extensor apparatus, anterior joint capsule and skin. Optimum placement of incision for arthrotomy is a subject of debate. Considering the main blood supply to the anterior knee may help in choosing a particular approach

We treated 17 knees in 15 patients with severe ligament derangement and dislocation by open repair and reconstruction. We assessed the competence of all structures thought to be important for stability by clinical examination, MRI interpretation, and surgery. Our findings showed that in these polytrauma patients clinical examination was not an accurate predictor of the extent or site of soft-tissue injury (53% to 82% correct) due mainly to the limitations of associated injuries. MRI was more accurate (85% to 100% correct) except for a negative result for the lateral collateral ligament and posterolateral capsule. The detail and reliability of MRI are invaluable in the preoperative planning of the surgical repair and reconstruction of dislocated knees

Background. Both from experimental studies and the large arthroplasty registries there is evidence that bacteria are more often involved in implant loosening then is currently reported. To further elucidate this potential problem, the current study investigated the hypothesis that many total hip arthroplasty revisions, classified as aseptic, are in fact low-grade infections missed with routine diagnostics. Methods. In 7 Dutch hospitals, 176 patients with the preoperative diagnosis of aseptic loosening of their total hip arthroplasty were enrolled. From each patient, the preoperative history was obtained. During surgery, between 14 and 20 tissue samples were obtained for routine culture, pathology analysis and broad range 16S rRNA PCR with reverse line blot hybridization (PCR-RLB). Samples were taken from the (neo-) capsule and acetabular and femoral interface tissue. Cultures were performed locally according to similar protocols. One specialized pathologist, blinded for all other results, analyzed all pathology samples. The PCR-RLB analysis was performed centrally, using a technique previously validated for orthopedic use. Patients were classified as not infected, suspect for infection or infected, according to strict, predefined criteria. Each patient had a follow-up visit after 1 year. Results. Seven patients were classified as infected, of whom 4 were not identified by routine culture. In these patients, positive PCR-RLB results were supported by pathology analyses suspect for infection as well. An additional 15 patients were suspect for infection as well. The microorganisms identified were low virulent bacteria, like coagulase negative staphylococci and Proprionibacterium acnes, in most cases. Twenty of these 22 patients received a cemented prosthesis, fixated with antibiotic-loaded bone cement. All patients received prophylactic systemic antibiotics, after obtaining the tissue samples. Seven of the 22 patients reported complaints one year post-surgery, only one showing signs of early loosening. However, in none of the patients additional surgery was performed. Discussion. Although percentages were not as high as previously reported in literature, between 4 and 13 percent of patients with the preoperative diagnosis of aseptic loosening were infected. However, as thorough debridement was performed during surgery and prophylactic antibiotics were used, it did not have many clinical consequences, as most patients performed well at the 1-year follow-up. Whether it has implications for long-term implant survival remains to be seen

Introduction. Osteoarthritis (OA) represents a leading cause of disability and a growing burden on healthcare budgets. OA is particularly vexing for young, active patients who have failed less invasive therapies but are not yet candidates for arthroplasty. Often, patients suffering in this wide therapeutic gap face a debilitating spiral of disease progression, increasing pain, and decreasing activity until they become suitable arthroplasty patients. An implantable load absorber was evaluated for the treatment of medial knee OA in this patient population. Joint overload has been cited as a contributor to OA onset or progression. In response, the KineSpring® System (Moximed, Inc, USA) has been designed to reduce the load acting on the knee. The absorber is implanted in the subcutaneous tissue without violating the joint capsule, thus preserving the option of future arthroplasty. The implant is particularly useful for young, active patients, given the reversibility of the procedure and the preservation of normal flexibility and range of motion. Methods and Results. The KineSpring System was implanted in 55 patients, with the longest duration exceeding two years. The treated group had medial knee OA, included younger OA sufferers (range 31–68 years), with a mean BMI > 30kg/m2. Acute implant success, adverse events, and clinical outcomes using validated patient reported outcomes tools were recorded at baseline, post-op, 2 and 6 weeks, and 3, 6, 12 and 24 months post-op. All patients were successfully implanted with a mean procedure time of 76.4 min (range 54–153 minutes). Mean hospital length of stay was 1.7 days (range 1–3 days), and patients recovered rapidly, achieving full weight bearing within 1–2 wks and normal range of motion by 6 weeks. Most patients experienced pain relief and functional improvement with 85% (35/41) reporting none or mild pain on the WOMAC pain subscale and 90% (37/41) reporting functional impairment as none on mild on the WOMAC function subscale at the latest follow-up visit (mean 9.3 ± 3.5 months). Clinically meaningful and statistically significant pain reduction and functional improvement were noted with baseline WOMAC pain scores (0–100 scale) improving from 42.4 to 16.1 (p<0.001) and WOMAC function (0–100 scale) improving from 42.0 to 14.7 (p<0.001) at latest follow-up. Patients reported satisfaction with the implant and its appearance. Conclusions. The KineSpring System preserves natural knee anatomy and kinematics while providing pain reduction and resumption of high activity levels that have proven durable. This device, with these excellent results, fills a major gap in treatment options for young and active OA patients

Introduction. The degeneration of the adjacent segment in lumbar spine with spondylodesis is well known, though the exact incidence and the mechanism is not clear. Several implants with semi rigid or dynamic behavior are available to reduce the biomechanical loads and to prevent an adjacent segment disease (ASD). Randomized controlled trials are not published. We investigated the biomechanical influence of dynamic and semi rigid implants on the adjacent segment in cadaver lumbar spine with monosegmental fusion (MF). Materials and Methods. 14 fresh cadaver lumbar spines were prepared; capsules and ligaments were kept intact. Pure rotanional moments of ±7.5 Nm were applied with a Zwick 1456 universal testing machine without preload in lateral bending and flexion/extension. The intradiscal pressure (IDP) and the range of motion (ROM) were measured in the segments L2/3 and L3/4 in following situations: in the native spine, monosegmental fusion L4/5 (MF), MF with dynamic rod to L3/4 (Dynabolt), MF with interspinous implant L3/4 (Coflex), and semi rigid fusion with PEEK rod (CD Horizon Legacy) L3-L5. Results. Under flexion load all implants reduced the IDP of segment L2/L3, whereas the IDP in the segment L3/4 was increased using interspinous implants in comparison to the other groups. The IDP was reduced in extension in both segments for all semi rigid or dynamic implants. Compared under extension to the native spine the MF had no influence on the IDP of the adjacent disc. The rod instrumentation (Dynabolt, PEEK rod) lead to a decreased IDP in lateral bending tests. The ROM in L3 was reduced in all groups compared to the native spine. The dynamic and semi rigid stabilization in the segment L3/4 limited the ROM more than the MF. Discussion. The MF reduced the ROM in all directions, whereas the IDP of the adjacent segment remained unaffected. The support of the adjacent segment by semi rigid and dynamic implants decreased the IDP of both segments in extension mainly. This fact is an agreement with other studies. Compared to our data, no significant effect on the adjacent levels was observed. Interestingly, in our study, the IDP of the adjacent segment is unaffected by MF. The biomechanical influence in the view of an ASD could be comprehended, but is not completely clear. The fact of persistent IDP in the adjacent segment suggests that MF has a lower effect on the adjacent segment degeneration as presumed. Biomechanical studies with human cadaver lumbar spines are limited and depend on age and degenerative situation. The effect on supporting implants on adjacent segment disease in lumbar spine surgery has to be investigated in clinical long term studies

Introduction. Osteoarthritis of the glenohumeral joint leads to global degeneration of the shoulder and often results in humeral or glenoid osteophytes. It is established that the axillary neurovascular bundle is in close proximity to the glenohumeral capsule. Similar to other compressive neuropathies, osteophytic impingement of the axillary nerve could result in axillary nerve symptoms. The purpose of this study was to compare the proximity of the axillary neurovascular bundle to the inferior humerus in shoulders to determine distance of the neurovascular bundle as the osteophyte (goat's beard) of glenohumeral osteoarthritis develops. Methods. In this IRB approved study, preoperative MRI's of 98 shoulders (89 patients) with primary osteoarthritis (OA group) were compared to 91 shoulders (86 patients) with anterior instability (Control group). For MRI measurements (mm) two coronal-oblique T1 or proton density weighted images were selected for each patient located at 5 and 6 o'clock position of the glenoid in the parasagittal plane. Humeral head diameter to standardize the glenohumeral measurements, size of the spurs, and 6 measurements between osseus structures and axillary neurovascular bundle were obtained on each image using a calibrated measurement system (Stryker Office PACS Power Viewer). Level of significance was set at p>.05. Results. Since results were both significant at 5 and 6 o'clock, for clarity we will only give the results at 6 o'clock. Humeral head osteophytes were present in 52% (51/86) of arthritic patients with an average size of 9.90 mm (range 0–24.31). Distance between humeral head or inferior osteophyte and neurovascular bundle was significantly decreased (p<0.05) in the OA group, 19.74 mm (range 2.80–35.12) compared to the control group 23.8 mm (14.25–31.89). If we compare the same distance between the Control group, OA group with a spur and OA group without a spur, the difference is only significant between the Control group and OA with spur. (p<0.05) In non-arthritic patients, the neurovascular bundle was closest to the inferior glenoid rim in all patients (91/91). By contrast, the neurovascular bundle was closest to the humeral head in 26.5% (26/98) of arthritic patients. Among these 26 patients, a large humeral head osteophyte was present in 96% (25/26). The neurovascular bundle distance and humeral head osteophyte size were inversely correlated (r=−0.45 at 5 o'clock, r=−0.546 at 6 o'clock) in the arthritic group (p<0.05). Discussion. The axillary neurovascular bundle was significantly closer to the osseous structures (humerus) in arthritic patients compared to non-arthritic patients (p<0.05). The neurovascular bundle was significantly closer to the bone when there was a humeral osteophyte, and the distance was inversely proportional to humeral osteophyte size (p<0.05). This study indicates humeral osteophytes are capable of encroaching on the axillary nerve. Axillary nerve entrapment may be a contributing and treatable factor of pain in patients with glenohumeral osteoarthritis

Aims

This study describes and compares the operative management and outcomes in a consecutive case series of patients with dislocated hemiarthroplasties of the hip, and compares outcomes with those of patients not sustaining a dislocation.

We evaluated the outcome of treatment of nonunion of an intracapsular fracture of the femoral neck in young patients using two cannulated screws and a vascularised bone graft. A total of 32 patients (15 women and 17 men, with a mean age of 36.5 years; 20 to 50) with failed internal fixation of an intracapsular fracture were included in the study. Following removal of the primary fixation, two cannulated compression screws were inserted with a vascularised iliac crest bone graft based on the ascending branch of the lateral femoral circumflex artery.

At a mean follow-up of 6.8 years (4 to 10), union was achieved in 27 hips (84%). A total of five patients with a mean age of 40.5 years (35 to 50) had a persistent nonunion and underwent total hip arthroplasty as also did two patients whose fracture united but who developed osteonecrosis of the femoral head two years post-operatively. Statistical analysis showed that younger patients achieved earlier and more reliable union (p < 0.001). The functional outcome, as assessed by the Harris Hip score, was better in patients aged < 45 years compared with those aged > 45 years (p < 0.001).

These findings suggest that further fixation using two cannulated compression screws and a vascularised iliac crest bone graft is an effective salvage treatment in patients aged <  45 years, in whom osteosynthesis of a displaced intracapsular fractures of the femoral neck has failed.

Cite this article: Bone Joint J 2015; 97-B:988–91.

This is a case series of prospectively gathered data characterising the injuries, surgical treatment and outcomes of consecutive British service personnel who underwent a unilateral lower limb amputation following combat injury. Patients with primary, unilateral loss of the lower limb sustained between March 2004 and March 2010 were identified from the United Kingdom Military Trauma Registry. Patients were asked to complete a Short-Form (SF)-36 questionnaire. A total of 48 patients were identified: 21 had a trans-tibial amputation, nine had a knee disarticulation and 18 had an amputation at the trans-femoral level. The median New Injury Severity Score was 24 (mean 27.4 (9 to 75)) and the median number of procedures per residual limb was 4 (mean 5 (2 to 11)). Minimum two-year SF-36 scores were completed by 39 patients (81%) at a mean follow-up of 40 months (25 to 75). The physical component of the SF-36 varied significantly between different levels of amputation (p = 0.01). Mental component scores did not vary between amputation levels (p = 0.114). Pain (p = 0.332), use of prosthesis (p = 0.503), rate of re-admission (p = 0.228) and mobility (p = 0.087) did not vary between amputation levels.

These findings illustrate the significant impact of these injuries and the considerable surgical burden associated with their treatment. Quality of life is improved with a longer residual limb, and these results support surgical attempts to maximise residual limb length.

Cite this article: Bone Joint J 2013;95-B:224–9.

Coronal plane fractures of the posterior femoral condyle, also known as Hoffa fractures, are rare. Lateral fractures are three times more common than medial fractures, although the reason for this is not clear. The exact mechanism of injury is likely to be a vertical shear force on the posterior femoral condyle with varying degrees of knee flexion. These fractures are commonly associated with high-energy trauma and are a diagnostic and surgical challenge. Hoffa fractures are often associated with inter- or supracondylar distal femoral fractures and CT scans are useful in delineating the coronal shear component, which can easily be missed. There are few recommendations in the literature regarding the surgical approach and methods of fixation that may be used for this injury. Non-operative treatment has been associated with poor outcomes. The goals of treatment are anatomical reduction of the articular surface with rigid, stable fixation to allow early mobilisation in order to restore function. A surgical approach that allows access to the posterior aspect of the femoral condyle is described and the use of postero-anterior lag screws with or without an additional buttress plate for fixation of these difficult fractures.

Cite this article: Bone Joint J 2013;95-B:1165–71.