Background/Aims. The development of extendable prostheses has permitted limb salvage surgery in paediatric patients with bone tumours in proximity to the physis. Prostheses are extended to offset limb length discrepancy as the child grows. Aseptic loosening (AL) is a recognised complication. The implant stem must fit the narrow paediatric medullary canal and remain fixed while withstanding growth and increasing physical demands. Novel designs incorporate a hydroxyapatite (HA) coated collar that manufacturers claim improves bony ongrowth and stability, providing even stress distribution in stem and shoulder regions and providing a bone-implant seal, resulting in decreased AL and prolonged survival. This study aims to assess whether there is a relationship between bony ongrowth onto a HA collar and AL. Hypothesis: Bone ongrowth onto the HA collar of extendable prostheses is associated with more stable fixation and less AL despite patient growth. Methods. Retrospective review of 51 primary partial femoral extendable prostheses implanted over 12 years from 1994–2006 (followed up to death at a mean of 2.5±2.2 years or last clinical encounter at a mean of 8.6 years) and 24 subsequent revisions, to ascertain failure rate and mode, together with a cohort study reviewing bony ongrowth onto the HA coated collar in 10 loose and 13 well fixed partial femoral, humeral and tibial implants. Patient growth was measured as a change in bone:implant-width ratio. Results. 21 (41.2%) primary femoral implants failed at a mean 42.8 months, 5 through AL. 1 secondary implant was revised for AL. 2 implants displayed evidence of progressive AL but had not failed at last follow-up. 5 of 11 tibial component revisions in distal femoral replacement were due to AL. 1 major complication occurred after revision surgery for AL in a primary implant: deep infection requiring 2 stage revision. Bony collar ongrowth was significantly higher in all 4 quadrants (anterior, posterior, medial and lateral) in the well-fixed as opposed to loose group, demonstrating a strong negative relationship in each quadrant between bony ongrowth and AL (p0.001) in the presence of patient growth as shown by increased bone:implant width ratio. In both groups, collar ongrowth was greatest in the posterior quadrant. Summary and Conclusions: AL has been confirmed as a common cause of failure in massive extendable endoprostheses. Revision surgery is difficult and may cause serious complications. For the first time, a significant relationship between a well fixed implant stem and bony ongrowth onto a HA coated collar in the context of massive implants used in tumour surgery has been demonstrated. This newly-proven relationship may result in longer-term implant survival and thus a reduced need for revision surgery. It is hoped that this study will provide the basis for further study of this relationship

Elevated fat pads on a paediatric elbow radiograph may represent an intraarticular fracture. If no obvious fracture is visible, the injury may be treated with a collar and cuff until discomfort resolves. In some centres these patients are discharged directly from A&E, easing the load on fracture clinics and reducing the number of visits required by the patient. A retrospective study was carried out to review patient journey for children referred to clinic with elevated fat pads only and to investigate whether such a protocol could be established locally. Notes for all children attending fracture clinic in May 2018 were reviewed. X-rays for patients with any elbow injury were then reviewed. Patients with raised fat pads only were included in the study. Outcome following clinic review was recorded. 818 patients (315 new referrals) attended 15 clinics. 31 were referred with raised fat pads only. Mean age was 7.7 years with mean time to clinic of 4 days. 74.2% required no further treatment and were discharged at first clinic appointment. 8 patients were kept in cast for another 1–2 weeks due to parental apprehension, patient apprehension or patient being uncomfortable without cast. None of our patients required surgical intervention or re-attended following discharge. This study showed that patients with raised fat pads only can be treated with collar and cuff, analgesia and discharged from A&E with an advice leaflet. This would reduce the number of patients unnecessarily attending clinics thereby reducing patient distress and enabling more efficient use of clinic appointments

Aims

Periprosthetic fractures (PPFs) following hip arthroplasty are complex injuries. This study evaluates patient demographic characteristics, management, outcomes, and risk factors associated with PPF subtypes over a decade.

Our aim in this pilot study was to evaluate the fixation of, the bone remodelling around, and the clinical outcome after surgery of a new, uncemented, fully hydroxyapatite-coated, collared and tapered femoral component, designed specifically for elderly patients with a fracture of the femoral neck. We enrolled 50 patients, of at least 70 years of age, with an acute displaced fracture of the femoral neck in this prospective single-series study. They received a total hip replacement using the new component and were followed up regularly for two years. Fixation was evaluated by radiostereometric analysis and bone remodelling by dual-energy x-ray absorptiometry. Hip function and the health-related quality of life were assessed using the Harris hip score and the EuroQol-5D. Up to six weeks post-operatively there was a mean subsidence of 0.2 mm (−2.1 to +0.5) and a retroversion of a mean of 1.2° (−8.2° to +1.5°). No component migrated after three months. The patients had a continuous loss of peri-prosthetic bone which amounted to a mean of 16% (−49% to +10%) at two years. The mean Harris hip score was 82 (51 to 100) after two years. The two-year results from this pilot study indicate that this new, uncemented femoral component can be used for elderly patients with osteoporotic fractures of the femoral neck

The reconstruction of lower limb defects after oncological reconstructions is still a problem in limb salvage surgery. Large bony defects need to be treated with sound and durable reconstructions. During recent decades, the life expectancy of patients affected with cancer has improved considerably because of advances in chemotherapy, immunotherapy, hormonal treatment and radiotherapy. This improvement requires greater reliability in the reconstructive procedure in order to avoid mechanical failure during prolonged survival of the patient. The author experience with modular megaprosthesis by Link (megasystem C) allowed us to present a rapid, effective and functional solution. From June 2001 to December 2007 225 patients have been operated with a megaprosthesis C for tumoral resection. The new megaprosthesis C by Link represents a wide-ranging system that can afford a large variety of reconstructions in the inferior limb, from very short replacement of 5 cm in proximal femur, to a total femur and proximal tibia replacement. Modularity is represented by 1 cm increase in length. The different options of cemented and not cemented stem may be used with intraoperative decision. In cemented stem a rough collar seals the osteotomy and prevents polyethylene debris from entering the femoral canal by inducing a scar tissue around the stem entrance (so-called purse-string effect). Moreover in patients with solitary lesions and very good prognosis an allograft-prosthesis composite can be performed with improved clinical results on walking and function. Of the 225 patients that underwent tumoral resection and reconstruction with a modular megaprosthesis approximately 43% (97 cases) were operated for metastatic disease. Among these cases 55 cases were proximal femoral recontructions, 39 cases were distal femoral reconstructions and 3 cases were proximal tibial reconstructions. All cases were performed with cemented stems. We experienced a 7% of postoperative infections, 2% of dislocations of proximal femoral prosthesis and 3% of mechanical failures. While infections and dislocation rates were in the average for this surgery, mechanical failures were relatively high. We should consider that in patients with relatively long resections and muscle deficiency the mechanical stress exerted on the prosthesis can explain this kind of mechanical failure. However the new design of morse tapers have annulled these problems

Introduction. The postoperative management of patients after total hip replacement traditionally includes restrictions of movements and the use of aids (toiletelevation, sleeping pillow, a.o.) in the first 3 months after operation. Few studies have investigated the benefit of such restrictions. The aim of the present study was to evaluate how patients with total hip replacements (THR) are doing with and without restrictions in the first 3 months after surgery, and if walking ability and patients satisfaction was influenced by the postoperative regime. Patients and Methods. 80 patients undergoing primary uncemented THR were randomized to either the conventional regime with restrictions of movement and obligatory use of aids, or a postoperative regime without restrictions. Surgery was performed through a posterolateral short incision. The femoral component was the uncemented Bimetric prosthesis, non collared with HA coating, and a 36 mm femoral head. The cup was the Trilogy cup with a highly crosslinked polyethylen liner. No postoperative drainage was used and immediate weight bearing was allowed in both groups. We monitored walking speed, TUG score (timed up and go) and VAS pain score. The patients were scored by a trained physiotherapist preoperatively, 2 times each day during admission, and 14 and 90 days after surgery. Radiographic examination was performed after 3 days and after 3 months. At the 3 months evaluation a SF-36 score was registered. Results. The two groups were similar in age, operation time blood loss, and position of the prosthesis. None of the patients had postoperative dislocation. No significant difference was seen in any of the registered parameters (p< 0,05). The two groups were not similar regarding pain score. Preoperatively there was a significant higher pain score(p<0,05) in the group without restrictions and this difference was present throughout the first postoperative days. Accordingly they spent more time walking 10m during the first postoperative days, though this difference was not statistically significant. After 3 months the results in the two groups were similar and the SF-36 score was without significant difference. Conclusion. There is no significant difference in TUG test, 10m test, SF 36 score and VAS score the first 3 months after THR in the 2 groups. We did not see an increase in postoperative complications, which implies that postoperative mobilisation without restrictions, can be allowed without the risk of increased complications, and the use of aids in activities of daily living are not necessary. This also implies the possibility of savings in the rehabilitation of patients after THR

Total hip replacements have been shown to give superior outcomes in patients with intracapsular fractures of the neck of femur compared with hemiarthroplasty. Collarless uncemented femoral stems give excellent long term results in elective hip replacements but there are few studies looking at their outcomes in fractured neck of femur patients. There is some concern that in trauma patients bone quality maybe inferior as most neck of femur fractures are secondary to osteoporosis. The presence of osteoporosis and subsequent widened femoral canal may compromise the mechanical stability of uncemented femoral stems and result in early subsidence, which can lead to altered leg length and decreased hip stability. The aim of this study was to assess whether early subsidence occurred when collarless uncemented stems were used to treat patients with fractures of the neck of femur. Post-operative radiographs of 33 patients, mean age 71, who underwent an uncemented collarless total hip replacement for a fracture, were reviewed. The distance from the calcar to the tip of the prosthesis was measured for each patient on the initial post operative radiograph and again on the follow-up radiograph at 6 months post operation. Any subsidence was recorded and magnification for each radiograph was calculated by measuring the diameter of the femoral head, which was known to be 36mm. Distances were then adjusted for magnification. The same procedure was performed on 36 age-matched patients, mean age 71, who underwent elective uncemented total hip replacements for osteoarthritis. Hospital notes for each patient were reviewed to assess for complications and DEXA scan results for trauma patients were also evaluated where available. The mean femoral stem subsidence was significantly greater in the fracture cohort than in elective patients (p = 0.001) with mean subsidence of 4.07mm (range 0.02–18.5mm) and 1.57mm (range 0–5.5mm) respectively. In the fracture cohort there were 3 revisions within 6 months of surgery, 1 for infection and 2 for femoral stem subsidence leading to dislocation. There were no revisions in the elective cohort. DEXA scan results were available for 21 of the 33 fracture cohort patients. All these patients had abnormal bone density with 52% being osteoporotic and 48% osteopenic. This study showed that collarless uncemented stems subsided significantly when performed for fractures and had a high early revision rate. We therefore recommend that cemented or collared femoral stems be used in patients with femoral neck fractures requiring total hip replacement to reduce the risk of femoral stem subsidence

We undertook a prospective, controlled trial which compared two rehabilitation programmes for 86 patients who sustained two-part fractures of the proximal humerus. Patients were randomised either to receive immediate physiotherapy within one week (group A) or delayed physiotherapy after three weeks of immobilisation in a collar and cuff sling (group B). At 16 weeks after the fracture, patients in group A had less pain (p < 0.01) and had greater shoulder function (p < 0.001) than those in group B. At 52 weeks, the differences between the groups had reduced. Although group A still had greater shoulder function and less pain, there was no statistical difference when compared with group B. By analysis of the area under the curve, an overall measure up to the 52-week period, group A experienced less pain as measured by the SF36 general health questionnaire and had improved shoulder function. Our results show that patients with two-part fractures of the proximal humerus who begin immediate physiotherapy, experience less pain. The gains in shoulder function persist at 52 weeks which suggests that patients do not benefit from immobilisation before beginning physiotherapy

Aims

To clarify the effectiveness of the induced membrane technique (IMT) using beta-tricalcium phosphate (β-TCP) for reconstruction of segmental bone defects by evaluating clinical and radiological outcomes, and the effect of defect size and operated site on surgical outcomes.

Aims

The Edinburgh Trauma Triage Clinic (TTC) streamlines outpatient care through consultant-led ‘virtual’ triage of referrals and the direct discharge of minor fractures from the Emergency Department. We compared the patient outcomes for simple fractures of the radial head, little finger metacarpal, and fifth metatarsal before and after the implementation of the TTC.

Aims

The aim of this prospective randomised controlled trial was to compare non-operative and operative management for acute isolated displaced fractures of the olecranon in patients aged ≥ 75 years.

The National Institute for Health and Clinical Excellence (NICE) guidelines from 2011 recommend the use of cemented hemi-arthroplasty for appropriate patients with an intracapsular hip fracture. In our institution all patients who were admitted with an intracapsular hip fracture and were suitable for a hemi-arthroplasty between April 2010 and July 2012 received an uncemented prosthesis according to our established departmental routine practice. A retrospective analysis of outcome was performed to establish whether the continued use of an uncemented stem was justified. Patient, surgical and outcome data were collected on the National Hip Fracture database. A total of 306 patients received a Cathcart modular head on a Corail uncemented stem as a hemi-arthroplasty. The mean age of the patients was 83.3 years (sd 7.56; 46.6 to 94) and 216 (70.6%) were women. The mortality rate at 30 days was 5.8%. A total of 46.5% of patients returned to their own home by 30 days, which increased to 73.2% by 120 days. The implant used as a hemi-arthroplasty for intracapsular hip fracture provided satisfactory results, with a good rate of return to pre-injury place of residence and an acceptable mortality rate. Surgery should be performed by those who are familiar with the design of the stem and understand what is required for successful implantation.

Cite this article: Bone Joint J 2013;95-B:1538–43.

Aims

The Intraosseous Transcutaneous Amputation Prosthesis (ITAP) may improve quality of life for amputees by avoiding soft-tissue complications associated with socket prostheses and by improving sensory feedback and function. It relies on the formation of a seal between the soft tissues and the implant and currently has a flange with drilled holes to promote dermal attachment. Despite this, infection remains a significant risk. This study explored alternative strategies to enhance soft-tissue integration.

Aims

Periprosthetic femoral fractures (PFF) following total hip arthroplasty (THA) are devastating complications that are associated with functional limitations and increased overall mortality. Although cementless implants have been associated with an increased risk of PFF, the precise contribution of implant geometry and design on the risk of both intra-operative and post-operative PFF remains poorly investigated. A systematic review was performed to aggregate all of the PFF literature with specific attention to the femoral implant used.

Aims

This study identifies early risk factors for symptomatic nonunion of displaced midshaft fractures of the clavicle that aid identification of an at risk group who may benefit from surgery.

Endoprosthetic replacement of the proximal femur may be required to treat primary bone tumours or destructive metastases either with impending or established pathological fracture. Modular prostheses are available off the shelf and can be adapted to most reconstructive situations for this purpose. We have assessed the clinical and functional outcome of using the METS (Stanmore Implants Worldwide) modular tumour prosthesis to reconstruct the proximal femur in 100 consecutive patients between 2001 and 2006. We compared the results with the published series for patients managed with modular and custom-made endoprosthetic replacements for the same conditions.

There were 52 males and 48 females with a mean age of 56.3 years (16 to 84) and a mean follow-up of 24.6 months (0 to 60). In 65 patients the procedure was undertaken for metastases, in 25 for a primary bone tumour, and in ten for other malignant conditions. A total of 46 patients presented with a pathological fracture, and 19 presented with failed fixation of a previous pathological fracture. The overall patient survival was 63.6% at one year and 23.1% at five years, and was significantly better for patients with a primary bone tumour than for those with metastatic tumour (82.3% vs 53.3%, respectively at one year (p = 0.003)). There were six early dislocations of which five could be treated by closed reduction. No patient needed revision surgery for dislocation. Revision surgery was required by six (6%) patients, five for pain caused by acetabular wear and one for tumour progression. Amputation was needed in four patients for local recurrence or infection.

The estimated five-year implant survival with revision as the endpoint was 90.7%. The mean Toronto Extremity Salvage score was 61% (51% to 95%). The implant survival and complications resulting from the use of the modular system were comparable to the published series of both custom-made and other modular proximal femoral implants.

We conclude that at intermediate follow-up the modular tumour prosthesis for proximal femur replacement provides versatility, a low incidence of implant-related complications and acceptable function for patients with metastatic tumours, pathological fractures and failed fixation of the proximal femur. It also functions as well as a custom-made endoprosthetic replacement.

The optimal method for the management of neglected traumatic bifacetal dislocation of the subaxial cervical spine has not been established. We treated four patients in whom the mean delay between injury and presentation was four months (1 to 5). There were two dislocations at the C5-6 level and one each at C4-5 and C3-4. The mean age of the patients was 48.2 years (27 to 60). Each patient presented with neck pain and restricted movement of the cervical spine. Three of the four had a myelopathy.

We carried out a two-stage procedure under the same anaesthetic. First, a posterior soft-tissue release and partial facetectomy were undertaken. This allowed partial reduction of the dislocation which was then supplemented by interspinous wiring and corticocancellous graft. Next, through an anterior approach, discectomy, tricortical bone grafting and anterior cervical plating were carried out.

All the patients achieved a nearly anatomical reduction and sagittal alignment. The mean follow-up was 2.6 years (1 to 4). The myelopathy settled completely in the three patients who had a pre-operative neurological deficit. There was no graft dislodgement or graft-related problems. Bony fusion occurred in all patients and a satisfactory reduction was maintained.

The posteroanterior procedure for neglected traumatic bifacetal dislocation of the subaxial cervical spine is a good method of achieving sagittal alignment with less risk of iatrogenic neurological injury, a reduced operating time, decreased blood loss, and a shorter hospital stay compared with other procedures.

There have been many advances in the resuscitation and early management of patients with severe injuries during the last decade. These have come about as a result of the reorganisation of civilian trauma services in countries such as Germany, Australia and the United States, where the development of trauma systems has allowed a concentration of expertise and research. The continuing conflicts in the Middle East have also generated a significant increase in expertise in the management of severe injuries, and soldiers now survive injuries that would have been fatal in previous wars. This military experience is being translated into civilian practice.

The aim of this paper is to give orthopaedic surgeons a practical, evidence-based guide to the current management of patients with severe, multiple injuries. It must be emphasised that this depends upon the expertise, experience and facilities available within the local health-care system, and that the proposed guidelines will inevitably have to be adapted to suit the local resources.

A single antegrade Rush nail was used to treat 37 fractures of the distal humerus extending to the olecranon fossa and up to 6.5 cm proximal to it. In order to stabilise the fracture, the bent tip of the Rush nail was directed into the lateral epicondylar ridge. This gave immediate stability. All the fractures united without residual stiffness of the shoulder or elbow.

We have reviewed our experience in managing 11 patients who sustained an indirect sternal fracture in combination with an upper thoracic spinal injury between 2003 and 2006. These fractures have previously been described as ‘associated’ fractures, but since the upper thorax is an anatomical entity composed of the upper thoracic spine, ribs and sternum joined together, we feel that the term ‘fractures of the upper transthoracic cage’ is a better description. These injuries are a challenge because they are unusual and easily overlooked. They require a systematic clinical and radiological examination to identify both lesions. This high-energy trauma gives severe devastating concomitant injuries and CT with contrast and reconstruction is essential after resuscitation to confirm the presence of all the lesions. The injury level occurs principally at T4–T5 and at the manubriosternal joint. These unstable fractures need early posterior stabilisation and fusion or, if treated conservatively, a very close follow-up.