Aims . To analyse the influence of upper extremity trauma on the long-term outcome of polytraumatised patients. . Patients and Methods. A total of 629 multiply injured patients were included in a follow-up study at least ten years after injury (mean age 26.5 years, standard deviation 12.4). The extent of the patients’ injury was classified using the Injury Severity Score. Outcome was measured using the Hannover Score for Polytrauma Outcome (HASPOC), Short Form (SF)-12, rehabilitation duration, and employment status. Outcomes for patients with and without a fracture of the upper extremity were compared and analysed with regard to specific fracture regions and any additional brachial plexus lesion. Results. In all, 307 multiply-injured patients with and 322 without upper extremity injuries were included in the study. The groups with and without upper limb injuries were similar with respect to demographic data and injury pattern, except for midface trauma. There were no significant differences in the long-term outcome. In patients with brachial plexus lesions there were significantly more who were unemployed, required greater retraining and a worse HASPOC. Conclusion. Injuries to the upper extremities seem to have limited effect on long-term outcome in patients with polytrauma, as long as no injury was caused to the brachial plexus. Cite this article: Bone Joint J 2017;99-B:255–60

Introduction. Lesions of the upper extremities, and especially of the hands, are the most common form of occupational injury in the agricultural and industrial sectors [1]. When the grip strength and the way of its development are relevant, it would be very useful to be able to rely on an instrumental procedure, in support of the clinical examination, for both clinical and legal purposes. The possibility of differentiating between healthy subjects and patients affected by disabilities of the upper extremities, using parameters based on force-time curves for handgrip tests, was investigated with the aim to obtain objective and comprehensive outcome, useful to support the clinical evaluation. Materials and Methods. The reference group consisted of 151 subjects examined for occupational trauma of the upper limbs, all with a dominant right arm, who had suffered an occupational injury. The 74% of the injuries affected the hand. A further 648 healthy people were enrolled as the control group. Grip strength was measured with an electronic dynamometer. The signals acquired with the dynamometer were subdivided into 5 characteristic phases [2]: first reaction, explosive contraction, isometric contraction, release and relaxation. The maximum force, the ratio between the maximum force exerted by the two arms and an index related to the explosive muscle power and the ability to maintain maximum voluntary contraction were calculated. Percentage variations of each parameter, as compared to a threshold value, were taken into account and an overall value (T) was calculated, representing the sum of these variations. Result and Discussion. This acquisition system was shown to be reliable and easy to use, and the test could be administered simply and fairly rapidly. The findings in the control group were comparable to those reported in the literature [3–4]. A negative value of T invariably identified a subject with a disability. By associating assessment of T with those of the specific indexes, other subjects with a clinical disability were identified. The use of the parameters we describe makes it possible not only to assess the maximum force of the handgrip but also how it is exerted and maintained, thus providing a more reliable method of differentiating between normal function and impairment and what it is more obtaining an objective and comprehensive outcome, which sensitivity is useful to support clinical evaluation. The proposed functional tests could offer the clinician a possible diagnostic aid, providing a method that can describe the motor skill on the basis of objective parameters. In view of its good sensitivity (0.99%) and specificity (0.84%), relatively rapid execution and the low cost of the tools, it could be usefully adopted in the clinical setting

Aims

This study aimed to investigate the clinical characteristics and outcomes associated with culture-negative limb osteomyelitis patients.

Introduction. Dedifferentiated chondrosarcoma (D.C.) has a very poor prognosis. The efficacy of chemotherapy is still debated. Aim of this study was to evaluate the survival of patients with D.C. and to evaluate possible prognostic factors. Methods. Between 1990 and 2006, 109 patients were treated for D.C.: 55 males and 54 females, mean age of 59.6 years. In 81 cases tumor was located in the extremities and in 28 cases in the trunk. The most frequent dedifferentiation was in osteosarcoma (53.2%) followed by spindle cell sarcoma (21%), malignant fibrous histiocytoma (13.8%), fibrosarcoma (6.4%). All patients received surgery and mostly, limb salvage with tumor resection and implantation of a megaprosthesis or allograft (65 patients). Chemotherapy was given to 43 patients. Results. 16 patients (15.5%) were Ned at a mean followup of 10 yrs, 8 patients Ned1 after treatment of relapse, 1 patient AWD at 4.7 yrs, 77 patients DWD at a mean time of 1.6 yrs, 1 patient dead for other causes and 6 patients lost to followup were excluded. The overall survival of patients was 15%. There was significant difference in survival between patientens with D.C. of the trunk and those with D.C. of the extremities (p=0.0156). There was no significant difference in survival with chemoterapy and surgery or with surgery only (p=0.1115). Conclusion. The prognosis for patients with D.C. remains dismal. Surgery with wide margins is the principal treatment for this condition. There was no statistical evidence of any beneficial effect from chemotherapy

Background. Ilizarov hip reconstruction is a salvage option traditionally done with fixators, which often face limited compliance. We aimed at reviewing our early results of a novel technique with internal devices. Material and Methods. Retrospective evaluation of 7 patients was done that underwent Milch Batchelor procedure with dual plates followed by a second stage femoral lengthening by retrograde magnetic nail. The mean patient age was 13.8 years. A mean valgus of 410 (range, 300 to 550) and extension of 220 (range, 100 to 300) were created proximally. Results. At their mean recent follow-up of 19 months, all extremities were aligned with a mean Pelvic Mechanical Axis Angle (PMAA) of 83.80 and lateral Mechanical Axis Deviation (MAD) of 25.3 mm. The mean Lower-extremity Length Discrepancy (LLD) improved from 3.7 cm (range, 3 to 5 cm) preoperatively to 0.7 cm (range, 0 to 2 cm). The Trendelenburg sign was eliminated in five and delayed in 2. According to a predesigned clinical scoring system, there were 3 (43%) excellent, 2 (28.5%) good, 2 (28.5%) fair, and no poor results. One patient at 9 weeks broke plates, however went for healing. Conclusion. PSHR with internal devices is a patient-friendly alternative to fixators

Introduction and objectives. Intramedullary nailing is indicated to stabilization of tibia shaft fractures. Intramedullary nailing through an infra-patellar incision is commonly the technique of choice. While intramedullary nailing of simple diaphyseal fracture patterns is relatively easy, proximal tibia fractures, extremely comminuted/segmental tibia fractures, politrauma with multiple fractures in both extremities and reconstruction of bone loss segment with stiffness of the knee joint can be very challenging to treat. A novel technique for intramedullary tibia nailing through the patella-femoral joint is described. This technique allow extension tibia during intervention time and it supplies easier reduction of the pattern of fracture above. The purpose of our investigation was to evaluate the use of this new technique in described above pattern fracture and patient situation; because we have thought that new technique can perform better outcomes in this situations. Materials and Methods. An observational study of tibia fractures or bone defect was performed for consecutive patients who presented: proximal tibia fractures, extremely comminuted/segmental tibia fractures, politrauma with multiple fractures in both extremities and reconstruction of bone loss segment in the Trauma unit of our institution from September 2009 to August 2010. A total of 32 were included in our study, which performed surgery intervention with Trigen tibia nail (Smith & Nephew, Memphis) with suprapatelar device. Demographic data, mechanism of injury, fracture classification, ROM (2 and 6 weeks, and 3 months), consolidation rate, reduction fracture quality and knee pain at 3 months were recorded. Results. Male was the gender most frequent (64%), the average age was 39,5 years and the main mechanism of injury was motor vehicle injury (30,6%). There were 7 proximal fractures, 1 bifocal fracture, 6 politrauma and 2 reconstruction bone loss segment, the others were comminuted and segmental tibia fracture. In all the patients, the fracture was consolidated between 8 to 14 weeks with average of 10,6 weeks. The quality of reduction was correct in all patients in different axis. The average of ROM at 2 weeks was (−2°/95°) at 3 months was (−0,4°/133°). The knee pain (VAS) average was 0,6 only in 2 patients were (4). Poller screw was used in 7 patients. Conclusion. The suprapatelar nailing is optimal technique to resolve complex fracture of the tibia (proximal, segmental conminution, politrauma) that perform correct consolidation rate without misalignment in the patients. Concerns about knee pain (VAS) from the technique not appear in our data. Prospective and clinical trials are needed to validate this approach

Background. Modular endoprostheses today represent a standard treatment option in the management of musculoskeletal tumors of the lower extremities. Long-term results of these reconstructions, however, are often limited by the course of the underlying disease. We therefore report our experiences in cancer patients with megaprostheses of the lower limb after a minimum of 15 years. Materials and Methods. 62 patients, 34 men and 28 women, with a mean age of 26 years (median, 20; range, 6–83) were included in this investigation with a mean follow-up of 230 months (median, 228; range, 180–342). Endoprosthetic reconstructions of the proximal femur (11), the distal femur (28), the total femur (2) or the proximal tibia (21) were indicated for osteosarcoma (43), chondrosarcoma (5), malignant fibrous histiocytoma (3) or other tumors (11). All patients have received either a KMFTR (22) or a HMRS (40) modular prosthesis; 23 patients had a muscle flap, 14 had a fibular transposition osteotomy and 4 have received an artificial LARS ligament for soft-tissue reconstruction. Results. 7 patients (11.3%) died throughout the follow-up period, but none succumbed to primary disease. One patient (1.6%) developed a local recurrence after 31 months that was resected. Overall, 56 patients (90.3%) underwent revision of their prosthesis; 50 (80.7%) had multiple revisions up to a maximum of 12 operations (mean, 3 per patient). The median overall prosthetic survival to first revision was 40 months; the corresponding 5-, 10- and 15-year survival rates were 35.5%, 14.5% and 12.9%, respectively. 3 patients (5.4%) had an infection, 8 (14.3%) had a soft-tissue related failure, 30 (53.6%) had a mechanical or structural failure and 15 (26.8%) had an aseptic loosening. The 15-year survival rates of these respective endpoints were 87.1% for infection, 79.0% for soft-tissue related failure, 32.3% for mechanical or structural failure and 56.5% for aseptic loosening. 59 patients (95.2%) have retained their prosthesis; 2 patients (3.2%) underwent secondary amputation due to an irresolvable complication, another one (1.6%) for a second malignancy. Conclusion. Modular prosthetic reconstructions of the lower extremities have a high revision rate in the long-term, primarily due to mechanical failures. Given that patients survive their malignant disease the rate of secondary implant removal, however, tends to be low, providing satisfactory function and body integrity. Further advances in implant design, soft tissue management and infection prophylaxis are required to reduce revision rates

Introduction. Displaced fractures in the sacrum are associated with other intra-pelvic organ injuries. There are some reports on short term outcome, however there is little knowledge about the long-term morbidity after these severe injuries. Aims of study. -. Describe neurologic deficits in the lower extremities and impairments involving the uro-genital, bowel and sexual functions a minimum of 8 years after injury. -. Compare the long-term results with our previously published results after one-year follow-up (1). Materials and methods. 39 consecutive patients with displaced sacral fractures were prospectively registered at Oslo university hospital, Ullevaal between 1996 and 2001. Tötterman et al. published 1-year results on 32 of the 39 patients(1). In the present study we followed 29 of these 32 patients for 8 years or more. The following evaluation instruments were used: Neurology: Sensorimotor function was classified according to ASIA score. Bladder function: Structured questionnaire with regards to frequency, urge or incontinence. Also, flowmetry and ultrasound were done to determine maximum flow and post-micturition volume. Bowel function: Structured questionnaire with regards to frequency, urge, diarrhea, constipation and incontinence. Sexual function: Open questions to address any problems associated with sexual function. For male patients, selected questions from the International Index of Erectile Function were used. For comparison with previous data from the one year follow-up we used the Wilcoxon Signed-rank test for non-parametric data. Results. Neurology: 26 patients had neurologic deficits in the lower extremities. Two patients were not testable and only 1 was asymptomatic. Bladder function: 5 had slightly changed, 11 significantly changed and 4 completely changed voiding pattern. Bowel function: 6 had slightly changed and 3 completely changed bowel pattern. Comparing our results with previous data showed deterioration in voiding function over time in 38%(p=0.005), improved bowel function in 28%(p=0.047) and no significant changes in neurological deficits (p=0.47). Sexual function: 45% reported sexual dysfunction versus 38% at the 1-year follow-up. Conclusion. Neurologic deficits, uro-genital and bowel dysfunction are frequent after displaced sacral fractures. Voiding and sexual problems deteriorated over time, while bowel function improved, and neurological deficits showed no significant changes. Pathologic bladder function may cause irreversible structural damage to the bladder, and subsequent impaired renal function. These problems should therefore be addressed early in the rehabilitation period and the patients must be followed by adequate expertise for many years after the injury

Purpose. Angular deformity in the lower extremities can result in pain, gait disturbance, cosmetic deformity and joint degeneration. Up until the introduction of guided growth in 2007, which has since become the gold standard, treatment for correcting angular deformities in skeletally immature patients had been either an osteotomy, a hemiepiphysiodesis, or the use of staples. Methods. We reviewed the surgical records and diagnostic imaging in our childrens hospital to identify all patients who had guided growth surgery since 2007. All patients were followed until skeletal maturity or until their metalwork was removed. Results. 113 patients, with 147 legs were assessed for eligibility. Three were excluded for various reasons including inadequate follow-up or loss of records. Of the 144 treated legs which met the criteria for final assessment 32 (22.2%) were unsuccessful, the other 112 (77.8%) were deemed successful at final follow up. Complications were few, but included infection in one case and metal failure in another. Those with a pre-treatment diagnosis of idiopathic genu valgum/genu varum had a success rate of 83.6%. Conclusions. In our hands, guided growth had a seventy-eight percent success rate when all diagnosis were considered. Those procedures that were unlikely to be successful included growth disturbances due to mucopolysaccharide storage disease (28% failure rate), Blounts disease (66.6% failure rate) and achondroplasia (37.5% failure rate). If you exclude those three diagnoses, success rate for all other conditions was 81.4%. We continue to advocate the use of guided growth as a successful treatment option for skeletally immature patients with limb deformity

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.

Objective. Ankle fractures are frequent and seem to be easy to handle in most cases. Of course, also these easy fractures can cause infections that must be carefully managed. What risk factors do we find? What options do we have in treating these complications? What are the consequences and what will the result for the patient be like, compared to non-infected cases?. In a retrospective study we included 82 patients treated with an osteosynthesis in ankle fractures (AO 44 B or C fractures). Average age was 52.4 years (range 20–84 years, median 51.0). Results. In 9 (10.9%) patients there were septic complications. Concerning risk factors, we found 4 (44.4%) patients with nicotine abuse, 2 (22.2%) with additional alcohol abuse. Average stay in hospital was 39.6 days (range 9–95 days). In 4 (44.4%) cases local infection was treated with antibiotics and rest alone. 5 (55.5%) of the patients had additional operations due to infection, in average 5.4 per patient (range 1–10). Early implant removal was done in 3 (33.3%) cases, in average after 3 months. We found 2 (22.2%) infections due to Staphylococcus aureus, 1 (11.1%) due to MRSA and one infection with MRSA and Proteus mirabilis. In one case vacuum dressing had been applied for 44 days. In another case infection could only be healed with an intramedullary vancomycin augmented spacer and finally a screw arthodesis of the ankle, this was a patient with proven arteriosclerosis of the lower extremities. All other fractures finally showed bony healing in xrays. No plastic surgery (e.g. flaps) was needed to close a wound definitely. In follow up (in average after 33 months, range 17–42), the average AOFAS of these patients was 76.5 (range 35–100, median 81.5), compared to an average AOFAS of 89.4 (range 35–100, median 98.0) of all patients. No patient developed a septic syndrom, no ICU stay occurred because of the infection. Conclusions. In spite of most cases of ankle fractures having good outcomes without complications, once infected an ankle osteosynthesis can be a serious problem for both surgeon and patient. Consequent surgical therapy at the right time including early hardware removal, spacers or vacuum dressing if necessary as well as an antibiotic regime addressing problematic pathogens like MRSA are needed to control infections. Problems remaining are functional outcome and wound closure in this sensitive area. Plastic surgery might be needed

Introduction. An important number of factors affecting the outcome of surgical treatment have been identified, and these factors can affect the patient's selection for lumbar surgery. Study Design. Retrospective study with data collected prospectively on patients undergoing surgery for degenerative lumbar pathology (DLP). Purpose. Identification and evaluation of epidemiological factors that influence the quality of life improvement, disability and chronic pain. Outcome measures. Visual Analogue Scale (VAS) to assess pain in lower back and extremities, Short Form-36v2 (SF-36), Oswestry Disability Index (ODI) and Core Outcome Measures Index (COMI). Method. 263 patients were included in our study, with a mean age of 54.0 years (22–86 years). 131 patients were women (49.8%). Questionnaires were completed in the preoperative visit and 2 years after surgery. Epidemiological data collected were age, sex, educational level, employment status, diagnosis, treatment, and comorbidity measure by ASA. The most frequent diagnostics were degenerative discal disease (36,5%) and lumbar stenosis (30,4%) and a main surgical treatment was TLIF (31,9 %). To compare means we used t-Student and Pearson's coefficient or Spearman's test was used to assess the correlation, and, finally, linear regression study (ANOVA) was performed with variables that showed statistically significant correlation. SPSS 15.0 statistical package. Results. Sex and employment status was correlated with the improvement of COMI (r=− 0.257, p <0.05, r=0.272, p <0.05). Employment status was correlated with in ODI (r=0.249, p <0.05) and the degree of improvement physical component of SF-36 (PCS, r=− 0.254, p <0.05). Linear regression showed statistically significant influence of the age (r=0.334, p <0.05) and employment status (r=14.146, p <0.01) on ODI. COMI is statistically influenced by sex (r=− 0.869, p <0.01), age (r=0.027, p <0.05) and employment status (r=0.830, p <0.05). PCS is statistically influenced by the employment status (r=− 8.568, p <0.01), age (r=− 0.228, p <0.05) and sex (r=5.525, p <0.05). Conclusions. According to the present study we observed that the perception of change in the quality of life and disability after surgery of the lumbar spine is independent of the initial pathology, the type of surgery and previous pain and disability; but sex, age and employment status have an important influence

Introduction. Patellar tracking in total knee replacements has been extensively studied, but little is known about patellar tracking in isolated patellofemoral replacements. We compared patellar tracking and the position of the patellar groove in the natural knee, followed by implantation of the femoral component of a PFR (patella unresurfaced) and after implantation of the femoral & patellar component of the PFR. Methods. Computer navigation was used to track the patella in eight whole lower extremities of four cadavers in the natural knee, in the same knee with the femoral component of the PFR (PFR-P) and with the femoral and patellar component of the PFR (PFR+P, patella resurfaced) (Depuy Sigma PFR). The form and position of the trochlea in the natural knee and the patellar groove of the femoral component was also analysed. Values are means+/−SD, two tailed Student's t-test for paired samples. Results. With a PFR-P the patella had a slightly more lateral tilt (0.8+/−0.8° to 2.8+/−2.5° at 40–100° of flexion, p<0.05 vs. Nat), this was more pronounced with the PFR+P (2.0+/−0.7° to 4.9+/−1.8° at 20–90° flexion, p<0.05 vs. Nat., p<0.05 vs. PFR-P at 20–80° flexion). No differences in patella rotation were seen between the three groups. In the PFR-P group the patella tracked a little more medially compared to the natural knee (0.6+/− 0.7mm to 1.3+/−2.6mm, p<0.05 at 20°,80°,90° flexion). The difference was more pronounced after patella resurfacing (PFR+P) (2.1+/−2.0mm to 3.0+/−2.2mm, p<0.05 vs. Nat. at 10°–100°, p<0.05 vs. PFR-P from 10–100°). When analysed relative to the patellar groove of the trochlea/femoral component the patella in the natural knee tracked slightly lateral to the groove (2.0+/−1.7mm to 2.9+/−2.0mm at 50–100° p<0.05), so did the patella of PFR-P (2.0+/−2.3mm to 2.3+/−2.3mm at 60–90° flexion, p<0.05), whilst the PFR+P tracked right on the groove (0.6+/−3.7mm medially to 0.6+/−2.9mm laterally, p<0.05 vs Nat at 10–30° & 70–100°, p<0.05 vs. PFR-P at 10–100°). Distance from the patellatot the epicondylar axis was slightly larger in the PFR-P group (0.6+/− 0.7mm to 1.3+/−1.4mm, p<0.05 vs. Natu at 20,80 & 90°. This was more pronounced with patellar resurfacing (2.1+/−2.0 to 3.0+/−2.2mm, p<0.05 vs. Nat at 10–100°, p<0.05 vs. PFR-P at 20–100°) The patella groove on the natural knee and the implanted femoral component of the implanted PFR had the same radius, inclination relative to the femoral mechanical axis, antero-posterior position and medio-lateral orientation. As intended by the designers the groove of the patellar component extended about 13mm further superiorly and 0.5mm more inferiorly. Discussion. The patella groove on the femoral component of the PFR reproduces the natural trochlear anatomy well. Patella tracking in the PFR-P shows only minor differences compared to the natural knee. Resurfacing of the patella in the PFR+P group causes the patella to tilt a little more laterally and track a little more medially, the distance to the epicondylar axis is slightly larger but this allows the patella to engage better in the patellar groove of the femoral component

Aims

This study aimed to analyze the correlation between transverse process (TP) fractures of the fourth (L4) and fifth (L5) lumbar vertebrae and biomechanical and haemodynamic stability in patients with a pelvic ring injury, since previous data are inconsistent.

Aims

We compared the accuracy, operating time and radiation exposure of the introduction of iliosacral screws using O-arm/Stealth Navigation and standard fluoroscopy.

This is a retrospective study of survivors of recent conflicts with an open fracture of the femur. We analysed the records of 48 patients (48 fractures) and assessed the outcome. The median follow up for 47 patients (98%) was 37 months (interquartile range 19 to 53); 31 (66%) achieved union; 16 (34%) had a revision procedure, two of which were transfemoral amputation (4%).

The New Injury Severity Score, the method of fixation, infection and the requirement for soft-tissue cover were not associated with a poor outcome. The degree of bone loss was strongly associated with a poor outcome (p = 0.00204). A total of four patients developed an infection; two with S. aureus, one with E. coli and one with A. baumannii.

This study shows that, compared with historical experience, outcomes after open fractures of the femur sustained on the battlefield are good, with no mortality and low rates of infection and late amputation. The degree of bone loss is closely associated with a poor outcome.

Cite this article: Bone Joint J 2015;97-B:842–6.

The types of explosive devices used in warfare and the pattern of war wounds have changed in recent years. There has, for instance, been a considerable increase in high amputation of the lower limb and unsalvageable leg injuries combined with pelvic trauma.

The conflicts in Iraq and Afghanistan prompted the Department of Military Surgery and Trauma in the United Kingdom to establish working groups to promote the development of best practice and act as a focus for research.

In this review, we present lessons learnt in the initial care of military personnel sustaining major orthopaedic trauma in the Middle East.

Injuries to the limb are the most frequent cause of permanent disability following combat wounds. We reviewed the medical records of 450 soldiers to determine the type of upper limb nerve injuries sustained, the rate of remaining motor and sensory deficits at final follow-up, and the type of Army disability ratings granted. Of 189 soldiers with an injury of the upper limb, 70 had nerve-related trauma. There were 62 men and eight women with a mean age of 25 years (18 to 49). Disabilities due to nerve injuries were associated with loss of function, neuropathic pain or both. The mean nerve-related disability was 26% (0% to 70%), accounting for over one-half of this cohort’s cumulative disability. Patients injured in an explosion had higher disability ratings than those injured by gunshot. The ulnar nerve was most commonly injured, but most disability was associated with radial nerve trauma. In terms of the final outcome, at military discharge 59 subjects (84%) experienced persistent weakness, 48 (69%) had a persistent sensory deficit and 17 (24%) experienced chronic pain from scar-related or neuropathic pain. Nerve injury was the cause of frequent and substantial disability in our cohort of wounded soldiers.

Cite this article: Bone Joint J 2014;96-B:254–8.

Patients with transfemoral amputation (TFA) often experience problems related to the use of socket-suspended prostheses. The clinical development of osseointegrated percutaneous prostheses for patients with a TFA started in 1990, based on the long-term successful results of osseointegrated dental implants.

Between1999 and 2007, 51 patients with 55 TFAs were consecutively enrolled in a prospective, single-centre non-randomised study and followed for two years. The indication for amputation was trauma in 33 patients (65%) and tumour in 12 (24%). A two-stage surgical procedure was used to introduce a percutaneous implant to which an external amputation prosthesis was attached. The assessment of outcome included the use of two self-report questionnaires, the Questionnaire for Persons with a Transfemoral Amputation (Q-TFA) and the Short-Form (SF)-36.

The cumulative survival at two years’ follow-up was 92%. The Q-TFA showed improved prosthetic use, mobility, global situation and fewer problems (all p < 0.001). The physical function SF-36 scores were also improved (p < 0.001). Superficial infection was the most frequent complication, occurring 41 times in 28 patients (rate of infection 54.9%). Most were treated effectively with oral antibiotics. The implant was removed in four patients because of loosening (three aseptic, one infection).

Osseointegrated percutaneous implants constitute a novel form of treatment for patients with TFA. The high cumulative survival rate at two years (92%) combined with enhanced prosthetic use and mobility, fewer problems and improved quality of life, supports the ‘revolutionary change’ that patients with TFA have reported following treatment with osseointegrated percutaneous prostheses.

Cite this article: Bone Joint J 2014;96-B:106–13.

Gunshot injuries to the shoulder are rare and difficult to manage. We present a case series of seven patients who sustained a severe shoulder injury to the non-dominant side as a result of a self-inflicted gunshot wound. We describe the injury as ‘suicide shoulder’ caused by upward and outward movement of the gun barrel as the trigger is pulled. All patients were male, with a mean age of 32 years (21 to 48). All were treated at the time of injury with initial repeated debridement, and within four weeks either by hemiarthroplasty (four patients) or arthrodesis (three patients). The hemiarthroplasty failed in one patient after 20 years due to infection and an arthrodesis was attempted, which also failed due to infection. Overall follow-up was for a mean of 26 months (12 to 44). All four hemiarthroplasty implants were removed with no feasible reconstruction ultimately possible, resulting in a poor functional outcome and no return to work. In contrast, all three primary arthrodeses eventually united, with two patients requiring revision plating and grafting. These patients returned to work with a good functional outcome. We recommend arthrodesis rather than replacement as the treatment of choice for this challenging injury.

Cite this article: Bone Joint J 2013;95-B:820–4.