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The Bone & Joint Journal
Vol. 100-B, Issue 5 | Pages 634 - 639
1 May 2018
Davda K Heidari N Calder P Goodier D

Aims. The management of a significant bony defect following excision of a diaphyseal atrophic femoral nonunion remains a challenge. We present the outcomes using a combined technique of acute femoral shortening, stabilized with a long retrograde intramedullary nail, accompanied by bifocal osteotomy compression and distraction osteogenesis with a temporary monolateral fixator. Patients and Methods. Eight men and two women underwent the ‘rail and nail’ technique between 2008 and 2016. Proximal locking of the nail and removal of the external fixator was undertaken once the length of the femur had been restored and prior to full consolidation of the regenerate. Results. The mean lengthening was 7 cm (3 to 11). The external fixator was removed at a mean of 127 days (57 to 220). The mean bone healing index was 28 days/cm and the mean external fixation index was 20 days/cm (11 to 18). There were no superficial or deep infections. Conclusion. This small retrospective study shows encouraging results for a combined technique, enabling compression of the femoral osteotomy, alignment, and controlled lengthening. Removal of the fixator and proximal locking of the nail reduces the risk of complications and stabilizes the femur with the maximum working length of the nail. Cite this article: Bone Joint J 2018;100-B:634–9


Orthopaedic Proceedings
Vol. 99-B, Issue SUPP_13 | Pages 4 - 4
1 Jun 2017
Davda K Wright S Heidari N Calder P Goodier W
Full Access

Introduction

The management of a significant bone defect following excision of a diaphyseal atrophic femoral non-union remains a challenge. Traditional bone transport techniques require prolonged use of an external fixator with associated complications. We present our clinical outcomes using a combined technique of acute femoral shortening, stabilised with a deliberately long retrograde intramedullary nail, accompanied by bifocal osteotomy compression and distraction osteogenesis to restore segment length utilising a temporary monolateral fixator.

Method

9 patients underwent the ‘rail and nail’ technique for the management of femoral non-union. Distraction osteogenesis was commenced on the 6th post-operative day. Proximal locking of the nail and removal of the external fixator was performed approximately one month after length had been restored. Full weight bearing and joint rehabilitation was encouraged throughout. Consolidation was defined by the appearance of 3 from 4 cortices of regenerate on radiographs.


The Journal of Bone & Joint Surgery British Volume
Vol. 94-B, Issue 3 | Pages 398 - 404
1 Mar 2012
Seide K Aljudaibi M Weinrich N Kowald B Jürgens C Müller J Faschingbauer M

In an interdisciplinary project involving electronic engineers and clinicians, a telemetric system was developed to measure the bending load in a titanium internal femoral fixator. As this was a new device, the main question posed was: what clinically relevant information could be drawn from its application? As a first clinical investigation, 27 patients (24 men, three women) with a mean age of 38.4 years (19 to 66) with femoral nonunions were treated using the system. The mean duration of the nonunion was 15.4 months (5 to 69). The elasticity of the plate-callus system was measured telemetrically until union. Conventional radiographs and a CT scan at 12 weeks were performed routinely, and healing was staged according to the CT scans. All nonunions healed at a mean of 21.5 weeks (13 to 37). Well before any radiological signs of healing could be detected, a substantial decrease in elasticity was recorded. The relative elasticity decreased to 50% at a mean of 7.8 weeks (3.5 to 13) and to 10% at a mean of 19.3 weeks (4.5 to 37). At 12 weeks the mean relative elasticity was 28.1% (0% to 56%). The relative elasticity was significantly different between the different healing stages as determined by the CT scans. Incorporating load measuring electronics into implants is a promising option for the assessment of bone healing. Future application might lead to a reduction in the need for exposure to ionising radiation to monitor fracture healing


The Journal of Bone & Joint Surgery British Volume
Vol. 88-B, Issue 7 | Pages 928 - 932
1 Jul 2006
Patil S Montgomery R

We reviewed 78 femoral and tibial nonunions treated between January 1992 and December 2003. Of these, we classified 41 in 40 patients as complex cases because of infection (22), bone loss (6) or failed previous surgery (13). The complex cases were all treated with Ilizarov frames. At a mean time of 14.1 months (4 to 38), 39 had healed successfully.

Using the Association for the Study and Application of the Methods of Ilizarov scoring system we obtained 17 excellent, 14 good, four fair and six poor bone results. The functional results were excellent in 14 patients, good in 14, fair in two and poor in two. A total of six patients were lost to follow-up and two had amputations so were not evaluated for final functional assessment. All but two patients were very satisfied with the results. The average cost of treatment to the treating hospital was approximately £30 000 per patient.

We suggest that early referral to a tertiary centre could reduce the morbidity and prolonged time off work for these patients. The results justify the expense, but the National Health Service needs to make financial provision for the reconstruction of this type of complex nonunion.


Orthopaedic Proceedings
Vol. 88-B, Issue SUPP_I | Pages 159 - 159
1 Mar 2006
Micic I Mitkovic M Mladenovic D Golubovic Z Milenkovic S Stojiljkovic P
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The paper present our results in application of new method for nonunion treatment of the femoral diaphysis.

The internal fixator has been applied with 36 patients. Bone graft substitution is used with 11 (30,5%) patients. The method of placement and results of the work according to the modified system of the Karlstrom-Olerud method have been presented. Excellent condition was found with 25 (69,4%) patients, satisfactory with 8 (22,2%) and poor with 3 (8,3%) patients. Average healing time is 57 weeks.

The method in which the internal fixator is applied provides complete stability of the nonunion and makes possible spontaneous-biological dinamization of the nonunion. It doesn’t damage the periosteal and medullary bone vascularization which favors healing process.


Orthopaedic Proceedings
Vol. 98-B, Issue SUPP_20 | Pages 54 - 54
1 Nov 2016
Birch C Blankstein M Bartlett C
Full Access

Periprosthetic femoral shaft fractures are a significant complication of total hip arthroplasty. Plate osteosynthesis with or without onlay strut allograft has been the mainstay of treatment around well-fixed stems. Nonunions are a rare, challenging complication of this fixation method. The number of published treatment strategies for periprosthetic femoral nonunions are limited. In this series, we report the outcomes of a novel orthogonal plating surgical technique for addressing nonunions in the setting of Vancouver B1 and C-type periprosthetic fractures that previously failed open reduction internal fixation (ORIF). A retrospective chart review of all patients from 2010 to 2014 with Vancouver B1/C total hip arthroplasty periprosthetic femoral nonunions was performed. All patients were treated primarily with ORIF. Nonunion was defined as no radiographic signs of fracture healing nine months post-operatively, with or without hardware failure. Exclusion criteria included open fractures and periprosthetic infections. The technique utilised a mechanobiologic strategy of atraumatic exposure, resection of necrotic tissue, bone grafting with adjuvant recombinant growth factor and revision open reduction internal fixation. Initially, compression was achieved using an articulated tensioning device and application of an anterior plate. This was followed by locked lateral plating. Patients remained non-weight bearing for eight weeks. Six Vancouver B1/C periprosthetic femoral nonunions were treated. Five patients were female with an average age of 80.3 years (range 72–91). The fractures occurred at a mean of 5.8 years (range 1–10) from their initial arthroplasty procedure. No patients underwent further revision surgery; there were no wound dehiscence, hardware failures, infections, or surgical complications. All patients had a minimum of nine months follow up (mean 16.6, range 9–36). All fractures achieved osseous union, defined as solid bridging callus over at least two cortices and pain free, independent ambulation, at an average of 24.4 weeks (range 6.1–39.7 weeks). To our knowledge, this is the first case series describing 90–90 locked compression plating using modern implants for periprosthetic femoral nonunions. This is a rare but challenging complication of total hip arthroplasty and we present a novel solution with satisfactory preliminary outcomes. Orthogonal locked compression plating utilising an articulated tensioning device and autograft with adjuvant osteoinductive allograft should be considered in periprosthetic femur fractures around a well-fixed stem. Further biomechanical and clinical research is needed to improve our treatment strategies in this population


Orthopaedic Proceedings
Vol. 92-B, Issue SUPP_III | Pages 403 - 403
1 Jul 2010
Banks J Panchanni S Davies B Widnall J Giotakis N Narayan B Nayagam S
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Introduction: The treatment of femoral nonunions remains challenging despite modern surgical techniques and adjuncts to fracture healing. We present a series of 14 patients in whom a bifocal treatment technique has been used in order to achieve bony union and correct limb length. Methods: Patients were identified from theatre records and their hospital notes and x-rays were retrospectively reviewed. All patients underwent bifocal treatment for femoral nonunions – debridement and internal fixation (single or double plating) of the nonunion and lengthening at the opposite end of the bone to correct limb length discrepancy. Initially the procedures were staged, with treatment of the non-union then subsequent lengthening. However, our technique has evolved to perform all procedures in a single stage. All lengthening procedures were done with a monolateral (Orthofix LRS) fixator. Results: 11 patients had distal and 3 proximal femoral nonunions. 13 patients were male and 1 female. The non-union united with the index procedure in 13 patients, 1 is still undergoing treatment. Limb length discrepancy range 2–5 cm was fully corrected in all patients with no axial deviation of the regenerate. There were no pin site problems. Discussion: Femoral nonunions are challenging due to multiple previous procedures, insecure grip on the smaller fragment and bone loss. Successful union can be achieved by ORIF with bone grafting, but this does not restore length. Treatment by the Ilizarov method alone is associated with significant morbidity, particularly knee stiffness. A bifocal strategy provides stable internal fixation of the non-union to allow bone healing, and any consequent loss of length is safely restored. We believe this to be a safe and effective technique to treat femoral nonunions


The Journal of Bone & Joint Surgery British Volume
Vol. 92-B, Issue 4 | Pages 565 - 570
1 Apr 2010
Blum ALL Bongiovanni JC Morgan SJ Flierl MA dos Reis FB

We undertook a retrospective study of 50 consecutive patients (41 male, 9 female) with an infected nonunion and bone defect of the femoral shaft who had been treated by radical debridement and distraction osteogenesis. Their mean age was 29.9 years (9 to 58) and they had a mean of 3.8 (2 to 19) previous operations. They were followed for a mean of 5.9 years (2.0 to 19.0). The mean duration of the distraction osteogenesis was 24.5 months (2 to 39). Pin-track infection was observed in all patients. The range of knee movement was reduced and there was a mean residual leg-length discrepancy of 1.9 cm (0 to 8) after treatment. One patient required hip disarticulation to manage intractable sepsis. In all, 13 patients had persistant pain. Bony union was achieved in 49 patients at a mean of 20.7 months (12 to 35). Although distraction osteogenesis is commonly used for the treatment of infected femoral nonunion with bone defects, it is associated with a high rate of complications


The Bone & Joint Journal
Vol. 105-B, Issue 8 | Pages 888 - 894
1 Aug 2023
Murray J Jeyapalan R Davies M Sheehan C Petrie M Harrison T

Aims

Total femoral arthroplasty (TFA) is a rare procedure used in cases of significant femoral bone loss, commonly from cancer, infection, and trauma. Low patient numbers have resulted in limited published work on long-term outcomes, and even less regarding TFA undertaken for non-oncological indications. The aim of this study was to evaluate the long-term clinical outcomes of all TFAs in our unit.

Methods

Data were collected retrospectively from a large tertiary referral revision arthroplasty unit’s database. Inclusion criteria included all patients who underwent TFA in our unit. Preoperative demographics, operative factors, and short- and long-term outcomes were collected for analysis. Outcome was defined using the Musculoskeletal Infection Society (MSIS) outcome reporting tool.


Bone & Joint Research
Vol. 11, Issue 8 | Pages 541 - 547
17 Aug 2022
Walter N Hierl K Brochhausen C Alt V Rupp M

Aims

This observational cross-sectional study aimed to answer the following questions: 1) how has nonunion incidence developed from 2009 to 2019 in a nationwide cohort; 2) what is the age and sex distribution of nonunions for distinct anatomical nonunion localizations; and 3) how high were the costs for surgical nonunion treatment in a level 1 trauma centre in Germany?

Methods

Data consisting of annual International Classification of Diseases (ICD)-10 diagnosis codes from German medical institutions from 2009 to 2019, provided by the Federal Statistical Office of Germany (Destatis), were analyzed. Nonunion incidence was calculated for anatomical localization, sex, and age groups. Incidence rate ratios (IRRs) were determined and compared with a two-sample z-test. Diagnosis-related group (DRG)-reimbursement and length of hospital stay were retrospectively retrieved for each anatomical localization, considering 210 patients.


Bone & Joint Research
Vol. 11, Issue 6 | Pages 409 - 412
22 Jun 2022
Tsang SJ Ferreira N Simpson AHRW


Bone & Joint Open
Vol. 3, Issue 3 | Pages 173 - 181
1 Mar 2022
Sobol KR Fram BR Strony JT Brown SA

Aims

Endoprosthetic reconstruction with a distal femoral arthroplasty (DFA) can be used to treat distal femoral bone loss from oncological and non-oncological causes. This study reports the short-term implant survivorship, complications, and risk factors for patients who underwent DFA for non-neoplastic indications.

Methods

We performed a retrospective review of 75 patients from a single institution who underwent DFA for non-neoplastic indications, including aseptic loosening or mechanical failure of a previous prosthesis (n = 25), periprosthetic joint infection (PJI) (n = 23), and native or periprosthetic distal femur fracture or nonunion (n = 27). Patients with less than 24 months’ follow-up were excluded. We collected patient demographic data, complications, and reoperations. Reoperation for implant failure was used to calculate implant survivorship.


Orthopaedic Proceedings
Vol. 90-B, Issue SUPP_I | Pages 124 - 124
1 Mar 2008
Leighton R
Full Access

Retrospective data over an eight-year period was collected on twenty-four young patients with non-union of a femoral neck fracture who were followed to union. The cause of each nonunion was identified and a classification of the nonunions was established in order clarify treatment options. Patients were treated by a single surgeon. The treatment protocol was based on the classification of the femoral neck nonunion. There were no nonunions in the treated patients; however two patients who showed signs of avascular necrosis prior to treatment ultimately developed AVN. Femoral neck nonunion occurs in 20–30% of displaced femoral neck fractures. If the femoral head is viable, the treatment goal is femoral neck union to maintain it. Treatment options depend on the cause of nonunion. To clarify treatment options, a classification of nonunions was developed. The treatment regime developed was based on the type of nonunion. We believe that subclassification of the femoral nonunion improves the selection of treatment options. This classification-based treatment does not reduce the incidence of avascular necrosis, but does seem to guarantee union while permitting excellent function of the hip joint. A classification system based on the cause of the non-union clarifies treatment options to maintain the femoral head and produce union of the femoral neck. Based on the analysis a classification proposal relating to treatment was developed. In the original treatment group there were no nonunions but two cases of ultimate avascular necrosis— both showed signs of AVN on bone scan prior to treatment. Classifications:. Type I – Inadequate fixation or non-anatomic reduction (eight patients). Type II – Loss of fixation with displacement (fourteen patients). Type III (Rare) – Fibrous nonunion with no displacement and intact fixation (two patients). Twenty-four patients were treated by one surgeon and followed to union over eight years. The results were examined retrospectively to categorize cause of non-union and treatment protocol. A classification system that describes classes of nonunions and treatment for each type was developed


Bone & Joint Research
Vol. 10, Issue 5 | Pages 321 - 327
3 May 2021
Walter N Rupp M Hierl K Pfeifer C Kerschbaum M Hinterberger T Alt V

Aims

We aimed to evaluate the long-term impact of fracture-related infection (FRI) on patients’ physical health and psychological wellbeing. For this purpose, quality of life after successful surgical treatment of FRIs of long bones was assessed.

Methods

A total of 37 patients treated between November 2009 and March 2019, with achieved eradication of infection and stable bone consolidation after long bone FRI, were included. Quality of life was evaluated with the EuroQol five-dimension questionnaire (EQ-5D) and German Short-Form 36 (SF-36) outcome instruments as well as with an International Classification of Diseases of the World Health Organization (ICD)-10 based symptom rating (ISR) and compared to normative data.


Orthopaedic Proceedings
Vol. 87-B, Issue SUPP_III | Pages 249 - 249
1 Sep 2005
Catagni M Cattaneo R Lovisetti L
Full Access

Introduction: The bone defects in the long bones are traumatic as a consequence of open fractures or resections due to infection or necrotic nonunion. A devitalised bone with no nutrition or vascularity is liable to an infection, with extension proportional to the size of the necrotic bone. To be sure to eliminate the infection and the nonunion it is necessary to perform open surgery and remove the necrotic and infected segments thoroughly, and then proceed to osteosynthesis and internal transport after osteotomy. Material and Methods: From 1981 to 2002 203 cases were treated with the Ilizarov Method. The previous treatment given before the patients came to our center was as follows: 1) in tibial nonunion intramedullary nail 17%; 2) in femoral nonunion plates 46%, monoaxial external fixator 42%, intramedullary nail 10%, circular external fixator 4%; 3) humerus nonunion Ender 3%, plates 81%, intramedullary nail 16%; 4) forearm nonunion plates 80%, wires and cast 20%. Our treatment was resection of the infected bone segment and then bifocal internal transport in 162 patients, threefocal convergent transport in 41, or threefocal tandem transport. If the resection does not exceed 4–5 cm. it is possible to perform immediate shortening, first by placing the resection stumps in contact and compression, and then by performing bifocal transport. The bifocal method consists of resection and proximal or distal metaphyseal osteotomy and then internal transport of the free bone segment bringing it into contact with the stump where the resection was performed. In the threefocal convergent method, after resection, two osteotomies are performed, one proximal and the other one distal, and the two bone segments are made to converge on the resection site. In the threefocal tandem method, after resection on a clear-cut proximal or distal infection, the osteotomies are performed on the same bone segment with double level transport. The good result is conditioned by satisfying regeneration in the site of the osteotomies. The rhythm of transport is purely individual and proportional to the patient’s age, and ranges from 1 to ¼ mm a day. In case of hypotrophy of the regenerated bone, concertina manoeuvring becomes necessary, that is shortening and subsequent distraction of the transport segments. Results: According to these techniques we attained both consolidation and elimination of the infection in 181 cases, that is 89%. Conclusions: In infectious nonunion healing cannot be possibly achieved through antibiotic therapy, so the only resolving action is the eradication of the necrotic-septic site and then its resection. The consequent limb shortening is compensated, in the Ilizarov Method, by internal transport of the healthy bone segment. Our results are good for cases, and the infection is eliminated in any case


The Bone & Joint Journal
Vol. 102-B, Issue 4 | Pages 530 - 538
1 Apr 2020
Rollick NC Gadinsky NE Klinger CE Kubik JF Dyke JP Helfet DL Wellman DS

Aims

Dual plating of distal femoral fractures with medial and lateral implants has been performed to improve construct mechanics and alignment, in cases where isolated lateral plating would be insufficient. This may potentially compromise vascularity, paradoxically impairing healing. This study investigates effects of single versus dual plating on distal femoral vascularity.

Methods

A total of eight cadaveric lower limb pairs were arbitrarily assigned to either 1) isolated lateral plating, or 2) lateral and medial plating of the distal femur, with four specimens per group. Contralateral limbs served as matched controls. Pre- and post-contrast MRI was performed to quantify signal intensity enhancement in the distal femur. Further evaluation of intraosseous vascularity was done with barium sulphate infusion with CT scan imaging. Specimens were then injected with latex medium and dissection was completed to assess extraosseous vasculature.


Bone & Joint Open
Vol. 1, Issue 6 | Pages 287 - 292
19 Jun 2020
Iliadis AD Eastwood DM Bayliss L Cooper M Gibson A Hargunani R Calder P

Introduction

In response to the COVID-19 pandemic, there was a rapidly implemented restructuring of UK healthcare services. The The Royal National Orthopaedic Hospital, Stanmore, became a central hub for the provision of trauma services for North Central/East London (NCEL) while providing a musculoskeletal tumour service for the south of England, the Midlands, and Wales and an urgent spinal service for London. This study reviews our paediatric practice over this period in order to share our experience and lessons learned. Our hospital admission pathways are described and the safety of surgical and interventional radiological procedures performed under general anaesthesia (GA) with regards to COVID-19 in a paediatric population are evaluated.

Methods

All paediatric patients (≤ 16 years) treated in our institution during the six-week peak period of the pandemic were included. Prospective data for all paediatric trauma and urgent elective admissions and retrospective data for all sarcoma admissions were collected. Telephone interviews were conducted with all patients and families to assess COVID-19 related morbidity at 14 days post-discharge.


The Journal of Bone & Joint Surgery British Volume
Vol. 88-B, Issue 1 | Pages 26 - 30
1 Jan 2006
Lindahl H Malchau H Odén A Garellick G

Periprosthetic fracture of the femur is an uncommon complication after total hip replacement, but appears to be increasing. We undertook a nationwide observational study to determine the risk factors for failure after treatment of these fractures, examining patient- and implant-related factors, the classification of the fractures and the outcome. Between 1979 and 2000, 1049 periprosthetic fractures of the femur were reported to the Swedish National Hip Arthroplasty Register. Of these, 245 had a further operation after failure of their initial management. Data were collected from the Register and hospital records. The material was analysed by the use of Poisson regression models. It was found that the risk of failure of treatment was reduced for Vancouver type B2 injuries (p = 0.0053) if revision of the implant was undertaken (p = 0.0033) or revision and open reduction and internal fixation (p = 0.0039) were performed. Fractures classified as Vancouver type B1 had a significantly higher risk of failure (p = 0.0001). The strongest negative factor was the use of a single plate for fixation (p = 0.001). The most common reasons for failure in this group were loosening of the femoral prosthesis, nonunion and re-fracture. It is probable that many fractures classified as Vancouver type B1 (n = 304), were in reality type B2 fractures with a loose stem which were not recognised. Plate fixation was inadequate in these cases. The difficulty in separating type B1 from type B2 fractures suggests that the prosthesis should be considered as loose until proven otherwise


The Bone & Joint Journal
Vol. 101-B, Issue 6_Supple_B | Pages 23 - 30
1 Jun 2019
Neufeld ME Masri BA

Aims

The aim of this study was to determine if the Oxford Knee and Hip Score (OKHS) can accurately predict when a primary knee or hip referral is deemed nonsurgical versus surgical by the surgeon during their first consultation, and to identify nonsurgical OKHS screening thresholds.

Patients and Methods

We retrospectively reviewed pre-consultation OKHS for all consecutive primary total knee arthroplasty (TKA) and total hip arthroplasty (THA) consultations of a single surgeon over three years. The 1436 knees (1016 patients) and 478 hips (388 patients) included were categorized based on the surgeon’s decision into those offered surgery during the first consultation versus those not (nonsurgical). Spearman’s rank correlation coefficients and receiver operating characteristic (ROC) curve analysis were performed.


The Bone & Joint Journal
Vol. 101-B, Issue 2 | Pages 178 - 188
1 Feb 2019
Chaudhary MM Lakhani PH

Aims

Double-level lengthening, bone transport, and bifocal compression-distraction are commonly undertaken using Ilizarov or other fixators. We performed double-level fixator-assisted nailing, mainly for the correction of deformity and lengthening in the same segment, using a straight intramedullary nail to reduce the time in a fixator.

Patients and Methods

A total of 23 patients underwent this surgery, involving 27 segments (23 femora and four tibiae), over a period of ten years. The most common indication was polio in ten segments and rickets in eight; 20 nails were inserted retrograde and seven antegrade. A total of 15 lengthenings were performed in 11 femora and four tibiae, and 12 double-level corrections of deformity without lengthening were performed in the femur. The mean follow-up was 4.9 years (1.1 to 11.4). Four patients with polio had tibial lengthening with arthrodesis of the ankle. We compared the length of time in a fixator and the external fixation index (EFI) with a control group of 27 patients (27 segments) who had double-level procedures with external fixation. The groups were matched for the gain in length, age, and level of difficulty score.