Purpose of Study – The unusual presentation of this case posed a diagnostic dilemma between a chronic haematoma and soft tissue sarcoma even after full investigation and biopsy. Salient points to differentiate between the two are discussed along with literature review. Case Report – A 61 year old gentleman presented with sudden increase in size of an already existing swelling over the mid third of right leg associated with throbbing pain & foot drop of 4 months duration. There was no recent history of trauma or bleeding abnormalities but there was a vague history of injury to his leg during his late teens. Clinical signs showed features suggestive of malignancy with engorged veins and diffuse margins with complete foot drop (Fig 1 & 2). X-rays showed calcifications within the substance of the swelling along with proximal tibiofibular synostosis (Fig 3). MRI scan revealed a well encapsulated mass between the peroneal muscles mechanically compressing the common peroneal nerve (Fig 4). Trucut biopsy showed cholesterol clefts and areas of dystrophic calcification characteristic of chronic haematoma (Fig 5). Patient successfully underwent enucleation of the swelling along with cutaneofascial suture to obliterate the dead space leading to complete recovery of foot drop. Biopsy confirmed a Chronic Haematoma. Discussion – Reid et al first used the term chronic expanding haematoma for haematomas that persisted and increased in size more than a month after the initiating haemorrhage. The cause of initial haemorrhage is most commonly trauma which results in displacement of skin and subcutaneous fatty tissue from more deeply located fixed fascia with formation of blood filled cysts surrounded by dense fibrous tissue. Factors in the blood-clotting cascade are said to be associated with an inflammatory reaction leading to additional bleeding from fragile capillaries and thus to additional inflammation, hence setting up a self-perpetuating process. Although the MRI & biopsy results in this case were reassuring, the clinical scenario of sudden foot drop with increase in pain point more towards a malignant process rather than a benign condition. Some salient points to differentiate the two include that sarcoma have no history of trauma and the duration of symptoms is longer in haematoma than sarcoma. Also, sarcomas usually involve deeper structures while haematoma occur in superficial layers. It should also be noted that several soft tissue sarcoma themselves commonly reveal haemorrhagic or cystic changes. Other differential diagnosis includes myositis ossificans and tumoral calcinosis. Conclusion – It is difficult to differentiate between chronic haematoma and soft tissue sarcoma based on clinical findings alone. X-ray and biochemical tests are always essential to rule out any fracture or bony mass but MRI is the gold standard and biopsy is the only way to rule out a malignant tumour. Surgical excision of the swelling including the fibrous pseudocapsule along with cutaneofascial suture to obliterate the dead space is the treatment of choice for chronic haematoma because aspiration of the fluid or incomplete excision could lead to recurrence, continued growth or a chronic draining sinus with or without infection

1. The complications following standard tendon transfer to provide active correction of drop foot in Chinese patients with leprosy are reviewed. 2. An alternative method of foot drop correction is described in which reactivation of the remaining distal stump of the tibialis posterior tendon is provided to assist in maintaining the stability of the arch of the foot and to help to prevent dropped toes. 3. A review of thirteen patients is given. The indications are that this method is functionally as good as other methods. So far it has shown none of the complications usual in Chinese patients

A comparison was made of the results produced by the circumtibial and interosseous routes of transfer of tibialis posterior for the correction of foot drop due to leprosy neuritis. The findings in 69 feet, of which 63 also had elongation of tendo Achillis, showed that the interosseous route gave a much lower incidence of recurrent inversion deformity of the foot. The results, in terms of improvement in gait and prevention of trophic changes, were satisfactory

A primary hydatid cyst in the pelvis is rare, and usually presents with pressure symptoms affecting the adjacent abdominal organs. We describe such a cyst which protruded through the sciatic notch and presented as a gluteal swelling with a foot drop due to compression of the lumbosacral nerve roots. Surgical excision and postoperative treatment with albendazole for six weeks were effective in controlling the disease and preventing recurrence

Anesthetic peripheral nerve blocks (PNB) have been shown to be more advantageous than general anesthesia in a variety of surgical operations. In comparison to conventional methods of general anesthesia, the choice of regional localized infiltration has been shown to shorten hospital stays, decrease hospital readmissions, allow early mobilization, and reduce narcotic use. Perioperative complications of PNBs have been reported at varying rates in literature. Thus, the purpose of this study was to provide a review on the clinical evidence of PNB complications associated with foot and ankle surgeries. A systematic review of the literature was completed using PubMed search terms: “lower extremity”, “foot and ankle”, “nerve block”, and “complications”. All studies reporting minor and major complications were considered along with their acute management, treatments, and postoperative follow up timelines. The range of complications was reported for Sensory Abnormalities, Motor Deficits, Skin and systemic complications (local anesthetic systemic toxicity & intravascular injections). A designation of the scientific quality (Level I-IV) of all papers was assigned then a summary evidence grade was determined. The search strategy extracted 378 studies of which 38 studies were included after criteria review. Block complications were reported in 20 studies while 18 studies had no complications to report. The quality of evidence reviewed ranged from Level I to Level IV studies with follow up ranging from twenty four hours to one-three year timelines. The range of complications for all studies reporting sensory abnormalities was 0.53 to 45.00%, motor deficits 0.05 to 16.22% and skin and systemic complications 0.05 to 6.67%. Sensory abnormalities that persisted at last follow up occurred in six studies with incidence ranging from 0.23 to 1.57%. Two studies reported motor complications of a foot drop with an incidence of 0.05% and 0.12%. When considering only the highest quality studies (Level 1) that had complications to report, the complications rate was 10.00% to 45.00% for sensory abnormalities, 7.81 to 16.22% for motor deficits, 6.67% for skin complications and 2.50% for systemic complications. High quality studies (Level I providing Summary Grade A Evidence) reporting all complications with a range of incidence from 0 to 45%. While most of these complications were not serious and permanent, some were significant including sensory abnormalities, foot drop and CRPS. Based on this systematic review of the current literature, the authors emphasize a significant rate of complications with PNB and recommend that patients are appropriately informed prior to consenting to these procedures

Osteochondromas occur are most commonly in the distal femur, proximal tibia and fibula and the proximal humerus. There are no large studies focusing on the clinical presentation, management and outcome of treatment for patients with an osteochondroma involving the proximal fibula. The purpose of this study is to specifically understand the manifestation of the proximal fibular osteochondroma on the preoperative peroneal nerve function, and how surgical management of the osteochondroma affects function immediately postoperatively and at long-term followup. This is an IRB-approved retrospective review of a consecutive series of patients with a proximal fibular osteochondroma (PFO) treated operatively at a single institution from 1990 to 2013. The medical record was carefully reviewed to identify demographic data, clinical data and especially the status of the peroneal function at various time points. There were 25 patients with 31 affected extremities who underwent surgical excision of the PFO at an average age of 12.4 years (range 3.0–17.9 years). There were 16 males and 9 females. The underlying diagnosis was isolated PFO in 2(8%) patients and multiple hereditary exostosis (MHE) in 23(92%) patients. Preoperatively, 9 (29%) had a foot drop and 22 (71%) did not. Those with preoperative foot drop underwent surgery at a younger age (9.1 vs 13.8 years) (p<0.004). Five of the nine (55.5%) had complete resolution, three (33.3%) had improvement, and one (11.1%) persisted postoperatively and required AFO. Of the 22 who were normal preoperatively, 5 (22.7%) developed a postoperative foot drop-three (60%) completely resolved, 1 (20%) improved, and 1 (20%) persisted and was found to have a transected nerve at exploration. In total, 23 of the 25 (92%) patients who had a PFO excision, had a normal or near-normal peroneal nerve function including those who had poor function preoperatively. A proximal fibular osteochondroma can result in a high incidence of peroneal nerve dysfunction prior to any treatment, but responds the majority of the time to surgical intervention with removal of the osteochondroma. For those who have normal preoperative function, 1 in 4 will develop a postoperative foot drop but nearly all improve spontaneously unless iatrogenic injured

Abstract. Background. Traumatic knee dislocations are devastating injuries and there is no single best accepted treatment. Treatment needs to be customised to the patient taking into consideration injury to the knee; associated neurovascular and systemic injuries. Objective. This study looked at functional outcome of a single surgeon case series of patients who underwent surgical management of their knee dislocation. Methods. Seventy patients with knee dislocation were treated with multi-ligament reconstruction at a major trauma centre. Acute surgical repair and reconstruction with fracture fixation within 3 weeks was preferred unless the patient was too unstable (Injury severity score>16). PCL was primarily braced and reconstructed subsequently, if required. Outcome was collected prospectively using IKDC score, KOOS and Tegner score. Results. The mean age of the patients was 35yrs (17–74), 53 males and 17 females. 5 patients had CPN injury (7%), 3 had vascular injury (4.2%), 2 had combined CPN and vascular injury (2.8%). Acute surgical treatment was done in 48 patients while 10 had staged reconstruction. 22 patients had delayed reconstruction. The mean follow-up period was 4.8 years (1–12 yrs). According to the IKDC score 67% of the patients had near-normal knee function. The mean Tegner activity scale postoperatively was 4.5 (preinjury 6.5) and the mean KOOS score was 75.3. Four patients had stiffness and needed arthroscopic arthrolysis, two patients had a residual foot drop from the original injury and needed tendon transfer. Conclusion. Traumatic knee dislocation is a challenging problem but good outcomes can be achieved by surgical management

Introduction. Tomita En-bloc spondylectomy (TES) of L5 is one of the most challenging spinal surgical techniques. A 42-year-old female was referred with low back pain and L5 radiculopathy with background of right shoulder excision of liposarcoma. CT-PET confirmed a solitary L5 oligometastasis. MRI showed thecal sac indentation and therefore was not suitable for stereotactic ablative radiotherapy (SABR) alone. Planning Methodology. First Stage: Carbon fibre pedicle screws were planned from L2 to S2AI-Pelvis, aligned to her patient-specific rods. Custom 3D-printed navigation guides were used to overcome challenging limitations of carbon instruments. Radiofrequency ablation (RFA) of L5 pedicles prior to osteotomy was performed to prevent sarcoma cell seeding. Microscope-assisted thecal sac-tumour separation and L5 nerve root dissection was performed. Novel surgical navigation of the ultrasonic bone cutter assisted inferior L4 and superior S1 endplate osteotomies. Second stage: We performed a vascular-assisted retroperitoneal approach to L4-S1 with protection of the great vessels. Completion of osteotomies at L4 and S1 to en-bloc L5: (L4 inferior endplate, L4/5 disc, L5 body, L5/S1 disc and S1 superior endplate). Anterior reconstruction used an expandable PEEK cage obviating the need for a third posterior stage. Reinforced with a patient-specific carbon plate L4-S1 promontory. Sacrifice of left L5 nerve root undertaken. Results. Patient rehabilitated well and was discharged after 42 days. Patient underwent SABR two months post-operatively. Despite left foot drop, she was walking independently 9 months post-operatively. Conclusion. These challenging cases require a truly multi-disciplinary team approach. We share this technique for a dual stage TES and metal-free construct with post adjuvant SABR for maximum local control

The October 2012 Spine Roundup. 360. looks at: a Japanese questionnaire at work in Iran; curve progression in degenerative lumbar scoliosis; the cause of foot drop; the issue of avoiding the spinal cord at scoliosis surgery; ballistic injuries to the cervical spine; minimally invasive oblique lumbar interbody fusion; readmission rates after spinal surgery; clinical complications and the severely injured cervical spine; and stabilising the thoracolumbar burst fracture

To evaluate the gait of five-year old children with club-feet initially treated non-operatively with the French functional technique and to compare these results to the data from this same cohort at the age of two years. Thirty-three patients (fifty-two idiopathic clubfeet) were initially treated with the French functional (physiotherapy) program. At the age of two years, no child underwent surgery for its clubfoot. Gait Analysis was performed with the VICON system (kinematics). At the age of five years, these patients were all re-evaluated in the gait laboratory. Of the thirty-three patients (fifty-two clubfeet) initially treated non-operatively and tested in the gait lab at two years of age, thirty-seven feet required subsequent surgery by the age of five years. This included posterior release (41%), posteromedial release (35%), tibial osteotomy (19%), and tendo Achilles lengthening (5%). The proportion of feet with the following gait parameters changed significantly (p< 0.05) between the ages of two and five years: Equinus (15% at 2 yrs vs. 2% at 5 yrs), Calcaneus (7% vs. 23%), Foot Drop (18% vs. 4%). The proportion of patients with internal foot progression angle did not change over this time (46% vs. 50%), nor did the proportion with normal sagittal plane ankle motion (61% vs. 54%). At age two years, the majority of patients treated with the French Functional non-operative treatment had normal sagittal plane ankle motion. Gait disturbances, when present at this age, were generally ankle equinus, foot drop and in-toeing. By the age of five years, 71% of these patients underwent surgery for their clubfeet. When re-tested in the gait laboratory at age five years, the proportion of feet with normal sagittal plane ankle motion did not change significantly, however, their resultant gait disturbances, when present, were predominantly calcaneus rather than equinus and foot drop. By treating patients with clubfeet with the French Functional technique exclusively, equinus gait may result in a small proportion. By subsequently treating these patients surgically after the age of two years, over-lengthening or over-release may occur and result in calcaneus gait. The French originators of this technique now incorporate an early gastrocsnemius fascial lengthening as part of their technique. This modification of their technique should improve the gait characteristics observed at two years of age and should decrease the necessity for late surgery that may have contributed to the gait characteristics observed at five years of age

Aims. Due to the complex anatomy of the pelvis, limb-sparing resections of pelvic tumours achieving adequate surgical margins, can often be difficult. The advent of computer navigation has improved the precision of resection of these lesions, though there is little evidence comparing resection with or without the assistance of navigation. Our aim was to evaluate the efficacy of navigation-assisted surgery for the resection of pelvic bone tumours involving the posterior ilium and sacrum. . Patients and Methods. Using our prospectively updated institutional database, we conducted a retrospective case control study of 21 patients who underwent resection of the posterior ilium and sacrum, for the treatment of a primary sarcoma of bone, between 1987 and 2015. The resection was performed with the assistance of navigation in nine patients and without navigation in 12. We assessed the accuracy of navigation-assisted surgery, as defined by the surgical margin and how this affects the rate of local recurrence, the disease-free survival and the effects on peri-and post-operative morbidity. . Results. The mean age of the patients was 36.4 years (15 to 66). The mean size of the tumour was 10.9 cm. In the navigation-assisted group, the margin was wide in two patients (16.7%), marginal in six (66.7%) and wide-contaminated in one (11.1%) with no intralesional margin. In the non-navigated-assisted group; the margin was wide in two patients (16.7%), marginal in five (41.7%), intralesional in three (25.0%) and wide-contaminated in two (16.7%). Local recurrence occurred in two patients in the navigation-assisted group (22.2%) and six in the non-navigation-assisted group (50.0%). The disease-free survival was significantly better when operated with navigation-assistance (p = 0.048). The blood loss and operating time were less in the navigated-assisted group, as was the risk of a foot drop post-operatively. Conclusion . The introduction of navigation-assisted surgery for the resection of tumours of the posterior ilium and sacrum has increased the safety for the patients and allows for a better oncological outcome. . Cite this article: Bone Joint J 2017;99-B:261–6

Introduction: Although distraction osteogenesis techniques have been used clinically for the treatment of many skeletal conditions with great success over the last 2 decades, one-step larger extent tibial lengthening (> 5 cm) still remains a clinical challenge. In which tension unbalance of bone and soft-tissue may occur, and complications such as foot drop, ankle and knee dysfunction, cartilage injure and secondary osteoarthritis were common. We have designed and manufactured a new lengthener, which allows bone and soft tissue to be lengthened in synchronism, and ankle joint remain in functional position and may move freely during lengthening. Methods: A dynamic cross joint apparatus at ankle level was added to a classic Ilizarov circular four-ring lengthener, the apparatus is consisted of a half ring, two dynamic junctions and an elastic (spring) device. In application pins were inserted into distant and proximal segment of the tibia, also through calcanues, the external fixator with the trans-joint device was then applied. Total 296 patients (age 6–46, average 21), 466 legs, were treated with this new lengthener, among them were 55 cases of infantile paralysis, 38 cases of post-trauma bone defects, 33 cases with congenital dysplasia and 170 cases of chordrodysplasia, rickets, dwarf and short stature (height < 148cm). Unilateral tibia lengthening was performed in 126 legs and bilateral tibia lengthening was performed in 340 legs. Results: Average lengthening for lower limb discrepancy cases was 6.8 cm (2–8cm), and 8.8 cm (8–18cm) for dwarf and short stature. Patients can stand straight and walk during the lengthening. Average movement of ankle joint remained at 10 degree in all cases and x-ray confirmed that average ankle joint space was 2.2 mm (1–4mm). There was no foot drop and ankle joint deformity seen, and in 98% cases ankle joint function fully recovered within 1.5 years after lengthening (6–8 months). Common complications were pinhole infection (25 cases) and broken pin (8 cases). If total lengthening was over 10cm, 70% cases developed slight ankle joint stiffness that would gradually recover after physiotherapy. Severe complications occurred in 5 cases (1%), including nonunion 1 case, mal-union 1 case, bone deformity 1 case and re-fracture 2 cases. All of those cases were cured with satisfactory clinical outcome. Discussion: The challenge of larger range tibial lengthening is mainly the soft tissue complications, such as foot drop, varus and valgus deformity of ankle joint and loss of ankle function. Prolonged soft tissue traction around the ankle joint may lead to increasing cartilage compression, cartilage damage and partial or permanent loss of joint function. Our dynamic lengthener would allow synchronized lengthening of triceps, Achilles tendon and prosterior tibia muscle with tibia, maintain ankle joint space and free ankle movement. This device was simple and easy to apply, with no need of additional Achilles tendon lengthening. Our clinical study has demonstrated that this device drastically reduced the rate of soft tissue complication. This device makes larger extent tibial lengthening (> 5cm) safer and realistic in clinical practice

The aim of this study was to define objectively gait function in children with treated congenital talipes equinovarus (CTEV) and a good clinical result. The study also attempted an analysis of movement within the foot during gait. We compared 20 children with treated CTEV with 15 control subjects. Clinical assessment demonstrated good results from treatment. Three-dimensional gait analysis provided kinematic and kinetic data describing movement and moments at the joints of the lower limb during gait. A new method was used to study movement within the foot during gait. The data on gait showed significantly increased internal rotation of the foot during walking which was partially compensated for by external rotation at the hip. A mild foot drop and reduced plantar flexor power were also observed. Dorsiflexion at the midfoot was significantly increased, which probably compensated for reduced mobility at the hindfoot. Patients treated for CTEV with a good clinical result should be expected to have nearly normal gait and dynamic foot movement, but there may be residual intoeing, mild foot drop, loss of plantar flexor power with compensatory increased midfoot dorsiflexion and external hip rotation

Aim. Vascularized fibula flap is one of the available options in the management of bone loss that can follow cases of severe haematogenous osteomyelitis. The aim of this study was to evaluate the outcomes of this procedure in a pediatric population in a Sub-saharan setting. Method. The retrospective study focuses on the procedures done in the period between October 2013 and December 2016. Twenty-eight patients, 18 males and 10 females, were enrolled. The youngest was 2 years old, the oldest 13. The bones involved were tibia (13), femur (7), radius (5) and humerus (3). In 5 cases the fibula was harvested with its proximal epiphysis, whereas in 17 cases the flap was osteocutaneous and osseous in 6 cases. In most cases, operations for eradication of the infection were carried out prior to the graft. The flap was stabilized mainly with external fixators, rarely with Kirschner's wires or mini plate. No graft augmentation was used. Results. Graft integration was achieved in 24 cases. Three cases of early flap failure required the removal, while in one case complete reabsorption of the flap was noted a few months after the procedure. The follow-up period ranged from a minimum of 2 and half to a maximum of 6 years. Integration of the graft was obtained in a period of 4 months on average. The fibular flap with epiphysis had good functional outcomes with reconstruction of articular end. Early and delayed complications were observed. All grafts underwent a process of remarkable remodeling. No major problems were observed in the donor site, except for a transitory foot drop that resolved spontaneously. Conclusions. Reconstruction of segmental bone defects secondary to hematogenous osteomyelitis with vascularized fibula flap is a viable option that salvages and restores limb function. It can be safely used even in early childhood. The fibula can be harvested as required by the local conditions. When harvested with a skin island, bone loss and poor soft tissues envelope may be addressed concurrently. The procedure is long and difficult but rewarding. When surgical skills and facilities are available, it can be carried out even in settings located in low resources countries

Introduction. Severely comminuted, displaced acetabular fractures with articular impaction in the elderly population present significant treatment challenges. To allow early post-operative rehabilitation and limit the sequelae of immobility, treatment with acute total hip replacement (THA) has been advocated in selected patients. Achieving primary stability of the acetabular cup without early migration is challenging and there is no current consensus on the optimum method of acetabular reconstruction. We present clinical results and radiostereometric analysis of trabecular metal (TM) cup cage construct reconstruction in immediate THA without acetabular fracture fixation. Methods. Between 2011 and 2016, twenty-one acetabular fractures underwent acute THA with a TM cup cage construct. Patient, fracture and surgical demographics were collected. They were followed up for a mean of 24months (range 12–42months). Clinical and patient reported outcome measures were collected at regular post-operative intervals. Radiosterometric analysis (RSA) was used to measure superior migration and sagittal rotation of the acetabular component. Results. Thirteen fractures were classified as anterior column posterior hemi-transverse, two anterior column, two transverse and four associated both column acetabular fractures. There was one case of trochanteric fracture and transient foot drop. Mean Harris Hip Scores at 12months was 79 (range 33–98). The mean proximal migration of the acetabular components at 12months was 0.91mm (range 0.09–5.12 and mean sagittal rotation was 0.52mm (range 0.03–7.35). Conclusion. The TM cup-cage technique requires a single approach and provides immediate cup stability allowing full weight bearing day one post-op. To our knowledge this is the first study to accurately measure cup stability following THA for an acetabular fracture. Our promising early clinical and radiological outcomes suggest this technique may be an alternative to a fix and replace construct for immediate THA for acute acetabular fractures in the elderly

Ponseti first advocated his treatment for idiopathic clubfoot in the early 1950's. The method has only gained popularity and widespread use since the 1990's. Despite publications showing favourable results, there is little published data scrutinising the change in modes of talipes treatment. This study sought to define the trends in treatment for Idiopathic Clubfoot in Scotland over a twelve-year period (1997 – 2008). (i) A review was performed to identify the number of publications referencing the Ponseti method over the past 40 years. (ii) A structured questionnaire was sent to all Paediatric Orthopaedic practitioners in Scotland to ascertain the treatment methods used and over the time period. (iii) Data from the National Census for number of live births were combined with that obtained from the Scottish Morbidity Record (SMR01) for number of peritalar clubfoot surgeries performed over the study period. (iv) Similar data was also obtained for non-Talipes related peritalar surgeries, and data colleceted for the number of Tibialis Anterior transfer operations for this period. Clubfoot incidence data was measured indirectly by means of sample from the database of a tertiary referral Paediatric Orthopaedic Unit. Regression analysis was used to evaluate the trends over time. Review of the literature referencing the Ponseti method over the past 40 years showed an exponential increase from the late 1990's. The survey of Clubfoot management of Paediatric Orthopaedic Surgeons in Scotland showed a marked increase in use of the method over with this period. Over this period, the number of operations for clubfoot dropped substantially, from 55 releases in 1997 to 1 release in 2008. The linear equation estimated a decrease of approximately 5 surgical releases per year (R²= 0.87, p<0.05). In Scotland, most Tibialis Anterior transfers are performed at age 3years, the frequency of the procedure has increased in the latter half of the study period. In Scotland between 1997 and 2008, the number of peritalar (posterior, medial, posteromedial release) operations used in the primary treatment of idiopathic clubfoot has dropped substantially. This correlates with a marked increase in reference to the method within the literature and increased usage of the Ponseti technique by Paediatric Orthopaedic Consultants

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 6. th. 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. Results. 7 males and 2 females of adult age underwent treatment between 2009 and 2016. The mean lengthening was 6.6cm (3–10cm). The external fixator was removed at a mean 123 days (57–220), with an external fixation index of 20 days/cm. The regenerate healing index was 28 days/cm. There were no deep infections. Significant complications were seen in 4 patients including knee stiffness, a foot drop, delayed union of the non-union osteotomy (requiring exchange nailing and bone grafting) and revision nailing due to a prominent proximal tip. Conclusion. The combined over-sized intramedullary nail and external fixator enables compression of the femoral osteotomy, alignment of the bone and controlled lengthening. Once the length has been restored, removal of the external fixator and proximal locking of the nail reduces the risk of complications associated with the fixator and stabilises the femur with the maximum working length of the nail. This small retrospective study demonstrates encouraging results for this complex clinical scenario

Total knee arthroplasty in the setting of osseous defects has multiple management options. However, the optimal treatment strategy remains controversial. The purpose of this study is to report the clinical and radiographic results of trabecular metal cones in managing osseous defects in the setting of complex primary and revision total knee arthroplasty. There were 129 consecutive total knee arthroplasty procedures performed utilising trabecular metal cones reviewed for clinical and radiographic outcomes. Twenty-five had less than 2 years of follow-up and seven died, leaving 96 patients for evaluation. This cohort included a total of eighty-six (86) tibias with eleven (11) having Type 1 defects, twenty-five (25) having Type 2A defects, forty-three (43) with Type 2B defects and seven (7) with Type 3 defects. There were twenty-seven (27) femurs with one (1) Type 1 defect, nine (9) Type 2A defects, sixteen (16) with Type 2B defects and one (1) Type 3 defect based on the AORI classification. There were 28 male patients and 68 female patients, with an average age of 68 years and an average BMI of 35.0. There were six primary procedures and ninety revision procedures. Continuous variables were evaluated using a t-test. Twelve patients required revision leaving 84 knees (87.5%) with the cones in place at an average of 31 months of follow-up (range, 24–77.3 months). The mean KSS score increased from 51.0 preoperatively to 80.2 postoperatively (p<0.0001). The mean KSS functional score increased from 32.9 preoperatively to 47.8 postoperatively (p=0.0002). Including the twelve revisions, there were twenty-two knees requiring re-operation (22.9%) with another seventeen requiring manipulation under anesthesia and there were four additional non-operative complications (1 foot drop, 1 stress fracture, 2 superficial infections)

Elective repair of lesions of the common peroneal nerve was carried out in 27 patients between 1982 and 1992. Twenty-three have been reviewed of whom 11 recovered power sufficient to prevent foot drop and 13 recovered protective sensation or better