Introduction

Non-union is an unfortunate outcome of the fracture healing process for some patients; with an estimated annual incidence of 17.4- 18.9 per 100,00. The management of these patients depicts a significant clinical challenge for surgeons and financial burden to health services. External ultrasound stimulation devices (Exogen^TM) have been highlighted as a novel non invasive therapy to achieve union in cases of delayed and non-union. The aim of the current study was to assess the rate of union in patients using Exogen^TM therapy for delayed fracture union in a district general hospital.

Introduction

Non-union is debilitating, costly and affects 2–8% of intramedullary fixed fractures. Clinical data suggest that percutaneous interfragmentary screws offer a less invasive alternative to exchange nailing. This study aimed to assess their efficiency with biomechanical analyses.

We present a case of multifocal infection involving the left total hip replacement and the right total knee replacement of a patient, further complicated by an infected non-union of a periprosthetic fracture of the right knee. This required the unique simultaneous management of both infection eradication and fracture stabilization in the knee.

Both sites were treated with a 2-stage procedure, including the novel use of a stemmed articulating spacer for the right knee. This spacer was made combining a retrograde humeral nail, coated with antibiotic-impregnated cement, and a pre-formed articulating cement spacer. The patient was able to weight-bear on this spacer. The fracture went on to unite, and a second stage was performed with the use of stemmed prosthesis and augments. She remains infection free 2 years after the second stage operation.

The use of a stemmed articulating knee spacer can facilitate infection eradication and fracture stabilization while preserving some motion and weight-bearing ability in the 2 stage management of an infected periprosthetic fracture of the knee.

Introduction. Classical fixation using a circular frame involves two rings per segment and in many units this remains the norm whether using ilizarov or hexapod type frames. We present the results of two ring circular frame at King's College Hospital. Materials & Methods. A prospective database has been maintained of all frames applied since 2007. Radiographs from frames applied prior to July 2022 were examined. Clinic letters were then used to identify complications. Included: two ring hexapod for fracture, malunion, nonunion, arthrodesis or deformity correction in the lower limb. Excluded: patients under 16 years old, diabetic feet, Charcot joints, soft tissue contractures, arthrodiastasis, correction of the mid/forefoot, plate fixation augmentation, fixation off a third ring. Results. 518 two ring hexapods were identified. Mean age was 46 (16–89). 55% were for fracture, 18% for malunion, 11% for nonunion. Mean frame time was 7 months (2–29 months). All clinic letters from 384 patients showed 203 patients (52%) had at least one pin site infection, 27 nonunions (7%), 16 frame revisions (4%), 25 bone grafting procedures (7%), 5 cases of septic arthritis (1%), 3 periprosthetic fractures (0.8%),), 12 malunions (3%), 4 Amputations (1%). Conclusions. These results demonstrate the efficacy of a two ring hexapod for patients requiring reconstruction of the lower limb

Background. Scaphoid fractures with displacement have a higher incidence of nonunion and unite in a humpback position that can cause pain and reduced movement, strength and function. The aim of this study is to review the evidence available and establish the risk of nonunion associated with management of displaced scaphoid fractures in a plaster cast. Methods. Electronic databases were searched using the MeSH (Medical Subject Headings) controlled vocabulary (scaphoid fractures, AND'd with explode displaced, or explode nonunion, or explode non-healing or explode cast immobilisation, or explode plaster, or explode surgery). As no randomised or controlled studies were identified, the search was limited to observational studies based on consecutive cases with displaced scaphoid fractures treated in a plaster cast. The criterion for displacement was limited to gap or step of more than 1mm. The ‘random effects’ calculation was used to allow for the possibility that the results from the separate studies differ more than would be expected by chance. Results. Of the 27 articles identified, seven studies were eligible for the meta-analysis with a total of 1401 scaphoids. 93% (1311 scaphoids) of these scaphoid fractures healed in a plaster cast. 207 (15%) of all scaphoid fractures showed displacement of at least 1mm (Gap/step) between fracture fragments. Nonunion was identified in 18% (37/207) of displaced scaphoid fractures treated in a plaster cast. The pooled odds ratio of fracture nonunion between the displaced and undisplaced groups was five times higher with fracture displacement (pooled odds ratio: 5.5, 95%CI: 2.5–12.3; p=0.00, I. 2. =54.6%). The pooled relative risk of fracture nonunion was 4.4 (95%CI: 2.3–8.7; p=0.00 I. 2. =54.3%). Conclusions. Displaced fractures of scaphoid have a four times higher risk of nonunion when treated in a plaster cast and the patients should be advised of this potential risk

Aim. To analyse the results of the use of Recombinant Bone Morphogenic Protein (BMP-7) for treatment of fracture nonunions at our institution. Material and methods. From 2001 to 2006, 23 patients with fracture nonunion were treated with BMP-7 for bone healing. There were 14 male and 9 females. The mean age of patients was 45 years (Range 21-76 yrs). There were 11 femoral, 9 tibial and 3 humerus fractures. There were 4 open injuries. The average number of operations before BMP-7 insertion was 2.66 (Range 0-6). The mean time between the injury and BMP insertion was 54 months (Range 5-312). 9 patients had previous autologous bone graft inserted without union. Results. All the fracture went on to unite within an average of 7 months (Range 4-16). 4 patients had BMP-7 insertion on its own. In another 3 patients it was mixed with allograft. In the rest of 16 patients BMP-7 was mixed with autologous bone graft. 2 patients needed BMP-7 insertion on 2 separate occasions. In all except 1 patient the original fixation of the fracture had to be revised. There were no complications from the use of BMP-7. Conclusion. Use of recombinant BMP-7 lead to fracture union in all our patients. We believe that the use of BMP-7 improved the chances of fracture healing in persistent nonunions and it is safe and easy to use

Aims

The standard of wide tumour-like resection for chronic osteomyelitis (COM) has been challenged recently by adequate debridement. This paper reviews the evolution of surgical debridement for long bone COM, and presents the outcome of adequate debridement in a tertiary bone infection unit.

The Radiographic Union Score for Hip (RUSH) is an outcome instrument designed to describe radiographic healing of femoral neck fractures. The ability to identify fractures that have not healed is important for defining non-union in clinical trials and predicting patients that likely require additional surgery to promote fracture healing. We sought to determine a RUSH threshold score that defines nonunion at 6-months post-injury. Our secondary objective was to determine if this threshold was associated with increased risk for non-union surgery. A sample of 248 patients with adequate six-month hip radiographs and complete two-year clinical follow-up were analysed from a multi-national hip fracture trial (FAITH). All patients had a femoral neck fracture and were treated with either multiple cancellous screws or a sliding hip screw. Two reviewers independently determined the RUSH score based on the six-month post-injury radiographs, and agreement was assessed using the Interclass Correlation Coefficient (ICC). Fracture healing was determined by two independent methods: 1) prospectively by the treating surgeon using clinical and radiographic assessments, and 2) retrospectively by a Central Adjudication Committee using radiographs alone. Receiver Operator Curve analysis was used to define a RUSH threshold score that was specific for fracture nonunion. RUSH score inter-rater agreement was high (ICC: 0.81, 95% CI 0.76 to 0.85). The mean six-month RUSH score for all included patients was 24.4 (SD 3.4). A threshold score of <18 was associated with a greater than 98% specificity for nonunion. Furthermore, patients with a six-month RUSH score below 18 were more the seven-times more likely to require revision surgery for nonunion (Relative Risk: 7.25, 95% CI 2.62 to 20.00). The six-month RUSH score can effectively be used to communicate when a femoral neck fracture has not healed. The validity of our conclusions was further supported by the increased risk of nonunion surgery for patients below the RUSH threshold. We believe our findings can standardise a definition of nonunion for clinical trials and recommend the use of the RUSH and its <18-point threshold when describing femoral neck nonunion

Aims

The timing of when to remove a circular frame is crucial; early removal results in refracture or deformity, while late removal increases the patient morbidity and delay in return to work. This study was designed to assess the effectiveness of a staged reloading protocol. We report the incidence of mechanical failure following both single-stage and two stage reloading protocols and analyze the associated risk factors.

ORIF is the treatment of choice for the majority of acetabular fractures with the ultimate goal of native hip preservation. As long as anatomic reduction and joint congruency is achieved, the results of ORIF have led to good to excellent outcomes. Total hip arthroplasty (THA) after acetabular fracture is indicated: 1.) acutely in the setting of a fracture where ORIF has been shown to portray a poor prognosis (severe femoral head and/or posterior wall impaction, dome comminution (gull sign) or 2.) in the presence of the sequelae of acetabular fractures such as posttraumatic arthritis or osteonecrosis. Independent of the setting, THA after acetabular fracture presents unique challenges to the orthopaedic surgeon and in many instances requires a team approach that includes both joint reconstruction and trauma specialists. The main goal of the operation is to restore continuity of the fractured columns prior to implantation of an uncemented acetabular component. Technical challenges include infection, residual pelvic deformity, acetabular bone loss and/ or ununited fractures, osteonecrosis of bone fragments, retained hardware, heterotopic ossification, sciatic nerve compromise, and the difficulties in obtaining long-term socket fixation. Careful pre-operative assessment with review of x-rays and CT scans to assess bone loss, fracture nonunion, and infection is necessary. The surgeon must anticipate more blood loss, longer operative times, and difficulties with exposure and must anticipate the need of special tools intra-operatively such as pelvic reconstruction plates, use of autogenous bone graft, metal cutting instruments and post-operative heterotopic ossification prophylaxis either in the form of NSAIDS or radiation. In case of a necrosis, nonunion, or bone loss principles of revision total hip arthroplasty are commonly used and today the use of highly porous metals is particularly useful. Cemented acetabular components should be avoided. Care should be taken with cup position as distorted anatomy may influence cup position and bony impingement may lead to dislocation. The results of THA in general has provided excellent pain relief and functional improvement but the biggest historical problem has been socket fixation and bearing surface wear, hopefully now improved with the advent of highly porous metals and alternative bearing surfaces

Purpose. The ability to correctly interpret quantitative results is a crucial skill developed in medical school and surgical residency. It demands a basic understanding of epidemiological principles and modes of presenting data. Yet, there has been little investigation into the efficacy of current teaching methods and areas of difficulty among orthopaedic residents. Method. Forty orthopaedic residents attended a research course provided by the main author in preparation for this assessment. Immediately after formal teaching, these residents were administered a survey that assessed residents perceived and actual level of understanding of basic modes of presenting results including number needed to treat (NNT), relative risk (RR), odds ratio (OR), and absolute risk reduction (ARR). Residents were given a multiple choice clinical case scenario of fracture nonunion and asked to choose which result would be most efficacious at reducing nonunion. An All are equally efficacious option was given for each question. The multiple choice answers were purposefully identical with regard to effect size but answers differed in the way they were presented. Results. Over 81% of residents agreed or strongly agreed that they had a good understanding of the modes of presenting results. However, less than 20% of residents consistently identified that the choices to questions were identical with regard to effect on nonunion rate. When the effect sizes in the choices were coupled with significant p-values (p < 0.05) of variable sizes, significantly fewer residents identified the correct solution (p < 0.05). Confidence intervals were associated with a decrement in correct responses (p < 0.05). Conclusion. On average orthopaedic trainees have a poor understanding of presenting results and struggle to interpret them. Considerable confusion exists between measures of clinical significance and that of the effect size of treatment

Introduction. Ankle fusion presents a difficult problem in the presence of infection, inadequate soft tissue, poor bone stock and deformity. Nonunion and infection remains a problem even with internal fixation. Ilizarov frame provides an elegant solution to the problem with stable remote fixation while allowing lengthening, deformity correction and weight bearing. Patients and methods. Twenty-one consecutive patients were studied. The mean age at onset of disease was 52 years (range 4-70). Mean duration of the problem was 59.9 months (6-372). Aetiology included traumatic arthritis in 5, traumatic arthritis with osteomyelitis in 1, failed ankle fusion in 8, septic arthritis in 1, infected ankle fracture nonunion in 1, avascular necrosis of talus in 1, congenital deformity in 3 and failed ankle arthroplasty in 1. 15 patients had deformity of the ankle at the time of presentation. 15 of the 21 patients had either clinical or radiological evidence of infection. Treatment principles involved local excision, deformity correction with good alignment and soft tissue management. Static Compression was achieved with an Ilizarov frame while dynamic fixation was performed in 3 cases for lengthening. Antibiotics treatment was continued until union in the infected cases. On achieving union the frame was removed and a below knee cast was applied for 4 weeks. Results. Fusion was achieved in all cases at an average time of 5 months. One patient had below knee amputation for chronic pain. There was no recurrence of infection. Complications included pin site infection, lateral impingement, drug reaction and hind-foot pain. The results were assessed in terms of SF36 and Modified foot and ankle score. Conclusion. The Ilizarov ankle fusion is a reliable salvage procedure in difficult ankle problems

Purpose. On January 12th, 2010 a magnitude 7.0 earthquake struck the downtown area of Port au Prince, the capital of the poorest country in the western world. Nearly a quarter of a million people were killed and a million other were injured. Our goal was to provide follow up and acute care to injured Haitain patients. Method. During an eight day period in June of 2010 a group of three physicians from Memorial University were part of a humanitarian mission to this country in conjunction with the University of Maryland and the humanitarian group Catholic Relief Services (CRS). Attempting to provide orthopedic care six months after such a disaster presented numerous challenges in this part of the world. Security and travel were always a concern due to the rising number of foreign kidnappings that plague the capital city. The heat and humidity made the simplest of tasks exhausting and uncomfortable. Living conditions, although above average for Haiti, consisted of no heated water, diseased mosquitoes, and sleeping of concrete floors. CRS provided us with the means to deal with all of these challenges. Results. Care was provided at Hospital St. Francis de Sales which was devastated during the earthquake. Two hundred bodies remained buried in the rubble and less than 20% of the original structure remained standing and functional. Wards consisted of donated military style tents with minimal protection from the elements. Communication with the short staffed nurses and abundant patients required the use of translators or a familiarity with French or Creole. Attaining x-rays required outside transport of patients and blood work was only done in an emergency situation. Surgical cases took place in a surgical theatre with two OR tables operating simultaneously. A nurse anesthetist provided care for all surgical patients with only one operational anesthetic machine. Lack of basic supplies on a day to day basis and frequent and ill timed power outages ensured even the smallest of cases presented their own challenges. Greater than 25 orthopedic cases were completed during our mission. These were wide in scope including the complications of earthquake trauma, fresh trauma, hip fractures, and tumor removals. Five Moores hemiarthroplasties were performed as this was the only prosthesis available. ORIF of fracture nonunions included a midshaft humerus, a both bones forearm, several midshaft tibias, and an infected humeral supracondylar fracture. Cases were completed with incomplete equipment sets and without a scrub nurse. Conclusion. Providing orthopedic care in less developed areas of the world present numerous challenges. Utilizing humanitarian organizations that are well organized and integrated into the culture are essential. Orthopedic surgeons must be willing to rely less on technology and more on basic principles and hard work to provide safe and beneficial care where it is truly needed

Michael Robinson has been a Consultant Orthopaedic Surgeon and Senior Lecturer in the Department of Orthopaedics and Traumatology in Edinburgh, Scotland, United Kingdom for 10 years. His special interests include the treatment of proximal humeral and clavicle fractures, and shoulder instability. The traditional view that the vast majority clavicle fractures heal with non- operative treatment with consistently good functional outcomes is no longer valid. Recent studies have identified a higher rate of nonunion and specific defects of shoulder function in sub-groups of patients with these injuries. These fractures should therefore be viewed as a spectrum of injuries with diverse functional outcomes, each requiring careful assessment and individualised treatment. This talk provides an overview of the current knowledge regarding their epidemiology, classification, clinical assessment and treatment in adults. The following key points will be highlighted:. Undisplaced fractures of both the diaphysis and the lateral end of the clavicle have a high rate of union and good functional outcomes after non-operative treatment. Non-operative treatment of displaced shaft fractures may be associated with a higher rate of non-union and functional deficit than previously reported. However, it remains difficult to predict which patients will develop these complications. Since satisfactory functional outcome may be regained from operative treatment for clavicular nonunion or malunion, there is currently considerable debate about the benefits of primary operative treatment for these injuries. Displaced lateral-end fractures have a higher risk of nonunion after non-operative treatment than shaft fractures. However, nonunion is difficult to predict and may be asymptomatic in the elderly. The results of operative treatment are more unpredictable than for shaft fractures. None of the authors have received any payment or consideration from any source for the conduct of this study

The ipsilateral and contralateral fibulae have been used as a vascularised bone graft for loss of tibial bone usually by methods which have involved specialised microvascular techniques to preserve or re-establish the blood supply. We have developed a method of tibialisation of the fibula using the Ilizarov fixator system, ipsilateral vascularised fibular transport (IVFT), and have used it in five patients with massive loss of tibial bone after treatment of an open fracture, infected nonunion or chronic osteomyelitis. All had successful transport, proximal and distal union, and hypertrophy of the graft without fracture. One developed a squamous-cell carcinoma which ultimately required amputation of the limb. The advantage of IVFT is that the fibular segment retains its vascularity without the need for microvascular dissection or anastomoses. Superiosteal formation of new bone occurs if the tibial periosteal bed is retained. Other procedures such as corticotomy and lengthening can be carried out concurrently