We hypothesised that an independent Notch Trial is essential on the same lines as other Component Trials-Femoral, Tibial and Patellar - in posterior stabilised total knee arthroplasty. Therefore we evolved Notch Trial to visually ascertain the adequacy of intercondylar resection and eliminate the possibility of femoral intercondylar fractures. We undertook a retrospective study to evaluate Notch Trial by the frequency of the need to remove osteophytes or file uneven surfaces in intercondylar resection by using the detachable box part of the trial femoral component, assess occurrence of distal femoral intercondylar fractures and demonstrate Notch Trial in posterior stabilised total knee replacement. We studied 206 patients, 113 females and 93 males, who underwent consecutive primary posterior stabilised total knee replacements applying Notch Trial between 2000 and 2008 in a District General Hospital under our team. Outcome Measurements were 1) frequency of the need to remove osteophytes or file uneven surfaces in intercondylar resection and 2) occurrence of distal femoral intercondylar fractures intraoperatively or on postoperative radiographs. We had to remove the osteophytes and file the cut surfaces in 183 (88.88%) of patients after Notch Trial. We had no distal femoral intercondylar fractures intraoperatively or on postoperative radiographs. Notch Trial allows the surgeon to directly visualise and ascertain the adequacy and precise fit of femoral notch cut with cam part of femoral component to ensure a press fit femoral component in condylar posterior cruciate substituting total knee replacement. Notch Trial prior to Femoral Component Trial effectively pre-empts intraoperative distal femoral intercondylar fractures. We recommend that Notch Trial should become part of the protocol for cruciate substituting total knee replacement and implants of all companies should have the option of a detachable box component for Notch Trial

Aims. Posterior column plating through the single anterior approach reduces the morbidity in acetabular fractures that require stabilization of both the columns. The aim of this study is to assess the effectiveness of posterior column plating through the anterior intrapelvic approach (AIP) in the management of acetabular fractures. Methods. We retrospectively reviewed the data from R G Kar Medical College, Kolkata, India, from June 2018 to April 2023. Overall, there were 34 acetabulum fractures involving both columns managed by medial buttress plating of posterior column. The posterior column of the acetabular fracture was fixed through the AIP approach with buttress plate on medial surface of posterior column. Mean follow-up was 25 months (13 to 58). Accuracy of reduction and effectiveness of this technique were measured by assessing the Merle d’Aubigné score and Matta’s radiological grading at one year and at latest follow-up. Results. Immediate postoperative radiological Matta’s reduction accuracy showed anatomical reduction (0 to 1 mm) in 23 cases (67.6%), satisfactory (2 to 3 mm) in nine (26.4%), and unsatisfactory (> 3 mm) in two (6%). Merle d’Aubigné score at the end of one year was calculated to be excellent in 18 cases (52.9%), good in 11 (32.3%), fair in three (8.8%), and poor in two (5.9%). Matta’s radiological grading at the end of one year was calculated to be excellent in 16 cases (47%), good in nine (26.4%), six in fair (17.6%), and three in poor (8.8%). Merle d’Aubigné score at latest follow-up deteriorated by one point in some cases, but the grading remained the same; Matta’s radiological grading at latest follow-up also remained unchanged. Conclusion. Stabilization of posterior column through AIP by medial surface plate along the sciatic notch gives good stability to posterior column, and at the same time can avoid morbidity of the additional lateral window. Cite this article: Bone Jt Open 2024;5(2):147–153

Aims. The primary aim of this study was to address the hypothesis that fracture morphology might be more important than posterior malleolar fragment size in rotational type posterior malleolar ankle fractures (PMAFs). The secondary aim was to identify clinically important predictors of outcome for each respective PMAF-type, to challenge the current dogma that surgical decision-making should be based on fragment size. Methods. This observational prospective cohort study included 70 patients with operatively treated rotational type PMAFs, respectively: 23 Haraguchi Type I (large posterolateral-oblique), 22 Type II (two-part posterolateral and posteromedial), and 25 (avulsion-) Type III. There was no standardized protocol on how to address the PMAFs and CT-imaging was used to classify fracture morphology and quality of postoperative syndesmotic reduction. Quantitative 3D-CT (Q3DCT) was used to assess the quality of fracture reduction, respectively: the proportion of articular involvement; residual intra-articular: gap, step-off, and 3D-displacement; and residual gap and step-off at the fibular notch. These predictors were correlated with the Foot and Ankle Outcome Score (FAOS) at two-years follow-up. Results. Bivariate analyses revealed that fracture morphology (p = 0.039) as well as fragment size (p = 0.007) were significantly associated with the FAOS. However, in multivariate analyses, fracture morphology (p = 0.001) (but not fragment size (p = 0.432)) and the residual intra-articular gap(s) (p = 0.009) were significantly associated. Haraguchi Type-II PMAFs had poorer FAOS scores compared with Types I and III. Multivariate analyses identified the following independent predictors: step-off in Type I; none of the Q3DCT-measurements in Type II, and quality of syndesmotic reduction in small-avulsion Type III PMAFs. Conclusion. PMAFs are three separate entities based on fracture morphology, with different predictors of outcome for each PMAF type. The current debate on whether or not to fix PMAFs needs to be refined to determine which morphological subtype benefits from fixation. In PMAFs, fracture morphology should guide treatment instead of fragment size. Cite this article: Bone Joint J 2020;102-B(9):1229–1241

Introduction. Reverse shoulder replacement is a surgical option for cuff tear arthropathy. However scapular notching is a concern. Newer designs of glenospheres are available to reduce scapular notching. Eccentric glenosphere with a lowered centre of rotation have been shown to improve range of adduction in vitro. We hypothesize that the eccentric glenosphere improve clinical outcomes and reduce scapular notching. Method. This is an ongoing randomized controlled double blind prospective clinical trial. Patients 70 years or older at North Shore hospital who have a diagnosis of cuff tear arthropathy and require surgery were consented for this study. Patients were allocated a concentric or eccentric 36 mm glenosphere intraoperatively, using a computer generated randomization contained in a sealed envelope. The surgical technique and post operative rehabilitation were standardized. Patients were followed up by a research nurse and postoperative radiographs were also taken at regular intervals. Clinical assessment include a visual analogue pain score, subjective shoulder rating, American Shoulder and Elbow Society Score, and Oxford shoulder score. Complications were checked for and radiographs were assessed for scapular notching. Results. There were 23 patients in the concentric and 24 patients in the eccentric glenosphere group. Average age and duration of follow up were comparable. There was no statistical significant difference but there was a trend towards better functional outcome and better range of motion in the eccentric glenosphere group. There was no scapular notching in the eccentric and three cases of scapular notching in the concentric glenosphere group. Conclusions. Reverse shoulder replacement significantly improve pain, function and range of motion in patients with cuff tear arthropathy. Eccentric glenosphere prevents scapular notching in the SMR reverse prosthesis

Introduction. In oblique olecranon fracture, fracture line begins in the trochlear notch and proceeds distally to the dorsal cortex of the ulna. We have experienced a nonunion of reverse oblique fracture. Hypothesis. Reverse oblique olecranon fracture has instability. Materials & Methods. 130 patients with an olecranon fracture were retrospectively evaluated. Inclusion criteria are that fracture line begins at the base of the coronoid process, distal portion of the trochlear notch, and proceeds proximally to the dorsal cortex of the ulna on the lateral radiograph. Fractures with articular comminution were excluded. Results. Seven patients met the criteria. They were associated with local injuries: anterior translation of the proximal radius and ulna, fracture of the medial epicondyle or the lateral condyle of the humerus. One out of five patients treated with tension band wiring (TBW) was revised with screw fixation because of nonunion. Discussion. The associated injuries suggested the anterior and valgus instability. A nonunion case suggests a requirement of more secure fixation. However, these findings are common in distal olecranon fracture. Therefore, the instability in our series is due to the distal location of fracture on the trochlear notch rather than reverse obliquity. The reverse obliquity attributes to small proximal fragment. Conclusion. Reverse oblique olecranon fracture has instability because of its distal location. It should be distinguished from simple, stable fracture

Aims

The aims of this study were to identify means to quantify coronal plane displacement associated with distal radius fractures (DRFs), and to understand their relationship to radial inclination (RI).

This clinical study analyzes the long-term outcomes and potential complications of the Grammont's reverse prosthesis in case of trauma in elderly population. Between January 1993 and May 2010, thirty-seven consecutive patients with 26 three- and four-part fractures and 11 fracture-dislocations, mean age 75 (58 to 92) were evaluated with a mean follow-up of 7.3 years. Eight complications occurred: 2 complex sympathetic dystrophies, 3 dislocations, 2 deep infections and one aseptic loosening of the base-plate leading to 3 re-operations and 2 prosthesis revisions. The mean Constant's score dropped from 55 at two year follow-up to 52 (20 to 84) at last revision because of an augmentation of the pain and a diminution of the strength which represented 67% of the mean score for the injured side. Mean modified Constant's score was 68. Only 58% were satisfied or very satisfied because of poor internal and external rotations avoiding nourishment with utensils, dressing and personal hygiene when the dominant side was involved. Two complete glenoid borders, fourteen stable inferior spurs, twenty-one inferior scapular notches including ten of them with medial proximal humeral bone loss or radio lucent lines between the bone and the cement were observed. Notches were more important in size when the follow-up was longer. 62% of the patients had worrying images. The crossing of the clinical and radiological data showed a degradation of the mean Constant's score (41) for pain and strength in cases of notches with troubling proximal humeral images. In spite of only one case of aseptic loosening at 12 year follow-up, results are disappointing and complications and revisions rates important. The functional result is never equal to the pre-broken state. New developments in design, bearing surfaces and surgical technique and a more long term results will refine the role of the reverse concept for fracture

Introduction. The prosthetic impingement occurs if the range of motion of the hip exceeds implant mobility or in case of component malorientation. This retrieval study was designed to assess the frequency and the risk factors of this phenomenon. Material and Methods. The frequency and the severity of the impingement were calculated from a continuous series of 311 cups retrievals collected between 1989 and 2004 by a single surgeon. The reason for retrieval was loosening (131 cases), infection (43 cases), instability (56 cases), osteolysis (28 cases), unexplained pain (48 cases) and prosthetic impingent (5 cases all with hard bearings). The notching at the cup rim was assessed twice by two examiners with optic magnification. The risk factors were analyzed from clinical charts by univariate and cox multihazard. Results. Among the 311 cups explants, the frequency of impingement was 59.2% (it was severe in 11%, the notching exceeding 3 millimeters). The impingement was the reason for removal in only 1.6%, meaning that it was mainly unexpected (98.4 percent). The impingement was more frequent when revisions were performed because of instability (notching 80%), when the sum of hip motion exceeded 200 degrees (sum of motion in the 6 degrees of freedom of the hip) (notching 66%). The other risk factors were: use of heads with skirts, liner with an elevated rim, and head-neck ratio below 2, younger age at surgery. The multivariate analysis identified only two independent factors: 1) the use of skirted heads (Odd ratio 3.2 (1.2–15.3)), 2) and revision because of instability (Odd ratio 4.2 (1.1–16.2)). In contrast different classical factors were not correlated with impingement on retrieval: cup inclination, the duration before retrieval, the indication for primary prosthetic replacement. Discussion and Conclusion. This study underlines the impingement is common when assessing cup retrievals (over 50 percent). One should be aware of impingement when performing hip replacement in patients having a high range of motion. This situation may require prostheses with a high head-neck ratio, as well as use of computer-assisted surgery. One should avoid liners with elevated rim as well as heads with skirts to prevent dislocation, particularly when other risk factors are detected

We used an inverted shoulder arthroplasty in 43 consecutive patients with a mean age of 78 years (65 to 97) who had sustained a three- or four-part fracture of the upper humerus. All except two were reviewed with a mean follow-up of 22 months (6 to 58). The clinical outcome was satisfactory with a mean active anterior elevation of 97° (35° to 160°) and a mean active external rotation in abduction of 30° (0° to 80°). The mean Constant and the mean modified Constant scores were respectively 44 (16 to 69) and 66% (25% to 97%). Complications included three patients with reflex sympathetic dystrophy, five with neurological complications, most of which resolved, and one with an anterior dislocation. Radiography showed peri-prosthetic calcification in 36 patients (90%), displacement of the tuberosities in 19 (53%) and a scapular notch in ten (25%). Compared with conventional hemiarthroplasty, satisfactory mobility was obtained despite frequent migration of the tuberosities. However, long-term results are required before reverse shoulder arthroplasty can be recommended as a routine procedure in complex fractures of the upper humerus in the elderly

Approximately 30000 total knee replacements are performed annually in the UK. Standard practice is to obtain a radiograph during the initial post-operative period. We performed a retrospective review of 638 total knee replacements and found no significant complications were visible on post-operative radiographs. There were 4 cases of mild femoral notching. Cessation of initial radiographs could save the NHS two million pounds annually. We suggest check radiographs in the initial post-operative period are unnecessary and waste valuable resources which could be distributed elsewhere

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.

Aims

Complex displaced osteoporotic acetabular fractures in the elderly are associated with high levels of morbidity and mortality. Surgical options include either open reduction and internal fixation alone, or combined with total hip arthroplasty (THA). There remains a cohort of severely comorbid patients who are deemed unfit for extensive surgical reconstruction and are treated conservatively. We describe the results of a coned hemipelvis reconstruction and THA inserted via a posterior approach to the hip as the primary treatment for this severely high-risk cohort.

Aims

The anterior pelvic internal fixator is increasingly used for the treatment of unstable, or displaced, injuries of the anterior pelvic ring. The evidence for its use, however, is limited. The aim of this paper is to describe the indications for its use, how it is applied and its complications.

Objectives

The biomembrane (induced membrane) formed around polymethylmethacrylate (PMMA) spacers has value in clinical applications for bone defect reconstruction. Few studies have evaluated its cellular, molecular or stem cell features. Our objective was to characterise induced membrane morphology, molecular features and osteogenic stem cell characteristics.

The purpose of this study was to describe the radiological characteristics of a previously unreported finding: posterior iliac offset at the sacroiliac joint and to assess its association with pelvic instability as measured by initial displacement and early implant loosening or failure. Radiographs from 42 consecutive patients with a mean age of 42 years (18 to 77; 38 men, four women) and mean follow-up of 38 months (3 to 96) with Anteroposterior Compression II injuries, were retrospectively reviewed. Standardised measurements were recorded for the extent of any diastasis of the pubic symphysis, widening of the sacroiliac joint, static vertical ramus offset and a novel measurement (posterior offset of the ilium at the sacroiliac joint identified on axial CT scan). Pelvic fractures with posterior iliac offset exhibited greater levels of initial displacement of the anterior pelvis (anterior sacroiliac widening, pubic symphysis diastasis and static vertical ramus offset, p < 0.001,0.034 and 0.028, respectively). Pelvic fractures with posterior ilium offset also demonstrated higher rates of implant loosening regardless of fixation method (p = 0.05). Posterior offset of the ilium was found to be a reliable and reproducible measurement with substantial inter-observer agreement (kappa = 0.70). Posterior offset of the ilium on axial CT scan is associated with greater levels of initial pelvic displacement and early implant loosening.

Cite this article: Bone Joint J 2014;96-B:1535–9.

In order to achieve satisfactory reduction of complex distal humeral fractures, adequate exposure of the fracture fragments and the joint surface is required. Several surgical exposures have been described for distal humeral fractures. We report our experience using the anconeus pedicle olecranon flip osteotomy approach. This involves detachment of the triceps along with a sliver of olecranon, which retains the anconeus pedicle. We report the use of this approach in ten patients (six male, four female) with a mean age of 38.4 years (28 to 51). The mean follow-up was 15 months (12 to 18) with no loss to follow-up. Elbow function was graded using the Mayo Score. The results were excellent in four patients, good in five and fair in one patient. The mean time to both fracture and osteotomy union was 10.6 weeks (8 to 12) and 7.1 weeks (6 to 8), respectively. We found this approach gave reliably good exposure for these difficult fractures enabling anatomical reduction and bicondylar plating without complications.

Cite this article: Bone Joint J 2014;96-B:1252–7.

Fracture repair occurs by two broad mechanisms: direct healing, and indirect healing with callus formation. The effects of bisphosphonates on fracture repair have been assessed only in models of indirect fracture healing.

A rodent model of rigid compression plate fixation of a standardised tibial osteotomy was used. Ten skeletally mature Sprague–Dawley rats received daily subcutaneous injections of 1 µg/kg ibandronate (IBAN) and ten control rats received saline (control). Three weeks later a tibial osteotomy was rigidly fixed with compression plating. Six weeks later the animals were killed. Fracture repair was assessed with mechanical testing, radiographs and histology.

The mean stress at failure in a four-point bending test was significantly lower in the IBAN group compared with controls (8.69 Nmm^-2 (sd 7.63) vs 24.65 Nmm^-2 (sd 6.15); p = 0.017). On contact radiographs of the extricated tibiae the mean bone density assessment at the osteotomy site was lower in the IBAN group than in controls (3.7 mmAl (sd 0.75) vs 4.6 mmAl (sd 0.57); p = 0.01). In addition, histological analysis revealed progression to fracture union in the controls but impaired fracture healing in the IBAN group, with predominantly cartilage-like and undifferentiated mesenchymal tissue (p = 0.007).

Bisphosphonate treatment in a therapeutic dose, as used for risk reduction in fragility fractures, had an inhibitory effect on direct fracture healing. We propose that bisphosphonate therapy not be commenced until after the fracture has united if the fracture has been rigidly fixed and is undergoing direct osteonal healing.

Cite this article: Bone Joint J 2013;95-B:1263–8.

A new anterior intrapelvic approach for the surgical management of displaced acetabular fractures involving predominantly the anterior column and the quadrilateral plate is described. In order to establish five ‘windows’ for instrumentation, the extraperitoneal space is entered along the lateral border of the rectus abdominis muscle. This is the so-called ‘Pararectus’ approach. The feasibility of safe dissection and optimal instrumentation of the pelvis was assessed in five cadavers (ten hemipelves) before implementation in a series of 20 patients with a mean age of 59 years (17 to 90), of whom 17 were male. The clinical evaluation was undertaken between December 2009 and December 2010. The quality of reduction was assessed with post-operative CT scans and the occurrence of intra-operative complications was noted. In cadavers, sufficient extraperitoneal access and safe instrumentation of the pelvis were accomplished. In the patients, there was a statistically significant improvement in the reduction of the fracture (pre- versus post-operative: mean step-off 3.3 mm (sd 2.6) vs 0.1 mm (sd 0.3), p < 0.001; and mean gap 11.5 mm (sd 6.5) vs 0.8 mm (sd 1.3), p < 0.001). Lesions to the peritoneum were noted in two patients and minor vascular damage was noted in a further two patients. Multi-directional screw placement and various plate configurations were feasible in cadavers without significant retraction of soft tissues.

In the treatment of acetabular fractures predominantly involving the anterior column and the quadrilateral plate, the Pararectus approach allowed anatomical restoration with minimal morbidity related to the surgical access.

Filling the empty holes in peri-articular locking plates may improve the fatigue strength of the fixation. The purpose of this in vitro study was to investigate the effect of plugging the unused holes on the fatigue life of peri-articular distal femoral plates used to fix a comminuted supracondylar fracture model.

A locking/compression plate was applied to 33 synthetic femurs and then a 6 cm metaphyseal defect was created (AO Type 33-A3). The specimens were then divided into three groups: unplugged, plugged with locking screw only and fully plugged holes. They were then tested using a stepwise or run-out fatigue protocol, each applying cyclic physiological multiaxial loads.

All specimens in the stepwise group failed at the 770 N load level. The mean number of cycles to failure for the stepwise specimen was 25 500 cycles (sd 1500), 28 800 cycles (sd 6300), and 26 400 cycles (sd 2300) cycles for the unplugged, screw only and fully plugged configurations, respectively (p = 0.16). The mean number of cycles to failure for the run-out specimens was 42 800 cycles (sd 10 700), 36 000 cycles (sd 7200), and 36 600 cycles (sd 10 000) for the unplugged, screw only and fully plugged configurations, respectively (p = 0.50). There were also no differences in axial or torsional stiffness between the constructs. The failures were through the screw holes at the level of comminution.

In conclusion, filling the empty combination locking/compression holes in peri-articular distal femur locking plates at the level of supracondylar comminution does not increase the fatigue life of the fixation in a comminuted supracondylar femoral fracture model (AO 33-A3) with a 6 cm gap.

There remains uncertainty about the most effective surgical approach in the treatment of complex fractures of the acetabulum. We have reviewed the experience of a single surgeon using the extended iliofemoral approach, as described by Letournel.

A review of the database of such fractures identified 106 patients operated on using this approach with a minimum follow-up of two years. All data were collected prospectively. The fractures involved both columns in 64 (60%). Operation was undertaken in less than 21 days after injury in 71 patients (67%) and in 35 (33%) the procedure was carried out later than this. The reduction of the fracture was measured on plain radiographs taken after operation and defined as anatomical (0 to 1 mm of displacement); imperfect (2 to 3 mm) or poor (> 3 mm). The functional outcome was measured by the modified Merle d’Aubigné and Postel score. The mean follow-up was for 6.3 years (2 to 17).

All patients achieved union of the fractures. The reduction was graded as anatomical in 76 (72%) of the patients, imperfect in 23 (22%), and poor in six (6%). The mean Merle d’Aubigné and Postel score was 15 (5 to 18) with 68 patients (64%) showing good or excellent and 38 (36%) fair or poor results. Function correlated significantly with the accuracy of the reduction (p < 0.009). Significant heterotopic ossification developed in 32 patients (30%) and was associated with a worse mean Merle d’Aubigné and Postel score of 13.7.

The extended iliofemoral approach can be performed safely in selected complex acetabular fractures with an acceptable clinical outcome and rate of complications. Effective prophylaxis against heterotopic ossification should be strongly considered.