Between 1994 and 1999, we treated six patients with avascular necrosis of the talus by excision of the necrotic body of the talus and tibiocalcaneal fusion using an Ilizarov frame. This was combined with corticotomy and a lengthening procedure. Shortening was corrected in all patients except two, who were over 60 years of age. All patients had previous operations which had failed. All achieved solid bony fusion, with five out of six having either a good or an excellent result. We conclude that this is an effective reconstructive technique which gives a good functional result

We have carried out a prospective study of 17 patients (14 women, 3 men) of mean age 48 years (21 to 76) with transcervical fractures of the femur using MRI to detect early evidence of avascular necrosis of the head. Two fractures were Garden stage I, 12 stage II, and three stage III. We performed internal fixation under radiological control at a mean of five days (2 to 15) after injury using a titanium cannulated cancellous screw or a titanium compression hip screw. MRI was performed at one, six and 12 months and then yearly after operation. T1- and T2-weighted images were obtained by a spin-echo technique. The duration of follow-up of patients who did not subsequently require replacement of the head of the femur was from 2 to 5 years (mean 3.2). One month after operation eight of the 17 hips showed a band of low signal intensity on T1-weighted images and high signal intensity on T2-weighted images indicating lesions in the femoral head away from the fracture line. These were of three types: type I was a small infarct at the superolateral region of the femoral head and was seen in three hips; type II was a shallow lesion from the superolateral region to the fovea of the femoral head (three hips); and type III was a large lesion occupying most of the femoral head (two hips). No further changes were seen in the MRI after six months from operation. Collapse of the femoral head did not occur in the three hips with type-I lesions, but two of the three type-II hips and both type-III hips subsequently collapsed. At the final follow-up the three hips with a type-I lesion and one with a type-II were still asymptomatic but radiography showed sclerosis in the femoral head corresponding to the MRI lesions. The nine hips which showed no changes on MRI at one month had no abnormal findings on physical examination, radiography or MRI at final follow-up

Introduction

This study reports the results of percutaneous autologous bone marrow grafting in 62 patients with corticosteroids treatment who had one hip osteonecrosis treated with bone marrow (BM) injection and the other contralateral hip osteonecrosis with core decompression (CD) alone. Only patients with bilateral symptomatic osteonecrosis and with those hips at stage I or II (as defined by Steinberg) were included in this study.

Corticosteroid use has been implicated in the development of osteonecrosis of the femoral head (ONFH). The exact mechanism and predisposing factors such as age, gender, dosage, type and combination of steroid treatment remain controversial. Between March and July 2003, a total of 539 patients with severe acute respiratory syndrome (SARS) were treated with five different types of steroid. There were 129 men (24%) and 410 women (76%) with a mean age of 33.7 years (21 to 59). Routine screening was undertaken with radiographs, MRI and/or CT to determine the incidence of ONFH.

Of the 129 male patients with SARS, 51 (39.5%) were diagnosed as suffering from ONFH, compared with only 79 of 410 female patients (19.3%). The incidence of ONFH in the patients aged between 20 and 49 years was much higher than that of the group aged between 50 and 59 years (25.9% (127 of 491) versus 6.3% (3 of 48); p = 0.018). The incidence of ONFH in patients receiving one type of steroid was 12.5% (21 of 168), which was much lower than patients receiving two different types (28.6%; 96 of 336) or three different types of steroid (37.1%; 13 of 35).

Cite this article: Bone Joint J 2014;96-B:259–62.

Background

Skeletal stem cells (SSCs) have been used for the treatment of osteonecrosis of the femoral head to prevent subsequent collapse. In isolation SSCs do not provide structural support but an innovative case series in Southampton, UK, has used SSCs in combination with impaction bone grafting (IBG) to improve both the biological and mechanical environment and to regenerate new bone at the necrotic site.

Background

Several risk factors for the development of osteonecrosis following treatment of developmental dislocated hip have been reported. The need for further research with a large-enough sample size including statistical adjustment of confounders was demanded. The purpose of the present study was to find reliable predictors of osteonecrosis in patients managed for developmental dislocation of the hip.

Introduction

The purpose of this study was to clarify the incidence of steroid-induced osteonecrosis among different collagen diseases and to evaluate the predictive factors for steroid-induced osteonecrosis in a prospective MRI study.

Background

The reported outcomes of unicompartmental knee replacement (UKR) for spontaneous osteonecrosis of the knee (SPONK) often derive from small series with an average followup of 5 years, enabling to generate meaningful conclusions. Therefore, we determined the long-term functional results and the 10-years survivorship of the implant in all patients with advanced SPONK of the medial tibio-femoral compartment treated with a unicompartmental knee arthroplasty at our institute.

Prophylactic pinning of the contralateral hip in unilateral Slipped Upper Femoral Epiphysis (SUFE) persists as a source of debate with the majority of surgeons selecting this option in a proportion of patients whom they regard as at increased risk of a subsequent slip. Universal prophylactic pinning was introduced in our region in 2005 after an audit of ten years local practice identified 25% of unilateral cases presented with a subsequent slip. This study reports our experience between 2005 and 2020. In this prospective study, 44 patients presented with 55 affected hips compared with 60 patients with 67 affected hips in the original study. Two patients were excluded as their initial slip had not been treated in our unit. Of the 42 hips seven were bilateral, 34 of the 35 unilateral hips underwent prophylactic pinning. The one exception subsequently underwent prophylactic pinning due to developing pain. Consistent with our original series, at a minimum follow up of 13 months there have been no complications of infection, fracture, chondrolysis or avascular necrosis subsequent to prophylactic pinning. Over 25 years 70 patients have undergone prophylactic pinning without complication. On the premise that 25% of our unpinned hips presented with subsequent slips before instituting our policy we estimate that we have prevented 17 subsequent slips over 25 years including the consequences which can be significant. We continue to advocate universal prophylactic pinning as an effective and safe practice in the management of SUFE

Controversy surrounds the management of displaced three- and four-part fractures of the proximal humerus. The percutaneous Resch technique of stabilisation involves minimal soft-tissue dissection and a reduced risk of stiffness and avascular necrosis. However, it requires a second operation to remove Kirschner wires and the humeral block. We describe a modification of this technique that dispenses with the need for this second operation and relies on a sequential pattern of screw placement. We report the outcome of 32 three- or four-part fractures of the proximal humerus treated in this way at a mean follow-up of 3.8 years (2 to 8)). There were 14 men and 18 women with a mean age of 56 years (28 to 83). At final follow-up the mean Oxford shoulder scores were 38 (31 to 44) and 39 (31 to 42), and the mean Constant scores were 79 (65 to 92) and 72 (70 to 80) for three- and four-part fractures, respectively. We further analysed the results in patients aged < 60 years with high-energy fractures and those aged ≥ 60 years with osteoporotic fractures. There were no cases of nonunion or avascular necrosis. The results were good and comparable to those previously reported for the Resch technique and other means of fixation for proximal humeral fractures. We would recommend this modification of the technique for the treatment of displaced three-part and four-part fractures in patients both younger and older than 60 years of age

Surgical dislocation of the hip in the treatment of acetabular fractures allows the femoral head to be safely displaced from the acetabulum. This permits full intra-articular acetabular and femoral inspection for the evaluation and potential treatment of cartilage lesions of the labrum and femoral head, reduction of the fracture under direct vision and avoidance of intra-articular penetration with hardware. We report 60 patients with selected types of acetabular fracture who were treated using this approach. Six were lost to follow-up and the remaining 54 were available for clinical and radiological review at a mean follow-up of 4.4 years (2 to 9). Substantial damage to the intra-articular cartilage was found in the anteromedial portion of the femoral head and the posterosuperior aspect of the acetabulum. Labral lesions were predominantly seen in the posterior acetabular area. Anatomical reduction was achieved in 50 hips (93%) which was considerably higher than that seen in previous reports. There were no cases of avascular necrosis. Four patients subsequently required total hip replacement. Good or excellent results were achieved in 44 hips (81.5%). The cumulative eight-year survivorship was 89.0% (95% confidence interval 84.5 to 94.1). Significant predictors of poor outcome were involvement of the acetabular dome and lesions of the femoral cartilage greater than grade 2. The functional mid-term results were better than those of previous reports. Surgical dislocation of the hip allows accurate reduction and a predictable mid-term outcome in the management of these difficult injuries without the risk of the development of avascular necrosis

Aims

Occult (clinical) injuries represent 15% of all scaphoid fractures, posing significant challenges to the clinician. MRI has been suggested as the gold standard for diagnosis, but remains expensive, time-consuming, and is in high demand. Conventional management with immobilization and serial radiography typically results in multiple follow-up attendances to clinic, radiation exposure, and delays return to work. Suboptimal management can result in significant disability and, frequently, litigation.

Untreated 3- and 4-part fractures of the proximal humerus have a poor functional outcome. Open operation increases the risk of avascular necrosis and percutaneous reduction and fixation may be preferable. We report 27 patients, 9 with 3-part and 18 with 4-part fractures, treated by percutaneous reduction and screw fixation. Thirteen of the 4-part fractures were of the valgus type with no significant lateral displacement of the articular segment, and five showed significant shift. Instruments were introduced into the fracture through small incisions so that the fragments could be manoeuvred under the control of an image intensifier, taking advantage of ligamentotaxis as far as possible. A good reduction was achieved in most cases. The average follow-up was 24 months (18 to 47). All the 3-part fractures showed good to very good functional results, with an average Constant score of 91% (84% to 100%), and no signs of avascular necrosis. Good radiological results were achieved in 4-part fractures when impacted in valgus except for one patient with partial avascular necrosis of the head. In those with lateral displacement of the head, revision to a prosthesis was required in one patient because of avascular necrosis and in another because of secondary redisplacement of the fracture. Avascular necrosis was seen in 11% of 4-part fractures. The average Constant score in patients with 4-part fractures who did not need further operation was 87% (75% to 100%)

The aim of this study was to determine the comorbid risk factors for failure in young patients who undergo fixation of a displaced fracture of the femoral neck. We identified from a prospective database all such patients ≤ 60 years of age treated with reduction and internal fixation. The main outcome measures were union, failure of fixation, nonunion and the development of avascular necrosis. There were 122 patients in the study. Union occurred in 83 patients (68%) at a mean follow-up of 58 months (18 to 155). Complications occurred in 39 patients (32%) at a mean of 11 months (0.5 to 39). The rate of nonunion was 7.4% (n = 9) and of avascular necrosis was 11.5% (n = 14). Failures were more common in patients over 40 years of age (p = 0.03). Univariate analysis identified that delay in time to fixation (> 24 hours), alcohol excess and pre-existing renal, liver or respiratory disease were all predictive of failure (all p < 0.05). Of these, alcohol excess, renal disease and respiratory disease were most predictive of failure on multivariate analysis. Younger patients with fractures of the femoral neck should be carefully evaluated for comorbidities that increase the risk of failure after reduction and fixation. In patients with a history of alcohol abuse, renal or respiratory disease, arthroplasty should be considered as an alternative treatment

Aims

There has been an increasing use of early operative fixation for scaphoid fractures, despite uncertain evidence. We conducted a meta-analysis to evaluate up-to-date evidence from randomized controlled trials (RCTs), comparing the effectiveness of the operative and nonoperative treatment of undisplaced and minimally displaced (≤ 2 mm displacement) scaphoid fractures.

Historically avoidance of avascular necrosis (AVN) has been the primary objective in the management of an acute unstable slipped upper femoral epiphysis (SUFE). When achieved through pinning in situ it was invariably associated with significant malunion. With increasing appreciation of the consequences of femoroacetabular impingement, modern techniques aim to correct deformity and avoid AVN. Exactly what constitutes an acute unstable SUFE is a source of debate but should represent 5–10% of all cases. This audit reviewed cases over the past 25 years treated in one region. Of 89 patients with 113 slips, 21 hips were recorded as unstable. During this period the management has evolved from closed reduction and stabilization through pinning in situ, to open reduction. Radiographic outcomes following these three treatment methods were compared with record of any subsequent surgery in the form of osteotomy or total hip arthroplasty. Currently the lowest reported incidence of AVN in patients with an acute unstable slip is associated with the Parsch technique which combines open arthrotomy, digital reduction and screw fixation. Early outcomes with this technique are in accordance with those reported in the literature and represents a significant improvement in outcome when compared to earlier techniques used in the management of the severe unstable SUFE

A consecutive series of 320 patients with an intracapsular fracture of the hip treated with a dynamic locking plate (Targon Femoral Neck (TFN)) were reviewed. All surviving patients were followed for a minimum of two years. During the follow-up period 109 patients died. There were 112 undisplaced fractures, of which three (2.7%) developed nonunion or re-displacement and five (4.5%) developed avascular necrosis of the femoral head. Revision to an arthroplasty was required for five patients (4.5%). A further six patients (5.4%) had elective removal of the plate and screws. There were 208 displaced fractures, of which 32 (15.4%) developed nonunion or re-displacement and 23 (11.1%) developed avascular necrosis. A further four patients (1.9%) developed a secondary fracture around the TFN. Revision to a hip replacement was required for 43 patients (20.7%) patients and a further seven (3.3%) had elective removal of the plate and screws. It is suggested that the stronger distal fixation combined with rotational stability may lead to a reduced incidence of complications related to the healing of the fracture when compared with other contemporary fixation devices but this needs to be confirmed in further studies. Cite this article: Bone Joint J 2013;95-B:1402–5

Introduction. Femur neck fractures (NOF) in the young could result in mal-union, non-union and avascular necrosis of the femoral head. Osteosynthesis is the standard of management in NOFs in young patient above complications sometimes end in Arthroplasty. The aim of our study is to identify predictors of NOF failures in the young population. Method. A retrospective study conducted in a single center. Patients with NOF fractures below the age of <50y excluding pathological and osteoporotic fractures were assessed in the period from 2005–2008. The mean follow-up was 22 months (6–40). Fractures were classified according to Gardens classification. Our Aim was to identify causative factors for fixation failures. Analysis was done using SPSS 17.0. Results. Within the 4 year period we identified 41 NOF fractures, 24 (75%) fractures were displaced. 7 (25%) out of the displaced fractures went in to failure and required arthroplasty. 3 (42%) went in to avascular necrosis and 2(28.5%) went in to screw cut out and non unions. All failures were primarily fixed with cancellous screws. We identified Male sex (p=0.03), Pre-operative delay of >25h (p=0.04), Chronic alcohol intake (p=0.02) and intra operative time >107min (p=0.001) as the main predictors of NOF failures in the young. Conclusion. Early surgical intervention within 25h, restricting the operation time to less than 107min would reduce the failure rates. We would recommend arthroplasty for patients who are chronic alcoholics

Background. Femoral neck nonunion is a challenging problem. If it is not treated properly, it will be ended with a catastrophe because the victims are younger and active patients and missing hip joint will result in a handicapped like person. If the head is viable, the best treatment is valgus osteotomy. In the original technique, site of nonunion was not explored but in our technique, there is exploration and cleaning of nonunion site and after reduction of fragments, fixation and subtrochanteric osteotomy were done. Materials and methods. Patients with established nonunion of femoral neck fracture entered in study. Inclusion criteria's were age under 60 years old, spherical head of femur without changing the density of it and femoral neck nonunion at least 6 months after fracture. Nonunion site was freshed and any hard ware was removed and head was reduced as possible and subtrochanteric valgus osteotomy to 150 degree was done and fixed with angle blade plate. Bone graft was not used. Patients were studied one year monthly for signs of union of fracture site and signs of avascular necrosis of femoral head. Results. 29 patients were entered in study. 21 male and 8 female with the mean age of 33 years(18 to 55). 19 had Garden type 4 and 7 garden type 3 and the rest 3 had garden type2 at first. Fracture of fixation device were seen in 15 patients. After average 4 months (3 to 5.5) 27 of them showed union of fracture site but in 7 cases, because of some collapse in fracture site, tip of hard ware entered the joint and in 2 cases avascular necrosis of head appeared. Discussion. Exploration of nonunion has some advantages. At first, in some cases removing of broken implants would be necessary for proper insertion of new device. Second, better reduction of fracture site may improve fixation and biomechanics. Third, it seems that in these cases there were through union but in the original method, there were metaplasia of fibrous tissue in the fracture site nonunion

Several techniques are available for the treatment of displaced fractures of the neck of the radius in children. We report our experience in 14 children treated by indirect reduction and fixation using an elastic stable intramedullary nail. The patients were followed up for a mean of 28 months. One developed asymptomatic avascular necrosis. The rest had excellent results. One had a neuropraxia of the posterior interosseous nerve, which recovered within six weeks. We advocate elastic stable intramedullary nailing for the closed reduction and fixation of these fractures in children