Introduction. This study compares outcomes of vertebroplasty(VP) and kyphoplasty(KP) in 125 consecutive female Asian patients above 65 years with L1 osteoporotic vertebral compression fractures. Methods. 57 and 68 patients underwent VP and KP respectively from 2004 to 2008. Outcomes were measured prospectively at pre-operation, 1 month, 6 months and 2 years post-operation by blinded assessors. Radiographic outcome: Anterior, middle and posterior vertebral heights of the L1 vertebral body Functional outcome: Short-Form 36(SF-36) score, Visual Analogue Scale(VAS) score for back pain. Results. There was greater improvement of anterior and middle vertebral heights immediately post-surgery for the KP group as compared to the VP group(P<0.001). At 2 years post-surgery, the KP group had better maintenance of L1 vertebral body height with percentage loss of 16.4%, 17.3% and 8.84% of anterior, middle and posterior vertebral height respectively as compared to the VP group who had a greater loss of 29.2%, 42.3% and 17% respectively(p<0.001). Back pain improved post-operatively in both groups with no significant difference in VAS back pain score between the two groups at each follow-up time point(P>0.05). SF-36 score improved post-operatively in both groups (P=0.001). At 2 years post-surgery, the physical functioning domain of SF-36 was better in the KP group (P=0.01). Conclusion. KP provides better restoration and maintenance of anterior and middle vertebral heights with better physical function outcome”

Scheuermann's kyphosis is a structural deformity of the thoracic or thoracolumbar spine, which can result in severe pain, neurological compromise and cosmetic dissatisfaction. Modern surgical techniques have improved correction through a posterior-only or antero-posterior approach but can result in significant morbidity. We present our results of the surgical management of severe Scheuermann's kyphosis by a single surgeon with respect to deformity correction, global balance parameters, functional outcomes and complications at latest follow-up. We included 49 patients, of which 46 had thoracic and 3 had thoracolumbar kyphosis. Surgical indications included persistent back pain, progressive deformity, neurological compromise and poor self-image. Fourty-seven patients underwent posterior-only and 2 antero-posterior spinal arthrodesis utilising Chevron-type osteotomies and hybrid instrumentation. Mean age at surgery was 16.0 years with mean postoperative follow-up of 4.5 years. Mean kyphosis corrected from 92.1o to 46.9o (p<0.001). Concomitant scoliosis was eliminated in all of the 28 affected patients. Coronal and sagittal balance was corrected in all patients. Mean blood loss was 24% total blood volume. Mean operation time was 4.3 hours with mean inpatient stay of 9 days. SRS-22 questionnaire improved from a mean preoperative score of 3.4 to 4.6 at 2 years, with high treatment satisfaction rates. Complications included one toxic septicaemia episode but otherwise no wound infections, no junctional deformity, no loss of correction and no requirement for re-operation. Posterior spinal arthrodesis with the use of hybrid instrumentation can safely achieve excellent correction of severe Scheuermann's kyphosis helping to relieve back pain, improve functional outcomes and enhance self-image

Objective. Comparison of clinical outcome after Percutaneous Vertebro Plasty (PVP) for Osteoporotic Vertebral Compression Fractures (OVCFs) between patients with and without Intra Vertebral Clefts (IVCs). Background. PVP is a common treatment modality for painful OVCFs. Patients presenting with OVCFs with an IVC, also described as avascular necrosis of the vertebral body or intravertebral pseuadoarthrosis, are thought to represent a specific subgroup: filling the cleft might result in immediate and possibly superior pain relief due to stabilization of the excessive mobility associated with an IVC and the risk for cement leakage might be decreased due to its cavitational nature. Methods. 102 patients with 197 OVCFs were prospectively recruited for follow-up using a 0–10 Pain Intensity Numerical Rating Scale (PI-NRS) and the Short Form 36 (SF-36) Quality of Life questionnaire before PVP and at 7 days (PI-NRS only), 1, 3 and 12 months after PVP. Cement leakage was assessed on direct post-operative CT-scanning. At 6 and 52 weeks and at suspicion, patients were analyzed for new fractures. From blinded data two experienced musculoskeletal interventional radiologists retrospectively assessed all treated OVCFs for the presence of an IVC, defined as an abnormal, well-demarcated, linear or cystic hypointensity on MRI T1-weighted sequences and/or hyperintensity on MRI T2 STIR-sequences and/or the evident cleft filling on post-PVP CT-scanning. Outcome of patients with and without IVCs was compared using multivariate analysis correcting for confounders. For the purpose of comparison, a subgroup of all patients with PVP in isolated OVCFs was assessed as well. Results. In 48 OVCFs in 48 of 102 patients an IVC was identified (47.1%). Outcome regarding PI-NRS and SF-36 was comparable between both groups. In 42 patients who received PVP in only one OVCF, 21 clefts were detected. Despite similar baseline values, average back pain after PVP was significantly higher over time in patients with an IVC (1.1 point, p=0.03) but ultimately comparably lower at 12 months (4.4 and 4.3 points, p < 0.001). Outcome regarding SF-36 was comparable, as was occurrence of new OVCFs after PVP. The presence of an IVC was identified as a strong risk factor (OR 4.3, p=0.004) for occurrence of cortical (intradiscal) cement leakage. Conclusion. In patients with long-standing OVCFs, an IVC is a common entity. Patients with OVCFs with an IVC benefit from PVP, but do not comprehend a superior treatment indication. Overall benefit from PVP was comparable to patients without an IVC. In patients with treated isolated OVCFs with an IVC, average back pain is higher over the first year after PVP but ultimately comparable. Furthermore, an IVC is associated with an increased risk for cortical (intradiscal) cement leakage

Medical employment standards (MES) are used to identify and quantify the effects of pathology on a person's ability to carry out their duties. Any person requiring a change in their MES for longer than 28 days should have their permanent MES altered accordingly. In the Royal Air Force this is undertaken by Medical Boards. A retrospective review was performed of all personnel attending RAF Medical Boards for a change in their PMES between 15/1/12 and 31/10/13. The primary reason for downgrade was recorded using ICD-10 code. There were 1,583 PMES downgrades, approximately 800/year. This is approximately 2% of all regular RAF personnel. Musculoskeletal disease accounted for 58% of all cases (923 cases, 500/year). Other causes included medicine and general surgery (23%), mental health (10%), obstetrics and gynaecology (5%) and other causes (4%). The majority of the musculoskeletal cases were arthropathy (42%) or back pain (31%). Musculoskeletal disease is the most common cause for medical downgrade in the RAF. More data are required to ascertain the precise nature of these cases and the level of the imposed limitations. This will allow targeted use of increasingly limited resources to ensure that our personnel are as fit as possible to execute their duties

Introduction. Nociceptive and neuropathic components both contribute to chronic pain. Since these components require different pain management strategies, correct pain diagnosis before and during treatment is important. Freynhagen et al. (2006) reported that they had developed and validated the pain-DETECT questionnaire (PD-Q) to detect neuropathic components in chronic low back pain patients. They also reported that 37% of unselected cohort of chronic LBP patients had predominantly neuropathic pain. However, the extent to which neuropathic components relate to the pathomechanism of pain deriving from osteoarthritis of hip joint remains unknown. The purpose of this study was to utilize PD-Q to investigate the relationship between neuropathic components and pain deriving from osteoarthritis of the hip joint. Methods. Between March and August 2010, 125 patients with osteoarthritis of hip joint completed PD-Qs about their pain. From this data set, we investigated whether or not the patients’ pain contained neuropathic components. Results. Only 6.4% of the patients had a score 19, indicating that a neuropathic component was likely (90%). Conversely, 79.2 % had a score 12, indicating that a neuropathic component was unlikely (15%). For the remaining 14.4% with an intermediate score (13–18), the presence of a neuropathic component remained uncertain. Conclusion. In this set of patients with osteoarthritis of hip joint, the PD-Q responses indicated that only a small percentage (6.4%) were likely to have a neuropathic component to their hip pain

The reported results of compression fractures are poor. These results are not influenced by the severity of compression, the fracture site or the residual deformity. Otherwise, the factors that determine a patient's recovery are unknown. This study wants to identify the factors determining a patient's recovery after surgical treatment of compression fractures of the thoracolumbar spine. Therefore, in 31 surgically treated patients the pre-injury versus the 12-month follow-up differences in back pain, in global outcome and in participation were prospectively recorded. For this, the visual analogue scale for pain (VAS scale) and the Greenough and Fraser low back outcome scale were used. Of the latter scale, the 3 questions pertaining to participation were combined to create a participation subscale. For these differences and for time lost from work multiple linear regressions with combinations of 16 possible predictors were performed. At one year patients who smoke report a 25% less favorable global outcome and return 2.8 points (out of 10) less closely to their pre-injury pain level than patients who do not smoke. Patients with a fracture at the thoraco-lumbar junction return 3.3 points less closely to their pre-injury level on the VAS scale than those with a lumbar fracture. For each decrease in 1 of the 3 education levels, the patients stay away from work 15 weeks longer. Per degree of sagittal index at follow-up, patients stay 9 days longer at home. For each increase in level of occupation the return to the pre-injury participation level is 10% less favorable. The variability of time lost from work and of recovery of global outcome, pain and participation level explained by our models is 73%, 37%, 25% and 13% respectively. Smoking, localization of the fracture at the thoraco-lumbar junction and a high pre-existent level of occupation are strong negative predictors for recovery. A lower education level and sagittal fracture deformity at follow-up are negative predictors for sick leave but might also reflect the concerns of the physician when deciding about return to work

BACKGROUND. As life expectancy in the population rises, osteoporotic fractures are seen most frequently in the vertebral column. Percutaneous kyphoplasty is increasingly used for pain reduction and stabilization in these patients, but the efficacy, cost-effectiveness, and safety of the procedure remain uncertain. OBJECTIVE. To clarify whether kyphoplasty has additional value compared with optimum pain treatment in patients with acute vertebral fractures. MATERIALS & METHODS. From January 2004 to June 2009, 122 patients (31 males and 91 females), from 56 to 85 years old (mean age 68.5) were treated for 165 osteoporotic vertebral fractures of the thoracic or lumbar spine (minimum 15% height loss; level of fracture at Th5 or lower; bone oedema on MRI), with back pain for 6 weeks or less, and a visual analogue scale (VAS) score of 5 or more. Twelve patients (15 fractures) were lost at follow-up period and excluded. Patients were randomly allocated to percutaneous kyphoplasty (75 patients) or conservative treatment by computer-generated randomization codes. All fractures were analyzed for improvement in sagittal alignment (Cobb angle, kyphotic angle, sagittal index, vertebral height); and pain relief at 1, 6, 12, 24 months, as measured by VAS score. RESULTS. Percutaneous kyphoplasty resulted in direct and greater pain relief than did conservative treatment; difference in mean VAS score between baseline and 1 month was −6,5 after kyphoplasty and −2.4 after conservative treatment, and between baseline and 1 year was −7.2 after kyphoplasty and −3.8 after conservative treatment. No serious complications or adverse events were reported. Apart from the pain, the patient's ability to ambulate independently and without difficulty, and the need for medications improved significantly (P < 0.001) after kyphoplasty. Vertebral height significantly increased at all postoperative intervals, with 10% height increases in 88% of fractures, in kyphoplasty group at 2 years. There were no severe kyphoplasty-related complications, such as neurological defects, cement leakage or narrowing of the spinal canal whereas additional fractures occurred at the adjacent vertebrae at a rate of 10%. 35% of patients treated conservatively, had limitations in everyday activities the first 6 months, whereas additional fractures occurred at the adjacent vertebrae at a rate of 14%. CONCLUSION. In patients with acute osteoporotic vertebral compression fractures and persistent pain, balloon kyphoplasty is effective and safe. Pain relief after kyphoplasty is immediate, is sustained for at least 2 years, and is significantly greater than that achieved with conservative treatment, at an acceptable cost

BACKGROUND. Osteoporosis with subsequent osteoporotic vertebral compression fractures is an increasingly important disease due not only to its significant economic impact but also to the increasing age of our population. Pain reduction and stabilization are of primary importance with osteoporotic vertebral compression fractures. OBJECTIVE. To compare the efficacy and safety of balloon kyphoplasty and vertebroplasty for the treatment of vertebral compression fractures. MATERIALS & METHODS. From January 2004 to December 2009, 142 patients (32 males and 110 females), from 54 to 84 years old (mean age 67.4) were treated for 185 osteoporotic vertebral fractures of the thoracic or lumbar spine (level of fracture at Th5 or lower), with back pain for more than 8 weeks, and a visual analogue scale (VAS) score of 5 or more. Twenty-two patients (29 fractures) were lost at follow-up period and excluded. Patients were randomly allocated to percutaneous kyphoplasty (64%) or vertebroplasty (36%). All fractures were analyzed for improvement in sagittal alignment (Cobb angle, kyphotic angle, sagittal index, vertebral height). The patients were evaluated using the visual analog scale (VAS) and the Oswestry Disability Score. Radiographs were performed postoperatively, and at 1, 3, 6, and 12 months. RESULTS. The score according to pain, the patient's ability to ambulate independently and without difficulty, and the need for medications improved significantly (P < 0.001) after kyphoplasty or vertebroplasty. No significant difference could be found between both groups for the mean VAS and ODI preoperative and postoperative. Vertebral body height and kyphotic wedge angle of the T-L spine were also improved (p < 0.001); although kyphosis correction seems to be improved better in kyphoplasty than vertebroplasty. The rate of leakage was 12% for kyphoplasty and 32% for vertebroplasty; nevertheless most of the leakage was clinically asymptomatic and the rate of serious problems remained low (pulmonary embolism 0.01% kyphoplasty vs 0.6% vertebroplasty). New fractures in the next 6 months at the adjacent vertebrae were observed ∼ 15% in both groups. More PMMA was used in the kyphoplasty group than in the vertebroplasty group (5.5 +/− 0.8 vs. 4.1 +/− 0.5 mL, p < 0.001). Operation time was longer in balloon kyphoplasty compared to vertebroplasty (mean time 20±5min/vertebral fracture in group B vs 30±5min in group A). CONCLUSION. Both balloon kyphoplasty and vertebroplasty provided a safe and effective treatment for pain and disability in patients with vertebral compression fractures due to trauma or osteoporosis. Balloon kyphoplasty led to an ongoing reduction of fractured vertebrae and was followed by a lower rate of cement leakage

Sacral tumours are rare and can present difficult diagnostic and therapeutic challenges even at an early diagnosis. Surgical resection margins have a reported prognostic role in local recurrence and improved survival. Successful management is achieved within a specialist multidisciplinary service and involves combination chemotherapy, radiotherapy and surgery. We present our experience of patients with sacral tumours referred to our unit, who underwent total and subtotal sacrectomy procedures. Materials and Methods. Between 1995 and 2010, we identified twenty-six patients who underwent a total or subtotal sacrectomy operation. Patients were referred from around the United Kingdom to our services. We reviewed all case notes, operative records, radiological investigations and histopathology, resection margins, post operative complications, functional outcomes and we recorded long-term survival outcomes. Patients who were discharged to local services for continued follow up or further oncological treatment were identified and information was obtained from their general practitioner or oncologist. We reviewed the literature available on total sacrectomy case series, functional outcomes and soft tissue reconstruction. Results. We reviewed 26 patients, 16 male and 10 female, with a mean age at presentation of 53.4 years (range 11–80 years). Duration of symptoms ranged from 2 weeks to 6 years; lower back pain and sciatica were amongst the most common presenting features. Histological diagnoses included chordoma, Ewing's, malignant peripheral nerve sheath tumour, chondromyxoid fibroma, spindle cell sarcoma, synovial sarcoma, chondrosarcoma. A combined approach was used in two-thirds of patients and most of these patients had a soft tissue reconstruction with pedicled vertical rectus myocutaneous flap. Complications were categorised into major and minor and subdivided into wound, bladder and bowel symptoms. Wound complications and need for further intervention were more common amongst the patient group who did not have simultaneous soft tissue reconstruction at operation. All patients had a degree of bladder dysfunction in the early postoperative period. We present survivorship curves including recurrence and development of metastases. Conclusion. Total sacrectomy procedures carry a high risk of associated morbidity but can improve survival amongst specific groups of patients. They present challenges in diagnosis and management, but must be referred to a specialist service, that will instigate appropriate investigations and treatment regimes within a multidisciplinary setting. The expansion of services from other specialties required for the postoperative and ongoing rehabilitation plays an important role in overall management and appropriate pathways to coordinate these services are necessary

Introduction. Degenerative disc disease results from mechanical alteration of the intervertebral disc. Biochemical modifications of the nucleus matrix are also incriminated. Furthermore, genetic predispositions as well as vascular factors have been advocated in the process of disc degeneration. A relationship between sciatica and Propionibacterium acnes has been described. However, it remains unclear if the hypothesis of a subclinical spondylodiscitis might play a role in the pathophysiology of degenerative disc disease. The purpose of this study was to analyze the possible presence of bacteria in lumbar discs of patients with degenerative disc disease. Methods. We prospectively analyzed the presence of bacteria in 83 patients (34 males and 49 females, average age 41 years) treated by lumbar disc replacement at L3-L4, L4-L5 or L5-S1. An intraoperative biopsy and microbiological culture were performed for each disc to determine if intradiscal bacteria were present. Great care was taken to avoid any source of contamination during the conditioning process of the biopsy. Microbiological results were compared to the magnetic resonance stages of disc degeneration according to the Pfirrmann and Modic classifications. Possible sources of previous iatrogenic disc contamination after discography or nucleotomy were analyzed. Results. The magnetic resonance stages were Pfirrmann IV or V, with Modic I signs in 32 and Modic II in 25 cases. A preoperative discography was performed in 49 patients, and 24 had previous nucleotomy. Germs were found in 40 discs, 43 cultures were steriles. The following bacteria were evidenced: Propionibacterium acnes 18, Staphylococcus coagulase negative 16, Staphylococcus aureus 3, Gram negative bacilli 3, Micrococcus 3, Corynebacterium 3, others 5. Ten biopsies presented several different germs. Bacteria were predominantly found in males (p=0.012). The mostly positive level was L4-L5 (p=0.075). Histological examination of 31 discs found inflammatory cells in 33 % of the biopsies with positive bacterial culture, versus 5 % of the sterile biopsies (p=0.038). There was no significant relationship between bacterial evidence and Modic sign. A preoperative discography or previous nucleotomies did not represent significant contamination sources. None of the patients presented clinical signs of infection. Conclusions. The finding of bacteria in 48 % of disc biopsies, presence of inflammatory cells at histological examination, the absence of responsibility of the discography as a factor of contamination, and the absence of clinical post-operative infection, defend the hypothesis of a low-grade spondylodiscitis which might play a role in the pathophysiology of degenerative disc disease. On the other hand, the presence of skin commensal bacteria, of ¼ of polymicrobial biopsies, and the fact that previous nucleotomy doesn't seem to be involved in inoculation, cannot allow to eliminate a contamination of the samples. Further studies are necessary to elucidate the responsability of intradiscal bacteria in degenerative disc disease. This could influence our treatment strategy of back pain, which could be based in the future on antibiotics

Background. Balloon kyphoplasty (BKP) is a minimally invasive cementing procedure, occasionally used in patients with painful vertebral compression fractures (VCF). In this multicenter Swedish RCT, we evaluated the cost-effectiveness of BKP compared with standard medical treatment, Control, in osteoporotic patients with acute/sub-acute VCF (<3 months). In a multicenter European clinical study (FREE trial) including 300 patients and FU after one year, BKP was suggested to be a safe and effective procedure in selected patients. The current study includes the Swedish patients in the FREE trial Method: Hospitalized patients with a back pain level of at least 4/10 on a visual analogue scale due to of VCF between Th5–L5 (confirmed by MRI) were randomized to either BKP or Control treatment (standard medical treatment with pain medication and functional support). All VCF-associated costs (hospital, primary care, rehabilitation, community care, private care, pharmaceuticals, assistance by relatives, work absenteeism) were identified and reported from the perspectives of cost to society, and costs to the healthcare system. Primary outcome was quality of life change (QoL) measured with the preference based EQ-5D instrument. The accumulated quality adjusted life years gained (QALYs) and costs per QALY gained was assessed. Willingness to pay (WTP) for a QALY gained in Sweden was estimated at approximately SEK 600,000 (EURO 62,500). Sensitivity analyses were performed. Results. Between February 2003 and December 2005, 70 patients were randomized to BKP (n=35) or to standard medical treatment (n=35). Three patients in the Control group declined to participate in an economic evaluation, and only patients answering EQ-5D at all FU occasions (1-3-6-12-24 months) were included in the analyses, leaving in all 63 patients, BKP=32, Control=31. Baseline data were similar. The mean age in the BKP group was 72 years (71% women) vs. 75 years (78% women) in the Control group. Baseline difference in QoL was adjusted for using statistical methods. There were no cross overs. Four patients in the BKP group and three patients in the Control group died within two years of causes not related to the VCF. Costs were collected using “cost diaries” in mailed questionnaires after 1-3-6-12-18-24 months. Costs and EQ-5D values (0 at FU after death) were carried forward. Total mean societal cost per patient for BKP and Control was SEK 160,017 (SD 151,083) and SEK 84,816 (SD 40,954), respectively. The difference was significant 75,198 (95% CI 16,037 to 120,104). The accumulated mean difference in QALYs was 0.085 (−0.132 to 0.306) units in favour of BKP. Cost per QALY gained using BKP was SEK 884,682 (EURO 92,154) with high uncertainty assessed using the bootstrapping technique, and demonstrated on the cost-effectiveness plane and on the acceptability curve. When the EQ-5D values from all patients in the FREE trials were included in a sensitivity analysis, cost/QALY was SEK 359,146 (EURO 37,411) Conclusion: Costs were significantly higher for BKP compared with standard medical treatment, with no significant difference in QALYs gained. In this selected patient population with vertebral compression fracture due to osteoporosis, BKP could not be concluded as cost-effective after two years

Aims

Osteopetrosis (OP) is a rare hereditary disease that causes reduced bone resorption and increased bone density as a result of osteoclastic function defect. Our aim is to review the difficulties, mid-term follow-up results, and literature encountered during the treatment of OP.

We have reviewed 22 patients at a mean of 30 years (28 to 31) after a whiplash injury. A complete recovery had been made in ten (45.5%) while one continued to describe severe symptoms. Persistent disability was associated with psychological distress but both improved in the period between 15 and 30 years after injury. After 30 years, ten patients (45.5%) were more disabled by knee than by neck pain.

We have reviewed our experience in managing 11 patients who sustained an indirect sternal fracture in combination with an upper thoracic spinal injury between 2003 and 2006. These fractures have previously been described as ‘associated’ fractures, but since the upper thorax is an anatomical entity composed of the upper thoracic spine, ribs and sternum joined together, we feel that the term ‘fractures of the upper transthoracic cage’ is a better description. These injuries are a challenge because they are unusual and easily overlooked. They require a systematic clinical and radiological examination to identify both lesions. This high-energy trauma gives severe devastating concomitant injuries and CT with contrast and reconstruction is essential after resuscitation to confirm the presence of all the lesions. The injury level occurs principally at T4–T5 and at the manubriosternal joint. These unstable fractures need early posterior stabilisation and fusion or, if treated conservatively, a very close follow-up.

We invited 1604 randomly selected women, all 75 years of age, to participate in a study on the risk factors for fracture. The women were divided into three groups consisting of 1044 (65%) who attended the complete study, 308 (19%) respondents to the study questionnaire only and 252 (16%) who did not respond. The occurrence of the life-time fracture was ascertained from radiological records in all groups and by questionnaires from the attendees and respondents.

According to the radiological records, fewer of the questionnaire respondents (88 of 308, 28.6%) and non-respondents (68 of 252, 27%) had sustained at least one fracture when compared with the attendees (435 of 1044, 41.7%; chi-squared test, p < 0.001). According to the questionnaire, fewer of the respondents (96 of 308, 31.1%) had sustained at least one previous fracture when compared with the attendees (457 of 1044, 43.7%; chi-squared test, p < 0.001).

Any study concerning the risk of fracture may attract those with experience of a fracture which explains the higher previous life-time incidence among the attendees. This factor may cause bias in epidemiological studies.

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

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

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