Introduction. Metatarsocuneiform (MTC) fusion is a standard treatment for arthritis, instability, and deformity of these joint. The MTC fusion achieves a good clinical outcome, but nonunion rates up to 12% have been reported. There are different methods for fixation of first MTC joint arthrodesis. Our aim was to compare the biomechanical characteristic of internal and external fixation constructs. Hypothesis. Plantar plate fixation provides higher construct stiffness and endurance stability than intraosseous fixation. Materials & Methods. Seven pairs of fresh-frozen human specimens were used in a matched pair test. In one foot the MTC joint was supplied with a plantar plate. On the other foot intraosseous-screw fixation was perfomed. The specimen constructs were loaded in a 4 point bending test. Parameters obtained were initial stiffness and number of cycles to failure. Failure was defined as displacement of more than 3 mm plantar gapping. Results. The intraosseous-screw fixation group showed significantly (p=0.002) less cycles to failure (n=2946) than the plantare plate (n=7517). The initial stiffness was 131 N/mm for the plantare plate and 43 N/mm for the intraosseous implant (p=0.005). Discussion & Conclusion. Plantar plate fixation of the first MTC fusion created a stronger and stiffer construct than intraosseous fixation. This was likely due to the plantar and dorsal implant position. A stiffer construct can reduce the risk of non-union and shorten the period of nonweight-bearing

We created virtual three-dimensional reconstruction models from computed tomography scans obtained from patients with acetabular fractures. Virtual cylindrical implants were placed intraosseously in the anterior column, the posterior column and across the dome of the acetabulum. The maximum diameter which was entirely contained within the bone was determined for each position of the screw. In the same model, the cross-sectional diameters of the columns were measured and compared to the maximum diameter of the corresponding virtual implant. We found that the mean maximum diameter of virtual implant accommodated by the anterior columns was 6.4 mm and that the smallest diameter of the columns was larger than the maximum diameter of the equivalent virtual implant. This study suggests that the size of the screw used for percutaneous fixation of acetabular fractures should not be based solely on the measurement of cross-sectional diameter and that virtual three-dimensional reconstructions might be useful in pre-operative planning

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. Methods. A total of eight cadaveric lower limb pairs were arbitrarily assigned to either 1) isolated lateral plating, or 2) lateral and medial plating of the distal femur, with four specimens per group. Contralateral limbs served as matched controls. Pre- and post-contrast MRI was performed to quantify signal intensity enhancement in the distal femur. Further evaluation of intraosseous vascularity was done with barium sulphate infusion with CT scan imaging. Specimens were then injected with latex medium and dissection was completed to assess extraosseous vasculature. Results. Quantitative MRI revealed a mean reduction of 21.2% (SD 1.3%) of arterial contribution in the lateral plating group and 25.4% (SD 3.2%) in the dual plating group (p = 0.051); representing a mean decrease in arterial contribution of 4.2%. The only significant difference found between both experimental groups was regionally, at the lateral aspect of the distal femur with a mean drop in arterial contribution in the lateral plating group of 18.9% (SD 2.6%) versus 24.0% (SD 3.2%) in the dual plating group (p = 0.048), representing a mean decrease in arterial contribution of 5.1%. Gross dissection revealed complete destruction of periosteal vessels underneath either medial or lateral plates in both groups. The network of genicular branches contributing to the posterior and distal femoral condyles was preserved in all specimens. A medial vascular pedicle was found dividing from the superficial femoral artery at a mean 12.7 cm (SD 1.7) proximal to the medial epicondyle and was undisrupted in the dual plating group. Conclusion. Lateral locking-plate application resulted in mean 21.2% reduction in distal femur vascularity. Addition of medial plates did not further markedly decrease vascularity. As such, the majority of the vascular insult occurred with lateral plating alone. Supplemental medially based fixation did not lead to marked devascularization of the distal femur, and should therefore be considered in the setting of comminution and poor bone stock in distal femoral fractures. Further clinical research is required to confirm the results of this study. Cite this article: Bone Joint J 2020;102-B(4):530–538

Aims. The Intraosseous Transcutaneous Amputation Prosthesis (ITAP) may improve quality of life for amputees by avoiding soft-tissue complications associated with socket prostheses and by improving sensory feedback and function. It relies on the formation of a seal between the soft tissues and the implant and currently has a flange with drilled holes to promote dermal attachment. Despite this, infection remains a significant risk. This study explored alternative strategies to enhance soft-tissue integration. Materials and Methods. The effect of ITAP pins with a fully porous titanium alloy flange with interconnected pores on soft-tissue integration was investigated. The flanges were coated with fibronectin-functionalised hydroxyapatite and silver coatings, which have been shown to have an antibacterial effect, while also promoting viable fibroblast growth in vitro. The ITAP pins were implanted along the length of ovine tibias, and histological assessment was undertaken four weeks post-operatively. Results. The porous titanium alloy flange reduced epithelial downgrowth and increased soft-tissue integration compared with the current drilled flange. The addition of coatings did not enhance these effects. Conclusion. These results indicate that a fully porous titanium alloy flange has the potential to increase the soft-tissue seal around ITAP and reduce susceptibility to infection compared with the current design. Cite this article: Bone Joint J 2017;99-B:393–400

A systematic literature review of distraction osteogenesis (DO) for the primary reconstruction of bone defects following resection of primary malignant tumours of long bones (PMTLB) is presented. Fewer than 50 cases were identified. Most reports relate to benign tumours or secondary reconstructive procedures. The outcomes of our own series of 7 patients is also presented (4 tibiae, 3 femora). All patients had isolated bone lesions without metastases and were assessed through the hospital sarcoma board. Mean follow-up was 59 months (17–144). Mean age was 42 years. Final histologic diagnoses were 3 chondrosarcoma, 2 malignant fibrous histiocytoma, 1 adamantinoma and 1 malignant intraosseous nerve sheath tumour. Mean bone defect after resection was 13.1cm (10–17) and bone transport was the reconstruction method in all. There was one local recurrence of tumour six months post-resection, necessitating amputation. Mean frame index for remaining cases was 30.9 days/cm (15.7–41.6). Complications included pin infection, docking site non-union, premature corticotomy union, soft-tissue infection and minor varus deformity. Six cases remain tumour-free with united, well-aligned bones and good long-term function. We conclude DO provides an effective biologic reconstruction option in select cases of PMTLB

Introduction. Intraosseous transcutaneous amputation prostheses (ITAP) provide an alternative means of attaching artificial limbs for amputees. Conventional stump-socket devices are associated with soft tissue complications including; pressure sores and tissue necrosis. ITAP resolves these problems by attaching the exo-prosthesis transcutaneously to the skeleton. The aim of this study is to increase the attachment of dermal fibroblasts to titanium alloy in vitro. Fibronectin (Fn) and laminin 332 (Ln) enhance early cell growth and adhesion. We hypothesize that silanized dual coatings of fibronectin and laminin (SiFnLn) will be more durable when compared with adsorbed dual coating (AdFnLn), and will enhance early fibroblast growth and adhesion compared to single coatings. Methods. The kinetics of dual single and dual protein coating attachment onto titanium alloy was quantified on silanized 10mm diameter discs using radiolabelled Fn (125I-Fn) and Ln (125I-Ln). Sixty discs were polished, sterilized and silanized. Coating durability was assessed when soaked in fetal calf serum (FCS) for 0, 1, 24, 48 and 72hrs. Data was compared to un-silanized Ti discs with the same coatings. Five thousand human dermal fibroblasts were seeded on discs (n = 6) of Ti polished alone (Pol), Ti with adsorbed fibronectin (AdFn), Ti with adsorbed laminin (AdLn), Ti adsorbed dual coating (AdFnLn), Ti silanized (Si), Ti silanized with fibronectin (SiFn), Ti silanized with laminin (SiLn), Ti silanized with a dual coating (SiFnLn) for 24hrs. In order to measure cell adhesion fibroblasts were fixed, vinculin stained using mouse vinculin antibody and alexa fluor. Axiovision Image Analysis software was used to measure cell area, vinculin focal adhesion markers per cell and per unit cell area. Data was analysed in SPSS and significance was assumed at the 0.05 level. Results. Silanized dual coatings bonded to Ti alloy in significantly larger quantities compared with adsorbed coatings at all time points (all p values < 0.05). Fibroblasts cultured on dual coatings were significantly larger, produced more vinculin markers per cell, and per unit cell area compared with single coatings. Cells on SiFnLn were larger with more numerous vinculin markers per cell, and per unit cell area compared with AdFnLn (p<0.05). Conclusion. This study has demonstrated that covalently bonding both fibronectin and laminin to Ti alloy provides a durable, dual coating that enhances early fibroblast growth and attachment compared with either protein coating alone in vitro. Our study showed that there is non-competitive binding of laminin on Ti surfaces in the presence of fibronectin. Dual coatings may be applied to the skin-penetrating region of transcutaneous devices to improve the skin seal and this may have positive implications for the development of ITAP

Introduction. Following amputation, residual stumps used to attach the external prostheses can be associated with sores, infection and skin necrosis. These problems could be overcome by off loading the soft tissues. Intraosseous transcutaneous amputation prostheses (ITAP) attach external implants directly to residual bone reducing these complications. However, a tight seal at the skin implant interface is crucial in preventing epithelial down-growth and infection. Fibronectin (Fn) and laminin 332 (Ln), enhance early cell growth and adhesion of keratinocytes. Silanization to titanium alloy (Ti) allows these proteins to bond to the metal directly. We hypothesize that silanized dual coatings of fibronectin and laminin (SiFnLn) will be more durable than absorbed proteins and that keratinocyte adhesion will be increased compared with Ti controls and single silanized proteins. Methods. 10 mm diameter Ti alloy discs were polished, sterilized and silanized. The kinetics of silanized single and dual protein coating attachment onto titanium alloy was quantified using radio-labelled Fn(125I-Fn) and Ln(125I-Ln). Coating durability was assessed when soaked in fetal calf serum (FCS) for 0, 1, 24, 48, 72hrs. Data was compared to un-silanized Ti discs with the same amount of adsorbed proteins. In order to study cell attachment 20 × 103 keratinocytes were seeded on the discs (n = 6): silanized (Si), silanized fibronectin (SiFn), silanized laminin (SiLn), silanized dual coating (SiFnLn) for 1, 4 and 24hrs. Adhesion of cells was assessed using mouse vinculin antibody for 2hrs and alexafluor for 1hr which stains focal adhesions responsible for attaching cells to surfaces. Axiovision Image Analysis software was used to measure cell area, vinculin markers per cell unit and per unit cell area on 15 cells per disc. Data was analysed in SPSS and significance was assumed at the 0.05 level. Results. Silanized dual coatings bonded to Ti alloy in significantly larger quantities compared with adsorbed coatings (all p values < 0.05). When proteins were combined on silanized discs the same amount of each protein was attached as when used as a single coating (i.e. non competitive binding). Keratinocytes cultured on silanized dual coatings were significantly larger, produced more vinculin markers per unit cell and per cell area compared with single coatings at all time points. Conclusion. This study has demonstrated that silanized using dual proteins on Ti alloy enhances early keratinocyte growth and attachment in vitro. It also shows that there is non-competitive binding of laminin to Ti alloys in presence of fibronectin. This may lead to improved epidermal attachment to ITAP creating a tight seal at the implant interface, which will prevent migration of the epithelium and subsequent infection in vivo

Aims

The fundamental concept of open reduction and internal fixation (ORIF) of ankle fractures has not changed appreciably since the 1960s and, whilst widely used, is associated with complications including wound dehiscence and infection, prominent hardware and failure. Closed reduction and intramedullary fixation (CRIF) using a fibular nail, wires or screws is biomechanically stronger, requires minimal incisions, and has low-profile hardware. We hypothesised that fibular nailing in the elderly would have similar functional outcomes to standard fixation, with a reduced rate of wound and hardware problems.

We hypothesised that the anterior and posterior walls of the body of the first sacral vertebra could be visualised with two different angles of inlet view, owing to the conical shape of the sacrum. Six dry male cadavers with complete pelvic rings and eight dry sacrums with K-wires were used to study the effect of canting (angling the C-arm) the fluoroscope towards the head in 5° increments from 10° to 55°. Fluoroscopic images were taken in each position. Anterior and posterior angles of inclination were measured between the upper sacrum and the vertical line on the lateral view. Three authors separately selected the clearest image for overlapping anterior cortices and the upper sacral canal in the cadaveric models. The dry bone and K-wire models were scored by the authors, being sure to check whether the K-wire was in or out.

In the dry bone models the mean score of the relevant inlet position of the anterior or posterior inclination was 8.875 (standard deviation (sd) 0.35), compared with the inlet position of the opposite inclination of –5.75 (sd 4.59). We found that two different inlet views should be used separately to evaluate the borders of the body of the sacrum using anterior and posterior inclination angles of the sacrum, during placement of iliosacral screws.

Cite this article: Bone Joint J 2015;97-B:705–10.

We describe a series of 20 patients with ununited fractures of the femoral neck following neglected trauma or failed primary internal fixation who were seen at a mean of 7.5 months (2 to 18) following injury. Open reduction and internal fixation of the fracture was performed in all patients, together with a myoperiosteal flap on the quadratus femoris muscle pedicle.

Union occurred at a mean of 4.9 months (2 to 10) in all patients. The mean follow-up was for 70 months (14 to 144). There was no further progression in six of seven patients with pre-operative radiological evidence of osteonecrosis of the femoral head. One patient had delayed collapse and flattening of the femoral head ten years after union of the fracture, but remained asymptomatic.

This study demonstrates the orthopaedic application of myoperiosteal grafting for inducing osteogenesis in a difficult clinical situation.

Coronal plane fractures of the posterior femoral condyle, also known as Hoffa fractures, are rare. Lateral fractures are three times more common than medial fractures, although the reason for this is not clear. The exact mechanism of injury is likely to be a vertical shear force on the posterior femoral condyle with varying degrees of knee flexion. These fractures are commonly associated with high-energy trauma and are a diagnostic and surgical challenge. Hoffa fractures are often associated with inter- or supracondylar distal femoral fractures and CT scans are useful in delineating the coronal shear component, which can easily be missed. There are few recommendations in the literature regarding the surgical approach and methods of fixation that may be used for this injury. Non-operative treatment has been associated with poor outcomes. The goals of treatment are anatomical reduction of the articular surface with rigid, stable fixation to allow early mobilisation in order to restore function. A surgical approach that allows access to the posterior aspect of the femoral condyle is described and the use of postero-anterior lag screws with or without an additional buttress plate for fixation of these difficult fractures.

Cite this article: Bone Joint J 2013;95-B:1165–71.

The types of explosive devices used in warfare and the pattern of war wounds have changed in recent years. There has, for instance, been a considerable increase in high amputation of the lower limb and unsalvageable leg injuries combined with pelvic trauma.

The conflicts in Iraq and Afghanistan prompted the Department of Military Surgery and Trauma in the United Kingdom to establish working groups to promote the development of best practice and act as a focus for research.

In this review, we present lessons learnt in the initial care of military personnel sustaining major orthopaedic trauma in the Middle East.