Aims. To investigate the risk factors for unsuccessful radial head reduction (RHR) in children with chronic Monteggia fractures (CMFs) treated surgically. Methods. A total of 209 children (mean age 6.84 years (SD 2.87)), who underwent surgical treatment for CMFs between March 2015 and March 2023 at six institutions, were retrospectively reviewed. Assessed risk factors included age, sex, laterality, dislocation direction and distance, preoperative proximal radial metaphysis width, time from injury to surgery, reduction method, annular ligament reconstruction, radiocapitellar joint fixation, ulnar osteotomy, site of ulnar osteotomy, preoperative and postoperative ulnar angulation, ulnar fixation method, progressive ulnar distraction, and postoperative cast immobilization. Independent-samples t-test, chi-squared test, and logistic regression analysis were used to identify the risk factors associated with unsuccessful RHR. Results. Redislocation occurred during surgery in 48 patients (23%), and during follow-up in 44 (21.1%). The mean follow-up of patients with successful RHR was 13.25 months (6 to 78). According to the univariable analysis, time from injury to surgery (p = 0.002) and preoperative dislocation distance (p = 0.042) were identified as potential risk factors for unsuccessful RHR. However, only time from injury to surgery (p = 0.007) was confirmed as a risk factor by logistic regression analysis. Receiver operating characteristic curve analysis and chi-squared test confirmed that a time from injury to surgery greater than 1.75 months increased the rate of unsuccessful RHR above the cutoff (p = 0.002). Conclusion. Time from injury to surgery is the primary independent risk factor for unsuccessful RHR in surgically treated children with CMFs, particularly in those with a time from injury to surgery of more than 1.75 months. No other factors were found to influence the incidence of unsuccessful RHR. Surgical reduction of paediatric CMFs should be performed within the first two months of injury whenever possible. Cite this article: Bone Jt Open 2024;5(7):581–591

Aims. Orthopaedic and reconstructive surgeons are faced with large defects after the resection of malignant tumours of the sacrum. Spinopelvic reconstruction is advocated for resections above the level of the S1 neural foramina or involving the sacroiliac joint. Fixation may be augmented with either free vascularized fibular flaps (FVFs) or allograft fibular struts (AFSs) in a cathedral style. However, there are no studies comparing these reconstructive techniques. Methods. We reviewed 44 patients (23 female, 21 male) with a mean age of 40 years (SD 17), who underwent en bloc sacrectomy for a malignant tumour of the sacrum with a reconstruction using a total (n = 20), subtotal (n = 2), or hemicathedral (n = 25) technique. The reconstructions were supplemented with a FVF in 25 patients (57%) and an AFS in 19 patients (43%). The mean length of the strut graft was 13 cm (SD 4). The mean follow-up was seven years (SD 5). Results. There was no difference in the mean age, sex, length of graft, size of the tumour, or the proportion of patients with a history of treatment with radiotherapy in the two groups. Reconstruction using an AFS was associated with nonunion (odds ratio 7.464 (95% confidence interval (CI) 1.77 to 31.36); p = 0.007) and a significantly longer mean time to union (12 months (SD 3) vs eight (SD 3); p = 0.001) compared with a reconstruction using a FVF. Revision for a pseudoarthrosis was more likely to occur in the AFS group compared with the FVF group (hazard ratio 3.84 (95% CI 0.74 to 19.80); p = 0.109); however, this was not significant. Following the procedure, 32 patients (78%) were mobile with a mean Musculoskeletal Tumor Society Score 93 of 52% (SD 24%). There was a significantly higher mean score in patients reconstructed with a FVF compared with an AFS (62% vs 42%; p = 0.003). Conclusion. Supplementation of spinopelvic reconstruction with a FVF was associated with a shorter time to union and a trend towards a reduced risk of hardware failure secondary to nonunion compared with reconstruction using an AFS. Spinopelvic fixation supplemented with a FVF is our preferred technique for reconstruction following resection of a sacral tumour. Cite this article: Bone Joint J 2021;103-B(8):1414–1420

Introduction. The incidence of distal femoral fractures in the geriatric population is growing and represents the second most common insufficiency fracture of the femur following fractures around the hip joint. Fixation of fractures in patients with poor bone stock and early mobilisation in feeble and polymorbide patients is challenging. Development of a fixation approach for augmentation of conventional LISS (less invasive stabilization system) plating may result in superior long-term clinical outcomes and enhance safe weight bearing. Objectives. The aim of this study was to investigate the biomechanical competence of two different techniques of augmented LISS plating for treatment of osteoporotic fractures of the distal femur in comparison to conventional LISS plating. Materials & methods. Unstable distal femoral fracture AO/OTA 33-A3 was set in artificial femora with low density simulating osteoporotic bone. Three study groups, consisting of 10 specimens each, were created for instrumentation with a 9-hole LISS plate, a LISS plate with an additional 3D-printed polyactide cylindrical intramedullary graft, as well as a LISS plate plus a medial 3.5mm LCP (locking compression plate) - double plating. All specimens were non-destructively tested under axial (20–150N) and torsional (0–4Nm) quasi-static loading. Each construct was tested with two different working length (WL) configurations (long and short) of the LISS plate. Relative movements between the most medial superior and inferior osteotomy aspects were investigated via three-dimensional motion tracking analysis. Results. Interfragmentary displacement along the femur axis (mm) under 150N axial loading was 2.03±0.23/1.65±0.27 for LISS with long/short WL, 0.18±0.06/0.18±0.04 for double plating with long/short WL, and 0.40±0.05/0.30±0.05 for LISS plus graft with long/short WL. Shear interfragmentary displacement (mm) under 4Nm torsional loading in internal rotation was 1.16±0.17/0.92±0.11 for LISS with long/short WL, 0.40±0.10/0.43±0.07 for double plating with long/short WL, and 1.09±0.13/0.82±0.11 for LISS plus graft with long/short WL. Double plating revealed significantly smaller longitudinal and shear displacement compared to the other two techniques for long and short WL, respectively (P≤0.010). In addition, LISS plus graft fixation was with significantly less longitudinal displacement in comparison to conventional LISS plating for long and short WL, respectively (P≤0.001). Long WL resulted in significantly higher longitudinal and shear displacement compared to short WL for LISS and LISS plus graft (P≤0.032), but not for double plating (P=1.000). Conclusion. Intramedullary grafting resulted in significantly increased fracture stability under axial loading in comparison to conventional LISS plating. However, it was not efficient enough to achieve comparable stability to double plating

Aims

Rotating-hinge knee prostheses are commonly used to reconstruct the distal femur after resection of a tumour, despite the projected long-term burden of reoperation due to complications. Few studies have examined the factors that influence their failure and none, to our knowledge, have used competing risk models to do so. The purpose of this study was to determine the risk factors for failure of a rotating-hinge knee distal femoral arthroplasty using the Fine-Gray competing risk model.

Introduction. Lesser toe proximal interphalangeal joint arthrodesis is a common forefoot procedure for correction of claw toe deformities. The most common method of fixation is with k-wires. Although this is a very cost-effective method of fixation, well-known disadvantages include pin site infection, non union, wire migration and the inconvenience to the patients of percutaneous wires for up to six weeks. For these reasons, intramedullary devices for joint fixation without crossing the distal IP joint have been developed. Many different designs are currently available. The Smart Toe prosthesis which has appeared as a type I and II, is one such implant. In two recent studies using type I, the use of this implant is advocated. We wish to present our experience with the use of the Smart Toe II. Methods. In this retrospective study we present a radiological review of 46 consecutive cases in 25 patients who underwent lesser toe interphalangeal arthrodeses using the Smart Toe II implant between July 2010 and November 2014 by the senior author. There were 7 (28%) male and 18 (72%) female patients. Post operative radiographs, taken at a mean follow up of 6 months, were reviewed for non-union, migration and implant failure. Results. There were 9 (20%) implant fractures, 10 (22%) radiological non- unions and 5 (11%) implant migrations. 4 toes (9%) were sufficiently symptomatic to require revision. Conclusion. In contrast to two previous studies, our series showed a high rate of implant fracture and non-union, sometimes leading to the need for revision surgery. We recommend caution in use of the Smart Toe II and welcome further reports of results. If our experience is replicated, we suggest the device's use is withheld pending appropriate studies to identify and address the reasons for implant failure, especially if more of the radiological failures come to require revision

Between 1982 and 2000, 37 cases of fractures of the odontoid process were treated at Hirosaki University Hospital. There were 16 females and 21 males, with an average age of 43.9 and 37.7 respectively. Twenty-three of 37 were type II and 14 were type III by the classification of Anderson and D’Alonzo. Eight of type II were old fractures. Nineteen of them were injured in traffic accidents, 9 in accidental falls from a height, 4 by falling down, 2 in lumbering accidents and 3 by unknown causes. Severe neurological disorders were recognized in 7, mild in 12 and 22 had no neurological disorders. Neurological disorders were correlated with SAC (space available for spinal cord) at C1-2. Twenty-two of type II (95.7%) and 10 of type III (71%) were treated surgically. Surgical methods were anterior screw fixation of the odontoid process in 7, anterior atlanto-axial joint fixation in 3, posterior atlanto-axial joint fixation in 5, posterior occipito-cervical fusion in 3, anterior and posterior combined fixation of the atlanto-axial joint in 2 and others in 2. Bone union was obtained in 18 (81.8%) of type II and 10 (100%) of type III by the primary operations. There was no nonunion in anterior screw fixation cases. Nonunion occured in one of type II (100%) and 2 of type III (50%) treated nonoperatively. Two of them were operated for nonunion. One of them remained nonunion by two additional operations. No case of nonunion showed neurological deterioration for 91.8 months after treatment on average. Anterior direct screw fixation of the odontoid process is superior to the other methods in the point of immobilization of the odontoid fragment without limiting the motion of the atlanto-axial joint. We recommend anterior direct screw fixation of the odontoid process as a first choice of the surgical method for fresh fractures of the odontoid process in cases with reduced fragments

Introduction. Haemodynamically compromised patients with biomechanically unstable pelvic fractures need reduction of the pelvic volume to effect tamponade of bleeding bone and vessels. Knee binding, to help achieve this, is advocated in standard Advanced Trauma and Life Support teaching but is rarely used. There are no reports in the literature as to the benefits derived from this simple manoeuvre. The aim of this study was to investigate whether there was an effect on symphysis pubis closure by binding the knees together and to quantify this. Methods. 13 consecutive patients who underwent open reduction and internal fixation of pubic symphysis diastasis +/− sacroiliac joint fixation were recruited prospectively. These patients were transferred from peripheral hospitals to this National tertiary referral level 1 trauma centre for definitive pelvic fracture management. All patients had sustained Antero-Posterior Compression (APC) type pelvic injuries. In theatre, a centred antero-posterior (AP) radiograph was taken without any form of binding on the pelvis. A second AP radiograph was then taken with the knees and ankles held together with the hips internally rotated. A third, final AP radiograph was taken post fixation. Measurements of symphysis pubis widening were made of the digital images taken in theatre. Results. The study population included 11 men and 2 women. The mean age was 46. The average percentage closure of symphysis following knee binding in relation to the final reduced symphysis, post fixation was 69%. Conclusion. Our impression is that this manoeuvre is rarely employed on patients with these types of injury. This is the first study to quantify the effects of this simple manoeuvre. Emergency measures to reduce the pelvic volume and thus limit pelvic haemorrhage are well recognised. We have shown that this simple measure is a useful adjunct and that it has a measurable effect on reducing pubic diastasis

Total knee arthroplasty (TKA) is reliable, durable, and reproducible in relieving pain and improving function in patients with arthritis of the knee joint. Cemented fixation is the gold standard with low rates of loosening and excellent survivorship in several large clinical series and joint registries. While cementless knee designs have been available for the past 3 decades, changing patient demographics (i.e. younger patients), improved implant designs and materials, and a shift towards TKA procedures being performed in ambulatory surgery centers has rekindled the debate of the role of cementless knee implants in TKA. The drive towards achieving biologic implant fixation in TKA is also driven by the successful transition from cemented hip implants to uncemented THA. However, new technologies and new techniques must be adopted as a result of an unmet need, significant improvement, and/or clinical advantage. Thus, the questions remain: 1) Why switch; and 2) Is cementless TKA more reliable, durable, or reproducible compared to cemented TKA?. There are several advantages to using cement during TKA. First, the technique can be universally applied to all cases without exception and without concerns for bone health or structure. Second, cement can mask imprecisions in bone cuts and is a remarkably durable grout. Third, cement allows for antibiotic delivery at the time surrounding surgery which has been shown in some instances to reduce the risk of subsequent infection. Finally, cement fixation has provided successful and durable fixation across various types knee designs, surface finishes, and articulations. On the other hand, cementless knee implants have had an inconsistent track record throughout history. While some have fared very well, others have exhibited early failures and high revision rates. Behery et al. reported on a series of 70 consecutive cases of cementless TKA matched with 70 cemented TKA cases based on implant design and demographics and found that cementless TKA was associated with a greater risk of aseptic loosening and revision surgery at 5 years follow up. Finally, to date, there has not been a randomised controlled clinical trial demonstrating superiority of cementless fixation compared to cemented fixation in TKA. Improvements in materials and designs have definitely made cementless TKA designs viable. However, concerns with added cost, reproducibility, and durability remain. Cement fixation has withstood the test of time and is not the main cause of TKA failure. Therefore, until there is significant data showing that cementless TKA is more durable, reliable, and reproducible compared to cemented TKA, the widespread use of these implants cannot be recommended

Purpose: 2–5 years results in the treatment of deep infection of total knee arthroplasty (TKA) after two-stage reimplantation are presented. An articulating antibiotic spacer prosthesis and a standardized antibiotic therapy were used. Material and Methods: In a prospective study 33 consecutive patients were treated with the articulating spacer, which was made on the table by cleaning and autoclaving removed parts of the infected TKA. A parenteral double antibiotic therapy in combination with rifampin was given for 10 days, followed by oral therapy for 4 weeks. Results: At a mean follow-up period of 47 months (31 to 67) three patients had reinfection (success rate 91 %). We could increase the average Hospital for Special Surgery knee score from 67 points (44 to 84) to 87 points (53 to 97) after reimplantation. Based on these results, 25 knees (76 %) were rated excellent, 5 knees (15 %) were rated good, 2 knees (6 %) were rated fair and one patient (3 %) had a poor result. Complications were one temporary peroneal palsy, one luxation of the spacer due to insufficient extensor mechanism and one fracture of the tibia due to substantial primary metaphyseal bone loss. Conclusion: Using articulating spacer prosthesis disadvantages of joint fixation between the two stages could be reduced. There is no difference in the reinfection rate compared to procedures using fixed spacer blocks. It facilitates the reimplantation and gives good functionel results

Osteoarthritis (OA) is a disease of the joints stemming from a variety of factors, including joint injuries and abnormally high mechanical loading. Although the traditional treatment alternatives for end-stage OA are arthroplasty in the case of the hip and knee, and arthroplasty or arthrodesis in the case of the ankle, these options are not ideal for younger, more active patients. For these patients, joint prostheses would be expected to fail relatively quickly, and ankle fusion is not amenable to maintaining their active lifestyles. In these cases, joint distraction has attracted investigative attention as a conservative OA treatment for younger patients. 9-14. . Based on the principle that decreasing the mechanical load on cartilage stimulates its regeneration. 15. , distraction treatment calls for reduced loading of the joint during a period of typically 3 months, during which time the load customarily passing through the joint is taken up by an external fixator spanning the joint . By mounting the fixator components to the bone on each side of the joint, and then lengthening the rods connecting the proximal and distal portions of the fixator, the joint is distracted. Assuming the fixation is appropriately stiff, any load passes through the fixator instead of the joint, and the two articular surfaces will not be allowed to contact each other under physiologic loading. The exact mechanisms leading to cartilage regeneration during distraction are not yet understood. A possible negative consequence of joint fixation is cartilage degeneration due to immobilization during the treatment. It has been shown by Haapala et al. and others that long-term immobilization can be detrimental to articular cartilage. 16-18. . Conversely, joint motion during fixation (even passive motion) is thought to stimulate or encourage cartilage regeneration. 19-22. Toward this end, considerable effort has been invested in the application of hinges to external fixation for joints Joint motion has also been suggested as a potentially beneficial factor in distraction treatment, as well. 10. This is borne out by data from an RCT comparing the use of a rigid vs motion external fixator. Change in joint biology due to resorption of cysts may be responsible for reversal of symptoms

Background: It is commonly believed that early motion after joint fixation is a good thing, especially in the upper limb, but in the ankle joint this is much less clear. No previous systematic review of the evidence for this could be found in the literature. Materials and Methods: Nine randomised Control Trials were identified which met the inclusion criteria and compared early motion of the ankle joint to immobilisation in a cast for six weeks. These varied in quality and numbers. All treated patients equally in all other respects including weight bearing. Where outcome measures were similar, some meta-analysis was possible. Results: There is good evidence that early motion results in a quicker return to work on average (p=0.008) and results in improved range of motion at 12 weeks (dorsiflexion p= 0.001; plantarflexion p < 0.00001) compared to cast immobilisation. However it also results in an increased risk of wound infection (p=0.002). There is a suggestion that early motion results in a lower rate of deep vein thrombosis, but this is not quite significant (p=0.12). There is no evidence that it results in improved joint specific outcome scores or range of motion at 1 year. Discussion: It is difficult to state that early motion is better or worse than cast immobilisation for every patient. The evidence suggests however that a young fit patient who needs to return to work may benefit from early motion of the ankle joint whereas an older diabetic patient with poor skin would be better treated in cast

Periprosthetic fractures involving the femoral meta/diaphysis can be treated in various fashions. The overall incidence of those fractures after primary total knee arthroplasties (TKA) ranges from 0.3 to 2.5%, however, can increase above 30% in revision TKA, especially in older patients with poorer bone quality. Various classifications suggest treatment algorithms. However, they are not followed consequently. Revision arthroplasty becomes always necessary if the implant becomes loose. Next, it should be considered in case of an unhappy TKA prior to the fracture rather than going for an osteosynthesis. Coverage of the associated segmental bone loss in combination with proximal fixation, can be achieved in either cemented or non-cemented techniques, with or without the combination of osteosynthetic fracture stabilization. Severe destruction of the metaphyseal bone, often does not allow adequate implant fixation for the revision implant and often does not allow proper anatomic alignment. In addition the destruction might include loss of integrity of the collaterals. Consequently standard or even revision implants might not be appropriate. Although first reports about partial distal femoral replacement are available since the 1960´s, larger case series or technical reports are rare within the literature and limited to some specialised centers. Most series are reported by oncologic centers, with necessary larger osseous resections of the distal femur. The implantation of any mega prosthesis system requires meticulous planning, especially to calculate the appropriate leg length of the implant and resulting leg length. After implant and maybe cement removal, non-structural bone might be resected. Trial insertion is important due to the variation of overall muscle tension and recreation of the former joint line. So far very few companies offer yet such a complete, modular system which might also be expanded to a total femur solution. Furthermore it should allow the implantation of either a cemented or uncemented diaphyseal fixation. In general, the fracture should be well bridged with a longer stem in place. At least 3 cm to 5 cm of intact diaphysis away to the fracture site is required for stable fixation for both cemented and cementless stems. Application of allograft struts and cables maximises the biomechanical integrity of the fracture zone to promote fracture repair and implant fixation. Modular bridging systems do allow centimeter wise adaption distally, to the knee joint. Consequently in modern systems fully hinged or rotational hinge knee systems can be coupled, and adjusted accordingly to the patellar tracking and joint line. Fixation of the tibial component can be achieved in uncemented and cemented techniques. We still prefer the latter. Although a reliable and relatively quick technique, frequent complications for all mega systems have been described. These usually include infections, rotational alignment and loosening of the femoral fixation or subsequent proximal femoral fractures. Infections usually can be related to large soft tissue compromise or extensive exposure or longer procedure times. Thus implantation of such reconstruction systems should be reserved to specialised centers, with adequate facilities experience, in order to minimise complications rates and optimise patients function postoperative

Introduction: The Collagen Meniscus Implant (CMI) has been shown to be effective for the replacement of lost medial meniscus tissue; however, no such device has been available for treatment of similar injuries to the lateral meniscus. Loss of the lateral meniscus results in a rapidly increased rate of knee degeneration compared to similar medial injuries. The purpose of this study was to determine if a CMI developed for use in treatment of lateral meniscus deficiencies is as safe and effective as has been reported for the medial CMI. Methods: Prospectively, 60 patients (12–65 years of age) were enrolled at 7 sites between March 2006 and October 2007. Patients had irreparable lateral meniscus tears requiring partial meniscectomy. The knee had to be ligamentously stable and in neutral alignment and with no untreated Grade IV cartilage damage. Patients gave informed consent and agreed to comply with postoperative assessments and standardized rehabilitation. The surgical technique involved insertion of the dry implant into the lateral compartment of the knee joint. Fixation of the implant to the host meniscus rim was accomplished with either an all-inside suture technique or a hybrid all-inside/inside-out technique. Clinical evaluations and patient self-assessments were conducted preoperatively and at defined intervals through 2 years postoperatively. Procedure specific intraoperative parameters, radiographic evaluations, and adverse events were documented. Data collection was monitored by a third party according to GCP regulations. Results: 49 patients received a lateral CMI. Currently, 24 patients have 1-year follow-up and 13 patients have been followed approximately 2 years; the mean follow-up is 22 months. Follow-up included assessments of changes in Lysholm, pain, Tegner and patient satisfaction. All patients showed clinical improvement from the preoperative to the 1 year postoperative time points. Four patients experienced adverse events which required an additional arthroscopic procedure between 4 and 16 months and included removal of implant remnants, synovectomy and debridement. Conclusions: These preliminary results appear to suggest that implantation of lateral CMI leads to improved clinical outcomes in pain, function, self-assessment and activity levels. Frequency and type of adverse events are comparable to those for suture repair reported in the literature. Based on results reported for the medical CMI, we anticipate that these lateral CMI patients will have improved long-term results compared to partial lateral meniscectomy

Aims

Patient-specific instrumentation of total knee arthroplasty (TKA) is a technique permitting the targeting of individual kinematic alignment, but deviation from a neutral mechanical axis may have implications on implant fixation and therefore survivorship. The primary objective of this randomized controlled study was to compare the fixation of tibial components implanted with patient-specific instrumentation targeting kinematic alignment (KA+PSI) versus components placed using computer-assisted surgery targeting neutral mechanical alignment (MA+CAS). Tibial component migration measured by radiostereometric analysis was the primary outcome measure (compared longitudinally between groups and to published acceptable thresholds). Secondary outcome measures were inducible displacement after one year and patient-reported outcome measures (PROMS) over two years. The secondary objective was to assess the relationship between alignment and both tibial component migration and inducible displacement.

Aims

Plate and screw fixation has been the standard treatment for painful conditions of the wrist in non-rheumatoid patients in recent decades. We investigated the complications, re-operations, and final outcome in a consecutive series of patients who underwent wrist arthrodesis for non-inflammatory arthritis.

Wrist arthrodesis is a common surgical procedure that provides a high level of functional outcome and pain relief among patients.[1] Upon partial arthrodesis, the wrist experiences changes in load transmission that are influenced by the type of arthrodesis performed. Measuring the load through the wrist joint is difficult, however, combined with computational models [2], it is possible to obtain data regarding the load mechanics of the wrist joint. Although successful fusion rates among patients have been reported, it remains unclear what the biomechanical consequences are. The aim of the study is to quantify pre and post operative load transmission through a cadaveric wrist which has undergone simulated arthrodesis of the radiolunate(RL) joint. An embalmed human wrist was dissected dorsally exposing distal radius, radiocarpal and carpometacarpal joints, and dorsal ligaments. The radioscaphoid(RS) ligament was sacrificed to accommodate insertion of a PPSEN-09375 force sensitive resistor (FSR) into the RS joint. The FSR was calibrated prior to measuring the contact force on the RS joint. The wrist was aligned in the neutral position in cardboard piping, and secured proximally and distally with Dental Plaster (OthoBock Healthcare Plc, Surrey, UK). The midsection of piping was windowed to permit placement of the FSR in the RS joint, and fixation of the RL joint using 2 Kirschner wires. The window was completed circumferentially and the specimen was placed in the Instron where a graduated axial compression was applied at 20 N/min. The results showed that when the radiolunate joint is fused, and a total axial load of 100N is applied, the load transmitted through the RS joint was approx 65N. i.e. 65% of the force. This is greater than the 56% measured experimentally by Blevens et al (1989) in an unfused specimen[3]. We plan to repeat our measurements and compare to an untreated cadaveric wrist

Aims

Fractures of the navicular can occur in isolation but, owing to the intimate anatomical and biomechanical relationships, are often associated with other injuries to the neighbouring bones and joints in the foot. As a result, they can lead to long-term morbidity and poor function. Our aim in this study was to identify patterns of injury in a new classification system of traumatic fractures of the navicular, with consideration being given to the commonly associated injuries to the midfoot.

Atlanto-axial rotatory fixation is one of a spectrum of rotatory abnormalities of the atlanto-axial joint. Rotatory fixation without anterior displacement of the atlas (Type I) has been reported in only a few cases in which there has been a prolonged interval between injury and diagnosis. The majority of these cases eventually required cervical fusion for persistent deformity or instability. Two cases are presented in which this diagnosis was made early with the aid of rotated odontoid radiographs, tomography and computerised axial tomography. Treatment by a short period of halter traction achieved reduction and early return of function. The authors conclude that early recognition and treatment of this rare condition may prevent the subsequent deformity and instability for which cervical fusion has been required

We report a prospective trial of 66 patients with intraarticular fractures of the calcaneum. All fractures were assessed by CT. Patients with displaced fractures were randomised to receive either conservative (n = 31) or operative treatment (n = 25). Undisplaced fractures (n = 10) were treated conservatively. Operation involved open reduction of the posterior subtalar joint, and fixation with Kirschner wires. All 66 patients were reviewed at a minimum of one year (mean 23 months). After conservative treatment the undisplaced fractures had slightly better results than the displaced fractures. There was no significant difference in outcome between the operatively and the conservatively treated displaced fractures. We have also documented prospectively the natural history of the injury, which is of use in assessing prognosis for both clinical and medicolegal purposes

Children with congenital vertical talus (CVT) have been treated with extensive soft-tissue releases, with a high rate of complications. Recently, reverse Ponseti-type casting followed by percutaneous reduction and fixation has been described, with excellent results in separate cohorts of children with CVT, of either idiopathic or teratological aetiology. There are currently no studies that compare the outcome in these two types. We present a prospective cohort of 13 children (21 feet) with CVT of both idiopathic and teratological aetiology, in which this technique has been used. Clinical, radiological and parent-reported outcomes were obtained at a mean follow-up of 36 months (8 to 57). Six children (nine feet) had associated neuromuscular conditions or syndromes; the condition was idiopathic in seven children (12 feet).

Initial correction was achieved in all children, with significant improvement in all radiological parameters. Recurrence was seen in ten feet. Modification of the technique to include limited capsulotomy at the initial operation may reduce the risk of recurrence.

The reverse Ponseti-type technique is effective in the initial correction of CVT of both idiopathic and teratological aetiology. Recurrence is a problem in both these groups, with higher rates than first reported in the original paper. However, these rates are less than those reported after open surgical release.

Cite this article: Bone Joint J 2014;96-B:274–8.