There is still no consensus on which concentration of mesenchymal stem cells (MSCs) to use for promoting fracture healing in a rat model of long bone fracture. To assess the optimal concentration of MSCs for promoting fracture healing in a rat model. Wistar rats were divided into four groups according to MSC concentrations: Normal saline (C), 2.5 × 106 (L), 5.0 × 106 (M), and 10.0 × 106 (H) groups. The MSCs were injected directly into the fracture site. The rats were sacrificed at 2 and 6 자 post-fracture. New bone formation [bone volume (BV) and percentage BV (PBV)] was evaluated using micro-computed tomography (CT). Histological analysis was performed to evaluate fracture healing score. The protein expression of factors related to MSC migration [stromal cell-derived factor 1 (SDF-1), transforming growth factor-beta 1 (TGF-β1)] and angiogenesis [vascular endothelial growth factor (VEGF)] was evaluated using western blot analysis. The expression of cytokines associated with osteogenesis [bone morphogenetic protein-2 (BMP-2), TGF-β1 and VEGF] was evaluated using real-time polymerase chain reaction. Micro-CT showed that BV and PBV was significantly increased in groups M and H compared to that in group C at 6 wk post-fracture (P = 0.040, P = 0.009; P = 0.004, P = 0.001, respectively). Significantly more cartilaginous tissue and immature bone were formed in groups M and H than in group C at 2 and 6 wk post-fracture (P = 0.018, P = 0.010; P = 0.032, P = 0.050, respectively). At 2 wk post fracture, SDF-1, TGF-β1 and VEGF expression were significantly higher in groups M and H than in group L (P = 0.031, P = 0.014; P < 0.001, P < 0.001; P = 0.025, P < 0.001, respectively). BMP-2 and VEGF expression were significantly higher in groups M and H than in group C at 6 wk postfracture (P = 0.037, P = 0.038; P = 0.021, P = 0.010). Compared to group L, TGF-β1 expression was significantly higher in groups H (P = 0.016). There were no significant differences in expression levels of chemokines related to MSC migration, angiogenesis and cytokines associated with osteogenesis between M and H groups at 2 and 6 wk post-fracture. The administration of at least 5.0 × 106 MSCs was optimal to promote fracture healing in a rat model of long bone fractures

This edition of Cochrane Corner looks at some of the work published by the Cochrane Collaboration, covering pharmacological interventions for the prevention of bleeding in people undergoing definitive fixation or joint replacement for hip, pelvic, and long bone fractures; interventions for reducing red blood cell transfusion in adults undergoing hip fracture surgery: an overview of systematic reviews; and pharmacological treatments for low back pain in adults: an overview of Cochrane Reviews

Objectives. Fracture non-union poses a significant challenge to treating orthopaedic surgeons. These patients often require multiple surgical procedures. The incidence of complications after Autologous Bone Graft (ABG) harvesting has been reported up to 44%. These complications include persistent severe donor site pain, infection, heterotopic ossification and antalgic gait. We retrospectively compared the use of BMP-7 alone in long bone fracture Non-union, with patients in whom BMP-7 was used in combination with the Autologous Bone Graft (ABG). Material and Methods. The databases of our dedicated Limb Reconstruction Unit were searched for patient with three common long bone fractures Non-unions (Tibia, Femur and Humerus). The patients who had intra-operative use of Bone Morphogenetic Protein (BMP-7) alone and in combination with ABG were evaluated. 53 Patients had combined use of ABG and BMP-7, and 65 patients had BMP-7 alone. Results. In the ABG and BMP-7 group, the union rate for femoral (n=18) Non-unions was 83%, for humeral (n=16) Non-unions 81%, and for tibia (n=19) Non-unions it was 47%. In the BMP-7 alone group, 83% of the femoral (n=12) Non-unions, 87% of the humeral (n=16) and 56% of the tibial (n=37) Non-unions healed. The common risk factors for Non-union were comparable in both the groups and included location and nature (open vs closed) of fracture, infection, smoking and NSAIDs use. The average time to union in ABG+BMP-7 group was 8.1 months (range 3-30 months) and in BMP-7 alone group it was 7.2 months (range 3-24 months). Conclusion. Autologous Bone Grafting has a pivotal role in limb reconstruction surgery but its indication should be carefully evaluated in view of considerable morbidity associated with graft donor site. Our study did not show any significant difference in the union rates of common long bone fracture Non-unions treated with BMP-7 alone or with a combination of Autologous Bone Graft and BMP-7

We report our clinical experience with the first 54 cases of long bone fractures treated with the Fixion IM Nail. This innovative nailing system eliminates the need for interlocking screws and reaming of the medullary canal when the nailing of a long bone fracture is needed, offers a minimally invasive procedure for intramedullary nailing, and significantly reduces fluoroscopy exposure. Biomechanically, the nail assumes the hourglass shape of the medullary canal by its abutment to the medullary walls. The formation of a supporting forces entity, that could be defined as “the bone-nail supporting forces system entity,” becomes practically an integral part of the medullary walls at the points of attachment. In order to avoid using interlocking screws and reaming of the medullary canal when the nailing of a long bone fracture is required, the “FIXION IMN” system was proposed. Since March 1999 we have implanted 54 Fixion Intramedullary Nails for traumatic and pathological fractures in 50 patients with a mean age of 52 years (18 to 85). Among these patients, 33 had humeral fractures, 13 had tibial fractures, and 8 had femoral fractures; the pathological fracture cases consisted of 4 humeral cases and 1 femoral case. The Fixion IM Nail system consists essentially of four longitudinal bars connected radially by four thin membranes. The nail is sealed proximally with a unidirectional valve. During insertion, the nail is connected to a driver handle which assists with insertion and serves as a conduit for the saline during the expansion process. Inflation of the nail is by means of a pump that connects to the driver handle. Once in position, the nail is expanded by inflation under controlled pressure with saline. The expansion causes abutment of the longitudinal bars to the inner surface of the canal along the entire length, resulting in fixation of the fracture. The procedure is monitored fluoroscopically and clinically to ensure accurate reduction of the fracture. The surgeries were uneventful. Postoperative complications were not reported in any of the cases. The nail was inserted easily and good fixation was achieved. The patients made a complete recovery with early pain-free mobilisation and full range of motion

Objective. To investigate the outcomes of patients following the chipping procedures as an alternative to bone grafting in treatment of non-unions after long bone fracture. Patients. Sixteen patients with femoral or tibial non-union were included. The median follow-up was 24 months. Intervention. Non-unions were treated by the chipping procedure and re-install of an intramedullary nail or locked plate(s) without bone grafting. Main Outcome Measurements. Radiographic bone union, walking ability, and complication were evaluated. Results. Fourteen non-unions clinically and radiographically healed with a median time of 7.5 months. For these cases, patients were able to walk without walking aids within 9 months after surgery. Pre-existing deformities (e.g., varus and mal-external rotation) were anatomically corrected after the revision surgery for non-union. Radiographic consolidation could not been obtained for two cases within 12 months after chipping procedures; one nonunion after old osteomyelitis and another after supracondylar fracture. Lack of stability at chipping site may be one of the reasons for failure of the procedures. Post-operative temporal anemia and swelling of the thigh were common complications after surgery. Conclusions. Chipping the non-union site was likely to enhance fracture healing, and this technique was useful as an alternative to bone grafting in treatment of femoral non-union, especially for both atrophic and hypertrophic non-unions with deformities

Purpose: To evaluate the use of locked Compression Plate (L.C.P.) in metaphyseal long bones fractures, and report our preliminary results. Materials and Methods: 23 patients 14–82 years old with long bones metaphyseal fractures underwent surgery with the use of L.C.P. between January 2004 and August 2004. Four patients were adolescents. 7 patients had Supracondylar femoral fracture. One of them had the fracture at the tip of IMN. 11 patients had distal Tibia, one had proximal+midshaft tibia and 4 had distal humerus fractures. All plates were prebended to fit the area of the fracture using a skeleton model. The plates were inserted percutaneously with reduction of the fracture. Partial weight bearing started after 6 weeks and full weight bearing started after 12 weeks. Results: Unuion was seen in x-ray after 6 to 12 week in 95% of patients. 20 patients regained full range of motion of the adjacent joints at 3 months follow-up. Complications: One patient developed compartment Syndrome in a high energy tibial fracture. One patient developed deep infection at the site of fibular plate not affecting the L.C.P. at the tibia. One patient developed temporary weakness of extensor Hallucis longus. Conclusions: L.C.P. proved to be effective in fixation of meta-epiphyseal zones which are difficult in IMN fixation. The use of this plate enables fixation of long bones in adolescents with open growth plate. The locking system enables good fixation of osteoporotic bones and in periprosthetic fracture. The high primary stability in combination with newly developed minimal-invasive techniques (MIPO = minimal invasive plate osteosynthesis) are the bases for a rapid bony consolidation, a low complication rate and good functional results

Closed manipulation of long bone fractures is often a difficult problem. Muscles and soft tissues along with gravity, acting along the fracture fragments, can cause complex displacement and deformity at the fracture site. At the same time surgeons have to rely on human assistants to manipulate and realign these fractures. This depends a lot on their individual skills and furthermore human assistants are prone to fatigue and are liable to imprecise movements. A robotic device has precision, accuracy, and steadiness along with the ability to be programmed. The purpose of this study is to conceptualize a device, which can aid orthopaedic surgeons to manipulate long bone fractures. Extensive literature search was done using the Internet and conventional resources, to find recent developments in the use of robotics in trauma and fracture surgery. Different models of robots were considered and finally a parallel robot of the Stewart platform type was considered to be of the design that will be more compatible with an orthopaedic operating environment. Computer aided design and graphics modelling of the robot was done and range of motion and force it can generate was calculated. The prototype that was built had six degrees of freedom and enough force and range of motion to reduce and manipulate long bone fractures. The actual controlling interface of the robot through a PC was established. It is possible to build a robot for manipulating long bone fractures. Further research is being done to focus on the integration of the robot to fluoroscopic images and designing the correct attachment tools for the extremities

Last decade intramedullary nailing is the choice method for the treatment of lower extremity’s long bone fractures. This method matches much better the biomechanics of bones and therefore it leads to faster and better fracture porosis. The aim of our study is to record our experience of using intramedullary nailing and other methods of osteosynthesis for femur and tibia fractures and pseudarthrosis. During the last 6 years we treated 264 with long bone fractures. One hundred ninety two of them are available at least for 2 years postoperatively. Patients with major health problems or tumors were excluded. From this group of patients 116 were men and 76 women with mean age 42 years (16 up to 75). They had 107 tibial fractures, 81 femoral fractures, 12 tibial pseudarthrosis and 3 femoral pseudarthrosis. We used reamed or undreamed intramedullary nails for 64 tibial and 52 femoral fractures and we used other methods (internal fixation with plates, external fixation) for 43 tibial and 29 femoral fractures. All the cases of pseudarthrosis were after surgical treatment and they were treated only with intramedullary nails. All the nails were dynamized depending on fracture type and the healing procedure. The follow up of our patients included clinical examination (pain, length, torsion etc) and x-rays at 1st, 3rd and 6th month postoperatively and after that every year. Our data (clinical examination and x-rays) were enriched with objective estimation of patients physical condition at specific time intervals from the operation. We recorded also their one opinion about their health standard. The analysis of our results shows that intramedullary nailing, and especially after reaming, provides more rigid and secure stabilization. It also leads to faster porosis. This method allows immediate mobilization of nearby joints and better rehabilitation. It has fewer complications and we found completely valuable for the pseudrathrosis cases. Regarding only patients general health condition and return in preinjury functional level and professional activities, intramedullary nailing becomes a statistically more useful method for treatment of long bone fractures of lower extremity

The use of locking intramedullary nails in the treatment of long bone fractures is common. We present our preliminary work in the use of inflatable self-locking intramedullary nails for the treatment of long bone fractures. Twenty one patients were included in this work: 13 males and 8 females. The mean age was 25 years (range (18 to 42 years)). There were 8 tibial, seven femoral, and six humeral fractures. The mean operation time was 40.5 minutes for the humeral fractures (range 30 to 170 minutes), 30 minutes for the tibial fractures (range 20–90 minutes), and 60 minutes (range 30–170 minutes) for the femoral fractures. The radiation exposure time was 0.22 minutes for the tibial fixation, 0.28 minutes for the humeral and 0.44 minutes for the femoral fractures. The mean follow-up period was 49 weeks (range 6 to 60 weeks). Stable fixation with no axial deviation or displacement of the fracture fragments was seen in all cases. Patients could partially weight bear on the 2nd day after surgery. No post-operative complications were noted. From this preliminary work we conclude that the use of the inflatable self-locking intramedullary nails in the treatment of long bone fractures is simple, quick and stable. This procedure does not need intramedullary reaming that may jeopardise the medullary canal vessels. The surgical as well as the radiation time required for fixation were reduced

Introduction ESIN is an established method of treatment of long bone fractures in children, which has been in regular use in our institution since 1996. We report on our 7-year experience of using ESIN for the treatment of long bone fractures in children. Method 92 fractures were nailed (26 femoral, 12 tibial, 17 humeral and 37 forearm). The average age was 12 years (7–15) and average follow-up 15 months. Main indications included unstable and severely displaced fractures, failure of conservative treatment and polytrauma or head injury. Data collection included mechanism of injury, fracture configuration, treatment delay, operation time and technique, length of hospital stay, rehabilitation, healing, nail removal and complications. Results 49% of fractures were caused by road traffic accidents. All were diaphyseal apart from 14 proximal humeral fractures. The average surgery delay was 7 days and operation time 78 minutes. Open reduction was performed in 3 femoral, 1 humeral and 18 forearm fractures. Single nailing was used for the proximal humeral and forearm fracture. The average hospital stay was 5.8 days, ranging from 12 days for femoral to 2 days for forearm fractures. Clinical healing was achieved at 3.5, 4.3, 2.4 and 2.1 months respectively for femoral, tibial, humeral and forearm fractures. The commonest complication (25%) was skiin irritation around the entry site, which invariably resolved after implant removal. Delayed union occurred in 2 femoral and 2 tibial fractures (all healed following bone marrow injection). 2 tibial fractures mal-united and 1 tibial fracture was complicated with compartment syndrome. The average nail removal time was 9 months. The nails could not be removed in 4 cases. Conclusion ESIN is minimally invasive and has a low complication rate. It avoids the lengthy immobilization of conservative treatment, and the surgical trauma of plating without the association of refractures or nerve damage. We believe it represents a valid option in the treatment of long bone fractures

Introduction: Our previous work has shown that angiogenesis occurs within the cartilaginous callus during long bone fracture healing1. Our aim in this study was to investigate the mechanisms involved in endochondral ossification within callus tissue during the secondary stages of fracture healing.

Methods: In this study, immunohistochemical techniques were used to localise the following proteins within the fracture callus at different times following injury. The angiogenic factors vascular endothelial growth factor (VEGF) and basic fibroblast growth factor (bFGF) were localised; bFGF is also involved in matrix remodelling and cell proliferation. In addition, urokinase plasminogen activator and its receptor (uPA and uPAr respectively), a proteolytic enzyme involved in matrix remodelling, was immunolocalised. The model used for the study was a standardised midtibial osteotomy performed on New Zealand white rabbits.

Results: Results showed that from early time points, VEGF and bFGF were detected in pericellular locations around the chondrocytes. However, VEGF was only detected around the chondrocytes in close proximity to infiltrating vessels whereas homogenous localisation of bFGF was seen throughout the cartilage. Urokinase was localised throughout the cartilage callus as well as within vascular cavities and its receptor was detected on the chondrocyte cell surface from early time points.

Discussion: The immunolocalisation of VEGF around large hypertrophic chondrocytes in close proximity to infiltrating vessels suggests that this growth factor plays a role in chondrocyte hypertrophy and death, similar to its role in the growth plate. In contrast, bFGF was strongly detected throughout cartilage from early time points, suggesting that it may also be involved with cartilage proliferation during callus formation and subsequent matrix remodelling. The localisation of urokinase around chondrocytes and within vascular cavities suggests that this enzyme plays an important role in matrix remodelling and the vascularisation of the cartilage. In conclusion, our work suggests that the following sequence of events takes place within the cartilaginous callus. Firstly, bFGF is involved in the rapid proliferation of chondrocytes in the early stages of cartilage formation following fracture. Chondrocytes then express high levels of urokinase and its receptor which is actively involved in the degradation of cartilage matrix and formation of vascular spaces which leads to angiogenesis, VEGF expression, chondrocyte hypertrophy and eventual death.

Introduction: Numerous studies had been published concerning the classification, biomechanics and the management of penetrating extremity trauma involving long-bone fractures. Significant controversy exists in protocols of the management and outcomes of these serious injuries. Bullets and multiple shrapnel injuries due to terror attacks may differ in injury pattern and severity. The role of immediate internal fixation still remains questionable. During a period of four years 92 patients suffering from 103 long bone fracture due to penetrating gunshot and shrapnel injuries were treated in our level I trauma center. The aim of this retrospective study is to evaluate the outcome of these patients regarding our treatment protocol. Patients and Methods: 92 patients suffering from 113 long bone fractures caused by firearms and shrapnel injuries were treated in a level I trauma centre between 1/2000 and 12/2003. There were 36 femoral fractures, 50 tibial fractures, 5 humeral fractures and 24 forearm fractures. 43% of the patients suffered from associated injuries. Fifty eight percent of the patients had an Injury severity score (ISS) of 9–14 and 21% had an ISS greater than 25. 30% of the patients suffered form an associated vascular injury and 32% from an associated nerve injury of the fractured extremity. 36% of patients had multiple fractures. Overall mortality rate was 4%. Results: 77% of the fractures were fixated primarily and 23% were splinted or put in a cast. 3% of limbs were amputated. Out of the primary fixation group, 45% of the fractures were fixed with intramedullary nails, 44% with an external fixator and 11% with plates. 28% of the fractures required arterial repair, 18% required nerve repair and soft tissue coverage procedures were needed in 14% of the fractures. The infection rate for the entire group was 12%. Non-union occurred in 8%. Secondary amputation rate was 4%. Discussion: The surge of violence in our region had produced penetrating long bone injuries with increased severity, often associated with polytrauma, differing from other published series. Our management of these serious injuries was aggressive with the increased use of primary intramedullary nailing and internal fixation with comparable results of other published series. We conclude that aggressive primary surgical approach using multidisciplinary teams can result in favourable results in these unique patients subset

Background: Transcranial Doppler Ultrasound has been used to detect cerebral micremboli following long bone fractures and intramedullary stabilization. However the clinical effects in terms of cognitive function remain unclear. We aim to measure the cerebral embolic load and to clarify clinical cognitive function following lower limb long bone fractures stabilised by reamed intramedullary fixation. Methods: 27 femoral and tibial diaphyseal fractures (median age 36 years) were cognitively assessed 3 days following surgery and compared to the normal age and intelligence matched population. A wide range of cognitive tests assessed: global cognitive function; verbal fluency and speed; immediate and delayed memory recall; attention and mental processing speeds. 20 patients had intra-operative transcranial Doppler ultrasound monitoring of the middle cerebral artery for embolic signals. In addition a marker of neuronal injury (S-100B protein) was measured pre-operatively and at 0, 24 and 48 hours following surgery. One sample Wilcoxon signed rank test compared median (percentile) cognitive scores for the fracture patient cohort to a value of 50 representing the normal population. Results: A significant deterioration in immediate memory recall of unstructured material was noted following surgery. Using established criteria, 4 patients had detectable cerebral emboli with a median count of 3 (range 2–9). Scatter plot graphs indicated no correlation between cerebral embolic events and clinical cognitive dysfunction. S-100B protein levels increased from a pre-operative median (interquartile range) of 0.20 (0.23) to a peak immediately following surgery of 0.51 (0.97) with no correlation to clinical cognitive dysfunction. Conclusions: A small number of cerebral embolic events occur during intramedullary fracture stabilisation but with no direct correlation made to cognitive dysfunction on detailed testing. Recent concerns over the specificity of S100B protein due to extracerebral tissue release appear to be confirmed. Significance: Clarify cognitive function following intramedullary fracture stabilisation and correlate with cerebral (systemic) embolic load

Background: Bacterial translocation is defined as a phenomenon in which live bacteria cross the intestinal barrier and spread the other systemic organs after various type of traumatic insults such as hemorrhagic shock, burn, malnutrition and abdominal trauma. It has also been shown that multiple fractures of long bones associated with head injury promote bacterial translocation. Aim: To determine whether early internal fixation of long bone fractures helps to prevent bacterial translocation. Materials and methods: Thirty-seven male Sprague-Dawley rats were divided into three groups. 1) anesthesia only (control group, n=12); 2) anesthesia + tibia fracture + femur fracture + moderate head trauma (trauma group, n=14), and 3) anesthesia + fixation of both tibia and femur fractures + moderate head trauma (fixation group, n=11). Head injury was created by using Marmarou’s impaction-acceleration model and fractures were created by using a blunt guillotine. After 24 hours, mesenteric lymph nodes, liver, spleen and systemic blood samples were quantitatively cultured to detect bacterial translocation. Finally, ileum was cultured to determine the indigenous intestinal flora. Results: The most commonly translocating bacteria were enterococci, E.coli, and group D streptococci. The incidence of bacterial translocation was lower in fixation group (2/11) than the trauma group (10/14) (Fishers exact test, p=0.025). No statistical difference was detected between the control and the fixation group. The number of organs containing viable bacteria was significantly lower in the control and fixation groups than the trauma group (Mann Whitney U test, p=0.002). Conclusion: Multiple organ failure which is the most severe complication after trauma has a mortality rate of 50–70%. It is believed that MOF results from sepsis from organisms in the intestinal flora; a process termed bacterial translocation. Our data revealed that in case of multiple long bone fractures combined with moderate head injury, systemic translocation of the gut bacteria may be prevented by early internal fixation of the bones

Objective: Prior to the appointment of a dedicated paediatric orthopaedic consultant at a tertiary referral centre (Feb 1999) the treatment of long bone fractures in paediatric patients with associated head injuries was predominately conservative. Current practice is now for early surgical stabilisation wherever possible. The aim of the study was to assess whether this change in clinical practice had resulted in any alteration in outcome. Design: A prospective analysis of patients admitted to the paediatric intensive care unit between Feb 1996 and Jan 2002. Setting: Leeds General Infirmary. Main outcome measures: Duration of ICU admission and time to independent walking was assessed. Results: A total of 37 patients were included in the study.17 patients were treated conservatively and 19 surgically .A reduction of approximately 30% was observed in ICU stay and time to independent walking was observed in those patients that underwent early surgical stabilisation. Conclusions: Early surgical stabilisation of long bone fractures in head injured children allows quicker rehabilitation

Twenty young men with displaced fractures of one or more long bones in the lower limb, but with no evidence of cranial, thoracic or abdominal injury, were studied prospectively. Although all the patients became hypoxaemic, the six who developed signs of respiratory distress (Group 1) were found to have a significantly lower arterial oxygen tension and a significantly higher rate of urinary urea excretion than the remaining 14 patients whose pulmonary function appeared to be clinically normal (Group 2). Circulating fat macroglobules were identified in three cases, only one of whom was in Group 1, and hence the tests for fat embolism were not of prognostic value. Although an immunodeficient state is considered to contribute to the pulmonary insufficiency which occurs after major trauma, convincing evidence of a lymphocyte-suppressive agent was found in only one patient.

Aim: To evaluate the technique of percutaneously harvested bone graft mixed with morphogenic bone protein and endoscopically delivered to ununited long bone fractures. Methods: Thirty-eight patients with established delayed union of long bone fractures were bone-grafted endoscopically. Morphogenic bone protein (OP1) was used in 12 cases and the graft was supplemented with calcium sulphate pellets (Osteoset). The minimum follow-up was eight months. The study group included eight femoral shaft fractures, two humeral shaft fractures and the remainder were tibial shaft fractures. Results: Four fractures failed to unite with this technique. Two femoral shaft non-unions required repeat surgery, one humeral shaft non-union and one tibial shaft non-union required supplementary grafting and fixation. The technique requires radiological imaging to supplement endoscopic preparation and graft delivery. For tibial fractures this can be used as a day-stay technique but most patients required one night in hospital. Conclusions: Endoscopic bone grafting can be supplemented with graft substitute (Osteoset) and morphogenic protein (OP1). It is as effective as standard open ‘onlay’ grafting but good fixation of the fracture is necessary before graft and supplements are effective

Definitions and perceptions of good and poor outcome vary between patients and surgeons, and perceived inadequate outcome can lead to litigation. We investigated outcomes of litigation claims relating to non-union and deformity following lower limb long bone fractures from 1995 to 2010. The database of all 10456 claims related to Trauma and Orthopaedic Surgery was obtained from the NHS Litigation Authority. Data was searched for “deformity, non-union and mal-union”, excluding spine, arthroplasty, foot and upper limb surgery. The type of complaint, whether defended or not, and costs was analysed. 241 claims met our criteria, 204 of which were closed, and 37 unsettled. Deformity/mal-union constituted 97, and non-union 143. Coronal/sagittal deformity cost £4.2 million, mean £45,487 (60% received compensation). Rotational mal-unions cost £1.6 million, mean £114,263 (87% received compensation). Non-union cost £5.3 million, mean £75,866 (60% received compensation). Mean legal fees for coronal/sagittal deformity was £18,772, rotational deformity £37,384, and non-union £24,680. The total cost of litigation was £12.2 million, with a mean of £59,597 per settled claim. The mean pay-out for all confirmed negligence/liability was £56,046 (£1,300–£500,000, median £21,500) per case. Non-union is an accepted complication following fracture surgery. However, this does not mitigate against non-union being seen as representing a poor standard of care. While it is unclear whether the payouts reflect a defensive culture or were due to avoidable errors, and notwithstanding the limitations of the database, we argue that failure of the index surgery should prompt a referral to a specialist centre. The cosmetic appearances of rotational malalignment results in higher compensation, reinforcing outward perception of outcome as being more important than harmful effects. We also note that the database sometimes contained conflicting and incomplete data, and make a case for standardisation of this component of the outcome process to allow for learning and reflection

1. A series of 102 cancellous strip grafts for delayed union of long bone fractures has been reviewed. 2. Half of the initial injuries were open. 3. Half of the fractures were butterfly or segmental lesions or were comminuted. 4. After strip grafting 84 per cent of the fractures were united within sixteen weeks, and only four took longer than twenty weeks. 5. Complete failure of union occurred in only one case, a tibial fracture complicated by low-grade pyocyaneus osteomyelitis. 6. A more aggressive attitude to the problem of delayed union is advocated

Recently, secondary life-threatening inflammatory reactions have been identified with molecular biological techniques in patients with multi-system injuries who were submitted to immediate or early intramedullary fixation of their fractured femora. This phenomenon was called “The second hit”, and it caused ARDS, PE, and Renal Failure. In a consecutive series of 135 trauma patients with high energy long bone fractures, 40 had sustained multiple-injuries. All fractures were reduced and stabilized on admission by AO-Tubular External Fixation systems. After 72–96 hours, this system was converted to an hybrid-ring-tubular system, which had three dimensional stability. They commenced partial weight bearing 24 hours later, and were followed by bony union. One patient developed DVT, none developed ARDS, PE, Renal Failure. Superficial pin-tract infection was common, but no-deep infection and’or osteomyelitis were encountered. With this minimal-invasive surgical technique, life threatening complications were avoided while preserving the integrity of the soft tissue envelope, the critical contributing biological factor for fracture healing