We evaluated the results of fibular centralisation as a stand alone technique to reconstruct defects that occurred after resection of tumours involving the tibial diaphysis and distal metaphysis. Between January 2003 and December 2006, 15 patients underwent excision of tumours of the tibial diaphysis or distal metaphysis and reconstruction by fibular centralisation. Their mean age was 17 years (7 to 40). Two patients were excluded; one died from the complications of chemotherapy and a second needed a below-knee amputation for a recurrent giant-cell tumour. A total of 13 patients were reviewed after a mean follow-up of 29 months (16 to 48). Only 16 of 26 host graft junctions united primarily. Ten junctions in ten patients needed one or more further procedure before union was achieved. At final follow-up 12 of the 13 patients had fully united grafts; 11 walked without aids. The mean time to union at the junctions that united was 12 months (3 to 36). The mean Musculoskeletal Tumor Society Score was 24.7 (16 to 30). Fibular centralisation is a durable reconstruction for defects of the tibial diaphysis and distal metaphysis with an acceptable functional outcome. Stable osteosynthesis is the key to successful union. Additional bone grafting is recommended for patients who need postoperative radiotherapy

Aims. This study examined whether systemic administration of melatonin would have different effects on osseointegration in ovariectomized (OVX) rats, depending on whether this was administered during the day or night. Methods. In this study, a titanium rod was implanted in the medullary cavity of one femoral metaphysis in OVX rats, and then the rats were randomly divided into four groups: Sham group (Sham, n = 10), OVX rat group (OVX, n = 10), melatonin day treatment group (OVX + MD, n = 10), and melatonin night treatment group (OVX + MN, n = 10). The OVX + MD and OVX + MN rats were treated with 30 mg/kg/day melatonin at 9 am and 9 pm, respectively, for 12 weeks. At the end of the research, the rats were killed to obtain bilateral femora and blood samples for evaluation. Results. Micro-CT and histological evaluation showed that the bone microscopic parameters of femoral metaphysis trabecular bone and bone tissue around the titanium rod in the OVX + MD group demonstrated higher bone mineral density, bone volume fraction, trabecular number, connective density, trabecular thickness, and lower trabecular speculation (p = 0.004) than the OVX + MN group. Moreover, the biomechanical parameters of the OVX + MD group showed higher pull-out test and three-point bending test values, including fixation strength, interface stiffness, energy to failure, energy at break, ultimate load, and elastic modulus (p = 0.012) than the OVX + MN group. In addition, the bone metabolism index and oxidative stress indicators of the OVX + MD group show lower values of Type I collagen cross-linked C-telopeptide, procollagen type 1 N propeptide, and malondialdehyde (p = 0.013), and higher values of TAC and SOD (p = 0.002) compared with the OVX + MN group. Conclusion. The results of our study suggest that systemic administration with melatonin at 9 am may improve the initial osseointegration of titanium rods under osteoporotic conditions more effectively than administration at 9 pm. Cite this article: Bone Joint Res 2022;11(11):751–762

The development of genu valgum in a child after a fracture of the upper metaphysis of the tibia with a medial gap is due to the interposition of a flap of fibrous tissue consisting of pes anserinus and periosteum avulsed from the lower fragment. The ensuing biomechanical disturbance induces bowing of the shaft and asymmetrical growth at both ends of the bone. Four cases of established deformity are reported, together with two cases of fresh fracture successfully treated by surgical clearance of the fibrous tissue from the gap

Aims. Obtaining solid implant fixation is crucial in revision total knee arthroplasty (rTKA) to avoid aseptic loosening, a major reason for re-revision. This study aims to validate a novel grading system that quantifies implant fixation across three anatomical zones (epiphysis, metaphysis, diaphysis). Methods. Based on pre-, intra-, and postoperative assessments, the novel grading system allocates a quantitative score (0, 0.5, or 1 point) for the quality of fixation achieved in each anatomical zone. The criteria used by the algorithm to assign the score include the bone quality, the size of the bone defect, and the type of fixation used. A consecutive cohort of 245 patients undergoing rTKA from 2012 to 2018 were evaluated using the current novel scoring system and followed prospectively. In addition, 100 first-time revision cases were assessed radiologically from the original cohort and graded by three observers to evaluate the intra- and inter-rater reliability of the novel radiological grading system. Results. At a mean follow-up of 90 months (64 to 130), only two out of 245 cases failed due to aseptic loosening. Intraoperative grading yielded mean scores of 1.87 (95% confidence interval (CI) 1.82 to 1.92) for the femur and 1.96 (95% CI 1.92 to 2.0) for the tibia. Only 3.7% of femoral and 1.7% of tibial reconstructions fell below the 1.5-point threshold, which included the two cases of aseptic loosening. Interobserver reliability for postoperative radiological grading was 0.97 for the femur and 0.85 for the tibia. Conclusion. A minimum score of 1.5 points for each skeletal segment appears to be a reasonable cut-off to define sufficient fixation in rTKA. There were no revisions for aseptic loosening at mid-term follow-up when this fixation threshold was achieved or exceeded. When assessing first-time revisions, this novel grading system has shown excellent intra- and interobserver reliability. Cite this article: Bone Joint J 2024;106-B(5):468–474

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

The traditional techniques involving an oblique tunnel or triangular wedge resection to approach a central or mixed-type physeal bar are hindered by poor visualisation of the bar. This may be overcome by a complete transverse osteotomy at the metaphysis near the growth plate or a direct vertical approach to the bar. Ilizarov external fixation using small wires allows firm fixation of the short physis-bearing fragment, and can also correct an associated angular deformity and permit limb lengthening.

We accurately approached and successfully excised ten central- or mixed-type bars; six in the distal femur, two in the proximal tibia and two in the distal tibia, without damaging the uninvolved physis, and corrected the associated angular deformity and leg-length discrepancy. Callus formation was slightly delayed because of periosteal elevation and stretching during resection of the bar. The resultant resection of the bar was satisfactory in seven patients and fair in three as assessed using a by a modified Williamson–Staheli classification.

Cite this article: Bone Joint J 2015;97-B:1726–31.

Aims

The main objective of this study is to analyze the penetration of bone cement in four different full cementation techniques of the tibial tray.

Distal femoral physeal fractures can cause of growth distrurbance which frequently requires further surgical intervention. The aim of this study was to determine if tibial tuberosity ossification at the time of injury can predict further surgery in patients who have sustained a physeal fracture of the distal femur. We retrospectively investigated all patients who had operative treatment for a distal femoral physeal fracture at a paediatric level one trauma center over a 17 year period. Logistic regression analysis was performed investigating associations between the need for further surgery to treat growth disturbance and tibial tuberosity ossification, age, Salter Harris grade, mode of fixation or mechanism of injury. 74 patients met the inclusion criteria. There were 57 boys (77%) and 17 girls (23%). The average age at time of injury was 13.1 years (range 2.-17.1 years). Following fixation, 30 patients (41%) underwent further surgery to treat growth disturbance. Absence of tibial tuberosity fusion to the metaphysis was significantly associated with need for further surgery (p = < 0 .001). Odds of requiring secondary surgery after tibial tuberosity fusion to metaphysis posteriorly (compared with not fused) were 0.12, 95% CI (0.04, 0.34). The estimate of effect of tibial tuberosity ossification on reoperation rates did not vary when adjusted for gender, mechanism, fixation and Salter Harris grade. When accounting for age, the odds of further operation if the tibial tuberosity is fused to the metaphysis posteriorly (compared with not fused) were 0.28, 95% CI (0.08, 0.94). Tibial tuberosity ossification stage at time of injury is a predictor of further surgery to treat growth disturbance in paediatric distal femoral fractures. Children with distal femoral physeal fractures whose tibial tuberosity was not fused to the metaphysis posteriorly were 8.3 times more likely to require further surgery

Aims. The aim of this study was to evaluate the correlation between Salter’s criteria and Kalamchi’s classification of avascular necrosis in patients treated for developmental dysphasia of the hip (DDH). Patients and Methods. The study involved a retrospective analysis of 123 patients (123 hips) with DDH treated by operative and non-operative reduction before the age of two years, with a minimum follow-up of ten years. Salter’s criteria (S1 to S4) were determined from radiographs obtained at one to two years post-reduction, whilst the Kalamchi grade was determined from radiographs obtained at ten or more years of age. Early post-reduction radiographs were also used to evaluate the centre-head distance discrepancy (CHDD) and the occurrence of a dome-shaped deformity of the proximal femoral metaphysis (D-shaped metaphysis). The prognosis was described as good (Kalamchi grade K0 or KI), fair (Kalamchi grade KII) or poor (Kalamchi grade KIII or KIV) for analysis and correlation with the early Salter criteria, CHDD and D-shaped metaphysis. Results. S1 and S2 criteria were predictive of a poor prognosis. The outcome following S3, S4 and S3 + S4 varied; 18 (40%) had a good prognosis, 17 (38%) a fair prognosis and ten (22%) a poor prognosis. A CHDD ≥ 10% and a D-shaped metaphysis were also predictive of a poor prognosis. Conclusion. The Salter criteria were predictive of the Kalamchi grade of avascular necrosis in patients with DDH aged ten or more years after reduction of the hip. . Cite this article: Bone Joint J 2017;99-B:1115–20

This study aims to assess the fracture mechanics of type-2 diabetic (T2D) femoral bone using innovative site-specific tests, whilst also examining the cortical and trabecular bone microarchitecture from various regions using micro-computed tomography (CT) of the femur as the disease progresses. Male [Zucker Diabetic Fatty (ZDF: fa/fa) (T2D) and Zucker Lean (ZL: fa/+) (Control)] rats were euthanized at 12-weeks of age, thereafter, right and left femora were dissected (Right femora: n = 6, per age, per condition; Left femora: n=8-9, per age, per condition). Right femurs were notched in the posterior of the midshaft. Micro-CT was used to scan the proximal femur, notched and unnotched femoral midshaft (cortical) of the right femur and the distal metaphysis (trabecular) of the left femur to investigate microarchitecture and composition. Right femurs were fracture toughness tested to measure the stress intensity factor (Kic) followed by a sideways fall test using a custom-made rig to investigate femoral neck mechanical properties. There was no difference in trabecular and cortical tissue material density (TMD) between T2D and control rats. Cortical thickness was unchanged, but trabeculae were thinner (p<0.01) in T2D rats versus controls. However, T2D rats had a greater number of trabeculae (p<0.05) although trabecular spacing was not different to controls. T2D rats had a higher connectivity distribution (p<0.05) and degree of anisotropy (p<0.05) in comparison to controls. There was no difference in the mechanical properties between strains. At 12-weeks of age, rats are experiencing early-stage T2Ds and the disease impact is currently not very clear. Structural and material properties are unchanged between strains, but the trabecular morphology shows that T2D rats have more trabecular struts present in order to account for the thinner trabeculae

Aims. In recent years, the use of a collared cementless femoral prosthesis has risen in popularity. The design intention of collared components is to transfer some load to the resected femoral calcar and prevent implant subsidence within the cancellous bone of the metaphysis. Conversely, the load transfer for a cemented femoral prosthesis depends on the cement-component and cement-bone interface interaction. The aim of our study was to compare the three most commonly used collared cementless components and the three most commonly used tapered polished cemented components in patients aged ≥ 75 years who have undergone a primary total hip arthroplasty (THA) for osteoarthritis (OA). Methods. Data from the Australian Orthopaedic Association National Joint Replacement Registry from 1 September 1999 to 31 December 2022 were analyzed. Collared cementless femoral components and cemented components were identified, and the three most commonly used components in each group were analyzed. We identified a total of 11,278 collared cementless components and 47,835 cemented components. Hazard ratios (HRs) from Cox proportional hazards models, adjusting for age and sex, were obtained to compare the revision rates between the groups. Results. From six months postoperatively onwards, patients aged ≥ 75 years undergoing primary THA with primary diagnosis of OA have a lower risk of all-cause revision with collared cementless components than with a polished tapered cemented component (HR 0.78 (95% confidence interval 0.64 to 0.96); p = 0.018). There is no difference in revision rate prior to six months. Conclusion. Patients aged ≥ 75 years with a primary diagnosis of OA have a significantly lower rate of revision with the most common collared cementless femoral component, compared with the most common polished tapered cemented components from six months postoperatively onwards. The lower revision rate is largely due to a reduction in revisions for fracture and infection. Cite this article: Bone Joint J 2024;106-B(3 Supple A):121–129

Introduction. Treatment pathways of 5. th. metatarsal fractures are commonly directed based on fracture classification, with Jones types for example, requiring closer observation and possibly more aggressive management. Primary objective. To investigate the reliability of assessment of subtypes of 5. th. metatarsal fractures by different observers. Methods. Patients were identified from our prospectively collected database. We included all patient referred to our virtual fracture clinic with a suspected or confirmed 5. th. metatarsal fracture. Plain AP radiographs were reviewed by two observers, who were initially trained on the 5. th. metatarsal classification identification. Zones were defined as Zone 1.1, 1.2, 1.3, 2, 3, diaphyseal shaft (DS), distal metaphysis (DM) and head. An inter-observer reliability analysis using Cohen's Kappa coefficient was carried out, and degree of observer agreement described using Landis & Koch's description. All data was analysed using IBM SPSS v.27. Results. 878 patients were identified. The two observers had moderate agreement when identifying fractures in all zones, apart from metatarsal head fractures, which scored substantial agreement (K=.614). Zones 1.1 (K=.582), 2 (K=.536), 3 (K=.601) and DS (K=.544) all tended towards but did not achieve substantial agreement. Whilst DS fractures achieved moderate agreement, there was an apparent difficulty with distal DS, resulting in a lot of cross over with DM (DS 210 vs 109; DM 76 vs 161). Slight agreement with the next highest adjacent zone was found when injuries were thought to be in zones 1.2, 1.3 and 2 (K=0.17, 0.115 and 0.152 respectively). Conclusions. Reliability of sub-categorising 5. th. metatarsal fractures using standardised instructions conveys moderate to substantial agreement in most cases. If the region of the fracture is going to be used in an algorithm to guide a management plan and clinical follow up during a virtual clinic review, defining fractures of zones 1–3 needs careful consideration

Introduction. Aneurysmal bone cysts commonly found in lower limbs are locally aggressive masses that can lead to bony erosion, instability and fractures. This has major implications in the lower limbs especially in paediatric patients, with potential growth disturbance and deformity. In this case series we describe radical aneurysmal bone cyst resection and lower limb reconstruction using cable transport and syndesmosis preservation. Materials & Methods. Case 1 - A 12-year-old boy presented with a two-week history of atraumatic right ankle pain. An X-ray demonstrated a distal tibia metaphyseal cyst confirmed on biopsy as an aneurysmal bone cyst. The cyst expanded on interval X-rays from 5.5cm to 8.5cm in 9 weeks. A wide-margin en-bloc resection was performed leaving a 13.8cm tibial defect. A cable transport hexapod frame and a proximal tibial osteotomy was performed, with syndesmosis screw fixation. The transport phase lasted 11 months. While in frame, the boy sustained a distal femur fracture from a fall. The femur and the docking site were plated at the same sitting and frame removed. At one-year post-frame removal he is pain-free, with full ankle dorsiflexion but plantarflexion limited to 25 degrees. He has begun graduated return to sport. Results. Case 2 - A 12-year-old girl was referred with a three-month history of lateral left ankle swelling. X-ray demonstrated an aneurysmal bone cyst in the distal fibula metaphysis. The cyst grew from 4.2 × 2.3cm to 5.2 × 3.32cm in 2 months. A distal fibula resection (6.2cm) with syndesmosis fixation and hexapod cable transport frame were undertaken. The frame was in situ for 13 weeks and during this time she required an additional osteotomy for premature consolidation and had one pin site infection. After 13 weeks a second syndesmosis screw was placed, frame removed, and a cast applied. 3 months later she had fibular plating, BMAC and autologous iliac crest bone graft for slow union. At 3 years post-operative she has no evidence of recurrence, is pain-free and has no functional limitation. Conclusions. We describe two cases of ankle syndesmosis preservation using cable transport for juxta-articular aneurysmal bone cysts. This allows wide resection to prevent recurrence while also preserving primary ankle stability and leg length in children. Both children had a minor complication, but both had an excellent final outcome. Cable bone transport and prophylactic syndesmosis stabilization allows treatment of challenging juxta-articular aneurysmal bone cysts about the ankle. These techniques are especially useful in large bone defects

We describe three cases of infantile tibia vara resulting from an atraumatic slip of the proximal tibial epiphysis upon the metaphysis. There appears to be an association between this condition and severe obesity. Radiologically, the condition is characterised by a dome-shaped metaphysis, an open growth plate and disruption of the continuity between the lateral borders of the epiphysis and metaphysis, with inferomedial translation of the proximal tibial epiphysis. All patients were treated by realignment of the proximal tibia by distraction osteogenesis with an external circulator fixator, and it is suggested that this is the optimal method for correction of this complex deformity. There are differences in the radiological features and management between conventional infantile Blount’s disease and this ‘slipped upper tibial epiphysis’ variant

Introduction. Fibrous dysplasia is a pathological condition, where normal medullary bone is replaced by fibrous tissue and small, woven specules of bone. Fibrous dysplasia can occur in epiphysis, metaphysis or diaphysis. Occationally, biopsy is necessary to establish the diagnosis. We present a review of operative treatment using the Ilizarov technique. The management of tibial fibrous dysplasia in children are curettage or subperiosteal resection to extra periosteal wide resection followed by bone transport. Materials and Methods. A total of 18 patients were treated between 2010 – 2020; 12 patients came with pain and 6 with pain and deformity. All patients were treated by Ilizarov technique. Age ranges from 4–14 years. 12 patients by enbloc excision and bone transportation and 6 patients were treated by osteotomy at the true apex of the deformity by introducing the k/wires in the medullary cavity with stable fixation by Ilizarov device. The longest duration for bone transport was 16 weeks (14–20 weeks) for application, after deformity correction was 20 weeks. We have never used any kind of bone grafts. Results. All the 18 patients were treated successfully by Ilizarov compression distraction device. The patients with localized tibial pathology with deformity had the shortest period on the Ilizarov apparatus, 14 weeks. Conclusions. Preservation and bone regeneration by distraction histogenesis constitutes a highly conservative limb saving surgery. Patients with bone defects of <10 cm, a great deal of preserved healthy tissue and good prognosis are good candidates for these methods

As the number of patients who have undergone total hip arthroplasty rises, the number of patients who require surgery for a failed total hip arthroplasty is also increasing. It is estimated that 183,000 total hip replacements were performed in the United States in the year 2000 and that 31,000 of these (17%) were revision procedures. Reconstruction of the failed femoral component in revision total hip arthroplasty can be challenging from both a technical perspective and in preoperative planning. With multiple reconstructive options available, it is helpful to have a classification system which guides the surgeon in selecting the appropriate method of reconstruction. A classification of femoral deficiency has been developed and an algorithmic approach to femoral reconstruction is presented. An extensively coated, diaphyseal filling component reliably achieves successful fixation in the majority of revision femurs. The surgical technique is straightforward and we continue to use this type of device in the majority of our revision total hip arthroplasties. However, in the severely damaged femur (Type IIIB and Type IV), other reconstructive options may provide improved results. Based on our results, the following reconstructive algorithm is recommended for femoral reconstruction in revision total hip arthroplasty. Type I: In a Type I femur, there is minimal loss of cancellous bone with an intact diaphysis. Cemented or cementless fixation can be utilised. If cemented fixation is selected, great care must be taken in removing the neo-cortex often encountered to allow for appropriate cement intrusion into the remaining cancellous bone. Type II: In a Type II femur, there is extensive loss of the metaphyseal cancellous bone and thus, fixation with cement is unreliable. In this cohort of patients, successful fixation was achieved using a diaphyseal fitting, extensively porous coated implant. However, as the metaphysis is supportive, a cementless implant that achieves primary fixation in the metaphysis can be utilised. Type IIIA: In a Type IIIA femur, the metaphysis is non-supportive and an extensively coated stem of adequate length is utilised to ensure that more than 4cm of scratch fit is obtained in the diaphysis. Type IIIB: Based on the poor results obtained with a cylindrical, extensively porous coated implant (with 4 of 8 reconstructions failing), our present preference is a modular, cementless, tapered stem with flutes for obtaining rotational stability. Type IV: The isthmus is completely non-supportive and the femoral canal is widened. Cementless fixation cannot be reliably used in our experience, as it is difficult to obtain adequate initial implant stability that is required for osseointegration. Reconstruction can be performed with impaction grafting if the cortical tube of the proximal femur is intact. However, this technique can be technically difficult to perform, time consuming and costly given the amount of bone graft that is often required. Although implant subsidence and peri-prosthetic fractures have been associated with this technique, it can provide an excellent solution for the difficult revision femur where cementless fixation cannot be utilised. Alternatively, an allograft-prosthesis composite can be utilised for younger patients in an attempt to reconstitute bone stock and a proximal femoral replacing endoprosthesis used for more elderly patients

As the number of patients who have undergone total hip arthroplasty rises, the number of patients who require surgery for a failed total hip arthroplasty is also increasing. Reconstruction of the failed femoral component in revision total hip arthroplasty can be challenging from both a technical perspective and in pre-operative planning. With multiple reconstructive options available, it is helpful to have a classification system which guides the surgeon in selecting the appropriate method of reconstruction. Type I: Minimal loss of metaphyseal cancellous bone with an intact diaphysis. Often seen when conversion of a cementless femoral component without biological ingrowth surface requires revision. Type II: Extensive loss of metaphyseal cancellous bone with an intact diaphysis. Often encountered after the removal of a cemented femoral component. Type IIIA: The metaphysis is severely damaged and non-supportive with more than 4 cm of intact diaphyseal bone for distal fixation. This type of defect is commonly seen after removal of grossly loose femoral components inserted with first generation cementing techniques. Type IIIB: The metaphysis is severely damaged and non-supportive with less than 4 cm of diaphyseal bone available for distal fixation. This type of defect is often seen following failure of a cemented femoral component that was inserted with a cement restrictor and cementless femoral components associated with significant distal osteolysis. Type IV: Extensive meta-diaphyseal damage in conjunction with a widened femoral canal. The isthmus is non-supportive. Based on our results, the following reconstructive algorithm is recommended for femoral reconstruction in revision total hip arthroplasty. An extensively coated, diaphyseal filling component reliably achieves successful fixation in the majority of revision femurs and the surgical technique is straightforward. However, in the severely damaged femur (Type IIIB and Type IV), other reconstructive options may provide improved results. Type I: Cemented or cementless fixation can be utilised. If cemented fixation is selected, great care must be taken in removing the neo-cortex often encountered to allow for appropriate cement intrusion into the remaining cancellous bone. Type II: In this cohort of patients, successful fixation was achieved using a diaphyseal fitting, extensively porous coated implant. However, as the metaphysis is supportive, a cementless implant that achieves primary fixation in the metaphysis can be utilised. Type IIIA: An extensively coated stem of adequate length is utilised to ensure that more than 4 cm of scratch fit is obtained in the diaphysis. Type IIIB: Our present preference is a modular, cementless, tapered stem with flutes for obtaining rotational stability. Type IV: Cementless fixation cannot be reliably used in our experience, as it is difficult to obtain adequate initial implant stability that is required for osseointegration. Reconstruction can be performed with impaction grafting if the cortical tube of the proximal femur is intact. However, this technique can be technically difficult to perform, time consuming and costly given the amount of bone graft that is often required. Although implant subsidence and peri-prosthetic fractures (both intra-operatively and post-operatively) have been associated with this technique, it can provide an excellent solution for the difficult revision femur where cementless fixation cannot be utilised. Alternatively, an allograft-prosthesis composite can be utilised for younger patients in an attempt to reconstitute bone stock and a proximal femoral replacing endoprosthesis used for more elderly patients

There is no mathematical relationship between the internal diameter of the femoral metaphysis and diaphysis. Unless an infinite number of monolithic stems are available with variable metaphyseal and diaphyseal diameters, which is not economically possible, even in virgin cases, the surgeon has to decide if the stem is going to fit in the metaphysis or the diaphysis. It is not possible to match both. In revision cases with a hollowed out metaphysis, the situation is much worse. As it is obviously easier to fit the diaphysis, this is what stems such as the AML and Wagner stem have done. They completely ignore the metaphysis and obtain fixation in the diaphysis. This is all well and good, but it means that the proximal femur is unloaded, like an astronaut in space. While, there will be some recovery due to removal of the toxins and local muscle pull, it will be incomplete. Furthermore, should sepsis occur, one is faced with the horror of removing a distally fixed implant. Clearly, if proximal fixation, i.e. above the level of lesser trochanter could reliably be achieved, this would be preferable in terms of proximal loading leading to bone recovery and ease of removal should it be required. The only way that proximal loading can be achieved is if the metaphyseal and diaphyseal parts of the component can be varied infinitely. This clearly can only be achieved by using a modular stem. The concern with modularity always has been fretting at the sleeve-stem locking mechanism with release of metal ions. The stem, which I have been using for the last 25 years, is the SROM stem. Fretting and ion release had never been an issue. As the components are made of a relatively soft titanium alloy, it is likely that the sleeve and the stem cold weld, thus, eliminating any movement and eliminating friction. I have a follow-up of roughly 120 revision cases with a minimum follow-up of 5 years and a maximum follow-up of 22 years. I have no loosening in easy revision cases where a primary stem was used. I have had some loosenings in extremely difficult revision situations where a long bowed stem was required, but even then, the loosening rate is less than 3%. I use this stem in primary situations, i.e. in about 80% of all the primaries I have done. This means I have done roughly 1500 cases or more. Other than some late infections, I have never, ever had any stem loosening in a simple case. Obviously, I have had loosenings in some cases, where we have been doing fancy shortening or de-rotation osteotomies, but none in simple primary cases. I would, therefore, suggest that the surgeon, if he wishes to use this stem, please try it out on some simple primary cases. The ability to vary distal and proximal internal diameters and proximal geometry makes for easy surgery. I have been using this stem for 25 years and continue to use it in all my primary noncemented cases. I believe in the adage of “train hard and fight easy.” I think that surgeons should not get themselves into a situation where they are forced in a difficult case to use something they have never seen before

Introduction. We report 3 cases from different centres of infantile tibia vara in which the deformity was due to slippage of the proximal tibial epiphysis on the metaphysis; the aim of this study was to define the features of this previously unreported condition, and their implications for management. Method. Three cases of tibia vara secondary to atraumatic slippage of the upper tibial epiphysis on the metaphysis were identified from three different centres. The case notes and imaging studies were retrospectively reviewed to distinguish common clinical and radiographic features. Results. There were one male and two females, all of non-Caucasian origin, (age 3–7 years). All patients' weights were above the 97th centile for age. In all cases there was an infero-medial subluxation of the tibial epiphysis over a dome shaped proximal tibial metaphysis, with disruption of continuity between their lateral borders. The height of the medial tibial plateau was preserved in all cases. New bone formation suggests this is a chronic process. The evolution of one case indicates that pathogenesis is shared with infantile Blount's disease. A gradual deformity correction was performed in all cases using circular external fixation, with the proximal ring secured to both the proximal epiphysis and metaphysis. Conclusion. Slipped upper tibial epiphysis is an uncommon but distinct cause of tibia vara. The radiological features are completely different from those previously described for infantile tibia vara and not encompassed by the existing classification. The unusual morphology has consequences for treatment. Management is analogous to a slipped upper femoral epiphysis – the physis has to be stabilized to the metaphysis and an osteotomy performed to restore the mechanical axis. We believe this is best achieved with a circular external fixator because this permits multiaxial correction including translation and rotation

Although much has been published on the causes of slipped upper femoral epiphysis and the results of treatment, little attention has been given to the mechanism of the slip. This study presents the results of the analysis of 13 adolescent femora, and the attempts to reproduce the radiological appearances of a typical slip. The mean age of the skeletons was 13 years (11 to 15). It was found that the internal bony architecture in the zone of the growth plate was such that a slip of the epiphysis on the metaphysis (in the normal meaning of the word slip) could not take place, largely relating to the presence of a tubercle of bone projecting down from the epiphysis. The only way that the appearance of a typical slipped upper femoral epiphysis could be reproduced was by rotating the epiphysis posteromedially on the metaphysis. The presence and size of this peg-like tubercle was shown radiologically by CT scanning in one pair of intact adolescent femurs