The Cierny and Mader classification assists with decision-making in the management of osteomyelitis by strafying the host status and the pathoanatomy of disease. However the anatomical type IV represents a heterogenous group with regards to treatment requirements and outcomes. We propose that modification of the Cierny and Mader anatomical classification with an additional type V classifier (diffuse corticomedullary involvement with an associated critical bone defect) will allow more accurate stratification of patients and tailoring of treatment strategies. A retrospective review of 83 patients undergoing treatment for Cierny and Mader anatomical type IV osteomyelitis of the appendicular skeleton at a single centre was performed. Risk factors for the presence of a critical bone defect were female patients (OR 3.1 (95% CI 1.08– 8.92)) and requirement for soft tissue reconstruction (OR 3.35 (95% CI 1.35–8.31)); osteomyelitis of the femur was negatively associated with the presence of a critical bone defect (OR 0.13 (95% CI 0.03–0.66)). There was no statistical significant risk of adverse outcomes (failure to eradicate infection or achieve bone union) associated with the presence of a critical-sized bone defect. The median time to bone union was ten months (95% CI 7.9–12.1 months). There was a statistically significant difference in the median time to bone union between cases with a critical bone defect (12.0 months (95% 10.2–13.7 months)) and those without (6.0 months (95% CI 4.8–7.1 months)). This study provided evidence to support the introduction of a new subgroup of the Cierny and Mader anatomical classification (Type V). Using a standardised approach to management, comparable early outcomes can be achieved in patients with Cierny and Mader anatomical type V osteomyelitis. However, to achieve a successful outcome, there is a requirement for additional bone and soft tissue reconstruction procedures with an associated increase in treatment time

Introduction. The Cierny and Mader classification assists with decision-making by stratifying host status and the pathoanatomy of the disease. However, the anatomical type IV represents a heterogenous group with regards to treatment requirements and outcomes. We propose that modification of the Cierny and Mader anatomical classification with an additional type V classifier (diffuse corticomedullary involvement with an associated critical bone defect) will allow more accurate stratification of patients and tailoring of treatment strategies. Materials & Methods. A retrospective review of 83 patients undergoing treatment for Cierny and Mader anatomical type IV osteomyelitis of the appendicular skeleton at a single centre was performed. Results. Risk factors for the presence of a critical bone defect were female patients (OR 3.1 (95% CI 1.08–8.92)) and requirement for soft tissue reconstruction (OR 3.35 (95% CI 1.35–8.31)); osteomyelitis of the femur was negatively associated with the presence of a critical bone defect (OR 0.13 (95% CI 0.03–0.66)). There was no statistically significant risk of adverse outcomes (failure to eradicate infection or achieve bone union) associated with the presence of a critical-sized bone defect. The median time to bone union was ten months (95% CI 7.9–12.1 months). There was a statistically significant difference in the median time to bone union between cases with a critical bone defect (12.0 months (95% 10.2–13.7 months)) and those without (6.0 months (95% CI 4.8–7.1 months)). Conclusions. This study provided evidence to support the introduction of a new subgroup of the Cierny and Mader anatomical classification (Type V). Using a standardised approach to management, comparable early outcomes can be achieved in patients with Cierny and Mader anatomical type V osteomyelitis. However, to achieve a successful outcome, there is a requirement for additional bone and soft tissue reconstruction procedures with an associated increase in treatment time

Introduction. Coronal plane deformity can pose difficulties with balancing in Total Ankle Replacement (TAR). Current reports outline improved outcomes in the presence of varus deformity. Soft tissue balancing techniques are well described, but are limited by no link to eitiology and pathoanatomy of the deformity. Method. A prospective review of all the TAR by the senior author was performed to identify cases of pre-operative varus greater than 10°. A chart review was performed to identify aetiology, intraoperative findings, and operative techniques to achieve a balanced TAR. X-rays were examined to measure deformity and amount of correction. Volumetric rendering and segmentalisation was performed on pre- and post-CTs to identify anatomical defects, osteophyte formation, rotational and translational changes of the hindfoot joints. Results. Between January 2002 and January 2009 there were thirty-five cases from two hundred and thirty cases with varus deformity greater than 10°, with an average 17° varus angle (range 10° to 30°). Multiple sprains and instability over several years was seen in 62% of patients. Clinically, increasing varus was associated with cavovarus foot position. Incongruent deformities had intact tibial plafond. Congruent deformities had tibial defects in the anteromedial tibial plafond and associated anterolateral tibial ostephyte. Increasing deformity often had lateral fibula osteophytes and ossicles between fibula osteophyte and anterolateral talar body. In more severe cases, 3D analysis showed the talus was anteriorly displaced and internally rotated. Post operative alignment improved from 17° to 1.5°. Conclusion. Understanding the pathoanatomy of the arthritic ankle with coronal plane deformity can help plan the surgical techniques required to correct this often challenging surgical reconstruction

Introduction. The Walch Type B2 glenoid has the hallmark features of posteroinferior glenoid erosion, retroversion, and posterior humeral head subluxation. Although our understanding of the pathoanatomy of bone loss and its evolution in Type B's has improved, the etiology remains unclear. Furthermore, the morphology of the humerus in Walch B types has not been studied. The purpose of this imaging based anthropometric study was to examine the humeral torsion in Walch Type B2 shoulders. We hypothesized that there would be a compensatory decrease in humeral retroversion in Walch B2 glenoids. Methods. Three-dimensional models of the full length humerus were generated from computed tomography data of normal cadaveric (n = 59) and Walch Type B shoulders (n = 59). An anatomical coordinate system referencing the medial and lateral epicondyles was created for each model. A simulated humeral head osteotomy plane was created and used to determine humeral version relative to the epicondylar axis and the head-neck angle. Measurements were repeated by two experienced fellowship-trained shoulder surgeons to determine inter-rater reliability. Glenoid parameters (version, inclination and 2D critical shoulder angle) and posterior humeral head subluxation were calculated in the Type B group to determine the pathologic glenohumeral relationship. Two-way ANOVAs compared group and sex within humeral version and head-neck angle, and intra-class correlation coefficients (ICCs) with a 2-way random effects model and absolute agreement were used for inter-rater reliability. Results. There were statistically significant differences in humeral version between normal and Type B shoulders (p < .001) and between males and females within the normal group (p = .043). Normal shoulders had a humeral retroversion of 36±12°, while the Walch Type B group had a humeral retroversion of 14±9° relative to the epicondylar axis. For head-neck angle, there were no significant differences between sexes (p = .854), or between normal and Type B shoulders when grouped by sex (p = .433). In the Type B group, the mean glenoid version was 22±7°, glenoid inclination was 8±6°, 2D critical shoulder angle was 30±5° and humeral head subluxation was 80±9%. Inter-rater reliability showed fair agreement between the two experienced observers for head-neck angle (ICC = .562; 95% CI: -.28 to .809) and excellent agreement for humeral version (ICC = .962;.913 to .983). Although only fair agreement was found between observers in head-neck angle ICC, the difference in mean angle was only 2°. Discussion. Although much time and effort has been spent understanding and managing Type B2 glenoids, little attention has been paid to investigating associated humeral contributions to the Type B shoulder. Our results indicate that the humeral retroversion in Type B shoulders is significantly lower than in normals. These findings have several implications, including, helping to understanding the etiology of the B2, the unknown effects of arbitrarily selecting higher version angles for the humeral component, and the unknown effects of altered version on glenohumeral joint stability, loading and implant survivorship post-arthroplasty. Our results also raise an important question, whether it is best to reconstruct Type B humeral component version to pathologic version or to non-pathologic population means

Total hip arthroplasty (THA) is frequently performed as a salvage procedure for the acetabular fracture when posttraumatic osteoarthritis, posttraumatic avascular necrosis, or fixation failure with subluxation develop. Special considerations for this situation include previous surgical exposure with dense scar tissue, the type and location of implants, the location and amount of heterotopic ossification, indolent infection, previous sciatic nerve palsy, and the pathoanatomy of existing acetabular defect. These factors can influence the choice of surgical exposure and the reconstructive method. The outcomes of THA after acetabular fracture are generally less favorable than those of the nontraumatic degenerative arthritis. Reason for this high failure is the low mean age and the high activity level of the patient. Other important reasons for failure include the problem of acetabular bone deficiency and compromised bone quality. We evaluated the results of cementless THA in patient who had previous acetabular fracture. We also compared this result with those of patients with posttraumatic avascular necrosis of the femoral head. Forty-five consecutive cementless THAs were performed for the treatment of post-traumatic osteoarthritis after acetabular fracture between December 1993 and December 2008. Of these patients, 15 patients were died or lost to follow-up monitoring before the end of the minimum one year follow-up period. This left 30 patients (30 hips) as the subjects of our retrospective review. We evaluated the clinical and radiographic results of these patients and compared with the results of THA in patients with post-traumatic AVN of the femoral head which had without acetabular damage. Two hips required revision of the cup secondary to early migration of the acetabular cup (1 hip) and postoperative deep infection (1 hip). There was no significant difference in clinical and radiographic results between two groups except implanted acetabular component size and required bone graft (p<0.05). The Kaplan-Meier ten-year survival rate, with revision as the end-point, was 90% and 96.7% with loosening of acetabular component as the end-point. Our series suggested that compared with cemented components, uncemented sockets may improve the results of arthroplasty after previous acetabular fracture. In conclusion, cementless THA following acetabular fracture presents unique challenge to the surgeon, careful preoperative assessment and secure component fixation with proper bone grafting is essential to minimize problems

Patellofemoral instability is common injury and proximal soft tissue stabilisation via MPFL reconstruction or imbrication is the mainstay of treatment. The contribution of certain pathoanatomies to the failure of patellofemoral stabilisation is unknown. The purpose of this study was to analyse the failure rate of patellar stabilisation procedures in a large cohort as measured by re-dislocation of the patella. A secondary purpose was to identify the pathoantomical features that may have predisposed these patients to failure. Between May 2008 and March 2014, 207 MPFL reconstructions and 70 MPFL imbrications were performed by a single surgeon. Post-operative assessment included clinical examination to assess the integrity of the MPFL graft, plain radiographs and the Banff Patellofemoral Instability Instrument (BPII), a disease-specific outcome measure. Failures were identified and risk factors including trochlear dysplasia, patella alta, generalised ligamentous laxity (GLL), femoral tunnel position and rotational abnormalities were evaluated as contributing factors. There were 48 male and 178 female patients. The mean duration of follow-up was 24.1 months (SD 9.4, range 12–74). The average age at time of surgery was 24.81 years (SD 8.87, range 50.35–8.99). The average BMI was 23.75 (SD 3.62, range 36.70–14.90). There were 10 failures in the MPFL reconstruction group (4.8%), 1 male and 9 females. Femoral tunnel position was assessed in relation to Schottle's point as good or excellent in all 10 cases. In terms of pathoanotomy, 8/10 failures had high-grade trochlear dysplasia, 1/10 had patella alta, 6/10 had a Beighton score of >/= 4, and 3/10 had clinically significant rotational abnormalities of the lower extremity. The primary cause attributed to the 10 failure cases was trauma in two, trochlear dysplasia in three, rotational abnormalities in one, combined femoral anteversion and GLL in two, and combined trochlear dysplasia and GLL in two. There were 13 failures in the MPFL imbrication group (18.6%), 2 males and 11 females. Among these failures, 4/13 had high-grade trochlear dysplasia, 3/13 had patella alta, 10/13 had a Beighton score of >/= 4, and one had clinically significant rotational abnormalities of the lower extremity. The primary pathology that was considered to contribute to the imbrication failure cases was trochlear dysplasia in four, generalised ligamentous laxity in six, rotational abnormalities in one, patella alta with trochlear dysplasia in one, and generalised ligamentous laxity with trochlear dysplasia in one. Prior to surgical failure the mean BPII score for the failure group was 71.5/100, compared with 74.6/100 for the remainder of the cohort. MPFL reconstruction is highly successful surgical procedure for stabilising the unstable patella with a failure rate of only 4.8%. Higher failure rates are seen in patients undergoing imbrication of the MPFL compared to a reconstruction. Pathoanatomies that contribute to failure vary between patients with the most common being trochlear dysplasia and generalised ligamentous laxity

Traumatic amputations (TAs) are amongst the most significant orthopaedic sequelae following IED strikes. Biomechanically, longer residual limb length confers better function. However, post-trauma definitive through knee amputation (TKA) remains controversial. UK military casualties sustaining ≥1 major TA, 01/08/2008–01/08/2010 were identified using the UK JTTR and post mortem CT databases. All through- and below-knee TAs were termed ‘potential TKAs’ (p-TKAs); hypothetical candidates for definitive TKA. We hypothesised that traumatic TKAs were more common than previously reported (4.5% of lower limb TAs) and a significant cohort of blast injuries exist suitable for definitive TKA. 146 cases (75 survivors, 71 fatalities) sustained 271 TAs (235 lower limb). TKA rate was 34/235 (14.2%). 63/130 survivor TAs and 66/140 fatality TAs merited analysis as p-TKAs. Detailed pathoanatomy was only available for fatality p-TKAs, for whom definitive TKA would have been proximal to the zone of injury (ZOI) in only 3/66 cases. Blast-mediated traumatic TKAs are significantly more common than previously reported (p=0.0118). Most lower limb TAs are skeletally amenable to definitive TKA. Maximising stump length for function incurs the risks of definitive amputation within the original ZOI (including infection and heterotopic ossification) but proximal extent of blast soft tissue injury commonly makes this unavoidable