Cannulated hip screws are frequently used in the management of hip fractures. There have been concerns over the failure rate of the technique and the outcomes of those that subsequently require conversion to total hip replacement (THR). This study utilised a database of over 600 cannulated hip screw (CHS) fixations performed over a 14-year period and followed up for a minimum of one year (1-14). We identified 57 cases where a conversion to THR took place (40 females, 17 males, mean age: 71.2 years). Patient demographics, original mechanism of injury, fracture classification, reason for fixation failure, time until arthroplasty, implant type and post-arthroplasty complications were recorded. Clinical outcomes were measured using the Oxford Hip Score. The failure rate of cannulated screw treatment was 9.4% and the mean time from initial fixation to arthroplasty was 15.4 (16.5) months. Thirty six fractures were initially undisplaced and 21 were displaced. As one might expect the displaced cases tended to be younger but this didn't reach statistical significance [66.5(14.3) vs 72.7(13.1), p=0.1]. The commonest causes of failure were non-union (25 cases, 44%) and avascular necrosis (17 cases, 30%). Complications after THR consisted of one leg length discrepancy and one peri-prosthetic fracture. The mean Oxford score pre-arthroplasty was 12.2 (8.4), improving to 38.4 (11.1) at one-year. Although the pre op Oxford scores tended to be lower in patients with undisplaced fractures and higher ASA scores, the improvement was the same whatever the pre-op situation. The one-year Oxford score and the improvement in score are comparable to those seen in the literature for THR in general. In conclusion, CHS has a high success rate and where salvage arthroplasty is required it can provide good clinical outcomes with low complication rates

Abstract. Objectives. The use of cannulated screws for femoral neck fractures is often limited by concerns of avascular necrosis (AVN) occurring, historically seen in 10–20% of fixed intracapsular fractures. The aim of this study was to investigate the rate of AVN with current surgical techniques within our unit. Methods. A single centre retrospective review was performed. Operative records between 1st July 2014 and 31st May 2019 were manually searched for patients with an intracapsular neck of femur fracture fixed with cannulated screws, with minimum one year follow up. Patient records and radiographs were reviewed for clinical and radiographic diagnoses of AVN and/or non-union. Fracture pattern and displacement, screw configuration and reduction techniques were recorded, with radiographs independently analysed by five orthopaedic surgeons. Results. Sixty-five patients were identified, average age of 72 years (range 48–87). Thirty-six patients (55%) sustained displaced fractures and 29 patients (45%) had undisplaced fractures. Two (3%) patients developed AVN, with no cases of fracture non-union. Ten patients (15%) sustained a high-energy injury, though none of these patients developed AVN. Screws configurations were: two (3%) triangle apex-superior, 39 (60%) triangle apex-inferior, 22 (34%) rhomboid and two (3%) other, with nine (14%) cases using washers. All fractures required closed reduction; no open reductions performed. Conclusions. Our observed AVN rate is much lower than widely reported, especially given the proportion of displaced fractures that were fixed. With adequate fixation, even in displaced fracture patterns with imperfect reduction, cannulated screws are an excellent option for intracapsular neck of femur fractures. Declaration of Interest. (b) declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported:I declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research project

Summary Statement. Atypical femoral fractures consist of a thin fracture line extending through the lateral cortex. The adjacent bone is undergoing resorption and mechanical abrasion and is often replaced with woven bone. The mechanical environment seems to inhibit healing. Background. The pathophysiology behind bisphosphonate-associated atypical femoral fractures remains unclear. Histological findings at the fracture site itself might provide important clues. So far only one case describing the histological appearance of the fracture has been published. Methods. Between 2008 and 2013, bone biopsies comprising the fracture site were collected from 8 patients with 4 displaced and 4 undisplaced atypical femoral fractures. Seven female patients reported continuous bisphosphonate use for an average of 9.5 years. One patient was a man, not using bisphosphonates. The bone biopsies were evaluated histologically, with Fourier transformed infrared imaging (FTIR) and micro-computed tomography. Results. The 4 undisplaced fractures engaged the whole cortical thickness and comprised a 150 to 200 µm wide, meandering fracture gap filled with amorphous necrotic material. Von Kossa staining showed occasional mineralised elements with bony structure within the amorphic material. Active resorption and remodeling was common in the close vicinity of the fracture, but seldom reached into the fracture gap. In some areas, the bone adjacent to the gap appeared to undergo fragmentation and disintegration, possibly due to abrasion. Woven bone was common adjacent to the fracture gap, and appeared to have been formed in defects caused by abrasion or where resorption cavities had reached into the fracture gap. Periosteal and endosteal callus was found in all cases. Far away from the fracture, large areas of osteonal bone with only empty osteocyte lacunae were found in some samples. In one patient, the remodeling process bridged the fracture gap at some points. The fracture was otherwise similar to the other undisplaced fractures. This patient had suffered from thigh pain since her bisphosphonate treatment was discontinued 18 months earlier, when the atypical fracture was diagnosed. Discussion. Atypical femoral fractures show signs of increased remodeling in the vicinity of the fracture gap. The narrow width of the gap and its necrotic contents suggest that micromotion leads to strains between the fracture fragments that precludes survival of ingrowing cells. Moreover, there seemed to be continuous mechanical fragmentation of the bone at the crack, and replacement of fragmented areas with woven bone. Thus, it appears that the fracture line is not static, but moves in the bone over time, like the changes in the course of a meandering river

Cubitus varus following paediatric supra-condylar humeral fracture represents a complex three-dimensional malunion. This affects cosmesis, function and subsequent distal humeral fracture risk. Operative correction is however difficult with high complication rates. We present the 40-year Yorkhill experience of managing this deformity. From a total of 3220 supracondylar humeral fractures, 40 cases of post-traumatic cubitus varus were identified. There were ten undisplaced fractures, treated in cast, and thirty displaced fractures. Five were treated in cast, thirteen manipulated (MUA), four MUA+k-wires, seven ORIF (six k-wire, one steinman pin) and one in skeletal-traction. Sixteen malunions were treated operatively. The mean pre-operative varus was 19°. All had cosmetic concerns, three mild pain, one paraesthesia/weakness and three reduced movement (ROM). The operative indication was cosmetic in fifteen and functional in one (concern about instability). Twelve patients had lateral closing-wedge osteotomies; three complex/3D osteotomies (dome, unspecified rotational, antero-lateral wedge) and two had attempted 8-plate guided-growth correction. Complications occurred in eight patients (50 %): Fixation was lost in three (two staples, one k-wiring), incomplete correction in six (both 8-plates, both staples, two standard plates) and one early wound infection requiring metalwork removal resulting in deformity recurrence. One patient underwent revision lateral wedge osteotomy with full deformity correction but marked ROM restriction (20–100°) secondary to loose bodies. Those without complications were satisfied (50 %). All patients with residual deformity were unsatisfied. 1 patient with keloid scarring was unsatisfied despite deformity correction. Varus malunion is uncommon (1 %) but needs to be guarded against. It tended to occur in displaced fractures treated with MUA and cast alone. We therefore recommend additional pin fixation in all displaced fractures. Deformity correction should only be attempted in those with significant symptomatic deformity due to the high complication/dissatisfaction rates. Staple osteotomy fixation and 8-plate guided growth correction are not recommended