A soft-tissue defect over an infected total knee replacement (TKR) presents a difficult technical problem that can be treated with a gastrocnemius flap, which is rotated over the defect during the first-stage of a revision procedure. This facilitates wound healing and the safe introduction of a prosthesis at the second stage. We describe the outcome at a mean follow-up of 4.5 years (1 to 10) in 24 patients with an infected TKR who underwent this procedure. A total of 22 (92%) eventually obtained a satisfactory result. The mean Knee Society score improved from 53 pre-operatively to 103 at the latest follow-up (p < 0.001). The mean Western Ontario and McMaster Universities osteoarthritis index and Short-Form 12 score also improved significantly (p < 0.001).

This form of treatment can be used reliably and safely to treat many of these complex cases where control of infection, retention of the components and acceptable functional recovery are the primary goals.

Cite this article: Bone Joint J 2013;95-B:1217–21.

Treatment of trochanteric fractures is associated a high complication rate. This prospective multicenter study evaluates the new Zimmer Cephalomedullary Nail (CMN).

Patients over 50 years sustaining a pertrochanteric or subtrochanteric femoral fracture were prospectively enrolled and patients with multiple injuries, pathological fractures or severe dementia were excluded.

101 patients (70% female, 30% male) from 5 different hospitals were prospectively recruited between January 2011 and August 2012. Mean age was 78 (51–98) years and mean Charlson Score was 2.6 (1–6). 65% of the trochanteric fractures were unstable, 35% were stable. There were 4 (5%) minor (3 superficial infections and 1 pain over distal locking screw) and 3 (4%) major (2 lag screw cut out, 1 nail breakage) complications Fracture healing was completed in 27 of 31 patients (87%) after 12 month (3 month: 14/42 (33%); 6 month: 27/39(69%)). The Barthel Index (85, SD 19) and EQ-5-D (0.61, SD 0.30) values reached prefracture level after 6 month.

The study population and fracture type were comparable to other studies and complication and early union rates were also comparable. Technical complications were low and early functional results encouraging. Final results of this trial at one year follow up are awaited.

Introduction Sequestered disc fragments in the achondroplastic dwarf are rare. They should be removed by an anterior approach because:

access to remove the fragment posteriorly is severely compromised by the condition.

Method The case is of a 30 year old achondroplastic dwarf with spontaneous sudden onset of myelopathy over three myotomes. An MRI scan revealed an L1-2 large disc herniation compressing the thecal sac in an already small canal.

Results The spinal decompression resulted in recovery from the paresis without creating the instability associated with a wide posterior exposure.

Discussion The thoraco-abdominal approach involves incision along the line of the rib two levels above the most proximal vertebral body to be visualized. The external oblique and internal oblique are incised in the line of the rib. The diaphragm is taken down from the costal cartilage to the crus posteriorly allowing access to the upper lumbar spine. The segmental vessels are identified and subperiosteal dissection carried out. The disc is excised and the adjacent posterolateral vertebral body extending toward the segmental vessels. The neural elements are decompressed and the spine is stabilized using the rib strut as graft in the space created by the vertebral resection with morselized graft into the intervertebral disc space.