The purpose of this study is to describe the use of the PHILOS plate (Synthes) in reverse configuration to treat complex distal humeral non-unions.

Non-union is a frequent complication of distal humeral fracture. It is a challenging problem due to the complex anatomy of the distal humerus, small distal fragment heavily loaded by the forearm acting as a long lever arm with powerful forces increasing the chances of displacement. Rigid fixation and stability with a device of high “pull-out” strength is required. The PHILOS plate has been used in reverse configuration to achieve good fixation while allowing central posterior placement of the implant.

11 patients with established non-union of distal humeral fractures were included in this study. No patient in whom this implant was used has been excluded. Initial fixation was revised using the PHILOS plate in reverse configuration and good fixation was achieved. Bone graft substitutes were used in all cases. Patients were followed to bony union, and functional recovery.

All fractures united. One required revision of plate due to fatigue failure. Average time to union was 8 months with excellent restoration of elbow function.

A reversed PHILOS plate provides an excellent method of fixation in distal humeral non-union, often complicated by distorted anatomy and previous surgical intervention. It has a high “pull-out” strength and may be placed in the centre of the posterior humerus, allowing proximal extension of the fixation as far as is required. It provides secure distal fixation without impinging on the olecranon fossa. It is more versatile and easier to use than available pre contoured plating systems.

The purpose of this study was to identify the prevalence of common mental disorders in patients undergoing complex limb reconstruction.

Patients undergoing limb reconstruction are vulnerable to mental health problem as they must adapt to significant and prolonged physical disability. Treatment emphasis has been on restoration and rehabilitation of physical health with little or no attention given to spectrum of psychological consequences. IMPARTS (Integrating Mental and Physical healthcare: Research, Training and Services) is a King's Health Partners initiative aiming to develop informatics to improve detection and management of common mental disorders in medical settings. IMPARTS screening in the King's College Hospital limb reconstruction clinic commenced in April 2012.

Outpatients attending between April 2012 and November 2013 were screened prior to their appointment. Patients were screened for symptoms of depression, anxiety, post-traumatic stress disorder (PTSD), alcohol dependence and drug use.

In total, 298 individual patients were screened. The prevalence of depression was found to be 21.8%, with 6.4% experiencing suicidal thoughts. Probable anxiety disorder was identified in 20.7% of patients. Symptoms of PTSD were reported by 29.2%, with 9.0% reporting severe symptoms. Probable alcohol dependence was identified in 2.7% of patients, and 3.0% screened positive for drug misuse.

The consequences of undergoing limb reconstruction stretch beyond the physical problem to mental well-being, rendering patients vulnerable to mental health problems and substance misuse. Early detection and management of such problems may have a significant effect on physical treatment outcome and rehabilitation to productive social life. There is urgent need to integrate mental health care as part of early management of severely injured patients.

The purpose of this study is to describe the use of intramedullary distraction coupled with an additional osteotomy to achieve union with simultaneous deformity correction and lengthening in femoral non-union.

Femoral non-union is a difficult problem often associated with shortening, angulation, and mal-rotation. We report the use of an intramedullary distraction device, with additional osteotomy, to achieve union, restore femoral length and alignment. Simple distraction in femoral non-union is often ineffective, possibly because the non-union site is relatively avascular. Osteotomy is known to increase blood flow and, with lengthening, promote union through distraction histiogenesis.

7 patients with posttraumatic diaphyseal femoral non-union with shortening were studied. Pre-operative planning included long leg standing views, with CT to measure mal-rotation. 6 patients were treated with the Intramedullary Skeletal Kinetic Distractor (ISKD) with an osteotomy distant from non-union site within the parameters required for the device. One patient underwent distraction without osteotomy. Patients were followed to union. Complications and adjuvant interventions were recorded.

All 7 patients with femoral non-union treated with ISKD were included and followed up. Patients treated with osteotomy united at average of 9 months with satisfactory deformity correction and lengthening. However patient who underwent pure distraction failed to unite. Complications included failure to lengthen, requiring manipulation, and delayed consolidation of regenerate requiring bone graft. The procedure was well tolerated

The initial results of the management of femoral non-union with deformity by intramedullary distraction coupled with osteotomy are encouraging. Complications were minor and readily manageable. We believe there is an important role for this method in the management of femoral non-unions associated with deformity and length discrepancy.

Limb lengthening with external fixators has many complications, like pin track infection, joint stiffness, severe pain and stress fracture after removal of external fixator. Prolonged period in external fixator interferes with rehabilitation and activities of daily living.

We describe our results with ISKD (intramedullary skeletal kinetic distractor) system, an internal limb lengthening device, activated with rotations of 3 degrees. In this retrospective cohort we performed lengthening with the use of ISKD in 12 patients from March 2006 to date. Ten patients were included in this study as two patients had not completed the stage of consolidation. There were 7 male and 3 female patients. Their average age was 44 years (range 23–63). The mean follow up period was 16 months (range 12–24 months). Two patients had tibial lengthening and eight patients had femoral lengthening. The average lengthening desired was 42.5 mm (range 2.5 mm–75 mm). The average lengthening achieved was 38 mm. Mean hospital stay was 7 days (range 5–11 days). The distraction index was 1.2 mm/day. The average time to full weight bearing was 6 months (range 4 to 10 months). Mean healing time was 10.25 months. The mean healing index was 90.7 days/cm. If we remove two patients who took long time to heal, the mean healing index drops to 61 days/cm. Two patients needed bone grafting at the distraction site. None of the patients had infection, non-union of the distraction site or breakage of the nail. None of the patients had joint stiffness. All patients were completely satisfied with the treatment and had excellent functional results. We conclude that the low rate of complications, higher patient acceptability and avoidance of external fixation make ISKD a very attractive option for limb lengthening.

We present a series of 11 patients with infected tibial intramedullary nails which were treated at our tertiary referral centre from January 2000 to November 2009. All of them were males and the mean age was 36 years (26 to 47 years). All the patients had sustained post traumatic fractures which were treated with intramedullary nail. Four patients (36%) had sustained open fractures in whom adequate soft tissue cover was provided by plastic surgeons. Five of them (45%) were smokers.

All of them underwent surgical debridement. Nine out of 11 patients had removal of metal work followed by one or more of the following procedures such as reaming, exchange nailing, excision of sequestrum, application of antibiotic beads and stabilisation with a frame with or without several bone grafts at a later date.

Out of 11 patients six (55%) had no further episodes of infection, three (27%) still need short courses of antibiotics when the disease flares up and two (18%) underwent amputation. Causative organisms were isolated in all the patients. Commonest organism was MRSA. Overall, most of the organisms were sensitive to Vancomycin and resistant to Penicillin.

Despite exploring most of the surgical procedures described for infected tibial intramedullary nails we have potentially eradicated infection only in about half of our patients. Hence we would like to emphasise that this condition still remains a serious problem and demands further insight in its management