Aims. This study analysed the clinical and radiological outcome of anatomical reduction of a moderate or severe stable slipped capital femoral epiphysis (SCFE) treated by subcapital osteotomy (a modified Dunn osteotomy) through the surgical approach described by Ganz. . Patients and Methods. We prospectively studied 31 patients (32 hips; 16 females and five males; mean age 14.3 years) with SCFE. On the Southwick classification, ten were of moderate severity (head-shaft angle > 30° to 60°) and 22 were severe (head-shaft angle > 60°). Each underwent open reduction and internal fixation using an intracapsular osteotomy through the physeal growth plate after safe surgical hip dislocation. Unlike the conventional procedure, 25 hips did not need an osteotomy of the apophysis of the great trochanter and were managed using an extended retinacular posterior flap. . Results. Clinical outcome was assessed using the range of movement and the Harris Hip (HHS), Western Ontario and McMaster Universities Osteoarthritis (WOMAC), and Merle d’Aubigné scores, while radiological measurements included slip and alpha angles. The mean duration of follow-up was 24.1 months (12 to 40). . There was a significant improvement in all clinical and radiological measurements after treatment (p < 0.001). Post-operative major complications were one deep infection and one case of femoral head collapse. . Conclusion. These findings suggest that a modified Dunn osteotomy carried out through Ganz approach is a safe and effective method of treating the stable SCFE with a high degree of slip. . Cite this article: Bone Joint J 2016;98-B:1283–8

Aims. The aim of this study was to investigate if there are differences in outcome between sliding hip screws (SHSs) and intramedullary nails (IMNs) with regard to fracture stability. Methods. We assessed data from 17,341 patients with trochanteric or subtrochanteric fractures treated with SHS or IMN in the Norwegian Hip Fracture Register from 2013 to 2019. Primary outcome measures were reoperations for stable fractures (AO Foundation/Orthopaedic Trauma Association (AO/OTA) type A1) and unstable fractures (AO/OTA type A2, A3, and subtrochanteric fractures). Secondary outcome measures were reoperations for A2, A3, and subtrochanteric fractures individually, one-year mortality, quality of life (EuroQol five-dimension three-level index score), pain (visual analogue scale (VAS)), and satisfaction (VAS) for stable and unstable fractures. Hazard rate ratios (HRRs) for reoperation were calculated using Cox regression analysis with adjustments for age, sex, and American Society of Anesthesiologists score. Results. Reoperation rate was lower after surgery with IMN for unstable fractures one year (HRR 0.82, 95% confidence interval (CI) 0.70 to 0.97; p = 0.022) and three years postoperatively (HRR 0.86, 95% CI 0.74 to 0.99; p = 0.036), compared with SHS. For individual fracture types, no clinically significant differences were found. Lower one-year mortality was found for IMN compared with SHS for stable fractures (HRR 0.87; 95% CI 0.78 to 0.96; p = 0.007), and unstable fractures (HRR 0.91, 95% CI 0.84 to 0.98; p = 0.014). Conclusion. This national register-based study indicates a lower reoperation rate for IMN than SHS for unstable trochanteric and subtrochanteric fractures, but not for stable fractures or individual fracture types. The choice of implant may not be decisive to the outcome of treatment for stable trochanteric fractures in terms of reoperation rate. One-year mortality rate for unstable and stable fractures was lower in patients treated with IMN. Cite this article: Bone Joint J 2022;104-B(2):274–282

Intertrochanteric fractures of the femur are usually classified into stable and unstable groups, partly to predict the likelihood of displacement with early weight-bearing after internal fixation. Of 82 internally fixed intertrochanteric fractures which would normally be classified as stable, 25 subsequently underwent impaction along the axis of the nail or screw; varus displacement occurred in another six. Of these 31 fractures, 10 were two-part fractures which had been anatomically reduced, and 12 were originally undisplaced. It did not seem possible to predict the subsequent instability from the pre-operative radiographs. Of the 82 fractures, 47 had been treated with a Jewett nail-plate and 35 by a Richards compression screw-plate. Two groups of stable fractures were recognised: Group 1 was undisplaced and Group 2 displaced. Axial impaction occurred in a quarter of all Group 1 fractures however treated. In Group 2 fractures it occurred in a quarter of those treated with a nail-plate, and in over a third of those treated with a sliding screw-plate. The six fractures that underwent varus displacement had all been treated with Jewett nail-plates. Penetration into the joint occurred in 10 patients, all of them in the group treated with Jewett nail-plates; four required re-operation

Aims. We describe the use of a protocol of irrigation and debridement (I& D) with retention of the implant for the treatment of periprosthetic infection of a total elbow arthroplasty (TEA). This may be an attractive alternative to staged re-implantation. . Patients and Methods. Between 1990 and 2010, 23 consecutive patients were treated in this way. Three were lost to follow-up leaving 20 patients (21 TEAs) in the study. There were six men and 14 women. Their mean age was 58 years (23 to 76). The protocol involved: component unlinking, irrigation and debridement (I& D), and the introduction of antibiotic laden cement beads; organism-specific intravenous antibiotics; repeat I& D and re-linkage of the implant if appropriate; long-term oral antibiotic therapy. . Results. The mean follow-up was 7.1 years (2 to 16). The infecting micro-organisms were Staphylococcus aureus in nine, coagulase-negative Staphylococcus in 13, Corynebacterium in three and other in six cases. Re-operations included three repeat staged I& Ds, two repeat superficial I& Ds and one fasciocutaneous forearm flap. One patient required removal of the implant due to persistent infection. All except three patients rated their pain as absent or mild. Outcome was rated as good or excellent in 15 patients (mean Mayo Elbow Performance Score 78 points, (5 to 100) with a mean flexion-extension arc of 103° (40° to 150°)). . Conclusion. A staged protocol can be successful in retaining stable components of an infected TEA. Function of the elbow may compare unfavourably to that after an uncomplicated TEA. Cite this article: Bone Joint J 2016;98-B:976–83

End caps are intended to prevent nail migration (push-out) in elastic stable intramedullary nailing. The aim of this study was to investigate the force at failure with and without end caps, and whether different insertion angles of nails and end caps would alter that force at failure. Simulated oblique fractures of the diaphysis were created in 15 artificial paediatric femurs. Titanium Elastic Nails with end caps were inserted at angles of 45°, 55° and 65° in five specimens for each angle to create three study groups. Biomechanical testing was performed with axial compression until failure. An identical fracture was created in four small adult cadaveric femurs harvested from two donors (both female, aged 81 and 85 years, height 149 cm and 156 cm, respectively). All femurs were tested without and subsequently with end caps inserted at 45°. In the artificial femurs, maximum force was not significantly different between the three groups (p = 0.613). Push-out force was significantly higher in the cadaveric specimens with the use of end caps by an up to sixfold load increase (830 N, standard deviation (SD) 280 vs 150 N, SD 120, respectively; p = 0.007). These results indicate that the nail and end cap insertion angle can be varied within 20° without altering construct stability and that the risk of elastic stable intramedullary nailing push–out can be effectively reduced by the use of end caps. Cite this article: Bone Joint J 2015;97-B:558–63

We determined the short-term clinical outcome and migration within the bone of the humeral cementless component of the Instrumented Bone Preserving (IBP) total elbow replacement in a series of 16 patients. There were four men and 12 women with a mean age at operation of 63 years (40 to 81). Migration was calculated using radiostereometric analysis. There were no intra-operative complications and no revisions. At two-year follow-up, all patients showed a significant reduction in pain and functional improvement of the elbow (both p < 0.001). Although ten components (63%) showed movement or micromovement during the first six weeks, 14 (88%) were stable at one year post-operatively. Translation was primarily found in the proximal direction (median 0.3 mm (interquartile range (IQR) -0.09 to 0.8); the major rotational movement was an anterior tilt (median 0.7° (IQR 0.4° to 1.6°)). One malaligned component continued to migrate during the second year, and one component could not be followed beyond three months because migration had caused the markers to break off the prosthesis. This study shows promising early results for the cementless humeral component of the IBP total elbow replacement. All patients had a good clinical outcome, and most components stabilised within six months of the operation. . Cite this article: Bone Joint J 2014;96-B:229–36

Several techniques are available for the treatment of displaced fractures of the neck of the radius in children. We report our experience in 14 children treated by indirect reduction and fixation using an elastic stable intramedullary nail. The patients were followed up for a mean of 28 months. One developed asymptomatic avascular necrosis. The rest had excellent results. One had a neuropraxia of the posterior interosseous nerve, which recovered within six weeks. We advocate elastic stable intramedullary nailing for the closed reduction and fixation of these fractures in children

Elastic stable intramedullary nailing (ESIN) is generally acknowledged to be the treatment of choice for displaced diaphyseal femoral fractures in children over the age of three years, although complication rates of up to 50% are described. Pre-bending the nails is recommended, but there are no published data to support this. Using synthetic bones and a standardised simulated fracture, we performed biomechanical testing to determine the influence on the stability of the fracture of pre-bending the nails before implantation. Standard ESIN was performed on 24 synthetic femoral models with a spiral fracture. In eight cases the nails were inserted without any pre-bending, in a further eight cases they were pre-bent to 30° and in the last group of eight cases they were pre-bent to 60°. Mechanical testing revealed that pre-bending to 60° produced a significant increase in the stiffness or stability of the fracture. Pre-bending to 60° showed a significant positive influence on the stiffness compared with unbent nails. Pre-bending to 30° improved stiffness only slightly. These findings validate the recommendations for pre-bending, but the degree of pre-bend should exceed 30°. Adopting higher degrees of pre-bending should improve stability in spiral fractures and reduce the complications of varus deformity and shortening

We reviewed 74 partial medial meniscectomies in 57 patients with stable knees, to assess the long-term functional and radiological outcome. The International Knee Documentation Committee score and the residual laxity were assessed in both knees. At the time of surgery the mean age of the patients was 36 ± 11 years and the mean follow-up was 12 ± 1 years. All had a limited medial meniscectomy. The anterior cruciate ligament was intact in all cases. The meniscal tear was vertical in 95% and complex in 5%. The posterior part of the meniscus was removed in 99%. A peripheral rim was preserved in all cases. After 12 years 95% of the patients were satisfied or very satisfied with their knee(s). Objectively, 57% had grade A function and 43% were grade B. The outcome correlated only with the presence of anterior knee pain at final follow-up. In the 49 cases of arthroscopic meniscectomy for which there was a contralateral normal knee there was narrowing of the ‘joint-space’ in 16% of the operated knees. There was no correlation between this and other parameters such as age or different meniscal pathologies

This study was performed to determine whether pure cancellous bone graft and Kirschner (K-) wire fixation were sufficient to achieve bony union and restore alignment in scaphoid nonunion. A total of 65 patients who underwent cancellous bone graft and K-wire fixation were included in this study. The series included 61 men and four women with a mean age of 34 years (15 to 72) and mean delay to surgery of 28.7 months (3 to 240). The patients were divided into an unstable group (A) and stable group (B) depending on the pre-operative radiographs. Unstable nonunion was defined as a lateral intrascaphoid angle > 45°, or a radiolunate angle > 10°. There were 34 cases in group A and 31 cases in group B. Bony union was achieved in 30 patients (88.2%) in group A, and in 26 (83.9%) in group B (p = 0.439). Comparison of the post-operative radiographs between the two groups showed no significant differences in lateral intrascaphoid angle (p = 0.657) and scaphoid length (p = 0.670) and height (p = 0.193). The radiolunate angle was significantly different (p = 0.020) but the mean value in both groups was < 10°. Comparison of the dorsiflexion and palmar flexion of movement of the wrist and the mean Mayo wrist score at the final clinical visit in each group showed no significant difference (p = 0.190, p = 0.587 and p = 0.265, respectively). Cancellous bone graft and K-wire fixation were effective in the treatment of stable and unstable scaphoid nonunion. Cite this article: Bone Joint J 2013;95-B:809–14

Fractures of the femur are the most incapacitating fractures in children. Conservative treatment necessitates a long stay in hospital for traction and subsequent immobilisation in an uncomfortable cast. This treatment is not well tolerated, especially in adolescents. Moreover, near the end of growth, accurate reduction is necessary, as malunion is no longer correctable by growth. Stable elastic intramedullary nailing uses two flexible nails which are introduced percutaneously either through the lower metaphysis or the subtrochanteric area. This technique does not disturb the healing of the fracture. The elasticity of the device allows slight movement at the fracture site which favours union. Reduction and stabilisation are adequate and the operative risk is very low. A cast is not required, functional recovery is rapid and the patient is allowed to walk with crutches after seven to ten days according to the type of fracture. This technique is very efficient in adolescents and can be used after the age of seven years when conservative treatment is unsuccessful

We report the use of elastic stable intramedullary nailing (ESIN) in 123 fractures of the femoral shaft in children. Flexible rods are introduced through the distal metaphyseal area, and the aim is to develop bridging callus. Early weight-bearing is possible and is recommended. There was one case of bone infection and no delayed union. Complications were minimal, the most common being minor skin ulceration caused by the ends of the rods. A surprising feature was the low incidence of growth changes, with a mean lengthening of only 1.2 mm after an average follow-up of 22 months. Compared with conservative treatment, ESIN obviates the need for prolonged bed rest and is thus particularly advantageous for treating children

1. The late consequences of stable fractures of the thoracic and lumbar spine have been assessed in a series of workmen. The incidence of symptoms has been recorded and an attempt made to assess the degree of associated incapacity. 2. It has been found that most patients continue to have some symptoms attributable to the back injury and that approximately one in five of the patients who attended for review was partially or completely incapacitated as a consequence of such symptoms. 3. The persistence of symptoms was found to be unrelated to the severity of fracture, to its level, to the presence of radiological evidence of degenerative change, or to the age of the patient. 4. Persistent symptoms were found more commonly in those patients who had received more treatment. The implications of this observation are discussed

Aims

Hydroxyapatite coatings for uncemented fixation in total knee arthroplasty can theoretically provide a long-lasting biological interface with the host bone. The objective of this study was to test this hypothesis with propriety hydroxyapatite, peri-apatite, coated tibial components using component migration measured with radiostereometric analysis over two years as an indicator of long-term fixation.

Aims

Early implant migration measured with radiostereometric analysis (RSA) has been proposed as a useful predictor of long-term fixation of tibial components in total knee arthroplasty. Evaluation of actual long-term fixation is of interest for cemented components, as well as for cementless fixation, which may offer long-term advantages once osseointegration has occurred. The objective of this study was to compare the long-term migration with one- and two-year migration to evaluate the predictive ability of short-term migration data and to compare migration and inducible displacement between cemented and cementless (porous metal monoblock) components at least ten years postoperatively.

We investigated whether, in the management of stable paediatric fractures of the forearm, flexible casts that can be removed at home are as clinically effective, cost-effective and acceptable to both patient and parent as management using a cast conventionally removed in hospital. A single-centre randomised controlled trial was performed on 317 children with a mean age of 9.3 years (2 to 16). No significant differences were seen in the change in Childhood Health Assessment Questionnaire index score (p = 0.10) or EuroQol 5-Dimensions domain scores between the two groups one week after removal of the cast or the absolute scores at six months. There was a significantly lower overall median treatment cost in the group whose casts were removed at home (£150.88 (sem 1.90) vs £251.62 (sem 2.68); p <  0.001). No difference was seen in satisfaction between the two groups (p = 0.48).

Cite this article: Bone Joint J 2013;95-B:1714–20.

We studied the contributions of the long and short heads of the biceps (LHB, SHB) to anterior stability in 13 cadaver shoulders. The LHB and SHB were replaced by spring devices and translation tests at 90 degrees abduction of the arm were performed by applying a 1.5 kg anterior force. The position of the humeral head was monitored by an electromagnetic tracking device with or without an anterior translational force; with 0 kg, 1.5 kg or 3 kg loads applied on either LHB or SHB tendons in 60 degrees, 90 degrees or 120 degrees of external rotation; and with the capsule intact, vented, or damaged by a Bankart lesion. The anterior displacement of the humeral head under 1.5 kg force was significantly decreased by both the LHB and SHB loading in all capsular conditions when the arm was in 60 degrees or 90 degrees of external rotation. At 120 degrees of external rotation, anterior displacement was significantly decreased by LHB and SHB loading only when there was a Bankart lesion. We conclude that LHB and SHB have similar functions as anterior stabilizers of the glenohumeral joint with the arm in abduction and external rotation, and that their role increases as shoulder stability decreases. Both heads of the biceps have been shown to have a stabilising function in resisting anterior head displacement, and consideration should therefore be given to strengthening the biceps during rehabilitation programmes for chronic anterior instability of the shoulder.