1 . A preliminary report is presented of a clinical trial to compare the results of early and late weight bearing in randomly selected patients of comparable age groups whose displaced femoral neck fractures were treated by internal fixation with a sliding nail-plate. 2. When 124 patients were assessed at three months and 107 at six months after operation there was no significant difference between those who started unguarded weight bearing two weeks after operation and those who avoided weight bearing for three months. 3. Early weight bearing appears to have no harmful effect on the early post-operative stability of this fracture when a sliding nail-plate is used for fixation. 4. Further information is necessary before any conclusion can be reached about the effect of early weight bearing on the ultimate fate of the fracture and of the femoral head. For this reason, and also to increase the numbers of patients in the series, the trial is continuing and the patients are being followed up for a three-year period

Aims

The aim of this study was to determine the immediate post-fixation stability of a distal tibial fracture fixed with an intramedullary nail using a biomechanical model. This was used as a surrogate for immediate weight-bearing postoperatively. The goal was to help inform postoperative protocols.

Aims. The primary objective of this study was to compare migration of the cemented ATTUNE fixed bearing cruciate retaining tibial component with the cemented Press-Fit Condylar (PFC)-sigma fixed bearing cruciate retaining tibial component. The secondary objectives included comparing clinical and radiological outcomes and Patient Reported Outcome Measures (PROMs). Methods. A single blinded randomized, non-inferiority study was conducted including 74 patients. Radiostereometry examinations were made after weight bearing, but before hospital discharge, and at three, six, 12, and 24 months postoperatively. PROMS were collected preoperatively and at three, six, 12, and 24 months postoperatively. Radiographs for measuring radiolucencies were collected at two weeks and two years postoperatively. Results. The overall migration (mean maximum total point motion (MPTM)) at two years was comparable: mean 1.13 mm (95% confidence interval (CI), 0.97 to 1.30) for the ATTUNE and 1.16 mm (95% CI, 0.99 to 1.35) for the PFC-sigma. At two years, the mean backward tilting was -0.43° (95% CI, -0.65 to -0.21) for the ATTUNE and 0.08° (95% CI -0.16 to 0.31), for the PFC-sigma. Overall migration between the first and second postoperative year was negligible for both components. The clinical outcomes and PROMs improved compared with preoperative scores and were not different between groups. Radiolucencies at the implant-cement interface were mainly seen below the medial baseplate: 17% in the ATTUNE and 3% in the PFC-sigma at two weeks, and at two years 42% and 9% respectively (p = 0.001). Conclusion. In the first two postoperative years the initial version of the ATTUNE tibial component was not inferior with respect to overall migration, although it showed relatively more backwards tilting and radiolucent lines at the implant-cement interface than the PFC-sigma. The version of the ATTUNE tibial component examined in this study has subsequently undergone modification by the manufacturer. Level of Evidence: 1 (randomized controlled clinical trial). Cite this article: Bone Joint J 2020;102-B(9):1158–1166

Aims. The treatment of tibial aplasia is controversial. Amputation represents the gold standard with good functional results, but is frequently refused by the families. In these patients, treatment with reconstructive limb salvage can be considered. Due to the complexity of the deformity, this remains challenging and should be staged. The present study evaluated the role of femoro-pedal distraction using a circular external fixator in reconstructive treatment of tibial aplasia. The purpose of femoro-pedal distraction is to realign the limb and achieve soft tissue lengthening to allow subsequent reconstructive surgery. Methods. This was a retrospective study involving ten patients (12 limbs) with tibial aplasia, who underwent staged reconstruction. During the first operation a circular hexapod external fixator was applied and femoro-pedal distraction was undertaken over several months. Subsequent surgery included reconstruction of the knee joint and alignment of the foot. Results. The mean follow-up was 7.1 years (2 to 10). The mean age of the patients at the time of the application of the fixator was 2.3 years (1.1 to 5.0). The mean time under distraction was 139.7 days (81.0 to 177.0). A mean fibular distalization of 38.7 mm (14.0 to 67.0) was achieved. Pin infections occurred in four limbs (33.3%) and osteitis in one. A femoral fracture occurred in one patient. Premature removal of the frame was not required in any patient. Sufficient realignment of the leg as well as soft tissue lengthening was achieved in all patients, allowing subsequent reconstruction. All patients were able to mobilize fully weight bearing after reconstruction. Functional outcome was limited in all limbs, and five patients (50.0%) required additional reconstructive operations. Conclusion. Regarding the functional results in the treatment of tibial aplasia, amputation remains superior to limb salvage. The latter procedure should only be performed in patients whose parents refuse amputation. Femoro-pedal distraction efficiently prepares the limb by realigning the leg and soft tissue lengthening. Minor complications are frequent, but usually do not hinder the continuation of distraction. Even though a fully weight-bearing limb is achieved, the functional outcome of reconstructive treatment remains limited. Recurrent deformities frequently occur and may require further operations. Cite this article: Bone Joint J 2020;102-B(9):1248–1255

The successful management of femoral neck fractures is obviously based upon many factors. The forces acting upon the proximal end of the femur are believed to be mainly compressive in nature, and the low-angle nail by stabilising the fully reduced fracture in the line of these forces is held to allow weight bearing to take place. Low-angle nailing is believed to offer many advantages over conventional methods of treatment but only in the presence of stability. Stable reduction is the essential preliminary to any form of treatment, and low-angle fixation with early weight bearing in the absence of stability is regarded as futile. It is suggested that those subcapital separations which follow trivial injury may originate as stress fractures accompanying the process of bone remodelling in the aged, and that many of these fractures may remain unrecognised and heal spontaneously. With rare exceptions, subcapital fractures are regarded as being of the same essential pattern, and their varying radiological appearance is considered to be due to the different degrees of displacement to which they have been subjected. A new classification based on this premise has been suggested. In a series of eighty subcapital fractures the incidence of avascular necrosis was not adversely affected by early weight bearing, but reduction in the extreme valgus position was invariably followed by this disaster. This is probably also true of any malposition in extreme rotation which must stretch and obliterate the vessels in the ligamentum teres. A rough alignment index of reduction was found to provide an almost infallible guide to the prognosis both in regard to union and to avascular change. It may therefore be possible to base prognosis on the quality of reduction before the fixation appliance has been inserted. The unsatisfactory results in those cases apparently destined to non-union or avascular necrosis may then be avoided by alternative means of treatment at an early stage. Whether this will prove to be true must depend upon a much longer experience of low-angle fixation, and, in common with almost every communication on this subject, premature publication must largely offset the value of the present findings

1 . A new surgical approach to the treatment of pes cavus is suggested. The operation consists in a subcutaneous division of the contracted plantar fascia and correction of the varus deformity of the heel by removing a wedge from its lateral aspect. It is submitted that, by approaching the deformity from behind and overcoming the varus of the heel, the foot is rendered plantigrade and that thereafter weight bearing exerts a corrective influence which results in progressive improvement of the deformity. The operation is essentially a prophylactic one and, for the best results, it should be performed before there is gross structural deformity and while active growth is still taking place. 2. Even in patients over the age of fourteen, improvement is obtained by doing nothing more than this simple operation. In the presence of fixed deformity of the forefoot, as encountered in older patients, inversion is corrected by removing a lateral wedge from the calcaneum and the cavus by taking a dorsal wedge from the tarso-metatarsal region. This has the double advantage of producing good correction of deformity, while at the same time preserving movement at the mid-tarsal-subtalar joint. Fixed clawing of the toes will require appropriate corrective treatment, but if the toes are malleable the simple effect of weight bearing on the plantigrade foot produces gradual correction

1. This paper presents a series of 135 patients with displaced ankle fractures treated by rigid internal fixation followed by early joint exercises in bed until movements were restored and followed then by full weight bearing in a plaster. 2. The advantages obtained are as follows: A high standard of reduction can be achieved and maintained. The joint movements are established before organisation of the traumatic exudate. Weight bearing in a plaster reduces the degree of disability and prevents osteoporosis. Further remedial treatment after removal of the plaster is usually unnecessary. 3. All but five of the fractures (3·7 per cent) could be classified in the manner described by Lauge-Hansen. 4. This classification is the most satisfactory of those available and is recommended for general use. 5. Anatomical reduction was obtained in 102 patients (77 per cent), with good objective clinical results in 108 patients (82 per cent). 6. The quality of the clinical result depends mostly on the accuracy of the reduction, to a lesser extent on the degree of initial displacement, and least on the type of fracture. 7. It is considered that the traditional concept of diastasis requires modification; it is felt that the term lateral ankle instability, which includes low fracture of the fibula (intraosseous diastasis) is preferable. 8. Internal fixation of the syndesmosis is to be avoided except in rare instances. 9. The incidence of arthritis is shown to depend mostly upon the accuracy of reduction; the initial degree of displacement is also of importance

The ‘jumbo’ acetabular component is now commonly used in acetabular revision surgery where there is extensive bone loss. It offers high surface contact, permits weight bearing over a large area of the pelvis, the need for bone grafting is reduced and it is usually possible to restore centre of rotation of the hip. Disadvantages of its use include a technique in which bone structure may not be restored, a risk of excessive posterior bone loss during reaming, an obligation to employ screw fixation, limited bone ingrowth with late failure and high hip centre, leading to increased risk of dislocation. Contraindications include unaddressed pelvic dissociation, inability to implant the component with a rim fit, and an inability to achieve screw fixation. Use in acetabulae with < 50% bone stock has also been questioned. Published results have been encouraging in the first decade, with late failures predominantly because of polyethylene wear and aseptic loosening. Dislocation is the most common complication of jumbo acetabular revisions, with an incidence of approximately 10%, and often mandates revision. Based on published results, a hemispherical component with an enhanced porous coating, highly cross-linked polyethylene, and a large femoral head appears to represent the optimum tribology for jumbo acetabular revisions. Cite this article: Bone Joint J 2016;98-B(1 Suppl A):64–7

1. The structure and blood supply of the femoral head and neck, the mechanics of weight bearing, and the known effects of an inert foreign body are considered in relation to arthroplasty. 2. Some artificial hips are reviewed from the biomechanical standpoint. 3. From the information now available it is inferred that mechanical soundness and clinical success are not only co-related but interdependent; and that the mechanical problem of design offers most scope for further development at the present stage of our knowledge. 4. To this end six propositions are submitted. 5. A theoretical replacement arthroplasty, confined to the head and neck, in which breakdown of the component forces suggests that reciprocal use of both tensional and compressive loads might occur as in the natural femur, is described

One hundred and seventy feet have been reviewed after operations for hallux valgus; eighty-five had had arthrodesis of the first metatarso-phalangeal joint and eighty-five had had Keller's operation. Footprints were made in order to assess the patterns of weight-bearing on the big toe and on the lesser metatarsal heads. After arthrodesis the big toe bore weight in 80 per cent compared with 40 per cent after Keller's operation. The ability to bear weight on the big toe is related to the presence of metatarsalgia and excessive weight bearing on the lesser metatarsal heads. These complications were seen more commonly after Keller's operation (particularly when more than one-third of the phalanx had been excised) than after arthrodesis

1. An operation to re-establish the continuity of the bone after resection of tumours of the lower end of the femur or upper end of the tibia is described. 2. Sound bony union may be obtained, allowing walking with weight bearing after three to four months. 3. The combination of a massive tibial or femoral graft (Juvara procedure) with an intramedullary nail, a massive homogenous graft, and fixation of the patella to the autograft to accelerate its revascularisation. has given constant and rapid bony union in five cases. 4. This possibility gives real value to wide resection in the treatment of severe cases of giant-cell tumours. especially those that are recurrent. osteolytic or suspect of malignancy. 5. Its value in the treatment of sarcoma cannot be assessed in so short a series

1. The problem of instability of reduction in congenital dislocation and congenital subluxation of the hip has been studied and it has been concluded that the basic cause of this instability is the abnormal direction in which the entire acetabulum faces. 2. An operation, innominate osteotomy, has been designed to correct the abnormal direction of the entire acetabulum in children over the age of eighteen months. The principle of innominate osteotomy is redirection of the acetabulum so that the reduced dislocation or subluxation, which previously was stable only in a position of abduction and flexion, is rendered stable in the functional position of weight bearing. 3. The operative technique, and the pre-operative and post-operative management are described. 4. The indications for innominate osteotomy are outlined and the advantages of the operation are enumerated. 5. The early results of innominate osteotomy are very encouraging

1. Forty-eight paralytic dislocations of the hip have been studied and twenty-seven operations for correction of valgus deformity of the femoral neck have been done. 2. The differing features of dislocations occurring in poliomyelitis, cerebral palsy and meningomyelocoele are considered in relation to management after operation. 3. Early recognition of subluxation is essential to a successful varus osteotomy. An angle of 105 degrees rather than the 120 degrees previously recommended is advisable for children under the age of five. 4. Redislocation is most likely to occur in meningomyelocoele in which muscular imbalance is greatest, and in later cases where the acetabulum has become shallow by growth without the femoral head within it. It has not occurred as a late complication after weight bearing has been established, from a recurrence of valgus deformity

1. Avascular necrosis of the bony epiphysis or necrosis of the articular cartilage of the hip joint–without bony necrosis–can occur after a slipped upper femoral epiphysis. 2. In avascular necrosis of the bony epiphysis the prognosis depends upon the degree of revascularisation that occurs and upon survival of the articular cartilage. The articular cartilage can survive and a good functioning hip result especially if aided by mobilisation without weight bearing. 3. The prognosis after necrosis of the articular cartilage is poor. This complication occurs more often when conservative treatment is used. 4. A certain number of hips will show poor results no matter what treatment is used. 5. Nutrition of the articular cartilage is probably by the synovial fluid. 6. Strong traction may damage the soft-tissue structure of the hip joint. 7. It is not advisable to perform an osteotomy soon after a slip of the epiphysis. It is better to wait until good function is assured in the joint

1. One hundred and eight osteotomies were reviewed with regard to union, and fourteen were found to be ununited. In only one was non-union detected clinically; the others required radiographic demonstration. Tomographs were particularly helpful in confirming non-union. 2. Nine patients with non-union had pain, equal to or worse than before operation. The pain could not be distinguished from that of osteoarthritis of the hip. 3. Six of the patients with non-union needed an operation. Five had cancellous bone grafts followed by union in all except one. 4. The causes of non-union are reviewed. This complication was found to be less frequent in patients above sixty with stiff hips and bony collapse on the radiograph. Horizontal osteotomy with a displacement of not more than one-third of the diameter of the shaft reduced the incidence of non-union. The variable-angle nail-plate provided the best fixation. Traction provided no benefit and increased the incidence of non-union. Weight bearing is best avoided for eight weeks

1. Sixty-five cases of medial fracture of the femoral neck treated by substitution of the head by an acrylic prosthesis have been studied. 2. In general, the long-term clinical results of prosthetic arthroplasty after fresh fractures have been disappointing. The method has given slightly better results in the treatment of old fractures. 3. In view of the almost perfect results obtained after successful Smith-Petersen nailing in the presence of an adequate blood supply to the femoral head, it seems unjustifiable to abandon this principle for immediate substitution with an acrylic femoral head. Nevertheless it is believed that an arthroplasty of this type is justified in fractures seen late, and in fresh subcapital fractures when the fracture is irreducible. If a prosthesis is to be used, more protection for the stump of the neck against the strain of weight bearing is essential; a simple head prosthesis is inadequate, and a head with either a neck extension or an intramedullary prolongation may give better results

1. The rate of non-union of 100 intertrochanteric osteotomies of the McMurray type, with internal fixation, is reported. One in five was not united one year after operation. The criteria of union are discussed. 2. The patient's disability in twelve ununited osteotomies has been assessed, and related to the mobility of the osteotomy. 3. The factors which prejudice union have been analysed. The principal cause of non-union appeared to be the varus angulation strain on a varus osteotomy displaced medially more than half the diameter of the bone. Obliquity inwards and upwards of the osteotomy was a contributory factor. The types of internal fixation used, the use of external splintage and the period of protected weight bearing with crutches did not appear to be related to the rate of union. 4. It is concluded that marked inward displacement of the osteotomy, combined with either obliquity of the osteotomy or a varus position, prejudices union; that the use of this technique is unfounded in principle and not supported empirically; and that displacement should be eschewed to avoid this complication of intertrochanteric osteotomy in the treatment of osteoarthritis of the hip

1. A family is described of which several members in four generations suffered epiphysial growth disturbances of an unusual kind in the capital epiphyses of the femur, with shortness of stature. 2. This disorder forms one of a group of epiphysial growth disturbances which embraces several recognised disorders, whose effects on the epiphyses vary in severity. They may occur sporadically or they may be inherited as recessive or dominant characters. 3. Differentiation depends on the behaviour of the joint line–in other words, whether the epiphysis starts to show defects through inability to sustain the stress of weight bearing. In the most serious cases the picture is that of Morquio-Brailsford's disease; when the changes are less severe the appearance may be that of bilateral Perthes' disease. Differential diagnosis is no longer possible in later life, because the ultimate condition of the defective femoral heads is the same. Only in the hereditary cases is one able, by studying the capital epiphyses of the hip in childhood, to differentiate between the changes like those of Perthes' disease on the one hand, and micro-epiphysial dysplasia without necrosis on the other

1. Bones consist essentially of bundles of collagenous fibres united by a cementing substance in which the inorganic material lies in the form of minute plate-like crystals. 2. During weight bearing and muscle action bones as a whole are deformed to a variable extent. Periods of deformation are followed by periods of relaxed pressure during which the bones tend to return to their normal form. 3. These variations in deformation and elastic recoil set up alternating pressures and tensions within the bones along the bone cyrstal encrusted fibres which make up the trabeculae, lamellae and Haversian systems, and these alternating phases of compression and tension stimulate the activity of osteoblasts so that bone formation predominates over bone resorption. 4. These alterations of pressure and tension are intermittent and reciprocal in nature and do not, as postulated by the trajectorial theory, involve different trabeculae, nor is it necessary to consider whether tension or pressure is the more important phase in determining bone deposition. 5. The pressure exerted by cysts, tumours, erupting teeth, etc., is of a quite different nature, as is the response to trauma or callus formation in the healing of fractures. These processes are essentially vascular phenomena involving localised areas of bony tissue and not bones as mechanical units

1. Posterior fusion of the spine in scoliosis cannot be relied upon to maintain correction of the curve or to prevent progression of a vicious resistant curve. It can, however, hold to some extent the correction of a mobile curve and the compensation of a fixed curve. 2. Despite generally poor results as assessed radiographically, the clinical improvement is often gratifying. Most patients claim to be greatly improved: the spine feels stronger, there is less fatigue, and balance is better controlled. Moreover, visible deformity may be improved markedly even though the anatomical correction as observed radiographically is slight (Figs. l0 and 11). 3. It is believed that the true cause of relapse is that the bone formed from sliver grafts remains immature for a long time. Even when incorporated with the immature bone of the child's spine or the mature bone of the adult spine, it remains soft and resilient. When subjected to the stresses and strains of weight bearing and gravity, and then to the unnatural forces which initiated or perpetuated the scoliosis, this immature bone undergoes remodelling to Wolff's Law—like the neck of the femur after slipping of the upper femoral epiphysis. The forces that alter the grafted bone are not only lateral forces but also—perhaps more important—rotational forces. There seems to be a definite link between the degree of rotation and the amount of relapse, correction being maintained best when rotation is least