Aims. In our unit, we adopt a two-stage surgical reconstruction approach using internal fixation for the management of infected Charcot foot deformity. We evaluate our experience with this functional limb salvage method. Methods. We conducted a retrospective analysis of prospectively collected data of all patients with infected Charcot foot deformity who underwent two-stage reconstruction with internal fixation between July 2011 and November 2019, with a minimum of 12 months’ follow-up. Results. We identified 23 feet in 22 patients with a mean age of 56.7 years (33 to 70). The mean postoperative follow-up period was 44.7 months (14 to 99). Limb salvage was achieved in all patients. At one-year follow-up, all ulcers have healed and independent full weightbearing mobilization was achieved in all but one patient. Seven patients developed new mechanical skin breakdown; all went on to heal following further interventions. Fusion of the hindfoot was achieved in 15 of 18 feet (83.3%). Midfoot fusion was achieved in nine of 15 patients (60%) and six had stable and painless fibrous nonunion. Hardware failure occurred in five feet, all with broken dorsomedial locking plate. Six patients required further surgery, two underwent revision surgery for infected nonunion, two for removal of metalwork and exostectomy, and two for dynamization of the hindfoot nail. Conclusion. Two-stage reconstruction of the infected and deformed Charcot foot using internal fixation and following the principle of ‘long-segment, rigid and durable internal fixation, with optimal bone opposition and local antibiotic elusion’ is a good form of treatment provided a multidisciplinary care plan is delivered. Cite this article: Bone Joint J 2021;103-B(10):1611–1618

Aims. Monocyte-lymphocyte ratio (MLR) or neutrophil-lymphocyte ratio (NLR) are useful for diagnosing periprosthetic joint infection (PJI), but their diagnostic values are unclear for screening fixation-related infection (FRI) in patients for whom conversion total hip arthroplasty (THA) is planned after failed internal fixation for femoral neck fracture. Methods. We retrospectively included 340 patients who underwent conversion THA after internal fixation for femoral neck fracture from January 2008 to September 2020. Those patients constituted two groups: noninfected patients and patients diagnosed with FRI according to the 2013 International Consensus Meeting Criteria. Receiver operating characteristic (ROC) curves were used to determine maximum sensitivity and specificity of these two preoperative ratios. The diagnostic performance of the two ratios combined with preoperative CRP or ESR was also evaluated. Results. The numbers of patients with and without FRI were 19 (5.6%) and 321 (94.4%), respectively. Areas under the ROC curve for diagnosing FRI were 0.763 for MLR, 0.686 for NLR, 0.905 for CRP, and 0.769 for ESR. Based on the Youden index, the optimal predictive cutoffs were 0.25 for MLR and 2.38 for NLR. Sensitivity and specificity were 78.9% and 71.0% for MLR, and 78.9% and 56.4% for NLR, respectively. The combination of CRP with MLR showed a sensitivity of 84.2% and specificity of 94.6%, while the corresponding values for the combination of CRP with NLR were 89.5% and 91.5%, respectively. Conclusion. The presence of preoperative FRI among patients undergoing conversion THA after internal fixation for femoral neck fracture should be determined. The combination of preoperative CRP with NLR is sensitive tool for screening FRI in those patients. Cite this article: Bone Joint J 2021;103-B(9):1534–1540

The results of meta-analysis show a revision rate of 33% for internal fixation of displaced fractures of the femoral neck, mostly because of nonunion. Osteopenia and osteoporosis are highly prevalent in elderly patients. Bone density has been shown to correlate with the intrinsic stability of the fixation of the fracture in cadaver and retrospective studies. We aimed to confirm or refute this finding in a clinical setting. We performed a prospective, multicentre study of 111 active patients over 60 years of age with a displaced fracture of the femoral neck which was eligible for internal fixation. The bone density of the femoral neck was measured pre-operatively by dual-energy x-ray absorptiometry (DEXA). The patients were divided into two groups namely, those with osteopenia (66%, mean T-score −1.6) and those with osteoporosis (34%, mean T-score −3.0). Age (p = 0.47), gender (p = 0.67), delay to surgery (p = 0.07), the angle of the fracture (p = 0.33) and the type of implant (p = 0.48) were similar in both groups. Revision to arthroplasty was performed in 41% of osteopenic and 42% of osteoporotic patients (p = 0.87). Morbidity (p = 0.60) and mortality were similar in both groups (p = 0.65). Our findings show that the clinical outcome of internal fixation for displaced fractures of the femoral neck does not depend on bone density and that pre-operative DEXA is not useful

Aims. The aim of this study was to describe the technique of distraction osteogenesis followed by arthrodesis using internal fixation to manage complex conditions of the ankle, and to present the results of this technique. Patients and Methods. Between 2008 and 2014, distraction osteogenesis followed by arthrodesis using internal fixation was performed in 12 patients with complex conditions of the ankle due to trauma or infection. There were eight men and four women: their mean age was 35 years (23 to 51) at the time of surgery. Bone healing and functional recovery were evaluated according to the criteria described by Paley. Function was assessed using the ankle-hindfoot scale of the American Orthopedic Foot and Ankle Society (AOFAS). Results. A solid fusion of the ankle and eradication of infection was achieved in all patients. A mean lengthening of 6.1 cm (2.5 to 14) was achieved at a mean follow-up of 25.2 months (14 to 37). The mean external fixation index (EFI) was 42 days/cm (33.3 to 58). The function was judged to be excellent in six patients and good in six patients. Bone results were graded as excellent in ten patients and good in two patients. The mean AOFAS score was 37.3 (5 to 77) preoperatively and 75.3 (61 to 82) at the final follow-up. Minor complications, which were treated conservatively, included pain, pin-tract infection, loosening of wires, and midfoot stiffness. Major complications, which were treated surgically included grade V pin-tract infection with inflammation and osteolysis, poor consolidation of the regenerate bone, and soft-tissue invagination. The reoperations required to treat the major complications included the exchange of pins and wires, bone grafting and invagination split surgery. Conclusion. The technique of distraction osteogenesis followed by arthrodesis using internal fixation is an effective form of treatment for the management of complex conditions of the ankle. It offers a high rate of union, an opportunity to remove the frame early, and a reduced EFI without infection or wound dehiscence. Cite this article: Bone Joint J 2018;100-B:755–60

Failed internal fixation of a fracture of the proximal humerus produces many challenges with limited surgical options. The aim of this study was to evaluate the clinical outcomes after the use of a reverse shoulder arthroplasty under these circumstances. Between 2007 and 2012, 19 patients (15 women and four men, mean age 66 years; 52 to 82) with failed internal fixation after a proximal humeral fracture, underwent implant removal and reverse shoulder arthroplasty (RSA). The mean follow-up was 36 months (25 to 60). The mean American Shoulder and Elbow Score improved from 27.8 to 50.1 (p = 0.019). The mean Simple Shoulder Test score improved from 0.7 to 3.2 (p = 0.020), and the mean visual analogue scale for pain improved from 6.8 to 4.3 (p = 0.012). Mean forward flexion improved from 58.7° to 101.1° (p < 0.001), mean abduction from 58.7° to 89.1° (p = 0.012), mean external rotation from 10.7° to 23.1° (p = 0.043) and mean internal rotation from buttocks to L4 (p = 0.034). A major complication was recorded in five patients (26%) (one intra-operative fracture, loosening of the humeral component in two and two peri-prosthetic fractures). A total of 15 patients (79%) rated their outcome as excellent or good, one (5%) as satisfactory, and three (16%) as unsatisfactory. . An improvement in outcomes and pain can be expected when performing a RSA as a salvage procedure after failed internal fixation of a fracture of the proximal humerus. Patients should be cautioned about the possibility for major complications following this technically demanding procedure. Cite this article: Bone Joint J 2015;97-B:967–72

Aims. Displaced, comminuted acetabular fractures in the elderly are increasingly common, but there is no consensus on whether they should be treated non-surgically, surgically with open reduction and internal fixation (ORIF), or with acute total hip arthroplasty (THA). A combination of ORIF and acute THA, an approach called ’combined hip procedure’ (CHP), has been advocated and our aim was to compare the outcome after CHP or ORIF alone. Patients and Methods. A total of 27 patients with similar acetabular fractures (severe acetabular impaction with or without concomitant femoral head injury) with a mean age of 72.2 years (50 to 89) were prospectively followed for a minimum of two years. In all, 14 were treated with ORIF alone and 13 were treated with a CHP. Hip joint and patient survival were estimated. Operating times, blood loss, radiological outcomes, and patient-reported outcomes were assessed. Results. No patient in the CHP group required further hip surgery, giving THA a survival rate of 100% (95% confidence interval (CI) 100 to 100) after three years, compared with 28.6% hip joint survival in the ORIF group (95% CI 12.5 to 65.4; p = 0.001). No dislocations or deep infections occurred in the CHP group. No patient died within the first year after index surgery, but patient survival was lower in the CHP group after three years. There were no relevant differences in patient-reported outcomes. Conclusion. The CHP confers a considerably reduced need of further surgery when compared with ORIF alone in elderly patients with complex acetabular fractures. These findings encourage both further use of, and larger prospective studies on, the CHP. Cite this article: Bone Joint J 2019;101-B:478–483

1. Eighty consecutive open fractures of the tibial shaft were treated by primary internal fixation and wound closure. Wound healing was complicated by deep infection in eight patients (10 per cent) and by skin loss of varying degree in ten (l2·5 per cent). 2. Careful selection of patients on the basis of associated soft-tissue injuries is urged. A simple method of grading open fractures by the appearance of the wound and adjacent skin and the effectiveness of wound closure is suggested. If internal fixation is indicated on mechanical grounds, the nature of the soft-tissue injury should be the deciding factor in the choice of the method of treatment. In the less severe (Grade 1) fractures internal fixation and wound closure may be safely employed. In the severe (Grade 3) injuries, primary wound closure with or without internal fixation should be avoided. Moderately severe (Grade 2) fractures should be carefully assessed and treated by internal fixation and wound closure only if primary wound healing is confidently expected. 3. Wound healing by first intention requires, in addition to adequate debridement of the deep layers of the wound, careful approximation of healthy wound edges without excessive tension. An adequate knowledge of skin-plastic procedures is essential to achieve this. 4. A combination of systemic penicillin and streptomycin in adequate doses is a safe and effective prophylactic antibiotic for use in the treatment of open fractures

We compared the reoperation rate after internal fixation for minimally displaced or impacted intracapsular fractures of the femoral neck in patients aged 80 years and above with that in similar patients aged 65 to 79 years. We also compared the results of internal fixation with those of hemiarthroplasty for displaced intracapsular fracture in an age- and sex-matched group of elderly patients. We found that a significantly greater proportion of the older patients treated by internal fixation required reoperation than either the younger group or the age-matched group treated by hemiarthroplasty. Our results indicate that internal fixation may not be the best treatment for extremely elderly patients with minimally displaced or impacted intracapsular fractures of the femoral neck

1. The results of internal fixation are described in 470 tibial shaft fractures. 2. The immediate internal fixation of compound fractures was followed by so high an incidence of serious complications that the use of this method is not recommended. The immediate internal fixation of fresh closed fractures was also followed by many complications. 3. Delayed rigid internal fixation proved satisfactory for difficult fractures in which an acceptable reduction could not be obtained by closed means ; skeletal traction was of value in such fractures until the skin was soundly healed. 4. Delayed internal fixation reduced both the healing time and the complications

We studied 60 patients with an acute displaced fracture of the femoral neck and with a mean age of 84 years. They were randomly allocated to treatment by either internal fixation with cannulated screws or hemiarthroplasty using an uncemented Austin Moore prosthesis. All patients had severe cognitive impairment, but all were able to walk independently before the fracture. They were reviewed at four, 12 and 24 months after surgery. Outcome assessments included complications, revision surgery, the status of activities of daily living (ADL), hip function according to the Charnley score and the health-related quality of life (HRQOL) according to the Euroqol (EQ-5D) (proxy report). General complications and the rate of mortality at two years (42%) did not differ between the groups. The rate of hip complications was 30% in the internal fixation group and 23% in the hemiarthroplasty group; this was not significant. There was a trend towards an increased number of re-operated patients in the internal fixation group compared with the hemiarthroplasty group, 33% and 13%, respectively (p = 0.067), but the total number of surgical procedures which were required did not differ between the groups. Of the survivors at two years, 54% were totally dependent in ADL functions and 60% were bedridden or wheelchair-bound regardless of the surgical procedure. There was a trend towards decreased mobility in the hemiarthroplasty group (p = 0.066). All patients had a very low HRQOL even before the fracture. The EQ-5D. index. score was significantly worse in the hemiarthroplasty group compared with the internal fixation group at the final follow-up (p < 0.001). In our opinion, there is little to recommend hemiarthroplasty with an uncemented Austin Moore prosthesis compared with internal fixation, in patients with severe cognitive dysfunction

A total of 455 patients aged over 70 years with a displaced intracapsular fracture of the proximal femur was randomised to be treated either by hemiarthroplasty or internal fixation. The preoperative characteristics of the patients in both groups were similar. Internal fixation has a shorter length of anaesthesia (36 minutes versus 57 minutes, p < 0.0001), lower operative blood loss (28 ml versus 177 ml, p < 0.0001) and lower transfusion requirements (0.04 units versus 0.39 units, p < 0.0001). In the internal fixation group 90 patients required 111 additional surgical procedures while only 15 additional operations on the hip were needed in 12 patients in the arthroplasty group. There was no statistically significant difference in mortality between the groups at one year (61/226 versus 63/229, p = 0.91), but there was a tendency for an improved survival in the older less mobile patients treated by internal fixation. For the survivors assessed at one, two and three years from injury there were no differences with regard to the outcome for pain and mobility. Limb shortening was more common after internal fixation (7.0 mm versus 3.6 mm, p = 0.004). We recommend that displaced intracapsular fractures in the elderly should generally be treated by arthroplasty but that internal fixation may be appropriate for those who are very frail

In a series of 450 patients over 70 years of age with displaced fractures of the femoral neck sustained between 1995 and 1997 treatment was randomised either to internal fixation or replacement. Depending on age and level of activity the latter was either a total hip replacement or a hemiarthroplasty. Patients who were confused or bed-ridden were excluded, as were those with rheumatoid arthritis. At ten years there were 99 failures (45.6%) after internal fixation compared with 17 (8.8%) after replacement. The rate of mortality was high at 75% at ten years, and was the same in both groups at all times. Patient-reported pain and function were similar in both groups at five and ten years. Those with successfully healed fractures had more hip pain and reduction of mobility at four months compared with patients with an uncomplicated replacement, and they never attained a better outcome than the latter patients regarding pain or function. Primary replacement gave reliable long-term results in patients with a displaced fracture of the femoral neck

Two hundred and thirty-two ankle fractures were treated in the orthopaedic department of the Royal Portsmouth Hospital between 1959 and 1960. Seventy-one fractures treated by internal fixation with screws have been seen at follow-up examination. Results show that open reduction, secure and accurate internal fixation and early movement without plaster or other splintage is a treatment which in most cases has been followed by a short convalescence, few post-operative complications, and a painless ankle and with good function

Over a seven-year period we treated a consecutive series of 58 patients, 20 men and 38 women with a mean age of 66 years (21 to 87) who had an acute complex anterior fracture-dislocation of the proximal humerus. Two patterns of injury are proposed for study based upon a prospective assessment of the pattern of soft-tissue and bony injury and the degree of devascularisation of the humeral head. In 23 patients, the head had retained capsular attachments and arterial back-bleeding (type-I injury), whereas in 35 patients the head was devoid of significant soft-tissue attachments with no active arterial bleeding (type-II injury). Following treatment by open reduction and internal fixation, only two of 23 patients with type-I injuries developed radiological evidence of osteonecrosis of the humeral head, compared with four of seven patients with type-II injuries. A policy of primary treatment by open reduction and internal fixation of type-I injuries is justified, whereas most elderly patients (aged 60 years or over) with type-II injuries are best treated by hemiarthroplasty. The best treatment for younger patients (aged under 60 years) who sustain type-II injuries is controversial and an individualised approach to their management is advocated

The operative treatment of displaced fractures of the tibial plateau is challenging. Recent developments in the techniques of internal fixation, including the development of locked plating and minimal invasive techniques have changed the treatment of these fractures. We review current surgical approaches and techniques, improved devices for internal fixation and the clinical outcome after utilisation of new methods for locked plating

The treatment of infected exposed implants which have been used for internal fixation usually involves debridement and removal of the implant. This can result in an unstable fracture or spinal column. Muscle flaps may be used to salvage these implants since they provide soft-tissue cover and fresh vascularity. However, there have been few reports concerning their use and these have concentrated on the eradication of the infection and successful soft-tissue cover as the endpoint. There is no information on the factors which may influence the successful salvage of the implant using muscle flaps. We studied the results and factors affecting outcome in nine pedicled muscle flaps used in the treatment of exposed metal internal fixation with salvage of the implant as the primary endpoint. This was achieved in four cases. Factors predicting success were age < 30 years, the absence of comorbid conditions and a favourable microbiological profile. The growth of multiple organisms, a history of smoking and the presence of methicillin-resistant Staphylococcus aureus on wound cultures indicated a poor outcome. The use of antibiotic beads, vacuum-assisted closure and dressing, the surgical site, the type of flap performed and the time from primary surgery to flap cover were not predictive of outcome

The place of internal fixation in the treatment of fractures of the shafts of the radius and ulna in adults is discussed, and the results in 130 fractures treated by internal fixation are reviewed. Non-union was found to be the most frequent and serious complication after internal fixation. The incidence of non-union can be greatly reduced if operation is delayed for at least one week, and preferably two to three weeks after injury. Evidence is presented to support the value of delayed operation in the promotion of union of fractures

1. The results in 211 fractures of the shaft of the femur in adults treated by internal fixation have been reviewed. 2. A comparison has been made between the effects of early internal fixation within the first six days of injury and delayed fixation. 3. Eighty-five fractures treated by early fixation gave a rate of non-union of 23 per cent; in 126 fractures treated by delayed fixation the rate was 0·8 per cent. 4. Delayed operation is therefore advocated for the majority of femoral shaft fractures for which internal fixation is indicated

We treated 34 consecutive articular fractures of the proximal humerus in 33 patients with good bone quality by open reduction and internal fixation. Anatomical or nearly anatomical reduction was achieved in 30, at a mean follow-up of 63 months (25 to 131), complete or partial avascular necrosis had occurred in 12 cases (35%). Two patients subsequently underwent arthroplasty and six further patients required additional surgery. The 32 patients who did not require arthroplasty obtained a mean Constant score of 78 points or 89% of an age- and gender-matched normal score (66 points or 76% in the presence and 83 points or 96% in the absence of avascular necrosis (p < 0.0005)); 22 were painfree, and seven had mild pain and three moderate pain. The mean active anterior elevation was 156°. Internal fixation of complex fractures of the proximal humerus restored good shoulder function if avascular necrosis did not develop

Aims. We report the long-term outcomes of the UK Heel Fracture Trial (HeFT), a pragmatic, multicentre, two-arm, assessor-blinded, randomized controlled trial. Methods. HeFT recruited 151 patients aged over 16 years with closed displaced, intra-articular fractures of the calcaneus. Patients with significant deformity causing fibular impingement, peripheral vascular disease, or other significant limb injuries were excluded. Participants were randomly allocated to open reduction and internal fixation (ORIF) or nonoperative treatment. We report Kerr-Atkins scores, self-reported difficulty walking and fitting shoes, and additional surgical procedures at 36, 48, and 60 months. Results. Overall, 60-month outcome data were available for 118 patients (78%; 52 ORIF, 66 nonoperative). After 60 months, mean Kerr-Atkins scores were 79.2 (SD 21.5) for ORIF and 76.4 (SD 22.5) for nonoperative. Mixed effects regression analysis gave an estimated effect size of -0.14 points (95% confidence interval -8.87 to 8.59; p = 0.975) in favour of ORIF. There were no between group differences in difficulty walking (p = 0.175), or on the type of shoes worn (p = 0.432) at 60 months. Additional surgical procedures were conducted on ten participants allocated ORIF, compared to four in the nonoperative group (p = 0.043). Conclusion. ORIF of displaced intra-articular calcaneal fractures, not causing fibular impingement, showed no difference in outcomes at 60 months compared to nonoperative treatment, but with an increased risk of additional surgery. Cite this article: Bone Joint J 2021;103-B(6):1040–1046

The aim of this study was to review the number of patients operated on for traumatic disruption of the pubic symphysis who developed radiological signs of movement of the anterior pelvic metalwork during the first post-operative year, and to determine whether this had clinical implications. A consecutive series of 49 patients undergoing internal fixation of a traumatic diastasis of the pubic symphysis were studied. All underwent anterior fixation of the diastasis, which was frequently combined with posterior pelvic fixation. The fractures were divided into groups using the Young and Burgess classification for pelvic ring fractures. The different combinations of anterior and posterior fixation adopted to stabilise the fractures and the type of movement of the metalwork which was observed were analysed and related to functional outcome during the first post-operative year. In 15 patients the radiographs showed movement of the anterior metalwork, with broken or mobile screws or plates, and in six there were signs of a recurrent diastasis. In this group, four patients required revision surgery; three with anterior fixation and one with removal of anterior pelvic metalwork; the remaining 11 functioned as well as the rest of the study group. We conclude that radiological signs of movement in the anterior pelvic metalwork, albeit common, are not in themselves an indication for revision surgery

1. A method of internal fixation for the supracondylar fracture of the femur in the elderly patient is presented. 2. The fixation obtained allows the unsupported use of the limb and early partial weightbearing. Convalescence is thereby considerably shortened. 3. The disappointing results of internal fixation previously reported can be largely related to poor methods of fixation

We report three cases of avulsion of the ischial tuberosity with marked chronic disability after delay in diagnosis and non-union of the fracture. All were treated by open reduction and internal fixation with return to full function, allowing in one case, athletic performances of Olympic standard. We also report one patient with an acute apophyseal avulsion treated by early reduction and internal fixation with restoration of full function

We describe a series of 20 patients with ununited fractures of the femoral neck following neglected trauma or failed primary internal fixation who were seen at a mean of 7.5 months (2 to 18) following injury. Open reduction and internal fixation of the fracture was performed in all patients, together with a myoperiosteal flap on the quadratus femoris muscle pedicle. Union occurred at a mean of 4.9 months (2 to 10) in all patients. The mean follow-up was for 70 months (14 to 144). There was no further progression in six of seven patients with pre-operative radiological evidence of osteonecrosis of the femoral head. One patient had delayed collapse and flattening of the femoral head ten years after union of the fracture, but remained asymptomatic. This study demonstrates the orthopaedic application of myoperiosteal grafting for inducing osteogenesis in a difficult clinical situation

We describe a method of internal fixation for occipito-cervical fusion utilising a standard "small fragment" T-plate bent and fixed to the skull with three screws. The lower end of the plate is screwed and wired firmly to the spine of the axis. Of 14 patients so treated, 12 fused, one died and one failed to unite to the skull. Of eight with cord signs, seven remitted or improved and one died

It remains a matter of debate whether displaced fractures of the neck of the femur should be treated by internal fixation or arthroplasty. We have compared the two methods with regard to complications, mortality and functional outcome. We studied 409 patients, aged 70 years and over, with subcapital fractures graded as Garden 3 or 4, in a two-year prospective multicentre study from 12 Swedish hospitals. They were randomised to internal fixation or arthroplasty. Patients who were mentally confused, bedridden or in a nursing-home were excluded from the survey. After two years the rate of failure was 43% in the internal fixation (IF) and 6% in the arthroplasty group (p < 0.001). In the IF group 36% had impaired walking and 6% had severe pain compared with 25% and 1.5%, respectively, in the arthroplasty group (both p < 0.05). There was no difference in mortality. With a high rate of failure and poor functional outcome after IF, we recommend primary arthroplasty for displaced fractures of the neck of the femur in patients over 70 years of age

We investigated the clinical outcome of internal fixation for pathological fracture of the femur after primary excision of a soft-tissue sarcoma that had been treated with adjuvant radiotherapy. A review of our database identified 22 radiation-induced fractures of the femur in 22 patients (seven men, 15 women). We noted the mechanism of injury, fracture pattern and any complications after internal fixation, including nonunion, hardware failure, secondary fracture or deep infection. The mean age of the patients at primary excision of the tumour was 58.3 years (39 to 86). The mean time from primary excision to fracture was 73.2 months (2 to 195). The mean follow-up after fracture fixation was 65.9 months (12 to 205). Complications occurred in 19 patients (86%). Nonunion developed in 18 patients (82%), of whom 11 had a radiological nonunion at 12 months, five a nonunion and hardware failure and two an infected nonunion. One patient developed a second radiation-associated fracture of the femur after internal fixation and union of the initial fracture. A total of 13 patients (59%) underwent 24 revision operations. Internal fixation of a pathological fracture of the femur after radiotherapy for a soft-tissue sarcoma has an extremely high rate of complication and requires specialist attention. Cite this article: Bone Joint J 2013;95-B:1144–8

A total of 179 adult patients with displaced intra-articular fractures of the distal radius was randomised to receive indirect percutaneous reduction and external fixation (n = 88) or open reduction and internal fixation (n = 91). Patients were followed up for two years. During the first year the upper limb musculoskeletal function assessment score, the SF-36 bodily pain sub-scale score, the overall Jebsen score, pinch strength and grip strength improved significantly in all patients. There was no statistically significant difference in the radiological restoration of anatomical features or the range of movement between the groups. During the period of two years, patients who underwent indirect reduction and percutaneous fixation had a more rapid return of function and a better functional outcome than those who underwent open reduction and internal fixation, provided that the intra-articular step and gap deformity were minimised

Fractures of the distal end of the radius should be treated on the same principles as other fractures involving joints. Displaced articular fractures require open reduction to allow anatomical reconstruction of both the radiocarpal and the radio-ulnar joints. For extra-articular fractures with severe comminution and shortening this enables the radial length to be re-established achieving radio-ulnar congruency. Stable internal fixation can be achieved with two 2.0 AO titanium plates placed on each of the ‘lateral’ and the ‘intermediate’ columns of the wrist at an angle of 50° to 70°. This gives good stability despite the tiny dimensions of the plates, and allows early function. We report a series of 20 fractures treated by this method of internal fixation with satisfactory results in all

We report a prospective single-blind controlled study of the incidence of early wound infection after internal fixation for trauma in 609 patients, of whom 132 were HIV-positive. Wounds were assessed for healing using the ASEPSIS score. There was no significant difference in the rate of infection between HIV-positive and HIV-negative patients undergoing clean surgery (4.2% vs 6%, respectively; p = 0.65). HIV-positive patients did not receive additional antibiotic prophylaxis or antiretroviral therapy as part of their management. The difference in the rate of infection between HIV-positive and HIV-negative patients with an open fracture or other contamination was not significant (33% vs 15%, respectively; p = 0.064). There was no relationship between CD4 count and infection rate. HIV status did not significantly influence the number of secondary surgical procedures (p = 0.183) or the likelihood of developing chronic osteomyelitis (p = 0.131). Although previous contamination from the time of injury was a risk factor for infection in mal- and nonunions, it was not significantly increased in HIV-positive patients (p = 0.144). We conclude that clean implant surgery in HIV-positive patients is safe, with no need for additional prophylaxis

Internal fixation with a trifin nail after displacement osteotomy of the femur permits reduction of external splintage to a degree that any patient can tolerate with ease; it also eliminates the problem of the stiff knee. The method has been used successfully for recent and old fractures of the femoral neck, for post-irradiation fractures, for failed nailing operations or arthroplastics, for osteoarthritis, for rheumatoid arthritis, for old congenital dislocations and subluxations, and to stabilise the hip after excision of the head and neck to create a pseudarthrosis

Our study describes a posterolateral approach to the distal humerus for open reduction and internal fixation of displaced fractures of the lateral condyle. A total of 20 patients had open reduction and internal fixation over a four-year period using this approach, and at a mean follow-up of 12 months had full union, range of movement and no complications, either clinical or radiological. This approach is well suited to the exact visualisation and accurate reduction of this difficult fracture with minimal dissection of tissues

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

Cadaveric experiments in 10 knees were used to study the strength of two methods of internal fixation for a fractured patella. A modified AO tension band technique was compared with the combination of cerclage wiring and a tension band used at Pyrford. The repairs were stressed to failure; the combination of cerclage and tension band wiring proved to be significantly stronger and is recommended

A prospective randomised trial of surgical treatment for the displaced subcapital femoral fracture in patients of 70 years or more is presented. Two hundred and eighteen patients were randomly allocated into one of three treatment groups: manipulative reduction and internal fixation using Garden screws; Thompson hemiarthroplasty through a posterior (Moore) approach; and Thompson hemiarthroplasty through an anterolateral (McKee) approach. There is no significant difference in the mortality of the internal fixation and posterior arthroplasty groups. Both groups showed a significantly higher mortality than patients operated on through the anterior approach. The technical results of operation were worse in the internally fixed group, with only 40 per cent being satisfactory. Mobilisation was best achieved after the posterior approach. It is concluded that Thompson hemiarthroplasty, using an anterolateral approach, is the safest operation in this group of patients

This study identified variables which influence the outcome of surgical management on 126 ununited scaphoid fractures managed by internal fixation and non-vascular bone grafting. The site of fracture was defined by a new method: the ratio of the length of the proximal fragment to the sum of the lengths of both fragments, calculated using specific views in the plain radiographs. Bone healing occurred in 71% (89) of cases. Only the site of nonunion (p = 1 × 10. −6. ) and the delay to surgery (p = 0.001) remained significant on multivariate analysis. The effect of surgical delay on the probability of union increased as the fracture site moved proximally. A prediction model was produced by stepwise logistic regression analysis, enabling the surgeon to predict the success of surgery where the site of the nonunion and delay to surgery is known

1. The use of metallic internal fixation in the primary treatment of 176 open skeletal injuries is discussed and the results presented. 2. The use of metal (stainless steel) in this type of injury is shown not to have any harmful effects. it can be used with safety and benefit in the primary treatment of open skeletal trauma, especially in the multiple and complicated injuries of war and motor vehicle accidents. 3. The place of antibiotics is discussed and adequate treatment of the soft-tissue wound is stressed

We used single-photon absorptiometry to assess the forearm bones after the removal of internal fixation plates in 14 patients. We found convincing evidence of cortical atrophy in only one patient, in whom the plates had been removed prematurely after only 16 months. It is suggested that such plates should be retained for at least 21 months, to allow bone density to return to its prefracture level. The recommendations of the AO/ASIF group are supported

In a prospective randomised study, the Hansson pin technique for internal fixation of fractures of the femoral neck was compared with the Uppsala screw technique. The series consisted of 115 consecutive patients, 97 women and 18 men, with a mean age of 80 years. There were 56 patients treated with Hansson pins and 59 with Uppsala screws. After one year 22 patients had died, eight in the Hansson pin group and 14 in the Uppsala screw group (p = 0.28). Twenty-four complications had occurred, 18 in the Hansson pin group and six in the Uppsala screw group (p = 0.008). After exclusion of those with complications, the patients in the Hansson pin group had significantly more pain, less mobility, and a smaller proportion were living in their own homes

We have compared the results and complications after closed and open reduction with internal fixation in young adults with displaced intracapsular fractures (Garden grades III and IV) of the neck of the femur. We also studied the risk factors which influenced nonunion and the development of avascular necrosis (AVN). A total of 102 patients aged between 15 and 50 years was randomised to receive either closed or open reduction. Both groups were compared for age, gender, time to surgery and posterior comminution as well as for union and complications. Using univariate and multivariate analysis the factors influencing nonunion and AVN were assessed. Of the 102 patients, 92 were available for review. There was no significant difference between the groups in terms of union (p = 0.93) and AVN at two years (p = 0.85). Posterior comminution, poor reduction and improper placement of the screws were the major factors contributing to nonunion. The overall incidence of AVN was 16.3% (15 of 92 patients) and it was not influenced by these factors. A delay of more than 48 hours before surgery did not influence the rate of union or the development of AVN when compared with operation within 48 hours of injury

Fifty-six patients with ununited intracapsular fractures of the femoral neck were treated by internal fixation and muscle-pedicle bone grafting. All had some absorption of the femoral neck, and many had avascular necrosis of the femoral head. At operation the sclerosed surfaces of the fractures were freshened, the avascular femoral head was decompressed and the muscle-pedicle graft was fixed with silk thread wrapped around pins. Satisfactory union occurred in 42 patients (75%), and delayed union in seven, of whom four (7%) eventually united without further treatment and three united after osteotomy. Non-union occurred in five patients and technical failure in two

Fifty-six patients with displaced malleolar fractures had open reduction and fixation of the fracture fragments using, by random selection, either biodegradable implants or metal AO plates and screws. The cylindrical biodegradable implants were made of polylactide-glycolide copolymer (polyglactin 910). The complications, radiographic results and functional recovery were studied prospectively. After follow-up of at least one year, no significant differences emerged in the complication rate or in the results of treatment between the two methods of fixation. Because of the advantage of avoiding the need to remove metal fixation after union, we now use biodegradable internal fixation routinely to treat displaced malleolar fractures

It seems right to draw the following conclusions from this study of the relative merits of early and delayed fixation for fractures of the femoral and tibial shafts. 1. In patients under the age of sixty years with femoral shaft fractures there seems to be a significant improvement in the speed and quality of union when internal fixation is delayed. In patients over the age of sixty years the results of delayed fixation are worse than those of early fixation, and in any case the dangers of prolonged recumbency make the latter method preferable. 2. Delaying fixation for tibial shaft fractures does not affect speed of union or functional result. However, the incidence of non-union in these fractures is reduced by over 50 per cent by delaying fixation. This is a good reason for delaying fixation of this fracture too. Some possible reasons for the improved results after delayed fixation have been discussed

We reviewed the records and radiographs from 10 hospitals to identify 50 patients with rheumatoid arthritis (RA) who had sustained 52 femoral neck fractures. Most patients were female (88%), elderly (mean age 66 years) and had had severe polyarticular disease for a mean duration of 16 years. Over half had taken systemic corticosteroids, nearly all were severely osteopenic but few had rheumatoid changes in the hip. Of the 20 fractures treated by internal fixation 12 had complications including nonunion (5), osteonecrosis (5), infection (1), and intertrochanteric fracture (1). Only one of the nine undisplaced fractures required reoperation, but seven of the 11 displaced fractures had revision surgery. Twenty fractures were treated by primary total hip arthroplasty with only one early complication. The other 12 fractures had been treated by hemiarthroplasty (9), hip excision (1) or non-operatively (2). Our results suggest that, in elderly rheumatoid patients, severely displaced femoral neck fractures should be treated by total hip replacement

In 42 elderly patients, 33 women and nine men with a mean age of 72 years, we treated displaced fractures of the proximal humerus (34 three-part, 8 four-part) using a blade plate and a standard deltopectoral approach. Functional treatment was started immediately after surgery. We reviewed 41 patients at one year and 38 at final follow-up at 3.4 years (2.4 to 4.5). At the final review, all the fractures had healed. The clinical results were graded as excellent in 13 patients, good in 17, fair in seven, and poor in one. The median Constant score was 73 ± 18. Avascular necrosis of the humeral head occurred in two patients (5%). We conclude that rigid fixation of displaced fractures of the proximal humerus with a blade plate in the elderly patient provides sufficient primary stability to allow early functional treatment. The incidence of avascular necrosis and nonunion was low. Restoration of the anatomy and biomechanics may contribute to a good functional outcome when compared with alternative methods of fixation or conservative treatment. Regardless of the age of the patients, we advocate primary open reduction and rigid internal fixation of three- and four-part fractures of the proximal humerus

We investigated whether patients who underwent internal fixation for an isolated acetabular fracture were able to return to their previous sporting activities. We studied 52 consecutive patients with an isolated acetabular fracture who were operated on between January 2001 and December 2002. Their demographic details, fracture type, rehabilitation regime, outcome and complications were documented prospectively as was their level and frequency of participation in sport both before and after surgery. Quality of life was measured using the EuroQol-5D health outcome tool (EQ-5D). There was a significant reduction in level of activity, frequency of participation in sport (both p < 0.001) and EQ-5D scores in patients of all age groups compared to a normal English population (p = 0.001). A total of 22 (42%) were able to return to their previous level of activities: 35 (67%) were able to take part in sport at some level. Of all the parameters analysed, the Matta radiological follow-up criteria were the single best predictor for resumption of sporting activity and frequency of participation

Three cases of anterior interosseous nerve palsy were diagnosed after internal fixation of fractures of the proximal radius. The suggestion that the nerve was injured at operation by bone-holding forceps was supported by operations on 12 cadaver forearms, in which the nerve was frequently trapped. Care should be taken to place such forceps in a subperiosteal plane

One hundred patients who had sustained a fracture of the tibial shaft and had been treated by internal fixation were reviewed to obtain information on residual ankle and subtalar disability. This study reinforces the belief that early mobilisation of patients with tibial shaft fractures does help to preserve subtalar movement

The treatment algorithms for displaced fractures of the femoral neck need to be improved if we are to reduce the need for secondary surgery. We have studied 102 patients of mean age 80 years, with an acute displaced fracture of the femoral neck. They were randomly placed into two groups, treated either by internal fixation (IF) with two cannulated screws or total hip replacement (THR). None showed severe cognitive dysfunction, all were able to walk independently, and all lived in their own home. They were reviewed at four, 12 and 24 months after surgery. Outcome measurements included hip complications, revision surgery, hip function according to Charnley and the health-related quality of life (HRQoL) according to EuroQol (EQ-5D). The failure rate after 24 months was higher in the IF group than in the THR group with regard to hip complications (36% and 4%, respectively; p < 0.001), and the number of revision procedures (42% and 4%, p < 0.001). Hip function was significantly better in the THR group at all follow-up reviews regarding pain (p < 0.005), movement (p < 0.05 except at 4 months) and walking (p < 0.05). The reduction in HRQoL (EQ-5D . index. score) was also significantly lower in the THR group than in the IF group, comparing the pre-fracture situation with that at all follow-up reviews (p < 0.05). The results of our study strongly suggest that THR provides a better outcome than IF for elderly, relatively healthy, lucid patients with a displaced fracture of the femoral neck

We reviewed 57 adult patients at an average of 37 months after early internal fixation for displaced fractures of the distal humerus. Two-thirds had intercondylar (Muller type C) fractures, and one-third had articular comminution (type C3). A chevron olecranon osteotomy was used, with early active movement after fixation. Results were good or excellent in 76% with an average range of movement of 115 degrees. Early stable fixation by an experienced surgeon is recommended for these fractures

We used calcium-phosphate cement combined with minimal internal fixation to treat 49 fractures of the lateral tibial plateau. There were 25 split depression fractures, 22 pure depression fractures and two bicondylar fractures. Anatomical reduction was obtained in 38 fractures, satisfactory reduction in nine and imperfect reduction in two. Of 44 patients reviewed at one year, 33 were rated as having an excellent reduction. Functional outcome as measured by the Rasmussen score was good or excellent at six months in 92% (44/48) of patients and in 95% (42/44) at one year. Eight (16%) showed some loss of reduction of the plateau. In seven of these the loss of reduction was slight (< 3 mm) and no action was taken. One patient with a deep infection had gross loss of reduction and a poor functional outcome. Calcium-phosphate cement is a useful alternative to bone grafting for the treatment of fractures of the tibial plateau

1. A report is presented of the results of a trial to compare the effects of early and late weight-bearing in patients with a transcervical fracture of the femur treated by reduction of the fracture and internal fixation with a sliding nail-plate. 2. One hundred and twelve patients have been assessed clinically and radiologically three years after operation. 3. Retrospective analysis of factors that affect the outcome of treatment suggests that the two groups were fairly evenly balanced. 4. The results show that full weight-bearing two weeks after operation did not increase the incidence of failure of fixation or of non-union. 5. The higher incidence of superior segmental collapse in patients in whom weight-bearing was deferred for twelve weeks can be explained by the greater number of high fractures in this group and the greater number with a poor reduction

We reviewed 24 displaced fractures through the physis of the medial epicondyle of the distal humerus. One was a Salter-Harris type-II fracture-separation of the whole distal humeral epiphysis; the others involved only the medial epicondylar centre of ossification. Two cases had presented as pseudarthroses. One fracture had been treated closed in a plaster slab and 21 had had open reduction and internal fixation with sutures, Kirschner wires or Palmer nails. At 2 to 13 years later we found five types of deformity of the epicondyle: pseudarthrosis, an ulnar sulcus, a double-contoured epicondyle, hypoplasia or hyperplasia. Pseudarthrosis had developed after either no treatment, closed reduction and plaster, or open reduction and suturing. Hypoplasia followed nailing, as did a trend to varus tilting of the joint surface. One very young patient, with fracture-separation of the whole distal epiphysis treated by nailing, developed marked cubitus varus

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

We have reviewed 402 traumatic fractures of the femoral shaft, 320 of which had been treated by operation and had a long follow-up. Of these, 228 closed fractures and 37 open fractures had been stabilised by plating. There was no significant difference in healing between those stabilised early and those having delayed internal fixation. Re-fracture after removal of the implant occurred more often after early operation. All 55 fractures treated by intramedullary nailing healed and there were no re-fractures after nail removal. We found no correlation between delay before operation and the incidence of postoperative infection

Ulnar nerve function, during and after open reduction and internal fixation of fractures of the distal humerus with subperiosteal elevation of the nerve, was assessed by intra-operative neurophysiological monitoring. Intermittent recording of the compound muscle action potentials was taken from the hypothenar muscles in 18 neurologically asymptomatic patients. The mean amplitude of the compound muscle action potential after surgery was 98.1% (. sd. 17.6; −37% to +25%). The amplitude improved in six patients following surgery. Despite unremarkable recordings one patient had progressive paresis. Motor impairment is unlikely if the compound muscle action potential is continuously preserved and not reduced by more than 40% at the end of surgery. Temporary decreases in amplitude by up to 70% were tolerated without clinical consequences. However, repeated clinical examination is obligatory to recognise and treat early post-operative palsy

Aims. The optimal procedure for the treatment of ossification of the posterior longitudinal ligament (OPLL) remains controversial. The aim of this study was to compare the outcome of anterior cervical ossified posterior longitudinal ligament en bloc resection (ACOE) with posterior laminectomy and fusion with bone graft and internal fixation (PTLF) for the surgical management of patients with this condition. Methods. Between July 2017 and July 2019, 40 patients with cervical OPLL were equally randomized to undergo surgery with an ACOE or a PTLF. The clinical and radiological results were compared between the two groups. Results. The Japanese Orthopaedic Association (JOA) score and recovery rate in the ACOE group were significantly higher than those in the PTLF group during two years postoperatively, provided that the canal occupying ratio (COR) was > 50%, or the K-line was negative. There was no significant difference in JOA scores and rate of recovery between the two groups in those in whom the COR was < 50%, or the K-line was positive. There was no significant difference in the Cobb angle between C2 and C7, sagittal vertical axis, cervical range of motion (ROM), and complications between the two groups. Conclusion. Compared with PTLF, ACOE is a preferred surgical approach for the surgical management of patients with cervical OPLL in that it offers a better therapeutic outcome when the COR is > 50%, or the K-line is negative, and it also preserves better cervical curvature and sagittal balance. The prognosis of ACOE is similar to that of PTLE when the COR is < 50%, or the K-line is positive. Cite this article: Bone Joint J 2023;105-B(4):412–421

Aims. The aim of the present study was to assess the outcomes of the induced membrane technique (IMT) for the management of infected segmental bone defects, and to analyze predictive factors associated with unfavourable outcomes. Methods. Between May 2012 and December 2020, 203 patients with infected segmental bone defects treated with the IMT were enrolled. The digital medical records of these patients were retrospectively analyzed. Factors associated with unfavourable outcomes were identified through logistic regression analysis. Results. Among the 203 enrolled patients, infection recurred in 27 patients (13.3%) after bone grafting. The union rate was 75.9% (154 patients) after second-stage surgery without additional procedures, and final union was achieved in 173 patients (85.2%) after second-stage surgery with or without additional procedures. The mean healing time was 9.3 months (3 to 37). Multivariate logistic regression analysis of 203 patients showed that the number (≥ two) of debridements (first stage) was an independent risk factor for infection recurrence and nonunion. Larger defect sizes were associated with higher odds of nonunion. After excluding 27 patients with infection recurrence, multivariate analysis of the remaining 176 patients suggested that intramedullary nail plus plate internal fixation, smoking, and an allograft-to-autograft ratio exceeding 1:3 adversely affected healing time. Conclusion. The IMT is an effective method to achieve infection eradication and union in the management of infected segmental bone defects. Our study identified several risk factors associated with unfavourable outcomes. Some of these factors are modifiable, and the risk of adverse outcomes can be reduced by adopting targeted interventions or strategies. Surgeons can fully inform patients with non-modifiable risk factors preoperatively, and may even use other methods for bone defect reconstruction. Cite this article: Bone Joint J 2024;106-B(6):613–622

Aims. The aim of this study was to investigate the rate of revision for distal femoral arthroplasty (DFA) performed as a primary procedure for native knee fractures using data from the Australian Orthopaedic Association National Joint Arthroplasty Registry (AOANJRR). Methods. Data from the AOANJRR were obtained for DFA performed as primary procedures for native knee fractures from 1 September 1999 to 31 December 2020. Pathological fractures and revision for failed internal fixation were excluded. The five prostheses identified were the Global Modular Arthroplasty System, the Modular Arthroplasty System, the Modular Universal Tumour And Revision System, the Orthopaedic Salvage System, and the Segmental System. Patient demographic data (age, sex, and American Society of Anesthesiologists grade) were obtained, where available. Kaplan-Meier estimates of survival were used to determine the rate of revision, and the reasons for revision and mortality data were examined. Results. The AOANJRR identified 153 primary DFAs performed for native knee fractures in 151 patients during the study period, with 63.3% of these (n = 97) performed within the last five years. The median follow-up was 2.1 years (interquartile range 0.8 to 4.4). The patient population was 84.8% female (n = 128), with a mean age of 76.1 years (SD 11.9). The cumulative percent revision rate at three years was 10%. The most common reason for revision was loosening, followed by infection. Patient survival at one year was 87.5%, decreasing to 72.8% at three years postoperatively. Conclusion. The use of DFA to treat native knee fractures is increasing, with 63.3% of cases performed within the last five years. While long-term data are not available, the results of this study suggest that DFA may be a reasonable option for elderly patients with native knee fractures where fixation is not feasible, or for whom prolonged non-weightbearing may be detrimental. Cite this article: Bone Joint J 2022;104-B(7):894–901

A total of 11 patients (12 knees) with stable lesions of osteochondritis dissecans of the knee underwent arthroscopic fixation of the fragments using polylactide bioabsorbable pins. The site of the lesion was the medial femoral condyle in ten knees and the lateral femoral condyle in two. The mean age of the patients was 14.8 years (12 to 16). At a mean follow-up of 32.4 months (13 to 38 months) all fragments had MRI evidence of union. One patient developed early transient synovitis, which resolved with non-steroidal anti-inflammatory medication. All patients returned to sporting activities within eight months of operation and did not require a period of immobilisation.

Aims. Surgery is often delayed in patients who sustain a hip fracture and are treated with a total hip arthroplasty (THA), in order to await appropriate surgical expertise. There are established links between delay and poorer outcomes in all patients with a hip fracture, but there is little information about the impact of delay in the less frail patients who undergo THA. The aim of this study was to investigate the influence of delayed surgery on outcomes in these patients. Methods. A retrospective cohort study was undertaken using data from the Scottish Hip Fracture Audit between May 2016 and December 2020. Only patients undergoing THA were included, with categorization according to surgical treatment within 36 hours of admission (≤ 36 hours = ‘acute group’ vs > 36 hours = ‘delayed’ group). Those with delays due to being “medically unfit” were excluded. The primary outcome measure was 30-day survival. Costs were estimated in relation to the differences in the lengths of stay. Results. A total of 1,375 patients underwent THA, with 397 (28.9%) having surgery delayed by > 36 hours. There were no significant differences in the age, sex, residence prior to admission, and Scottish Index of Multiple Deprivation for those with, and those without, delayed surgery. Both groups had statistically similar 30-day (99.7% vs 99.3%; p = 0.526) and 60-day (99.2% vs 99.0%; p = 0.876) survival. There was, however, a significantly longer length of stay for the delayed group (acute: 7.0 vs delayed: 8.9 days; p < 0.001; overall: 8.7 vs 10.2 days; p = 0.002). Delayed surgery did not significantly affect the rates of 30-day readmission (p = 0.085) or discharge destination (p = 0.884). The results were similar following adjustment for potential confounding factors. The estimated additional cost due to delayed surgery was £1,178 per patient. Conclusion. Delayed surgery does not appear to be associated with increased mortality in patients with an intracapsular hip fracture who undergo THA, compared with those who are treated with a hemiarthroplasty or internal fixation. Those with delayed surgery, however, have a longer length of stay, with financial consequences. Clinicians must balance ethical considerations, the local provision of orthopaedic services, and optimization of outcomes when determining the need to delay surgery in a patient with a hip fracture awaiting THA. Cite this article: Bone Joint J 2023;105-B(11):1201–1205

Aims. The aims of this study were to report the outcomes of patients with a complex fracture of the lower limb in the five years after they took part in the Wound Healing in Surgery for Trauma (WHIST) trial. Methods. The WHIST trial compared negative pressure wound therapy (NPWT) dressings with standard dressings applied at the end of the first operation for patients undergoing internal fixation of a complex fracture of the lower limb. Complex fractures included periarticular fractures and open fractures when the wound could be closed primarily at the end of the first debridement. A total of 1,548 patients aged ≥ 16 years completed the initial follow-up, six months after injury. In this study we report the pre-planned analysis of outcome data up to five years. Patients reported their Disability Rating Index (DRI) (0 to 100, in which 100 = total disability), and health-related quality of life, chronic pain scores and neuropathic pain scores annually, using a self-reported questionnaire. Complications, including further surgery related to the fracture, were also recorded. Results. A total of 1,015 of the original patients (66%) provided at least one set of outcome data during the five years of follow-up. There was no evidence of a difference in patient-reported disability between the two groups at five years (NPWT group mean DRI 30.0 (SD 26.5), standard dressing group mean DRI 31.5 (SD 28.8), adjusted difference -0.86 (95% CI -4.14 to 2.40; p = 0.609). There was also no evidence of a difference in the complication rates at this time. Conclusion. We found no evidence of a difference in disability ratings between NPWT compared with standard wound dressings in the five years following the surgical treatment of a complex fracture of the lower limb. Patients in both groups reported high levels of persistent disability and reduced quality of life, with little evidence of improvement during this time. Cite this article: Bone Joint J 2024;106-B(8):858–864

Aims

Tibial plateau fractures are serious injuries about the knee that have the potential to affect patients’ long-term function. To our knowledge, this is the first study to use patient-reported outcomes (PROs) with a musculoskeletal focus to assess the long-term outcome, as compared to a short-term outcome baseline, of tibial plateau fractures treated using modern techniques.

Aims

The optimal management of intracapsular fractures of the femoral neck in independently mobile patients remains open to debate. Successful fixation obviates the limitations of arthroplasty for this group of patients. However, with fixation failure rates as high as 30%, the outcome of revision surgery to salvage total hip arthroplasty (THA) must be considered. We carried out a systematic review to compare the outcomes of salvage THA and primary THA for intracapsular fractures of the femoral neck.

A consecutive series of 320 patients with an intracapsular fracture of the hip treated with a dynamic locking plate (Targon Femoral Neck (TFN)) were reviewed. All surviving patients were followed for a minimum of two years. During the follow-up period 109 patients died.

There were 112 undisplaced fractures, of which three (2.7%) developed nonunion or re-displacement and five (4.5%) developed avascular necrosis of the femoral head. Revision to an arthroplasty was required for five patients (4.5%). A further six patients (5.4%) had elective removal of the plate and screws.

There were 208 displaced fractures, of which 32 (15.4%) developed nonunion or re-displacement and 23 (11.1%) developed avascular necrosis. A further four patients (1.9%) developed a secondary fracture around the TFN. Revision to a hip replacement was required for 43 patients (20.7%) patients and a further seven (3.3%) had elective removal of the plate and screws.

It is suggested that the stronger distal fixation combined with rotational stability may lead to a reduced incidence of complications related to the healing of the fracture when compared with other contemporary fixation devices but this needs to be confirmed in further studies.

Cite this article: Bone Joint J 2013;95-B:1402–5.

This report describes a technique for the correction and fusion of scoliosis with the aid of a flexible metal rod that is fixed by wires under tension to the bases of the spinous processes on the convex side of the curve at a number of points. The results in a series of 100 cases are reported. In the last seventy patients, the average correction at one month was 51 per cent, and after two years 45 per cent. In these seventy cases the incidence of pseudarthrosis was 5-7 per cent.

Aims

The primary aim of this study was to determine if delayed clavicular fixation results in a greater risk of operative complications and revision surgery.

The extended lateral L-shaped approach for the treatment of displaced intra-articular fractures of the calcaneum may be complicated by wound infection, haematoma, dehiscence and injury to the sural nerve. In an effort to reduce the risk of problems with wound healing a technique was developed that combined open reduction and fixation of the joint fragments and of the anterior process with percutaneous reduction and screw fixation of the tuberosity. A group of 24 patients with unilateral isolated closed Sanders type II and III fractures was treated using this technique and compared to a similar group of 26 patients managed by the extended approach and lateral plating. The operation was significantly shorter (p < 0.001) in the first group, but more minor secondary procedures and removal of heel screws were necessary. There were no wound complications in this group, whereas four minor complications occurred in the second group. The accuracy and maintenance of reduction, and ultimate function were equivalent.

We reviewed a series of 79 distal radial fractures with volar displacement which had been fixed internally using a buttress plate. The fractures were classified using the Frykman and AO systems; 59% were intraarticular. Complications occurred in 40.5% of cases; malunion was most frequent (28%). Functional recovery in patients with malunion was significantly worse than in those with good anatomical restoration (p < 0.001). The AO and Frykman classifications and the degree of restoration of volar tilt were predictive of outcome.

Aims

The objective of this study was to investigate bone healing after internal fixation of displaced femoral neck fractures (FNFs) with the Dynamic Locking Blade Plate (DLBP) in a young patient population treated by various orthopaedic (trauma) surgeons.

We compared a new fixation system, the Targon Femoral Neck (TFN) hip screw, with the current standard treatment of cannulated screw fixation. This was a single-centre, participant-blinded, randomised controlled trial. Patients aged 65 years and over with either a displaced or undisplaced intracapsular fracture of the hip were eligible. The primary outcome was the risk of revision surgery within one year of fixation.

A total of 174 participants were included in the trial. The absolute reduction in risk of revision was of 4.7% (95% CI 14.2 to 22.5) in favour of the TFN hip screw (chi-squared test, p = 0.741), which was less than the pre-specified level of minimum clinically important difference. There were no significant differences in any of the secondary outcome measures.

We found no evidence of a clinical difference in the risk of revision surgery between the TFN hip screw and cannulated screw fixation for patients with an intracapsular fracture of the hip.

Cite this article: Bone Joint J 2014;96-B:652–7.

We describe a patient who sustained a displaced isolated intra-articular fracture of the distal ulna, causing limitation of rotation of the forearm. The extent of displacement of the fracture which was not evident on plain radiographs was revealed by CT. The fracture was reduced and internally fixed using a standard technique applicable to the fixation of fractures of the radial head. Full movement was restored. An isolated injury to the distal ulna is rare and requires careful clinical and radiological assessment.

In a prospective study we assessed the causes of mechanical failure in a series of 230 intertrochanteric femoral fractures which had been internally fixed with either a sliding hip screw or a Kuntscher Y-nail. The overall rate of mechanical failure was 16.5%; cutting-out of the implant from the femoral head was the cause in three-quarters of the instances. Implants placed posteriorly in the femoral head cut out more often (27%) than those placed centrally (7%). The cut-out rate was also determined by the quality of the fracture reduction, but age, walking ability and bone density (assessed by the Singh grade and metacarpal indices) had no significant influence. We conclude that these fractures should be reduced as accurately as possible and it is imperative that the implant is placed centrally within the femoral head.

A technique of subtalar arthrodesis by means of metallic internal stabilisation and autogenous cancellous bone grafting is described. Of forty-eight feet with mobile pes planus treated by this method forty-five gained union after an average of seven and a half weeks in a below-knee weight-bearing plaster, and forty-three had satisfactory correction of the deformity.

1. The probable greatest bending moment applied to a plated or nailed fracture of the tibia during restricted weight-bearing is estimated to be, in men, up to about 79 Newton metres (58 poundsforce feet). The maximum twisting moment is estimated to be about 29 Newton metres (22 poundsforce feet).

2. Twenty-two human tibiae were loaded in three-point bending and broke at bending moments of from 57·9 to 294 Newton metres (42·7 to 216 poundsforce feet) if they had not previously been drilled; tibiae which had holes made through both cortices with a c. 3-millimetre (⅛-inch) drill broke at from 32·4 to 144 Newton metres (23·8 to 106 poundsforce feet). Tibiae loaded in torsion broke at twisting moments of from 27·5 to 892 Newton metres (20·2 to 65·8 poundsforce feet) when not drilled, 23·6 to 77·5 Newton metres (l7·3 to 57·1 poundsforce feet) when drilled.

3. When bent so as to open the fracture site, the 14-centimetre Stamm was the strongest of all the single plates tested (reaching its elastic limit at a bending moment of 17·6 Newton metres (13 poundsforce feet) and 5 degrees total angulation at 22·6 Newton metres (16·6 poundsforce feet)), while the Venable was the weakest (elastic limit 4·9 Newton metres (3·6 poundsforce feet) and 5 degrees at 7·9 Newton metres (5·8 poundsforce feet)). A 13-millimetre Küntscher nail reached its elastic limit at 42·2 Newton metres (31·1 poundsforce feet) and 5 degrees total angulation at 49 Newton metres (36 poundsforce feet).

4. In torsion the 15-centimetre Hicks was the strongest ofthe plates (elastic limit 27·5 Newton metres (20·2 poundsforce feet) and 5 degrees rotation at 16·7 Newton metres (l2·3 poundsforce feet)).

5. Küntscher nails in bones provided no dependable strength in torsion.

6. In both bending and torsion, a preparation of one Venable plate on each of the two anterior surfaces was stronger than any single plate, and was as strong as the weaker drilled tibiae.

7. The three currently available metallic materials (stainless steel, cobalt-chrome and titanium) have static mechanical properties so similar that the choice between them can be made on other grounds.

8. The highest load applied to a screw during bending tests was about half that needed to pull a screw out of even a thin-walled tibia.

9. Screws beyond four for one plate are mechanically redundant at the moment of implantation but may be necessary as an insurance against subsequent deterioration in strength.

10. Countersinks in plates are a source of significant weakness, and should preferably be as shallow as possible.

11. An unoccupied screw hole in the centre of a plate is a source of serious weakness.

12. Only the strongest implants tested were strong enough to withstand the bending or twisting moments to be expected in restricted weight-bearing. In two-plate preparations a danger is introduced by the fact that these moments are similar to those required to Ireak a drilled tibia.

Aims

The fundamental concept of open reduction and internal fixation (ORIF) of ankle fractures has not changed appreciably since the 1960s and, whilst widely used, is associated with complications including wound dehiscence and infection, prominent hardware and failure. Closed reduction and intramedullary fixation (CRIF) using a fibular nail, wires or screws is biomechanically stronger, requires minimal incisions, and has low-profile hardware. We hypothesised that fibular nailing in the elderly would have similar functional outcomes to standard fixation, with a reduced rate of wound and hardware problems.

Stable fixation of fractures of the distal radius can be achieved by using two 2.0 mm titanium plates placed on the radial and intermediate columns angled 50° to 70° apart. We describe our results with this method in a prospective series of 74 fractures (58 severely comminuted) in 73 consecutive patients.

Early postoperative mobilisation was possible in all except four wrists. All of the 73 patients, except two with other injuries, returned to work and daily activities with no limitations. The anatomical results were excellent or good in 72 patients and fair in one.

Our discussion includes details of important technical considerations based on an analysis of the specific complications which were seen early in the series.

Neglected fractures of the femoral neck, common in young adults in underdeveloped countries, may be complicated by nonunion or avascular necrosis (AVN). We treated 52 cases by open reduction, fixation by compression screw and a free fibular graft. The mean delay between injury and operation was 5.1 months. Of 40 fractures assessed at a mean of 58.8 months (24 to 153), 38 were found to be united and two, owing to surgical errors, were not. Seven of eight heads which were avascular before operation revascularised without collapse, while seven others developed AVN after the procedure. At the last follow-up considerable collapse was apparent in five femoral heads, and 11 hips had developed coxa vara. The fibular graft had fractured in four cases. The hip had been penetrated by the screw in six cases and by the graft in three. Hip function was excellent in seven patients, good in 21 and fair in seven. Five patients had poor results. Incorporation of the fibular graft was seen after four years: in many cases the graft had been almost completely resorbed.

We recommend this procedure for the treatment of neglected fractures of the neck of the femur in young adults to reduce resorption of the neck, AVN and nonunion.

We performed posterior fixation with a Hartshill-Ransford contoured loop in 43 patients with instability at the craniocervical junction. No external bracing was used. Fifteen patients had congenital malformations, ten had tumours, seven had 'bone-softening' conditions (such as osteogenesis imperfecta), five had suffered complicated fractures, three had occipito-C1-C2 hypermobility due to lax ligaments and three had severe degenerative spondylosis with pseudotumours of the transverse ligament. Twenty-nine patients had transoral decompression of the cord before fixation. In most cases, cancellous bone grafts taken from the iliac crest were used to induce fusion; in nine very ill patients, no bone graft was used. In the whole series there was no instance of construct failure, broken wire or laminar fracture. The best results were achieved in patients with tumours or bone-softening conditions. No patient with normal neurology deteriorated after surgery but seven had worse neurological deficits after operation than before. Neck stiffness caused half the patients to change their lifestyle.

We present the results of a prospective trial of osteotomy of the metatarsal neck for hallux valgus in 31 feet of 23 women, using a new stapling device with no plaster splintage and early weight-bearing. Surgery was performed for pain (29 feet) and difficulty with footwear (nine feet). The average time for return to light work was 3.3 weeks, and to full work 8.3 weeks after operation. Seventeen patients had full recovery within three months and 21 of the 23 patients had complete relief of pain. Shoes were more comfortable in 17 feet and 9 patients could wear narrower shoes. Only two patients were unsatisfied with the appearance of the foot. All the osteotomies united, and the average hallux valgus angle was improved on radiographs from 35 degrees to 23 degrees. The mean first metatarsal angle was reduced from 16 degrees to 11 degrees. The new technique allows more accurate surgery and easier postoperative management.

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.

Between 1996 and 2000, we treated ten patients with severely comminuted fractures of the radial head using low-profile mini-plates. Their mean age was 42 years (24 to 71). Three fractures were Mason type III and seven were Mason-Johnston type IV. At a mean follow-up of 28.5 months (15 to 44), all fractures had united. The plates were removed in nine patients.

No patient had difficulty with daily activities or symptoms of instability of the elbow. The mean range of flexion of the elbow was from 7° to 135°, with 74° of supination and 85° of pronation. According to the Broberg and Morrey functional elbow index, the mean score was 90.7 points (73 to 100), and the outcome was excellent in three patients, good in six and fair in one.

These results compare favourably with those reported previously. The technique is applicable to severely comminuted fractures of the radial head which otherwise would require excision.

We identified 11 women with a mean age of 74 years (65 to 81) who sustained comminuted distal radial and ulnar fractures and were treated by volar plating and slight shortening of the radius combined with a primary Sauvé-Kapandji procedure.

At a mean of 46 months (16 to 58), union of distal radial fractures and arthrodesis of the distal radioulnar joint was seen in all patients. The mean shortening of the radius was 12 mm (5 to 18) compared to the contralateral side. Flexion and extension of the wrist was a mean of 54° and 50°, respectively, and the mean pronation and supination of the forearm was 82° and 86°, respectively. The final mean disabilities of the arm, shoulder and hand score was 26 points. According to the Green and O’Brien rating system, eight patients had an excellent, two a good and one a fair result.

The good clinical and radiological results, and the minor complications without the need for further operations related to late ulnar-sided wrist pain, justify this procedure in the elderly patient.

Two patients with osteochondritis dissecans of the hip were operated on and their case histories are presented. The relatively large foci were situated on the weight-bearing surface of the joint and the fragments were fixed using transplants of cortical bone. In both cases the focus healed, and the symptoms were relieved. At follow-up six and nine years later respectively, the clinical results were good and no signs of osteoarthritis had as yet developed.

The classification of intra-articular fractures of the calcaneum described in part I is related to an operative approach which allows accurate reduction and stable fixation of the fracture fragments. An extended lateral incision is used to avoid sural nerve damage and problems of soft-tissue healing. In type 3 fractures, access to the lateral joint fragment requires an osteotomy of the lateral wall, but after this the lateral joint fragment can be rotated out of the subtalar joint to allow transcalcaneal reduction of the medial wall. Reduction of the body fragment and lateral joint fragment on to the sustentacular fragment allows the three fragments to be stabilised by a 3.5 mm Y-shaped reconstruction plate. Our early results have been successful in terms of fracture reduction and the restoration of heel shape and joint congruity, but extended follow-up will be necessary to define the indications for this difficult procedure.

An experimental study is reported of fracture healing in the femora of 36 Beagle dogs, comparing the results of using stainless steel plates with those of using less rigid titanium alloy plates. The alloy plates led to the appearance of a small amount of periosteal callus without any histological evidence of fracture instability, thus allowing the radiological assessment of fracture union. This also produced less bone loss during the remodelling phase. Radiological measurements 24 weeks after osteotomy showed cortical thickness to be reduced by six per cent under titanium alloy and by 19 per cent under stainless steel, while histological measurements showed a total bone loss of 3.7 per cent under titanium alloy and of 11 per cent under stainless steel plates. Removal of the titanium alloy plates after eight weeks followed by a recovery period of 16 weeks produced an increase of cortical thickness of 69 per cent and a gain in total bone mass of 30 per cent. Titanium alloy plates also produced less soft-tissue reaction than stainless steel plates. It is concluded that this alloy is a promising material for internal fixation devices.

It has previously been suggested that among unstable ankle fractures, the presence of a malleolar fracture is associated with a worse outcome than a corresponding ligamentous injury. However, previous studies have included heterogeneous groups of injury. The purpose of this study was to determine whether any specific pattern of bony and/or ligamentous injury among a series of supination-external rotation type IV (SER IV) ankle fractures treated with anatomical fixation was associated with a worse outcome.

We analysed a prospective cohort of 108 SER IV ankle fractures with a follow-up of one year. Pre-operative radiographs and MRIs were undertaken to characterise precisely the pattern of injury. Operative treatment included fixation of all malleolar fractures. Post-operative CT was used to assess reduction. The primary and secondary outcome measures were the Foot and Ankle Outcome Score (FAOS) and the range of movement of the ankle.

There were no clinically relevant differences between the four possible SER IV fracture pattern groups with regard to the FAOS or range of movement. In this population of strictly defined SER IV ankle injuries, the presence of a malleolar fracture was not associated with a significantly worse clinical outcome than its ligamentous injury counterpart. Other factors inherent to the injury and treatment may play a more important role in predicting outcome.