There are a number of classification systems for intracapsular fractures of the proximal femur, but none has been shown to be practical with satisfactory reproducibility and accurate predictive value. We have investigated the AO classification and evaluated intra-and interobserver accuracy and its value in predicting treatment and outcome. We found it to have very poor intra- and interobserver reliability and to be of limited predictive use for the outcome of treatment. A simplified system in which the subdivisions were allocated to one of three groups of undisplaced, displaced and basal fractures was found to be of value. We conclude that this is the only division which is appropriate for these fractures and that the AO system for intracapsular fractures is too complicated and should not be used

Interobserver reliability of the AO system of classification of fractures of the distal radius was assessed using plain radiographs and CT. Five observers classified 30 Colles’-type fractures using only plain radiographs; two months later they were reclassified using CT in addition.

Interobserver reliability was poor in both series when detailed classification was used. By reducing the categories to five, interobserver reliability was slightly improved, but was still poor. When only two AO types were used, the reliability was moderate using plain radiographs and good to excellent with the addition of CT.

The use of CT as well as plain radiographs brings interobserver reliability to a good level in assessment of the presence or absence of articular involvement, but is otherwise of minor value in improving the interobserver reliability of the AO system of classification of fractures of the distal radius.

We sought to quantify agreement by different assessors of the AO classification for distal fractures of the radius. Thirty radiographs of acute distal radial fractures were evaluated by 36 assessors of varying clinical experience. Our findings suggest that AO ‘type’ and the presence or absence of articular displacement are measured with high consistency when classification of distal radial fractures is undertaken by experienced observers. Assessors at all experience levels had difficulty agreeing on AO ‘group’ and especially AO ‘subgroup’. To categorise distal radial fractures according to joint displacement and AO type is simple and reproducible. Our study examined only whether distal radial fractures could be consistently classified according to the AO system. Validation of the classification as a predictor of outcome will require a prospective clinical study

We conducted an observational radiographic study to determine the inter- and intra-observer reliability of the AO classification of fractures of the distal radius. Plain posteroanterior and lateral radiographs of 456 patients with an acute fracture of the distal radius were classified by a consultant orthopaedic hand specialist and two specialist trainees, and the k coefficient for the inter- and intra-observer reliability of the type, group and subgroup classification was calculated.

Only the type of fracture (A, B or C) was found to provide substantial intra-observer reliability (k _type 0.65). The inclusion of ‘group’ and ‘subgroup’ into the classification reduced the inter-observer reliability to fair (k_group 0.29, k_subgroup = 0.28) and the intra-observer reliability to moderate (k_group 0.53, k_subgroup 0.49). Disagreement was found to arise between specific subgroups, which may be amenable to clarification.

Cite this article: Bone Joint J 2015; 97-B:818–23.

Aims. We aimed to evaluate the health-related quality of life (HRQoL) in children with supracondylar humeral fractures (SCHFs), who were treated following the recommendations of the Paediatric Comprehensive AO Classification, and to assess if HRQoL was associated with AO fracture classification, or fixation with a lateral external fixator compared with closed reduction and percutaneous pinning (CRPP). Methods. We were able to follow-up on 775 patients (395 girls, 380 boys) who sustained a SCHF from 2004 to 2017. Patients completed questionnaires including the Quick Disabilities of the Arm, Shoulder and Hand questionnaire (QuickDASH; primary outcome), and the Pediatric Quality of Life Inventory (PedsQL). Results. An AO type I SCHF was most frequent (327 children; type II: 143; type III: 150; type IV: 155 children). All children with type I fractures were treated nonoperatively. Two children with a type II fracture, 136 with a type III fracture, and 141 children with a type IV fracture underwent CRPP. In the remaining 27 children with type III or IV fractures, a lateral external fixator was necessary for closed reduction. There were no open reductions. After a mean follow-up of 6.3 years (SD 3.7), patients with a type I fracture had a mean QuickDASH of 2.0 (SD 5.2), at a scale of 0 to 100, with lower values representing better HRQoL (type II: 2.8 (SD 10.7); type III: 3.3 (SD 8.0); type IV: 1.8 (SD 4.6)). The mean function score of the PedsQL ranged from 97.4 (SD 8.0) for type I to 96.1 (SD 9.1) for type III fractures, at a scale of 0 to 100, with higher values representing better HRQoL. Conclusion. In this cohort of 775 patients in whom nonoperative treatment was chosen for AO type I and II fractures and CRPP or a lateral external fixator was used in AO type III and IV fractures, there was equally excellent mid- and long-term HRQoL when assessed by the QuickDASH and PedsQL. These results indicate that the treatment protocol followed in this study is unambiguous, avoids open reductions, and is associated with excellent treatment outcomes. Cite this article: Bone Joint J 2020;102-B(6):755–765

In this study, we describe a morphological classification for greater tuberosity fractures of the proximal humerus. We divided these fractures into three types: avulsion, split and depression. We retrospectively reviewed all shoulder radiographs showing isolated greater tuberosity fractures in a Level I trauma centre between July 2007 and July 2012. We identified 199 cases where records and radiographs were reviewed and included 79 men and 120 women with a mean age of 58 years (23 to 96). The morphological classification was applied to the first 139 cases by three reviewers on two occasions using the Kappa statistic and compared with the AO and Neer classifications. The inter- and intra-observer reliability of the morphological classification was 0.73 to 0.77 and 0.69 to 0.86, respectively. This was superior to the Neer (0.31 to 0.35/0.54 to 0.63) and AO (0.30 to 0.32/0.59 to 0.65) classifications. The distribution of avulsion, split and depression type fractures was 39%, 41%, and 20%, respectively. This classification of greater tuberosity fractures is more reliable than the Neer or AO classifications. These distinct fracture morphologies are likely to have implications in terms of pathophysiology and surgical technique. Cite this article: Bone Joint J 2014;96-B:646–51

Sixteen patients who underwent a revision operation for nonunion of fractures of the distal humerus following previous internal fixation were reviewed at a mean follow-up of 39 months (8 to 69). The Mayo elbow performance score was excellent in 11, good in two, fair in two and poor in one. In 15 patients union was achieved and in one with an infected nonunion a subsequent bone graft was necessary in order to obtain union. Age, gender, a history of smoking, mechanism of the injury and the AO classification of the initial fracture did not correlate with the development of nonunion. In 12 patients (75%), the initial fixation was assessed as being suboptimal. The primary surgery was regarded as adequate in only three patients. Our findings suggest that the most important determinant of nonunion of a distal humeral fracture after surgery is the adequacy of fixation

Aims

Pneumatic tourniquets are often used during the surgical treatment of unstable traumatic ankle fractures. The aim of this study was to assess the risk of reoperation after open reduction and internal fixation of ankle fractures with and without the use of pneumatic tourniquets.

Aims

This study aimed to compare mortality in trochanteric AO/OTA A1 and A2 fractures treated with an intramedullary nail (IMN) or sliding hip screw (SHS). The primary endpoint was 30-day mortality, with secondary endpoints at 0 to 1, 2 to 7, 8 to 30, 90, and 365 days.

We performed an epidemiological analysis of 523 fractures treated in the Edinburgh Orthopaedic Trauma Unit over a three-year period using modern descriptive criteria. The fractures were defined in terms of their AO morphology and their degree of comminution, location and cause. Closed fractures were classified using the Tscherne grading system and open fractures according to the Gustilo classification. Further analysis of fractures caused by road-traffic accidents and football was carried out. The use of the AO classification allowed the common fracture patterns to be defined. Correlation of the classification systems showed an association between the AO morphological system and the Tscherne and Gustilo classifications. The relative rarity of severe tibial fractures is indicated and it is suggested that in smaller orthopaedic units the infrequency of these fractures has implications for training and the development of treatment protocols

Aims

There is no level I evidence dealing with the optimal period of immobilization for patients with a displaced distal radial fracture following closed reduction. A shorter period might lead to a better functional outcome due to less stiffness and pain. The aim of this study was to investigate whether this period could be safely reduced from six to four weeks.

Aims

This study aimed to compare the outcomes of two different postoperative management approaches following surgical fixation of ankle fractures: traditional cast immobilization versus the Early Motion and Directed Exercise (EMADE) programme.

Aims

This study aims to determine the rate of and risk factors for total knee arthroplasty (TKA) after operative management of tibial plateau fractures (TPFs) in older adults.

Between 1995 and 2000, 19 consecutive patients with fractures of the distal humerus were treated by primary total elbow replacement using the Coonrad-Morrey prosthesis. No patient had inflammatory or degenerative arthritis of the elbow. The mean age at the time of injury was 73 years (61 to 95). According to the AO classification, 11 patients had suffered a C3 injury, two a B3 and two an A3. One fracture was unclassified. Two patients died from unrelated causes and one was unable to be assessed because of concurrent illness. The mean time to follow-up was three years (1 to 5.5). At follow-up 11 patients (68%) reported no pain, four (25%) had mild pain with activity and one had mild pain at rest. The mean flexion arc was 24° to 125°. The mean supination was 90° (70 to 100) and pronation 70° (50 to 110). No elbow was unstable. The mean Disabilities of the Arm, Shoulder and Hand score was 23 (0.92 to 63.3) and the mean Mayo elbow performance score was 93 (80 to 100). Of the 16 patients, 15 were satisfied with the outcome. Radiological evaluation revealed only one patient with a radiolucent line at the cement-bone interface. It was between 1 and 2 mm in length, was present on the initial postoperative radiograph and was non-progressive at the time of follow-up. Primary total elbow arthroplasty is an acceptable option for the management of comminuted fractures of the distal humerus in elderly patients when the configuration of the fracture and the quality of the bone make reconstruction difficult

Aims

The aim of this study was to describe the incidence of refractures among children, following fractures of all long bones, and to identify when the risk of refracture decreases.

Aims

Proximal humeral fractures are the third most common fracture among the elderly. Complications associated with fixation include screw perforation, varus collapse, and avascular necrosis of the humeral head. To address these challenges, various augmentation techniques to increase medial column support have been developed. There are currently no recent studies that definitively establish the superiority of augmented fixation over non-augmented implants in the surgical treatment of proximal humeral fractures. The aim of this systematic review and meta-analysis was to compare the outcomes of patients who underwent locking-plate fixation with cement augmentation or bone-graft augmentation versus those who underwent locking-plate fixation without augmentation for proximal humeral fractures.

Aims

The aim of this study was to compare the functional and radiological outcomes and the complication rate after nail and plate fixation of unstable fractures of the ankle in elderly patients.

Aims

The aim of this study was to investigate if there are differences in outcome between sliding hip screws (SHSs) and intramedullary nails (IMNs) with regard to fracture stability.

Aims

The prevalence of ipsilateral total hip arthroplasty (THA) and total knee arthroplasty (TKA) is rising in concert with life expectancy, putting more patients at risk for interprosthetic femur fractures (IPFFs). Our study aimed to assess treatment methodologies, implant survivorship, and IPFF clinical outcomes.

Aims

The morphology of medial malleolar fracture is highly variable and difficult to characterize without 3D reconstruction. There is also no universally accepeted classification system. Thus, we aimed to characterize fracture patterns of the medial malleolus and propose a classification scheme based on 3D CT reconstruction.

Aims

To compare operative and nonoperative treatment for displaced distal radius fractures in patients aged over 65 years.

Aims

The aim of this study was to explore why some calcar screws are malpositioned when a proximal humeral fracture is treated by internal fixation with a locking plate, and to identify risk factors for this phenomenon. Some suggestions can be made of ways to avoid this error.

Aims

The aims of this study were to investigate the mortality following a proximal humeral fracture. Data from a large population-based fracture register were used to quantify 30-day, 90-day, and one-year mortality rates after a proximal humeral fracture. Associations between the risk of mortality and the type of fracture and its treatment were assessed, and mortality rates were compared between patients who sustained a fracture and the general population.

Aims

The primary aim of this study was to develop a reliable, effective radiological score to assess the healing of humeral shaft fractures, the Radiographic Union Score for HUmeral fractures (RUSHU). The secondary aim was to assess whether the six-week RUSHU was predictive of nonunion at six months after the injury.

Aims

The aim of this study was to develop a psychometrically sound measure of recovery for use in patients who have suffered an open tibial fracture.

Aims

This study explores data quality in operation type and fracture classification recorded as part of a large research study and a national audit with an independent review.

Aims

Patient engagement in adaptive health behaviours and interactions with their healthcare ecosystem can be measured using self-reported instruments, such as the Patient Activation Measure (PAM-13) and the Effective Consumer Scale (ECS-17). Few studies have investigated the influence of patient engagement on limitations (patient-reported outcome measures (PROMs)) and patient-reported experience measures (PREMs). First, we assessed whether patient engagement (PAM-13, ECS-17) within two to four weeks of an upper limb fracture was associated with limitations (the Quick Disabilities of the Arm, Shoulder and Hand questionnaire (QuickDASH), and Patient-Reported Outcome Measurement Information System Upper Extremity Physical Function computer adaptive test (PROMIS UE PF) scores) measured six to nine months after fracture, accounting for demographic, clinical, and psychosocial factors. Secondly, we assessed the association between patient engagement and experience (numerical rating scale for satisfaction with care (NRS-C) and satisfaction with services (NRS-S) six to nine months after fracture.

Aims

The aim of this study was to investigate mortality and risk of intraoperative medical complications depending on delay to hip fracture surgery by using data from the Norwegian Hip Fracture Register (NHFR) and the Norwegian Patient Registry (NPR).

Aims

This study aimed to analyze the correlation between transverse process (TP) fractures of the fourth (L4) and fifth (L5) lumbar vertebrae and biomechanical and haemodynamic stability in patients with a pelvic ring injury, since previous data are inconsistent.

Stable fractures of the ankle can be safely treated non-operatively. It is also gradually being recognised that the integrity of the ‘medial column’ is essential for the stability of the fracture. It is generally thought that bi- and tri-malleolar fractures are unstable, as are pronation external rotation injuries resulting in an isolated high fibular fracture (Weber type-C), where the deltoid ligament is damaged or the medial malleolus fractured. However, how best to identify unstable, isolated, trans-syndesmotic Weber type-B supination external rotation (SER) fractures of the lateral malleolus remains controversial.

We provide a rationale as to how to classify SER distal fibular fractures using weight-bearing radiographs, and how this can help guide the management of these common injuries.

Cite this article: Bone Joint J 2017;99-B:851–5.

We performed a retrospective study to determine the effect of osteoporosis on the functional outcome of osteoporotic distal radial fractures treated with a volar locking plate. Between 2009 and 2012 a total of 90 postmenopausal women with an unstable fracture of the distal radius treated with a volar locking plate were studied. Changes in the radiological parameters of 51 patients with osteoporosis (group 1, mean age 66.9, mean T-score –3.16 (sd 0.56)) were not significantly different from those in 39 patients without osteoporosis (group 2, mean age 61.1, mean T-score –1.72 (sd 0.57)). The mean Disabilities of the Arm, Shoulder and Hand (DASH) score at final follow-up was 11.5 (sd 12.2) in group 1 and 10.5 (sd 13.25) in group 2. The mean modified Mayo wrist score at final follow-up was 79.0 (sd 14.04) in group 1 and 82.6 (sd 13.1) in group 2. However, this difference was not statistically significant (p = 0.35 for DASH score, p = 0.2 for modified Mayo wrist score). Univariable and multivariable logistic regression analysis showed that only the step-off of the radiocarpal joint was related to both a poor DASH and modified Mayo wrist score. Pearson’s correlation coefficient showed a weak negative relationship only between the T-score and the change in volar tilt (intraclass coefficient –0.26, p = 0.02).

We found that osteoporosis does not have a negative effect on the functional outcome and additional analysis did not show a correlation between T-score and outcome.

Cite this article: Bone Joint J 2015;97-B:229–34.

Aims

Fractures of the navicular can occur in isolation but, owing to the intimate anatomical and biomechanical relationships, are often associated with other injuries to the neighbouring bones and joints in the foot. As a result, they can lead to long-term morbidity and poor function. Our aim in this study was to identify patterns of injury in a new classification system of traumatic fractures of the navicular, with consideration being given to the commonly associated injuries to the midfoot.

Aims

To compare the outcomes for trochanteric fractures treated with a sliding hip screw (SHS) or a cephalomedullary nail.

Fractures of the tibial shaft are common injuries, but there are no long-term outcome data in the era of increased surgical management. The aim of this prospective study was to assess the clinical and functional outcome of this injury at 12 to 22 years. Secondary aims were to determine the short- and long-term mortality, and if there were any predictors of clinical or functional outcome or mortality. From a prospective trauma database of 1502 tibial shaft fractures in 1474 consecutive adult patients, we identified a cohort of 1431 tibial diaphyseal fractures in 1403 patients, who fitted our inclusion criteria. There were 1024 men, and mean age at injury was 40.6 years. Fractures were classified according to the AO system, and open fractures graded after Gustilo and Anderson. Requirement of fasciotomy, time to fracture union, complications, incidence of knee and ankle pain at long-term follow-up, changes in employment and the patients’ social deprivation status were recorded. Function was assessed at 12 to 22 years post-injury using the Short Musculoskeletal Function Assessment and short form-12 questionnaires. Long-term functional outcome data was available for 568 of the surviving patients, 389 were deceased and 346 were lost to follow-up. Most fractures (90.7%, n = 1363) united without further intervention. Fasciotomies were performed in 11.5% of patients; this did not correlate with poorer functional outcome in the long term. Social deprivation was associated with a higher incidence of injury but had no impact on long-term function. The one-year mortality in those over 75 years of age was 29 (42%). At long-term follow-up, pain and function scores were good. However, 147 (26%) reported ongoing knee pain, 62 (10%) reported ankle pain and 97 (17%) reported both. Such joint pain correlated with poorer functional outcome.

Cite this article: Bone Joint J 2014;96-B:1370–7.

Unstable pelvic injuries in young children with an immature pelvis have different modes of failure from those in adolescents and adults. We describe the pathoanatomy of unstable pelvic injuries in these children, and the incidence of associated avulsion of the iliac apophysis and fracture of the ipsilateral fifth lumbar transverse process (L5-TP). We retrospectively reviewed the medical records of 33 children with Tile types B and C pelvic injuries admitted between 2007 and 2014; their mean age was 12.6 years (2 to 18) and 12 had an immature pelvis. Those with an immature pelvis commonly sustained symphyseal injuries anteriorly with diastasis, rather than the fractures of the pubic rami seen in adolescents. Posteriorly, transsacral fractures were more commonly encountered in mature children, whereas sacroiliac dislocations and fracture-dislocations were seen in both age groups. Avulsion of the iliac apophysis was identified in eight children, all of whom had an immature pelvis with an intact ipsilateral L5-TP. Young children with an immature pelvis are more susceptible to pubic symphysis and sacroiliac diastasis, whereas bony failures are more common in adolescents. Unstable pelvic injuries in young children are commonly associated with avulsion of the iliac apophysis, particularly with displaced SI joint dislocation and an intact ipsilateral L5-TP.

Cite this article: Bone Joint J 2015; 97-B:696–704.

Aims

Fractures of the distal femur can be challenging to manage and are on the increase in the elderly osteoporotic population. Management with casting or bracing can unacceptably limit a patient’s ability to bear weight, but historically, operative fixation has been associated with a high rate of re-operation. In this study, we describe the outcomes of fixation using modern implants within a strategy of early return to function.

Several studies have reported the rate of post-operative mortality after the surgical treatment of a fracture of the hip, but few data are available regarding the delayed morbidity. In this prospective study, we identified 568 patients who underwent surgery for a fracture of the hip and who were followed for one year. Multivariate analysis was carried out to identify possible predictors of mortality and morbidity. The 30-day, four-month and one-year rates of mortality were 4.3%, 11.4%, and 18.8%, respectively. General complications and pre-operative comorbidities represented the basic predictors of mortality at any time interval (p < 0.01). In-hospital, four-month and one-year general complications occurred in 29.4%, 18.6% and 6.7% of patients, respectively. After adjusting for confounding variables, comorbidities and poor cognitive status determined the likelihood of early and delayed general complications, respectively (p < 0.001). Operative delay was the main predictor of the length of hospital stay (p < 0.001) and was directly related to in-hospital (p = 0.017) and four-month complications (p = 0.008).

Cite this article: Bone Joint J 2015;97-B:383–90

Aim

The primary aim of this retrospective study was to identify the incidence of heterotopic ossification (HO) following elective and trauma elbow arthroplasty. The secondary aim was to determine clinical outcomes with respect to the formation of heterotopic ossification.

We report our experience of performing an elbow hemiarthroplasty in the treatment of comminuted distal humeral fractures in the elderly patients.

A cohort of 42 patients (three men and 39 women, mean age 72; 56 to 84) were reviewed at a mean of 34.3 months (24 to 61) after surgery. Functional outcome was measured with the Mayo Elbow Performance Score (MEPS) and range of movement. The disabilities of the arm, shoulder and hand questionnaire (DASH) was used as a patient rated evaluation. Complications and ulnar nerve function were recorded. Plain radiographs were obtained to assess prosthetic loosening, olecranon wear and heterotopic bone formation.

The mean extension deficit was 23.5° (0° to 60°) and mean flexion was 126.8° (90° to 145°) giving a mean arc of 105.5° (60° to 145°). The mean MEPS was 90 (50 to 100) and a mean DASH score of 20 (0 to 63). Four patients had additional surgery for limited range of movement and one for partial instability. One elbow was revised due to loosening, two patients had sensory ulnar nerve symptoms, and radiographic signs of mild olecranon wear was noted in five patients.

Elbow hemiarthroplasty for comminuted intra-articular distal humeral fractures produces reliable medium-term results with functional outcome and complication rates, comparable with open reduction and internal fixation and total elbow arthroplasty.

Cite this article: Bone Joint J 2015;97-B:1377–84.

Fractures around total knee arthroplasties pose a significant surgical challenge. Most can be managed with osteosynthesis and salvage of the replacement. The techniques of fixation of these fractures and revision surgery have evolved and so has the assessment of outcome. This specialty update summarises the current evidence for the classification, methods of fixation, revision surgery and outcomes of the management of periprosthetic fractures associated with total knee arthroplasty.

Cite this article: Bone Joint J 2016;98-B:1489–96.

Aims

The aim of this study was to report the clinical, functional and radiological outcomes of children and adolescents with tibial fractures treated using the Ilizarov method.

We describe the routine imaging practices of Level 1 trauma centres for patients with severe pelvic ring fractures, and the interobserver reliability of the classification systems of these fractures using plain radiographs and three-dimensional (3D) CT reconstructions. Clinical and imaging data for 187 adult patients (139 men and 48 women, mean age 43 years (15 to 101)) with a severe pelvic ring fracture managed at two Level 1 trauma centres between July 2007 and June 2010 were extracted. Three experienced orthopaedic surgeons classified the plain radiographs and 3D CT reconstruction images of 100 patients using the Tile/AO and Young–Burgess systems. Reliability was compared using kappa statistics. A total of 115 patients (62%) had plain radiographs as well as two-dimensional (2D) CT and 3D CT reconstructions, 52 patients (28%) had plain films only, 12 (6.4%) had 2D and 3D CT reconstructions images only, and eight patients (4.3%) had no available images. The plain radiograph was limited to an anteroposterior pelvic view. Patients without imaging, or only plain films, were more severely injured. A total of 72 patients (39%) were imaged with a pelvic binder in situ.

Interobserver reliability for the Tile/AO (Kappa 0.10 to 0.17) and Young–Burgess (Kappa 0.09 to 0.21) was low, and insufficient for clinical and research purposes.

Severe pelvic ring fractures are difficult to classify due to their complexity, the increasing use of early treatment such as with pelvic binders, and the absence of imaging altogether in important patient sub-groups, such as those who die early of their injuries.

Cite this article: Bone Joint J 2013;95-B:1396–1401.

We describe the outcome of tibial diaphyseal fractures in the elderly (≥ 65 years of age). We prospectively followed 233 fractures in 225 elderly patients over a minimum ten-year period. Demographic and descriptive data were acquired from a prospective trauma database. Mortality status was obtained from the General Register Office database for Scotland. Diaphyseal fractures of the tibia in the elderly occurred predominantly in women (73%) and after a fall (61%). During the study period the incidence of these fractures decreased, nearly halving in number. The 120-day and one-year unadjusted mortality rates were 17% and 27%, respectively, and were significantly greater in patients with an open fracture (p < 0.001). The overall standardised mortality ratio (SMR) was significantly increased (SMR 4.4, p < 0.001) relative to the population at risk, and was greatest for elderly women (SMR 8.1, p < 0.001). These frailer patients had more severe injuries, with an increased rate of open fractures (30%), and suffered a greater rate of nonunion (10%).

Tibial diaphyseal fractures in the elderly are most common in women after a fall, are more likely to be open than in the rest of the population, and are associated with a high incidence of nonunion and mortality.

Cite this article: Bone Joint J 2013;95-B:1255–62.

The purpose of this study was to identify factors that predict implant cut-out after cephalomedullary nailing of intertrochanteric and subtrochanteric hip fractures, and to test the significance of calcar referenced tip-apex distance (CalTAD) as a predictor for cut-out.

We retrospectively reviewed 170 consecutive fractures that had undergone cephalomedullary nailing. Of these, 77 met the inclusion criteria of a non-pathological fracture with a minimum of 80 days radiological follow-up (mean 408 days; 81 days to 4.9 years). The overall cut-out rate was 13% (10/77).

The significant parameters in the univariate analysis were tip-apex distance (TAD) (p <  0.001), CalTAD (p = 0.001), cervical angle difference (p = 0.004), and lag screw placement in the anteroposterior (AP) view (Parker’s ratio index) (p = 0.003). Non-significant parameters were age (p = 0.325), gender (p = 1.000), fracture side (p = 0.507), fracture type (AO classification) (p = 0.381), Singh Osteoporosis Index (p = 0.575), lag screw placement in the lateral view (p = 0.123), and reduction quality (modified Baumgaertner’s method) (p = 0.575). In the multivariate analysis, CalTAD was the only significant measurement (p = 0.001). CalTAD had almost perfect inter-observer reliability (interclass correlation coefficient (ICC) 0.901).

Our data provide the first reported clinical evidence that CalTAD is a predictor of cut-out. The finding of CalTAD as the only significant parameter in the multivariate analysis, along with the univariate significance of Parker’s ratio index in the AP view, suggest that inferior placement of the lag screw is preferable to reduce the rate of cut-out.

Cite this article: Bone Joint J 2014; 96-B:1029–34.

Aims

We review our experience of Coonrad-Morrey total elbow arthroplasty (TEA) for fractures of the distal humerus in non-rheumatoid patients with a minimum of ten years follow-up.

An atypical femoral fracture (AFF), with a transverse fracture radiologically through the lateral cortex is a rare but serious condition. In order to improve our ability to identify patients with this condition, we retrospectively surveyed all subtrochanteric, peri-implant and diaphyseal femoral fractures in patients aged ≥ 65 years who underwent surgical treatment at our hospital between 2004 and 2011.

We describe the incidence of atypical fractures and their characteristics, with observational data including a review of the hospital and general practitioner records. Clinical outcomes were evaluated using the Harris hip score (HHS) and the timed up-and-go (TUG) test.

Atypical fractures only occurred in women with an incidence of 9.8 per 100 000 person-years. The incidence in those who were treated with bisphosphonates was 79.0 per 100 000 person-years; eight of 17 fractures occurred around metal implants. There was a high incidence of delayed union and revision surgery. A total of nine patients (ten AFFs) were available for review at a mean follow-up of 36.5 months (10 to 104). The clinical outcome was poor with a mean HHS of 58.9 (95% CI 47.4 to 70.4) and a mean TUG test of 25.7 s (95% CI 12.7 to 38.8).

The delay in diagnosis and treatment of AFF may result from a lack of knowledge of this condition.

Cite this article: Bone Joint J 2014; 96-B:1035–40.

We carried out a retrospective review over ten months of patients who had presented with a low-energy subtrochanteric fracture. We identified 13 women of whom nine were on long-term alendronate therapy and four were not. The patients treated with alendronate were younger, with a mean age of 66.9 years (55 to 82) vs 80.3 years (64 to 92) and were more socially active. The fractures sustained by the patients in the alendronate group were mainly at the femoral metaphyseal-diaphyseal junction and many had occurred after minimal trauma. Five of these patients had prodromal pain in the affected hip in the months preceding the fall, and three demonstrated a stress reaction in the cortex in the contralateral femur.

Our study suggests that prolonged suppression of bone remodelling with alendronate may be associated with a new form of insufficiency fracture of the femur. We believe that this finding is important and indicates the need for caution in the long-term use of alendronate in the treatment of osteoporosis.

Aims

Although infrequent, a fracture of the cuboid can lead to significant disruption of the integrity of the midfoot and its function. The purpose of this study was to classify the pattern of fractures of the cuboid, relate them to the mechanism of injury and suggest methods of managing them.