Aims. The aim of this study was to assess the safety and clinical outcome of patients with a femoral shaft fracture and a previous complex post-traumatic femoral malunion who were treated with a clamshell osteotomy and fixation with an intramedullary nail (IMN). Methods. The study involved a retrospective analysis of 23 patients. All had a previous, operatively managed, femoral shaft fracture with malunion due to hardware failure. They were treated with a clamshell osteotomy between May 2015 and March 2020. The mean age was 42.6 years (26 to 62) and 15 (65.2%) were male. The mean follow-up was 2.3 years (1 to 5). Details from their medical records were analyzed. Clinical outcomes were assessed using the quality of correction of the deformity, functional recovery, the healing time of the fracture, and complications. Results. The mean length of time between the initial injury and surgery was 4.5 years (3 to 10). The mean operating time was 2.8 hours (2.05 to 4.4)), and the mean blood loss was 850 ml (650 to 1,020). Complications occurred in five patients (21.7%): two with wound necrosis, and three with deep vein thrombosis. The mean coronal deformity was significantly corrected from 17.78° (SD 4.62°) preoperatively to 1.35° (SD 1.72°) postoperatively (p < 0.001), and the mean sagittal deformity was significantly corrected from 20.65° (SD 5.88°) preoperatively to 1.61° (SD 1.95°; p < 0.001) postoperatively. The mean leg length discrepancy was significantly corrected from 3.57 cm (SD 1.27) preoperatively to 1.13 cm (SD 0.76) postoperatively (p < 0.001). All fractures healed at a mean of seven months (4 to 12) postoperatively. The mean Lower Extremity Functional Scale score improved significantly from 45.4 (SD 9.1) preoperatively to 66.2 (SD 5.5) postoperatively (p < 0.001). Partial cortical nonunion in the deformed segment occurred in eight patients (34.8%) and healed at a mean of 2.4 years (2 to 3) postoperatively. Conclusion. A clamshell osteotomy combined with IMN fixation in the treatment of patients with a femoral shaft fracture and a previous post-traumatic femoral malunion achieved excellent outcomes. Partial cortical nonunions in the deformed segment also healed satisfactorily. Cite this article: Bone Joint J 2023;105-B(4):449–454

Intramedullary locking nails have proved to be of considerable advantage when treating complex, comminuted or segmental femoral shaft fractures. We have reviewed 117 patients with 120 femoral shaft fractures treated with the Strasbourg device. These included 20 compound fractures, 13 pathological fractures and two non-unions. Rehabilitation and union rates have been very satisfactory and there have been no serious infections in the series. Comminution of the proximal femur has occurred in six patients and there have been three femoral neck fractures, but all of these have healed without further complications

Fractures of the femoral shaft are generally considered to affect young patients, but we have reviewed 24 cases in patients over 60 years who have been treated by locked nailing, usually by closed methods. Most were women with low-velocity injuries, but despite this, 14 fractures were significantly comminuted. The complication rate was 54% with a peri-operative mortality of 17%. Most complications were the general ones of operating on elderly patients. Specific complications included: fractures below an abnormal hip, proximal fracture related to the nail and poor purchase in the distal femur. In all survivors, the femoral shaft fractures united satisfactorily, and the fixation allowed early mobilisation. The locking nail appears to be an effective method of managing femoral shaft fractures in the elderly patient

We analysed the results of 93 tibial shaft fractures treated with the Grosse-Kempf locked nail. Twenty-six fractures were comminuted, 19 were open grade I to II, and 54 were located outside the middle third of the tibia. The deep infection rate was 3.2%. There were only two poor results. The use of this method is recommended and discussed

All tibial shaft fractures treated at one hospital during a five-year period were studied in a prospective trial. Ninety-one displaced fractures in adults were treated using a conservative policy that included early bone grafting when indicated. Sound bony union was obtained in all cases. Those that healed primarily took on average 16.3 weeks whereas the 24 per cent that required bone grafts took 35.1 weeks. The number of complications, most of which were minor, was considered acceptable. It is concluded that provided early bone grafting is performed when necessary, a basically conservative policy of treatment is satisfactory; bony union of all displaced tibial fractures is achieved in a reasonable period of time

The torsion of both femora was evaluated in 110 patients who had been treated by intramedullary nailing for unilateral femoral shaft fractures. The anteversion (AV) angle was measured by ultrasound, using a tilted-transducer technique. True torsional deformity, defined as an AV difference of 15 degrees or more between sides was found in 21 patients, but only eight had complaints related to the deformity. Three patients had reoperations for troublesome external torsional deformities. Of 26 patients with AV differences of 10 degrees to 14 degrees, defined as possible torsional deformity, three had complaints, but none had serious problems. AV differences of up to 29 degrees were observed in symptom-free patients, and no patients with AV differences below 10 degrees had complaints. Static and dynamic nailing showed almost equal tendencies to lead to torsional deformity. We conclude that torsional deformities are usually established during the operation. Many patients tolerate abnormal torsion, but efforts should be made to reduce and stabilise the femoral shaft fracture with an AV difference of less than 15 degrees

In two hospitals, 115 consecutive open femoral shaft fractures were treated by meticulous wound excision and early locked (97) or unlocked (18) intramedullary nailing. All the fractures united; union was delayed in four, three of which required bone grafting. The average range of knee flexion at follow-up was 134 degrees (60 to 148). Five patients had a final range of less than 120 degrees, but three of these improved after manipulation under general anaesthesia. Three patients developed staphylococcal infections and required further surgical treatment. All eventually healed

We studied 47 patients with closed, displaced, diaphyseal fractures of the femur caused by blunt trauma, to determine the incidence of associated knee injuries, particularly of the meniscus. After femoral nailing, all patients had an examination under anaesthesia and an arthroscopy. There were 12 medial meniscal injuries (5 tears) and 13 injuries of the lateral meniscus (8 tears). Ten of the 13 tears were in the posterior third of the meniscus, and two patients had tears of both menisci. Synovitis was common at the meniscal attachments. Complex and radial tears were more common than peripheral or bucket-handle tears. Examination under anaesthesia revealed ligamentous laxity in 23 patients (49%), but meniscal injuries had a similar incidence in knees with and without ligament injury. Femoral shaft fractures are often associated with injuries to the ipsilateral knee, and a high index of suspicion is necessary to identify these lesions

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

We describe the use of Ender nails for the internal fixation of femoral shaft fractures by a closed technique via the greater trochanter and report the treatment of 100 patients with 106 fractures, of which 88 were reviewed 12 months or more after operation. There was primary union in 85 fractures (96.6%) and significant angulation, rotation or leg length discrepancy in eight (9%). We discuss the principles of management which we have evolved

Ten patients with humeral shaft fractures and no clinical or radiographic signs of healing after at least six weeks' immobilisation were treated by flexible intramedullary nailing using a closed retrograde technique. Bone grafting was not performed, and active movement was encouraged after operation. Nine fractures healed; the mean time to union was 10.5 weeks (range 6 to 22 weeks). One patient needed compression plating and bone grafting at 22 weeks, and another required re-operation for distal migration of the rods. There were no infections, nerve palsies or other complications. Stiffness of the shoulder which had developed during early treatment improved after operation

The stability of union following the conservative treatment of tibial shaft fractures has been examined in 157 patients by a non-invasive method. With this technique it is possible to ascertain when the fragments are united and whether the strength of union is sufficient for full weight-bearing without protection. The mean time required for union was 14.0 +/- 9.2 weeks, with a range of 4 to 48 weeks. In 31 cases union was judged to be delayed; in 22 of these, intended operations were avoided because repeated stability determinations indicated progressive union. Of nine fracture variables examined, the only ones which significantly affected the time required to achieve union were the age and the weight of the patient. Irrelevant factors were the type and level of the fracture, the energy of trauma, soft-tissue injury and the presence of multiple injuries

Sixty patients each of whom had a fracture of the lower limb a minimum of five years (median 11 years) previously were studied by photoplethysmography, foot volumetry, popliteal venous reflux and arterial Doppler measurements. The non-fractured limb was used as a control. Postphlebitic symptoms were present in 51% and signs in 49% of fractured limbs compared with 4% and 24% respectively in the control limbs. The incidence was greater in patients who had fractured 15 years or more previously than in those who had fractured 5 to 15 years previously. Eleven limbs had clinically disabling postphlebitic symptoms including venous ulceration. The postphlebitic syndrome following lower limb fractures in young patients is more common than generally appreciated and develops after a prolonged latent interval. A prospective randomised study using prophylactic anticoagulation for lower limb shaft fractures may be justified

We performed a prospective randomised trial on matched groups of patients with displaced tibial shaft fractures to compare conservative treatment with closed intramedullary nailing. The results showed conclusively that intramedullary nailing gave more rapid union with less malunion and shortening. Nailed patients had less time off work with a more predictable and rapid return to full function. We therefore consider that closed intramedullary nailing is the most efficient treatment for displaced fractures of the tibial shaft

A prospective study of 141 patients with 143 tibial shaft fractures has been carried out; 102 fractures were closed and 41 open. All the patients were treated by Ender's nailing and early weight-bearing. The average healing time was 15.2 weeks. There were no cases of bone infection and complications were minimal, the commonest being slight malalignment. Using this method, rapid restoration of bone continuity was achieved, combined with almost normal limb function during treatment

We have reviewed our recent results with functional bracing of tibial shaft fractures in adults in order to define its role in management. We also analysed several parameters of these fractures to discover those which influence healing. A total of 780 tibial fractures treated in prefabricated functional braces were followed to union; shortening of less than 10 mm and angulation of less than 5 degrees in any plane were our parameters for successful treatment. The average time before applying a brace was 3.8 weeks for closed fractures and 5.2 weeks for open ones. Closed fractures healed in an average of 17.4 weeks and open fractures in an average of 21.7 weeks, 90% of them with 10 mm of shortening or less. Varus angulation and posterior angulation were the most common deformities encountered at union. There were 20 nonunions (2.5%) and 46 braces were discontinued during treatment. We found no association between fracture healing and the patient's age, the mechanism of injury or the fracture location. The degree of soft tissue injury appeared to have most influence on the speed of fracture healing. Fracture comminution and initial displacement, the condition of the fibula and the time from injury to bracing also appeared to affect the speed of union

One hundred consecutive closed fractures of the adult tibial shaft treated by closed methods were surveyed prospectively in order to observe their natural history. The fractures were analysed with regards to speed of healing and the influence of age, sex, causal force, radiological morphology and concurrent fibular fracture. At 20 weeks 19 fractures had not yet united, but 15 of these had united by 30 weeks with conservative treatment alone. The remaining four cases were operated upon because no further progress in healing was anticipated. These findings suggest that, with regard to healing, open reduction and internal fixation is rarely justified in closed adult tibial shaft fractures

We reviewed and radiographed 30 skeletally-mature patients after isolated closed femoral shaft fractures in childhood which had been treated conservatively. When the fracture had occurred between the ages of 7 and 13 years, the limb overgrew about 1 cm regardless of sex, upper limb dominance, age, fracture site or configuration. Excessive fracture overlap at the time of injury, but not at union, increased limb overgrowth. Angulation of the fracture remodelled in children injured under 10 years of age, but in older patients this sometimes added to limb shortening. Rotational deformities were minor and gave no symptoms. Treatment of the 7- to 13-year-old patient should aim at 1 cm overlap at union, with correction of angular deformity being more important in children over 10 years of age. This management of fractures will give a maximum leg length discrepancy of 1 cm at skeletal maturity

Excellent results can be achieved by plating fractures of the shaft of the humerus in patients with multiple injuries. This helps in nursing care and in the management of other injuries. In 38 patients admitted to a regional trauma centre, 39 humeral shaft fractures were plated. There were 27 men and 11 women, with an average age of 31.5 years. Fourteen of the humeral fractures were compound and 20 had significant comminution; 23 were fixed by a plate on the day of admission and all 39 by the twentieth day. Follow-up of 34 fractures showed that all had united, 33 primarily. All patients but one had a fully functional shoulder and no patient with a fractured humerus alone had lost any elbow movement. Complications were rare--one case each of non-union, fixation failure and infection. No permanent nerve injuries were produced at operation. The plating of fractures of the humerus in these circumstances has been shown to produce excellent results and has a place in the management of the patient with multiple injuries

Over 15 years (1967 to 1982) 140 uncomplicated femoral shaft fractures in children under four years of age were successfully treated using Bryant's traction. Forty of these children were treated after the introduction of the domiciliary management policy in 1976; 13 children were managed at hospital and 27 were managed at home. No significant complications occurred. The advantages to the family, and the safety and economy of domiciliary management lead us to recommend its adoption in favourable cases. Treatment at home relies on an efficient and experienced home nursing service. Possible complications of the injury and treatment with recommendations to prevent them are discussed

Aims

The aims of this study were to identify means to quantify coronal plane displacement associated with distal radius fractures (DRFs), and to understand their relationship to radial inclination (RI).

We have analysed 249 consecutive fractures of the humeral shaft treated over a three-year period. The fractures were defined by their AO morphology, position, the age and gender of the patient and the mechanism of injury. Open fractures were classified using the Gustilo system and soft-tissue injury, and closed fractures using the Tscherne system.

The fractures were classified as AO type A in 63.3%, type B in 26.2% and type C in 10.4%. Most (60%) occurred in the middle third of the diaphysis with 30% in the proximal and 10% in the distal third. The severity of the fracture and soft-tissue injury was greater with increasing injury severity. Less than 10% of the fractures were open. There was a bimodal age distribution with a peak in the third decade as a result of moderate to severe injury in men and a larger peak in the seventh decade after a simple fall in women.

Ninety-eight fractures of the shaft of the femur were seen in one unit over the two years 1974 and 1975, and the results have been assessed in sixty-nine. Of these, thirty-eight were treated by skeletal traction in a Thomas's splint followed by skin traction, and thirty-one by skeletal traction followed by a cast-brace. The technique of application is described in some detail. The average time for application of the cast-brace was six weeks after the injury, the time in hospital eight weeks and the time till removal fifteen weeks. The patients selected for a cast-brace were in hospital for just over half the time of the others and their fractures on average united more quickly, though with some trouble from angulation of fractures of the uppermost third of the shaft. It is concluded that when used with all the judgment and skill it demands, the cast-brace method is a great advance in conservative treatment.

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

From a series of 190 consecutive fractures of the shaft of the femur treated by closed Kuntscher nailing, 32 of the more severely comminuted have been studied to determine whether treatment by closed nailing was justified. Radiological criteria were used to divide them into 19 who were moderately comminuted and 13 grossly so. Twenty-four patients were less than 21 years of age and 19 patients had 40 significant associated injuries. Fifteen fractures were nailed on the day of injury, and complications were few. Nineteen patients had a supplementary cast-brace and all those who had been employed returned to work. Twelve patients had shortening of up to two centimetres and two had three centimetres; four had mild rotational deformities; seven had mild restriction of knee flexion; and two had delayed union. There were no infections. The advantages of this technique include a negligible risk of infection and rapid stabilisation of even grossly comminuted fractures, thus facilitating management of other injuries. The 44 per cent incidence of shortening is counterbalanced by early mobilisation and rapid return of knee function. It is concluded that when proper equipment and expertise are available then closed nailing is the treatment of choice for severely comminuted fractures of the femoral shaft.

The treatment of fractures of the femoral shaft by traction may delay union and produce stiffness of the knee. The technique of Perkins' method is described and the results reported in 50 cases. All patients had at least 120 degrees of flexion of the knee when traction was discontinued, and 47 patients were considered to have clinical and radiological union of the fracture by 12 weeks. The main complications of the method was loosening of the Denham pin or infection of the pin-track in the proximal tibia. It is suggested that Perkins' traction is an excellent form of treatment for fractures of the femoral shaft, and has several advantages over other forms of traction.

The off-loading characteristics of the cast-braces of 30 patients with fractures of the shaft of the femur have been investigated, during axial loading, using strain-gauge transducers. These were applied at the level of the fracture, where the cast was circumferentially split, and to the hinges of the brace at the knee. They measured the load transferred between the two portions of the thigh cast, and between the thigh cast as a whole and the below-knee cast; by subtraction from the total load on the limb, the skeletal force at the fracture level and at the knee could be calculated. In all patients there was an increase in the fracture load as union progressed which was thought to be due to physiological feedback mechanism from the fracture site. The load carried by the two portions of the thigh cast and by the thigh cast as a whole was proportionately high at first and stabilised at an average of 35 per cent of body weight.

We reviewed 28 children with unilateral middle-third fractures of the femoral shaft who had an angular deformity after union of 10 degrees to 26 degrees. At an average follow-up of 45 months (20 to 66), we measured remodelling of the proximal physis, the distal physis and the femoral shaft. The average correction was 85% of the initial deformity. We found that 74% of correction occurred at the physes and only 26% at the fracture site. Neither the direction nor the magnitude of the angulation much influenced the degree of remodelling. Younger children remodelled only a little better than older children. We conclude that in children under 13 years of age, malunion of as much as 25 degrees in any plane will remodel enough to give normal alignment of the joint surfaces.

We treated 39 patients with fractures of the humeral shaft by closed retrograde locked intramedullary nailing, using Russell-Taylor humeral nails. The mean healing time of all fractures was 13.7 weeks. After consolidation, shoulder function was excellent in 92.3% and elbow function excellent in 87.2%. Functional end-results were excellent in 84.6% of patients, moderate in 10.3% and bad in 5.1%. One patient had a postoperative radial nerve palsy, which recovered within three months. There was additional comminution at the fracture site in three patients (7.7%) which did not affect healing, and slight nail migration in two older patients (5.1%). Two patients (5.1%) needed a second procedure because of disturbed fracture healing. One screw breakage was seen in a patient with delayed union. Retrograde locked humeral nailing appears to be a better solution for the stabilisation of fractures of the humeral shaft than anterograde nailing or plate and screw fixation. We found the complication rate to be acceptable and shoulder and elbow function to recover rapidly in most cases.

We measured pressures in the anterior and deep posterior compartments continuously for up to 72 hours in 20 patients with closed fractures of the tibial shaft treated primarily in plaster casts. All were examined independently after periods of three to 14 months. Pressures above 40 mmHg occurred in seven (35%) and above 30 mmHg in 14 (70%). No patient had the symptoms of compartment syndrome during monitoring. Abnormalities at review did not correlate with the maximum consecutive time periods during which the compartment pressures were raised. Thus, in the absence of symptoms the monitored pressures did not relate to outcome. Routine monitoring in this type of patient is therefore of doubtful benefit.

In a prospective study, we randomly allocated 39 patients with isolated fractures of the lower two-thirds of the ulnar shaft to treatment either by a prefabricated functional brace or a long-arm cast. Significantly better wrist function and a higher percentage of satisfied patients were found in the braced group. Thirteen patients returned to employment while still wearing the brace but only one was able to work in a cast.

We report the results of locked Seidel nailing for 30 fractures of the humerus. There were frequent technical difficulties at operation especially with the locking mechanisms. Protrusion of the nail above the greater tuberosity occurred in 12 cases, usually due to inadequate locking, and resulted in shoulder pain and poor function. Poor shoulder function was also seen in five patients with no nail protrusion, presumably because of local rotator cuff damage during insertion. Our results suggest that considerable modifications are required to the nail, and possibly to its site of insertion, before its use can be advocated.

One hundred and two fractures of the femoral shaft, including eighteen pathological fractures, in 100 patients were internally fixed by closed Kuntscher nailing. Sixty-eight fractures resulted from motor vehicle accidents; ten were compound. Seventy-five patients were under the age of thirty years and thirty-four had multiple injuries. Sixty-nine fractures were nailed on the day of the accident and the operative technique is described. Complications during and after operations were few. Fifty-eight patients left hospital within four weeks and 77% of those working returned to work in less than four months. There were no wound or bone infections. The results are discussed and it is concluded that, with the correct equipment and careful attention to detail, closed nailing is a straightforward procedure with few complications. Advantages include the wide range of fractures that can be nailed, the short hospitalisation, the rapid return of function to the knee, the early return to work and the absence of infection.

We report our experience with a modified implant and a new technique for locked intramedullary nailing of the humerus in 41 patients. Locking was by cross-screws placed from lateral to medial in the proximal humerus, and anteroposteriorly in the distal humerus. Early in the series, 11 nails were inserted at the shoulder, but we found that rehabilitation was faster after retrograde nailing through the olecranon fossa, which was used for the other 30. We used a closed technique for 29 of the nailings. Of the 41 patients treated, 21 had acute fractures, five had nonunion, and 15 had pathological fractures. Secure fixation was obtained for comminuted and osteoporotic fractures in any part of the humeral shaft, which allowed the early use of crutches and walking frames. Two nails were locked at only one end, and one of these became the only failure of union after an acute fracture.

Benefits of early stabilization of femoral shaft fractures, in mitigation of pulmonary and other complications, have been recognized over the past decades. Investigation into the appropriate level of resuscitation, and other measures of readiness for definitive fixation, versus a damage control strategy have been ongoing. These principles are now being applied to fractures of the thoracolumbar spine, pelvis, and acetabulum. Systems of trauma care are evolving to encompass attention to expeditious and safe management of not only multiply injured patients with these major fractures, but also definitive care for hip and periprosthetic fractures, which pose a similar burden of patient recumbency until stabilized. Future directions regarding refinement of patient resuscitation, assessment, and treatment are anticipated, as is the potential for data sharing and registries in enhancing trauma system functionality. Cite this article: Bone Joint J 2023;105-B(4):361–364

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. Patients and Methods. Initially, 20 patients with radiographs six weeks following a humeral shaft fracture were selected at random from a trauma database and scored by three observers, based on the Radiographic Union Scale for Tibial fractures system. After refinement of the RUSHU criteria, a second group of 60 patients with radiographs six weeks after injury, 40 with fractures that united and 20 with fractures that developed nonunion, were scored by two blinded observers. Results. After refinement, the interobserver intraclass correlation coefficient (ICC) was 0.79 (95% confidence interval (CI) 0.67 to 0.87), indicating substantial agreement. At six weeks after injury, patients whose fractures united had a significantly higher median score than those who developed nonunion (10 vs 7; p < 0.001). A receiver operating characteristic curve determined that a RUSHU cut-off of < 8 was predictive of nonunion (area under the curve = 0.84, 95% CI 0.74 to 0.94). The sensitivity was 75% and specificity 80% with a positive predictive value (PPV) of 65% and a negative predictive value of 86%. Patients with a RUSHU < 8 (n = 23) were more likely to develop nonunion than those with a RUSHU ≥ 8 (n = 37, odds ratio 12.0, 95% CI 3.4 to 42.9). Based on a PPV of 65%, if all patients with a RUSHU < 8 underwent fixation, the number of procedures needed to avoid one nonunion would be 1.5. Conclusion. The RUSHU is reliable and effective in identifying patients at risk of nonunion of a humeral shaft fracture at six weeks after injury. This tool requires external validation but could potentially reduce the morbidity associated with delayed treatment of an established nonunion. Cite this article: Bone Joint J 2019;101-B:1300–1306

Aims. Osteopetrosis (OP) is a rare hereditary disease that causes reduced bone resorption and increased bone density as a result of osteoclastic function defect. Our aim is to review the difficulties, mid-term follow-up results, and literature encountered during the treatment of OP. Methods. This is a retrospective and observational study containing data from nine patients with a mean age of 14.1 years (9 to 25; three female, six male) with OP who were treated in our hospital between April 2008 and October 2018 with 20 surgical procedures due to 17 different fractures. Patient data included age, sex, operating time, length of stay, genetic type of the disease, previous surgery, fractures, complications, and comorbidity. Results. The mean follow-up period was 92.5 months (25 to 140). Bony union was observed in all of our patients. Osteomyelitis developed in two patients with femoral shaft fractures, and two patients had peri-implant stress fractures. Conclusion. Treatment of fractures in OP patients is difficult, healing is protracted, and the risk of postoperative infection is high. In children and young adults with OP who have open medullary canal and the epiphyses are not closed, fractures can be treated with surgical techniques such as intramedullary titanium elastic nail (TENS) technique or fixation with Kirschner (K)-wire. Cite this article: Bone Joint J 2020;102-B(8):1082–1087

Aims. We compared implant and patient survival following intraoperative periprosthetic femoral fractures (IOPFFs) during primary total hip arthroplasty (THA) with matched controls. Patients and Methods. This retrospective cohort study compared 4831 hips with IOPFF and 48 154 propensity score matched primary THAs without IOPFF implanted between 2004 and 2016, which had been recorded on a national joint registry. Implant and patient survival rates were compared between groups using Cox regression. Results. Ten-year stem survival was worse in the IOPFF group (p < 0.001). Risk of revision for aseptic loosening increased 7.2-fold following shaft fracture and almost 2.8-fold after trochanteric fracture (p < 0.001). Risk of periprosthetic fracture of the femur revision increased 4.3-fold following calcar-crack and 3.6-fold after trochanteric fracture (p < 0.01). Risk of instability revision was 3.6-fold after trochanteric fracture and 2.4-fold after calcar crack (p < 0.001). Risk of 90-day mortality following IOPFF without revision was 1.7-fold and 4.0-fold after IOPFF with early revision surgery versus uncomplicated THA (p < 0.001). Conclusion. IOPFF increases risk of stem revision and mortality up to ten years following surgery. The risk of revision depends on IOPFF subtype and mortality risk increases with subsequent revision surgery. Surgeons should carefully diagnose and treat IOPFF to minimize fracture progression and implant failure. Cite this article: Bone Joint J 2019;101-B:1199–1208

Aims. Type IIIB open tibial fractures are devastating high-energy injuries. At initial debridement, the surgeon will often be faced with large bone fragments with tenuous, if any, soft-tissue attachments. Conventionally these are discarded to avoid infection. We aimed to determine if orthoplastic reconstruction using mechanically relevant devitalized bone (ORDB) was associated with an increased infection rate in type IIIB open tibial shaft fractures. Patient and Methods. This was a consecutive cohort study of 113 patients, who had sustained type IIIB fractures of the tibia following blunt trauma, over a four-year period in a level 1 trauma centre. The median age was 44.3 years (interquartile range (IQR) 28.1 to 65.9) with a median follow-up of 1.7 years (IQR 1.2 to 2.1). There were 73 male patients and 40 female patients. The primary outcome measures were deep infection rate and number of operations. The secondary outcomes were nonunion and flap failure. Results. In all, 44 patients had ORDB as part of their reconstruction, with the remaining 69 not requiring it. Eight out of 113 patients (7.1%) developed a deep infection (ORDB 1/44, non-ORDB 7/69). The median number of operations was two. A total of 16/242 complication-related reoperations were undertaken (6.6%), with 2/16 (12.5%) occurring in the ORDB group. Conclusion. In the setting of an effective orthoplastic approach to type IIIB open diaphyseal tibial fractures, using mechanically relevant debrided devitalized bone fragments in the definitive reconstruction appears to be safe. Cite this article: Bone Joint J 2019;101-B:1002–1008

We performed a retrospective review of all patients admitted to two large University Hospitals in the United Kingdom over a 24-month period from January 2008 to January 2010 to identify the incidence of atypical subtrochanteric and femoral shaft fractures and their relationship to bisphosphonate treatment. Of the 3515 patients with a fracture of the proximal femur, 156 fractures were in the subtrochanteric region. There were 251 femoral shaft fractures. The atypical fracture pattern was seen in 27 patients (7%) with 29 femoral shaft or subtrochanteric fractures. A total of 22 patients with 24 atypical fractures were receiving bisphosphonate treatment at the time of fracture. Prodromal pain was present in nine patients (11 fractures); 11 (50%) of the patients on bisphosphonates suffered 12 spontaneous fractures, and healing of these fractures was delayed in a number of patients. This large dual-centre review has established the incidence of atypical femoral fractures at 7% of the study population, 81% of whom had been on bisphosphonate treatment for a mean of 4.6 years (0.04 to 12.1). This study does not advocate any change in the use of bisphosphonates to prevent fragility fractures but attempts to raise awareness of this possible problem so symptomatic patients will be appropriately investigated. However, more work is required to identify the true extent of this new and possibly increasing problem

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

Tibial tubercle osteotomy (TTO) facilitates surgical exposure and protects the extensor mechanism during revision total knee arthroplasty (rTKA). The purpose of this study was to determine the rates of bony union, complications, and reoperations following TTO during rTKA, to assess the functional outcomes of rTKA with TTO at two years’ minimum follow-up, and to identify the risk factors of failure.

1. The frequency of variable degrees of ischaemia of soft tissue in closed tibial and fibular shaft fractures is emphasised. 2. Two cases with ischaemia of calf musculature are described. 3. A follow-up study of 100 cases of closed tibial shaft fractures is analysed; ten patients were found to be affected. 4. The anatomical and pathological changes are discussed. 5. A plea is made for early surgical exploration in cases manifesting signs of ischaemia

1. The combination of femoral shaft fracture with dislocation of the hip in the same limb has been recorded in eighty-one patients since 1823. 2. A further fourteen cases are reported. 3. In over half the cases the hip dislocation was diagnosed late or not at all, and this error has occurred more often in modern times. The reasons for this are outlined. 4. The diagnostic physical signs of hip dislocation in the presence of a femoral shaft fracture are described. 5. The mechanism, sequels and treatment of this combined injury are discussed