Infected nonunion of a long bone continues to present difficulties in management. In addition to treating the infection, it is necessary to establish bony stability, encourage fracture union and reconstruct the soft-tissue envelope. We present a series of 67 infected nonunions of a long bone in 66 patients treated in a multidisciplinary unit. The operative treatment of patients suitable for limb salvage was performed as a single procedure. Antibiotic regimes were determined by the results of microbiological culture. At a mean follow-up of 52 months (22 to 97), 59 patients (88%) had an infection-free united fracture in a functioning limb. Seven others required amputation (three as primary treatment, three after late failure of limb salvage and one for recalcitrant pain after union). The initial operation achieved union in 54 (84%) of the salvaged limbs at a mean of nine months (three to 26), with recurrence of infection in 9%. Further surgery in those limbs that remained ununited increased the union rate to 62 (97%) of the 64 limbs treated by limb salvage at final follow-up. The use of internal fixation was associated with a higher risk of recurrent infection than external fixation. Cite this article: Bone Joint J 2015; 97-B:814–17

The treatment of infected nonunions is difficult. Antibiotic cement-coated (ACC) rods provide stability as well as delivering antibiotics. We conducted a review of 110 infected nonunions treated with ACC rods. Patients were divided into two groups: group A (67 patients) with an infected arthrodesis, and group B (43 patients) with an infected nonunion in a long bone. In group A, infected arthrodesis, the success rate after the first procedure was 38/67 (57%), 29/67 (43%) required further surgery for either control of infection or non-union. At last follow-up, five patients required amputation, representing a limb salvage rate of 62/67 (93%) overall. In all, 29/67 (43%) presented with a bone defect with a mean size of 6.78 cm (2 to 25). Of those with a bone defect, 13/29 (45%) required further surgery and had a mean size of defect of 7.2 cm (3.5 to 25). The cultures were negative in 17/67 (26%) and the most common organism cultured was methicillin-resistant staphylococcus aureus (MRSA) (23/67, (35%)). In group B, long bones nonunion, the success rate after the first procedure was 26/43 (60%), 17/43 (40%) required further surgery for either control of infection or nonunion. The limb salvage rate at last follow-up was 43/43 (100%). A total of 22/43 (51%) had bone defect with a mean size of 4.7 cm (1.5 to 11.5). Of those patients with a bone defect, 93% required further surgery with a mean size of defect of 5.4 cm (3 to 8.5). The cultures were negative in 10/43 (24%) and the most common organism cultured was MRSA, 15/43 (35%). ACC rods are an effective form of treatment for an infected nonunion, with an acceptable rate of complications. Cite this article: Bone Joint J 2014; 96-B:1349–54

We investigated the fracture-free survival of long bones stabilised by a telescopic intramedullary rod (TIMR) in patients with osteogenesis imperfecta with respect to the remodelling status of fracture or osteotomy sites and TIMR regions, in order to identify risk factors for fracture. A total of 44 femora and 28 tibiae in 25 patients with a mean age of 5.0 years (1.9 to 10.5) at presentation were studied. There were six patients with Sillence type I, five with type III, 13 with type IV and one with type V osteogenesis imperfecta. All received bisphosphonate treatment at the same stage during the mean follow-up of 7.3 years (0.5 to 18.1). The fracture-free survival was estimated at 6.2 years (95% confidence interval 5.1 to 7.3) by Kaplan-Meier analysis. More than half the fracture or osteotomy sites remained in a less-remodelled state at the latest follow-up or time of fracture. Of the 33 fractures, 29 (87.9%) occurred in long bones containing a less-remodelled site, and these fractures were located at this site. The relative fracture risk at the rod tip was significantly greater than in any other TIMR region (p < 0.001), and this was higher in bone segments having a less-remodelled site. This study shows a persistent fracture risk in TIMR-stabilised long bones, especially at less-remodelled fracture or osteotomy sites and at the rod tip

The Chevron osteotomy was described in 1976. There have, however, been only short- to mid-term follow-up reviews, often with small numbers of patients. We looked at 112 feet (73 patients) with a minimum follow-up of ten years following Chevron osteotomy with a distal soft-tissue procedure. Clinical evaluation was calculated using the hallux score of the American Orthopedic Foot and Ankle Society (AOFAS). For 47 feet (30 patients), the results were compared with those from an interim follow-up of 5.6 years. The AOFAS-score improved from a pre-operative mean of 46.5 points to a mean of 88.8 points after a mean of 12.7 years. The first metatarsophalangeal (MTP) angle showed a mean pre-operative value of 27.6° and was improved to 14.0°. The first intermetatarsal (IM) angle improved from a pre-operative mean value of 13.8° to 8.7°. The mean pre-operative grade of sesamoid subluxation was 1.7 on a scale from 0 to 3 and improved to 1.2. Measured on a scale from 0 to 3, arthritis of the first MTP joint progressed from a mean of 0.8 to 1.7. Comparing the results in patients younger and older than 50 years, the Chevron osteotomy performed equally in both age groups. Analysing the subgroup of 47 feet with a post-operative follow-up of both 5.6 and 12.7 years, the AOFAS pain and the overall score showed a further improvement between both follow-up evaluations. The MTP angle, first IM angle and sesamoid position remained unchanged. The progression of arthritis of the first MTP joint between 5.6 and 12.7 years post-operatively was statistically significant. Only one patient required a revision procedure due to painful recurrence of the deformity. Excellent clinical results following Chevron osteotomy not only proved to be consistent, but showed further improvement over a longer follow-up period. The mean radiographic angles were constant without recurrence of the deformity. So far, the statistically significant progression of first MTP joint arthritis has not affected the clinical result, but this needs further observation

This retrospective study analyses the results of subtalar bone block distraction arthrodesis used in the treatment of late complications of calcaneal fractures, acute severely comminuted fractures, nonunion (and malunion) of attempted subtalar arthrodeses, avascular necrosis of the talus, and club-foot deformity. Of 39 patients (41 feet) who had this procedure, 35 (37 feet) returned for follow-up after a mean of 70 months (26 to 140). There were 24 men (25 feet) and 11 women (12 feet) with a mean age of 41 years (16 to 63). Each completed a standardised questionnaire, based on the hindfoot-scoring system of the American Orthopaedic Foot and Ankle Society and were reviewed both clinically and radiologically. Of the 37 operations, 32 (87%) achieved union. The mean hindfoot score (maximum of 94 points) increased from 21.1 points (8 to 46) preoperatively to 68.9 (14 to 82) at the final follow-up. The mean talocalcaneal and calcaneal pitch angles were 20.5° and 4.9° before operation, 25.9° and 8.3° immediately after, and 24.6° and 7.7° at the final follow-up, respectively. The mean talar declination angle improved from 6.5° (−10 to 22) before operation to 24.8° (14 to 32) at the final follow-up. The mean talocalcaneal height increased from 68.7 mm before operation to 74.5 mm immediately after and 73.5 mm at the final follow-up. Of the 37 arthrodeses available for review, 32 were successful; 29 patients (30 arthrodeses) were satisfied with the procedure. Minimal loss of hindfoot alignment occurred when comparing radiographs taken immediately after operation and at final follow-up

Intramedullary infection in long bones represents a complex clinical challenge, with an increasing incidence due to the increasing use of intramedullary fixation. We report a prospective case series using an intramedullary reaming device, the Reamer–Irrigator–Aspirator (RIA) system, in association with antibiotic cement rods for the treatment of lower limb long bone infections. A total of 24 such patients, 16 men and eight women, with a mean age of 44.5 years (17 to 75), 14 with femoral and 10 with tibial infection, were treated in a staged manner over a period of 2.5 years in a single referral centre. Of these, 21 patients had had previous surgery, usually for fixation of a fracture (seven had sustained an open fracture originally and one had undergone fasciotomies). According to the Cierny–Mader classification system, 18 patients were classified as type 1A, four as 3A (discharging sinus tract), one as type 4A and one as type 1B. Staphylococcus species were isolated in 20 patients (83.3%). Local antibiotic delivery was used in the form of impregnated cement rods in 23 patients. These were removed at a mean of 2.6 months (1 to 5). Pathogen-specific antibiotics were administered systemically for a mean of six weeks (3 to 18). At a mean follow-up of 21 months (8 to 36), 23 patients (96%) had no evidence of recurrent infection. One underwent a planned trans-tibial amputation two weeks post-operatively due to peripheral vascular disease and chronic recalcitrant osteomyelitis of the tibia and foot. The combination of RIA reaming, the administration of systemic pathogen-specific antibiotics and local delivery using impregnated cement rods proved to be a safe and efficient form of treatment in these patients. Cite this article: Bone Joint J 2014; 96-B:783–8

We performed a prospective study to assess the long-term outcome of 57 arthroscopic debridement procedures carried out to treat anterior impingement in the ankle. Using preoperative radiographs, we grouped patients according to the extent of their osteoarthritis (OA). The symptoms of those with grade-0 changes could be attributed to anterior soft-tissue impingement alone. Patients with grade-I disease had both anterior soft-tissue and osteophytic impingement, but no narrowing of the joint space. In those with grade-II OA, narrowing of the joint space was accompanied by osteophytic impingement. Radiographs taken before and after operation and at follow-up were compared to assess the recurrence of osteophytes and the progression of narrowing of the joint space. At a mean follow-up of 6.5 years (5 to 8) all patients without OA had excellent or good results. There were excellent or good results in 77% of patients with grade-I OA, despite partial or complete recurrence of osteophytes in two-thirds. In most patients with grade-II OA, narrowing of the joint space had not progressed at follow-up. There was a notable improvement in pain in these patients, 53% of whom had excellent or good results. Although some osteophytes recurred, at long-term follow-up arthroscopic excision of soft-tissue overgrowths and osteophytes proved to be an effective way of treating anterior impingement of the ankle in patients who had no narrowing of the joint space

Autologous chondrocyte implantation (ACI) has been used most commonly as a treatment for cartilage defects in the knee and there are few studies of its use in other joints. We describe ten patients with an osteochondral lesion of the talus who underwent ACI using cartilage taken from the knee and were prospectively reviewed with a mean follow-up of 23 months. In nine patients the satisfaction score was ‘pleased’ or ‘extremely pleased’, which was sustained at four years. The mean Mazur ankle score increased by 23 points at a mean follow-up of 23 months. The Lysholm knee score returned to the pre-operative level at one year in three patients, with the remaining seven showing a reduction of 15% at 12 months, suggesting donor-site morbidity. Nine patients underwent arthroscopic examination at one year and all were shown to have filled defects and stable cartilage. Biopsies taken from graft sites showed mostly fibrocartilage with some hyaline cartilage. The short-term results of ACI for osteochondral lesions of the talus are good despite some morbidity at the donor site

We reviewed 116 patients who underwent 118 arthroscopic ankle arthrodeses. The mean age at operation was 57 years, 2 months (20 to 86 years). The indication for operation was post-traumatic osteoarthritis in 67, primary osteoarthritis in 36, inflammatory arthropathy in 13 and avascular necrosis in two. The mean follow-up was 65 months (18 to 144). Nine patients (10 ankles) died before final review and three were lost to follow-up, leaving 104 patients (105 ankles) who were assessed by a standard telephone interview. The pre-operative talocrural deformity was between 22° valgus and 28° varus, 94 cases were within 10° varus/valgus. The mean time to union was 12 weeks (6 to 20). Nonunion occurred in nine cases (7.6%). Other complications included 22 cases requiring removal of a screw for prominence, three superficial infections, two deep vein thromboses/pulmonary emboli, one revision of fixation, one stress fracture and one deep infection. Six patients had a subtalar fusion at a mean of 48 months after ankle fusion. There were 48 patients with excellent, 35 with good, 10 with fair and 11 with poor clinical results

We present the results of the surgical correction of lower-limb deformities caused by metabolic bone disease. Our series consisted of 17 patients with a diagnosis of hypophosphataemic rickets and two with renal osteodystrophy; their mean age was 25.6 years (14 to 57). In all, 43 lower-limb segments (27 femora and 16 tibiae) were osteotomised and the deformity corrected using a monolateral external fixator. The segment was then stabilised with locked intramedullary nailing. In addition, six femora in three patients were subsequently lengthened by distraction osteogenesis. The mean follow-up was 60 months (18 to 120). The frontal alignment parameters (the mechanical axis deviation, the lateral distal femoral angle and the medial proximal tibial angle) and the sagittal alignment parameters (the posterior distal femoral angle and the posterior proximal tibial angle) improved post-operatively. The external fixator was removed either at the end of surgery or at the end of the lengthening period, allowing for early mobilisation and weight-bearing. We encountered five problems and four obstacles in the programme of treatment. The use of intramedullary nails prevented recurrence of deformity and refracture

We assessed the long-term outcome of open debridement for the treatment of anterior impingement of the ankle in 27 patients. By using preoperative radiographs to group patients according to both the McDermott and the van Dijk scoring system, we assessed the accuracy of these classifications in predicting outcome. The Ogilvie-Harris scoring system, a visual analogue scale of patient satisfaction, the time to return to full activities, and the ability to return to sports determined the clinical outcome. Follow-up radiographs were used to assess the recurrence of osteophytes. We also assessed the incidence of talar osteochondral lesions at surgery. At a mean follow-up of 7.3 years, 23 of 25 patients (92%) without joint-space narrowing had a good or excellent result. Improvement in the Ogilvie-Harris score was seen in all patients. In athletes, 19 of 24 (79%) were able to return to sports at the same level. Two patients with preoperative joint-space narrowing had a poor result. Osteophytes usually recurred and most patients did not feel that the range of dorsiflexion returned to normal, but symptomatic relief allowed most to return to high-level sport. Our results for non-arthritic joints suggest that this is a safe and successful procedure

We prospectively reviewed 24 patients (35 feet) who had been treated by a Scarf osteotomy and Akin closing-wedge osteotomy for hallux valgus between June 2000 and June 2002. There were three men and 21 women with a mean age of 46 years at the time of surgery. The mean follow-up time was 20 months. Our results showed that 50% of the patients were very satisfied, 42% were satisfied, and 8% were not satisfied. The mean American Orthopaedic Foot and Ankle Society score improved significantly from 52 points pre-operatively to 89 at follow-up (p < 0.001). The intermetatarsal and hallux valgus angles improved from the mean pre-operative values of 15° and 33° to 9° and 14°, respectively. These improvements were significant (p < 0.0001). The change in the distal metatarsal articular angle was not significant (p = 0.18). There was no significant change in the mean pedobarographic measurements of the first and second metatarsals after surgery (p = 0.2). The mean pedobarographic measurements of the first and second metatarsals at more than one year after surgery were within the normal range. Two patients had wound infections which settled after the administration of antibiotics. One patient had an intra-operative fracture of the first metatarsal and one required further surgery to remove a long distal screw which was irritating the medial sesamoids. We conclude that the Scarf osteotomy combined with the Akin closing-wedge osteotomy is safe and effective for the treatment of hallux valgus

We have studied 105 patients with 107 acute, primary, dislocations of the glenohumeral joint seen between January 1, 1991 and July 1, 1994. The mean time of follow-up was 71 months (46 to 91). In 34% the injury occurred during a sports activity and in 28% at home. The bias toward sport was even greater in patients less than 40 years of age, and in men. In patients older than 40 years of age, and in women, the dislocation occurred more often at home. The overall probability of recurrence within four years was 26%. Age was the most significant prognostic factor in recurrence which took place in 64% of patients less than 20 years of age and in 6% of those older than 40 years. Statistically, there was no difference between the rates of recurrence in patients who were active in sport and those who were not. The mean Rowe score for the whole group was 87 (15 to 100). Associated fractures were found in 20 patients (19%) and nerve injuries in 22 (21%). None of those in whom a fracture of the greater tuberosity was seen subsequently suffered a recurrent dislocation. At follow-up we found that 36 patients (34%) had not returned to their former employment but in only 2% was this owing to the injured shoulder

In this retrospective study we have assessed the results of low tibial valgus osteotomy for varus-type osteoarthritis of the ankle and its indications. We performed an opening wedge osteotomy in 25 women (26 ankles). The mean follow-up was for eight years and three months (2 years 3 months to 17 years 11 months). Of the 26 ankles, 19 showed excellent or good clinical results. Their mean scores for pain, walking, and activities of daily living were significantly improved but there was no change in the range of movement. In the ankles which were classified radiologically as stage 2 according to our own grading system, with narrowing of the medial joint space, and in 11 as stage 3a, with obliteration of the joint space at the medial malleolus only, the joint space recovered. In contrast, such recovery was seen in only two of 12 ankles classified as stage 3b, with obliteration of the joint space advancing to the upper surface of the dome of the talus. Low tibial osteotomy is indicated for varus-type osteoarthritis of stage 2 or stage 3a

The treatment of osteochondral lesions of the talus has evolved with the development of improved imaging and arthroscopic techniques. However, the outcome of treatment for large cystic type-V lesions is poor, using conventional grafting, debridement or microfracture techniques. This retrospective study examined the outcomes of 50 patients with a cystic talar defect who were treated with arthroscopically harvested, cored osteochondral graft taken from the ipsilateral knee. Of the 50 patients, 45 (90%) had a mean good to excellent score of 80.3 (52 to 90) in the Karlsson-Peterson Ankle Score, at a mean follow-up of 36 months (24 to 83). A malleolar osteotomy for exposure was needed in 26 patients and there were no malleolar mal- or nonunions. One patient had symptoms at the donor site three months after surgery; these resolved after arthroscopic release of scar tissue. This technique is demanding with or without a malleolar osteotomy, but if properly performed has a high likelihood of success

We describe the results of arthrodesis for the treatment of recurrent acute neuropathic bone disease in 24 feet and of chronic disease with deformity in 91 feet, undertaken between January 1984 and December 2003. All were due to leprosy. Correction of the deformity was achieved in 80 of 106 feet (76%) and fusion in 97 of 110 feet (88%). In the 24 feet in which recurrent neuropathic bone disease was the reason for surgery, 17 (71%) obtained stability while in seven (29%) symptoms recurred postoperatively. Complications were experienced following 58 of the 110 operations (53%). In patients presenting primarily with deformity with a minimum follow-up of two years (79 feet), there was a reduced frequency of ulceration in 40 (51%). Normal footwear could be worn by 32 patients (40%) after surgery, while 40 (51%) required a moulded insole. Arthrodesis of the ankle in the neuropathic foot due to leprosy has a good overall rate of success although the rate of complications is high

Fragility fractures of the ankle occur mainly in elderly osteoporotic women. They are inherently unstable and difficult to manage. There is a high incidence of complications with both non-operative and operative treatment. We treated 12 such fractures by closed reduction and stabilisation using a retrograde calcaneotalotibial expandable nail. The mean age of patients was 84 years (75 to 95). All were women and were able to walk fully weight-bearing after surgery. There were no wound complications. One patient died from a myocardial infarction 24 days after surgery. The 11 other patients were followed up for a mean of 67 weeks (39 to 104). All the fractures maintained satisfactory alignment and healed without delay. Six patients refused removal of the nail after union of the fracture. The functional rating using the scale of Olerud and Molander gave a mean score at follow-up of 61, compared with a pre-injury value of 70

The results of primary total knee replacement performed on a group of haemophiliac patients in a single institution by the same surgeon using the same surgical technique and prosthesis are reported. A total of 35 primary replacements in 30 patients were carried out between 1996 and 2005 and were reviewed retrospectively. The mean age of the patients was 31 years (24 to 42) and the mean follow-up was for 7.5 years (1 to 10). There were 25 patients with haemophilia A and five with haemophilia B. The HIV status and CD4 count were recorded, and Knee Society scores determined. Two patients had inhibitors to the deficient coagulation factor. There were no early wound infections and only one late deep infection which required a two-stage revision arthroplasty, with a good final result. The incidence of infection in HIV-positive and negative patients was thus similar. One knee in a patient with inhibitor had excessive bleeding due to a pseudoaneurysm which required embolisation. The results were excellent in 27 knees (77%), good in six (17%) and fair in two (6%). The survival rate at 7.5 years taking removal of the prosthesis for loosening or infection as the end-point was 97%. The mechanical survival of total knee replacements in haemophiliacs is very good. Our results confirm that this is a reproducible procedure in haemophilia, even in HIV-positive patients with a CD4 count > 200 mm. 3. and those with inhibitors. Our rate of infection was lower than previously reported. This could be due to better control of the HIV status with highly active anti-retroviral therapy and the use of antibiotic-loaded cement

Aims

Patients undergoing femoral lengthening by external fixation tolerate treatment less well when compared to tibial lengthening. Lengthening of the femur with an intramedullary device may have advantages.

Aims

This study describes the Osseointegration Group of Australia’s Accelerated Protocol two-stage strategy (OGAAP-1) for the osseointegrated reconstruction of amputated limbs.