1. A study of the late results of 343 soundly united tibial shaft fractures was carried out. Limitation of ankle and/or foot movement occurred in twenty-one patients (6 per cent) and was found to be the most important cause of disability. Knee stiffness (2·3 per cent of cases) and shortening of up to three-quarters of an inch (5·5 per cent of cases) caused little functional impairment.

2. Stiffness of the foot and ankle was correlated with the severity of injury, occurring in 1 per cent of minor, 5 per cent of moderate and 22 per cent of major injuries.

3. One-third of the patients with limitation of foot and ankle movement had clinical evidence of ischaemic contracture.

4. It is argued that, in the absence of direct injury to the joint, persistent joint stiffness is caused by replacement fibrosis of soft tissues. This may result either from direct tissue injury or from associated vascular damage.

1. The Moe plate has been used in 256 of 270 consecutive intertrochanteric fractures of the femur. There was an operative mortality of l8·8 per cent and an overall mortality of 20·7 per cent in a group averaging 75·2 years of age.

2. The method proved satisfactory, giving secure fixation and also approximation of the fragments by the lag action of the three large screws driven into the head. There was only one case of non-union.

3. In the survivors anatomical and functional results have been satisfactory in about 70 per cent, with half of these showing full functional recovery and the other half requiring only occasional use of a stick or crutch.

4. There are a few intertrochanteric fractures of the femur too comminuted for any form of internal fixation. Traction should be used in this group.

5. A varus deformity developed in about one half of the cases. This is consistent with a good functional result.

6. The main difficulty in these aged people has been survival. The problems have been discussed with suggestions that may perhaps reduce in part a mortality that seems inherent in this injury and at this age.

We adduce the following conclusions from our experience of using this spring-loaded compression screw on completely displaced medial fractures of the femoral neck:

1. That this method probably eliminates non-union when the head is fully viable.

2. That primary "first-intention" osseous union occurs in approximately 33·3 per cent of cases.

3. That a vascular complication, of varying severity, undetectable by orthodox radiological tests, is revealed by extrusion of the screw in 66·6 per cent of cases.

4. That these observations disprove the idea that the main obstacle to revascularisation of an ischaemic head is the existence of forces so inclined to the axis of the femoral neck as to cause "shear."

5. That, compared with the Smith-Petersen nail used for completely displaced fractures, continuous spring compression can materially reduce the incidence of utter mechanical failure within the first year after operation. This is the result of "mushroom" impaction which itself can resist shearing strain and so can permit function as a fibrous union.

6. That early and rapid extrusion is a sensitive indication of a vascular complication in the head. Forewarned by this, activity can be restricted, or possibly other measures adopted, to anticipate or permanently postpone serious trouble.

1. A case of spontaneous fracture of a first rib is described.

2. Its evolution from a previously intact rib through the stage of a "linear" crack to pseudarthrosis has been traced.

3. An older pseudarthrosis was present on the opposite side.

4. Alderson's observation is confirmed—that the breach in the rib is acquired. There is no need to suppose a developmental anomaly of ossification, even in a bilateral case.

Aims. Using tibial shaft fracture participants from a large, multicentre randomized controlled trial, we investigated if patient and surgical factors were associated with health-related quality of life (HRQoL) at one year post-surgery. Methods. The Study to Prospectively Evaluate Reamed Intramedullary Nails in Patients with Tibial Fractures (SPRINT) trial examined adults with an open or closed tibial shaft fracture who were treated with either reamed or unreamed intramedullary nails. HRQoL was assessed at hospital discharge (for pre-injury level) and at 12 months post-fracture using the Short Musculoskeletal Functional Assessment (SMFA) Dysfunction, SMFA Bother, 36-Item Short Form 36 (SF-36) Physical, and SF-36 Mental Component scores. We used multiple linear regression analysis to determine if baseline and surgical factors, as well as post-intervention procedures within one year of fracture, were associated with these HRQoL outcomes. Significance was set at p < 0.01. We hypothesize that, irrespective of the four measures used, prognosis is guided by both modifiable and non-modifiable factors and that patients do not return to their pre-injury level of function, nor HRQoL. Results. For patient and surgical factors, only pre-injury quality of life and isolated fracture showed a statistical effect on all four HRQoL outcomes, while high-energy injury mechanism, smoking, and race or ethnicity, demonstrated statistical significance for three of the four HRQoL outcomes. Patients who did not require reoperation in response to infection, the need for bone grafts, and/or the need for implant exchanges had statistically superior HRQoL outcomes than those who did require intervention within one year after initial tibial fracture nailing. Conclusion. We identified several baseline patient factors, surgical factors, and post-intervention procedures within one year after intramedullary nailing of a tibial shaft fracture that may influence a patient’s HRQoL. Cite this article: Bone Jt Open 2021;2(1):22–32

We have reviewed a series of 56 consecutive patients treated by the Ilizarov circular fixator for various combinations of nonunion, malunion and infection of fractures. We used segmental excision, distraction osteogenesis and gradual correction of the deformity as appropriate.

Treatment was effective in eliminating 40 out of 46 nonunions and all 22 infections. There were two cases of refracture some months after removal of the frame, both of which healed securely in a second frame. Correction of malunion was good in the coronal plane but there was a tendency to anterior angulation, often occurring in the regenerate bone rather than at the original fracture site, after removal of the frame. This was associated with very slow maturation of regenerate bone in some patients, occurring largely, but not exclusively, in those who smoked heavily.

Patients expressed high levels of satisfaction with the outcome, despite relatively modest improvements in pain and function, presumably because their longstanding and intractable nonunion had been treated. None the less, the degree of satisfaction correlated strongly with the degree of improvement in pain and function.

We emphasise the importance of a multidisciplinary team in the assessment and support of patients undergoing long and demanding treatment. The Ilizarov method is valuable, but research is needed to overcome the problems of delayed maturation of the regenerate and slow or insecure healing of the docking site.

We reviewed the surgical treatment and oncological results of 40 patients with pathological fractures from localised osteosarcoma of the long bones to determine the outcome of limb salvage in their management. All had had adjuvant chemotherapy. There were 26 males and 14 females with a median age at diagnosis of 18 years (2 to 46) and a median follow-up of 55 months (8 to 175).

We performed limb salvage in 27 patients and amputation in 13. The margins of resection were radical in five patients, wide in 26, marginal in six, wide but contaminated in two and intralesional in one. Local recurrence developed in 19% of those treated by limb salvage and in none of those who had an amputation. The cumulative five-year survival of all the patients was 57% and in those treated by limb salvage or amputation it was 64% and 47%, respectively (p > 0.05).

Limb-sparing surgery with adequate margins of excision can be achieved in many patients with pathological fractures from primary osteosarcoma without compromising survival, but the risk of local recurrence is significant.

We performed a prospective, randomised study on 50 patients with Tscherne C1 tibial diaphyseal fractures comparing treatment with reamed and unreamed intramedullary nails. Our results show that reamed nailing is associated with a significantly lower time to union and a reduced requirement for a further operation. Unreamed nailing should not be used in the treatment of the common Tscherne C1 tibial fracture.

In a prospective, randomised trial of 81 patients with fractures of the ankle of AO types A, B and C we compared two regimes of postoperative management after internal fixation. The patients were mobilised either non-weight-bearing with crutches or weight-bearing in a below-knee walking plaster.

We found a temporary benefit in subjective evaluation only (65 v 50 points, Mann-Whitney test, cft, p = 0.02) for those with a below-knee walking plaster. There were no significant differences between the groups in the loaded dorsal range of movement (25° v 23°, Mann-Whitney test, cft, p = 0.16) or in the overall clinical result. Both treatments were considered to be satisfactory and their choice depends on the ability to mobilise non-weight-bearing, wound healing, the type of work and personal preference.

We performed a prospective, randomised controlled trial of the operative versus non-operative treatment of 42 displaced fractures of the distal femur in elderly patients.

Excellent or good results were achieved in 53% of the operated group and in 31% of the non-operated group. There were more complications in the latter, and the time to discharge was considerably longer.