Aims

Varus-valgus constrained (VVC) implants are often used during revision total knee arthroplasty (TKA) to gain coronal plane stability. However, the increased mechanical torque applied to the bone-cement interface theoretically increases the risk of aseptic loosening. We assessed mid-term survivorship, complications, and clinical outcomes of a fixed-bearing VVC device in revision TKAs.

The tissue surrounding carbon fibre reinforced epoxy resin plates applied to forearm and tibial fractures was biopsied in 32 patients at the time the plates were removed. The reaction was minimal and was compared with that in a control group of 16 similar patients in whom stainless steel plates were used. No significant histological differences were found. A series of experiments on rats, in which the histology was studied from 2 to 78 weeks, also showed that there was very little reaction to carbon fibre reinforced plastic

1. One hundred and eighty-one fractures of the tibial shaft were treated by rigid fixation using conventional plates. 2. Comparison is made with series of fractures treated by the closed method. 3. The incidence of non-union, or delayed union requiring a long period of plaster immobilisation, was found to be less with the open method of treatment. 4. Plating was also found to give better functional results with a shorter period of disability except in severe open fractures. 5. Plating is a valuable method of treatment for tibial fractures in the elderly

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.

Intramedullary rods manufactured from polyacetal were used to fix diaphyseal fractures in osteoporotic bone. They are pliable and can be introduced without further damage to such bone. Their low elastic modulus induces abundant callus. They can be locked with cortical bone screws without the need of jigs or radiographic control. Nine femoral and five tibial fractures were fixed in 10 patients, all with osteoporosis; 13 united primarily; one required bone grafting. No implant broke; however, no ambulant patient weighed more than 75 kg. The rods offer a promising treatment for diaphyseal fractures in osteoporotic bone

Fifty-five adults who had sustained a tibial fracture, or a femoral fracture, or both, were subjected to a double-blind randomised study to determine the efficacy of methylprednisolone in treating the fat embolism syndrome. This drug maintained arterial oxygen levels, stabilised or reduced the serum level of free fatty acids, and decreased the risk of the fat embolism syndrome in a statistically significant proportion of patients. Gurd's criteria for the diagnosis of the fat embolism syndrome were found inadequate. Other more sensitive criteria for early diagnosis and effective management were determined. There were no deaths or serious morbidity in our series

1. A series of 102 cancellous strip grafts for delayed union of long bone fractures has been reviewed. 2. Half of the initial injuries were open. 3. Half of the fractures were butterfly or segmental lesions or were comminuted. 4. After strip grafting 84 per cent of the fractures were united within sixteen weeks, and only four took longer than twenty weeks. 5. Complete failure of union occurred in only one case, a tibial fracture complicated by low-grade pyocyaneus osteomyelitis. 6. A more aggressive attitude to the problem of delayed union is advocated

There is concern about the incidence and serious nature of infection after intramedullary nailing of the tibia, especially for open injuries. We have reviewed 459 patients with tibial fractures treated by primary reamed nailing. The incidence of infection was 1.8% in closed and Gustilo type I open fractures, 3.8% in type II, and 9.5% in type III fractures (5.5% in type IIIa, 12.5% in type IIIb). These incidences appear to be acceptable in comparison with other published results. We describe the different modes of presentation of infection in these cases, and suggest a protocol for its management, which has been generally successful in our series

We performed a prospective, randomised trial in 39 patients with open tibial fractures treated initially by external fixation to compare cast immobilisation (group A) and intramedullary nailing (group B) as a sequential protocol planned from the onset of treatment. The results showed that group B achieved faster union (p < 0.05) than group A with less malunion or shortening and a greater range of movement. Patients treated by intramedullary nailing required fewer radiographs and outpatient visits (p = 0.0015) and had a more predictable and rapid return to full function. We feel that these severe fractures are better treated by delayed intramedullary nailing and that this has an acceptable rate of complications

1. Intramedullary nailing in two-level tibial fractures provides the following advantages: it allows walking with full weight-bearing in an average time ofthree to four months; it decreases the rate of non-union ; it decreases the rate of malunion ; it should decrease the rate of infection in closed fractures when compared with other types of internal fixation, due to the technique of blind nailing without exposure of the fracture site. 2. Compound tibia! fractures treated by nailing are still often complicated by infection. Nevertheless, we have not been able to find studies in the literature based on series large enough to permit the conclusion that other methods could lower significantly the infection rate

Objectives

The aim of this study was to review the impact of smoking tobacco on the musculoskeletal system, and on bone fractures in particular.

Exchange nailing for failure of union after primary intramedullary nailing of the tibia is widely used but the indications and effectiveness have not been reported in detail. We have reviewed 33 cases of uninfected nonunion of the tibia treated by exchange nailing. This technique was successful without open bone grafting in all closed fractures and in open fractures of Gustilo types I, II and IIIa. The requirement for open bone grafting was reduced in type-IIIb fractures, but exchange nailing failed in type-IIIb fractures with significant bone loss. For these we recommend early open bone grafting. The most common complication was wound infection, seen more often than after primary nailing. We discuss our protocol for the use and timing of exchange nailing of all grades and types of tibial fracture

In the assessment of fracture healing by monitoring stiffness with vibrational analysis or instrumented external fixators, it has been assumed that there is a workable correlation between stiffness and strength. We used four-point bending tests to study time-related changes in stiffness and strength in healing tibial fractures in sheep. We aimed to test the validity of the measurement of stiffness to assess fracture strength. At each duration of healing examined, we found marked variations in stiffness and strength. Stiffness was shown to be load-dependent: measurements at higher loads reflected ultimate strength more accurately. There was a biphasic relationship between stiffness and strength: at first there was a strong correlation regardless of loading conditions, but in the second phase, which included the period of ‘clinical healing’, stiffness and strength were not significantly correlated. We conclude that the monitoring of stiffness is useful primarily in assessing progress towards union but is inherently limited as an assessment of strength at the time of clinical union. Any interpretation of stiffness must take into account the load conditions

The August 2013 Trauma Roundup. 360 . looks at: reverse oblique fractures do better with a cephalomedullary device; locking screws confer no advantage in tibial plateau fractures; it’s all about the radius of curvature; radius of curvature revisited; radial head replacement in complex elbow reconstruction; stem cells in early fracture haematoma; heterotrophic ossification in forearms; and Boston in perspective

Aims

Metaphyseal fixation during revision total knee arthroplasty (TKA) is important, but potentially difficult when using historical designs of cone. Material and manufacturing innovations have improved the size and shape of the cones which are available, and simplified the required bone preparation. In a large series, we assessed the implant survivorship, radiological results, and clinical outcomes of new porous 3D-printed titanium metaphyseal cones featuring a reamer-based system.

Over 200 high-velocity missile injuries treated in a low-technology environment were audited under the aegis of the International Committee of the Red Cross Hospitals in Afghanistan and Northern Kenya. Femoral fractures were treated either by traction or external fixation using a uniaxial frame. The results showed that patients treated by external fixation remained in hospital longer than those treated on traction. The positional outcome was identical in both groups. In tibial fractures the external fixator was only of extra benefit in those of the lower third when compared with simple plaster slabs unless more complex procedures such as flaps or vascular repair were to be performed. In complex humeral fractures, external fixation resulted in long stays in hospital and a large number of interventions when compared with simple treatment in a sling. We conclude therefore that in an environment where facilities are limited and surgeons have only general experience very careful initial wound excision is the most important factor determining outcome. The application of complex holding techniques was generally inappropriate

We used a rabbit model to investigate the mechanism by which the angulation of fractures is corrected in children. We produced a transverse proximal tibial fracture in one leg of 12 eight-week-old New Zealand white rabbits and measured bone alignment and length and the patterns of bone growth and remodelling. The angle between the joint surfaces changed rapidly to correct the alignment of the limb as a result of asymmetrical growth of epiphyseal plates. In an adult with closed plates, the angle between the joint surfaces cannot therefore improve. The angle at the fracture itself showed slow improvement because of bone drift and the asymmetrical growth of the epiphyseal plates. Remodelling corrected the shape of the bone in the region of the fracture. Periosteal division on the convex side increased the growth of the epiphyseal plate on that side, thus slowing the correction. The effect was relatively small, providing an indication that factors other than the periosteum are important in inducing correction. External torsional deformities developed because of helical growth at the plate. This was probably caused by abnormal posture which induced a torque at the growth plate. Helical growth is the mechanism by which rotational deformities can occur and correct

Implant-related infection is one of the leading reasons for failure in orthopaedics and trauma, and results in high social and economic costs. Various antibacterial coating technologies have proven to be safe and effective both in preclinical and clinical studies, with post-surgical implant-related infections reduced by 90% in some cases, depending on the type of coating and experimental setup used. Economic assessment may enable the cost-to-benefit profile of any given antibacterial coating to be defined, based on the expected infection rate with and without the coating, the cost of the infection management, and the cost of the coating. After reviewing the latest evidence on the available antibacterial coatings, we quantified the impact caused by delaying their large-scale application. Considering only joint arthroplasties, our calculations indicated that for an antibacterial coating, with a final user’s cost price of €600 and able to reduce post-surgical infection by 80%, each year of delay to its large-scale application would cause an estimated 35 200 new cases of post-surgical infection in Europe, equating to additional hospital costs of approximately €440 million per year. An adequate reimbursement policy for antibacterial coatings may benefit patients, healthcare systems, and related research, as could faster and more affordable regulatory pathways for the technologies still in the pipeline. This could significantly reduce the social and economic burden of implant-related infections in orthopaedics and trauma.

Cite this article: C. L. Romanò, H. Tsuchiya, I. Morelli, A. G. Battaglia, L. Drago. Antibacterial coating of implants: are we missing something? Bone Joint Res 2019;8:199–206. DOI: 10.1302/2046-3758.85.BJR-2018-0316.

The risk of articular penetration during tibial nailing is well known, but the incidence of unrecognised damage to joint cartilage has not been described. We have identified this complication in the treatment of tibial fractures, described the anatomical structures at risk and examined the most appropriate site of entry for tibial nailing in relation to the shape of the bone, the design of the nail and the surgical approach. We studied the relationship between the intra-articular structures of the knee and the entry point used for nailing in 54 tibiae from cadavers. The results showed that the safe zone in some bones is smaller than the size of standard reamers and the proximal part of some nails. The structures at risk are the anterior horns of the medial and lateral menisci, the anterior part of the medial and lateral plateaux and the ligamentum transversum. This was confirmed by observations made after nailing 12 pairs of cadaver knees. A retrospective radiological analysis of 30 patients who had undergone tibial nailing identified eight at risk according to the entry point and the size of the nail. Unrecognised articular penetration and damage during surgery were confirmed in four. Although intramedullary nailing has been shown to be a successful method for treating fractures of the tibia, one of the most common problems after bony union is pain in the knee. Unrecognised intra-articular injury of the knee may be one cause of this