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.

We describe a semi-closed method of Herbert screw fixation for acute fractures of the scaphoid. All 40 patients treated achieved solid union with satisfactory wrist function. This technique gave a significantly shorter time to union and allowed an earlier return to manual labour compared with conservative treatment. There were no complications.

Semi-closed insertion requires considerable skill, but produces consistently satisfactory results after minimal exposure of the scaphoid.

We have treated 42 consecutive complex ununited fractures of the femoral shaft by wave-plate osteosynthesis at five different medical centres. There were 13 with previous infection, 12 with segmental cortical defects, and 3 were pathological fractures. In 39 cases there had been previous internal fixation and 21 patients had had more than one earlier operation.

Union was achieved in 41 patients at an average of six months, although three had required a second bone graft. Two patients had recurrence of infection and in one this resulted in the persistence of nonunion. There were no failures of the implant. All 41 patients with union are now fully weight-bearing, but four have a leg-length discrepancy, one has axial malalignment, and nine have residual stiffness of the knee. These results are surprisingly good, despite the complexity of the initial problem, and appear to confirm the biological and mechanical advantages of the wave plate over the conventional plate for such cases.

We have compared the results of simple patellectomy (group A, n = 16) and patellectomy with advancement of the vastus medialis obliquus (group B, n = 12) in a prospective, randomised trial, with a minimum follow-up of three years.

The results in group B were significantly better (p < 0.001) than those in group A. Although the patella should be preserved if possible, we advocate advancement of the vastus medialis obliquus when patellectomy is necessary.

Objectives. Ubiquitin E3 ligase-mediated protein degradation regulates osteoblast function. Itch, an E3 ligase, affects numerous cell functions by regulating ubiquitination and proteasomal degradation of related proteins. However, the Itch-related cellular and molecular mechanisms by which osteoblast differentiation and function are elevated during bone fracture repair are as yet unknown. Methods. We examined the expression levels of E3 ligases and NF-κB members in callus samples during bone fracture repair by quantitative polymerase chain reaction (qPCR) and the total amount of ubiquitinated proteins by Western blot analysis in wild-type (WT) mice. The expression levels of osteoblast-associated genes in fracture callus from Itch knockout (KO) mice and their WT littermates were examined by qPCR. The effect of NF-κB on Itch expression in C2C12 osteoblast cells was determined by a chromatin immunoprecipitation (ChIP) assay. Results. The expression levels of WW Domain Containing E3 Ubiquitin Protein Ligase 1 (Wwp1), SMAD Specific E3 Ubiquitin Protein Ligase 1 (Smurf1), SMAD Specific E3 Ubiquitin Protein Ligase 2 (Smurf2) and Itch were all significantly increased in the fracture callus of WT mice, which was associated with elevated expression of NF-κB members and total ubiquitinated proteins. Callus tissue isolated from Itch KO mice expressed higher levels of osteoblast-associated genes, including Runx2, a positive regulator of osteoblast differentiation, but osteoclast-associated genes were not increased. Both NF-κB RelA and RelB proteins were found to bind to the NF-κB binding site in the mouse Itch promoter. Conclusions. Our findings indicate that Itch depletion may have a strong positive effect on osteoblast differentiation in fracture callus. Thus, ubiquitin E3 ligase Itch could be a potential target for enhancing bone fracture healing. Cite this article: J. Liu, X. Li, H. Zhang, R. Gu, Z. Wang, Z. Gao, L. Xing. Ubiquitin E3 ligase Itch negatively regulates osteoblast function by promoting proteasome degradation of osteogenic proteins. Bone Joint Res 2017;6:154–161. DOI: 10.1302/2046-3758.63.BJR-2016-0237.R1

We treated 24 patients with high-energy fractures of the tibial plateau by the Ilizarov fixator and transfixion wires. Eleven fractures were open, and 20 patients had complex injuries. Twelve were treated by ligamentotaxis and percutaneous fixation, seven by limited open reduction and five by extensive open reduction. All were followed for at least 24 months.

All the fractures united, with an average time to healing of 14.4 weeks. Thirteen patients achieved full extension and 13 more than 110° of flexion. Twenty-two knees were stable. Fifteen patients walked normally and the rest with only a slight limp. All but two knees had an articular step-off of less than 4 mm and all had normal axial alignment except two. There were no cases of postoperative skin infection, osteomyelitis or septic arthritis.

Ilizarov circular fixation is an ideal method of treatment for these fractures when extensive dissection and internal fixation are contraindicated due to trauma to the soft tissue, deficiency of bone stock, and bony comminution.

We re-examined clinically and radiologically 88 patients with a fracture of the lower leg at a mean follow-up of 15 years. Forty-three fractures (49%) had healed with malalignment of at least 5°. More arthritis was found in the knee and ankle adjacent to the fracture than in the comparable joints of the uninjured leg. Malaligned fractures showed significantly more degenerative changes.

Eighteen patients (20%) had symptoms in the fractured leg. There was a significant correlation between symptoms in the knee and arthritis but not between symptoms and ankle arthritis or malalignment.

We conclude that fractures of the lower leg should be managed so that the possibility of angular deformity and thereby late arthritis is minimised.

We reviewed retrospectively 490 patellar ligament reconstructions for cruciate ligament injuries performed from 1980 to 1990. There were six cases of patellar splitting and three displaced patellar fractures in donor knees. The fissure fractures all occurred during the removal of the patellar bone block. The displaced fractures were sustained during early rehabilitation, and in two of the three patients, involved the normal contralateral knee. The major reasons for this complication were imprecise saw cuts, spreading osteotomies, and the use of a too large patellar bone block. When a trapezoidal bone block is used to self-lock in the femoral tunnel, this should preferably be taken from the tibia. Special care is needed in rehabilitation when the graft has been taken from the contralateral knee.

We report the results of treatment with the dynamic condylar screw of 21 cases of supracondylar and intercondylar fractures of the femur in patients aged 22 to 91 years. There were two nonunions and no deaths. We found the device easy to use and the good fixation allowed early patient mobilisation.

The retrospective analysis of 131 patients suffering from a fracture of the ring of the axis is reported. The injury was classified into three types according to radiological displacement and stability. Associated injuries and neurological deficit are discussed and a theory of pathogenesis presented. Guidelines for the management of each type of fracture are proposed.

The incidence and prognostic significance of fractures of acrylic cement related to the stem of a femoral head prosthesis in total hip replacement are examined. These fractures are demonsfrated when the cement has been rendered radio-opaque by the addition of barium sulphate. One and a half per cent of the radiographs of 6,649 patients showed these fractures, which were sometimes associated with subsidence of the prosthesis. Fracture of the cement was usually evident at the six-month post-operative review, if it occurred at all. This radiological complication was devoid of symptoms in the majority of cases and tended to occur in patients with excellent functional recovery. In a minority of patients pain in the thigh during the first six months seemed likely to be explained by this fracture. Slight subsidence of the prosthesis in the cement bed appeared to result in a new and final position of stability. The prognosis was very good; only when separation of the fracture exceeded about 4 millimetres was the prognosis doubtful, in which case a chronic deep infection might be suspected. Possible mechanical and structural causes of fracture of the cement are discussed.

1. The results of internal fixation are described in 470 tibial shaft fractures.

2. The immediate internal fixation of compound fractures was followed by so high an incidence of serious complications that the use of this method is not recommended. The immediate internal fixation of fresh closed fractures was also followed by many complications.

3. Delayed rigid internal fixation proved satisfactory for difficult fractures in which an acceptable reduction could not be obtained by closed means ; skeletal traction was of value in such fractures until the skin was soundly healed.

4. Delayed internal fixation reduced both the healing time and the complications.

1. The late consequences of stable fractures of the thoracic and lumbar spine have been assessed in a series of workmen. The incidence of symptoms has been recorded and an attempt made to assess the degree of associated incapacity.

2. It has been found that most patients continue to have some symptoms attributable to the back injury and that approximately one in five of the patients who attended for review was partially or completely incapacitated as a consequence of such symptoms.

3. The persistence of symptoms was found to be unrelated to the severity of fracture, to its level, to the presence of radiological evidence of degenerative change, or to the age of the patient.

4. Persistent symptoms were found more commonly in those patients who had received more treatment. The implications of this observation are discussed.

It seems right to draw the following conclusions from this study of the relative merits of early and delayed fixation for fractures of the femoral and tibial shafts.

1. In patients under the age of sixty years with femoral shaft fractures there seems to be a significant improvement in the speed and quality of union when internal fixation is delayed. In patients over the age of sixty years the results of delayed fixation are worse than those of early fixation, and in any case the dangers of prolonged recumbency make the latter method preferable.

2. Delaying fixation for tibial shaft fractures does not affect speed of union or functional result. However, the incidence of non-union in these fractures is reduced by over 50 per cent by delaying fixation. This is a good reason for delaying fixation of this fracture too.

Some possible reasons for the improved results after delayed fixation have been discussed.

1. A simple method of internal fixation of adult forearm fractures which gives consistent good results is necessary because the closed method of treatment is of limited application.

2. Open reduction of fractures without rigid internal fixation gives a high proportion of non-union and poor results.

3. Rigid internal fixation with standard plates and screws has been shown to give a low incidence of non-union in this series.

4. A three and a half inch long plate with six screws is suitable for most fractures, but if there is moderate or severe comminution, or if there is a segmental fracture, longer plates and more screws should be used to provide sound fixation.

5. Severely comminuted fractures with large avascular bone fragments should have the addition of a bone graft at the time of the plating operation in order that union may be assured. Thin strips of iliac bone are preferred.

6. Rigid plating is considered to be the most satisfactory treatment for open fractures.

7. Immobilisation of the limb after operation is not necessary and is undesirable if the fixation is rigid.

8. The functional results of this treatment are good and seemingly better than those achieved by other methods.

9. Serious complications of the plating operation are few and avoidable.

1. Fifteen cases of bone transplantation for fibrous union of fractures of long bones are described, using boiled minced cancellous bone from cadavers. One transplant became infected but the infection responded to treatment.

2. In one patient with non-union of the shaft of the humerus, bony union was not obtained, but a good functional result obviated further treatment.

3. It is suggested that this relatively simple method of bone transplantation could be used more widely if its potentialities were appreciated more fully.

1. The results in 211 fractures of the shaft of the femur in adults treated by internal fixation have been reviewed.

2. A comparison has been made between the effects of early internal fixation within the first six days of injury and delayed fixation.

3. Eighty-five fractures treated by early fixation gave a rate of non-union of 23 per cent; in 126 fractures treated by delayed fixation the rate was 0·8 per cent.

4. Delayed operation is therefore advocated for the majority of femoral shaft fractures for which internal fixation is indicated.

1. Three cases are reported of avascular necrosis of the head of the femur after undisplaced fractures of the neck of the femur in childhood.

2. It is suggested that the diaphysial vessels play a more important part in the supply of the epiphysis than has previously been recognised.

3. The prognosis for any fracture of the neck of the femur in a child given at the time of the injury should be guarded.