Failed internal fixation of a fracture of the proximal humerus produces many challenges with limited surgical options. The aim of this study was to evaluate the clinical outcomes after the use of a reverse shoulder arthroplasty under these circumstances. Between 2007 and 2012, 19 patients (15 women and four men, mean age 66 years; 52 to 82) with failed internal fixation after a proximal humeral fracture, underwent implant removal and reverse shoulder arthroplasty (RSA). The mean follow-up was 36 months (25 to 60). The mean American Shoulder and Elbow Score improved from 27.8 to 50.1 (p = 0.019). The mean Simple Shoulder Test score improved from 0.7 to 3.2 (p = 0.020), and the mean visual analogue scale for pain improved from 6.8 to 4.3 (p = 0.012). Mean forward flexion improved from 58.7° to 101.1° (p < 0.001), mean abduction from 58.7° to 89.1° (p = 0.012), mean external rotation from 10.7° to 23.1° (p = 0.043) and mean internal rotation from buttocks to L4 (p = 0.034). A major complication was recorded in five patients (26%) (one intra-operative fracture, loosening of the humeral component in two and two peri-prosthetic fractures). A total of 15 patients (79%) rated their outcome as excellent or good, one (5%) as satisfactory, and three (16%) as unsatisfactory.

An improvement in outcomes and pain can be expected when performing a RSA as a salvage procedure after failed internal fixation of a fracture of the proximal humerus. Patients should be cautioned about the possibility for major complications following this technically demanding procedure.

Cite this article: Bone Joint J 2015;97-B:967–72.

The objective of this study was to validate the efficacy of Takeuchi classification for lateral hinge fractures (LHFs) in open wedge high tibial osteotomy (OWHTO). In all 74 osteoarthritic knees (58 females, 16 males; mean age 62.9 years, standard deviation 7.5, 42 to 77) were treated with OWHTO using a TomoFix plate. The knees were divided into non-fracture (59 knees) and LHF (15 knees) groups, and the LHF group was further divided into Takeuchi types I, II, and III (seven, two, and six knees, respectively). The outcomes were assessed pre-operatively and one year after OWHTO. Pre-operative characteristics (age, gender and body mass index) showed no significant difference between the two groups. The mean Japanese Orthopaedic Association score was significantly improved one year after operation regardless of the presence or absence of LHF (p = 0.0015, p < 0.001, respectively). However, six of seven type I cases had no LHF-related complications; both type II cases had delayed union; and of six type III cases, two had delayed union with correction loss and one had overcorrection. These results suggest that Takeuchi type II and III LHFs are structurally unstable compared with type I.

Cite this article: Bone Joint J 2015;97-B:1226–31.

Using human cadaver specimens, we investigated the role of supplementary fibular plating in the treatment of distal tibial fractures using an intramedullary nail. Fibular plating is thought to improve stability in these situations, but has been reported to have increased soft-tissue complications and to impair union of the fracture. We proposed that multidirectional locking screws provide adequate stability, making additional fibular plating unnecessary. A distal tibiofibular osteotomy model performed on matched fresh-frozen lower limb specimens was stabilised with reamed nails using conventional biplanar distal locking (CDL) or multidirectional distal locking (MDL) options with and without fibular plating. Rotational stiffness was assessed under a constant axial force of 150 N and a superimposed torque of ± 5 Nm. Total movement, and neutral zone and fracture gap movement were analysed.

In the CDL group, fibular plating improved stiffness at the tibial fracture site, albeit to a small degree (p = 0.013). In the MDL group additional fibular plating did not increase the stiffness. The MDL nail without fibular plating was significantly more stable than the CDL nail with an additional fibular plate (p = 0.008).

These findings suggest that additional fibular plating does not improve stability if a multidirectional distal locking intramedullary nail is used, and is therefore unnecessary if not needed to aid reduction.

Cite this article: Bone Joint J 2014;96-B:385–9.

The incidence of periprosthetic fractures of the ankle is increasing. However, little is known about the outcome of treatment and their management remains controversial. The aim of this study was to assess the impact of periprosthetic fractures on the functional and radiological outcome of patients with a total ankle arthroplasty (TAA).

A total of 505 TAAs (488 patients) who underwent TAA were retrospectively evaluated for periprosthetic ankle fracture: these were then classified according to a recent classification which is orientated towards treatment. The outcome was evaluated clinically using the American Orthopedic Foot and Ankle Society (AOFAS) score and a visual analogue scale for pain, and radiologically.

A total of 21 patients with a periprosthetic fracture of the ankle were identified. There were 13 women and eight men. The mean age of the patients was 63 years (48 to 74). Thus, the incidence of fracture was 4.17%.

There were 11 intra-operative and ten post-operative fractures, of which eight were stress fractures and two were traumatic. The prosthesis was stable in all patients. Five stress fractures were treated conservatively and the remaining three were treated operatively.

A total of 17 patients (81%) were examined clinically and radiologically at a mean follow-up of 53.5 months (12 to 112). The mean AOFAS score at follow-up was 79.5 (21 to 100). The mean AOFAS score in those with an intra-operative fracture was 87.6 (80 to 100) and for those with a stress fracture, which were mainly because of varus malpositioning, was 67.3 (21 to 93). Periprosthetic fractures of the ankle do not necessarily adversely affect the clinical outcome, provided that a treatment algorithm is implemented with the help of a new classification system.

Cite this article: Bone Joint J 2015;97-B:950–6.

The April 2015 Research Roundup360 looks at: MCID in grip strength and distal radial fracture; Experiencing rehab in a trial setting; Electrical stimulation and nerve recovery; Molecular diagnosis of TB?; Acetabular orientation: component and arthritis; Analgesia after knee arthroplasty; Bisphosphonate-associated femoral fractures

Between 2003 and 2007, 99 knees in 77 patients underwent opening wedge high tibial osteotomy. We evaluated the effect of initial stable fixation combined with an artificial bone substitute on the mid- to long-term outcome after medial opening-wedge high tibial osteotomy (HTO) for medial compartmental osteoarthritis or spontaneous osteonecrosis of the knee in 78 knees in 64 patients available for review at a minimum of five years (mean age 68 years; 49 to 82). The mean follow-up was 6.5 years (5 to 10). The mean Knee Society knee score and function score improved from 49.6 (sd 11.4, 26 to 72) and 56.6 (sd 15.6, 5 to 100) before surgery to 88.1 (sd 12.5, 14 to 100) and 89.4 (sd 15.6, 5 to 100) at final follow-up (p <  0.001) respectively. There were no significant differences between patients aged ≥ 70 and < 70 years. The mean standing femorotibial angle was corrected significantly from 181.7° (sd 2.7°, 175° to 185°) pre-operatively to 169.7° (sd 2.4°, 164° to 175°) at one year’s follow-up (p < 0.001) and 169.6° (sd 3.0°, 157° to 179°) at the final follow-up (p = 0.69 vs one year).

Opening-wedge HTO using a stable plate fixation system combined with a bone substitute is a reliable procedure that provides excellent results. Although this treatment might seem challenging for older patients, our results strongly suggest that the results are equally good.

Cite this article: Bone Joint J 2014;96-B:339–44.

Controversy surrounds the management of displaced three- and four-part fractures of the proximal humerus. The percutaneous Resch technique of stabilisation involves minimal soft-tissue dissection and a reduced risk of stiffness and avascular necrosis. However, it requires a second operation to remove Kirschner wires and the humeral block. We describe a modification of this technique that dispenses with the need for this second operation and relies on a sequential pattern of screw placement. We report the outcome of 32 three- or four-part fractures of the proximal humerus treated in this way at a mean follow-up of 3.8 years (2 to 8)). There were 14 men and 18 women with a mean age of 56 years (28 to 83). At final follow-up the mean Oxford shoulder scores were 38 (31 to 44) and 39 (31 to 42), and the mean Constant scores were 79 (65 to 92) and 72 (70 to 80) for three- and four-part fractures, respectively. We further analysed the results in patients aged < 60 years with high-energy fractures and those aged ≥ 60 years with osteoporotic fractures. There were no cases of nonunion or avascular necrosis.

The results were good and comparable to those previously reported for the Resch technique and other means of fixation for proximal humeral fractures. We would recommend this modification of the technique for the treatment of displaced three-part and four-part fractures in patients both younger and older than 60 years of age.

The management of children’s fractures has evolved as a result of better health education, changes in lifestyle, improved implant technology and the changing expectations of society. This review focuses on the changes seen in paediatric fractures, including epidemiology, the increasing problems of obesity, the mechanisms of injury, non-accidental injuries and litigation. We also examine the changes in the management of fractures at three specific sites: the supracondylar humerus, femoral shaft and forearm. There has been an increasing trend towards surgical stabilisation of these fractures. The reasons for this are multifactorial, including societal expectations of a perfect result and reduced hospital stay. Reduced hospital stay is beneficial to the social, educational and psychological needs of the child and beneficial to society as a whole, due to reduced costs.

Cite this article: Bone Joint J 2015; 97-B:442–8.

The role of arthroscopy in the treatment of soft-tissue injuries associated with proximal tibial fractures remains debatable. Our hypothesis was that MRI over-diagnoses clinically relevant associated soft-tissue injuries. This prospective study involved 50 consecutive patients who underwent surgical treatment for a split-depression fracture of the lateral tibial condyle (AO/OTA type B3.1). The mean age of patients was 50 years (23 to 86) and 27 (54%) were female. All patients had MRI and arthroscopy. Arthroscopy identified 12 tears of the lateral meniscus, including eight bucket-handle tears that were sutured and four that were resected, as well as six tears of the medial meniscus, of which five were resected. Lateral meniscal injuries were diagnosed on MRI in four of 12 patients, yielding an overall sensitivity of 33% (95% confidence interval (CI) 11 to 65). Specificity was 76% (95% CI 59 to 88), with nine tears diagnosed among 38 menisci that did not contain a tear. MRI identified medial meniscal injuries in four of six patients, yielding an overall sensitivity of 67% (95% CI 24 to 94). Specificity was 66% (95% CI 50 to 79), with 15 tears diagnosed in 44 menisci that did not contain tears.

MRI appears to offer only a marginal benefit as the specificity and sensitivity for diagnosing meniscal injuries are poor in patients with a fracture. There were fewer arthroscopically-confirmed associated lesions than reported previously in MRI studies.

Cite this article: Bone Joint J 2014;96-B:1631–6.

The December 2014 Trauma Roundup³⁶⁰ looks at: infection and temporising external fixation; Vitamin C in distal radial fractures; DRAFFT: Cheap and cheerful Kirschner wires win out; femoral neck fractures not as stable as they might be; displaced sacral fractures give high morbidity and mortality; sanders and calcaneal fractures: a 20-year experience; bleeding and pelvic fractures; optimising timing for acetabular fractures; and tibial plateau fractures.

Patients with pain and loss of shoulder function due to nonunion of a fracture of the proximal third of the humerus may benefit from reverse total shoulder replacement. This paper reports a prospective, multicentre study, involving three hospitals and three surgeons, of 35 patients (28 women, seven men) with a mean age of 69 years (46 to 83) who underwent a reverse total shoulder replacement for the treatment of nonunion of a fracture of the proximal humerus. Using Checchia’s classification, nine nonunions were type I, eight as type II, 12 as type III and six as type IV. The mean follow-up was 51 months (24 to 99). Post-operatively, the patients had a significant decrease in pain (p < 0.001), and a significant improvement in flexion, abduction, external rotation and Constant score (p < 0.001), but not in internal rotation. A total of nine complications were recorded in seven patients: six dislocations, one glenoid loosening in a patient who had previously suffered dislocation, one transitory paresis of the axillary nerve and one infection.

Reverse total shoulder replacement may lead to a significant reduction in pain, improvement in function and a high degree of satisfaction. However, the rate of complications, particularly dislocation, was high.

Cite this article: Bone Joint J 2014;96-B:1239–43.

In order to achieve satisfactory reduction of complex distal humeral fractures, adequate exposure of the fracture fragments and the joint surface is required. Several surgical exposures have been described for distal humeral fractures. We report our experience using the anconeus pedicle olecranon flip osteotomy approach. This involves detachment of the triceps along with a sliver of olecranon, which retains the anconeus pedicle. We report the use of this approach in ten patients (six male, four female) with a mean age of 38.4 years (28 to 51). The mean follow-up was 15 months (12 to 18) with no loss to follow-up. Elbow function was graded using the Mayo Score. The results were excellent in four patients, good in five and fair in one patient. The mean time to both fracture and osteotomy union was 10.6 weeks (8 to 12) and 7.1 weeks (6 to 8), respectively. We found this approach gave reliably good exposure for these difficult fractures enabling anatomical reduction and bicondylar plating without complications.

Cite this article: Bone Joint J 2014;96-B:1252–7.

We are currently facing an epidemic of periprosthetic fractures around the hip. They may occur either during surgery or post-operatively. Although the acetabulum may be involved, the femur is most commonly affected. We are being presented with new, difficult fracture patterns around cemented and cementless implants, and we face the challenge of an elderly population who may have grossly deficient bone and may struggle to rehabilitate after such injuries. The correct surgical management of these fractures is challenging. This article will review the current choices of implants and techniques available to deal with periprosthetic fractures of the femur.

Cite this article: Bone Joint J 2014;96-B(11 Suppl A):48–55.

The June 2014 Children’s orthopaedics Roundup³⁶⁰ looks at: plaster wedging in paediatric forearm fractures; the medial approach for DDH; Ponseti – but not as he knew it?; Salter osteotomy more accurate than Pemberton in DDH; is the open paediatric fracture an emergency?; bang up-to-date with femoral external fixation; indomethacin, heterotopic ossification and cerebral palsy hips; lengthening nails for congenital femoral deformities, and is MRI the answer to imaging of the physis?

We identified 11 women with a mean age of 74 years (65 to 81) who sustained comminuted distal radial and ulnar fractures and were treated by volar plating and slight shortening of the radius combined with a primary Sauvé-Kapandji procedure.

At a mean of 46 months (16 to 58), union of distal radial fractures and arthrodesis of the distal radioulnar joint was seen in all patients. The mean shortening of the radius was 12 mm (5 to 18) compared to the contralateral side. Flexion and extension of the wrist was a mean of 54° and 50°, respectively, and the mean pronation and supination of the forearm was 82° and 86°, respectively. The final mean disabilities of the arm, shoulder and hand score was 26 points. According to the Green and O’Brien rating system, eight patients had an excellent, two a good and one a fair result.

The good clinical and radiological results, and the minor complications without the need for further operations related to late ulnar-sided wrist pain, justify this procedure in the elderly patient.

Management of bisphosphonate-associated subtrochanteric fractures remains opinion- or consensus-based. There are limited data regarding the outcomes of this fracture.

We retrospectively reviewed 33 consecutive female patients with a mean age of 67.5 years (47 to 91) who were treated surgically between May 2004 and October 2009. The mean follow-up was 21.7 months (0 to 53). Medical records and radiographs were reviewed to determine the post-operative ambulatory status, time to clinical and radiological union and post-fixation complications such as implant failure and need for second surgery.

The predominant fixation method was with an extramedullary device in 23 patients. 25 (75%) patients were placed on wheelchair mobilisation or no weight-bearing initially. The mean time to full weight-bearing was 7.1 months (2.2 to 29.7). The mean time for fracture site pain to cease was 6.2 months (1.2 to 17.1). The mean time to radiological union was 10.0 months (2.2 to 27.5). Implant failure was seen in seven patients (23%, 95 confidence interval (CI) 11.8 to 40.9). Revision surgery was required in ten patients (33%, 95 CI 19.2 to 51.2).

A large proportion of the patients required revision surgery and suffered implant failure. This fracture is associated with slow healing and prolonged post-operative immobility.

Cite this article: Bone Joint J 2014;96-B:658–64.

In 1999, we developed a technique for biological reconstruction after excision of a bone tumour, which involved using autografts of the bone containing the tumour treated with liquid nitrogen. We have previously reported the use of this technique in 28 patients at a mean follow up of 27 months (10 to 54).

In this study, we included 72 patients who underwent reconstruction using this technique. A total of 33 patients died and three were lost to follow-up, at a mean of 23 months (2 to 56) post-operatively, leaving 36 patients available for a assessment at a mean of 101 months 16 to 163) post-operatively. The methods of reconstruction included an osteo-articular graft in 16, an intercalary in 13 and, a composite graft with prosthesis in seven.

Post-operative function was excellent in 26 patients (72.2%), good in seven (19.4%), and fair in three (8.3%) according to the functional evaluation system of Enneking. No recurrent tumour occurred within the grafts. The autografts survived in 29 patients (80.6%), and the rates of survival at five and ten years were 86.1% and 80.6 %, respectively. Seven of 16 osteo-articular grafts (44%) failed because of fracture or infection, but all the composite and intercalary grafts survived.

The long-term outcomes of frozen autografting, particularly using composite and intercalary grafts, are satisfactory and thus represent a good method of treatment for patients with a sarcoma of bone or soft tissue.

Cite this article: Bone Joint J 2014;96-B:555–61.

Bicondylar tibial plateau fractures result from high-energy injuries. Fractures of the tibial plateau can involve the tibial tubercle, which represents a disruption to the extensor mechanism and logically must be stabilised. The purpose of this study was to identify the incidence of an independent tibial tubercle fracture in bicondylar tibial plateau fractures, and to report management strategies and potential complications. We retrospectively reviewed a prospectively collected orthopaedic trauma database for the period January 2003 to December 2008, and identified 392 bicondylar fractures of the tibial plateau, in which 85 tibial tubercle fractures (21.6%) were identified in 84 patients. There were 60 men and 24 women in our study group, with a mean age of 45.4 years (18 to 71). In 84 fractures open reduction and internal fixation was undertaken, either with screws alone (23 patients) or with a plate and screws (61 patients). The remaining patient was treated non-operatively. In all, 52 fractures were available for clinical and radiological assessment at a mean follow-up of 58.5 weeks (24 to 94). All fractures of the tibial tubercle united, but 24 of 54 fractures (46%) required a secondary procedure for their tibial plateau fracture. Four patients reported pain arising from prominent tubercle plates and screws, which in one patient required removal. Tibial tubercle fractures occurred in over one-fifth of the bicondylar tibial plateau fractures in our series. Fixation is necessary and can be reliably performed with screws alone or with a screw and plate, which restores the extensor mechanism and facilitates early knee flexion.

Cite this article: Bone Joint J 2013;95-B:1697–1702.

The October 2013 Wrist & Hand Roundup³⁶⁰ looks at: Cost effectiveness of Dupuytren’s surgery; A 'new horizon' in distal radius imaging; Undisplaced means undisplaced; The mystery of the distal radial fracture continues; How thick is thick enough?: articular cartilage step off revisited; Is the midcarpal joint more important than we think?; Plates and Kirschner wires; Better early results with an IM nail?