Fractures of the femoral shaft are generally considered to affect young patients, but we have reviewed 24 cases in patients over 60 years who have been treated by locked nailing, usually by closed methods. Most were women with low-velocity injuries, but despite this, 14 fractures were significantly comminuted. The complication rate was 54% with a peri-operative mortality of 17%. Most complications were the general ones of operating on elderly patients. Specific complications included: fractures below an abnormal hip, proximal fracture related to the nail and poor purchase in the distal femur. In all survivors, the femoral shaft fractures united satisfactorily, and the fixation allowed early mobilisation. The locking nail appears to be an effective method of managing femoral shaft fractures in the elderly patient

We undertook 114 arthroscopic meniscal repairs in 111 patients and subsequently carried out second-look arthroscopy to confirm meniscal healing at a mean of 13 months after repair. Stable healing at the repaired site was seen in 90. Of these, however, 13 had another arthroscopy later for a further tear. The mean period between the repair and the observation of a repeat tear was 48 months. Of the 13 patients, 11 had returned to high activity levels (International Knee Documentation Committee level I or II) after the repair. An attempt should be made to preserve meniscal function by repairing tears, but even after arthroscopic confirmation of stable healing repaired menisci may tear again. The long-term rate of healing may not be as high as is currently reported. Second-look arthroscopy cannot predict late meniscal failure and may not be justified as a method of assessment for meniscal healing. Young patients engaged in arduous sporting activities should be reviewed regularly even after arthroscopic confirmation of healing

We report the ulnar impingement syndrome, which is caused by a shortened ulna impinging on the distal radius and causing a painful, disabling pseudarthrosis. Of the 11 cases reported, 10 were due to excision of the distal ulna after injury to the wrist; the other was a result of a growth arrest after a fracture of the distal ulna in a child. The symptoms are a painful, clicking wrist and a weak grip; clinical examination reveals a narrow wrist with pain on compression of the radius and ulna and on forced supination. Radiographs in the majority of cases show scalloping of the distal radius corresponding to the site of impingement. The mechanism by which ulnar impingement occurs after radio-ulnar convergence is illustrated. The plan of management for the young patient with traumatic dysfunction of the distal radio-ulnar joint is discussed; excision of the lower end of the ulna is not advised in such patients

We reviewed 24 displaced fractures through the physis of the medial epicondyle of the distal humerus. One was a Salter-Harris type-II fracture-separation of the whole distal humeral epiphysis; the others involved only the medial epicondylar centre of ossification. Two cases had presented as pseudarthroses. One fracture had been treated closed in a plaster slab and 21 had had open reduction and internal fixation with sutures, Kirschner wires or Palmer nails. At 2 to 13 years later we found five types of deformity of the epicondyle: pseudarthrosis, an ulnar sulcus, a double-contoured epicondyle, hypoplasia or hyperplasia. Pseudarthrosis had developed after either no treatment, closed reduction and plaster, or open reduction and suturing. Hypoplasia followed nailing, as did a trend to varus tilting of the joint surface. One very young patient, with fracture-separation of the whole distal epiphysis treated by nailing, developed marked cubitus varus

Sixty patients each of whom had a fracture of the lower limb a minimum of five years (median 11 years) previously were studied by photoplethysmography, foot volumetry, popliteal venous reflux and arterial Doppler measurements. The non-fractured limb was used as a control. Postphlebitic symptoms were present in 51% and signs in 49% of fractured limbs compared with 4% and 24% respectively in the control limbs. The incidence was greater in patients who had fractured 15 years or more previously than in those who had fractured 5 to 15 years previously. Eleven limbs had clinically disabling postphlebitic symptoms including venous ulceration. The postphlebitic syndrome following lower limb fractures in young patients is more common than generally appreciated and develops after a prolonged latent interval. A prospective randomised study using prophylactic anticoagulation for lower limb shaft fractures may be justified

Objectives

Using a simple classification method, we aimed to estimate the collapse rate due to osteonecrosis of the femoral head (ONFH) in order to develop treatment guidelines for joint-preserving surgeries.

The results of conventional hip replacement in young patients with osteoarthritis have not been encouraging even with improvements in the techniques of fixation and in the bearing surfaces. Modern metal-on-metal hip resurfacing was introduced as a less invasive method of joint reconstruction for this particular group. This is a series of 446 hip resurfacings (384 patients) performed by one of the authors (DJWM) using cemented femoral components and hydroxyapatite-coated uncemented acetabular components with a maximum follow-up of 8.2 years (mean 3.3). Their survival rate, Oxford hip scores and activity levels are reviewed. Six patients died due to unrelated causes. There was one revision (0.02%) out of 440 hips. The mean Oxford score of the surviving 439 hips is 13.5. None of the patients were told to change their activities at work or leisure; 31% of the men with unilateral resurfacings and 28% with bilateral resurfacings were involved in jobs that they considered heavy or moderately heavy; 92% of men with unilateral hip resurfacings and 87% of the whole group participate in leisure-time sporting activity. The extremely low rate of failure in spite of the resumption of high level occupational and leisure activities provides early evidence of the suitability of this procedure for young and active patients with arthritis

We have studied the long-term results of core decompression as the sole treatment for Ficat stages I, II and III ischaemic necrosis of 128 femoral heads in 90 patients. The 5-, 10- and 15-year survival rates for the three stages were respectively: stage I 100%, 96% and 90%; stage II 85%, 74% and 66%; and stage III 58%, 35% and 23%. At a mean follow-up of 11 years (4.5 to 19), 55 hips had failed (43%). No further surgery had been needed for 88% of stage-I, 72% of stage-II and 26% of stage-III hips; but despite the generally satisfactory clinical results, 56% of the hips had progressed radiographically by at least one Ficat stage. Complications of the core procedure included four fractures, all from postoperative falls, and one head perforation due to technical error. We conclude that core decompression delays the need for total hip replacement in young patients with ischaemic necrosis

We review the history and literature of hip resurfacing arthroplasty. Resurfacing and the science behind it continues to evolve. Recent results, particularly from the national arthroplasty registers, have spread disquiet among both surgeons and patients. A hip resurfacing arthroplasty is not a total hip replacement, but should perhaps be seen as a means of delaying it. The time when hip resurfacing is offered to a patient may be different from that for a total hip replacement. The same logic can apply to the timing of revision surgery. Consequently, the comparison of resurfacing with total hip replacement may be a false one. Nevertheless, the need for innovative solutions for young arthroplasty patients is clear. Total hip replacement can be usefully delayed in many of these patients by the use of hip resurfacing arthroplasty

We reviewed 20 patients with spina bifida who had had surgical management of tibial torsion. Eight had had bilateral procedures and 12 a unilateral procedure, giving a total of 28 limbs for analysis. We performed closed osteoclasis on seven limbs and tibial osteotomy on 21. In the closed osteoclasis group six limbs (85%) had a good result after an average follow-up of nine years (2 to 22). All limbs developed postoperative anteromedial bowing of the tibia which later remodelled. In the tibial osteotomy group 19 (90%) had a good result. The average follow-up was nine years (2 to 28). Complications occurred in seven limbs (33%). We recommend closed osteoclasis of the tibia for the young patient with spina bifida in whom walking is impeded by excessive internal tibial torsion, and supramalleolar tibial osteotomy in the older patient with excessive external tibial torsion and a planovalgus foot

The treatment of osteonecrosis of the femoral head (FHN) is controversial. It mainly occurs in young patients in whom total hip replacement is best avoided because of an increased risk of revision. The objective of this long-term follow-up study was to evaluate the outcome of intertrochanteric flexion osteotomy as a hip joint preserving operation for FHN. Over a 19-year period we carried out 70 intertrochanteric flexion osteotomies for FHN in 64 patients. The mean follow-up was 10.4 years (3.0 to 20.3). The overall mean Harris hip score increased from 51 points preoperatively to 71 points postoperatively. Six patients (9%) developed early postoperative complications. A total of 19 hips (27%) underwent total hip arthroplasty at a mean of 8.7 years after osteotomy. The five-year survival rate was 90%. Survival rates of hips in Ficat stage 2 were higher than those in stages 3 or 4. Hips with a preoperative necrotic angle of < 200° had a better survival probability than those with a necrotic angle > 200°. Our findings suggest that flexion osteotomy is a safe and effective procedure in Ficat stage 2 and 3 FHN, preferably with a necrotic angle of < 200°

1. An analysis has been made of the clinical features and investigations in ninety-five cases of primary intraspinal tumours. 2. Loss of muscle power was the commonest symptom, and was often ignored until late in the course of the disease. 3. Two-thirds of the patients had no pain in the spinal region, although five of these had either extensive growths or radiographical evidence of bone erosion by tumour. 4. One-third of the patients had urinary symptoms, and two of them had acute retention initially attributed to prostatic obstruction. 5. In eighteen cases posture and gait were abnormal. The case histories of five of these patients are recorded, and they emphasise the importance of recognising lumbar spasm and hamstring tightness in young patients as signs of a cauda equina neoplasm. 6. All patients had some detectable sensory, motor, or reflex changes, and these were mostly bilateral. 7. Radiography, and cerebrospinal fluid manometry and analysis, were helpful in establishing the diagnosis. 8. Hysteria should not be diagnosed until all efforts have been made to prove otherwise

From 1988 to 1994 a consecutive series of 1000 fractures of the adult clavicle was treated in the Orthopaedic Trauma Clinic of the Royal Infirmary of Edinburgh. In males, the annual incidence was highest under 20 years of age, decreasing in each subsequent cohort until the seventh decade. In females, the incidence was more constant, but relatively frequent in teenagers and the elderly. In young patients, fractures usually resulted from road-traffic accidents or sport and most were diaphyseal. Fractures in the outer fifth were produced by simple domestic falls and were more common in the elderly. A new classification was developed based on radiological review of the anatomical site and the extent of displacement, comminution and articular extension. There were satisfactory levels of inter- and intraobserver variation for reliability and reproducibility. Fractures of the medial fifth (type 1), undisplaced diaphyseal fractures (type 2A) and fractures of the outer fifth (type 3A) usually had a benign prognosis. The incidence of complications of union was higher in displaced diaphyseal (type 2B) and displaced outer-fifth (type 3B) fractures. In addition to displacement, the extent of comminution in type-2B fractures was a risk factor for delayed and nonunion

We have made a retrospective study of 1001 custom-made prostheses used as replacements after surgery for bone tumours. There were 493 distal femoral, 263 proximal femoral and 245 proximal tibial prostheses. Aseptic loosening was shown to be the principal mode of failure of the implants, and 71 patients had revision for aseptic loosening of a cemented intramedullary stem. The probability of a patient surviving aseptic loosening for 120 months was 93.8% for a proximal femoral replacement, 67.4% for a distal femoral prosthesis and 58% for a proximal tibial implant. In patients with distal femoral replacements the age of the patient at the time of operation and the percentage of bone resected were related to the risk of aseptic loosening. Young patients with distal femoral prostheses in whom a high percentage of the femur had been replaced had the poorest prognosis for survival without aseptic loosening. The percentage of bone removed had a significant effect in the proximal tibial replacement group, but the age of the patient did not. By contrast, neither the age nor the percentage of bone removed was a factor after proximal femoral replacement. The significance of these findings is discussed in relation to mechanical factors

Aims

Second-generation metal-on-metal (MoM) articulations in total hip arthroplasty (THA) were introduced in order to reduce wear-related complications. The current study reports on the serum cobalt levels and the clinical outcome at a minimum of 20 years following THA with a MoM (Metasul) or a ceramic-on-polyethylene (CoP) bearing.

The October 2012 Foot & Ankle Roundup. 360. looks at: ankle arthrodesis in young active patients; the Bologna-Oxford total ankle replacements; significant failure and revision rates for total ankle arthroplasty; surgical treatment of Achilles tendon rupture; selective plantar fascia release; whether removal of metalwork can resolve foot pain; allografting of osteochondral lesions; distracting from osteoarthritis; and ultrasound-guided minimally invasive surgery

Aims

There is little literature about total knee arthroplasty (TKA) after distal femoral osteotomy (DFO). Consequently, the purpose of this study was to analyze the outcomes of TKA after DFO, with particular emphasis on: survivorship free from aseptic loosening, revision, or any re-operation; complications; radiological results; and clinical outcome.

We studied the rates of revision for 53 698 primary total hip replacements (THRs) in nine different groups of disease. Factors which have previously been shown to be associated with increased risk of revision, such as male gender, young age, or certain types of uncemented prosthesis, showed important differences between the diagnostic groups. Without adjustment for these factors we observed an increased risk of revision in patients with paediatric hip diseases and in a small heterogeneous ‘other’ group, compared with patients with primary osteoarthritis. Most differences were reduced or disappeared when an adjustment for the prognostic factors was made. After adjustment, an increased relative risk (RR) of revision compared with primary osteoarthritis was seen in hips with complications after fracture of the femoral neck (RR = 1.3, p = 0.0005), in hips with congenital dislocation (RR = 1.3, p = 0.03), and in the heterogenous ‘other’ group. The analyses were also undertaken in a more homogenous subgroup of 16 217 patients which had a Charnley prosthesis implanted with high-viscosity cement. The only difference in this group was an increased risk for revision in patients who had undergone THR for complications after fracture of the femoral neck (RR = 1.5, p = 0.0005). THR for diagnoses seen mainly among young patients had a good prognosis, but they had more often received inferior uncemented implants. If a cemented Charnley prosthesis is used, the type of disease leading to THR seems in most cases to have only a minor influence on the survival of the prosthesis