Sacral insufficiency fractures are traditionally treated with bed rest and analgesia. The importance of early rehabilitation is generally appreciated; but pain frequently delays this, resulting in prolonged hospital stay and the risk of complications related to immobility. We describe three women with sacral insufficiency fractures who were treated with percutaneous sacroiliac screws and followed up for a mean of 18 months (12 to 24). They had immediate pain relief, uncomplicated rehabilitation and uneventful healing.

We present a 25-year-old patient with juvenile rheumatoid arthritis and ankylosis of both hips and both knees treated by staged bilateral hip and knee arthroplasty. She was followed up for 18 months. We discuss the pre-operative planning, surgical details and post-operative rehabilitation.

Highly active anti-retroviral therapy has transformed HIV into a chronic disease with a long-term asymptomatic phase. As a result, emphasis is shifting to other effects of the virus, aside from immunosuppression and mortality. We have reviewed the current evidence for an association between HIV infection and poor fracture healing.

The increased prevalence of osteoporosis and fragility fractures in HIV patients is well recognised. The suggestion that this may be purely as a result of highly active anti-retroviral therapy has been largely rejected. Apart from directly impeding cellular function in bone remodelling, HIV infection is known to cause derangement in the levels of those cytokines involved in fracture healing (particularly tumour necrosis factor-α) and appears to impair the blood supply of bone.

Many other factors complicate this issue, including a reduced body mass index, suboptimal nutrition, the effects of anti-retroviral drugs and the avoidance of operative intervention because of high rates of wound infection. However, there are sound molecular and biochemical hypotheses for a direct relationship between HIV infection and impaired fracture healing, and the rewards for further knowledge in this area are extensive in terms of optimised fracture management, reduced patient morbidity and educated resource allocation. Further investigation in this area is overdue.

This prospective study presents the ten-year (5 to 16) clinical and radiological results of 55 primary total hip replacements (THR) using a cementless modular femoral component (S-ROM). All patients had a significant anatomical abnormality which rendered the primary THR difficult.

The mean Harris hip score was 36 (12 to 72) pre-operatively, 83 (44 to 100) at five years, and 85 (45 to 99) at ten years. The Western Ontario and McMaster Universities osteoarthritis index (WOMAC) and short-form (SF)-12 scores were recorded from the year 2000. The mean SF-12 score at five years after surgery was 45.24 (22.74 to 56.58) for the physical component and 54.14 (29.20 to 66.61) for the mental component. By ten years the SF-12 scores were 42.86 (21.59 to 58.95) and 51.03 (33.78 to 61.40), respectively. The mean WOMAC score at five years post-operatively was 25 (0 to 59), and at ten years was 27 (2 to 70).

No femoral components were radiologically loose, although five had osteolysis in Gruen zone 1, three had osteolysis in zone 7, and two showed osteolysis in both zones 1 and 7. No osteolysis was observed around or distal to the prosthetic sleeve. No femoral components were revised, although three hips underwent an acetabular revision and two required a liner exchange. At a mean of ten years’ follow-up the S-ROM femoral component implanted for an anatomically difficult primary THR has excellent clinical and radiological results.

Secure fixation of displaced proximal fractures of the humerus is a challenging problem. A total of 32 patients with acutely displaced three- or four-part proximal fractures of the humerus were treated by open reduction and internal fixation using the proximal humeral internal locking system (PHILOS) plate. There were 23 women and nine men with a mean age of 59.9 years (18 to 87). Data were collected prospectively and the outcomes were assessed using the Constant score. The mean follow-up was for 11 months (3 to 24). In 31 patients (97%) the fracture united clinically and radiologically at a mean of 10 weeks (8 to 24). The mean Constant score at final review was 66.5 (30 to 92). There was no significant difference in outcome when comparing patients aged more than 60 years (18 patients) with those aged less than 60 years (14 patients) (t-test, p = 0.8443). There was one case each of nonunion, malunion and a broken screw in the elderly population.

This plate provides an alternative method of fixation for fractures of the proximal humerus. It provides a stable fixation in young patients with good-quality bone sufficient to permit early mobilisation. Failure of the screws to maintain fixation in the elderly remains a problem.

Operative fixation is the treatment of choice for a rupture of the distal tendon of biceps. A variety of techniques have been described including transosseous sutures and suture anchors. The poor quality of the bone of the radial tuberosity might affect the load to failure of the tendon repair in early rehabilitation.

The aim of this study was to determine the loads to failure of different techniques of fixation and to investigate their association with the bone mineral density of the radial tuberosity.

Peripheral quantitative computed tomography was carried out to measure the trabecular and cortical bone mineral density of the radial tuberosity in 40 cadaver specimens. The loads to failure in four different techniques of fixation were determined.

The Endobutton-based method showed the highest failure load at 270 N (sd 22) (p < 0.05). The mean failure load of the transosseous suture technique was 210 N (sd 66) and that of the TwinFix-QuickT 5.0 mm was 57 N (sd 22), significantly lower than those of all other repairs (p < 0.05). No significant correlation was seen between bone mineral density and loads to failure.

The transosseous technique is an easy and cost-saving procedure for fixation of the distal biceps tendon. TwinFix-QuickT 5.0 mm had significantly lower failure loads, which might affect early rehabilitation, particularly in older patients.

Revision surgery of the hip was performed on 114 hips using an extensively porous-coated femoral component. Of these, 95 hips (94 patients) had a mean follow-up of 10.2 years (5 to 17). No cortical struts were used and the cortical index and the femoral cortical width were measured at different levels.

There were two revisions for aseptic loosening. Survivorship at 12 years for all causes of failure was 96.9% (95% confidence interval 93.5 to 100) in the best-case scenario. Fibrous or unstable fixation was associated with major bone defects. The cortical index (p = 0.045) and the lateral cortical thickness (p = 0.008) decreased at the proximal level over time while the medial cortex increased (p = 0.001) at the proximal and distal levels. An increase in the proximal medial cortex was found in patients with an extended transtrochanteric osteotomy (p = 0.026) and in those with components shorter than 25 cm (p = 0.008).

The use of the extensively porous-coated femoral component can provide a solution for difficult cases in revision surgery. Radiological bony ingrowth is common. Although without clinical relevance at the end of follow-up, the thickness of the medial femoral cortex often increased while that of the lateral cortex decreased. In cases in which a shorter component was used and in those undertaken using an extended trochanteric osteotomy, there was a greater increase in thickness of the femoral cortex over time.

Finite element analysis was used to examine the initial stability after hip resurfacing and the effect of the procedure on the contact mechanics at the articulating surfaces. Models were created with the components positioned anatomically and loaded physiologically through major muscle forces. Total micromovement of less than 10 μm was predicted for the press-fit acetabular components models, much below the 50 μm limit required to encourage osseointegration. Relatively high compressive acetabular and contact stresses were observed in these models. The press-fit procedure showed a moderate influence on the contact mechanics at the bearing surfaces, but produced marked deformation of the acetabular components. No edge contact was predicted for the acetabular components studied.

It is concluded that the frictional compressive stresses generated by the 1 mm to 2 mm interference-fit acetabular components, together with the minimal micromovement, would provide adequate stability for the implant, at least in the immediate post-operative situation.

Limited access surgery is thought to reduce post-operative morbidity and provide faster recovery of function. The percutaneous compression plate (PCCP) is a recently introduced device for the fixation of intertrochanteric fractures with minimal exposure. It has several potential mechanical advantages over the conventional compression hip screw (CHS). Our aim in this prospective, randomised, controlled study was to compare the outcome of patients operated on using these two devices.

We randomised 104 patients with intertrochanteric fractures (AO/OTA 31.A1–A2) to surgical treatment with either the PCCP or CHS and followed them for one year postoperatively.

The mean operating blood loss was 161.0 ml (8 to 450) in the PCCP group and 374.0 ml (11 to 980) in the CHS group (Student’s t-test, p < 0.0001). The pain score and ability to bear weight were significantly better in the PCCP group at six weeks post-operatively. Analysis of the radiographs in a proportion of the patients revealed a reduced amount of medial displacement in the PCCP group (two patients, 4%) compared with the CHS group (10 patients, 18.9%); Fisher’s exact test, p < 0.02.

The PCCP device was associated with reduced intra-operative blood loss, less postoperative pain and a reduced incidence of collapse of the fracture.

We reviewed 142 consecutive primary total hip replacements implanted into 123 patients between 1988 and 1993 using the Exeter Universal femoral stem. A total of 74 patients (88 hips) had survived for ten years or more and were reviewed at a mean of 12.7 years (10 to 17). There was no loss to follow-up.

The rate of revision of the femoral component for aseptic loosening and osteolysis was 1.1% (1 stem), that for revision for any cause was 2.2% (2 stems), and for re-operation for any cause was 21.6% (19 hips). Re-operation was because of failure of the acetabular component in all but two hips.

All but one femoral component subsided within the cement mantle to a mean of 1.52 mm (0 to 8.3) at the final follow-up. One further stem had subsided excessively (8 mm) and had lucent lines at the cement-stem and cement-bone interfaces. This was classified as a radiological failure and is awaiting revision. One stem was revised for deep infection and one for excessive peri-articular osteolysis. Defects of the cement mantle (Barrack grade C and D) were found in 28% of stems (25 hips), associated with increased subsidence (p = 0.01), but were not associated with endosteal lysis or failure.

Peri-articular osteolysis was significantly related to the degree of polyethylene wear (p < 0.001), which was in turn associated with a younger age (p = 0.01) and male gender (p < 0.001).

The use of the Exeter metal-backed acetabular component was a notable failure with 12 of 32 hips (37.5%) revised for loosening. The Harris-Galante components failed with excessive wear, osteolysis and dislocation with 15% revised (5 of 33 hips). Only one of 23 hips with a cemented Elite component (4%) was revised for loosening and osteolysis.

Our findings show that the Exeter Universal stem implanted outside the originating centre has excellent medium-term results.

We reviewed 13 patients with infected nonunion of the distal femur and bone loss, who had been treated by radical surgical debridement and the application of an Ilizarov external fixator. All had severely restricted movement of the knee and a mean of 3.1 previous operations. The mean length of the bony defect was 8.3 cm and no patient was able to bear weight.

The mean external fixation time was 309.8 days. According to Paley’s grading system, eight patients had an excellent clinical and radiological result and seven excellent and good functional results. Bony union, the ability to bear weight fully, and resolution of the infection were achieved in all the patients. The external fixation time was increased when the definitive treatment started six months or more after the initial trauma, the patient had been subjected to more than four previous operations and the initial operation had been open reduction and internal fixation.

Peri-prosthetic bone loss caused by stress shielding may be associated with aseptic loosening of femoral components. In order to increase primary stability and to reduce stress shielding, a three-dimensional, cementless individual femoral (Evolution K) component was manufactured using pre-operative CT scans. Using dual energy x-ray absorptiometry, peri-prosthetic bone density was measured in 43 patients, three months, six months, 3.6 and 4.6 years after surgery. At final follow-up there was a significant reduction in mean bone density in the proximal Gruen zones of −30.3% (zone 7) and −22.8% (zone 1). The density in the other zones declined by a mean of between −4% and −16%. We conclude that the manufacture of a three-dimensional, custom-made femoral component could not prevent a reduction in peri-prosthetic bone density.

We present the medium-term results of hybrid total hip arthroplasties using pre-coated stems with a second-generation cementing technique. The 128 hips in 111 patients (18 men and 93 women) were followed up at a mean of 11 years after surgery. The mean age at the time of surgery was 61 years. Both components of one hip were removed at ten months after surgery for infection. None of the other 127 femoral components showed possible, probable, or definite loosening at the most recent follow-up. Five acetabular components were revised for aseptic loosening, recurrent dislocation, or displacement of the polyethylene liner from the metal shell. The mean Harris hip score at follow-up was 84 points. A pre-coated femoral component with a second-generation cementing technique provides good clinical function and survival in the medium term.

Fragility fractures of the ankle occur mainly in elderly osteoporotic women. They are inherently unstable and difficult to manage. There is a high incidence of complications with both non-operative and operative treatment.

We treated 12 such fractures by closed reduction and stabilisation using a retrograde calcaneotalotibial expandable nail. The mean age of patients was 84 years (75 to 95). All were women and were able to walk fully weight-bearing after surgery. There were no wound complications. One patient died from a myocardial infarction 24 days after surgery. The 11 other patients were followed up for a mean of 67 weeks (39 to 104).

All the fractures maintained satisfactory alignment and healed without delay. Six patients refused removal of the nail after union of the fracture. The functional rating using the scale of Olerud and Molander gave a mean score at follow-up of 61, compared with a pre-injury value of 70.

We reviewed retrospectively the results in 211 consecutive patients who had undergone limb salvage for bone neoplasia with endoprosthetic reconstruction of the proximal femur (96), distal femur (78), proximal tibia (30) and total femur (7). Their mean age was 50 years (11 to 86) and the mean follow-up period was 37.3 months (1 to 204). A total of 35 (16.6%) prostheses failed. Overall, implant survival was 78% (95% confidence interval (CI) 0.29 to 0.54) at five years, 60% (95% CI 0.93 to 2.35) at ten years and 60% (95% CI 1.27 to 3.88) at 15 years. Survivorship of the limb was 97.6% (95% CI 1.73 to 3.35) at ten years. The gender, age, diagnosis and location of the tumour were not prognostic variables for failure. Modular endoprosthetic replacement in the lower limb is a durable long-term reconstructive option, with the implants generally outlasting the patient.

We have evaluated the functional, clinical and radiological outcome of patients with simple and complex acetabular fractures involving the posterior wall, and identified factors associated with an adverse outcome.

We reviewed 128 patients treated operatively for a fracture involving the posterior wall of the acetabulum between 1982 and 1999. The Musculoskeletal Functional Assessment and Short-Form 36 scores, the presence of radiological arthritis and complications were assessed as a function of injury, treatment and clinical variables.

The patients had profound functional deficits compared with the normal population. Anatomical reduction alone was not sufficient to restore function. The fracture pattern, marginal impaction and residual displacement of > 2 mm were associated with the development of arthritis, which related to poor function and the need for hip replacement. It may be appropriate to consider immediate total hip replacement for patients aged > 50 years with marginal impaction and comminution of the wall, since 7 of 13 (54%) of these required early hip replacement.