We have designed a modular cemented femoral component for revision of failed total hip arthroplasty in which deficiency of the proximal femur is such as to require a variable extrafemoral portion of the stem. We present the results of the first 74 operations in 72 patients; 56 of the patients had grade-3 or grade-4 femoral deficiency as defined by Gustilo and Pasternak and 24 had fractures of the proximal femur, of which 22 were periprosthetic. There was or had been infection in 19 hips. At a mean follow-up of 5 years 9 months (1 to 12 years) nine stems were radiologically loose of which three had been revised. There were no failures in 45 cases in which there was fixation of the distal stem of 10 cm or more. Dislocation occurred in nine patients and there were four cases of infection in the 19 which were, or had been, infected previously. There were no neurovascular complications and no intraoperative femoral fractures. The femoral bone stock improved radiologically in 45 hips of which 29 showed considerable reformation of the proximal femur; 27 remained unchanged and two showed increasing osteoporosis

Post-traumatic elbow stiffness is a disabling condition that remains challenging for upper limb surgeons. Open elbow arthrolysis is commonly used for the treatment of stiff elbow when conservative therapy has failed. Multiple questions commonly arise from surgeons who deal with this disease. These include whether the patient has post-traumatic stiff elbow, how to evaluate the problem, when surgery is appropriate, how to perform an excellent arthrolysis, what the optimal postoperative rehabilitation is, and how to prevent or reduce the incidence of complications. Following these questions, this review provides an update and overview of post-traumatic elbow stiffness with respect to the diagnosis, preoperative evaluation, arthrolysis strategies, postoperative rehabilitation, and prevention of complications, aiming to provide a complete diagnosis and treatment path.

Cite this article: Bone Joint Open 2020;1-9:576–584.

This abridged account of a report to the British Medical Research Council describes a long-term investigation of 1,503 subcapital fractures of the femur, almost all of which were treated by reduction and internal fixation. With three exceptions, union occurred in all Garden Stage I and Stage II fractures and in 67% of Stage III and Stage IV fractures, of which only 14-5% were united at six months. In women, late segmental collapse was seen after union had occurred in 16% of Stage I and in 27-6% of Stage III and Stage IV fractures. Delay of up to one week before operation had no significant effect on the incidence of non-union or of late segmental collapse. The incidence of union followed by late segmental collapse was higher in women with normal bone density than in those with osteoporosis. Smith-Petersen nailing was found to be the least effective form of fixation in displaced fractures. The age and physical state of the patient, the accuracy of reduction, and the security of fixation had the greatest influence on union

Simple pinning to fix the epiphysis in those patients in whom the position is acceptable is a valuable surgical procedure. It is safe and gives good results. It eliminates the danger of further displacement, promotes fusion of the epiphysial plate and allows the patient to return to full activity within one month, thus avoiding joint stiffness, muscle atrophy, osteoporosis and interference with growth at other sites. Fixation by small pins is preferable to the use of the trifin nail, the latter giving excessive trauma and predisposing to subtrochanteric fracture. Gentle replacement of the epiphysis, when loose, into an acceptable position is a valuable method of treatment. It is essential that replacement is not undertaken by force. The problem of major displacement of the epiphysis which cannot be so replaced is unsolved. Conservative treatment in this group is useless and harmful. Intra-articular osteotomy can give good results in most cases but is risky and may cause stiffening of the hip. Subtrochanteric osteotomy does not give a good anatomical result but in most cases the function of the hip is satisfactory. Slipping of the upper femoral epiphysis, however slight, should be regarded as a surgical emergency

Aims

To compare complication-related reoperation rates following primary arthroplasty for proximal humerus fractures (PHFs) versus secondary arthroplasty for failed open reduction and internal fixation (ORIF).

1. It is well known that the administration of corticosteroids may result in necrosis and progressive destruction of the femoral head. Identical changes have been found in chronic alcoholics, in South African negroes suffering from iron-overload osteoporosis and in patients with arthritis of the hip treated with non-steroid anti-inflammatory and analgesic preparations. The term "drug-induced arthropathy" is used to describe the common pathological lesion. 2. Seventy-two patients with this complication have been investigated and forty-two femoral heads were available for detailed study. The characteristic change is subchondral fragmentation and osteonecrosis, followed later by reactive bone formation and the typical increased radiographic density. 3. The frequent occurrence of fat occupying the Haversian canals in the affected femoral heads has not been adequately explained and its relationship to the destructive arthropathy remains obscure. The findings presented here do not support the theory that fat emboli are responsible for the subchondral bone changes. 4. More credence is given to the theory of subchondral microfracture in osteoporotic bone. The destructive arthropathy invariably follows the administration of some anti-inflammatory or analgesic preparation. It is postulated that a state of diminished sensibility predisposes to microtrauma in osteoporotic bone resulting in subarticular collapse of the femoral head

We have studied the effect of hydroxyapatite (HA) coating in 15 ovariectomised and 15 normal rats which had had a sham procedure. Twenty-four weeks after operation, HA-coated implants were inserted into the intramedullary canal of the right femur and uncoated implants into the left femur. The prostheses were removed four weeks after implantation. Twelve specimens in each group had mechanical push-out tests. Sagittal sections of the other three were evaluated by SEM. The bone mineral density (BMD) of the dissected left tibia was measured by dual-energy x-ray absorptiometry. The difference in BMD between the control and ovariectomised tibiae was 35.01 mg/cm. 2. (95% CI, 26.60 to 43.42). The push-out strength of the HA-coated implants was higher than that of the uncoated implants in both groups (p < 0.0001), but the HA-coated implants of the ovariectomised group had a reduction in push-out strength of 40.3% compared with the control group (p < 0.0001). Our findings suggest that HA-coated implants may improve the fixation of a cementless total hip prosthesis but that the presence of osteoporosis may limit the magnitude of this benefit

The aim of limb-salvage surgery in malignant bone tumours in children is to restore function and eradicate local disease with as little morbidity as possible. Allografts are associated with a high rate of complications, particularly malunion at the allograft-host junction. We describe a simple technique which enhances union of allograft to host bone taking advantage of the discrepancy in size between the adult allograft and the child’s bone. This involves lifting a flap of periosteum before resection from the host bone, which is then telescoped into the allograft medullary canal, which may require internal burring or splitting, for a distance of 1.5 to 2 cm and covering the bone junction with the periosteal flap. This is more stable than conventional end-to-end opposition. For each centimetre of telescoping the surface area available for bony union is increased more than three times. The periosteal flap also augments union. Additional surface fixation with a plate and screws is not necessary. We have used this technique in nine children, in eight of whom there was complete union at a mean of 16 weeks. Delayed union, associated with generalised limb osteoporosis, occurred in one. Early mobilisation, with weight-bearing by three weeks, was possible. There was only one fracture of the allograft

1. The appearance of decalcified bone matrix in the electron microscope is described. 2. In the matrix two types of collagen fibril have been distinguished. Differences observed are in solubility, x-ray diffraction pattern and appearance. In infant bone the form which appears as fine fibrils predominates. In adult bone the form which appears as tubular fibrils of larger diameter predominates. 3. In bones from elderly subjects the chemical reaction employed to convert collagen into eucollagen sometimes hydrolyses fatty acid esters, and lines due to the free fatty acid are found on the x-ray diffraction patterns of the insoluble residue after citrate extraction. 4. In ancient bones and fossils the stable tubular form of collagen survives, but not the fine fibrils. 5. When decalcified, the matrix in osteoporotic bones loses its architecture and fibrillar form. Under conditions in which only a small fraction is dissolved from normal bone most of the collagen in osteoporotic bone disperses in citric acid. The insoluble residue then gives a modified x-ray diffraction pattern. 6. Evidence has been produced to suggest that the immediate cause of many forms of osteoporosis is some local factor affecting the osteocytes, rather than a general chemical effect

Aims

The aim of this study is to report the results of a case series of olecranon fractures and olecranon osteotomies treated with two bicortical screws.

1. Osteogenesis imperfecta is characterised by osseous fragility. Patients with the "congenita" form have multiple fractures before birth; those with the "tarda" form have osteoporosis, and develop multiple fractures and milder deformities of long bones at varying times after birth. 2. The frequency of blue sclera, dentinogenesis imperfecta, bruising, ligamentous laxity, and deafness are recorded in sixty patients seen at the Hospital for Sick Children, Toronto, from 1949 to 1969. The major orthopaedic deformities of long bones were antero-lateral bowing of femur and anterior bowing (sabre shin) of tibia. 3. The incidence of scoliosis (40 per cent) is high in osteogenesis imperfecta. Two patients, one in Toronto and one in Seattle, have had Harrington instrumentation and fusion for this. 4. Fractures were commonest in the femur and tibia and few in the cervical spine and femoral neck. There were four cases of disturbing hyperplastic callus formation. 5. Twenty-one patients were operated on for long bone deformities and recurrent fractures by the Sofield technique. Despite extensive subperiosteal dissection non-union is rare (four cases). Fourteen of twenty-one patients so treated are able to walk, with or without assistance. Surgical intervention to both correct and prevent deformities is justified. 6. Patients with osteogenesis imperfecta compensated for their disability by reasonable academic achievement and by choosing a sedentary occupation

Bone growth into cementless prosthetic components is compromised by osteoporosis, by any gap between the implant and the bone, by micromotion, and after the revision of failed prostheses. Recombinant human transforming growth factor-β1 (rhTGF-β1) has recently been shown to be a potent stimulator of bone healing and bone formation in various models in vivo. We have investigated the potential of rhTGF-β1, adsorbed on to weight-loaded tricalcium phosphate (TCP) coated implants, to enhance bone ongrowth and mechanical fixation. We inserted cylindrical grit-blasted titanium alloy implants bilaterally into the weight-bearing part of the medial femoral condyles of ten skeletally mature dogs. The implants were mounted on special devices which ensured stable weight-loading during each gait cycle. All implants were initially surrounded by a 0.75 mm gap and were coated with TCP ceramic. Each animal received two implants, one with 0.3 μg rhTGF-β1 adsorbed on the ceramic surface and the other without growth factor. Histological analysis showed that bone ongrowth was significantly increased from 22 ± 5.6% bone-implant contact in the control group to 36 ± 2.9% in the rhTGF-β stimulated group, an increase of 59%. The volume of bone in the gap was increased by 16% in rhTGF-β1-stimulated TCP-coated implants, but this difference was not significant. Mechanical push-out tests showed no difference in fixation of the implant between the two groups. Our study suggests that rhTGF-β1 adsorbed on TCP-ceramic-coated implants can enhance bone ongrowth

We measured the extent and rate of new bone formation over an 18-month period before, during and after the lengthening of ten leg segments in six patients aged between 8 and 18 years, using dual-energy X-ray absorptiometry (DEXA). New bone formation could be identified within one week of the start of distraction. As lengthening proceeded, the bone density of the gap fell, reaching minimum values at the time of maximal distraction. Consolidation of the regenerating bone was started 1 to 2 weeks later in the tibia, and 2.5 to 3.0 weeks later in the femur. The rate of mineral accretion in new bone was significantly greater in the tibia than in the femur (16 +/- 1.86%/month, and 11 +/- 1.1%/month respectively; mean +/- SEM). There was significant osteoporosis distal to the osteotomy, more in the tibia than in the femur, particularly on the side of the fixator. The bone mineral density of the distal segment remained low at the time of fixator removal (44.2 +/- 5.58% and 61.0 +/- 4.2% of the control values at the tibia and femur respectively) and was only partially reversed by subsequent weight-bearing. We conclude that dual-energy X-ray absorptiometry provides an objective and quantitative assessment of new bone formation during leg lengthening. The technique also allows the measurement of the distraction gap and the assessment of leg alignment from the high-resolution images. Its use may decrease the requirements for conventional radiography

1. This paper presents a series of 135 patients with displaced ankle fractures treated by rigid internal fixation followed by early joint exercises in bed until movements were restored and followed then by full weight bearing in a plaster. 2. The advantages obtained are as follows: A high standard of reduction can be achieved and maintained. The joint movements are established before organisation of the traumatic exudate. Weight bearing in a plaster reduces the degree of disability and prevents osteoporosis. Further remedial treatment after removal of the plaster is usually unnecessary. 3. All but five of the fractures (3·7 per cent) could be classified in the manner described by Lauge-Hansen. 4. This classification is the most satisfactory of those available and is recommended for general use. 5. Anatomical reduction was obtained in 102 patients (77 per cent), with good objective clinical results in 108 patients (82 per cent). 6. The quality of the clinical result depends mostly on the accuracy of the reduction, to a lesser extent on the degree of initial displacement, and least on the type of fracture. 7. It is considered that the traditional concept of diastasis requires modification; it is felt that the term lateral ankle instability, which includes low fracture of the fibula (intraosseous diastasis) is preferable. 8. Internal fixation of the syndesmosis is to be avoided except in rare instances. 9. The incidence of arthritis is shown to depend mostly upon the accuracy of reduction; the initial degree of displacement is also of importance

1. The effect of immobilisation on bone formation has been investigated in the rat. As chlortetracycline has the property of being deposited preferentially in areas of newly deposited bone, its uptake can be used as a reflection of osseous formation. 2. One hind limb of albino rats was immobilised either by section of the second, third and fourth lumbar nerve trunks or by section of tendo calcaneus and ligamentum patellae. The incorporation of chlortetracycline was determined quantitatively in the femur and tibia of both hind limbs at intervals after immobilisation. 3. Tetracycline uptake is expressed in terms of bone weight, this being most important in order to obtain correct values. 4. A comparison between the tetracycline uptake and the weight of the bones gives information about the rate of bone destruction. 5. In animals immobilised by nerve section three phases can be distinguished: a first phase with diminished bone formation, a second with increased formation and increased destruction and a third phase with diminished bone formation. Both mechanisms, decreased formation and increased destruction, are therefore important in the production of immobilisation osteoporosis; their relative importance depending upon the duration of the immobilisation. 6. In animals immobilised by tendon section the mechanical function becomes restored in the second week as a result of healing: this explains the rapid compensation for the initial loss of weight of the bones accompanied by a marked increase in tetracycline uptake. 7. These results are discussed and compared with information in the literature. Variations in bone formation and destruction rates with time could explain the varied results reported by other authors

Aims

Bone health assessment and the prescription of medication for secondary fracture prevention have become an integral part of the acute management of patients with hip fracture. However, there is little evidence regarding compliance with prescription guidelines and subsequent adherence to medication in this patient group.

Aims

Currently, the US Center for Medicaid and Medicare Services (CMS) has been testing bundled payments for revision total joint arthroplasty (TJA) through the Bundled Payment for Care Improvement (BPCI) programme. Under the BPCI, bundled payments for revision TJAs are defined on the basis of diagnosis-related groups (DRGs). However, these DRG-based bundled payment models may not be adequate to account appropriately for the varying case-complexity seen in revision TJAs.

Aims

Elective surgery has been severely curtailed as a result of the COVID-19 pandemic. There is little evidence to guide surgeons in assessing what processes should be put in place to restart elective surgery safely in a time of endemic COVID-19 in the community.

Aims

Sickle cell disease (SCD) is an autosomal recessive inherited condition that presents with a number of clinical manifestations that include musculoskeletal manifestations (MM). MM may present differently in different individuals and settings and the predictors are not well known. Herein, we aimed at determining the predictors of MM in patients with SCD at the University Teaching Hospital, Lusaka, Zambia.