Aims

To report the outcome of spinal deformity correction through anterior spinal fusion in wheelchair-bound patients with myelomeningocele.

Avascular necrosis of the scaphoid following a fracture in children is rare and there is no established treatment protocol in the literature. We present two boys with nonunion and avascular necrosis of the scaphoid treated by simple immobilisation. Both cases healed with painless wrists and full movements. Our cases confirm that an ununited scaphoid fracture in children may heal with conservative treatment, even when an MRI scan suggests avascular necrosis. Unlike in adults, operative treatment need only be considered in children when conservative treatment fails

Most patients with a nightstick fracture of the ulna are treated conservatively. Various techniques of immobilisation or early mobilisation have been studied. We performed a systematic review of all published randomised controlled trials and observational studies that have assessed the outcome of these fractures following above- or below-elbow immobilisation, bracing and early mobilisation. We searched multiple electronic databases, related bibliographies and other studies. We included 27 studies comprising 1629 fractures in the final analysis. The data relating to the time to radiological union and the rates of delayed union and nonunion could be pooled and analysed statistically. We found that early mobilisation produced the shortest radiological time to union (mean 8.0 weeks) and the lowest mean rate of nonunion (0.6%). Fractures treated with above- or below-elbow immobilisation and braces had longer mean radiological times to union (9.2 weeks, 9.2 weeks and 8.7 weeks, respectively) and higher mean rates of nonunion (3.8%, 2.1% and 0.8%, respectively). There was no statistically significant difference in the rate of non- or delayed union between those treated by early mobilisation and the three forms of immobilisation (p = 0.142 to p = 1.000, respectively). All the studies had significant biases, but until a robust randomised controlled trial is undertaken the best advice for the treatment of undisplaced or partially displaced nightstick fractures appears to be early mobilisation, with a removable forearm support for comfort as required. Cite this article: Bone Joint J 2013;95-B:952–9

Aims

Monocyte-lymphocyte ratio (MLR) or neutrophil-lymphocyte ratio (NLR) are useful for diagnosing periprosthetic joint infection (PJI), but their diagnostic values are unclear for screening fixation-related infection (FRI) in patients for whom conversion total hip arthroplasty (THA) is planned after failed internal fixation for femoral neck fracture.

Transarticular screw fixation with autograft is an established procedure for the surgical treatment of atlantoaxial instability. Removal of the posterior arch of C1 may affect the rate of fusion. This study assessed the rate of atlantoaxial fusion using transarticular screws with or without removal of the posterior arch of C1. We reviewed 30 consecutive patients who underwent atlantoaxial fusion with a minimum follow-up of two years. In 25 patients (group A) the posterior arch of C1 was not excised (group A) and in five it was (group B). Fusion was assessed on static and dynamic radiographs. In selected patients CT imaging was also used to assess fusion and the position of the screws. There were 15 men and 15 women with a mean age of 51.2 years (23 to 77) and a mean follow-up of 7.7 years (2 to 11.6). Stable union with a solid fusion or a stable fibrous union was achieved in 29 patients (97%). In Group A, 20 patients (80%) achieved a solid fusion, four (16%) a stable fibrous union and one (4%) a nonunion. In Group B, stable union was achieved in all patients, three having a solid fusion and two a stable fibrous union. There was no statistically significant difference between the status of fusion in the two groups. Complications were noted in 12 patients (40%); these were mainly related to the screws, and included malpositioning and breakage. The presence of an intact or removed posterior arch of C1 did not affect the rate of fusion in patients with atlantoaxial instability undergoing C1/C2 fusion using transarticular screws and autograft. Cite this article: Bone Joint J 2013;95-B:972–6

Aim

There is insufficient evidence to support bony reconstruction of the pubis after a type III internal hemipelvectomy (resection of all or part of the pubis). In this study, we compared surgical complications, postoperative pain, and functional outcome in a series of patients who had undergone a type III internal hemipelvectomy with or without bony reconstruction.

We studied the effect of trochanteric osteotomy in 192 total hip replacements in 140 patients with congenital hip disease. There was bony union in 158 hips (82%), fibrous union in 29 (15%) and nonunion in five (3%). The rate of union had a statistically significant relationship with the position of reattachment of the trochanter, which depended greatly on the pre-operative diagnosis. The pre-operative Trendelenburg gait substantially improved in all three disease types (dysplasia, low and high dislocation) and all four categories of reattachment position. A persistent Trendelenburg gait post-operatively was noticed mostly in patients with defective union (fibrous or nonunion). Acetabular and femoral loosening had a statistically significant relationship with defective union and the position of reattachment of the trochanter. These results suggest that the complications of trochanteric osteotomy in total hip replacement for patients with congenital hip disease are less important than the benefits of this surgical approach

Fractures and nonunions of the proximal humerus are increasingly treated by open reduction and internal fixation. The extended deltopectoral approach remains the most widely used for this purpose. However, it provides only limited exposure of the lateral and posterior aspects of the proximal humerus. We have previously described the alternative extended deltoid-splitting approach. In this paper we outline variations and extensions of this technique that we have developed in the management of further patients with these fractures

We report a prospective single-blind controlled study of the incidence of early wound infection after internal fixation for trauma in 609 patients, of whom 132 were HIV-positive. Wounds were assessed for healing using the ASEPSIS score. There was no significant difference in the rate of infection between HIV-positive and HIV-negative patients undergoing clean surgery (4.2% vs 6%, respectively; p = 0.65). HIV-positive patients did not receive additional antibiotic prophylaxis or antiretroviral therapy as part of their management. The difference in the rate of infection between HIV-positive and HIV-negative patients with an open fracture or other contamination was not significant (33% vs 15%, respectively; p = 0.064). There was no relationship between CD4 count and infection rate. HIV status did not significantly influence the number of secondary surgical procedures (p = 0.183) or the likelihood of developing chronic osteomyelitis (p = 0.131). Although previous contamination from the time of injury was a risk factor for infection in mal- and nonunions, it was not significantly increased in HIV-positive patients (p = 0.144). We conclude that clean implant surgery in HIV-positive patients is safe, with no need for additional prophylaxis

We report the clinical and radiological outcome of subcapital osteotomy of the femoral neck in the management of symptomatic femoroacetabular impingement (FAI) resulting from a healed slipped capital femoral epiphysis (SCFE). We believe this is only the second such study in the literature. . We studied eight patients (eight hips) with symptomatic FAI after a moderate to severe healed SCFE. There were six male and two female patients, with a mean age of 17.8 years (13 to 29). . All patients underwent a subcapital intracapsular osteotomy of the femoral neck after surgical hip dislocation and creation of an extended retinacular soft-tissue flap. The mean follow-up was 41 months (20 to 84). Clinical assessment included measurement of range of movement, Harris Hip Score (HHS) and Western Ontario and McMaster Universities Osteoarthritis score (WOMAC). Radiological assessment included pre- and post-operative calculation of the anterior slip angle (ASA) and lateral slip angle (LSA), the anterior offset angle (AOA) and centre head–trochanteric distance (CTD). The mean HHS at final follow-up was 92.5 (85 to 100), and the mean WOMAC scores for pain, stiffness and function were 1.3 (0 to 4), 1.4 (0 to 6) and 3.6 (0 to 19) respectively. There was a statistically significant improvement in all the radiological measurements post-operatively. The mean ASA improved from 36.6° (29° to 44°) to 10.3° (5° to 17°) (p <  0.01). The mean LSA improved from 36.6° (31° to 43°) to 15.4° (8° to 21°) (p < 0.01). The mean AOA decreased from 64.4° (50° to 78°) 32.0° (25° to 39°) post-operatively (p < 0.01). The mean CTD improved from -8.2 mm (-13.8 to +3.1) to +2.8 mm (-7.6 to +11.0) (p < 0.01). Two patients underwent further surgery for nonunion. No patient suffered avascular necrosis of the femoral head. Subcapital osteotomy for patients with a healed SCFE is more challenging than subcapital re-orientation in those with an acute or sub-acute SCFE and an open physis. An effective correction of the deformity, however, can be achieved with relief of symptoms related to impingement. Cite this article: Bone Joint J 2014;96-B:1441–8

We identified 16 patients with a mean age of 56.5 years (31 to 86) from a large consecutive series of patients with proximal humeral fractures over a 15-year period, who had sustained a fracture with skin compromise after a blunt injury. The study group represented 0.2% of 7825 proximal humeral fractures treated during this period and all had a displaced Neer two-part fracture pattern. Two patterns of skin injury were identified: in ten patients there was skin penetration at the time of the original injury, and the other six patients initially had closed injuries. These six patients had fracture fragments penetrating the muscular envelope to lie subcutaneously producing either early skin tethering (two patients) or delayed skin penetration and sinus formation (four patients). The pattern of injury to the soft-tissue envelope and the fracture pattern were similar for all injuries. Treatment of these injuries was determined by the initial severity of the soft-tissue injury and the medical status of the patient. We currently favour open reduction and internal fixation of these fractures wherever possible, owing to the high rate of nonunion with non-operative management

Aims

The aim of this study was to investigate whether on-demand removal (ODR) is noninferior to routine removal (RR) of syndesmotic screws regarding functional outcome.

Aims

We aimed to evaluate the long-term impact of fracture-related infection (FRI) on patients’ physical health and psychological wellbeing. For this purpose, quality of life after successful surgical treatment of FRIs of long bones was assessed.

Aims

In contrast to operations performed for other fractures, there is a high incidence rate of surgical site infection (SSI) post-open reduction and internal fixation (ORIF) done for tibial plateau fractures (TPFs). This study investigates the effect of induced membrane technique combined with internal fixation for managing SSI in TPF patients who underwent ORIF.

Aims

To determine the relationship between articular cartilage status and clinical outcomes after medial opening-wedge high tibial osteotomy (MOHTO) for medial compartmental knee osteoarthritis at intermediate follow-up.

Aims

One-stage revision hip arthroplasty for periprosthetic joint infection (PJI) has several advantages; however, resection of the proximal femur might be necessary to achieve higher success rates. We investigated the risk factors for resection and re-revisions, and assessed complications and subsequent re-revisions.

Aims

We have previously reported cryoablation-assisted joint-sparing surgery for osteosarcoma with epiphyseal involvement. However, it is not clear whether this is a comparable alternative to conventional joint arthroplasty in terms of oncological and functional outcomes.