We reviewed 14 patients (16 hips) treated by open reduction and upper femoral derotation osteotomy for congenital dislocation of the hip. Nine patients with 11 treated hips had growth deformities of the proximal femur; in all of them the top screw of the fixation plate lay within the cartilaginous precursor of the greater trochanter. In the five control hips the top screw was more distal. In the nine patients (mean follow-up 10.8 years) there was an increase of 14 degrees in the neck-shaft angle (p = 0.01) and of 18 degrees in the angle between the capital femoral physis and the shaft (p = 0.01) compared to the control group. This indicates that growth disturbance of the greater trochanteric apophysis as a result of plate fixation leads to long-term deformity

Complete fractures through bone affected by Paget's disease may not deserve their innocent reputation. This retrospective study of 182 such femoral fractures, the largest reported series to date, was carried out to discover the behaviour of these fractures in the absence of specific therapy for the Paget's disease. Most previous series have concluded that healing is uneventful but the findings in these patients from the West Midlands do not bear this out. After exclusion of the early deaths, the overall incidence of non-union was 40 per cent, the main problems being posed by the subtrochanteric fractures and those of the upper shaft. Although callus may be abundant, it may itself be involved in the disease process and is not a reliable sign of union. Based on these observations, suggestions for management in the different regions of the femur are made

The results of 140 total hip revision procedures for "non-septic" loosening, dislocation, and fracture of the femoral stem or shaft have been personally reviewed and rated by the Harris method. The minimum follow-up period was six months: thirty-three (24 per cent) showed excellent or good results, seventy-two (51 per cent) showed fair or poor results. Subsequent excision arthroplasty was performed in thirty-one patients. The infection rate for these revision procedures was very high, suggesting that many were already infected at the time of revision, and that every "loose" hip must be assumed to be infected until proved otherwise. The mortality rate of 3 per cent was surprisingly low after more than one major surgical procedure in these elderly patients

1. The surgical treatment of idiopathic aseptic necrosis of the femoral head has been reviewed in the light of experience gained from 240 hips operated upon. 2. When pain is not severe and the necrosis of bone as seen in serial radiographs is not rapidly progressive, simple observation and palliative medical treatment are indicated. 3. When pain disables the patient and collapse of the head is progressive, operation is indicated. If radiographs show necrosis limited to the anterior part of the head and sparing an arc of at least 20 degrees of the lateral part, either an osteotomy bringing the shaft into adduction and flexion or an "adjusted cup" arthroplasty is indicated, with a preference for the latter because it gives better results in a shorter time. 4. If at arthrotomy the necrosis appears to involve the posterior slope of the head, prosthetic replacement, preferably total, should be undertaken

The results of 110 operations for the treatment of fractures through metastases in the femoral neck and intertrochanteric region have been studied. Of these, forty-four fractures were treated by internal fixation, forty-six by resection of the femoral head and neck, and twenty by prosthetic replacement. The following conclusions were reached. 1. Prosthetic replacement of the femoral head is a reliable procedure. 2. The long stem type of prosthesis has the advantages of greater stability and simultaneous fixation of the shaft. 3. Patients with diffuse metastatic disease of the ilium are not suitable for prosthetic replacement. These patients should be treated by resection of the femoral head and neck. 4. Resection is a less traumatic procedure and therefore useful in the palliative treatment of patients in poor general condition. 5. Internal fixation leads more often to complications and unfavourable results than do the other methods

We used the stainless steel cable grip system described by Dall and Miles in 1983 to fix trochanters in 40 hips after total arthroplasty with trochanteric osteotomy. The cable broke in 32.5% of the hips; the trochanter failed to unite in 37.5%. Significantly more cables broke when placed inside the femoral canal than when the cable was placed round the femoral shaft (58% as against 9.5%, difference p less than 0.01). The high incidence of breakage may have resulted from contact between the stainless steel cable and the titanium prosthesis, from the acute angulation, or because of the lower fatigue strength of stainless steel. Better results have been obtained using cables with a higher fatigue strength, passed outside the proximal femur

Total hip replacement was performed in 27 hips of patients who had sickle cell anaemia with avascular necrosis of the femoral head. The disease was bilateral in 11 patients. Considerable medical problems were encountered although most of the patients had exchange transfusion before surgery (86%), which prevented postoperative sickle cell crises in all but two cases. At the primary operation hard sclerotic bone was seen in nine femora with complete obliteration of the femoral canal. There were four femoral fractures, three following perforation of the shaft due to this hard bone. There was a very high morbidity due to loosening in both cemented and uncemented prostheses. With a rate of 59% over a cumulative 5.5 year period, revision was being performed at an average of only 43 months. Surgeons should be aware of these problems

1. Fracture of the neck of the femur in childhood and its complications are discussed. 2. The high incidence of these complications is not generally appreciated–in this series of twenty-four patients only eight achieved normal hip joints. 3. The complications are due to the arrangement of the blood supply to the head and neck. Avascular necrosis is unavoidable in a high proportion, and is not directly related to any particular method of treatment. 4. Extreme care and gentleness in handling the injured limb will help to reduce the incidence of deformities; internal fixation is not suitable for the very young as it may predispose to necrosis or may damage the epiphysis. In older children it can be used with care. 5. Where growth is still taking place in the limb the retention of the angle between neck and shaft is most important, as this will prevent coxa vara and progressive shortening with the consequent unsightly Trendelenburg limp

With the identification of literature shortfalls on the techniques employed in intraoperative navigated (ION) spinal surgery, we outline a number of measures which have been synthesised into a coherent operative technique. These include positioning, dissection, management of the reference frame, the grip, the angle of attack, the drill, the template, the pedicle screw, the wire, and navigated intrathecal analgesia. Optimizing techniques to improve accuracy allow an overall reduction of the repetition of the surgical steps with its associated productivity benefits including time, cost, radiation, and safety.

Cite this article: Bone Joint J 2020;102-B(3):371–375.

We investigated the spines of 15 patients who had significant leg-length inequality as a result of femoral shaft fractures sustained after skeletal maturity but below the age of 21 years. The patients were examined at least 10 years after fracture. The spines were studied clinically and radiographically before and after correction of leg-length inequality with a shoe-raise. Lateral spinal flexion was measured from radiographs. The lumbar scoliosis associated with the leg-length inequality was compensatory: after equalisation of leg-length the overall curve and the axial rotation were corrected completely. There was also an equal range of lateral flexion to either side after correction. Minor malalignments of the whole spine remained despite correction of the compensatory scoliosis, and within the lumbar spine correction of the scoliosis had not occurred equally at all levels. No patients complained of significant discomfort and neither structural abnormalities nor degenerative changes were seen on the radiographs

In this study of fractures of the shaft of the tibia and femur in children, the growth rate of these long bones after injury was assessed by serial radiographical measurements of bone length, accurate to the nearest millimetre. Within three months of injury the rate of growth was at its maximum and was 38 per cent in excess of normal. The rate then decreased but remained significantly raised for two years and returned to normal in the tibia approximately 40 months after injury and in the femur between 50 and 60 months. The uninjured tibia in the same limb as a fractured femur also underwent an acceleration of growth, but to a lesser degree. An uninjured femur was not so affected by an injured tibia. The growth rate in these limbs was unaffected by the age or sex of the child, or the site or direction of the fracture. These findings may be of clinical use in the timing of corrective treatment where a leg length discrepancy exists as a result of injury to, or malunion of, a long bone in the lower limb of a child

1. One hundred and eight osteotomies were reviewed with regard to union, and fourteen were found to be ununited. In only one was non-union detected clinically; the others required radiographic demonstration. Tomographs were particularly helpful in confirming non-union. 2. Nine patients with non-union had pain, equal to or worse than before operation. The pain could not be distinguished from that of osteoarthritis of the hip. 3. Six of the patients with non-union needed an operation. Five had cancellous bone grafts followed by union in all except one. 4. The causes of non-union are reviewed. This complication was found to be less frequent in patients above sixty with stiff hips and bony collapse on the radiograph. Horizontal osteotomy with a displacement of not more than one-third of the diameter of the shaft reduced the incidence of non-union. The variable-angle nail-plate provided the best fixation. Traction provided no benefit and increased the incidence of non-union. Weight bearing is best avoided for eight weeks

1. The customary method of broaching and of knocking the prosthesis down into the neck of the femur produces an indeterminate interference fit. 2. The usual interference fit may suffer progressive breakdown under even small, steady loads. This results in a permanent relative movement between prosthesis and femur as the metal insert "beds " into the bone. 3. Modification of the usual practice by providing a clearance fit between prosthesis and femur and cementing of the metal into the bone provides a system which has been shown to be free of breakdown under steady loads up to about 450 pounds. 4. By cementing the prosthesis shaft into the femur permanent relative movement between the elements has been shown to be reduced from approximately four-hundredths of an inch per 100 pounds load to two ten-thousandths of an inch per 100 pounds load–that is, a reduction of 200 to 1

1. If a vertical load is applied to the head of the femur parallel to its shaft, the upper cortex is stretched and the lower cortex is compressed. The neck breaks from the upper subcapital border to the lesser trochanter. This type of fracture is rarely found clinically. 2. If a compressive force is applied to the area between head and greater trochanter while the head is loaded vertically, a transverse fracture of clinical appearance is produced. If this axial pressure acts along the part of the neck above the central axis a subcapital comminuted fracture results. If the pressure acts below the central axis the result is a transcervical fracture. 3. Strain gauge experiments have shown that axial compression within the upper segment of the neck is produced by the abductor muscles of the hip. Adductor muscles produce a low axial compression. It is suggested that muscular action at the time of injury influences the type of fracture produced by the injury

1. The arterial supply of the upper end of the femur has been studied in twenty-four children and twenty adults. 2. The arterial system was demonstrated by injection of radio-opaque material, with Spalteholz' method of clarification, and histological section of the neck and ligamentum teres. 3. The upper end of the femur is supplied by the nutrient artery of the shaft, the retinacular vessels of the capsule, and the foveolar artery of the ligamentum teres. 4. The retinacular vessels consist of three separate groups: postero-superior, posteroinferior, and anterior. These vessels are the chief supply to the epiphysis and femoral head at all ages. 5. The foveolar artery constitutes a small and subsidiary blood supply to the femoral epiphysis. In this series, it penetrated the cartilaginous or osseous head in 33 per cent. of young specimens and 70 per cent. of adult specimens. The foveolar vessels increase in size with age. 6. The site of the vascular pathology in various lesions of the femoral head is considered

We compared 54 patients treated by a Medoff sliding plate (MSP) with 60 stabilised by a compression hip screw (CHS) in a prospective, randomised study of the management of intertrochanteric femoral fractures. Four months after the operation femoral shortening was determined from radiographs of both femora. In unstable fractures the mean femoral shortening was 15 mm with the MSP and 11 mm with the CHS (p = 0.03). A subgroup in which shortening was classified as large, comprising one-third of the patients in each group, had a similar extent of shortening, but more medialisation of the femoral shaft occurred in the CHS (26%) than in the MSP (12%) group (p = 0.03). Five postoperative failures of fixation occurred with the CHS and none with the MSP (p = 0.03). The marginally greater femoral shortening seen with the MSP compared with the CHS appeared to be justified by the improved control of impaction of the fracture. Biaxial dynamisation in unstable intertrochanteric fractures is a safe principle of treatment, which minimises the rate of postoperative failure of fixation

We have used the Ilizarov technique for severe flexion deformity of the knee in 11 patients (13 knees) between 1986 and 1994 and have followed them up for an average of 4.1 years. The age of the patients at operation ranged from 1.7 to 18.8 years. The femoral and tibial components were connected by two anterior hinges, medial and lateral, and two posterior distraction rods. The deformity was corrected to a femorotibial lateral shaft angle of less than 20°. A permanent orthosis was applied after removal of the fixator. Fractures occurred in four patients and paralysis of the common peroneal nerve in another. There was a recurrence of the deformity in four patients. At the last review all patients were able to walk on their operated leg with or without an orthosis. We have found the Ilizarov method to be helpful in correcting severe fixed flexion deformity of the knee, with relatively few complications, but the basic principles of the method must be carefully followed

We treated 50 consecutive patients with infected total hip arthroplasties according to a standard protocol. Previous surgery to eradicate the infection had been attempted in 13 patients and discharging sinuses were present in 20. Aspiration arthrography was routinely carried out before our interventions. The first stage was a meticulous removal of all foreign and potentially infected material. Samples were taken for culture and a thorough lavage carried out. Antibiotic-loaded beads were placed in the femoral shaft and an antibiotic-loaded cement ball in the acetabulum. At the second stage an uncemented arthroplasty was introduced. Bone allograft was used in 18 patients. The interval between procedures was usually three weeks, but this was extended if the wound was slow to heal or there was extensive bony destruction. Appropriate antibiotics were given for three months. At a mean follow-up of 5.8 years the rate of reinfection was 8% (4 patients). Two of these patients have had another, successful, two-stage revision. At this medium-term review, a satisfactory clinical and radiological outcome was obtained in all except two patients

The Gamma nail was designed to treat unstable intertrochanteric and subtrochanteric fractures. The device was developed after cadaver studies and has been used clinically since February 1985 in a total of 421 patients. The results in 123 patients treated by the third version of this design are reported. The Gamma nail transmits weight closer to the calcar than does the dynamic hip screw and it has greater mechanical strength. A semi-closed operative technique is used, with an average duration of operation of 35 minutes and little blood loss. Distal locking screws can be used to maintain rotational stability, and can be inserted without the use of an image intensifier. Results showed satisfactory fracture union with little loss of position, even in comminuted fractures. Operative complications were few, but included fractures of the base of the greater trochanter. The most important postoperative complication, seen in one case, was fracture of the shaft of the femur at the distal end of the nail, but this healed well after re-nailing