This study identified variables which influence the outcome of surgical management on 126 ununited scaphoid fractures managed by internal fixation and non-vascular bone grafting. The site of fracture was defined by a new method: the ratio of the length of the proximal fragment to the sum of the lengths of both fragments, calculated using specific views in the plain radiographs. Bone healing occurred in 71% (89) of cases. Only the site of nonunion (p = 1 × 10. −6. ) and the delay to surgery (p = 0.001) remained significant on multivariate analysis. The effect of surgical delay on the probability of union increased as the fracture site moved proximally. A prediction model was produced by stepwise logistic regression analysis, enabling the surgeon to predict the success of surgery where the site of the nonunion and delay to surgery is known

Seventy-nine open tibial fractures were treated with unilateral uniplanar tubular external fixators. Excellent stability allowed early weight-bearing. All comminuted fractures, with or without bone loss, and some transverse or short oblique fractures with intermediate fragments were treated by early bone grafting through a posterolateral approach. The external fixator was dynamised as soon as periosteal callus was seen on the radiograph. Bone healing times ranged from 11 to 40 weeks (mean 20). Significant ankle stiffness occurred in 10.9% and leg shortening in 2.8%. Pin track infection was seen in 45.2% but was easily controlled with standard management. The external fixation frame allowed excellent functional freedom for Oriental patients to sit cross-legged and squat. Combined with early bone grafting, external fixation is an excellent method for the management of open tibial fractures

We have reviewed the results of 30 operations performed on 23 patients with Ficat stage-III or stage-IV osteonecrosis of the femoral head in which autogenous cortical and cancellous bone grafting had been performed through a so-called trapdoor made in the femoral head. At a mean of 56 months (30 to 60) after operation 20 of 24 stage-III hips (83%) had a good or excellent result as determined by the Harris hip-scoring system. Two of six stage-IV hips (33%) had good or excellent results. Eighteen of 21 hips (86%) with a combined necrotic angle of 200° had good or excellent clinical results compared with only four of nine hips (44%) with a combined necrotic angle of more than 200°. Six of the eight hips which had fair or poor results were in patients who had received corticosteroids; five of these six hips had lesions with a combined necrotic angle of greater than 200° or were in a late stage (stage IV). There were no perioperative complications. Our results suggest that the trapdoor procedure with autogenous cancellous and cortical bone grafting can be successful in Ficat and Arlet stage-III osteonecrosis of the hip in patients with small- to medium-sized lesions

We have reviewed retrospectively 68 revisions of the femoral component in arthroplasties of the hip in 65 patients, using impaction bone grafting, at a median of three years (1 month to 6 years). We employed the cemented Exeter X-Change technique in 36 patients and the uncemented Bi-Metric allografting method in 32. The 37 bone defects were grade 3 or grade 4 on the Endo-Klinik classification. The Mayo hip score improved from a mean of 32 (. sd. ± 18) to 62 (. sd. ± 15). Most (25) of the 34 complications occurred in grade-3 and grade-4 defects; nine were intraoperative diaphyseal fractures and eight fractures of the greater trochanter. All the fractures united. The risk of intraoperative fracture was prevented by supporting the bone with wires in 16 hips, with reinforcement mesh in 18 and by a plate in six. Early migration of the stem of more than 10 mm during the first year indicated rotational instability; it occurred in three cases. In difficult revision cases with large defects of the femoral bone, bone-impaction techniques carry a high risk of complications

Delayed union or non-union of the scaphoid was treated by a bone graft on a pronator quadratus pedicle in eight cases. This produced earlier union than the Russe procedure. The procedure is simple and is recommended for old un-united scaphoid fractures

We describe a new method of reconstruction after resection of tumours of the proximal tibia by grafting and arthrodesis of the knee. Two separate vascularised bone grafts from the ipsilateral limb were used, one a gastrocnemius-pedicled femoral graft and the other a pedicled fibular graft. An anatomical study of the gastrocnemius-pedicled femoral graft was made. The method was shown to be practical and reproducible. One patient with osteosarcoma has a successful result with no recurrence at two-and-a-half years

Between June 1991 and May 1996 we carried out arthrodesis on 15 patients with flail or partially flail wrists using an AO/ASIF dynamic compression plate (DCP) without a bone graft. The wrist was approached through the second extensor compartment. The minimum follow-up was for 24 months with a mean of 34.2 months. All 15 wrists fused without major complications at a mean of 11.9 weeks. Stabilisation improved the function of the hand affected with paralysis and the appearance of the extensively paralysed upper limb with a flail hand. In the absence of bony abnormality fusion can be obtained with a DCP alone without the need for bone grafting

Dysplastic acetabula were augmented during total hip replacement by superolateral autografts. In cases of primary arthroplasty these were taken from the excised femoral head and in revision surgery from the iliac crest. Two or (usually) three small grafts were used to facilitate revascularisation; they were fixed with lag screws to the roughened iliac bone above the acetabulum. We reviewed 84 hips (63 primary arthroplasties and 21 revisions) more than five years (mean 10.1) after operation. All but one of the grafts showed consolidation within three months and they had become structurally integrated with the iliac bone, as evidenced by the trabecular reorientation. Resorption, which has caused early socket failure when large bone grafts have been used, did not occur

Sixty-one patients with 68 osteonecrotic femoral heads, at different stages of development, were treated surgically; their average age was 36 years. Necrosis followed a fracture in 43 hips and traumatic dislocation in three. It was idiopathic in 14, cortisone-induced in seven and associated with gout in one. The operation of multiple drilling, curettage of the necrotic bone and muscle pedicle bone grafting was performed in all. Cheilectomy of the superolateral part of the femoral head and adductor tenotomy were added in cases of advanced necrosis. Of the several types of muscle pedicle used, tensor fasciae latae anteriorly and quadratus femoris posteriorly were preferred. Full weight-bearing was not permitted for five to six months. The follow-up period varied from three to 12 years. Hip pain was regularly relieved and abduction and rotation of the joints were improved. Those with post-traumatic or idiopathic necrosis did better than those with cortisone-induced necrosis

Aims

This single-centre observational study aimed to describe the results of extensive bone impaction grafting of the whole acetabular cavity in combination with an uncemented component in acetabular revisions performed in a standardized manner since 1993.

We describe a new technique for open reduction, bone grafting and fixation with a single Kirschner wire of unstable fractures of the distal radius. Of the 83 patients treated by this technique, most had regained volar tilt when seen at an average of 13 months after injury. Malunion was seen in 18 patients due either to poor placement of the graft and Kirschner wire or because of both volar and dorsal comminution. Assessment of hand and wrist function showed an average recovery of 63% of mass grip strength with an excellent return of specialised grip strength and range of movement. The advantages of this technique over closed methods include the ability to regain the volar tilt of the distal radius and to achieve reduction at any time before union of the fracture

Fifty-six patients with ununited intracapsular fractures of the femoral neck were treated by internal fixation and muscle-pedicle bone grafting. All had some absorption of the femoral neck, and many had avascular necrosis of the femoral head. At operation the sclerosed surfaces of the fractures were freshened, the avascular femoral head was decompressed and the muscle-pedicle graft was fixed with silk thread wrapped around pins. Satisfactory union occurred in 42 patients (75%), and delayed union in seven, of whom four (7%) eventually united without further treatment and three united after osteotomy. Non-union occurred in five patients and technical failure in two

In fully-grown mongrel dogs, diaphyseal ulnar defects 25 mm long were stabilised by screws and plates, and were temporarily filled with silicone rubber blocks. After eight weeks the block was replaced either by fresh autogeneic cancellous bone, allogeneic deep-frozen cancellous bone, allogeneic decalcified bone matrix, or bone matrix gelatin. After 24 weeks the implants were evaluated by radiography, histology, and measurements of new bone volume, using computer-assisted density registration on microradiographs. Only the autogeneic bone grafts led to healing in all instances. Bone regeneration in the other groups was not significantly better than in the sham group in which no graft was employed. Decalcified bone matrix proved ineffective

Segmental collapse occurs in the early stage of a vascular necrosis (AVN) of the femoral head, and is associated with a poor prognosis. Since it develops at a relatively young age, the long-term outcome after total hip replacement is a major concern. We have compared the long-term results of pedicle bone grafting (PBG) with those of transtrochanteric rotational osteotomy (TRO). In the PBG group there were 23 men (27 hips) and three women (4 hips) with a mean age at the time of surgery of 38 years and a mean follow-up of 13 years. In the TRO group there were 44 men (55 hips) and 19 women (22 hips) with a mean age at the time of surgery of 39 years and a mean follow-up of seven years. Failure was defined as a need for total hip replacement or a Harris hip score below 70. The long-term results were similar for the two groups. The survival rates at five and ten years were 85% and 67%, respectively, in the PBG group, and 71% and 61%, respectively, in the TRO group, according to Kaplan-Meier survivorship analysis. In the TRO group patients in stage II had significantly better results that those in stage III

In revision total hip replacement, bone loss can be managed by impacting porous bone chips. In order to guarantee sufficient mechanical strength, the bone chips have to be compacted. The aim of this study was to determine in an in vitro simulation whether the use of a pneumatic hammer leads to higher primary stability than manual impaction. Bone mass characteristics were measured by force and distance variation of a penetrating punch, which was lowered into a plastic cup filled with bone chips. From these measurements bulk density, contact stiffness, impaction hardness and penetration resistance were calculated for different durations of impaction.

We found that the pneumatic method reached higher values of impaction hardness, contact stiffness and bulk density suggesting an increase in stability of the implant. No significant differences were found between the two different methods concerning the penetration resistance. The pneumatic method might reduce the risk of fracture in vivo, as force peaks are smaller and applied for a shorter period. Results from manual impaction showed higher variability and depend much on the experience of the surgeon. The pneumatic hammer is a suitable tool to standardise the impaction process.

We performed curettage and bone grafting of amyloid cysts of the femoral neck in five patients on long-term haemodialysis. All had had hip pain on weight-bearing. The duration of haemodialysis before the operation averaged 15 years and the average age of the patients was 53 years. All the large cystic lesions were located in the anterosuperior quadrant of the femoral neck. At operation, they were found to consist of fibrous tissue containing amyloid deposits. Postoperatively, all five patients had painless hips and the grafts had incorporated into the bone defects

The use of impacted, morsellised bone grafts has become popular in revision total hip arthroplasty (THA). The initial stability of the reconstruction and the effectiveness of any subsequent process of revitalisation and incorporation will depend on the mechanical integrity of the graft. Our aim in this study was to document the time-dependent mechanical properties of the morsellised graft. This information is useful in clinical application of the graft, in studies of migration of the implant and in the design of the joint. We used 16 specimens of impacted, morsellised cancellous bone from the sternum of goats to assess the mechanical properties by confined compression creep tests. Consideration of the graft material as a porous, permeable solid, filled with fluid, allowed determination of the compressive modulus of the matrix, and its permeability to fluid flow. In all specimens the compression tests showed large, irreversible deformations, caused by flow-independent creep behaviour as a result of rolling and sliding of the bone chips. The mean permeability was 8.82 *10. −12. m. 4. /Ns (SD 43%), and the compressive modulus was 38.7 MPa (SD 34%). No correlation was found between the apparent density and the permeability or between the apparent density and the compressive modulus. The irreversible deformations in the graft could be captured by a creep law, for which the parameters were quantified. We conclude that in clinical use the graft is bound to be subject to permanent deformation after operation. The permeability of the material is relatively high compared with, for example, human cartilage. The confined compression modulus is relatively low compared with cancellous bone of the same apparent density. Designs of prostheses used in revision surgery must accommodate the viscoelastic and permanent deformations in the graft without causing loosening at the interface

Total hip replacement has been very successful in patients with painful, stiff hips associated with protrusio acetabuli, but the heat of polymerisation of methylmethacrylate cement may cause necrosis of the thin medial wall with consequent danger of migration of the cup. Since 1968 at Wrightington, thin slices of the head of the femur have been used as bone grafts to reinforce the acetabulum. We have reviewed 61 hips in 51 patients at an average of 4 years 3 months after operation. Grading for severity is discussed and the degree of physiological remodelling of the medial wall of the acetabulum after grafting assessed. There was an average of about 4 mm of remodelling, but this varied considerably; most took place within the first year. In no case was there relapse of the protrusio

The properties of impacted morsellised bone graft (MBG) in revision total knee arthroplasty (TKA) were studied in 12 horses. The left hind metatarsophalangeal joint was replaced by a human TKA. The horses were then randomly divided into graft and control groups. In the graft group, a unicondylar, lateral uncontained defect was created in the third metatarsal bone and reconstructed using autologous MBG before cementing the TKA. In the control group, a cemented TKA was implanted without the bone resection and grafting procedure. After four to eight months, the animals were killed and a biomechanical loading test was performed with a cyclic load equivalent to the horse’s body-weight to study mechanical stability. After removal of the prosthesis, the distal third metatarsal bone was studied radiologically, histologically and by quantitative and micro CT. Biomechanical testing showed that the differences in deformation between the graft and the control condyles were not significant for either elastic or time-dependent deformations. The differences in bone mineral density (BMD) between the graft and the control condyles were not significant. The BMD of the MBG was significantly lower than that in the other regions in the same limb. Micro CT showed a significant difference in the degree of anisotropy between the graft and host bone, even although the structure of the area of the MBG had trabecular orientation in the direction of the axial load. Histological analysis revealed that all the grafts were revascularised and completely incorporated into a new trabecular structure with few or no remnants of graft. Our study provides a basis for the clinical application of this technique with MBG in revision TKA

We treated three patients with malunion after comminuted intercondylar fractures of the humerus by intra-articular derotational opening-wedge osteotomy and the insertion of a tricortical iliac bone graft. Two patients required additional operations, including interposition arthroplasty and hardware removal. A mean arc of increased motion of 65 degrees was achieved in flexion and extension in two patients and a more functional arc in the third. Although this is viewed as a salvage procedure in patients who are thought to be too young for elbow arthroplasty, none of the three patients has significant pain and none has required total elbow arthroplasty after an average follow-up of 7.6 years