Aims

Preserving growth following limb-salvage surgery of the upper limb in children remains a challenge. Vascularized autografts may provide rapid biological incorporation with the potential for growth and longevity. In this study, we aimed to describe the outcomes following proximal humeral reconstruction with a vascularized fibular epiphyseal transfer in children with a primary sarcoma of bone. We also aimed to quantify the hypertrophy of the graft and the annual growth, and to determine the functional outcomes of the neoglenofibular joint.

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 ipsilateral and contralateral fibulae have been used as a vascularised bone graft for loss of tibial bone usually by methods which have involved specialised microvascular techniques to preserve or re-establish the blood supply. We have developed a method of tibialisation of the fibula using the Ilizarov fixator system, ipsilateral vascularised fibular transport (IVFT), and have used it in five patients with massive loss of tibial bone after treatment of an open fracture, infected nonunion or chronic osteomyelitis. All had successful transport, proximal and distal union, and hypertrophy of the graft without fracture. One developed a squamous-cell carcinoma which ultimately required amputation of the limb. The advantage of IVFT is that the fibular segment retains its vascularity without the need for microvascular dissection or anastomoses. Superiosteal formation of new bone occurs if the tibial periosteal bed is retained. Other procedures such as corticotomy and lengthening can be carried out concurrently

1. At an operation for recurrent posterior dislocation of the shoulder observations were made on the mechanism, head defect, method of reduction, and the position of greatest stability. 2. Experimentally, avulsion of the glenoid labrum in a monkey was shown to be capable of sound repair without operation. 3. In the treatment of primary posterior dislocation it is suggested that the position of abduction, lateral rotation and extension is favourable for the approximation of the stripped labrum and capsule to the glenoid rim, and for an effective buttress after cicatrisation. 4. If the risk of recurrence is to be reduced to a minimum the shoulder should be retained in the position of greatest stability for at least four weeks, to allow firm union of the avulsed soft tissues. 5. This position for an optimum buttress would also apply after surgical repair for recurrent posterior dislocation

Between 1993 and 1999, we treated ten patients with comminuted fractures of the olecranon by multiple tension-band wiring and a graft from the iliac crest. Their mean age was 35 years (19 to 56). The mean follow-up was for 28.5 months (15 to 46) and the mean time to union of the fractures was four months (3 to 7). No patient reported difficulties with activities of daily living or symptoms of instability of the elbow. The mean flexion was to 135° (125 to 145) with a mean flexion contracture of 15° (10 to 30). The mean pronation was 70° (60 to 80) and mean supination 79° (70 to 90). Only three patients had mild pain and loss of strength. Five patients had excellent and five good results with a mean Broberg and Morrey index score of 94.5 points (84 to 100). Our results compare favourably with those previously reported and the technique is thought to be a practical alternative to plate fixation in fractures with extreme comminution

Patients with spina bifida cystica commonly have significant disability from a combination of valgus deformity of the ankle and subtalar joints with lateral tibial torsion and plano-abduction deformity of the foot. These deformities can be corrected by a single procedure which combines a supramalleolar tibial osteotomy with a lateral inlay triple fusion. This procedure was carried out on 20 feet in 15 patients and the results were reviewed after an average of three years (range 18 months to 7 years). In 75 per cent of feet the combination of deformities was fully corrected, ulcers and callosities were eliminated in 95 per cent, the use of calipers minimised in 95 per cent, and in all patients the problem of shoe-wrecking was reduced. Complications included recurrent valgus deformity, delayed union of the tibial osteotomy and failure of midtarsal fusion

The scaphoid fracture is commonest in young men in the age group 15 to 29 years, who have the highest incidence of non-union, take the longest time to unite, lose more time from work, and spend the longest time as outpatients. A union rate of 95 per cent can be achieved using standard simple treatment. All but a few fractures are visible on the first radiograph, and failure of visualisation at this stage is not associated with a bad outcome. The postero-anterior and semipronated views are the most important to scrutinise. Crank-handle injuries have a particularly bad prognosis when they produce a transverse fracture of the waist of the scaphoid. Poor prognostic factors are displacement during treatment, the fracture line becoming increasingly more obvious, and the presence of early cystic change. The severity of trauma is an important factor to elicit from the history

The off-loading characteristics of the cast-braces of 30 patients with fractures of the shaft of the femur have been investigated, during axial loading, using strain-gauge transducers. These were applied at the level of the fracture, where the cast was circumferentially split, and to the hinges of the brace at the knee. They measured the load transferred between the two portions of the thigh cast, and between the thigh cast as a whole and the below-knee cast; by subtraction from the total load on the limb, the skeletal force at the fracture level and at the knee could be calculated. In all patients there was an increase in the fracture load as union progressed which was thought to be due to physiological feedback mechanism from the fracture site. The load carried by the two portions of the thigh cast and by the thigh cast as a whole was proportionately high at first and stabilised at an average of 35 per cent of body weight

1. In unreduced congenital dislocation of the hip in adults, causing severe symptoms, it seems that there is a place for a calculated abduction type of femoral osteotomy, which should "defunction" a painful false joint. Care should be taken to avoid excessive angulation, which may lead to painful symptoms from contact of the osteotomy apex to the area of the true acetabulum. Genu valgum and lateral rotation deformity are complications, as is failure of union at the osteotomy site. 2. A series of eleven hips in seven patients is reported, in which such an abduction type of osteotomy has been done. Six of these hips have been highly satisfactory. Three have required subsequent operations to correct deformity. Only one has ended up with arthrodesis. In three, results have been only fair. The use of a reversed nail-plate to secure internal fixation is described

In a prospective, randomised controlled trial, 68 children who had a completely displaced metaphyseal fracture of the distal radius were treated either by manipulation (MUA) and application of an above-elbow cast alone or by the additional insertion of a percutaneous Kirschner (K-) wire. Full radiological follow-up to union was obtained in 65 children and 56 returned for clinical evaluation three months after injury. Maintenance of reduction was significantly better in the K-wire group and fewer follow-up radiographs were required. There was no significant difference in the clinical outcome measured three months after injury. Seven of 33 patients in the MUA group had to undergo a second procedure because of an unacceptable position compared with none of the 35 in the K-wire group (chi-squared test, p < 0.01). One patient in the K-wire group required exploration for recovery of a migrated wire. We conclude that the use of a percutaneous K-wire to augment the reduction of the fracture in children who have a completely displaced metaphyseal fracture of the distal radius is a safe and reliable way of maintaining alignment of the fracture

We reviewed the results of the treatment of 30 tibial fractures with minor to severe bone loss in 29 patients by early soft-tissue and bony debridement followed by primary locked intramedullary nailing. Subsequent definitive closure was obtained within the first 48 hours usually with a soft-tissue flap, and followed by bone-grafting procedures which were delayed for six to eight weeks after the primary surgery. The time to fracture union and the eventual functional outcome were related to the severity and extent of bone loss. Twenty-nine fractures were soundly united at a mean of 53.4 weeks, with delayed amputation in only one patient. Poor functional outcome and the occurrence of complications were usually due to a departure from the standard protocol for primary management. We conclude that the protocol produces satisfactory results in the management of these difficult fractures, and that intramedullary nailing offers considerable practical advantages over other methods of primary bone stabilisation

We performed total hip replacement on 25 congenitally dislocated hips using corticocancellous bone from the femoral neck as a bone graft to reconstruct the deficient acetabulum. Two patients (two hips) died less than five years after surgery and three hips developed deep infection. We reviewed the remaining 20 hips at an average interval of 8.4 years (5.2 to 12.9). Their functional scores (modified Merle d'Aubigne and Postel) averaged 5.7 for pain, 5.1 for walking ability, and 4.2 for range of motion. Radiographs showed union and remodelling of the grafted bone in every case. There were radiological signs of aseptic loosening in three sockets (15%) without collapse of the grafted bone. None of the femoral stems was loose. No revision operation has been performed. Our results confirm the usefulness in the long term of femoral autografts for severe acetabular deficiency

We report the results in 24 consecutive patients treated from 1976 to 1991 for nonunion of olecranon fractures. Their mean age was 42 years, and the mean interval from fracture to treatment for nonunion was 19 months. Management was by rehabilitation and activity as tolerated for three, continued immobilisation for one, and operative treatment for 20. Operations included excision of the olecranon fragment (1), osteosynthesis (16), and joint replacement (3). Four patients also had distraction arthroplasty. At a mean follow-up of 18 months no patient had severe residual elbow pain but three had moderate and six had mild symptoms. The mean arc of motion was 98 degrees representing an average improvement of 11 degrees. Twelve patients had an excellent result, four good, six fair, and two a poor result. Union had been achieved in 15 of the 16 patients treated by osteosynthesis

We report our experience with a modified implant and a new technique for locked intramedullary nailing of the humerus in 41 patients. Locking was by cross-screws placed from lateral to medial in the proximal humerus, and anteroposteriorly in the distal humerus. Early in the series, 11 nails were inserted at the shoulder, but we found that rehabilitation was faster after retrograde nailing through the olecranon fossa, which was used for the other 30. We used a closed technique for 29 of the nailings. Of the 41 patients treated, 21 had acute fractures, five had nonunion, and 15 had pathological fractures. Secure fixation was obtained for comminuted and osteoporotic fractures in any part of the humeral shaft, which allowed the early use of crutches and walking frames. Two nails were locked at only one end, and one of these became the only failure of union after an acute fracture

Aims

The management of a significant bony defect following excision of a diaphyseal atrophic femoral nonunion remains a challenge. We present the outcomes using a combined technique of acute femoral shortening, stabilized with a long retrograde intramedullary nail, accompanied by bifocal osteotomy compression and distraction osteogenesis with a temporary monolateral fixator.

We present a prospective study of patients with tuberculosis of the dorsal, dorsolumbar and lumbar spine after combined anterior (radical debridement and anterior fusion) and posterior (instrumentation and fusion) surgery. The object was to study the progress of interbody union, the extent of correction of the kyphosis and its maintenance with early mobilisation, and the incidence of graft and implant-related problems. The American Spinal Injury Association (ASIA) score was used to assess the neurological status. The mean preoperative vertebral loss was highest (0.96) in the dorsal spine. The maximum correction of the kyphosis in the dorsolumbar spine was 17.8°. Loss of correction was maximal in the lumbosacral spine at 13.7°. All patients had firm anterior fusion at a mean of five months. The incidence of infection was 3.9% and of graft-related problems 6.5%. We conclude that adjuvant posterior stabilisation allows early mobilisation and rehabilitation. Graft-related problems were fewer and the progression and maintenance of correction of the kyphosis were better than with anterior surgery alone. There is no additional risk relating to the use of an implant either posteriorly or anteriorly even when large quantities of pus are present

We describe 11 patients with congenital pseudarthrosis of the tibia treated by a free vascularised fibular graft (FVFG) and followed up from 10 to 64 months (mean 38). Bony union was achieved in nine of the 11 cases: two failures required amputation. The mean time for union in the successful cases was five months. Nine of the 11 patients had had an average of four surgical procedures before the FVFG, so the graft was a salvage procedure for which the only alternative was amputation. FVFG is recommended as a primary procedure for the treatment of congenital pseudarthrosis of the tibia if there is a large tibial defect (over 3 cm) or shortening of more than 5 cm. The primary use of this operation is not advised for cases in which standard orthopaedic procedures are expected to succeed. For a small defect with a favourable prognosis (Boyd and Sage 1958), we recommend conventional bone grafting, intramedullary nailing and electrical stimulation