Fragility fractures of the ankle occur mainly in elderly osteoporotic women. They are inherently unstable and difficult to manage. There is a high incidence of complications with both non-operative and operative treatment. We treated 12 such fractures by closed reduction and stabilisation using a retrograde calcaneotalotibial expandable nail. The mean age of patients was 84 years (75 to 95). All were women and were able to walk fully weight-bearing after surgery. There were no wound complications. One patient died from a myocardial infarction 24 days after surgery. The 11 other patients were followed up for a mean of 67 weeks (39 to 104). All the fractures maintained satisfactory alignment and healed without delay. Six patients refused removal of the nail after union of the fracture. The functional rating using the scale of Olerud and Molander gave a mean score at follow-up of 61, compared with a pre-injury value of 70

Aims

The aim of this study was to report the outcome of femoral condylar fresh osteochondral allografts (FOCA) with concomitant realignment osteotomy with a focus on graft survivorship, complications, reoperation, and function.

We conducted this prospective randomised and externally evaluated study to investigate whether the use of a navigation system during total knee arthroplasty leads to significantly better results than the hand-guided technique. A total of 240 patients was included in the study. All patients received a condylar knee prosthesis. Two surgeons performed all the operations using the Stryker knee navigation system. Exclusion criteria included the necessity for the primary use of constrained implants. The results revealed a highly significant difference between the two groups in favour of navigation with regard to the mechanical axis, the frontal and sagittal femoral axis and the frontal tibial axis (p < 0.0001). The use of a navigation system was therefore shown to improve the alignment of the implant

Posterior spinal instrumentation with the placement of intrapedicular implants has become an important technique. We have designed a hand-held target device to facilitate the open or percutaneous location and penetration of the thoracolumbar pedicles. A cylindrical pin guide incorporates two metal rings and can be moved under image intensifier control until the rings are superimposed to show correct alignment. The radiation dosage for the surgeon is minimal; the device allowed accurate placement of 106 consecutive pedicle screws

Aims

Primary (or spontaneous) and secondary osteonecrosis of the knee can lead to severe joint degeneration, for which either total or unicompartmental arthroplasty may be considered. However, there are limited studies analyzing outcomes of unicompartmental knee arthroplasties (UKAs) for osteonecrosis involving an isolated compartment of the knee. The aims of this study were to analyze outcomes of UKAs for osteonecrosis with specific focus on 1) survivorship free of any revision or reoperation, 2) risk factors for failure, 3) clinical outcomes, and 4) complications.

We treated 25 patients with severely deformed and shortened lower limbs by double oblique diaphyseal osteotomy of the short deformed bone, followed by balanced skeletal traction to correct the alignment and increase the length of the limb. The technique is simple and inexpensive and does not require special equipment. It has the advantage of allowing rapid lengthening and secure healing as the overlap allows end-to-end union with no bone gap. The lengthening achieved ranged from 6 to 16 cm. No serious complications were encountered

The Denham knee replacement is a relatively simple unconstrained prosthesis. The design ensures good alignment and full extension, but does not allow flexion beyond 90 degrees or tibiofemoral rotation. The results after eight years' experience have been assessed in four different ways in over 600 cases. They show that for the limited needs of the elderly arthritic patient, the Denham arthroplasty provides a high proportion of satisfactory results with an unusually low rate of late failure

Wear of high-density polyethylene on bone and cartilage has resulted in a large volume of plastic particles being shed into the two knees and two hips studied. The giant-cell foreign-body reaction of the synovium may not be sufficient to cope with the amount of debris presented and the destruction of the endosteal bone in one hip, caused by the wear particles and movement of the prosthesis, has made revision impossible. Articulation of high-density polyethylene against bone or cartilage either by design or by the failure of alignment of the component must be avoided

An electromyographic investigation of patients with subluxation of the patella has been carried out on the parts of the extensor apparatus which actively contribute to the alignment of the patella, both before and after the operation to correct this disorder. The electromyographic pictures have revealed a sharp fall in the activity of the vastus medialis, with full recovery to normal values after a corrective operation. Even if the aligning function of the patella is altered by a variety of factors, the present study confirms the importance of the vastus medialis in the pathogenesis of malalignment of the extensor mechanism

A total of 344 patients underwent bilateral total knee replacement (TKR) using a different prosthesis on each side. Four knee prostheses were used: anterior and posterior cruciate-retaining (ACL-PCL), posterior cruciate-retaining (PCL), medial or lateral pivot (MLP), and posterior cruciate-substituting (PS). All patients had good or excellent results. The range of movement, relief from pain, alignment, and stability did not vary among any of the prostheses. Forty-one of 46 patients (89%) preferred the ACL-PCL to the PS knee and 27 of 35 patients (77%) the MLP knee to the PS knee. Of the patients with an ACL-PCL knee on one side and a MLP on the other, an equal number preferred each type. The MLP knee was preferred to the PCL by 34 (79%) patients. PS and PCL knees were preferred equally. Patients with bilateral TKRs preferred retention of both their cruciate ligaments or substitution with a medial or lateral pivot prosthesis

We describe a little-known variety of hip dysplasia, termed ‘acetabular retroversion’, in which the alignment of the mouth of the acetabulum does not face the normal anterolateral direction, but inclines more posterolaterally. The condition may be part of a complex dysplasia or a single entity. Other than its retroversion, the acetabulum is sited normally on the side wall of the pelvis, and its articular surface is of normal extent and configuration. The retroverted orientation may give rise to problems of impingement between the femoral neck and anterior acetabular edge. We define the clinical and radiological parameters and discuss pathological changes which may occur in the untreated condition. A technique of management is proposed

1. Further consideration has been given to the lateral rotation which occurs at the ankle joint in uncorrected club feet. 2. Medial rotation osteotomy of the tibia may be used to restore more normal alignment to the hind foot at the expense of an increase in varus of the forefoot, which must be corrected at a second operation. 3. The early results in seven feet treated in this manner are reported. 4. We hope that this paper will be regarded more as a contribution to the understanding of the anatomy of uncorrected club foot than as advocacy of a new method of surgical treatment

Aims

Flexor hallucis longus (FHL) tendon transfer is a well-recognized technique in the treatment of the neglected tendo Achillis (TA) rupture.

We reviewed 19 children with 24 congenital club feet at a mean of 11 years after one-stage posteromedial release at the age of five years or older (mean 6.8 years). Thirteen feet had undergone previous surgery. Nineteen feet were functionally excellent or good, three were fair and two had required subtalar arthrodesis. Radiographs showed good alignment of the tarsal bones, although mild adduction or varus deformity remained in several feet. Deformities of the bones were more common in feet which had had previous surgery

We present a series of ten hypertrophic nonunions in which bony alignment and length were restored and union induced by external fixation and callus distraction. The mean length gained was 3.5 cm (1 to 6) and the mean angular correction was 13.5° (0 to 40). The mean treatment time was 10.2 months (3 to 15) and mean follow-up was 40 months (6 to 71). There have been no refractures or loss of correction or length. The technique of callus distraction at a site of hypertrophic nonunion can correct shortening and angulation as well as induce bony union. No extra equipment is needed beyond readily-available external fixation systems

Accurate measurement of the alignment of the tibia is important both clinically and in research. The conventional method of measuring the angle of malunion after a fracture of the shaft of the tibia is potentially inaccurate because the mechanical axis of the normal bone may not pass down the centre of the medullary canal. An alternative method is described in which a radiograph of the opposite tibia is used as a template. A sample of 56 sets of standard radiographs of healed fractures of the shaft of the tibia was evaluated. The 95% limits of agreement between this and the conventional method were wide, being −6.2° to +5.5° for coronal angulation and −6.7° to +8.1° for sagittal angulation. These results suggest that the conventional method is inaccurate. The new method has good inter- and intraobserver reliability

Out of a total of 623 patients who, over a ten-year period, underwent primary total knee replacement (TKR) without patellar resurfacing, 20 underwent secondary resurfacing for chronic anterior knee pain. They were evaluated pre- and postoperatively using the clinical and radiological American Knee Society score. The mean follow-up was 36.1 months (12 to 104). The mean knee score improved from 46.7 to 62.2 points and the mean functional score from 44.7 to 52.2 points. Only 44.4% of the patients, however, reported some improvement; the remainder reported no change or deterioration. The radiographic alignment of the TKR did not influence the outcome of secondary resurfacing of the patella. Complications were noted in six of the 20 patients including fracture and instability of the patella and loss of movement. Anterior knee pain after TKR remains difficult to manage. Secondary resurfacing of the patella is not advocated in all patients since it may increase patient dissatisfaction and hasten revision

We have analysed retrospectively the relationship between the axial parameters of alignment of the lower limb and the recurrence of varus deformity after high tibial osteotomy. We studied 29 patients (37 knees) with a mean age at surgery of 66 years. The mean follow-up was for 7.4 years (5 to 10.5). Recurrence of varus deformity was defined as an increase in the femorotibial angle of 3° or more, compared with that obtained six months after the operation. There were four patients (four knees) with recurrence of varus deformity. They had a greater varus inclination of the distal femur than those without varus recurrence. An association between varus inclination of the distal femur and horizontal obliquity of the joint surface was observed. Excessive obliquity prevents the shift of weight-bearing to the lateral compartment, and may cause a recurrence of varus deformity after high tibial osteotomy

A randomised, prospective study was carried out on 60 patients with unstable fractures of the distal radius to compare bridging with non-bridging external fixation using pins placed in the distal fragment of the radius. The radiological results showed significant improvement in the non-bridging group at all stages of review. In particular, normal volar tilt and carpal alignment were regained and maintained. The functional results at six weeks, three months, six months and one year showed statistically better grip strength and flexion in the non-bridging group at all stages of review. Other ranges of movement showed an early advantage in the non-bridging group. Non-bridging external fixation is the treatment of choice for unstable fractures of the distal radius which have sufficient space for the placement of pins in the distal fragment

The treatment of acquired flat foot secondary to dysfunction of the posterior tibial tendon (PTT) of stage II, as classified by Johnson and Strom, remains controversial. Joint sparing and soft-tissue reconstructive procedures give good early results, but few studies describe those in the medium-term. We studied prospectively the outcome of surgery in 51 patients with classical stage-II dysfunction of the PTT treated by a medial displacement calcaneal osteotomy and transfer of the tendon of flexor digitorum longus. We reviewed 44 patients with a mean follow-up of 51 months (38 to 62). The mean American Orthopaedic Foot and Ankle Society ankle/hindfoot rating scale improved from 48.8 before operation to 88.5 at follow-up. The operation failed in two patients who later had a calcaneocuboid fusion. The outcome in 43 patients was rated as good to excellent for pain and function, and in 36 good to excellent for alignment. There were no poor results