The treatment of large bony defects by callus distraction is well accepted, but the duration of treatment is long and the rate of complications increases accordingly. We have examined the effect of the stiffness of the axial fixator on reducing the time for maturation of callus. We created a mid-diaphyseal defect of 15 mm in the metatarsal bone in sheep and stabilised it with a ring fixator. After four days a bony segment was transported for 16 days at 1 mm per day. After 64 days the animals were divided into four groups, three with axial interfragmentary movement (IFM) of 0.5, 1.2 and 3.0 mm, respectively, and a control group. The 3.0 mm IFM group had the smallest bone density (p = 0.001) and area of callus and the largest IFM after 12 weeks; it also had typical clinical signs of hypertrophic nonunion. The most rapid stiffening of the callus was in the 0.5 mm group which had the smallest IFM (p = 0.04) after 12 weeks and radiological signs of bridging of the defect. These results indicate that suitable dynamic axial stimulation can enhance maturation of distraction callus when the initial amplitude is small, but that a large IFM can lead to delayed union

We assessed the intermediate functional results of eight patients after wide resection of the proximal humerus for malignant bone tumour. We used a free vascularised fibular graft as a functional spacer and a sling procedure to preserve passive scapulohumeral movement. Scapulohumeral arthrodesis was not carried out. Five patients had osteosarcoma, two achondrosarcoma and one a malignant fibrous histiocytoma of the bone. The mean duration of follow-up was 70 months (median, 76) for the seven patients who were still alive at the time of the latest follow-up. One patient died from the disease 12 months after surgery. There were no local recurrences. The functional results were described and graded quantitatively according to the rating system of the Musculoskeletal Tumour Society. Our results were satisfactory with regard to pain, emotional acceptance and manual dexterity. Function and lifting ability were unsatisfactory in two patients. One patient had delayed union between host and graft, but this united after six months without further surgery. Radiographs of the shoulder showed absorption or collapse of the head of the fibula in four of the eight patients and a fracture in another. No functional problems related to absorption or fracture of the head of the fibula were noted. There was no infection or subluxation of the head. We conclude that this is a reasonably effective technique of limb salvage after resection of the proximal humerus

Aims

We present our experience of using a metal-backed prosthesis and autologous bone graft to treat gross glenoid bone deficiency.

Two acetabula which contained large bone allografts introduced at revision arthroplasty were obtained at post-mortem. The allografts had been placed in superior defects to support cementless acetabular components, and both hips were functioning well at the time of death. Clinical radiographs demonstrated apparent healing of graft to host bone, no graft collapse and stability of the acetabular components. Microscopic examination of sections through these specimens showed that the bulk allografts were encapsulated in fibrous tissue. Vascularity was increased at the host-graft interface, but there was limited evidence of bone union between the graft and the host. In the few areas where union had occurred, revascularisation extended no more than 2 mm beyond the graft-host interface. Within the body of the graft, the acellular matrix of trabecular bone maintained structural integrity up to 48 months after surgery. In areas where the allograft was adjacent to an implant, there was fibrous tissue orientated parallel to the implant surface. The acetabulum which contained a porous-coated component showed evidence of bone growth into the porous surface where it was in contact with viable host bone. No ingrowth occurred in areas where the porous coating was in contact with the graft. Although the grafts were functioning well, allograft revascularisation and remodelling were minimal, and the radiological appearance of healing did not correlate with histological findings

Aims

The crucial role of the radial head in the stability of the elbow in terrible triad injury is acknowledged. This retrospective study aims to compare the results of resection of a severely comminuted radial head with or without prosthetic arthroplasty as part of the reconstruction for this injury.

Aims

This study reports the outcomes of a technique of soft-tissue coverage and Chopart amputation for severe crush injuries of the forefoot.

From a series of 190 consecutive fractures of the shaft of the femur treated by closed Kuntscher nailing, 32 of the more severely comminuted have been studied to determine whether treatment by closed nailing was justified. Radiological criteria were used to divide them into 19 who were moderately comminuted and 13 grossly so. Twenty-four patients were less than 21 years of age and 19 patients had 40 significant associated injuries. Fifteen fractures were nailed on the day of injury, and complications were few. Nineteen patients had a supplementary cast-brace and all those who had been employed returned to work. Twelve patients had shortening of up to two centimetres and two had three centimetres; four had mild rotational deformities; seven had mild restriction of knee flexion; and two had delayed union. There were no infections. The advantages of this technique include a negligible risk of infection and rapid stabilisation of even grossly comminuted fractures, thus facilitating management of other injuries. The 44 per cent incidence of shortening is counterbalanced by early mobilisation and rapid return of knee function. It is concluded that when proper equipment and expertise are available then closed nailing is the treatment of choice for severely comminuted fractures of the femoral shaft

1. Fifty-one cases of fracture of the odontoid have been analysed. Forty were reported by other surgeons; eleven were new cases first reported by us. 2. Fracture of the odontoid in young children is an epiphysial separation. It occurs up to the age of seven years. As in epiphysial separations elsewhere, it unites readily, and remodelling occurs when reduction has been incomplete, so that normal anatomy is restored. 3. In adults forward displacement is twice as common as backward displacement. 4. Immediate paralysis is commoner if backward displacement occurs, but late neurological disorders are seen only after fractures with forward displacement. 5. Failure of bony healing is not dangerous if treatment has resulted in firm fibrous union, for there is neither excessive abnormal mobility nor progressive subluxation, either of which could injure the spinal cord or medulla. Neurological disorders developing after the fracture are the result of mobility from inadequate early treatment. It is the results of inadequate early treatment which have given this fracture a sinister reputation. 6. The fracture should be reduced by skeletal traction through a skull caliper. The reduction should be maintained for six weeks by continuous traction, and this should be followed by a period of six weeks in a plaster. 7. The increasing definition of the fracture-line seen in the radiographs of some patients indicates non-union

Aims

Open wedge high tibial osteotomy (OWHTO) for medial-compartment osteoarthritis of the knee can be complicated by intra-operative lateral hinge fracture (LHF). We aimed to establish the relationship between hinge position and fracture types, and suggest an appropriate hinge position to reduce the risk of this complication.

One hundred and sixty-four cases of intramedullary nailing of the long bones have been studied with special reference to the difficulties and complications encountered. There was one death not attributable to the method. Two cases of pulmonal fat embolism and one case of thrombosis occurred, all in fractures of the femur. The lessons we have learned from our mistakes can be summarised as follows:. 1 . The method requires technical experience and knowledge and is not suited to inexperienced surgeons or surgeons with little fracture material at their disposal. 2. Intramedullary nailing should only be used in fractures to which the method is suited. In general, comminuted fractures or fractures near a joint are unsuitable. 3. Open reduction is preferable to closed methods. 4. The nail should never be driven in with violence. It should be removed and replaced with a new one if difficulty is encountered when inserting it. 5. In fractures of the femur the nail should be driven in from the tip of the trochanter after careful determination of the direction. 6. The nail should be introduced only to the level of the fracture before exploring and reducing the fracture. 7. Distraction of the fragments must be avoided. 8. If the nail bends it should be replaced by a new one, at least in femoral fractures. 9. If union is delayed, the fracture should be explored and chip grafts of cancellous bone placed around it. 10. Improvised nails or nails which are not made of absolutely reliable material should never be used. 11 . Make sure that the nail is equipped with an extraction hole for removal

Aims

Intercalary allografts following resection of a primary diaphyseal tumour have high rates of complications and failures. At our institution intercalary allografts are augmented with intramedullary cement and fixed using compression plating. Our aim was to evaluate their long-term outcomes.

This retrospective study analyses the results of subtalar bone block distraction arthrodesis used in the treatment of late complications of calcaneal fractures, acute severely comminuted fractures, nonunion (and malunion) of attempted subtalar arthrodeses, avascular necrosis of the talus, and club-foot deformity. Of 39 patients (41 feet) who had this procedure, 35 (37 feet) returned for follow-up after a mean of 70 months (26 to 140). There were 24 men (25 feet) and 11 women (12 feet) with a mean age of 41 years (16 to 63). Each completed a standardised questionnaire, based on the hindfoot-scoring system of the American Orthopaedic Foot and Ankle Society and were reviewed both clinically and radiologically. Of the 37 operations, 32 (87%) achieved union. The mean hindfoot score (maximum of 94 points) increased from 21.1 points (8 to 46) preoperatively to 68.9 (14 to 82) at the final follow-up. The mean talocalcaneal and calcaneal pitch angles were 20.5° and 4.9° before operation, 25.9° and 8.3° immediately after, and 24.6° and 7.7° at the final follow-up, respectively. The mean talar declination angle improved from 6.5° (−10 to 22) before operation to 24.8° (14 to 32) at the final follow-up. The mean talocalcaneal height increased from 68.7 mm before operation to 74.5 mm immediately after and 73.5 mm at the final follow-up. Of the 37 arthrodeses available for review, 32 were successful; 29 patients (30 arthrodeses) were satisfied with the procedure. Minimal loss of hindfoot alignment occurred when comparing radiographs taken immediately after operation and at final follow-up

Aims

The objective of this study was to investigate bone healing after internal fixation of displaced femoral neck fractures (FNFs) with the Dynamic Locking Blade Plate (DLBP) in a young patient population treated by various orthopaedic (trauma) surgeons.

A study of a collected series of femoral neck fractures in seventy-one children observed for one to nineteen years shows:. 1. This injury is rare but occurs in children of all ages from three to sixteen years old. 2. The fractures may be classified as transepiphysial, transcervical (the commonest), basal and pertrochanteric. Displacement was frequent. 3. The fracture usually followed severe violence, especially falls from a height or motor accidents. 4. Complications were frequent and included avascular necrosis, delayed union (seventeen cases), non-union (seven cases) and disturbances of growth at both the upper and lower ends of the femur. 5. Avascular necrosis occurred in thirty patients (42 per cent). Three patterns of necrosis are described : diffuse, localised and confined to the femoral neck. The radiographic appearances of avascular necrosis after this fracture are different from those of pseudocoxalgia (Legg-Calvé-Perthes' disease). 6. Non-union did not occur after adequate primary internal fixation or after primary subtrochanteric osteotomy. 7. The management of an undisplaced fracture presented no great problem and the results were good. A plaster spica is recommended for treatment of this fracture. Exceptionally, avascular necrosis developed. 8. Treatment of the displaced fractures (forty-nine cases) was less satisfactory. A good result was obtained from primary treatment in only fifteen patients. 9. The value of different methods of primary treatment is discussed, including manipulative reduction and immobilisation in a plaster spica, manipulative reduction and internal fixation, and primary subtrochanteric osteotomy. Manipulative reduction and immobilisation in a plaster spica is not recommended. 10. Salvage operations were required in nineteen patients. Late subtrochanteric osteotomy is of value in the management of some of these problems

1. A method is described for measuring blood flow to the head of the femur after fracture of the femoral neck, by estimation of the rate of uptake of radioactive phosphorus. 2. Of one hundred cases investigated the readings in fifteen were incomplete, and in seventeen were unreliable. Reasons are given for discarding the latter seventeen cases. After two years seven patients had died, leaving sixty-one available for analysis. 3. The results in sixty-one surviving patients with a follow-up of not less than two years are analysed. In twenty of these radioactivity was measured by bone sampling and in forty-one by direct readings with a needle counter. 4. The twenty-one intertrochanteric fractures studied were used as controls. In these the P. 32. ratio varied from 0·4 to 3·0. Union occurred in all patients and none developed avascular necrosis. 5. Of the forty patients with displaced fractures of the femoral neck twenty-eight showed a low P. 32. ratio. In twenty-three of these (82 per cent) the fracture united. 6. Twelve patients with fractures of the femoral neck showed a borderline or abnormal P. 32. ratio. In ten of these there was subsequent avascular necrosis or non-union. 7. The possible reasons for the discrepancy between expected and actual results are discussed. 8. Almost 40 per cent of the cases investigated had to be abandoned because of technical faults and in one-fifth of the remaining cases the expected results failed to agree with the clinical results. The method of investigation is therefore not of much practical value at the present time. Improvements in apparatus and technique might make the method more reliable and more useful

1. In this series of posterior onlay grafting with fresh autogenous bone and without internal fixation, in the treatment of non-infective structural lesions in the lumbo-sacral area, 71 per cent of the patients were relieved of their symptoms, but bony fusion was obtained in only 60 per cent. 2. It is probable that with this technique twelve weeks' immobilisation in a plaster bed is required. 3. Some failures are ascribed to the use of an insufficient quantity of bone or to poor apposition of the graft to its bed. 4. It is evident that the more vertebrae one attempts to fuse the more difficult it is to succeed. When the diseased area is successfully fused but an unnecessarily long graft has been used, a pseudarthrosis above the level of the pre-operative pathology may be the cause of persisting backache. For these reasons we believe that one should not attempt to graft more vertebrae than is necessary to stabilise the local lesion. 5. The complication rate, particularly from deep vein thrombosis, was high. This major complication could perhaps be overcome by using banked bone. 6. The indications for the operation are assessed as follows. It should be done for low back pain only when there is a definite diagnosis and a limited extent of structural pathology; one can then expect excellent results when successful fusion is achieved and also an appreciably high proportion of satisfied patients even when bony fusion has not been obtained, presumably because there is a fibrous union strong enough to stabilise the affected spine. It is inadvisable to undertake lumbar-lumbo-sacral fusion for intervertebral disc degeneration when there are more than three adjacent vertebrae involved, and in any case operation should be confined to the indicated extent