The best method of reconstruction after resection of malignant tumours of the tibial diaphysis is unknown. In the absence of any long-term studies analysing the results of intercalary endoprosthetic replacement, we present a retrospective review of 18 patients who underwent limb salvage using a tibial diaphyseal endoprosthetic replacement following excision of a malignant bone tumour. There were ten men and eight women with a mean age of 42.5 years (16 to 76). Mean follow-up was 58.5 months (20 to 141) for all patients and 69.3 months (20 to 141) for the 12 patients still alive. Cumulative patient survival was 59% (95% confidence interval (CI) 32 to 84) at five years. Implant survival was 63% (95% CI 35 to 90) at ten years. Four patients required revision to a proximal tibial replacement at a mean follow-up of 29 months (10 to 54). Complications included metastases in five patients, aseptic loosening in four, peri-prosthetic fracture in two, infection in one and local recurrence in one. The mean Musculoskeletal Tumor Society score and the mean Toronto Extremity Salvage Score were 23 (17 to 28) and 74% (53 to 91), respectively. Although rates of complication and revision were high, custom-made tibial diaphyseal replacement following resection of malignant bone tumours enables early return to function and provides an attractive alternative to other surgical options, without apparent compromise of patient survival

Bone loss secondary to primary or metastatic lesions of the proximal humerus remains a challenging surgical problem. Options include preservation of the joint with stabilisation using internal fixation or resection of the tumour with prosthetic replacement. Resection of the proximal humerus often includes the greater tuberosity and adjacent diaphysis, which may result in poor function secondary to loss of the rotator cuff and/or deltoid function. Preservation of the joint with internal fixation may reduce the time in hospital and peri-operative morbidity compared with joint replacement, and result in a better functional outcome. We included 32 patients with pathological fractures of the proximal humerus in this study. Functional and radiological assessments were performed. At a mean follow-up of 17.6 months (8 to 61) there was no radiological evidence of failure of fixation. The mean revised musculoskeletal Tumour Society functional score was 94.6% (86% to 99%). There was recurrent tumour requiring further surgery in four patients (12.5%). Of the 22 patients who were employed prior to presentation all returned to work without restrictions. The use of a locking plate combined with augmentation with cement extends the indications for salvage of the proximal humerus with good function in patients with pathological and impending pathological fractures

The clinical results of 26 digits (18 patients) lengthened by distraction callotasis were evaluated and the factors which influenced healing were analysed. There were 14 men and four women, with a mean age of 39 years. All digits had suffered traumatic amputation. There were eight thumbs and 18 fingers. The level of the site of the osteotomy was at the proximal metaphysis in ten, the middle diaphysis in 13 and the distal metaphysis in three. Although the proposed length was achieved in 23 of the 26 digits, five required additional bone grafts. The rate of healing was 96 days/cm in the digits without complications such as callus fracture or poor callus formation, and 158 days/cm in those with complications. Lengthening at the proximal metaphysis gave a better result than at the diaphysis or distal metaphysis

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The primary aim was to estimate the cost-effectiveness of routine operative fixation for all patients with humeral shaft fractures. The secondary aim was to estimate the health economic implications of using a Radiographic Union Score for HUmeral fractures (RUSHU) of < 8 to facilitate selective fixation for patients at risk of nonunion.

We have used the Ilizarov technique for the management of subarticular defects after the excision of giant-cell tumours in the proximal tibia in five patients. The defect was reconstructed with a segment of 5 to 6 cm obtained from the diaphysis of the affected tibia and by autogenous bone graft from the iliac crest. The newly developed defect in the diaphysis was reconstructed by distraction using the Ilizarov apparatus. Bone grafting at the docking site was performed soon after positioning the bone segments. The mean length of the bone defect was 5.7 cm and the mean duration of external fixation was 233 days. The relative blood flow in the leg measured by . 99m. Tc angiography increased by 1.7 to 2.3 times that of the control level during distraction and consolidation. When seen at a mean of 43 months all patients showed a normal range of motion in the knee and ankle with no collapse of the articular surfaces

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To fully quantify the effect of posterior tibial slope (PTS) angles on joint kinematics and contact mechanics of intact and anterior cruciate ligament-deficient (ACLD) knees during the gait cycle.

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Assessment of bone mineral density (BMD) with dual-energy X-ray absorptiometry (DXA) is a well-established clinical technique, but it is not available in the acute trauma setting. Thus, it cannot provide a preoperative estimation of BMD to help guide the technique of fracture fixation. Alternative methods that have been suggested for assessing BMD include: 1) cortical measures, such as cortical ratios and combined cortical scores; and 2) aluminium grading systems from preoperative digital radiographs. However, limited research has been performed in this area to validate the different methods. The aim of this study was to investigate the evaluation of BMD from digital radiographs by comparing various methods against DXA scanning.

Femoral revision after cemented total hip replacement (THR) might include technical difficulties, following essential cement removal, which might lead to further loss of bone and consequently inadequate fixation of the subsequent revision stem. . Femoral impaction allografting has been widely used in revision surgery for the acetabulum, and subsequently for the femur. In combination with a primary cemented stem, impaction grafting allows for femoral bone restoration through incorporation and remodelling of the impacted morsellized bone graft by the host skeleton. Cavitary bone defects affecting meta-physis and diaphysis leading to a wide femoral shaft, are ideal indications for this technique. Cancellous allograft bone chips of 1 mm to 2 mm size are used, and tapered into the canal with rods of increasing diameters. To impact the bone chips into the femoral canal a prosthesis dummy of the same dimensions of the definitive cemented stem is driven into the femur to ensure that the chips are very firmly impacted. Finally, a standard stem is cemented into the neo-medullary canal using bone cement. . To date several studies have shown favourable results with this technique, with some excellent long-term results reported in independent clinical centres worldwide. Cite this article: Bone Joint J 2013;95-B, Supple A:92–4

1. A detailed study of density variations with age in cortical bone samples from different areas of the femoral diaphysis has been carried out. 2. Bone of relatively high density and, conversely, of low density was found to have a spiral pattern along the bone shaft. 3. Moving distally along the femoral shaft there was a transposition of the greatest density from the anterior to the posterior aspect. 4. In the erect body posture the femoral inclination is such that areas of denser bone might be expected to be aligned vertically because of the weight-bearing characteristics of the femur. 5. Most areas of the cortex tended to decrease in density after the age of fifty, the less dense areas changing more than those with an initial high density. Thus, osteoporosis tended not only to maintain but to accentuate the spiral pattern of density distribution by increasing the difference between dense and less dense bone. 6. In the distal region of the diaphysis bone resorption was greatest anteriorly but hardly affected the posterior aspect. A densitometric comparison between these two sites provided a clear indication of the effect of osteoporosis

The results of the treatment of 31 open femoral fractures (29 patients) with significant bone loss in a single trauma unit were reviewed. A protocol of early soft-tissue and bony debridement was followed by skeletal stabilisation using a locked intramedullary nail or a dynamic condylar plate for diaphyseal and metaphyseal fractures respectively. Soft-tissue closure was obtained within 48 hours then followed, if required, by elective bone grafting with or without exchange nailing. The mean time to union was 51 weeks (20 to 156). The time to union and functional outcome were largely dependent upon the location and extent of the bone loss. It was achieved more rapidly in fractures with wedge defects than in those with segmental bone loss. Fractures with metaphyseal defects healed more rapidly than those of comparable size in the diaphysis. Complications were more common in fractures with greater bone loss, and included stiffness of the knee, malunion and limb-length discrepancy. Based on our findings, we have produced an algorithm for the treatment of these injuries. We conclude that satisfactory results can be achieved in most femoral fractures with bone loss using initial debridement and skeletal stabilisation to maintain length, with further procedures as required

Aims

Periprosthetic hip fractures (PPFs) after total hip arthroplasty are difficult to treat. Therefore, it is important to identify modifiable risk factors such as stem selection to reduce the occurrence of PPFs. This study aimed to clarify differences in fracture torque, surface strain, and fracture type analysis between three different types of cemented stems.

Unstable bicondylar tibial plateau fractures are rare and there is little guidance in the literature as to the best form of treatment. We examined the short- to medium-term outcome of this injury in a consecutive series of patients presenting to two trauma centres. Between December 2005 and May 2010, a total of 55 fractures in 54 patients were treated by fixation, 34 with peri-articular locking plates and 21 with limited access direct internal fixation in combination with circular external fixation using a Taylor Spatial Frame (TSF). At a minimum of one year post-operatively, patient-reported outcome measures including the WOMAC index and SF-36 scores showed functional deficits, although there was no significant difference between the two forms of treatment. Despite low outcome scores, patients were generally satisfied with the outcome. We achieved good clinical and radiological outcomes, with low rates of complication. In total, only three patients (5%) had collapse of the joint of > 4 mm, and metaphysis to diaphysis angulation of greater than 5º, and five patients (9%) with displacement of > 4 mm. All patients in our study went on to achieve full union. This study highlights the serious nature of this injury and generally poor patient-reported outcome measures following surgery, despite treatment by experienced surgeons using modern surgical techniques. Our findings suggest that treatment of complex bicondylar tibial plateau fractures with either a locking plate or a TSF gives similar clinical and radiological outcomes. Cite this article: Bone Joint J 2014;96-B:956–62

We measured the insertion and extraction torque forces in a randomised study of 76 external fixation screws in 19 patients treated by hemicallotasis for osteoarthritis of the medial side of the knee. The patients were randomised to have either standard tapered screws (Orthofix 6/5 mm) or the same screws with hydroxyapatite (HA) coating. One patient had two standard and two HA-coated screws. All patients had an anterior external fixator (Orthofix T-garche), with two screws in the proximal tibial metaphysis parallel to and about 2 cm below the joint surface and two in the tibial diaphysis. The mean torque forces for insertion of the standard screws were 260 Ncm for the proximal to medial screw, 208 for the proximal to lateral screw and 498 and 546 Ncm for the diaphyseal pins. The corresponding forces for the HA-coated pins were not significantly different. The torque forces for the extraction of the standard pins were 2 Ncm for the proximal pins, 277 and 249 Ncm for the distal pins and 482, 478, 585 and 620 Ncm, respectively (p < 0.005) for the HA-coated pins. All 18 of the metaphyseal standard screws were loose at extraction (extraction force < 20 Ncm), but only one of the HA screws in the metaphysis was loose. In the diaphysis the standard screws lost about 40% of their fixation in contrast to the HA-coated screws which retained full fixation strength

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Osteofibrous dysplasia (OFD) is a rare benign lesion predominantly affecting the tibia in children. Its potential link to adamantinoma has influenced management. This international case series reviews the presentation of OFD and management approaches to improve our understanding of OFD.

We present an unusual cause of anterior tibial pain in a 24-year-old professional international football player who was found to have a synostosis of the middle-third of the diaphysis of the tibia and fibula. This is a rarely described phenomenon. Conservative treatment is the recommended treatment of choice, but this failed in our patient. Resection produced resolution of symptoms; he remained symptom-free three years later

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This study investigated the effects of β-caryophyllene (BCP) on protecting bone from vitamin D deficiency in mice fed on a diet either lacking (D-) or containing (D+) vitamin D.

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The primary aim of this study was to determine the rates of return to work (RTW) and sport (RTS) following a humeral shaft fracture. The secondary aim was to identify factors independently associated with failure to RTW or RTS.

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The aim of this study was to determine the association between knee alignment and the vertical orientation of the femoral neck in relation to the floor. This could be clinically important because changes of femoral neck orientation might alter chondral joint contact zones and joint reaction forces, potentially inducing problems like pain in pre-existing chondral degeneration. Further, the femoral neck orientation influences the ischiofemoral space and a small ischiofemoral distance can lead to impingement. We hypothesized that a valgus knee alignment is associated with a more vertical orientation of the femoral neck in standing position, compared to a varus knee. We further hypothesized that realignment surgery around the knee alters the vertical orientation of the femoral neck.

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The Uppföljningsprogram för cerebral pares (CPUP) Hip Score distinguishes between children with cerebral palsy (CP) at different levels of risk for displacement of the hip. The score was constructed using data from Swedish children with CP, but has not been confirmed in any other population. The aim of this study was to determine the calibration and discriminatory accuracy of this score in children with CP in Scotland.

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To develop an early implant instability murine model and explore the use of intermittent parathyroid hormone (iPTH) treatment for initially unstable implants.