Aims

The distal radius is a major site of osteoporotic bone loss resulting in a high risk of fragility fracture. This study evaluated the capability of a cortical index (CI) at the distal radius to predict the local bone mineral density (BMD).

Congenital pseudarthrosis of the tibia remains one of the most difficult orthopaedic problems. We describe early excision and the use of the Masquelet technique to reconstruct the bone defect in a child aged 14 months. Consolidation sufficient for complete weight-bearing was achieved by seven weeks. After two and a half years, the child was asymptomatic with a fully reconstructed tibia and no leg-length discrepancy

At least four ways have been described to determine femoral component rotation, and three ways to determine tibial component rotation in total knee replacement (TKR). Each method has its advocates and each has an influence on knee kinematics and the ultimate short and long term success of TKR. Of the four femoral component methods, the author prefers rotating the femoral component in flexion to that amount that establishes a stable symmetrical flexion gap. This judgement is made after the soft tissues of the knee have been balanced in extension. Of the three tibial component methods, the author prefers rotating the tibial component into congruency with the established femoral component rotation with the knee is in extension. This yields a rotationally congruent articulation during weight-bearing and should minimise the torsional forces being transferred through a conforming tibial insert, which could lead to wear to the underside of the tibial polyethylene. Rotating platform components will compensate for any mal-rotation, but can still lead to pain if excessive tibial insert rotation causes soft-tissue impingement. Cite this article: Bone Joint J 2013;95-B, Supple A:140–3

The management of injury to the distal tibiofibular syndesmosis remains controversial in the treatment of ankle fractures. Operative fixation usually involves the insertion of a metallic diastasis screw. There are a variety of options for the position and characterisation of the screw, the type of cortical fixation, and whether the screw should be removed prior to weight-bearing. This paper reviews the relevant anatomy, the clinical and radiological diagnosis and the mechanism of trauma and alternative methods of treatment for injuries to the syndesmosis

We retrospectively reviewed 20 patients at three to 19 years after displaced anterior fracture-dislocations of the hip. Eighteen of them were treated by traction, after ensuring that the femoral head was adequately reduced beneath the undisrupted part of the weight-bearing dome. Two required operation. Although none of the 18 conservatively treated fractures was reduced anatomically, the results were good in ten patients and excellent in the seven in whom the fracture did not involve the weight-bearing dome. We conclude that anterior column fractures have a favourable prognosis after conservative treatment

Our goal was to evaluate the use of Ponseti’s method, with minor adaptations, in the treatment of idiopathic clubfeet presenting in children between five and ten years of age. A retrospective review was performed in 36 children (55 feet) with a mean age of 7.4 years (5 to 10), supplemented by digital images and video recordings of gait. There were 19 males and 17 females. The mean follow-up was 31.5 months (24 to 40). The mean number of casts was 9.5 (6 to 11), and all children required surgery, including a percutaneous tenotomy or open tendo Achillis lengthening (49%), posterior release (34.5%), posterior medial soft-tissue release (14.5%), or soft-tissue release combined with an osteotomy (2%). The mean dorsiflexion of the ankle was 9° (0° to 15°). Forefoot alignment was neutral in 28 feet (51%) or adducted (< 10°) in 20 feet (36%), > 10° in seven feet (13%). Hindfoot alignment was neutral or mild valgus in 26 feet (47%), mild varus (< 10°) in 19 feet (35%), and varus (> 10°) in ten feet (18%). Heel–toe gait was present in 38 feet (86%), and 12 (28%) exhibited weight-bearing on the lateral border (out of a total of 44 feet with gait videos available for analysis). Overt relapse was identified in nine feet (16%, six children). The parents of 27 children (75%) were completely satisfied. A plantigrade foot was achieved in 46 feet (84%) without an extensive soft-tissue release or bony procedure, although under-correction was common, and longer-term follow-up will be required to assess the outcome. Cite this article: Bone Joint J 2013;95-B:1721–5

There have been many reports which suggest that in patients with tibiofemoral osteoarthritis, a reduction in joint space is demonstrated better on weight-bearing radiographs taken with the knee in semiflexion than in full extension. The reduction has been attributed to the loss of articular cartilage in the contact area in a semiflexed arthritic knee. None of these studies have, however, included normal knees. We have therefore undertaken a prospective, double-blind, randomised study in order to evaluate the difference in the joint-space of arthroscopically-proven normal tibiofemoral joints as seen on weight-bearing full-extension and 30° flexion posteroanterior radiographs. Twenty-two knees were evaluated and the results showed that there may be a difference of up to 2 mm in the two views. This difference could be attributed to the inherent differential thickness of the articular cartilage in different areas of the femoral and tibial condyles and a change in the areas of contact between them

The Bisurface knee prosthesis (BP) has a posterior stabilising cam (ball-and-socket joint) in the mid-posterior region of the femorotibial joint in an attempt to improve the range of movement. Based on an in vitro weight-bearing study contact areas of the Insall/Burstein 2 (IB2) and the BP knee were compared using pressure-sensitive films. The stability afforded by the cam was evaluated by means of dislocation distances in the vertical and horizontal planes. Significant adverse anterior translation in mid-flexion was not observed with the BP knee since the cam was effective above 60° of flexion. At flexion of 60° or more, the total contact areas were larger, as the cam represented a weight-bearing surface. The dislocation distances for the BP knee compared favourably with those for the IB2 knee. We conclude that the cam of the BP knee allows good movement, stability and wear

Following the discovery of a powerful venous pump in the foot that is activated by weight-bearing independently of muscular action, a pneumatic impulse device was developed to actuate this pump artificially. In a multicentre international trial the device was shown to reduce post-traumatic and postoperative swelling; pain also was alleviated. Evidence is also presented that dangerously high compartment pressures may be reduced to acceptable levels and fasciotomy avoided. We present an explanation of the clinical effects of activation of the venous footpump, based on recent improved understanding of the physiology of the microcirculation. The hyperaemic response that follows the liberation of endothelial-derived relaxing factor (EDRF) by sudden changes of pressure after weight-bearing or impulse compression is particularly important

This prospective randomised controlled double-blind trial compared two types of PFC Sigma total knee replacement (TKR), differing in three design features aimed at improving flexion. The outcome of a standard fixed-bearing posterior cruciate ligament-preserving design (FB-S) was compared with that of a high-flexion rotating-platform posterior-stabilised design (RP-F) at one year after TKR. The study group of 77 patients with osteoarthritis of the knee comprised 37 men and 40 women, with a mean age of 69 years (44.9 to 84.9). The patients were randomly allocated either to the FB-S or the RP-F group and assessed pre-operatively and at one year post-operatively. The mean post-operative non-weight-bearing flexion was 107° (95% confidence interval (CI) 104° to 110°)) for the FB-S group and 113° (95% CI 109° to 117°) for the RP-F group, and this difference was statistically significant (p = 0.032). However, weight-bearing range of movement during both level walking and ascending a slope as measured during flexible electrogoniometry was a mean of 4° lower in the RP-F group than in the FB-S group, with 58° (95% CI 56° to 60°) versus 54° (95% CI 51° to 57°) for level walking (p = 0.019) and 56° (95% CI 54° to 58°) versus 52° (95% CI 48° to 56°) for ascending a slope (p = 0.044). Further, the mean post-operative pain score of the Western Ontario and McMaster Universities Osteoarthritis Index was significantly higher in the RP-F group (2.5 (95% CI 1.5 to 3.5) versus 4.2 (95% CI 2.9 to 5.5), p = 0.043). Although the RP-F group achieved higher non-weight-bearing knee flexion, patients in this group did not use this during activities of daily living and reported more pain one year after surgery

Fine-wire accepted as a minimally external fixation is invasive technique, which can provide better outcomes than traditional open methods in the management of complex fractures of the tibial plateau. Available fixators vary in their biomechanical stability, and we believe that a stable beam-loading system is essential for consistently good outcomes. We assessed, prospectively, the clinical, radiological and general health status of 20 of 21 consecutive patients with complex fractures of the tibial plateau who had been treated using a standard protocol, with percutaneous screw fixation and a neutralisation concept with a fine wire beam-loading fixator allowing early weight-bearing. Bony union was achieved in all patients, with 85% having good or excellent results. Full weight-bearing started during the first six weeks in 60% of patients. The general health status assessment correlated well with the knee scores and reflected a satisfactory outcome

We report a prospective study of the causes and treatment of 26 long-standing neuropathic ulcers of the foot in 21 patients. The most important causal factor, well illustrated by pressure studies, was the presence of a dynamic or static deformity leading to local areas of peak pressure on insensitive skin. All but one of the 26 ulcers had healed after an average of 10 weeks of treatment in a light, skin-tight plaster cast, with the prohibition of weight-bearing. Recurrent ulceration was prevented in all but one foot by early operation to correct the causative deformity; this was performed after the ulcer had healed and before allowing weight-bearing on the limb. Pressure studies after operation confirmed that pressure points had been relieved

Valgus high tibial osteotomy for osteoarthritis of the medial compartment of the knee can be performed using medial opening- and lateral closing-wedge techniques. The latter have been thought to offer greater initial stability. We measured and compared the stability of opening- and closing-wedge osteotomies fixed by TomoFix plates using radiostereometry in a series of 42 patients in a prospective, randomised clinical trial. There were no differences between the opening- and closing-wedge groups in the time to regain knee function and full weight-bearing. Pain and knee function were significantly improved in both groups without any differences between them. All the osteotomies united within one year. Radiostereometry showed no clinically relevant movement of bone or differences between either group. Medial opening-wedge high tibial osteotomy secured by a TomoFix plate offers equal stability to a lateral closing-wedge technique. Both give excellent initial stability and provide significantly improved knee function and reduction in pain, although the opening-wedge technique was more likely to produce the intended correction

Destruction of the articular cartilage is the first change seen on gross examination of the knee in osteoarthritis. Weight-bearing radiographs are conventionally taken with the knee in full extension. Biomechanical studies have shown, however, that the major contact stresses in the femorotibial articulation occur when the knee is flexed about 28 degrees. Arthroscopy has confirmed that cartilage loss occurs in a more posterior portion of the femoral condyles than is revealed by radiographs taken in full extension. The 'standing tunnel view' is a weight-bearing postero-anterior radiograph taken with the knee in 30 degrees of flexion. The radiographs of 64 patients have been used to compare the conventional with the standing tunnel view. In 10 knees in which the conventional view suggested normal cartilage the standing tunnel view revealed severe degeneration

The Swansea Morriston Achilles Rupture Treatment (SMART) programme was introduced in 2008. This paper summarises the outcome of this programme. Patients with a rupture of the Achilles tendon treated in our unit follow a comprehensive management protocol that includes a dedicated Achilles clinic, ultrasound examination, the use of functional orthoses, early weight-bearing, an accelerated exercise regime and guidelines for return to work and sport. The choice of conservative or surgical treatment was based on ultrasound findings. . The rate of re-rupture, the outcome using the Achilles Tendon Total Rupture Score (ATRS) and the Achilles Tendon Repair Score, (AS), and the complications were recorded. An elementary cost analysis was also performed. . Between 2008 and 2014 a total of 273 patients presented with an acute rupture 211 of whom were managed conservatively and 62 had surgical repair. There were three re-ruptures (1.1%). There were 215 men and 58 women with a mean age of 46.5 years (20 to 86). Functional outcome was satisfactory. Mean ATRS and AS at four months was 53.0 (. sd . 14), 64.9 (. sd. 15) (n = 135), six months 67.8 (. sd. 16), 73.8 (. sd. 15) (n = 103) and nine months (72.4; . sd. 14) 72.3 (. sd. 13) (n = 43). The programme realised estimated cost savings exceeding £91 000 per annum. The SMART programme resulted in a low rate of re-rupture, a satisfactory outcome, a reduced rate of surgical intervention and a reduction in healthcare costs. Cite this article: Bone Joint J 2015; 97-B:510–15

In a prospective study, 170 impacted femoral neck fractures were treated by early mobilisation and weight-bearing. The overall mortality at one year was 16%. In the 167 patients who were followed up until fracture healing or secondary instability, 143 fractures (86%) united. Instability occurred only in patients over 70 years of age, and in younger patients with a short life expectancy. Stepwise logistic regression analysis indicated that poor general health and old age (over 70 years) were risk factors. None of the other variables, such as the Garden index, Pauwels' type, and time to full weight-bearing had any influence on the development of secondary instability. Delayed operation after secondary instability caused no increase in mortality, nonunion or avascular necrosis. Functional treatment of all patients with impacted femoral neck fractures seems therefore to be justified

We used fluoroscopy to study the kinematics of the knee in 47 patients with total knee arthroplasty (TKA) and four control subjects with normal knees while performing a single-leg deep-knee bend. The videos were analysed using still photographs taken at 5 degrees increments of flexion. Femorotibial contact points, patellar ligament rotation, and patellar rotation were calculated from each image. Maximum weight-bearing flexion was determined for each knee. Compared with the control group, posterior-cruciate-retaining TKA did not reproduce normal knee kinematics in any case, but showed a starting point posterior to the tibial midline which translated anteriorly with flexion. The curves from successive knee bends could not be consistently reproduced. Under weight-bearing conditions, the maximum flexion for any PCR TKA was 98 degrees and several patients could not flex beyond 70 degrees

We used demineralised bone matrix (DBM) to augment re-attachment of tendon to a metal prosthesis in an in vivo ovine model of reconstruction of the extensor mechanism at the knee. We hypothesised that augmentation of the tendon-implant interface with DBM would enhance the functional and histological outcomes as compared with previously reported control reconstructions without DBM. Function was assessed at six and 12 weeks postoperatively, and histological examination was undertaken at 12 weeks. A significant increase of 23.5% was observed in functional weight-bearing at six weeks in the DBM-augmented group compared with non-augmented controls (p = 0.004). By 12 weeks augmentation with DBM resulted in regeneration of a more direct-type enthesis, with regions of fibrocartilage, mineralised fibrocartilage and bone. In the controls the interface was predominantly indirect, with the tendon attached to the bone graft-hydroxyapatite base plate by perforating collagen fibres

This prospective study compares the outcome of 157 hydroxyapatite (HA)-coated tibial components with 164 cemented components in the ROCC Rotating Platform total knee replacement in 291 patients. The mean follow-up was 7.6 years (5.2 to 11). There were two revisions for loosening: one for an HA-coated and one for a cemented tibial component. Radiological evaluation demonstrated no radiolucent lines with the HA-coated femoral components. A total of three HA-coated tibial components exhibited radiolucent lines at three months post-operatively and these disappeared after three further months of protected weight-bearing. With HA-coated components the operating time was shorter (p <  0.006) and the radiological assessment of the tibial interface was more stable (p < 0.01). Using revision for aseptic loosening of the tibial component as the end point, the survival rates at nine years was identical for both groups at 99.1%. Our results suggest that HA-coated components perform at least as well as the same design with cemented components and compare favourably with those of series describing cemented or porous-coated knee replacements, suggesting that fixation of both components with hydroxyapatite is a reliable option in primary total knee replacement

We reviewed 25 patients who had undergone resection of a primary bone sarcoma which extended to within 5 cm of the knee with reconstruction by a combination of a free vascularised fibular graft and a massive allograft bone shell. The distal femur was affected in four patients and the proximal tibia in 21. Their mean age at the time of operation was 19.7 years (5 to 52) and the mean follow-up period 140 months (28 to 213). Three vascularised transfers failed. The mean time to union of the fibula was 5.6 months (3 to 10) and of the allograft 19.6 months (10 to 34). Full weight-bearing was allowed at a mean of 21.4 months (14 to 36). The mean functional score at final follow-up was 27.4 (18 to 30) using a modfied 30-point Musculoskeletal Tumour Society rating system. The overall limb-salvage rate was 88%. The results of our study suggest that the combined use of a vascularised fibular graft and allograft is of value as a limb-salvage procedure for intercalary reconstruction after resection of bone tumours around the knee, especially in skeletally immature patients