There is an increased risk of fracture following osteoplasty of the femoral neck for cam-type femoroacetabular impingement (FAI). Resection of up to 30% of the anterolateral head–neck junction has previously been considered to be safe, however, iatrogenic fractures have been reported with resections within these limits. We re-evaluated the amount of safe resection at the anterolateral femoral head–neck junction using a biomechanically consistent model.

In total, 28 composite bones were studied in four groups: control, 10% resection, 20% resection and 30% resection. An axial load was applied to the adducted and flexed femur. Peak load, deflection at time of fracture and energy to fracture were assessed using comparison groups.

There was a marked difference in the mean peak load to fracture between the control group and the 10% resection group (p < 0.001). The control group also tolerated significantly more deflection before failure (p < 0.04). The mean peak load (p = 0.172), deflection (p = 0.547), and energy to fracture (p = 0.306) did not differ significantly between the 10%, 20%, and 30% resection groups.

Any resection of the anterolateral quadrant of the femoral head–neck junction for FAI significantly reduces the load-bearing capacity of the proximal femur. After initial resection of cortical bone, there is no further relevant loss of stability regardless of the amount of trabecular bone resected.

Based on our findings we recommend any patients who undergo anterolateral femoral head–neck junction osteoplasty should be advised to modify their post-operative routine until cortical remodelling occurs to minimise the subsequent fracture risk.

Cite this article: Bone Joint J 2015;97-B:1214–19.

We report our experience of performing an elbow hemiarthroplasty in the treatment of comminuted distal humeral fractures in the elderly patients.

A cohort of 42 patients (three men and 39 women, mean age 72; 56 to 84) were reviewed at a mean of 34.3 months (24 to 61) after surgery. Functional outcome was measured with the Mayo Elbow Performance Score (MEPS) and range of movement. The disabilities of the arm, shoulder and hand questionnaire (DASH) was used as a patient rated evaluation. Complications and ulnar nerve function were recorded. Plain radiographs were obtained to assess prosthetic loosening, olecranon wear and heterotopic bone formation.

The mean extension deficit was 23.5° (0° to 60°) and mean flexion was 126.8° (90° to 145°) giving a mean arc of 105.5° (60° to 145°). The mean MEPS was 90 (50 to 100) and a mean DASH score of 20 (0 to 63). Four patients had additional surgery for limited range of movement and one for partial instability. One elbow was revised due to loosening, two patients had sensory ulnar nerve symptoms, and radiographic signs of mild olecranon wear was noted in five patients.

Elbow hemiarthroplasty for comminuted intra-articular distal humeral fractures produces reliable medium-term results with functional outcome and complication rates, comparable with open reduction and internal fixation and total elbow arthroplasty.

Cite this article: Bone Joint J 2015;97-B:1377–84.

We define the long-term outcomes and rates of further operative intervention following displaced Bennett’s fractures treated with Kirschner (K-) wire fixation between 1996 and 2009. We retrospectively identified 143 patients (127 men and 16 women) with a mean age at the time of injury of 33.2 years (18 to 75). Electronic records were examined and patients were invited to complete the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire in addition to a satisfaction questionnaire. The time since injury was a mean of 11.5 years (3.4 to 18.5). In total 11 patients had died, one had developed dementia and 12 patients were lost to follow-up. This left 119 patients available for recruitment. Of these, 57 did not respond, leaving a study group of 62 patients. Patients reported excellent functional outcomes and high levels of satisfaction at follow-up. Median satisfaction was 94% (interquartile range 91.5 to 97.5) and the mean DASH score was 3.0 (0 to 38). None of the patients had undergone salvage procedures and none of the responders had changed occupation or sporting activities. Long-term patient reported outcomes following displaced Bennett’s fractures treated by closed reduction and K-wire fixation show excellent functional results and a high level of patient satisfaction. The rate of infection is low and similar to other surgical procedures with percutaneous K-wires.

Cite this article: Bone Joint J 2015;97-B:1004–6.

We aimed to determine whether cemented hemiarthroplasty is associated with a higher post-operative mortality and rate of re-operation when compared with uncemented hemiarthroplasty. Data on 19 669 patients, who were treated with a hemiarthroplasty following a fracture of the hip in a nine-year period from 2002 to 2011, were extracted from NHS Scotland’s acute admission database (Scottish Morbidity Record, SMR01). We investigated the rate of mortality at day 0, 1, 7, 30, 120 and one-year post-operatively using 12 case-mix variables to determine the independent effect of the method of fixation. At day 0, those with a cemented hemiarthroplasty had a higher rate of mortality (p < 0.001) compared with those with an uncemented hemiarthroplasty, equivalent to one extra death per 424 procedures. By day one this had become one extra death per 338 procedures. Increasing age and the five-year co-morbidity score were noted as independent risk factors. By day seven, the cumulative rate of mortality was less for cemented hemiarthroplasty though this did not reach significance until day 120. The rate of re-operation was significantly higher for uncemented hemiarthroplasty. Despite adjusting for 12 confounding variables, these only accounted for 15% of the observed variability.

The debate about the choice of the method of fixation for a hemiarthroplasty with respect to the rate of mortality or the risk of re-operation may be largely superfluous. Our results suggest that uncemented hemiarthroplasties may have a role to play in elderly patients with significant co-morbid disease.

Cite this article: Bone Joint J 2014;96-B:1185–91.

This article is a systematic review of the published literature about the biomechanics, functional outcome and complications of intramedullary nailing of fractures of the distal radius.

We searched the Medline and EMBASE databases and included all studies which reported the outcome of intramedullary (IM) nailing of fractures of the distal radius. Data about functional outcome, range of movement (ROM), strength and complications, were extracted. The studies included were appraised independently by both authors using a validated quality assessment scale for non-controlled studies and the CONSORT statement for randomised controlled trials (RCTs).

The search strategy revealed 785 studies, of which 16 were included for full paper review. These included three biomechanical studies, eight case series and five randomised controlled trials (RCTs).

The biomechanical studies concluded that IM nails were at least as strong as locking plates. The clinical studies reported that IM nailing gave a comparable ROM, functional outcome and grip strength to other fixation techniques.

However, the mean complication rate of intramedullary nailing was 17.6% (0% to 50%). This is higher than the rates reported in contemporary studies for volar plating. It raises concerns about the role of intramedullary nailing, particularly when comparative studies have failed to show that it has any major advantage over other techniques. Further adequately powered RCTs comparing the technique to both volar plating and percutaneous wire fixation are needed.

Cite this article: Bone Joint J 2015;97-B:1370–6.

Monostotic fibrous dysplasia of the proximal femur has a variable clinical course, despite its reported limited tendency to progress.

We investigated the natural history and predisposing factors for progression of dysplasia in a group of 76 patients with a mean follow-up of 8.5 years (2.0 to 15.2). Of these, 31 (41%) presented with an asymptomatic incidental lesion while 45 (59%) presented with pain or a pathological fracture. A group of 23 patients (30%) underwent early operative treatment for pain (19: 25%) or pathological fracture (4: 5%).

Of the 53 patients who were initially treated non-operatively, 45 (85%) remained asymptomatic but eight (15%) needed surgery because of pain or fracture. The progression-free survival of the observation group was 81% (sd 6.4%) at five-years follow-up. An initial presentation of pain (p < 0.001), a limp (p < 0.001), radiological evidence of microfracture (p = 0.001) and younger age (< 17 years) (p = 0.016) were significant predisposing factors for disease progression.

The risk of experiencing pain or pathological fracture is considerable in monostotic fibrous dysplasia of the proximal femur. Patients presenting with pain, a limp or radiological evidence of microfracture have a high chance of needing surgical treatment.

Cite this article: Bone Joint J 2014;96-B:673–6.

C5 nerve root palsy is a rare and potentially debilitating complication of cervical spine surgery. Currently, however, there are no guidelines to help surgeons to prevent or treat this complication.

We carried out a systematic review of the literature to identify the causes of this complication and options for its prevention and treatment. Searches of PubMed, Embase and Medline yielded 60 articles for inclusion, most of which addressed C5 palsy as a complication of surgery. Although many possible causes were given, most authors supported posterior migration of the spinal cord with tethering of the nerve root as being the most likely.

Early detection and prevention of a C5 nerve root palsy using neurophysiological monitoring and variations in surgical technique show promise by allowing surgeons to minimise or prevent the incidence of C5 palsy. Conservative treatment is the current treatment of choice; most patients make a full recovery within two years.

Cite this article: Bone Joint J 2014;96-B:950–5.

The June 2015 Oncology Roundup³⁶⁰ looks at: Infection in megaprosthesis; Impressive results for mid femoral reconstruction; Revered teaching or old myth? Femoral neck protection in metastatic disease; Megaprosthesis about the knee; Malignant transformation in multiple hereditary exostoses; Fracture of intercalary bone allograft; Comorbidity and outcomes in sarcoma; A worrying turn? Use of denosumab for giant cell tumour of bone

The aim of this study was to assess a specific protocol for the treatment of patients with a parosteal osteosarcoma of the distal femur with limb salvage involving hemicortical resection and reconstruction using recycled pasteurised autograft and internal fixation. Between January 2000 and January 2010, 13 patients with a mean age of 26.5 years (17 to 39) underwent this procedure. All the tumours were staged according to Enneking’s criteria: there were eight stage IA tumours and five stage IB tumours. The mean follow-up was 101.6 months (58 to 142), and mean post-operative Musculoskeletal Tumour Society functional score was 88.6% (80% to 100%) at the final follow-up. All the patients had achieved bony union; the mean time to union was 11.2 months (6 to 18). Local recurrence occurred in one patient 27 months post-operatively. No patient had a pulmonary metastasis.

A hemicortical procedure for the treatment of a parosteal osteosarcoma is safe and effective. Precise pre-operative planning using MRI is essential in order to define the margins of resection. Although it is a technically demanding procedure, gratifying results make it worthwhile for selected patients.

Cite this article: Bone Joint J 2013;95-B:1275–9.

Primary total knee arthroplasty (TKA) is a reliable procedure with reproducible long-term results. Nevertheless, there are conditions related to the type of patient or local conditions of the knee that can make it a difficult procedure. The most common scenarios that make it difficult are discussed in this review. These include patients with many previous operations and incisions, and those with severe coronal deformities, genu recurvatum, a stiff knee, extra-articular deformities and those who have previously undergone osteotomy around the knee and those with chronic dislocation of the patella.

Each condition is analysed according to the characteristics of the patient, the pre-operative planning and the reported outcomes.

When approaching the difficult primary TKA surgeons should use a systematic approach, which begins with the review of the existing literature for each specific clinical situation.

Cite this article: Bone Joint J 2015;97-B(10 Suppl A):30–9.

The June 2015 Trauma Roundup³⁶⁰ looks at: HIV-related implant surgery in trauma; Major transfusion under the spotlight; Surgery and mortality in elderly acetabular fractures; Traction pin safety; Obesity and trauma; Salvage of acetabular fixation in the longer term

In this study we quantified and characterised the return of functional mobility following open tibial fracture using the Hamlyn Mobility Score. A total of 20 patients who had undergone reconstruction following this fracture were reviewed at three-month intervals for one year. An ear-worn movement sensor was used to assess their mobility and gait. The Hamlyn Mobility Score and its constituent kinematic features were calculated longitudinally, allowing analysis of mobility during recovery and between patients with varying grades of fracture. The mean score improved throughout the study period. Patients with more severe fractures recovered at a slower rate; those with a grade I Gustilo-Anderson fracture completing most of their recovery within three months, those with a grade II fracture within six months and those with a grade III fracture within nine months.

Analysis of gait showed that the quality of walking continued to improve up to 12 months post-operatively, whereas the capacity to walk, as measured by the six-minute walking test, plateaued after six months.

Late complications occurred in two patients, in whom the trajectory of recovery deviated by > 0.5 standard deviations below that of the remaining patients. This is the first objective, longitudinal assessment of functional recovery in patients with an open tibial fracture, providing some clarification of the differences in prognosis and recovery associated with different grades of fracture.

Cite this article: Bone Joint J 2015; 97-B:1118–25.

There is no consensus on the benefit of arthroscopically assisted reduction of the articular surface combined with fixation using a volar locking plate for the treatment of intra-articular distal radial fractures. In this study we compared the functional and radiographic outcomes of fluoroscopically and arthroscopically guided reduction of these fractures.

Between February 2009 and May 2013, 74 patients with unilateral unstable intra-articular distal radial fractures were randomised equally into the two groups for treatment. The mean age of these 74 patients was 64 years (24 to 92). We compared functional outcomes including active range of movement of the wrist, grip strength and Disabilities of the Arm, Shoulder, and Hand scores at six and 48 weeks; and radiographic outcomes that included gap, step, radial inclination, volar angulation and ulnar variance.

There were no significant differences between the techniques with regard to functional outcomes or radiographic parameters. The mean gap and step in the fluoroscopic and arthroscopic groups were comparable at 0.9 mm (standard deviation (sd) 0.7) and 0.7 mm (sd 0.7) and 0.6 mm (sd 0.6) and 0.4 mm (sd 0.5), respectively; p = 0.18 and p = 0.35).

Arthroscopic reduction conferred no advantage over conventional fluoroscopic guidance in achieving anatomical reduction of intra-articular distal radial fractures when using a volar locking plate.

Cite this article: Bone Joint J 2015; 97-B:957–62.

This randomised trial evaluated the outcome of a single design of unicompartmental arthroplasty of the knee (UKA) with either a cemented all-polyethylene or a metal-backed modular tibial component. A total of 63 knees in 45 patients (17 male, 28 female) were included, 27 in the all-polyethylene group and 36 in the metal-backed group. The mean age was 57.9 years (39.6 to 76.9). At a mean follow-up of 6.4 years (5 to 9.9), 11 all-polyethylene components (41%) were revised (at a mean of 5.8 years; 1.4 to 8.0) post-operatively and two metal-backed components were revised (at one and five years). One revision in both groups was for unexplained pain, one in the metal-backed group was for progression of osteoarthritis. The others in the all-polyethylene group were for aseptic loosening. The survivorship at seven years calculated by the Kaplan–Meier method for the all-polyethylene group was 56.5% (95% CI 31.9 to 75.2, number at risk 7) and for the metal-backed group was 93.8% (95% CI 77.3 to 98.4, number at risk 16) This difference was statistically significant (p <  0.001). At the most recent follow-up, significantly better mean Western Ontario and McMaster Universities Arthritis Index Scores were found in the all-polyethylene group (13.4 vs 23.0, p = 0.03) but there was no difference in the mean Knee injury and Osteoarthritis Outcome scores (68.8; 41.4 to 99.0 vs 62.6; 24.0 to 100.0), p = 0.36). There were no significant differences for range of movement (p = 0.36) or satisfaction (p = 0.23).

This randomised study demonstrates that all-polyethylene components in this design of fixed bearing UKA had unsatisfactory results with significantly higher rates of failure before ten years compared with the metal-back components.

Cite this article: Bone Joint J 2015;97-B:786–92.

The outcome of 219 revision total hip arthroplasties (THAs) in 98 male and 121 female patients, using 137 long length and 82 standard length cemented collarless double-taper femoral stems in 211 patients, with a mean age of 72 years (30 to 90) and mean follow-up of six years (two to 18) have been described previously. We have extended the follow-up to a mean of 13 years (8 to 20) in this cohort of patients in which the pre-operative bone deficiency Paprosky grading was IIIA or worse in 79% and 73% of femurs with long and standard stems, respectively.

For the long stem revision group, survival to re-revision for aseptic loosening at 14 years was 97% (95% confidence interval (CI) 91 to 100) and in patients aged > 70 years, survival was 100%. Two patients (two revisions) were lost to follow-up and 86 patients with 88 revisions had died. Worst-case analysis for survival to re-revision for aseptic loosening at 14 years was 95% (95% CI 89 to 100) and 99% (95% CI 96 to 100) for patients aged > 70 years. One additional long stem was classified as loose radiographically but not revised.

For the standard stem revision group, survival to re-revision for aseptic loosening at 14 years was 91% (95% CI 83 to 99). No patients were lost to follow-up and 49 patients with 51 hips had died. No additional stems were classified as loose radiographically.

Femoral revision using a cemented collarless double-taper stem, particularly with a long length stem, and in patients aged > 70 years, continues to yield excellent results up to 20 years post-operatively, including in hips with considerable femoral metaphyseal bone loss.

Cite this article: Bone Joint J 2015;97-B:1038–45.

There is little information about the management of peri-prosthetic fracture of the humerus after total shoulder replacement (TSR). This is a retrospective review of 22 patients who underwent a revision of their original shoulder replacement for peri-prosthetic fracture of the humerus with bone loss and/or loose components. There were 20 women and two men with a mean age of 75 years (61 to 90) and a mean follow-up 42 months (12 to 91): 16 of these had undergone a previous revision TSR. Of the 22 patients, 12 were treated with a long-stemmed humeral component that bypassed the fracture. All their fractures united after a mean of 27 weeks (13 to 94). Eight patients underwent resection of the proximal humerus with endoprosthetic replacement to the level of the fracture. Two patients were managed with a clam-shell prosthesis that retained the original components. The mean Oxford shoulder score (OSS) of the original TSRs before peri-prosthetic fracture was 33 (14 to 48). The mean OSS after revision for fracture was 25 (9 to 31). Kaplan-Meier survival using re-intervention for any reason as the endpoint was 91% (95% confidence interval (CI) 68 to 98) and 60% (95% CI 30 to 80) at one and five years, respectively.

There were two revisions for dislocation of the humeral head, one open reduction for modular humeral component dissociation, one internal fixation for nonunion, one trimming of a prominent screw and one re-cementation for aseptic loosening complicated by infection, ultimately requiring excision arthroplasty. Two patients sustained nerve palsies.

Revision TSR after a peri-prosthetic humeral fracture associated with bone loss and/or loose components is a salvage procedure that can provide a stable platform for elbow and hand function. Good rates of union can be achieved using a stem that bypasses the fracture. There is a high rate of complications and function is not as good as with the original replacement.

Bone sarcomas are rare cancers and orthopaedic surgeons come across them infrequently, sometimes unexpectedly during surgical procedures. We investigated the outcomes of patients who underwent a surgical procedure where sarcomas were found unexpectedly and were subsequently referred to our unit for treatment. We identified 95 patients (44 intra-lesional excisions, 35 fracture fixations, 16 joint replacements) with mean age of 48 years (11 to 83); 60% were males (n = 57). Local recurrence arose in 40% who underwent limb salvage surgery versus 12% who had an amputation. Despite achieving local control, overall survival was worse for patients treated with amputation rather than limb salvage (54% vs 75% five-year survival). Factors that negatively influenced survival were invasive primary surgery (fracture fixation, joint replacement), a delay of greater than two months until referral to our oncology service, and high-grade tumours. Survival in these circumstances depends mostly on factors that are determined prior to definitive treatment by a tertiary orthopaedic oncology unit. Limb salvage in this group of patients is associated with a higher rate of inadequate marginal surgery and, consequently, higher local recurrence rates than amputation, but should still be attempted whenever possible, as local control is not the primary determinant of survival.

Cite this article: Bone Joint J 2014;96-B:665–72.