In 11 patients juxta-articular osteosarcoma around the knee was treated by intraepiphyseal excision of the tumour and reconstruction of the bone defect by distraction osteogenesis. Preoperative and postoperative chemotherapy was given to eight patients with high-grade tumours. The articular cartilage of the epiphysis and a maximum of healthy soft tissues were preserved. Distraction osteogenesis was then carried out. The mean gain in length was 9.7 cm. Full function of the limb was preserved in all except one patient, with a mean follow-up of 53.8 months. Treatment of juxta-articular osteosarcomas around the knee with joint preservation and biological reconstruction using distraction osteogenesis can give excellent functional results

We report the case of a 74-year-old woman who sustained an intertrochanteric fracture of the femoral neck in a previously arthrodesed hip. The hip arthrodesis had been performed 53 years earlier to treat septic arthritis. The fracture was treated successfully using a double-plating technique with 4.5 mm titanium reconstruction plates

A retrospective analysis was performed of eight patients with an open triradiate cartilage, who underwent resection for osteosarcoma and reconstruction of the proximal femur with a hemiarthroplasty, in order to identify changes of acetabular development. An analysis of the centre-edge angle, teardrop-to-medial prosthesis distance, superior joint space, teardrop-to-superior prosthesis distance, degree of lateral translation, and arthritic changes, was performed on serial radiographs. The median age at the time of the initial surgery was 11 years (5 to 14). All patients developed progressive superior and lateral migration of the prosthetic femoral head. Following hemiarthroplasty in the immature acetabulum, the normal deepening and enlargement of the acetabulum is arrested. The degree of superior and lateral migration of the prosthetic head depends on the age at diagnosis and the length of follow-up

A man of 52 years of age had a grand mal seizure. He presented to our unit three months later with irreducible bilateral posterior dislocation of the shoulder. CT scans revealed large compression defects on the anteromedial aspect of the heads of both humeri. The defect on the right side was of more than 50% of the articular surface, and on the left side of 40%. He was treated by a one-stage operation with a hemiarthroplasty on one side and reconstruction of the head by an osteochondral autograft on the other. Three years later the clinical and radiological results were excellent

Aims

Vancouver type B periprosthetic femoral fractures (PFF) are challenging complications after total hip arthroplasty (THA), and some treatment controversies remain. The objectives of this study were: to evaluate the short-to-mid-term clinical outcomes after treatment of Vancouver type B PFF and to compare postoperative outcome in subgroups according to classifications and treatments; to report the clinical outcomes after conservative treatment; and to identify risk factors for postoperative complications in Vancouver type B PFF.

Hypermobility is an acknowledged risk factor for patellar instability. In this case control study the influence of hypermobility on clinical outcome following medial patellofemoral ligament (MPFL) reconstruction for patellar instability was studied. A total of 25 patients with hypermobility as determined by the Beighton criteria were assessed and compared with a control group of 50 patients who were matched for age, gender, indication for surgery and degree of trochlear dysplasia. The patients with hypermobility had a Beighton Score of ≥ 6; the control patients had a score of < 4. All patients underwent MPFL reconstruction performed using semitendinosus autograft and a standardised arthroscopically controlled technique. The mean age of the patients was 25 years (17 to 49) and the mean follow-up was 15 months (6 to 30). Patients with hypermobility had a significant improvement in function following surgery, with reasonable rates of satisfaction, perceived improvement, willingness to repeat and likelihood of recommendation. Functional improvements were significantly less than in control patients (p < 0.01). Joint hypermobility is not a contraindication to MPFL reconstruction although caution is recommended in managing the expectations of patients with hypermobility before consideration of surgery

This study describes the surgical technique used for reconstruction and reinforcement of the lateral collateral ligament complex in patients with posterolateral instability of the elbow and the results. A triceps tendon graft from the ipsilateral elbow which was inserted through bone tunnels and fixed with bone anchors augmented the reconstruction. The operation was performed on 18 consecutive patients with instability after an acute traumatic dislocation. The mean follow-up was 44 months (14 to 88). There were no recurrent dislocations. The elbow was stable in 14 patients; three had some minor limitation of movement. Thirteen had no or only occasional slight pain, 15 returned to their normal level of activity and 17 were satisfied with the outcome. There was only one failure

Seven children with chronic post-traumatic dislocation of the radial head were treated by open reduction and ligament reconstruction by a triceps tendon slip. In the four patients with anterior dislocation, good results were achieved; in the two with anterolateral dislocations bowing of the ulna persisted and subluxation recurred. One patient with an anterior dislocation developed a radio-ulnar synostosis. For anterolateral dislocations, we advise the combining of open reduction and ligament reconstruction with osteotomy of the ulna

We reviewed the clinical and radiological results of 131 patients who underwent acetabular revision for aseptic loosening with impacted bone allograft and a cemented acetabular component. The mean follow-up was 51.7 months (24 to 156). The mean post-operative Merle D’Aubigné and Postel scores were 5.7 points (4 to 6) for pain, 5.2 (3 to 6) for gait and 4.5 (2 to 6) for mobility. Radiological evaluation revealed migration greater than 5 mm in four acetabular components. Radiological failure matched clinical failure. Asymptomatic radiolucent lines were observed in 31 of 426 areas assessed (7%). Further revision was required in six patients (4.5%), this was due to infection in three and mechanical failure in three. The survival rate for the reconstruction was 95.8% (95% confidence interval 92.3 to 99.1) overall, and 98%, excluding revision due to sepsis. Our study, from an independent centre, has reproduced the results of the originators of the method

Limb salvage involving wide resection and reconstruction is now well established for managing musculoskeletal sarcomas. However, involvement of major nerves and vessels with a large volume of muscle and skin may result in a useless limb, contributing to depression and a low quality of life. We have been studying alternative treatments for musculoskeletal sarcoma since 1990, and have recently established a regime using photodynamic surgery with cells labelled with acridine orange, photodynamic therapy with cells treated similarly and radiodynamic treatment using the effect of X-rays on such cells. These techniques have been used after marginal or intralesional resection of tumours since 1999 and have enabled maintenance of excellent limb function in patients with sarcomas

We treated 50 patients with bony malignancy by en-bloc resection, extracorporeal irradiation with 50 Gy and re-implantation of the bone segment. The mean survivor follow-up was 38 months (12 to 92) when 42 patients were alive and without disease. There were four recurrences. The functional results were good according to the Mankin score (17 excellent, 13 good, nine fair, three failures), the Musculoskeletal Tumour Society score (mean 77) and the Toronto Extremity Salvage score (mean 81). There was solid union, but bone resorption was seen in some cases. The dose of radiation was lethal to all cells and produced a dead autograft of perfect fit. Extracorporeal irradiation is a useful technique for limb salvage when there is reasonable residual bone stock. It allows effective re-attachment of tendons and produces a lasting biological reconstruction. There should be no risk of local recurrence or of radiotherapy-induced malignancy in the replanted bone

We retrospectively studied the possibility that direct trauma to the biceps muscle might be the cause of poor elbow flexion and supination in 18 consecutive children with birth lesions of the brachial plexus who had delayed or impaired biceps recovery despite neurophysiological evidence of reinnervation. All had good shoulder and hand function at three months of age. Eight recovered a strong biceps after six months, but nine required a pectoralis minor to biceps transfer to augment elbow flexion and supination. One had a delayed but good recovery of the biceps after microsurgical reconstruction of the plexus. All had a clinical ‘pseudotumour’ in the biceps muscle, which was biopsied during pectoralis minor transfer in two patients and showed rupture and degeneration of muscle fibres with a fibro-fatty infiltrate, suggesting previous muscle trauma. Direct muscle trauma is an uncommon but important cause of delayed or impaired biceps recovery after brachial plexus birth injuries. Surgery to reinnervate the biceps muscle will not work if substantial muscle damage is present when a suitable muscle transfer should be considered

Metal meshes are used in revision surgery of the hip to contain impacted bone grafts in cases with cortical or calcar defects in order to provide rotational stability to the stem. However, the viability of bone allografts under these metal meshes has been uncertain. We describe the histological appearances of biopsies obtained from impacted bone allografts to the calcar contained by a metal mesh in two femoral reconstructions which needed further surgery at 24 and 33 months after the revision procedure. A line of osteoid and viable new bone was observed on the surface of necrotic trabeculae. Active bone marrow between these trabeculae showed necrotic areas in some medullary spaces with reparative fibrous tissue and isolated reactive lymphocytes. This is interpreted as reparative changes after revascularisation of the cancellous allografts. These pathological findings are similar to those reported in allografts contained by cortical host bone and support the hypothesis that incorporation of morcellised bone under metal meshes is not affected by these devices

A segment of tibia 4.5 centimetres long was removed from one hind limb of fifteen dogs. It was then replaced and the main vasculature was restored by a microsurgical technique. In eight controls the segment was replaced without such restoration. In two-thirds of the former cases the microvascular reconstruction was successful; the rate of infection was found to be reduced, bone union was guaranteed and the rate of union accelerated. Success or failure of the reconstruction was clearly demonstrated in five cases by early bone scanning using technetium-labelled polyphosphate

In 28 patients with a solitary diagnosis of instability of the trapeziometacarpal joint because of a rupture of the anterior oblique ligament, reconstruction was carried out using a slip of the tendon of flexor carpi radialis. We were able to review 26 patients. The results after a follow-up of four years seven months showed that most (87%) had significant relief from pain and symptoms. Seventeen were graded as good to excellent. The mean grip strength recovered to 86% of the contralateral side. Most patients (81%) felt that they had subjective improvement and would have undergone the operation again. A lesser functional result was seen in those who developed a flexion deformity because of overtightening of the reconstruction. Increased awareness of this lesion can lead to an early and clear diagnosis so that the patient may be advised adequately. We describe a specific, diagnostic, clinical test which we have used consistently and successfully

We have assessed the biomechanical properties of a 'double-bundle' prosthetic ligament replacing the anterior cruciate in cadaver knees. We compared the results with those of single bundle 'over-the-top' and 'through-the-condyle' techniques, performing anterior drawer tests at 20 degrees and 90 degrees knee flexion. The over-the-top reconstruction gave better anteroposterior stability at 20 degrees, while the through-the-condyle repair was more stable at 90 degrees. The double-bundle reconstruction gave practically normal anterior stability at both 20 degrees and 90 degrees

Infection of a total hip replacement (THR) requires component removal and thorough local debridement. Usually, long-term antibiotic treatment in conjunction with a two-stage revision is required. This may take several months. One-stage revision using antibiotic-loaded cement has not gained widespread use, although the clinical and economic advantages are obvious. Allograft bone may be impregnated with high levels of antibiotics, and in revision of infected THR, act as a carrier providing a sustained high local concentration. We performed 37 one-stage revision of infected THRs, without the use of cement. There were three hips which required further revision because of recurrent infection, the remaining 34 hips (92%) stayed free from infection and stable at a mean follow-up of 4.4 years (2 to 8). No adverse effects were identified. Incorporation of bone graft was comparable with unimpregnated grafts. Antibiotic-impregnated allograft bone may enable reconstruction of bone stock, insertion of an uncemented implant and control of infection in a single operation in revision THR for infection

We describe two patients aged 16 and 25 years with osteogenesis imperfecta who sustained displaced fractures of the acetabulum following minor trauma. The femoral heads were deformed by impact against the acetabular margin and both cases underwent surgical reconstruction. The quality of the bone and soft tissues made the operations challenging. There were potential complications specific to osteogenesis imperfecta, including bleeding, the creation of secondary fracture lines and shredding of the soft-tissue. The cases provide useful guidelines for addressing these difficulties