We describe the technique and results of medial submuscular plating of the femur in paediatric patients and discuss its indications and limitations. Specifically, the technique is used as part of a plate-after-lengthening strategy, where the period of external fixation is reduced and the plate introduced by avoiding direct contact with the lateral entry wounds of the external fixator pins. The technique emphasises that vastus medialis is interposed between the plate and the vascular structures.

A total of 16 patients (11 male and five female, mean age 9.6 years (5 to 17)), had medial submuscular plating of the femur. All underwent distraction osteogenesis of the femur with a mean lengthening of 4.99 cm (3.2 to 12) prior to plating. All patients achieved consolidation of the regenerate without deformity. The mean follow-up was 10.5 months (7 to 15) after plating for those with plates still in situ, and 16.3 months (1 to 39) for those who subsequently had their plates removed. None developed a deep infection. In two patients a proximal screw fractured without loss of alignment; one patient sustained a traumatic fracture six months after removal of the plate.

Placing the plate on the medial side is advantageous when the external fixator is present on the lateral side, and is biomechanically optimal in the presence of a femoral defect. We conclude that medial femoral submuscular plating is a useful technique for specific indications and can be performed safely with a prior understanding of the regional anatomy.

Cite this article: Bone Joint J 2014;96-B:137–42.

Fractures of the odontoid peg are common spinal injuries in the elderly. This study compares the survivorship of a cohort of elderly patients with an isolated fracture of the odontoid peg versus that of patients who have sustained a fracture of the hip or wrist. A six-year retrospective analysis was performed on all patients aged > 65 years who were admitted to our spinal unit with an isolated fracture of the odontoid peg. A Kaplan–Meier table was used to analyse survivorship from the date of fracture, which was compared with the survivorship of similar age-matched cohorts of 702 consecutive patients with a fracture of the hip and 221 consecutive patients with a fracture of the wrist.

A total of 32 patients with an isolated odontoid fracture were identified. The rate of mortality was 37.5% (n = 12) at one year. The period of greatest mortality was within the first 12 weeks. Time made a lesser contribution from then to one year, and there was no impact of time on the rate of mortality thereafter. The rate of mortality at one year was 41.2% for male patients (7 of 17) compared with 33.3% for females (5 of 15).

The rate of mortality at one year was 32% (225 of 702) for patients with a fracture of the hip and 4% (9 of 221) for those with a fracture of the wrist. There was no statistically significant difference in the rate of mortality following a hip fracture and an odontoid peg fracture (p = 0.95). However, the survivorship of the wrist fracture group was much better than that of the odontoid peg fracture group (p < 0.001). Thus, a fracture of the odontoid peg in the elderly is not a benign injury and is associated with a high rate of mortality, especially in the first three months after the injury.

Cite this article: Bone Joint J 2014;96-B:88–93.

A delay in the diagnosis of paediatric acute and subacute haematogenous osteomyelitis can lead to potentially devastating morbidity. There are no definitive guidelines for diagnosis, and recommendations in the literature are generally based on expert opinions, case series and cohort studies. All articles in the English literature on paediatric osteomyelitis were searched using MEDLINE, CINAHL, EMBASE, Google Scholar, the Cochrane Library and reference lists. A total of 1854 papers were identified, 132 of which were examined in detail. All aspects of osteomyelitis were investigated in order to formulate recommendations. On admission 40% of children are afebrile. The tibia and femur are the most commonly affected long bones. Clinical examination, blood and radiological tests are only reliable for diagnosis in combination. Staphylococcus aureus is the most common organism detected, but isolation of Kingella kingae is increasing. Antibiotic treatment is usually sufficient to eradicate the infection, with a short course intravenously and early conversion to oral treatment. Surgery is indicated only in specific situations. Most studies were retrospective and there is a need for large, multicentre, randomised, controlled trials to define protocols for diagnosis and treatment. Meanwhile, evidence-based algorithms are suggested for accurate and early diagnosis and effective treatment

Large ceramic femoral heads offer several advantages that are potentially advantageous to patients undergoing both primary and revision total hip replacement. Many high-quality studies have demonstrated the benefit of large femoral heads in reducing post-operative instability. Ceramic femoral heads may also offer an advantage in reducing polyethylene wear that has been reported in vitro and is starting to become clinically apparent in mid-term clinical outcome studies. Additionally, the risk of taper corrosion at a ceramic femoral head–neck junction is clearly lower than when using a metal femoral head. With improvements in the material properties of both modern ceramic femoral heads and polyethylene acetabular liners that have reduced the risk of mechanical complications, large ceramic heads have gained popularity in recent years.

Cite this article: Bone Joint J 2013;95-B, Supple A:63–6.

Satisfactory primary wound healing following total joint replacement is essential. Wound healing problems can have devastating consequences for patients. Assessment of their healing capacity is useful in predicting complications. Local factors that influence wound healing include multiple previous incisions, extensive scarring, lymphoedema, and poor vascular perfusion. Systemic factors include diabetes mellitus, inflammatory arthropathy, renal or liver disease, immune compromise, corticosteroid therapy, smoking, and poor nutrition. Modifications in the surgical technique are necessary in selected cases to minimise potential wound complications. Prompt and systematic intervention is necessary to address any wound healing problems to reduce the risks of infection and other potential complications.

Cite this article: Bone Joint J 2013;95-B, Supple A:144–7.

Patient safety is a critical issue in elective total joint replacement surgery. Identifying risk factors that might predict complications and intensive care unit (ICU) admission proves instrumental in reducing morbidity and mortality. The institution’s experience with risk stratification and pre-operative ICU triage has resulted in a reduction in unplanned ICU admissions and post-operative complications after total hip replacement. The application of the prediction tools to total knee replacement has proven less robust so far. This work also reviews areas for future research in patient safety and cost containment.

Cite this article: Bone Joint J 2013;95-B, Supple A:74–6.

The December 2013 Hip & Pelvis Roundup³⁶⁰ looks at: Enhanced recovery works; Acetabular placement; Exercise better than rest in osteoarthritis patients; if Birmingham hip resurfacing is immune from pseudotumour; HIV and arthroplasty; Labral tears revisited; Prophylactic surgery for FAI; and Ceramics and impaction grafting

The December 2013 Children’s orthopaedics Roundup³⁶⁰ looks at: Long term-changes in hip morphology following osteotomy; Arthrogrypotic wrist contractures are surgically amenable; Paediatric femoral lengthening over a nail; Current management of paediatric supracondylar fractures; MRI perfusion index predictive of Perthes’ progression; Abduction bracing effective in residual acetabular deformity; Hurler syndrome in the spotlight; and the Pavlik works for femoral fractures too!

Two-stage exchange remains the gold standard for treatment of peri-prosthetic joint infection after total hip replacement (THR). In the first stage, all components and associated cement if present are removed, an aggressive debridement is undertaken including a complete synovectomy, and an antibiotic-loaded cement spacer is put in place. Patients are then treated with six weeks of parenteral antibiotics, followed by an ‘antibiotic free period’ to help ensure the infection has been eradicated. If the clinical evaluation and serum inflammatory markers suggest the infection has resolved, then the second stage can be completed, which involves removal of the cement spacer, repeat debridement, and placement of a new THR.

Cite this article: Bone Joint J 2013;95-B, Supple A:84–7.

We retrospectively reviewed 30 patients with a diffuse-type giant-cell tumour (Dt-GCT) (previously known as pigmented villonodular synovitis) around the knee in order to assess the influence of the type of surgery on the functional outcome and quality of life (QOL). Between 1980 and 2001, 15 of these tumours had been treated primarily at our tertiary referral centre and 15 had been referred from elsewhere with recurrent lesions.

The mean follow-up was 64 months (24 to 393). Functional outcome and QOL were assessed with range of movement and the Knee injury and Osteoarthritis Outcome Score (KOOS), the Musculoskeletal Tumour Society (MSTS) score, the Toronto Extremity Salvage Score (TESS) and the SF-36 questionnaire. There was recurrence in four of 14 patients treated initially by open synovectomy. Local control was achieved after a second operation in 13 of 14 (93%). Recurrence occurred in 15 of 16 patients treated initially by arthroscopic synovectomy. These patients underwent a mean of 1.8 arthroscopies (one to eight) before open synovectomy. This achieved local control in 8 of 15 (53%) after the first synovectomy and in 12 of 15 (80%) after two. The functional outcome and QOL of patients who had undergone primary arthroscopic synovectomy and its attendant subsequent surgical procedures were compared with those who had had a primary open synovectomy using the following measures: range of movement (114º versus 127º; p = 0.03); KOOS (48 versus 71; p = 0.003); MSTS (19 versus 24; p = 0.02); TESS (75 versus 86; p = 0.03); and SF-36 (62 versus 80; p = 0.01).

Those who had undergone open synovectomy needed fewer subsequent operations. Most patients who had been referred with a recurrence had undergone an initial arthroscopic synovectomy followed by multiple further synovectomies. At the final follow-up of eight years (2 to 32), these patients had impaired function and QOL compared with those who had undergone open synovectomy initially.

We conclude that the natural history of Dt-GCT in patients who are treated by arthroscopic synovectomy has an unfavourable outcome, and that primary open synovectomy should be undertaken to prevent recurrence or residual disease.

Cite this article: Bone Joint J 2014; 96-B:1111–18.

We describe the impact of a targeted performance improvement programme and the associated performance improvement interventions, on mortality rates, error rates and process of care for haemodynamically unstable patients with pelvic fractures. Clinical care and performance improvement data for 185 adult patients with exsanguinating pelvic trauma presenting to a United Kingdom Major Trauma Centre between January 2007 and January 2011 were analysed with univariate and multivariate regression and compared with National data. In total 62 patients (34%) died from their injuries and opportunities for improved care were identified in one third of deaths.

Three major interventions were introduced during the study period in response to the findings. These were a massive haemorrhage protocol, a decision-making algorithm and employment of specialist pelvic orthopaedic surgeons. Interventions which improved performance were associated with an annual reduction in mortality (odds ratio 0.64 (95% confidence interval (CI) 0.44 to 0.93), p = 0.02), a reduction in error rates (p = 0.024) and significant improvements in the targeted processes of care. Exsanguinating patients with pelvic trauma are complex to manage and are associated with high mortality rates; implementation of a targeted performance improvement programme achieved sustained improvements in mortality, error rates and trauma care in this group of severely injured patients.

Cite this article: Bone Joint J 2014;96-B:1090–7.

Although gradual bone transport may permit the restoration of large-diameter bones, complications are common owing to the long duration of external fixation. In order to reduce such complications, a new technique of bone transport involving the use of an external fixator and a locking plate was devised for segmental tibial bone defects.

A total of ten patients (nine men, one woman) with a mean age at operation of 40.4 years (16 to 64) underwent distraction osteogenesis with a locking plate to treat previously infected post-traumatic segmental tibial defects. The locking plate was fixed percutaneously to bridge proximal and distal segments, and was followed by external fixation. After docking, percutaneous screws were fixed at the transported segment through plate holes. At the same time, bone grafting was performed at the docking site with the external fixator removed.

The mean defect size was 5.9 cm (3.8 to 9.3) and mean external fixation index was 13.4 days/cm (11.8 to 19.5). In all cases, primary union of the docking site and distraction callus was achieved, with an excellent bony result. There was no recurrence of deep infection or osteomyelitis, and with the exception of one patient with a pre-existing peroneal nerve injury, all achieved an excellent or good functional result.

With short external fixation times and low complication rates, bone transport with a locking plate could be recommended for patients with segmental tibial defects.

Cite this article: Bone Joint J 2013;95-B:1667–72.

The National Institute for Health and Clinical Excellence (NICE) guidelines from 2011 recommend the use of cemented hemi-arthroplasty for appropriate patients with an intracapsular hip fracture. In our institution all patients who were admitted with an intracapsular hip fracture and were suitable for a hemi-arthroplasty between April 2010 and July 2012 received an uncemented prosthesis according to our established departmental routine practice. A retrospective analysis of outcome was performed to establish whether the continued use of an uncemented stem was justified. Patient, surgical and outcome data were collected on the National Hip Fracture database. A total of 306 patients received a Cathcart modular head on a Corail uncemented stem as a hemi-arthroplasty. The mean age of the patients was 83.3 years (sd 7.56; 46.6 to 94) and 216 (70.6%) were women. The mortality rate at 30 days was 5.8%. A total of 46.5% of patients returned to their own home by 30 days, which increased to 73.2% by 120 days. The implant used as a hemi-arthroplasty for intracapsular hip fracture provided satisfactory results, with a good rate of return to pre-injury place of residence and an acceptable mortality rate. Surgery should be performed by those who are familiar with the design of the stem and understand what is required for successful implantation.

Cite this article: Bone Joint J 2013;95-B:1538–43.

The October 2013 Children’s orthopaedics Roundup³⁶⁰ looks at: Half a century of Pavlik treatment; Step away from the child!: trends in fracture management; Posterolateral rotatory elbow instability in children; Osteochondral lesions undiagnosed in patellar dislocations; Oral bisphosphonates in osteogenesis imperfecta; Crossed or parallel pins in supracondylar fractures?; Not too late nor too early: getting epiphysiodesis right; Fixation of supramalleolar osteotomies.

The strain on clinic and surgeon resources resulting from a rise in demand for total knee replacement (TKR) requires reconsideration of when and how often patients need to be seen for follow-up. Surgeons will otherwise require increased paramedical staff or need to limit the number of TKRs they undertake. We reviewed the outcome data of 16 414 primary TKRs undertaken at our centre to determine the time to re-operation for any reason and for specific failure mechanisms. Peak risk years for failure were determined by comparing the conditional probability of failure, the number of failures divided by the total number of TKRs cases, for each year. The median times to failure for the most common failure mechanisms were 4.9 years (interquartile range (IQR) 1.7 to 10.7) for femoral and tibial loosening, 1.9 years (IQR 0.8 to 3.9) for infection, 3.1 years (IQR 1.6 to 5.5) for tibial collapse and 5.6 years (IQR 3.4 to 9.3) for instability. The median time to failure for all revisions was 3.3 years (IQR 1.2 to 8.5), with an overall revision rate of 1.7% (n = 282). Results from our patient population suggest that patients be seen for follow-up at six months, one year, three years, eight years, 12 years, and every five years thereafter. Patients with higher pain in the early post-operative period or high body mass index (≥ 41 kg/m²) should be monitored more closely.

Cite this article: Bone Joint J 2013;95-B:1484–9.

Follow-up radiographs are usually used as the reference standard for the diagnosis of suspected scaphoid fractures. However, these are prone to errors in interpretation. We performed a meta-analysis of 30 clinical studies on the diagnosis of suspected scaphoid fractures, in which agreement data between any of follow-up radiographs, bone scintigraphy, magnetic resonance (MR) imaging, or CT could be obtained, and combined this with latent class analysis to infer the accuracy of these tests on the diagnosis of suspected scaphoid fractures in the absence of an established standard. The estimated sensitivity and specificity were respectively 91.1% and 99.8% for follow-up radiographs, 97.8% and 93.5% for bone scintigraphy, 97.7% and 99.8% for MRI, and 85.2% and 99.5% for CT. The results were generally robust in multiple sensitivity analyses. There was large between-study heterogeneity for the sensitivity of follow-up radiographs and CT, and imprecision about their sensitivity estimates.

If we acknowledge the lack of a reference standard for diagnosing suspected scaphoid fractures, MRI is the most accurate test; follow-up radiographs and CT may be less sensitive, and bone scintigraphy less specific.

The October 2013 Foot & Ankle Roundup³⁶⁰ looks at: Operative treatment of calcaneal fractures advantageous in the long term?; Varus ankles and arthroplasty; Reducing autograft complications in foot and ankle surgery; The biomechanics of ECP in plantar fasciitis; Minimally invasive first ray surgery; Alcohol: better drunk than injected?; Is it different in the foot?; It’s all about the temperature

The purpose of this study was to evaluate treatment results following arthroscopic triangular fibrocartilage complex (TFCC) debridement for recalcitrant ulnar wrist pain. According to the treatment algorithm, 66 patients (36 men and 30 women with a mean age of 38.1 years (15 to 67)) with recalcitrant ulnar wrist pain were allocated to undergo ulnar shortening osteotomy (USO; n = 24), arthroscopic TFCC repair (n = 15), arthroscopic TFCC debridement (n = 14) or prolonged conservative treatment (n = 13). The mean follow-up was 36.0 months (15 to 54). Significant differences in Hand20 score at 18 months were evident between the USO group and TFCC debridement group (p = 0.003), and between the TFCC repair group and TFCC debridement group (p = 0.029). Within-group comparisons showed that Hand20 score at five months or later and pain score at two months or later were significantly decreased in the USO/TFCC repair groups. In contrast, scores in the TFCC debridement/conservative groups did not decrease significantly. Grip strength at 18 months was significantly improved in the USO/TFCC repair groups, but not in the TFCC debridement/conservative groups. TFCC debridement shows little benefit on the clinical course of recalcitrant ulnar wrist pain even after excluding patients with ulnocarpal abutment or TFCC detachment from the fovea from the indications for arthroscopic TFCC debridement.

Cite this article: Bone Joint J 2013;95-B:1687–96.

The April 2013 Children’s orthopaedics Roundup³⁶⁰ looks at: improving stress distribution in dysplastic hips; the dangers of fashion; the natural history of supracondylar fractures; ankles that perform well as knees; intra-articular hip pathology at osteotomy; the safe removal of flexible nails; supracondylar fracture fixation; and talipes.

Most patients with a nightstick fracture of the ulna are treated conservatively. Various techniques of immobilisation or early mobilisation have been studied. We performed a systematic review of all published randomised controlled trials and observational studies that have assessed the outcome of these fractures following above- or below-elbow immobilisation, bracing and early mobilisation. We searched multiple electronic databases, related bibliographies and other studies. We included 27 studies comprising 1629 fractures in the final analysis. The data relating to the time to radiological union and the rates of delayed union and nonunion could be pooled and analysed statistically.

We found that early mobilisation produced the shortest radiological time to union (mean 8.0 weeks) and the lowest mean rate of nonunion (0.6%). Fractures treated with above- or below-elbow immobilisation and braces had longer mean radiological times to union (9.2 weeks, 9.2 weeks and 8.7 weeks, respectively) and higher mean rates of nonunion (3.8%, 2.1% and 0.8%, respectively). There was no statistically significant difference in the rate of non- or delayed union between those treated by early mobilisation and the three forms of immobilisation (p = 0.142 to p = 1.000, respectively). All the studies had significant biases, but until a robust randomised controlled trial is undertaken the best advice for the treatment of undisplaced or partially displaced nightstick fractures appears to be early mobilisation, with a removable forearm support for comfort as required.

Cite this article: Bone Joint J 2013;95-B:952–9.