Objectives

The purpose of this study was to investigate whether the femoral head–neck contour, characterised by the alpha angle, varies with the stage of physeal maturation using MRI evaluation of an asymptomatic paediatric population.

1. A case of femoral artery occlusion after fracture of the femur occurring several days after internal fixation with a medullary nail is described. 2. Arterial reconstruction was undertaken seventeen days after the internal fixation, twenty-seven days after the injury, with restoration of flow and recovery of the limb

1. A method of internal fixation for the supracondylar fracture of the femur in the elderly patient is presented. 2. The fixation obtained allows the unsupported use of the limb and early partial weightbearing. Convalescence is thereby considerably shortened. 3. The disappointing results of internal fixation previously reported can be largely related to poor methods of fixation

We report the histology of a femur retrieved 3.5 years after a cemented revision of a hip replacement in which impaction allografting had been used to fill two large cortical defects. The allograft chips had largely been replaced by viable cortical bone, and the interface between cement and tissue resembled that seen after primary cemented arthroplasty

In six unloaded cadaver knees we used MRI to determine the shapes of the articular surfaces and their relative movements. These were confirmed by dissection. Medially, the femoral condyle in sagittal section is composed of the arcs of two circles and that of the tibia of two angled flats. The anterior facets articulate in extension. At about 20° the femur ‘rocks’ to articulate through the posterior facets. The medial femoral condyle does not move anteroposteriorly with flexion to 110°. Laterally, the femoral condyle is composed entirely, or almost entirely, of a single circular facet similar in radius and arc to the posterior medial facet. The tibia is roughly flat. The femur tends to roll backwards with flexion. The combination during flexion of no antero-posterior movement medially (i.e., sliding) and backward rolling (combined with sliding) laterally equates to internal rotation of the tibia around a medial axis with flexion. About 5° of this rotation may be obligatory from 0° to 10° flexion; thereafter little rotation occurs to at least 45°. Total rotation at 110° is about 20°, most if not all of which can be suppressed by applying external rotation to the tibia at 90°

We reviewed the records and radiographs of seven children who presented with knee pain, local tenderness over the medial femoral condyle, and radiological irregularity of the distal medial metaphysis of the femur suggestive of malignancy. In the five patients who had biopsies, histological changes were consistent with musculotendinous avulsion, and the dissection of ten cadavers confirmed the site to be the insertion of part of the adductor magnus. The recognition of this lesion and knowledge of its benign nature may avoid unnecessary anxiety and needless biopsy

A series of 81 patients has been reviewed to determine the value of endoprosthetic replacement of the proximal femur and hip in the treatment of bone tumours. Standard statistical methods were used to evaluate the survival of the replacements and the patients. Taking removal of the prosthesis, irrespective of the cause, as the criterion for failure the survival of the replacements was found to be 63 per cent after 10 years. If deaths are regarded as failures, then the survival value falls to 48 per cent. The survival of patients with chondrosarcoma and osteoclastoma treated by endoprosthetic replacement compares favourably with survival after amputation or excision of the tumour

There are a number of classification systems for intracapsular fractures of the proximal femur, but none has been shown to be practical with satisfactory reproducibility and accurate predictive value. We have investigated the AO classification and evaluated intra-and interobserver accuracy and its value in predicting treatment and outcome. We found it to have very poor intra- and interobserver reliability and to be of limited predictive use for the outcome of treatment. A simplified system in which the subdivisions were allocated to one of three groups of undisplaced, displaced and basal fractures was found to be of value. We conclude that this is the only division which is appropriate for these fractures and that the AO system for intracapsular fractures is too complicated and should not be used

A personal experience is recounted of operations in cases of tumour involving the humerus or femur with restoration by endoprostheses. Twenty-four patients were treated in this way from 1950 to 1969 inclusive and have been followed up for between four and twenty-four years. The patients selected for treatment have presented chondrosarcoma (ten), so-called benign giant-cell tumour of bone, usually recurrent (nine), angiomatous osteolysis (two), seemingly single thyroid or renal metastasis (two), and ununited pathological fracture after irradiation of a tumour (one). Development of the prostheses from early beginnings is outlined. Some points in surgical management are referred to. The complications and results are recorded

1. One hundred patients with fractures of the upper end of the femur were investigated clinically and radiographically to ascertain the incidence and site of deep venous thrombosis during convalescence. 2. The technique of phlebography used has its own inherent dangers, but we believe that familiarity with the technique reduces the risk of complications. 3. The investigation revealed thrombi that were clinically unsuspected and indicates a need for further investigation of factors such as manipulation and retraction that may promote deep thrombosis. 4. The study has provided a control series for an investigation of the effect of prophylactic anticoagulants upon the incidence of deep venous thrombosis and pulmonary embolism after fractures about the hip

We used 15 pairs of femora from fresh human cadavers to study the effects of the size and location of the entry hole for an intramedullary nail on the strength of the femur. Right femora were used as controls. Left femora in group 1 had a 10 mm entry hole in the 'ideal' location in the piriformis fossa. Group 2 had a 14 mm entry hole in the same position and group 3 had a 14 mm entry hole anterior to this on the superior aspect of the femoral neck. Femora were equipped with strain gauges and loaded to failure in compression. There was reduced stiffness and load to failure in group 3 specimens, suggesting that the location of the hole was more important than its size

We report our results in 24 children with malignant primary bone tumours of the distal femur treated with a Stanmore extendible endoprosthesis (SEER). This consists of a femoral component that can be lengthened, a constrained knee and an uncemented sliding tibial component which crosses the proximal tibial physeal plate perpendicularly. The average age of the patients at diagnosis was ten years and the mean follow-up was 4.7 years (2.5 to 7.9). The mean growth of the affected tibia was 76% (18 to 136) and of the fibula 83% (15 to 750) of the growth of the unaffected limb. Measurement of growth arrest lines showed that the mean growth of the proximal tibial physis on the affected side was 69% (43 to 100) of that of the normal side. The great variability in the growth of the physis cannot yet be explained

We have studied the medium- and long-term effects of femoral intramedullary nailing in 34 children. There was a high incidence of abnormality at the proximal end of the femur, including coxa valga, arrest of growth of the greater trochanter and thinning of the neck of the femur, because of damage to the trochanterocervical growth plate. These disorders affected 30% of the patients, mostly under the age of 13 years (p < 0.05), and were seen more frequently when the nail had been introduced through the piriform fossa. Other factors, such as the side, gender, aetiology, proximal or retrograde insertion, the size of nail and removal of the implant did not influence the result. We recommend that in patients under the age of 13 years other methods of management should be used to avoid damage to the growth plate

Complete fractures through bone affected by Paget's disease may not deserve their innocent reputation. This retrospective study of 182 such femoral fractures, the largest reported series to date, was carried out to discover the behaviour of these fractures in the absence of specific therapy for the Paget's disease. Most previous series have concluded that healing is uneventful but the findings in these patients from the West Midlands do not bear this out. After exclusion of the early deaths, the overall incidence of non-union was 40 per cent, the main problems being posed by the subtrochanteric fractures and those of the upper shaft. Although callus may be abundant, it may itself be involved in the disease process and is not a reliable sign of union. Based on these observations, suggestions for management in the different regions of the femur are made

To define the natural history of bone loss around a femoral prosthesis, the bone mineral content and bone mineral density were measured for each femur in 28 patients with unilateral total hip arthroplasty, 18 age-matched controls, and seven patients with unilateral osteoarthritis. The areas measured were inside the lesser trochanter and 4.8 cm distal to it. The contralateral hip served as the control. Three years after arthroplasty there was 40% loss in average bone mineral content inside the lesser trochanter, and 28% loss in average bone mineral content 4.8 cm distally in the medial cortex. At seven to 14 years after operation, patients had lost 40% of bone proximally and 49% distally. The data suggest that this may progress in a proximal-to-distal fashion, and could account for a 50% decrease in bone mass seven to 14 years after surgery

1. If a vertical load is applied to the head of the femur parallel to its shaft, the upper cortex is stretched and the lower cortex is compressed. The neck breaks from the upper subcapital border to the lesser trochanter. This type of fracture is rarely found clinically. 2. If a compressive force is applied to the area between head and greater trochanter while the head is loaded vertically, a transverse fracture of clinical appearance is produced. If this axial pressure acts along the part of the neck above the central axis a subcapital comminuted fracture results. If the pressure acts below the central axis the result is a transcervical fracture. 3. Strain gauge experiments have shown that axial compression within the upper segment of the neck is produced by the abductor muscles of the hip. Adductor muscles produce a low axial compression. It is suggested that muscular action at the time of injury influences the type of fracture produced by the injury

1. Seventy-six patients with fracture of the upper end of the femur were examined phlebographically for evidence of thrombosis. The patients were randomly divided into two groups : one was given phenindione post-operatively ; the other acted as a control. 2. Analysis of the select series showed that the incidence of venous thrombosis in the anticoagulation group (19 per cent) was significantly less than that in the control group (48 per cent). 3. However, analysis of the complete series failed to show that the incidence of venous thrombosis in the anticoagulation group was significantly less than in the control group. 4. The number of bleeding complications in the anticoagulation group (47 per cent) exceeded those in the control group (16 per cent). The only life-endangering haemorrhage occurred in a patient who had not received an anticoagulant for five months. 5. We were unable to show that the fracture significantly influenced the site or the incidence of venous thrombosis. 6. No correlation was found between the clinical and phlebographic diagnosis of venous thrombosis. 7. It is concluded that the early use of a prophylactic anticoagulant is an effective means of reducing the incidence of venous thrombosis in patients with a fracture about the hip

A series of ten infants is reported, seven of whom showed evidence of osteomyelitis of the upper end of the femur; the remaining three did not, but presented with an acute subluxation of the hip in a febrile illness. Four sequelae among the seven more severe cases were: 1) destruction of the capital epiphysis with dislocation at the hip; 2) destruction of the capital epiphysis, the femoral neck remaining in the acetabulum; 3) destruction of the epiphysial plate with the femoral head, remaining in the acetabulum, connected to the femoral neck by a fibrous union; 4) recovery with coxa magna but no other deformity. The streptococcus plays a greater part in this osteomyelitis of infancy than in osteomyelitis of older children, but various other organisms were identified. The organism should be sought by blood culture as well as from the local lesion. Aspiration of the hip, treatment of the hip in abduction and the use of the appropriate antibiotic are recommended. If there is marked swelling and induration, freer release of the pus is strongly advised. Controlled abduction osteotomy plays a useful part in stabilising the femoral neck in the acetabulum or in stabilising the femoral neck beneath the capital epiphysis, but may usefully be preceded by an arthrograph because late ossification of a detached head sometimes occurs

Coronal plane fractures of the posterior femoral condyle, also known as Hoffa fractures, are rare. Lateral fractures are three times more common than medial fractures, although the reason for this is not clear. The exact mechanism of injury is likely to be a vertical shear force on the posterior femoral condyle with varying degrees of knee flexion. These fractures are commonly associated with high-energy trauma and are a diagnostic and surgical challenge. Hoffa fractures are often associated with inter- or supracondylar distal femoral fractures and CT scans are useful in delineating the coronal shear component, which can easily be missed. There are few recommendations in the literature regarding the surgical approach and methods of fixation that may be used for this injury. Non-operative treatment has been associated with poor outcomes. The goals of treatment are anatomical reduction of the articular surface with rigid, stable fixation to allow early mobilisation in order to restore function. A surgical approach that allows access to the posterior aspect of the femoral condyle is described and the use of postero-anterior lag screws with or without an additional buttress plate for fixation of these difficult fractures.

Cite this article: Bone Joint J 2013;95-B:1165–71.

Seventy patients with 91 congenital short femora are classified. Deformities resulting maternal Thalidomide treatment are compared with those where Thalidomide was not involved and genetic and epidemiological factors investigated in 50 patients. No essential anatomical difference was found between the two groups of femora but the whole complex of abnormalities differed: the Thalidomide group showed femur-tibia-radius anomalies while the non-Thalidomide garoup had femur-fibula-ulna anomalies, indicating either different aetiological factors or different timing of the insult to the foetus. Some differences between congenital coxa vara and congenital short femur associated with coxa vara are mentioned. Simple hypoplasia of the femur may possibly have a multifactorial genetic background since it is associated with other minor abnormalities of the limbs in these families, whereas environmental factors only are associated with the more severe femoral defects