1 . The indications, technique and results of supra-malleolar wedge osteotomy of the tibia in the management of valgus or varus deformity of the ankle in children with myelomeningocele are described. 2. This operation should not be performed until as much correction as possible has been obtained by soft-tissue release and muscle balance has been restored by tendon transfer. 3. In sixteen feet satisfactory correction was obtained and maintained in fourteen, one of which had required revision for over-correction. 4. A closing-wedge osteotomy is recommended ; the two failures occurred after opening-wedge osteotomies. 5. In the fourteen feet with satisfactory correction the complications were negligible, deformity has not recurred and epiphysial growth has been well sustained

Between 1986 and 1991, 106 patients (127 knees) underwent uncemented knee arthroplasty for osteoarthritis. There were 106 total knee arthroplasties and 21 medial unicompartmental knee arthroplasties. The arthroplasties were evaluated for aseptic loosening during the year 2000. For total arthroplasty we used 77 porous-coated anatomic prostheses and 29 press-fit condylar prostheses. The mean bone mineral content of the proximal tibia, measured the day before surgery using dual-photon absorptiometry was 5.48 g/cm for the porous-coated anatomic prostheses which were revised for aseptic loosening (n = 9). This was significantly higher (p = 0.02) than the mean of 4.33 g/cm for those which were not revised. Values for the two revised press-fit condylar knees (4.78 and 4.93 g/cm) were above the mean value (4.23 g/cm) for those which were not revised. We found no statistically significant (p = 0.38) difference between the bone mineral content of the 12 revised and nine unrevised unicompartmental arthroplasties. Low trabecular bone quality, measured as the pre-operative bone mineral content of the proximal tibia, was not a predictor for later revision surgery following uncemented total knee or unicompartmental knee arthroplasty

A non-invasive method of electrical stimulation of healing in ununited fractures of the tibia by pulsed magnetic fileds has been evaluated. In a series of 17 patients all but two of the fractures united within 4 to 10 months, with an average time of just under six months. The method is sufficiently promising to merit further clinical investigation

We have treated 12 adolescent patients with idiopathic tibia vara by asymmetrical physeal distraction using a modified Wagner external fixator. There were no major complications and a mean correction of 13 degrees was achieved. The main advantages of the technique are that no osteotomy, internal fixation or bone graft is needed, and that the operation can be performed on both tibiae simultaneously. No shortening is produced and lengthening can be added to angular correction if required

1. A case is described of fatigue fractures occurring in the lowest thirds of the right tibia and fibula simultaneously. 2. The fibular fracture was a runner's fracture. 3. The tibial fracture was ascribed to the application of a below-knee walking plaster to treat the fibular lesion. 4. Both fractures were slow in uniting. 5. The fractures occurred in a rapidly growing youth but no clinical evidence of an endocrine dysfunction was found

Five cases of congenital pseudarthrosis of the tibia successfully treated by a free vascularised fibular graft are described. Follow-up ranged from 5 to 34 months with a mean of 17.5 months. The technique, which includes radical excision of abnormal bone and soft tissue around the pseudarthrosis, also permits primary bone lengthening, and correction of deformity. The early results indicate that satisfactory bony union is achieved in a relatively short period of time

Five children with congenital pseudarthrosis of the tibia treated by free vascularised fibular grafts were followed up until skeletal maturity. The ipsilateral fibula was used in four cases, the contralateral fibula in one. All our cases achieved bone union, but leg length discrepancy, atrophy of the foot and ankle stiffness were frequent complications, due perhaps to the many previous operations. Vascularised fibular grafting might achieve better results if it were done as the primary procedure

We report the results of a three-year study of bifocal fractures of the tibia and fibula, excluding segmental shaft fractures. In our whole series, these formed 4.7% of all tibial diaphyseal fractures. We describe three groups: bifocal fractures of both the proximal and the distal joint surfaces, fractures of the shaft and tibial plateau, and fractures of the shaft and ankle. These groups of fractures had different characteristics and prognoses. We discuss treatment protocols for each of these three groups

1. A case of congenital bowing of the tibia is described in which pseudarthrosis developed and recurred after nine operations performed by the age of ten years. 2. Union was finally secured by a procedure based on deep impaction of the trimmed upper fragment into the reamed-out lower fragment. This was followed by a Boyd type of partial amputation of the foot with calcaneo-tibial arthrodesis. 3. The end-bearing stump four years later is entirely satisfactory and the simple prosthesis gives equality of leg lengths

There is concern about the incidence and serious nature of infection after intramedullary nailing of the tibia, especially for open injuries. We have reviewed 459 patients with tibial fractures treated by primary reamed nailing. The incidence of infection was 1.8% in closed and Gustilo type I open fractures, 3.8% in type II, and 9.5% in type III fractures (5.5% in type IIIa, 12.5% in type IIIb). These incidences appear to be acceptable in comparison with other published results. We describe the different modes of presentation of infection in these cases, and suggest a protocol for its management, which has been generally successful in our series

We have carried out a prospective, randomised trial to measure the rise of temperature during reaming of the tibia before intramedullary nailing. We studied 34 patients with a mean age of 35.1 years (18 to 63) and mean injury severity score of 10 (9 to 13). The patients were randomised into two groups: group 1 included 18 patients whose procedure was undertaken without a tourniquet and group 2, 16 patients in whom a tourniquet was used. The temperature in the bone was measured directly by two thermocouples inserted into the cortical bone near the isthmus of the tibial diaphysis. Reaming was carried out to at least 1.5 mm above the required diameter of the nail. Blood loss was assessed by recording the preoperative and postoperative haemoglobin (Hb) level. The minimum clinical follow-up was six months. In group 1 (no tourniquet), the mean Hb dropped 2.8 g/dl from 14.3 ± 1.02 g/dl to 11.5 ± 1.04 g/dl (p = 0.0001), whereas with the tourniquet, the mean decrease was 1.3 g/dl from 14 ± 1 g/dl to 12.7 ± 1.3 g/dl (p = 0.007). This difference was not statistically significant. The mean initial tibial temperature was 35.6°C (. sd. 0.6) and rose with reaming to levels between 36.3°C and 51.6°C. The highest temperatures were obtained with the largest reamers (11 and 12 mm, p = 0.0001) and the most rapid rise with the smallest diameters of medullary canal (8 or 9 mm). The rise of temperature was transient (20s). We were unable to identify any effect of the use of a tourniquet on the temperature achieved. Reamed intramedullary tibial nailing induces a transient elevation of temperature which is directly related to the amount of reaming

A 14-year-old girl with a congenitally deformed and shortened right leg and foot is described. The patient could not bear weight on the deformed limb and had to hop on the left leg. The deformed foot faced backwards and had nine toes. The right leg was shorter than the left by 26 centimetres. Radiologically, the lower end of the right femur was ill-developed and there was no knee joint. There were two fibulae and the tibia and the patella were absent. A through-knee disarticulation was done and a prosthesis fitted later. The amputated leg and foot were dissected. Many of the muscles in the leg and foot were duplicated. There were two calcanei, one talus, one navicular, two cuboids and four cuneiforms. Ther were nine metatarsals, and all the toes had three phalanges except for one which had two

Thirty-five patients (28 children and seven adults) were reviewed six months to 22 years after sustaining the common childhood fracture of the intercondylar eminence of the tibia. The aim was to assess both short-term and long-term results and prognosis by clinical and radiological examination and to discover whether conservative treatment was adequate for those severe fractures where a fragment of the tibial crest had been totally displaced. All the less severe fractures and 14 of the 17 severe fractures were treated conservatively. Early improvement occurred in more patients when the knee was immobilised in extension rather than in flexion, but long-term results were similar. Seven patients had slight discomfort, two of whom had had operative treatment. Radiographs of all patients showed a projection at the fracture site but its size did not correlate with the extent of displacement of the fragment nor with the degree of discomfort suffered; in the severe group a smaller projection developed after open reduction and after immobilisation in extension than after immobilisation in flexion. There was no instability due to functional lengthening of the cruciate ligaments and no increased incidence of degenerative change

We describe a rare form of congenital snapping knee. In six knees in four children, the tibia subluxed anteriorly on the femur when the knee was extended and reduced spontaneously on flexion. The abnormal movements were seen and felt as sudden snaps or clunks at about 30 degrees of flexion. All six knees showed similar dysplastic features, although the patients had different clinical syndromes. The mechanism of the subluxation and its management are discussed

We compared the outcome of closed intramedullary nailing with minimally invasive plate osteosynthesis using a percutaneous locked compression plate in patients with a distal metaphyseal fracture in a prospective study. A total of 85 patients were randomised to operative stabilisation either by a closed intramedullary nail (44) or by minimally invasive osteosynthesis with a compression plate (41). Pre-operative variables included the patients’ age and the side and pattern of the fracture. Peri-operative variables were the operating time and the radiation time. Postoperative variables were wound problems, the time to union of the fracture, the functional American Orthopaedic Foot and Ankle surgery score and removal of hardware. We found no significant difference in the pre-operative variables or in the time to union in the two groups. However, the mean radiation time and operating time were significantly longer in the locked compression plate group (3.0 vs 2.12 minutes, p < 0.001, and 97.9 vs 81.2 minutes, p < 0.001, respectively). After one year, all the fractures had united. Patients who had intramedullary nailing had a higher mean pain score, but better function, alignment and total American Orthopaedic Foot and Ankle surgery scores, although the differences were not statistically significant (p = 0.234, p = 0.157, p = 0.897, p = 0.177 respectively). Three (6.8%) patients in the intramedullary nailing group and six (14.6%) in the locked compression plate group showed delayed wound healing, and 37 (84.1%) in the former group and 38 (92.7%) in the latter group expressed a wish to have the implant removed. We conclude that both closed intramedullary nailing and a percutaneous locked compression plate can be used safely to treat Orthopaedic Trauma Association type-43A distal metaphyseal fractures of the tibia. However, closed intramedullary nailing has the advantage of a shorter operating and radiation time and easier removal of the implant. We therefore prefer closed intramedullary nailing for patients with these fractures

A series of 3061 patients with fracture of the distal tibia or ankle was studied for a possible link between overweight and failed reduction. The relative body-weight was recorded as the preoperative self-reported body mass index (BMI) of each patient. There were 109 patients (3.6%) with failure of internal fixation or of closed reduction severe enough to necessitate refixation or corrective osteotomy. The mean BMI in all age- and gender-specific groups studied was found to be significantly higher in patients with failed reduction than in those with an uneventful course (p < 0.01). The relative risk of loss of reduction for patients with a BMI greater than 1SD above the BMI of the corresponding age and gender group of the general population was 3.72 for distal tibial fractures and 3.04 for ankle fractures. Overweight should be recognised as a significant factor in predicting a complicated course after a fracture of the lower leg. Awareness of the increased risk of loss of reduction in overweight patients is important in all phases of management

Thirty-five patients were treated for Type III fractures of the intercondylar eminence of the tibia and were followed up for two to seven years. There were 20 Type IIIA fractures and 15 Type IIIB fractures. The avulsed fragment was reduced by operative arthroscopy and maintained either by extension and immobilisation in a cast or by crossed percutaneous pin fixation. Involvement of the medial collateral ligament or lateral meniscus was confirmed by valgus stress radiographs and by arthroscopy. Primary surgical repair through a separate incision was required in a significant number of patients. At follow-up, few patients suffered ligamentous instability, lack of extension, atrophy of the quadriceps, pain or effusion, and symptoms were minimal. Patients requiring surgical repairs of collateral ligaments or of peripheral detachments of the meniscus generally required a longer period of rehabilitation. Arthroscopic reduction and percutaneous pin fixation provided an effective treatment and significantly decreased the time spent in hospital and the morbidity experienced after alternative treatments

We have reviewed 15 cases of triplane fracture of the distal tibia. The mechanism of injury is lateral rotation and the anatomical pattern of the fracture depends on the state of the growth plate at the time of injury. In seven of our cases the anteromedial part of the growth plate was fused, but in eight children the plate was completely open. In six of these eight children there was a hump or projection of the medial growth plate. It is suggested that this hump stabilises the anteromedial part of the epiphysis in a manner similar to the partial anteromedial fusion seen in older children, and that this accounts for the occurrence of triplane fracture in the presence of an open growth plate

1. The Küntscher method of intramedullary reaming and nail fixation was applied to thirty-five cases of non-union of the lower extremity, twenty femurs and fifteen tibias. A bone graft was generally not used. 2. Most of the patients were allowed to bear weight and to exercise the joints within a few days of the operation. Additional measures such as pre-operative surgery for infection or distraction of shortening were used in some cases. 3. The pseudarthrosis healed in all cases, even when infection was present. The nails were generally not removed until after healing had occurred. 4. It is concluded that the Küntscher method gives remarkably rapid consolidation and restoration of function even in difficult cases of non-union of shaft fracture, particularly of the femur