Objectives

Bisphosphonates (BP) are the first-line treatment for preventing fragility fractures. However, concern regarding their efficacy is growing because bisphosphonate is associated with over-suppression of remodelling and accumulation of microcracks. While dual-energy X-ray absorptiometry (DXA) scanning may show a gain in bone density, the impact of this class of drug on mechanical properties remains unclear. We therefore sought to quantify the mechanical strength of bone treated with BP (oral alendronate), and correlate data with the microarchitecture and density of microcracks in comparison with untreated controls.

Migration of 65 Charnley stems implanted with modern cementing techniques was studied by roentgen stereophotogrammetry. There were 25 patients with rheumatoid arthritis (RA) and 40 with osteoarthritis (OA) followed up for two years. In 43 cases a bone sample for histomorphometric analysis was obtained from the femur during the operation. In 22 cases the mean subsidence of the prosthetic head was 0.40 mm and in 20 the mean posterior migration was 1.25 mm. There was no difference in migration between the two diagnostic groups (p = 0.8) after adjusting for variations in gender, age and weight. Male gender was associated with increased subsidence (p = 0.006). Histological examination showed that the RA series had more osteoid surface (p = 0.04), but neither this, nor any of the other histomorphometric variables, influenced migration. These results suggest that, unlike the acetabular socket, the cemented Charnley femoral component is equally secure in osteoarthritis and in rheumatoid arthritis, and that its initial fixation is not influenced by the quality of the local cancellous bone. Our results provide data with which the early performance of new prosthetic designs and fixation methods can be compared

We report the use of a new method of locked intramedullary flexible osteosynthesis (LIFO) in the treatment of 118 unstable fractures of the femur and tibia. The implant utilises a set of flexible pins with a separate locking device for their proximal ends. The LIFO system proved capable of stabilising unstable fractures, and most of the complications occurred during the early testing. At follow-up, 19 of 21 femoral fractures had healed; one become infected and one showed defective callus. Of the 78 tibial shaft fractures, five failed to consolidate and five had inadequate callus. Reaming of the tibial medullary canal was never necessary. Of 28 open fractures only one became infected. The system was most difficult to use in comminuted distal fractures of the tibia, with five failures of healing in 19 cases; these cases require considerable technical proficiency. The flexibility of the system appears to promote earlier consolidation of open fractures, and normal consolidation times for fractures with interfragmentary gaps of up to 10 to 12 mm. A comparative study of callus density in tibial fractures showed a mean improvement of 50 days in cases treated by the LIFO system compared with similar cases treated by rigid nailing

Objectives

The purpose of this study was to evaluate the existing literature from 2005 to 2016 reporting on the efficacy of surgical management of patients with femoroacetabular impingement (FAI) secondary to slipped capital femoral epiphysis (SCFE).

Intertrochanteric fractures of the femur are usually classified into stable and unstable groups, partly to predict the likelihood of displacement with early weight-bearing after internal fixation. Of 82 internally fixed intertrochanteric fractures which would normally be classified as stable, 25 subsequently underwent impaction along the axis of the nail or screw; varus displacement occurred in another six. Of these 31 fractures, 10 were two-part fractures which had been anatomically reduced, and 12 were originally undisplaced. It did not seem possible to predict the subsequent instability from the pre-operative radiographs. Of the 82 fractures, 47 had been treated with a Jewett nail-plate and 35 by a Richards compression screw-plate. Two groups of stable fractures were recognised: Group 1 was undisplaced and Group 2 displaced. Axial impaction occurred in a quarter of all Group 1 fractures however treated. In Group 2 fractures it occurred in a quarter of those treated with a nail-plate, and in over a third of those treated with a sliding screw-plate. The six fractures that underwent varus displacement had all been treated with Jewett nail-plates. Penetration into the joint occurred in 10 patients, all of them in the group treated with Jewett nail-plates; four required re-operation

Stereoradiography with a base shift of the source of illumination was used to produce pairs of radiographs to be measured by stereophotogrammetric techniques. The direction of shift was parallel with the longitudinal axis of the body, so that each radiograph in the stereopair could be used for other clinical purposes. A base shift of 10 centimetres with a distance of 100 centimetres between the focus and the film gave acceptable value of stereoscopic parallax. The radiographs were measured using a Hilger and Watts medical stereometer. This method was checked with test specimens, namely an osteotomised pelvis in which one acetabulum could be rotated and an osteotomised femur in which the whole upper portion could be rotated against the shaft. Measurements made on the acetabulum and its radiographs showed a correlation coefficient of 0.9838 over the range 0 to 30 degrees of anteversion, with a mean error +2.54 degrees and a standard deviation of +/- 1.52 degrees (n = 21). For the femoral neck, over the range from 10 degrees of retroversion to 80 degrees of anteversion, the correlation coefficient was 0.9979, the mean error +2.46 and the standard deviation +/- 1.48 degrees (n = 30)

Serial arterial blood-gas analyses showed a phase of primary hypoxaemia in thirty-two out of fifty fracture patients (64 per cent) without head, chest or abdominal injury. The incidence was greater in those with shaft fractures of the femur or tibia or both, than in those with fractured hips, and was related to the severity of injury and the nature of the accident. Most affected subjects were already hypoxaemic on admission to hospital: the arterial PO. 2. commonly fell to between 60 and 70 millimetres of mercury, and the episode generally lasted a few days. The hypoxaemia was generally subclinical but four patients developed mild clinical fat embolism. Early hypoxaemia was not found in six patients admitted with only soft-tissue injuries. One or more subsequent attacks of subclinical hypoxaemia, each lasting a few days, occurred in half of those previously affected. Most episodes followed fracture operation or manipulation. Pulmonary thromboembolism seemed responsible in two patients, but it could be excluded in others given oral anticoagulant prophylaxis from soon after admission. Pulmonary fat embolism is the most likely explanation of the primary episodes and could account for most of the subsequent periods of hypoxaemia

1. Thirty-seven specimens of the proximal third of the human femur were subjected to cyclically varying loads applied in a physiological direction to the femoral head, having maximum values of from four to thirteen times body weight. 2. Ten of these specimens sustained subcapital fractures of the femoral neck after numbers of cycles of loading varying from 123 to 8,193. 3. The maximum value of cyclic load needed to give fatigue fracture after 10,000 or fewer cycles was found to vary from about twelve times the body weight at ages twenty to fifty to about five times the body weight at age seventy or more. 4. In youth and in middle age the load levels mentioned above are greater than those encountered in normal living, but are comparable to those which may be applied to the femoral head during activities known to produce "fatigue" fractures clinically in young adults. 5. In the elderly the load levels mentioned above are within the range that can be applied in normal living. It is inferred that some femoral neck fractures in the elderly may be fatigue fractures caused by the cyclic loading of normal walking

1. Paralytic dislocation of the hip in spina bifida generally requires reduction and iliopsoas transfer. The muscle transfer ensures that the hip remains reduced, lessens the need for calipers and prevents progressive flexion deformity. In addition, varus and rotation osteotomy of the femur and innominate osteotomy are sometimes required. Varus and rotation osteotomy alone is indicated if the psoas is not strong enough for transfer. The age for reduction of dislocated hips and muscle transfer has been reduced to eight months as experience and confidence has been gained. 2. Flexion deformity is best prevented by early iliopsoas transfer. An anterior release operation is occasionally indicated when there is flexion deformity and a weak psoas muscle. This procedure, alone or supplemented by extension osteotomy, may be necessary to correct severe flexion deformity in children seen late. 3. Lateral rotation deformity of the hip may be caused by unbalanced iliopsoas action or the unbalanced action, or contracture, of the short lateral rotator muscles. If the deformity is sufficient to make the gait bizarre, or if it is difficult to fit a caliper, then soft-tissue operations as described are of value. 4. Abduction deformity can be corrected by division of the unopposed or contracted abductors

1. Penetrating defects were cut in the femora of twenty-five albino rats. In fifteen of the animals the defects in the right legs were protected with cellulose-acetate shields while those in the left legs were unprotected and allowed to heal as controls. In the remaining ten animals the defects in both legs were protected with shields made of homogenous organic bone. 2. New bone was found to proliferate into the concavity of the shields in most of the animals and this protruded beyond the contour of the femur. The development of the protuberance appeared to depend upon the degree to which the shield was adapted to the femoral surface. 3. The cellulose-acetate shield was not removed by the host, but the homogenous organic bone was actively resorbed; multinucleated giant cells were associated with this process. 4. There are indications that the maintenance of the protuberance is dependent upon the continued presence of the shield. Exostoses protected by intact cellulose-acetate shields have been recognised up to eighteen months after operation. 5. The function of the shield in the formation of the bony protuberance is thought to be two-fold, in that it protects the haematoma from invasion by non-osteogenic extra-skeletal connective tissue, and that it governs the size of the haematoma and prevents its distortion by the pressure of the overlying soft tissue

We report the treatment in 17 patients of 27 angular deformities of the long bones by progressive opening-wedge osteotomy. The technique consists of percutaneous osteotomy and progressive angular correction using a modified Wagner distractor. Ten patients (20 bone segments) had adolescent bilateral idiopathic tibia vara with a mean angular deformity of 12 degrees varus (10 to 16). Seven other adolescent patients had secondary angular deformities either at the distal femur or the distal tibia. One of the femoral deformities had an associated 5.5 cm of shortening which was treated simultaneously. The patients with idiopathic tibia vara achieved a final mean angular correction of 15 degrees (mechanical axis from 12 degrees varus to 3 degrees valgus). In patients with secondary angular deformities the mean angular correction was 17 degrees. The Wagner device was removed in an average period of 12 weeks (9 to 27), and no major complications were observed. Progressive opening-wedge osteotomy is an alternative to conventional osteotomies for the treatment of angular deformities of the long bones in adolescent patients, and has the advantage of requiring less invasive surgery, allowing progressive and adjustable correction with bone lengthening if needed

CT and advanced computer-aided design techniques offer the means for designing customised femoral stems. Our aim was to determine the Hounsfield (HU) value of the bone at the corticocancellous interface, as part of the criteria for the design algorithm. We obtained transverse CT images from eight human cadaver femora. The proximal femoral canal was rasped until contact with dense cortical bone was achieved. The femora were cut into several sections corresponding to the slice positions of the CT images. After obtaining a computerised image of the anatomical sections using a scanner, the inner cortical contour was outlined and transferred to the corresponding CT image. The pixels beneath this contour represent the CT density of the bone remaining after surgical rasping. Contours were generated automatically at nine HU levels from 300 to 1100 and the mean distance between the transferred contour and each of the HU-generated contours was computed. The contour generated along the 600-HU pixels was closest to the inner cortical contour of the rasped femur and therefore 600 HU seem to be the CT density of the corticocancellous interface in the proximal part of cadaver femora. Generally, femoral bone with a CT density beyond 600 HU is not removable by conventional reamers. Thus, we recommend the 600 HU threshold as one of several criteria for the design of custom femoral implants from CT data

We describe the results of a prospective study of 28 children with spastic diplegia and in-toed gait, who had bilateral femoral derotation osteotomies undertaken at either the proximal intertrochanteric or the distal supracondylar level of the femur. Preoperative clinical evaluation and three-dimensional movement analysis determined any additional soft-tissue surgery. Distal osteotomy was faster with significantly lower blood loss than proximal osteotomy. The children in the distal group achieved independent walking earlier than those in the proximal group (6.9 ± 1.3 v 10.7 ± 1.7 weeks; p < 0.001). Transverse plane kinematics demonstrated clinically significant improvements in rotation of the hip and the foot progression angle in both groups. Correction of rotation of the hip was from 17 ± 11° internal to 3 ± 9.5° external in the proximal group and from 9 ± 14° internal to 4 ± 12.4° external in the distal group. Correction of the foot progression angle was from a mean of 10.0 ± 17.3° internal to 13.0 ± 11.8° external in the proximal group (p < 0.001) compared with a mean of 7.0 ± 19.4° internal to 10.0 ± 12.2° external in the distal group (p < 0.001). Femoral derotation osteotomy at both levels gives comparable excellent correction of rotation of the hip and foot progression angles in children with spastic diplegia

Aims

Pelvic reconstruction after the resection of a tumour around the acetabulum is a challenging procedure due to the complex anatomy and biomechanics. Several pelvic endoprostheses have been introduced, but the rates of complication remain high. Our aim was to review the use of a stemmed acetabular pedestal cup in the management of these patients.

A follow-up study, on average four years after operation, of seventy-six cildren with myelomeningocele who had surgical treatment for flexion contracture of the knee, is reported. After a single operation sixty-eight knees (55 per cent) had a contracture of less than 20 degrees, which was the main criterion of success. About half of the cases of transplantation of the hamstrings to the femur, division or elongation of the hamstrings, or supracondylar osteotomy had successful results. Transfer of the hamstring tendons to the patella was successful in nine of twelve instances, so giving the lowest rate of failure. Forty-five patients were active walkers at follow-up as compared to eighteen before operation. However, only one of the eleven patients over twelve years of age with a motor level above T.12 was an active walker at review. Several conclusions are drawn. A flexion contracture of the hip greater than 30 degress should be corrected before operation of the knee. Supracondylar osteotomy as a primary procedure should only be used to correct flexion contracture of the knee secondary to malunited fractures. Faradic stimulation is useful in the evaluation of muslce function before operation. An intelligence quotient below 65 and weakness of the arms are relative contraindications for correction of the deformity of the knee

It has been suggested that reamed intramedullary nailing of the femur should be avoided in some patients with multiple injuries. We have studied prospectively the effect of femoral reaming on the inflammatory process as implicated in the pathogenesis of acute respiratory distress syndrome (ARDS) and multiple-organ failure (MOF). We studied changes in the levels of serum interleukin-6 (IL-6) (proinflammatory cytokine), neutrophil CD11b (C3) receptor expression (activated neutrophil adhesion molecule), serum soluble intracellular adhesion molecule (s-ICAM-1), serum soluble E-selectin (the soluble products of endothelial adhesion molecules) and plasma elastase (neutrophil protease) in a series of patients with femoral fractures treated by nailing. We have also compared reamed nailing with unreamed nailing. We found that the levels of serum IL-6 and elastase rose significantly during the nailing procedure indicating a measurable ‘second hit’. There was no clear response in leukocyte activation and no difference in the release of endothelial adhesion molecule markers. There was no significant difference between groups treated by reamed and unreamed nailing. Although clinically unremarkable, the one patient who died from ARDS was shown to be hyperstimulated after injury and again after nailing, suggesting the importance of an excessive inflammatory reaction in the pathogenesis of these serious problems. Our findings have shown that there is a second hit associated with femoral nailing and suggest that the degree of the inflammatory reaction may be important in the pathogenesis of ARDS and MOF

We have reviewed retrospectively 80 patients who were treated for traumatic fractures of the femur with a Grosse-Kempf nail to assess the incidence and causes of persisting pain in the proximal thigh. At a mean of 21 months after operation 33 patients had residual pain severe enough to interfere with their lifestyle or mobility. This was in the region of the scar on the greater trochanter in three-quarters of the patients. Only four showed no radiological abnormality. There was nonunion of the fracture in two, Paget’s disease in one, breakage of the nail in two and prominence of the proximal locking screw in five, although we found no correlation between prominence of the nail and pain. There was a strong relationship between pain and heterotopic ossification at the proximal end of the implant; this was present in 64% of the patients with pain as compared with those without pain (p < 0.001, Mann-Whitney U test). Of the 80 patients, 27 had the implant removed after 18 months, 17 of them because of pain. In six of these 17, the pain was not relieved. Prominence of the nail proximally was not associated with pain, but protuberance of laterally-based proximal locking screws caused problems. We found a strong association between heterotopic bone formation and pain, but it is uncertain whether this is the true cause or merely an indication of some other factor such as traumatic damage to the glutei during insertion of the nail. Removal of the implant does not always cure such pain

Aims

The aim of this independent multicentre study was to assess the mid-term results of mobile bearing unicondylar knee arthroplasty (UKA) for isolated lateral osteoarthritis of the knee joint.

From a series of 190 consecutive fractures of the shaft of the femur treated by closed Kuntscher nailing, 32 of the more severely comminuted have been studied to determine whether treatment by closed nailing was justified. Radiological criteria were used to divide them into 19 who were moderately comminuted and 13 grossly so. Twenty-four patients were less than 21 years of age and 19 patients had 40 significant associated injuries. Fifteen fractures were nailed on the day of injury, and complications were few. Nineteen patients had a supplementary cast-brace and all those who had been employed returned to work. Twelve patients had shortening of up to two centimetres and two had three centimetres; four had mild rotational deformities; seven had mild restriction of knee flexion; and two had delayed union. There were no infections. The advantages of this technique include a negligible risk of infection and rapid stabilisation of even grossly comminuted fractures, thus facilitating management of other injuries. The 44 per cent incidence of shortening is counterbalanced by early mobilisation and rapid return of knee function. It is concluded that when proper equipment and expertise are available then closed nailing is the treatment of choice for severely comminuted fractures of the femoral shaft

Specimens of femoral heads were studied at necropsy in two cases of Legg-Calve-Perthes' disease. One was that of a boy aged four years ten months who died from appendicitis; the other was from a boy aged six years who died from a malignant glioma. Both had been treated for one and a half years for Legg-Calve-Perthes' disease which was in a stage of repair at the time of death. The diseased femoral heads were moderately flattened but the surface cartilage was intact. Epiphysial bone and bone marrow were partly replaced by cartilage, fibrous tissue and granulation tissue, and new bone was being formed. Inflammatory reaction was inconspicuous. Enchondral bone formation was only slightly decreased, and the structure of the growth plate was undisturbed. There was no sign of systemic bone disease. In the first case the changes indicated that more than one episode of ischaemia had occurred, and an occlusion--probably from an old thrombus--was demonstrated in the posterior inferior retinacular artery of the femoral head. The last episode of ischaemia, furthermore, had caused infarction of part of the metaphysial bone. In both cases, the central area of the metaphysial bone of the affected femur contained fat, but there were few haemopoietic cells and it therefore looked pale. The findings are discussed in relation to previous work on the pathology in Legg-Calve-Perthes' disease, recent information on the vascularisation of the femoral head in children, and experimental and comparative animal studies