The incidence and long-term outcome of undisplaced fatigue fractures of the femoral neck treated conservatively were examined in Finnish military conscripts between 1970 and 1990. From 106 cases identified, 66 patients with 70 fractures were followed for a mean of 18.3 years (11 to 32). The original medical records and radiographs were studied and physical and radiological follow-up data analysed for evidence of risk factors for this injury. The development of avascular necrosis and osteoarthritis was determined from the follow-up radiographs and MR scans. The impact of new military instructions on the management of hip-related pain was assessed following their introduction in 1986. The preventive regimen (1986) improved awareness and increased the detected incidence from 13.2 per 100 000 service-years (1970 to 1986) to 53.2 per 100 000 (1987 to 1990). No patient developed displacement of the fracture or avascular necrosis of the femoral head, or suffered from adverse complications. No differences were found in MRI-measured hip joint spaces at final follow-up. The mean Harris Hip Score was 97 (70 to 100) and the Visual Analogue Scale 5.85 mm (0 to 44). Non-operative treatment, including avoidance of or reduced weight-bearing, gave favourable short- and long-term outcomes. Undisplaced fatigue fractures of the femoral neck neither predispose to avascular necrosis nor the subsequent development of osteoarthritis of the hip

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

Aims

The risk of mechanical failure of modular revision hip stems is frequently mentioned in the literature, but little is currently known about the actual clinical failure rates of this type of prosthesis. The current retrospective long-term analysis examines the distal and modular failure patterns of the Prevision hip stem from 18 years of clinical use. A design improvement of the modular taper was introduced in 2008, and the data could also be used to compare the original and the current design of the modular connection.

1. A hope expressed in 1940, that further cases of spontaneous fracture of the lowest third of the apparently normal fibula would be described, has been fulfilled. The literature is here reviewed. Five further personal cases are added. 2. The clinical and radiographic features, diagnosis, treatment and results are considered in the light of the information so far available. Special note is made of misleading freedom of ankle and tarsal movements and the occasional absence of tenderness. 3. It is established that fractures of the lowest third occur particularly in two groups of subjects: 1) young male runners and skaters; 2) active and hard-pressed women of middle age and over. 4. In male runners and skaters the fracture usually occurs through slender, mainly cortical bone, two inches or more above the tip of the lateral malleolus; in middle-aged women the fracture is usually distal to the interosseous ligament through thicker, mainly cancellous bone, one and a half inches from the tip of the lateral malleolus. 5. The most convenient name for both groups of fractures in the lowest third is low fatigue fracture of the fibula. 6. A review of the literature of fatigue fracture of the uppermost third of the fibula shows that it is very often precipitated by jumping. The most convenient name for it is high fatigue fracture of the fibula. 7. Like all clinical classifications this distinction between low and high fractures has exceptions (a low fracture of one fibula in a runner was followed later by a high fracture of the other; most military fractures were high, but a few may have occurred at other levels). 8. Fatigue fracture of the fibula, high or low, may be bilateral. 9. A fracture similarly situated to the high fatigue fracture of the fibula has been frequent in parachute schools. It is a speculative possibility that military and parachutist fractures of the upper third of the fibula indicate the link between true fatigue fractures (as exemplified by march fractures with minimal trauma often repeated) and purely traumatic fractures (with adequate trauma applied once only)

1. The femoral head has been examined in specimens taken from cadavers, patients suffering subcapital fracture of the femoral neck and patients undergoing total replacement arthroplasty for osteoarthrosis and rheumatoid arthritis. 2. Lesions have been seen, some of which appear to be uniting fatigue fractures of individual trabeculae. 3. It is suggested that excessive cyclical loading, sometimes leading to fatigue fractures, may represent a fundamental pathological process of general importance in the evolution of certain skeletal and articular diseases

We evaluated 31 patients who were treated with a non-vascularised fibular graft after resection of primary musculoskeletal tumours, with a median follow-up of 5.6 years (3 to 26.7 years). Primary union was achieved in 89% (41 of 46) of the grafts in a median period of 24 weeks. All 25 grafts in 18 patients without additional chemotheraphy and/or radiotherapy achieved primary union, compared with 16 of the 21 grafts (76%; 13 patients) with additional therapy (p = 0.017). Radiographs showed an increase in diameter in 70% (59) of the grafts. There were seven fatigue fractures in six patients, but only two needed treatment. Non-vascularised fibular transfer is a simpler, less expensive and a shorter procedure than the use of vascularised grafts and allows remodelling of the fibula at the donor site. It is a biological reconstruction with good long-term results, and a relatively low donor site complication rate of 16%

Aims

Pelvic discontinuity is a rare but increasingly common complication of total hip arthroplasty (THA). This single-centre study evaluated the performance of custom-made triflange acetabular components in acetabular reconstruction with pelvic discontinuity by determining: 1) revision and overall implant survival rates; 2) discontinuity healing rate; and 3) Harris Hip Score (HHS).

Non-modular tapered fluted, titanium stems are available for use in femoral revision. The combination of taper and flutes on the stem provides axial and rotational stability, respectively. The material and surface properties of the stem promotes bone on-growth. If the surgeon is confident and reasonably experienced in the surgical use of this sort of design and the case is relatively straightforward, a non-modular design is effective. It also potentially reduces implant inventory, and circumvents the potential problems of taper junction corrosion and fatigue fracture. There are reports of excellent survival, good clinical and functional results and evidence of subsequent increase in proximal bone stock. Cite this article: Bone Joint J 2014;96-B(11 Suppl A):56–9

Aims

Taper corrosion has been widely reported to be problematic for modular total hip arthroplasty implants. A simple and systematic method to evaluate taper damage with sufficient resolution is needed. We introduce a semiquantitative grading system for modular femoral tapers to characterize taper corrosion damage.

Aims

This study reports the ten-year wear rates, incidence of osteolysis, clinical outcomes, and complications of a multicentre randomized controlled trial comparing oxidized zirconium (OxZr) versus cobalt-chrome (CoCr) femoral heads with ultra-high molecular weight polyethylene (UHMWPE) and highly cross-linked polyethylene (XLPE) liners in total hip arthroplasty (THA).

1. Two cases of fatigue fracture of the ulna are reported. 2. Three cases previously reported are reviewed and a striking similarity with one of the present cases is noted. 3. In all cases the mechanism of injury appears to have been the same

1. Senile subcapital fractures in osteoporotic patients are due to fatigue, not to the impact of a fall, since they are preceded by the local accumulation of isolated trabecular fatigue fractures. 2. One pathological significance of the isolated trabecular fractures described by Todd, Freeman and Pirie (1972) has been demonstrated

1. Five patients with seven fatigue fractures of the lower third of the tibia are described; two had bilateral fractures. There is a striking similarity in the site and appearance of these fractures. 2. All occurred in middle-aged or elderly people without a history of unusual activity or illness. 3. The fractures are so nearly identical as to constitute an entity which, as far as we are aware, has not been described before

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

1. The results of the by-pass grafting operation in eleven cases of pseudarthrosis of the tibia in childhood are presented. 2. The operation was successful in securing sound bone union in nine cases, and unsuccessful in two. 3. The causes of failure in the two unsuccessful cases are analysed. 4. The possible causes of occurrence and persistence of tibial pseudarthrosis in childhood are discussed. 5. It is suggested that the pseudarthrosis results from a fatigue fracture of a congenitally abnormal tibia, but that its persistence depends entirely on mechanical factors. 6. There is evidence to suggest that the underlying congenital abnormality may arise from dysplasia of the mesenchyme

We report a retrospective review of 62 consecutive patients who had a vascularised fibular transfer to reconstruct a large skeletal defect. We were particularly interested in the bone dynamics of the vascularised graft, since fractures occurred in 25% of the cases at an average time of eight months after surgery. Hypertrophy was more common when the limb was mechanically loaded; it was enhanced where the graft was not bypassed by internal fixation. The length of the graft and the use of additional bone graft material had no influence on the incidence of stress fracture or on hypertrophy. We conclude that a vascularised graft should be protected against fatigue fracture during the first year, and that a gradual increase in mechanical loading will enhance remodelling and hypertrophy

Fatigue fractures which originate at stress-concentrating voids located at the implant-cement interface are a potential cause of septic loosening of cemented femoral components. Heating of the component to 44°C is known to reduce the porosity of the cement-prosthesis interface. The temperature of the cement-bone interface was recorded intra-operatively as 32.3°C. A simulated femoral model was devised to study the effect of heating of the component on the implant-cement interface. Heating of the implant and vacuum mixing have a synergistic effect on the porosity of the implant-cement interface, and heating also reverses the gradients of microhardness in the mantle. Heating of the implant also reduces porosity at the interface depending on the temperature. A minimum difference in temperature between the implant and the bone of 3°C was required to produce this effect. The optimal difference was 7°C, representing a balance between maximal reduction of porosity and an increased risk of thermal injury. Using contemporary cementing techniques, heating the implant to 40°C is recommended to produce an optimum effect

Spondylolysis occurring after a spinal fusion is considered to result from operative damage to the pars interarticularis on both sides. Fourteen cases are reported, and compared with the 23 cases which have previously been published. The defects are usually recognised within five years of fusion, and usually occur immediately above the fusion mass. Other contributory causes may be: fatigue fracture from concentration of stress; damage and altered function of the posterior ligament complex; and degenerative disc disease immediately above or below the fusion. Fusion technique is critical, since virtually all cases occurred after posterior interlaminar fusions. This complication is easily overlooked in patients with recurrent back pain after an originally successful posterior spinal fusion

Aims

There are concerns regarding nail/medullary canal mismatch and initial stability after cephalomedullary nailing in unstable pertrochanteric fractures. This study aimed to investigate the effect of an additional anteroposterior blocking screw on fixation stability in unstable pertrochanteric fracture models with a nail/medullary canal mismatch after short cephalomedullary nail (CMN) fixation.

1. Prosthetic acetabular cups of the Charnley and McKee-Farrar designs were cemented into cadaveric pelves using different procedures for preparing the acetabulum. 2. The torsional moments needed to loosen these cups were measured. 3. The torsional moments so measured were found to be from about four to more than twenty times higher than the frictional moments measured in independent tests on the two designs of prosthesis. 4. It is argued that late looseness of the acetabular component after total hip replacement, in the absence of infection, seems most likely to be due to thermal damage to the bone occurring at the time of polymerisation of the cement, and to subsequent bone resorption. 5. Surgical preparation of the acetabulum should include removal of all the articular cartilage and cleaning of the acetabular fossa, but the drilling of additional holes in the floor of the acetabulum seems unimportant. 6. The possibility of fatigue fracture in bone as a factor contributing to late loosening is an argument in favour of metal-on-polyethylene prostheses with their lower frictional moments, although the importance of this factor cannot be estimated

1. Experience with a refined type of implantable electrode for the myo-electric control of externally powered prostheses is reported. 2. The electrodes are externally energised by electromagnetic induction and therefore do not contain any battery cells. The myo-potentials are transmitted in frequency-modulated form and detected by a receiver placed on the skin. The implantable electrode, measuring 5x11x4 millimetres, is encapsulated in epoxy resin. 3. Six electrodes have been implanted in the forearms of two normal subjects and two below-elbow amputees. The time of implantation ranged from three to fifteen months. Macroscopically, a fibrous capsule developed around the electrodes. Histological examination showed a capsule of granulation tissue of varying thickness with slight inflammatory reaction and foreign-body giant cells. 4. In all cases except one the signals received have been of high quality as ascertained by conventional electromyography and frequency analysis. There has been no significant deterioration in signal quality during the follow-up periods. 5. The major source of failure was fatigue fracture of the gold wires making contact with the body tissues. In one case, however, the electrode was still functioning normally at the time of removal fifteen months after insertion. 6. The patients have not been inconvenienced either by the operative procedures or by the presence of the electrodes in the tissues

Aims

Orthopaedic and reconstructive surgeons are faced with large defects after the resection of malignant tumours of the sacrum. Spinopelvic reconstruction is advocated for resections above the level of the S1 neural foramina or involving the sacroiliac joint. Fixation may be augmented with either free vascularized fibular flaps (FVFs) or allograft fibular struts (AFSs) in a cathedral style. However, there are no studies comparing these reconstructive techniques.

Aims

The Exeter V40 cemented polished tapered stem system has demonstrated excellent long-term outcomes. This paper presents a systematic review of the existing literature and reports on a large case series comparing implant fractures between the Exeter V40 series; 125 mm and conventional length stem systems.

Aims

The material and design of knee components can have a considerable effect on the contact characteristics of the tibial post. This study aimed to analyze the stress distribution on the tibial post when using different grades of polyethylene for the tibial inserts. In addition, the contact properties of fixed-bearing and mobile-bearing inserts were evaluated.

Aims

To determine whether half-threaded screw holes in a new titanium locking plate design can substantially decrease the notch effects of the threads and increase the plate fatigue life.

Aims

To compare time dependent functional improvement for patients with medial, respectively lateral knee osteoarthritis (OA) after treatment with opening wedge osteotomy relieving the pressure on the osteoarthritic part of the knee.

Aims

Magnetically controlled growing rods (MCGR) have been gaining popularity in the management of early-onset scoliosis (EOS) over the past decade. We present our experience with the first 44 MCGR consecutive cases treated at our institution.

Aims

The aims of this study were to validate the outcome of total elbow arthroplasty (TEA) in patients with rheumatoid arthritis (RA), and to identify factors that affect the outcome.

Aims

Aseptic loosening is a major cause of failure in cemented endoprosthetic reconstructions. This paper presents the long-term outcomes of a custom-designed cross-pin fixation construct designed to minimize rotational stress and subsequent aseptic loosening in selected patients. The paper will also examine the long-term survivorship and modes of failure when using this technique.

Aims

This study aimed to determine if macrophages can attach and directly affect the oxide layers of 316L stainless steel, titanium alloy (Ti6Al4V), and cobalt-chromium-molybdenum alloy (CoCrMo) by releasing components of these alloys.

Aims

The aim of this study was to report the outcomes of different treatment options for glenoid loosening following reverse shoulder arthroplasty (RSA) at a minimum follow-up of two years.

If a modular convertible total shoulder system is used as a primary implant for an anatomical total shoulder arthroplasty, failure of the prosthesis or the rotator cuff can be addressed by converting it to a reverse shoulder arthroplasty (RSA), with retention of the humeral stem and glenoid baseplate. This has the potential to reduce morbidity and improve the results.

In a retrospective study of 14 patients (15 shoulders) with a mean age of 70 years (47 to 83) we reviewed the clinical and radiological outcome of converting an anatomical shoulder arthroplasty (ASA) to a RSA using a convertible prosthetic system (SMR system, Lima, San Daniele, Italy).

The mean operating time was 64 minutes (45 to 75). All humeral stems and glenoid baseplates were found to be well-fixed and could be retained. There were no intra-operative or early post-operative complications and no post-operative infection.

The mean follow-up was 43 months (21 to 83), by which time the mean visual analogue scale for pain had decreased from 8 pre-operatively to 1, the mean American Shoulder and Elbow Surgeons Score from 12 to 76, the mean Oxford shoulder score from 3 to 39, the mean Western Ontario Osteoarthritis of the Shoulder Score from 1618 to 418 and the mean Subjective shoulder value from 15 to 61.

On radiological review, one patient had a lucency around the humeral stem, two had stress shielding. There were no fatigue fractures of the acromion but four cases of grade 1 scapular notching.

The use of a convertible prosthetic system to revise a failed ASA reduces morbidity and minimises the rate of complications. The mid-term clinical and radiological results of this technique are promising.

Cite this article: Bone Joint J 2015;97-B:1662–7.

Aims

Free vascularised fibular grafting has been used for the treatment of large bony defects for more than 40 years. However, there is little information about the risk factors for failure and whether newer locking techniques of fixation improve the rates of union. The purpose of this study was to compare the rates of union of free fibular grafts fixed with locking and traditional techniques, and to quantify the risk factors for nonunion and failure.

We retrospectively evaluated 18 patients with a mean age of 37.3 years (14 to 72) who had undergone pelvic reconstruction stabilised with a non-vascularised fibular graft after resection of a primary bone tumour. The mean follow-up was 10.14 years (2.4 to 15.7). The mean Musculoskeletal Tumor Society Score was 76.5% (50% to 100%). Primary union was achieved in the majority of reconstructions within a mean of 22.9 weeks (7 to 60.6). The three patients with delayed or nonunion all received additional therapy (chemotherapy/radiation) (p = 0.0162). The complication rate was comparable to that of other techniques described in the literature.

Non-vascularised fibular transfer to the pelvis is a simpler, cheaper and quicker procedure than other currently described techniques. It is a biological reconstruction with good results and a relatively low donor site complication rate. However, adjuvant therapy can negatively affect the outcome of such grafts.

Following the recall of modular neck hip stems in July 2012, research into femoral modularity will intensify over the next few years. This review aims to provide surgeons with an up-to-date summary of the clinically relevant evidence. The development of femoral modularity, and a classification system, is described. The theoretical rationale for modularity is summarised and the clinical outcomes are explored. The review also examines the clinically relevant problems reported following the use of femoral stems with a modular neck.

Joint replacement registries in the United Kingdom and Australia have provided data on the failure rates of modular devices but cannot identify the mechanism of failure. This information is needed to determine whether modular neck femoral stems will be used in the future, and how we should monitor patients who already have them implanted.

Cite this article: Bone Joint J 2013;95-B:1011–21.

When fracture of an extensively porous-coated femoral component occurs, its removal at revision total hip arthroplasty (THA) may require a femoral osteotomy and the use of a trephine. The remaining cortical bone after using the trephine may develop thermally induced necrosis. A retrospective review identified 11 fractured, well-fixed, uncemented, extensively porous-coated femoral components requiring removal using a trephine with a minimum of two years of follow-up.

The mean time to failure was 4.6 years (1.7 to 9.1, standard deviation (sd) 2.3). These were revised using a larger extensively porous coated component, fluted tapered modular component, a proximally coated modular component, or a proximal femoral replacement. The mean clinical follow-up after revision THA was 4.9 years (2 to 22, sd 3.1). The mean diameter of the femoral component increased from 12.7 mm (sd 1.9) to 16.2 mm (sd 3.4; p >  0.001). Two revision components had radiographic evidence of subsidence that remained radiographically stable at final follow-up. The most common post-operative complication was instability affecting six patients (54.5%) on at least one occasion.

A total of four patients (36.4%) required further revision: three for instability and one for fracture of the revision component. There was no statistically significant difference in the mean Harris hip score before implant fracture (82.4; sd 18.3) and after trephine removal and revision THA (81.2; sd 14.8, p = 0.918).

These findings suggest that removal of a fractured, well-fixed, uncemented, extensively porous-coated femoral component using a trephine does not compromise subsequent fixation at revision THA and the patient’s pre-operative level of function can be restored. However, the loss of proximal bone stock before revision may be associated with a high rate of dislocation post-operatively.

Cite this article: Bone Joint J 2015;97-B:1192–6.

Since the Oxford knee was first used unicompartmentally in 1982, a small number of bearings have fractured. Of 14 retrieved bearings, we examined ten samples with known durations in situ (four Phase 1, four Phase 2 and two Phase 3). Evidence of impingement and associated abnormally high wear (> 0.05 mm per year) as well as oxidation was observed in all bearings. In four samples the fracture was associated with the posterior radio-opaque wire. Fracture surfaces indicated fatigue failure, and scanning electron microscopy suggested that the crack initiated in the thinnest region. The estimated incidence of fracture was 3.20% for Phase 1, 0.74% for Phase 2, 0.35% for Phase 3, and 0% for Phase 3 without the posterior marker wire. The important aetiological factors for bearing fracture are impingement leading to high wear, oxidation, and the posterior marker wire. With improved surgical technique, impingement and high wear should be prevented and modern polyethylene may reduce the oxidation risk. A posterior marker wire is no longer used in the polyethylene meniscus. Therefore, the rate of fracture, which is now very low, should be reduced to a negligible level.

The incidence of periprosthetic fractures of the ankle is increasing. However, little is known about the outcome of treatment and their management remains controversial. The aim of this study was to assess the impact of periprosthetic fractures on the functional and radiological outcome of patients with a total ankle arthroplasty (TAA).

A total of 505 TAAs (488 patients) who underwent TAA were retrospectively evaluated for periprosthetic ankle fracture: these were then classified according to a recent classification which is orientated towards treatment. The outcome was evaluated clinically using the American Orthopedic Foot and Ankle Society (AOFAS) score and a visual analogue scale for pain, and radiologically.

A total of 21 patients with a periprosthetic fracture of the ankle were identified. There were 13 women and eight men. The mean age of the patients was 63 years (48 to 74). Thus, the incidence of fracture was 4.17%.

There were 11 intra-operative and ten post-operative fractures, of which eight were stress fractures and two were traumatic. The prosthesis was stable in all patients. Five stress fractures were treated conservatively and the remaining three were treated operatively.

A total of 17 patients (81%) were examined clinically and radiologically at a mean follow-up of 53.5 months (12 to 112). The mean AOFAS score at follow-up was 79.5 (21 to 100). The mean AOFAS score in those with an intra-operative fracture was 87.6 (80 to 100) and for those with a stress fracture, which were mainly because of varus malpositioning, was 67.3 (21 to 93). Periprosthetic fractures of the ankle do not necessarily adversely affect the clinical outcome, provided that a treatment algorithm is implemented with the help of a new classification system.

Cite this article: Bone Joint J 2015;97-B:950–6.

The purpose of this study was to describe the anatomical distribution and incidence of fatigue injuries of the femur in physically-active young adults, based upon MRI studies. During a period of 70 months, 1857 patients with exercise-induced pain in the femur underwent MRI of the pelvis, hips, femora, and/or knees.

Of these, 170 patients had a total of 185 fatigue injuries, giving an incidence of 199 per 100 000 person-years. Bilateral injuries occurred in 9% of patients. The three most common sites affected were the femoral neck (50%), the condylar area (24%) and the proximal shaft (18%). A fatigue reaction was seen in 57%, and a fracture line in 22%. There was a statistical correlation between the severity of the fatigue injury and the duration of pain (p = 0.001). The location of the pain was normally at the site of the fatigue injury. Fatigue injuries of the femur appear to be relatively common in physically-active patients.

Acetabular bone loss is a challenging problem facing the revision total hip replacement surgeon. Reconstruction of the acetabulum depends on the presence of anterosuperior and posteroinferior pelvic column support for component fixation and stability. The Paprosky classification is most commonly used when determining the location and degree of acetabular bone loss. Augments serve the function of either providing primary construct stability or supplementary fixation.

When a pelvic discontinuity is encountered we advocate the use of an acetabular distraction technique with a jumbo cup and modular porous metal acetabular augments for the treatment of severe acetabular bone loss and associated chronic pelvic discontinuity.

Cite this article: Bone Joint J 2014;96-B(11 Suppl A):36–42.

Epidemiological studies enhance clinical practice in a number of ways. However, there are many methodological difficulties that need to be addressed in designing a study aimed at the collection and analysis of data concerning fractures and other injuries. Most can be managed and errors minimised if careful attention is given to the design and implementation of the research.

Cite this article: Bone Joint J 2014;96-B:863–7.

We describe a patient with insufficient bone regeneration of the tibia after bone transport over an intramedullary nail, in whom union was ultimately achieved after exchange nailing and intramedullary application of rh-bone morphogenetic protein-7 at the site of distraction.

Between 1996 and 2003, 16 patients (nine female, seven male) were treated for a primary bone sarcoma of the femur by wide local excision of the tumour, extracorporeal irradiation and re-implantation. An additional vascularised fibular graft was used in 13 patients (81%). All patients were free from disease when reviewed at a minimum of two years postoperatively (mean 49.7 months (24 to 96).

There were no cases of infection. Primary union was achieved after a median of nine months (interquartile range 7 to 11). Five host-donor junctions (16%) united only after a second procedure. Primary union recurred faster at metaphyseal junctions (94% (15) at a median of 7.5 months (interquartile range 4 to 12)) than at diaphyseal junctions (75% (12) at a median of 11.1 months (interquartile range 5 to 18)).

Post-operatively, the median Musculoskeletal Tumour Society score was 85% (interquartile range 75 to 96) and the median Toronto Extremity Salvage score 94% (interquartile range 82 to 99). The Mankin score gave a good or excellent result in 14 patients (88%).

The range of movement of the knee was significantly worse when the extracorporeally irradiated autografts were fixed by plates rather than by nails (p = 0.035).

A total of 16 (62%) of the junctions of the vascularised fibular grafts underwent hypertrophy, indicating union and loading.

Extracorporeal irradiation autografting with supplementary vascularised fibular grafting is a promising biological alternative for intercalary reconstruction after wide resection of malignant bone tumours of the femur.

We investigated a new intramedullary locking nail that allows the distal interlocking screws to be locked to the nail. We compared fixation using this new implant with fixation using either a conventional nail or a locking plate in a laboratory simulation of an osteoporotic fracture of the distal femur. A total of 15 human cadaver femora were used to simulate an AO 33-A3 fracture pattern. Paired specimens compared fixation using either a locking or non-locking retrograde nail, and using either a locking retrograde nail or a locking plate. The constructs underwent cyclical loading to simulate single-leg stance up to 125 000 cycles. Axial and torsional stiffness and displacement, cycles to failure and modes of failure were recorded for each specimen. When compared with locking plate constructs, locking nail constructs had significantly longer mean fatigue life (75 800 cycles (sd 33 900) vs 12 800 cycles (sd 6100); p = 0.007) and mean axial stiffness (220 N/mm (sd 80) vs 70 N/mm (sd 18); p = 0.005), but lower mean torsional stiffness (2.5 Nm/° (sd 0.9) vs 5.1 Nm/° (sd 1.5); p = 0.008). In addition, in the nail group the mode of failure was either cut-out of the distal screws or breakage of nails, and in the locking plate group breakage of the plate was always the mode of failure. Locking nail constructs had significantly longer mean fatigue life than non-locking nail constructs (78 900 cycles (sd 25 600) vs 52 400 cycles (sd 22 500); p = 0.04).

The new locking retrograde femoral nail showed better stiffness and fatigue life than locking plates, and superior fatigue life to non-locking nails, which may be advantageous in elderly patients.

Cite this article: Bone Joint J 2014;96-B:114–21.