Aims. There is ambiguity surrounding the degree of scaphoid union required to safely allow mobilization following scaphoid waist fracture. Premature mobilization could lead to refracture, but late mobilization may cause stiffness and delay return to normal function. This study aims to explore the risk of refracture at different stages of scaphoid waist fracture union in three common fracture patterns, using a novel finite element method. Methods. The most common anatomical variant of the scaphoid was modelled from a CT scan of a healthy hand and wrist using 3D Slicer freeware. This model was uploaded into COMSOL Multiphysics software to enable the application of physiological enhancements. Three common waist fracture patterns were produced following the Russe classification. Each fracture had differing stages of healing, ranging from 10% to 90% partial union, with increments of 10% union assessed. A physiological force of 100 N acting on the distal pole was applied, with the risk of refracture assessed using the Von Mises stress. Results. Overall, 90% to 30% fracture unions demonstrated a small, gradual increase in the Von Mises stress of all fracture patterns (16.0 MPa to 240.5 MPa). All fracture patterns showed a greater increase in Von Mises stress from 30% to 10% partial union (680.8 MPa to 6,288.6 MPa). Conclusion. Previous studies have suggested 25%, 50%, and 75% partial union as sufficient for resuming hand and wrist mobilization. This study shows that 30% union is sufficient to return to normal hand and wrist function in all three fracture patterns. Both 50% and 75% union are unnecessary and increase the risk of post-fracture stiffness. This study has also demonstrated the feasibility of finite element analysis (FEA) in scaphoid waist fracture research. FEA is a sustainable method which does not require the use of finite scaphoid cadavers, hence increasing accessibility into future scaphoid waist fracture-related research. Cite this article: Bone Jt Open 2023;4(8):612–620

The February 2024 Wrist & Hand Roundup. 360. looks at: Occupational therapy for thumb carpometacarpal osteoarthritis?; Age and patient-reported benefits from operative management of intra-articular distal radius fractures: a meta-regression analysis; Long-term outcomes of nonsurgical treatment of thumb carpometacarpal osteoarthritis: a cohort study; Semi-occlusive dressing versus surgery in fingertip injuries: a randomized controlled trial; Re-fracture in partial union of the scaphoid waist?; The WALANT distal radius fracture: a systematic review; Endoscopic carpal tunnel release with or without hand therapy?; Ten-year trends in the level of evidence in hand surgery

Aims. The aim of this study was to present a series of patients with aseptic failure of a total ankle arthroplasty (TAA) who were treated with fusion of the hindfoot using a nail. Patients and Methods. A total of 23 TAAs, in 22 patients, were revised for aseptic loosening and balloon osteolysis to a hindfoot fusion by a single surgeon (NH) between January 2012 and August 2014. The procedure was carried out without bone graft using the Phoenix, Biomet Hindfoot Arthrodesis Nail. Preoperative investigations included full blood count, CRP and ESR, and radiological investigations including plain radiographs and CT scans. Postoperative plain radiographs were assessed for fusion. When there was any doubt, CT scans were performed. Results. The mean follow-up was 13.9 months (4.3 to 37.2). Union occurred at the tibiotalar joint in 22 ankles (95.6%) with one partial union. Union occurred at the subtalar joint in 20 ankles (87%) of cases with two nonunions. The nail broke in one patient with a subtalar nonunion and revision was undertaken. The only other noted complication was one patient who suffered a stress fracture at the proximal aspect of the nail, which was satisfactorily treated conservatively. Conclusion. This study represents the largest group of patients reported to have undergone revision TAA to fusion of the hindfoot with good results. Cite this article: Bone Joint J 2018;100-B:475–9

There have been few reports regarding the efficacy of posterior instrumentation alone as surgical treatment for patients with pyogenic spondylitis, thus avoiding the morbidity of anterior surgery. We report the clinical outcomes of six patients with pyogenic spondylitis treated effectively with a single-stage posterior fusion without anterior debridement at a mean follow-up of 2.8 years (2 to 5). Haematological data, including white cell count and level of C-reactive protein, returned to normal in all patients at a mean of 8.2 weeks (7 to 9) after the posterior fusion. Rigid bony fusion between the infected vertebrae was observed in five patients at a mean of 6.3 months (4.5 to 8) post-operatively, with the remaining patient having partial union. Severe back pain was immediately reduced following surgery and the activities of daily living showed a marked improvement. Methicillin-resistant Staphylococcus aureus was detected as the causative organism in four patients. Single-stage posterior fusion may be effective in patients with pyogenic spondylitis who have relatively minor bony destruction

Aims

Children with spinal dysraphism can develop various musculoskeletal deformities, necessitating a range of orthopaedic interventions, causing significant morbidity, and making considerable demands on resources. This systematic review aimed to identify what outcome measures have been reported in the literature for children with spinal dysraphism who undergo orthopaedic interventions involving the lower limbs.

In a rabbit model we investigated the efficacy of a silk fibroin/hydroxyapatite (SF/HA) composite on the repair of a segmental bone defect. Four types of porous SF/HA composites (SF/HA-1, SF/HA-2, SF/HA-3, SF/HA-4) with different material ratios, pore sizes, porosity and additives were implanted subcutaneously into Sprague-Dawley rats to observe biodegradation. SF/HA-3, which had characteristics more suitable for a bone substitite based on strength and resorption was selected as a scaffold and co-cultured with rabbit bone-marrow stromal cells (BMSCs). A segmental bone defect was created in the rabbit radius. The animals were randomised into group 1 (SF/HA-3 combined with BMSCs implanted into the bone defect), group 2 (SF/HA implanted alone) and group 3 (nothing implanted). They were killed at four, eight and 12 weeks for visual, radiological and histological study. The bone defects had complete union for group 1 and partial union in group 2, 12 weeks after operation. There was no formation of new bone in group 3. We conclude that SF/HA-3 combined with BMSCs supports bone healing and offers potential as a bone-graft substitute

Aims

There has been an increasing use of early operative fixation for scaphoid fractures, despite uncertain evidence. We conducted a meta-analysis to evaluate up-to-date evidence from randomized controlled trials (RCTs), comparing the effectiveness of the operative and nonoperative treatment of undisplaced and minimally displaced (≤ 2 mm displacement) scaphoid fractures.

Aims

Our aim was to investigate the outcomes of patients with a displaced fracture of the glenoid fossa who are treated conservatively. There is little information in the literature about the treatment of these rare injuries non-operatively.

We hypothesised that the use of pulsed electromagnetic field (PEMF) bone growth stimulation in acute scaphoid fractures would significantly shorten the time to union and reduce the number of nonunions in a randomised, double-blind, placebo-controlled multicentre trial. A total of 102 patients (78 male, 24 female; mean age 35 years (18 to 77)) from five different medical centres with a unilateral undisplaced acute scaphoid fracture were randomly allocated to PEMF (n = 51) or placebo (n = 51) and assessed with regard to functional and radiological outcomes (multiplanar reconstructed CT scans) at 6, 9, 12, 24 and 52 weeks. The overall time to clinical and radiological healing did not differ significantly between the active PEMF group and the placebo group. We concluded that the addition of PEMF bone growth stimulation to the conservative treatment of acute scaphoid fractures does not accelerate bone healing.

Cite this article: Bone Joint J 2014; 96-B:1070–6.

The best method of reconstruction after resection of malignant tumours of the tibial diaphysis is unknown. In the absence of any long-term studies analysing the results of intercalary endoprosthetic replacement, we present a retrospective review of 18 patients who underwent limb salvage using a tibial diaphyseal endoprosthetic replacement following excision of a malignant bone tumour. There were ten men and eight women with a mean age of 42.5 years (16 to 76). Mean follow-up was 58.5 months (20 to 141) for all patients and 69.3 months (20 to 141) for the 12 patients still alive. Cumulative patient survival was 59% (95% confidence interval (CI) 32 to 84) at five years. Implant survival was 63% (95% CI 35 to 90) at ten years. Four patients required revision to a proximal tibial replacement at a mean follow-up of 29 months (10 to 54). Complications included metastases in five patients, aseptic loosening in four, peri-prosthetic fracture in two, infection in one and local recurrence in one. The mean Musculoskeletal Tumor Society score and the mean Toronto Extremity Salvage Score were 23 (17 to 28) and 74% (53 to 91), respectively.

Although rates of complication and revision were high, custom-made tibial diaphyseal replacement following resection of malignant bone tumours enables early return to function and provides an attractive alternative to other surgical options, without apparent compromise of patient survival.

We studied, ten patients (11 elbows) who had undergone 14 allograft-prosthesis composite reconstructions following failure of a previous total elbow replacement with massive structural bone loss. There were nine women and one man with a mean age of 64 years (40 to 84), who were reviewed at a mean of 75 months (24 to 213). One patient developed a deep infection after 26 months and had the allograft-prosthesis composite removed, and two patients had mild pain. The median flexion-extension arc was 100° (95% confidence interval (CI) 76° to 124°). With the exception of the patient who had the infected failure, all the patients could use their elbows comfortably without splints or braces for activities of daily living. The mean Mayo Elbow Performance Index improved from 9.5 (95% CI 4.4 to 14.7) pre-operatively to 74 (95% CI 62.4 to 84.9) at final review.

Radiologically, the rate of partial resorption was similar in the humeral and ulnar allografts (three of six and four of eight, respectively; p > 0.999). The patterns of resorption, however, were different. Union at the host-bone-allograft junction was also different between the humeral and ulnar allografts (one of six and seven of eight showing union, respectively; p = 0.03).

At medium-term follow-up, allograft-prosthesis composite reconstruction appears to be a useful salvage technique for failed elbow replacements with massive bone loss. The effects of allograft resorption and host-bone-allograft junctional union on the longevity of allograft-prosthesis composite reconstruction, however, remain unknown, and it is our view that these patients should remain under long-term regular review.

We have treated 14 patients (15 fractures) with nonunion of an intra-articular fracture of the body of the calcaneum. The mean follow-up was six years (2 to 8.5). A total of 14 fractures (93%) had initially been treated operatively with 12 (86%) having non-anatomical reductions. Four feet (27%) had concomitant osteomyelitis. Of the nonunions, 14 (93%) went on to eventual union after an average of two reconstructive procedures. All underwent bone grafting of the nonunion. The eventual outcome was a subtalar arthrodesis in ten (67%) cases, a triple arthrodesis in four (27%) and a nonunion in one (6%). Three patients had a wound dehiscence; all required a local rotation flap. The mean American Orthopaedic Foot and Ankle Society score at latest follow-up was 69, and the mean Visual analogue scale was 3. Of those who were initially employed, 82% (9 of 11) eventually returned to work. We present an algorithm for the treatment of calcaneal nonunion, and conclude that despite a relatively high rate of complication, this complex surgery has a high union rate and a good functional outcome.