Conventional computer navigation systems using bone fixation have been validated in measuring anteroposterior (AP) translation of the tibia. Recent developments in non-invasive skin-mounted systems may allow quantification of AP laxity in the out-patient setting. We tested cadaveric lower limbs (n=12) with a commercial image free navigation system using passive trackers secured by bone screws. We then tested a non-invasive fabric-strap system. The lower limb was secured at 10° intervals from 0° to 60° knee flexion and 100N of force applied perpendicular to the tibial tuberosity using a secured dynamometer. Repeatability coefficient was calculated both to reflect precision within each system, and demonstrate agreement between the two systems at each flexion interval. An acceptable repeatability coefficient of ≤3mm was set based on diagnostic criteria for ACL insufficiency when using other mechanical devices to measure AP tibial translation. Precision within the individual invasive and non-invasive systems measuring AP translation of the tibia was acceptable throughout the range of flexion tested (repeatability coefficient ≤1.6 mm). Agreement between the two systems was acceptable when measuring AP laxity between full extension and 40° knee flexion (repeatability coefficient ≤2.1 mm). Beyond 40° of flexion, agreement between the systems was unacceptable (repeatability coefficient >3 mm). These results indicate that from full knee extension to 40° flexion, non-invasive navigation-based quantification of AP tibial translation is as accurate as the standard invasive system, particularly in the clinically and functionally important range of 20° to 30° knee flexion. This could be useful in diagnosis and post-operative follow-up of ACL pathology

Background. In poliomyelitis; hand to knee gait is the sum of quadriceps weakness and fixed knee flexion deformity. Limb shortening is another added problem. Usually, each problem is attacked separately; with variable end results and complication rates for each procedure. Patients and methods. 22 patients (16–46 y.); with poliomyelitis with hand to knee gait due to fixed knee flexion deformity of mild to moderate degree (10–400); and limb shortening of 4.5–9.5 cm., were managed simultaneously by a single operation. A distal femoral metaphyseal anterior closing wedge (recurvatum) corrective osteotomy was done to treat acutely the fixed knee flexion deformity(and subsequently hand to knee gait). A modified Wagner or Orthofix frame was applied as a mono-plane mono-axial lengthening device to stabilize the osteotomy and to lengthen the short limb. Lengthening was started in all cases two weeks post-operatively. Results. All cases showed full correction of the deformity with elimination of the hand to knee gait problem and all showed - the desired - limb length equalization. The femora were lengthened to an average of 6.4 cm.(= 21% of original femoral bone length), range of lengthening was: 4–9 cm. (= 11–26%). The average healing index was 37 days per centimeter (with a range of 31 to 53 days per centimeter.). Conclusion. Simultaneous management of hand to knee and limb shortening could be achieved by a single osteotomy which is used to extend the knee acutely and for distraction two weeks later using a mono-lateral frame. Results were good, complications were few and accepted and the procedure is well tolerated by the patients

Injuries to the ankle are common in children. We investigated whether decreased dorsiflexion predisposes to such fractures and sprains. Passive dorsiflexion in children with ankle injuries was compared with that in a control group of patients with a normal ankle. The uninjured side was examined to determine flexibility in those patients with ankle injuries. In 82, the mean dorsiflexion was 5.7° with the knee extended and 11.2° with the knee flexed. In 85 controls, the mean dorsiflexion was 12.8° with the knee extended and 21.5° with the knee flexed (p < 0.001, Student’s t-test). There was a strong association between decreased ankle dorsiflexion and injury in children. A flexible triceps surae appeared to absorb energy and protect the bone and ligaments, while stiffness predisposed to injury. We suggest that children with tight calf muscles should undergo a regimen of stretching exercises to improve their flexibility

Bicondylar tibial plateau fractures result from high-energy injuries. Fractures of the tibial plateau can involve the tibial tubercle, which represents a disruption to the extensor mechanism and logically must be stabilised. The purpose of this study was to identify the incidence of an independent tibial tubercle fracture in bicondylar tibial plateau fractures, and to report management strategies and potential complications. We retrospectively reviewed a prospectively collected orthopaedic trauma database for the period January 2003 to December 2008, and identified 392 bicondylar fractures of the tibial plateau, in which 85 tibial tubercle fractures (21.6%) were identified in 84 patients. There were 60 men and 24 women in our study group, with a mean age of 45.4 years (18 to 71). In 84 fractures open reduction and internal fixation was undertaken, either with screws alone (23 patients) or with a plate and screws (61 patients). The remaining patient was treated non-operatively. In all, 52 fractures were available for clinical and radiological assessment at a mean follow-up of 58.5 weeks (24 to 94). All fractures of the tibial tubercle united, but 24 of 54 fractures (46%) required a secondary procedure for their tibial plateau fracture. Four patients reported pain arising from prominent tubercle plates and screws, which in one patient required removal. Tibial tubercle fractures occurred in over one-fifth of the bicondylar tibial plateau fractures in our series. Fixation is necessary and can be reliably performed with screws alone or with a screw and plate, which restores the extensor mechanism and facilitates early knee flexion. Cite this article: Bone Joint J 2013;95-B:1697–1702

Introduction. Stiffness of the knee after total knee arthroplasty (TKA) impairs knee function and reduces patient satisfaction. Limited preoperative range of motion (ROM) and a diagnosis of osteoarthritis seem to be associated with postoperative stiffness, and medical comorbidities such as diabetes mellitus have been discussed as predisposing factors. The present study was undertaken in order to analyse both patient-related and surgical factors that could be associated with the need for mobilization under anaesthesia (MUA) after TKA. Methods. We designed a case-control-study and extracted the study population from our local arthroplasty register. We identified all patients in our register that required MUA following primary TKA (n=35) and then randomly selected 4 control patients for each case of MUA. Incomplete medical records resulted in the exclusion of 18 patients, leaving 157 patients. Univariate analysis was used in order to investigate differences between the two groups with respect to demographics, pre- and postoperative ROM, medical or psychiatric comorbidities, and the type of implant. Variables with a proposed influence on outcome were entered into a binary logistic regression model, and risk ratios (RR) were calculated with 95% confidence intervals (CI). Results. Regression analysis showed that age at operation, the presence of chronic obstructive lung disease (COLD), and preoperative flexion significantly affected outcome: Increasing age decreased the risk for needing MUA with a RR of 0.88 (CI 0.82–0.94, p<0.001) per year. Patients with COLD had significantly higher risk of needing MUA with a RR of 9.82 (CI 1.84–52.3, p=0.007). Impaired preoperative flexion was an important predictor of postoperative stiffness with a RR of 0.97 (CI 0.95–0.99, p=0.027), implicating that the risk for MUA decreased by approximately 3% for each additional degree of flexion. Gender, BMI, cardiovascular comorbidity, the presence of rheumatoid arthritis, diabetes mellitus, previous knee injury, and the type of implant did not significantly affect the risk for MUA. In univariate analysis, patients requiring MUA had significantly lower knee flexion at discharge than control patients (78° vs. 61°, p<0.001). Interpretation. We conclude that the presence of COLD, impaired preoperative knee flexion, and younger age increase the risk for needing MUA after primary TKA. The finding that COLD increases the risk for MUA is novel: It is known that patients with COLD have higher systemic levels of inflammatory mediators, and we are tempted to speculate that postoperative arthrofibrosis could be a result of enhanced systemic inflammatory activity. In our hands, the choice of implant and comorbidities other than COLD were not associated with an increased risk for MUA

We examined the recovery of power in the muscles of the lower limb after fracture of the tibial diaphysis, using a Biodex dynamometer. Recovery in all muscle groups was rapid for 15 to 20 weeks following fracture after which it slowed. Two weeks after fracture the knee flexors and extensors have about 40% of normal power, which rises to 75% to 85% after one year. The dorsiflexors and plantar flexors of the ankle and the invertors and evertors of the subtalar joint are much weaker two weeks after injury, but at one year their mean power is more than that of the knee flexors and extensors. Our findings showed that age, the mode of injury, fracture morphology, the presence of an open wound and the Tscherne grade of closed fractures correlated with muscle power. It is age, however, which mainly determines muscle recovery after fracture of the tibial diaphysis

Aims

Our objective was to conduct a systematic review and meta-analysis, to establish whether differences arise in clinical outcomes between autologous and synthetic bone grafts in the operative management of tibial plateau fractures.

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

Purpose. Tibia plateau fractures are severe knee injuries which have a great impact on the patients' lives, but in what extend is not clear yet in the literature. The purpose of this study was to investigate the gait alternations after treatment of patients who had severe tibia plateau fractures which were treated with circular ilizarov frame. Materials & Methods. We have evaluated the gait pattern of patients who were treated with circular Ilizarov frame after severe tibia plateau fractures (Schatzker IV-VI) in our department. The gait was tested by using a force plate in a walking platform. Ground Reaction Forces (GRF) data were collected during level walking at self-selected speeds. The patients performed two walking tasks for each limb and the collected data were averaged for each limb. Demographic, clinical, radiological and quality of life questionnaire (SF-12) data were also collected. Results. We have analysed the gait through the GRF of fifteen patients (aged 50.8 ±17.3 years), who had undergone treatment with circular Ilizarov frame following severe tibia plateau fractures (Schatzker IV-VI). Nine were male and six were female. The tests were performed at an average of 13.2 months after the initial treatment. SF-12 Mental scores have returned to normal (mean 54.6 ±12.3) but physical scores remained impaired (mean 40.6 ±10.8). A one-way repeated measures ANOVA was conducted to compare the GRFs and gait timing data of the affected limb with the normal one. Single limb support interval was significantly reduced to the affected limb (p=0.001) and terminal stance phase was prolonged for the normal limb (p=0.035). During this phase of the gait circle the knee is on its maximum flexion and the quadriceps contracts to bring the femur above the tibia. It seems that these patients during the gait circle reduce the flexion of their affected knee to make their single stance shorter. To the normal limb the patients manage to reduce more the GRFs during the mid-stance phase (F2 force), this difference do not reach significance, but illuminates the tendency of reduced knee flexion in that phase. The rest of the GRF and gait timing data did not had significant differences. Conclusions. One year after severe tibia plateau fracture treated with circular ilizarov frame the patients manage to return to almost normal gait pattern. Reduce single limb stance and terminal stance phase to the affected knee can be explained by the tendency of not flexing their deficient knee as much during that gait phase

The purpose of this study is to analyze what kind of pattern of change in each posterior femoral condyle allows for a greater degree of flexion after total knee arthroplasty (TKA). The flexion angle was assessed pre-operatively, and at 12 months after the surgery in 98 patients (106 knees) who underwent consecutive TKA. We used a quantitative 3 dimensional technique using computed tomography for the assessment of changes in both the medial and lateral femoral condylar offset. There were no significant correlation between changes of each posterior condylar offset and post flexion angle (medial condyle; R=−0.038, p=0.70, lateral condyle; R=−0.090, p=0.36). There were no significant differences between changing patterns and increase rate of flexion (p=0.443). Additionally there were no significant differences between changing patterns and increase of flexion angle (p=0.593). Changes of each posterior condylar offset were no correlation to knee flexion after TKA in the current design prosthesis

Introduction. While clinically successful for decades, CR TKA is persistently compromised by inconsistent PCL function. Problems of mid-flexion instability, incomplete knee flexion, erratic kinematic behavior and posterior instability, not seen with PS devices, raise concerns about the consistency of the technique, and the devices used. Most TKA systems offer at least 2 different geometries of tibial inserts to address this clinical problem. We hypothesize these problems are a result of compromise of PCL anatomy. To avoid compromise to the PCL 3 steps are required: 1) The slope of tibial resection must be less than 5°; 2) the depth of tibial resection must be based off the insertion footprint of the PCL, not the deficiencies of the tibial articular surface; and 3) the tibial insert must be modified to allow intraoperative balancing of the PCL. Results. The CR Slope ™ implants and technique (Exactech) (“Posterior Cruciate Referencing Technique (PCRT)”) reflect this philosophy and have allowed consistent surgical intervention without PCL release and without multiple inserts. We present data identifying, the footprint, and the instrument and technique modifications that allow for predictable identification of the depth and angle of resection. At 2 years post implantation in the first 100 patients implanted, the study group has demonstrated similar operative time, LOS and Oxford knee scores (OKS), while ROM averaged 5° greater, and time to achieved flexion was decreased. Conclusion. The PCRT offers a new conceptual and clinical approach to predictable CR TKA

Background. The reported outcomes of unicompartmental knee replacement (UKR) for spontaneous osteonecrosis of the knee (SPONK) often derive from small series with an average followup of 5 years, enabling to generate meaningful conclusions. Therefore, we determined the long-term functional results and the 10-years survivorship of the implant in all patients with advanced SPONK of the medial tibio-femoral compartment treated with a unicompartmental knee arthroplasty at our institute. Methods. We retrospectively evaluated 84 consecutive patients with late stage SPONK. All patients received a pre-operative MRI to confirm the diagnosis, to exclude any metaphyseal involvement and to assess the absence of significative degenerative changes in the lateral and PF compartment. Mean age at surgery was 66 years and mean body mass index (BMI) was 28.9. In all cases, SPONK involved the medial compartment; in 77 cases the medial femoral condyle (MFC) was involved, while in 7 cases the pathology site was the medial tibial plateau (MTP). Radiological evaluation was conducted by 3 different radiologists and clinical evaluation according to KSS and WOMAC score was performed by 3 fellows from outside institutions, with no previous clinical contact with the patients, at a mean followup of 98 months. Results. We found a significant improvement in VAS score for residual pain self-assessment and maximum knee flexion (p<0.0001). The 10-year Kaplan-Meier survivorship with revision for any reason as endpoint was 89%. Mean results at final observation point for global KSS and WOMAC score were 87.1 (range 45–100; standard deviation 13.8) and 12 (range 0–44; standard deviation 10.3), respectively. No patient had significant radiographic signs of osteoarthritis progression in the lateral compartment or in the patello-femoral compartment at final evaluation. Conclusions. Our findings suggest that medial UKR performed for late stage SPONK of the medial tibio-femoral compartment in selected patients provides satisfactory long term clinical and radiographical results, with a 10-years Kaplan-Meier survivorship of the implant of 89%

Aim. The purpose of this study was to analyze the patellofemoral kinematics in neglected adult developmental dysplasia of the hip patients with patellofemoral symptoms and tried to clarify the affect of the severity of dislocation, the amount of limb length discrepancy, the deviation of mechanical axis and the changes in femoral anteversion on patellofemoral alignment. Methods. The dynamic patellofemoral CT results of 39 patients with DDH suffering from knee pain were reviewed. The mean age was 40.07 (range: 22–61). 14 of them were bilateral and 25 were unilateral neglected DDH patients. The CT results of 12 patients suffering from unilateral patellofemoral pain following the treatment of locked intramedullary nailing was taken as control group. In this patients atraumatic and asymptomatic normal site was taken as control group. Results. In unilateral neglected DDH patients there was significantly higher medial patellar displacement in 0, 15, 30, 60 degrees flexion in the knee at the site of dislocation. Again in uninvolved site medial patellar displacement in 15, 30, 60 degrees flexion was higher with respect to control group. In the involved extremity the PTA angle in 0, 15, 30, 60 degrees flexion were significantly higher than in control group. This increase in PTA angle corresponding to medial patellar tilt was observed only in involved extremity. In the knees of patients with bilateral DDH there was significant medial patellar displacement in every flexion degrees with respect to control group. Besides in bilateral DDH patients, the PTA angle in 15, 30, 60 degrees flexion were significantly higher than control group corresponding to medial patellar tilt. The amount of leg length discrepancy and the severity of dislocation as well as mechanical axis deviation were not affecting the patellofemoral parameters in both unilateral and bilateral DDH patients. Conclusion. Both in unilateral and bilateral DDH patients there are major changes in patellar tracking on femur during knee flexion. Increased medial shift and medial patellar tilt were seen in these patient groups. The neglected DDH patients suffering from knee pain should be analyzed not only for tibiofemoral abnormalities but also for patellofemoral malignment

Objective. In many institutions, serial casting and splinting requires many weeks of treatment and frequently results in surgery. This study evaluated the results of neonatal clubfoot correction with the Furlong method. This method was created by Furlong M.B. and Lawn G.W. in New York and was published in Archives of Pediatrics in 1960. Materials and Methods. This study reviews 95 neonates with 128 severe clubfeet (initial Pirani score 4,0 or more). Patients with arthrogrypotic clubfeet and other syndromes were not included. Age at presentation ranged from 4 hours to 18 days. All patients had no previous treatment. The cast application with extra space above the foot was performed as follows: a special elastic pad was placed on the dorsal aspect of the foot and fixed with a cotton bandage. Then plaster cast was applied with knee flexion 110–120 degrees. After the cast was set, the elastic pad was removed, leaving a reserve space on the dorsal aspect of the foot. The cast was changed every 3–7 days. Typical corrective maneures were performed. Foot displacement into dorsiflexion occured spontaneously as an active motion and also with manipulations. Abduction braces or knee-flexed splints were applied after the complete foot correction. Pirani score and foot dorsiflexion angle were documented during each step of correction. Results. A detailed rating system (with radiologic criteria) was used for result evaluatiion. Correction was successful in all but 5 patients. 90 % required less than 6 casts. There were 12 recurrences and they were related with compliance with the abduction brace, but not with age or number of casts required for correction. Only 13 patients required surgery (6 posterior releases, 6 posteromedial releases and 1 complete subtalar release). Mean follow-up was 12 years. 23% of feet were evaluated as excellent, 71 %- as good and 6%- as poor results. Conclusion. The Furlong method is succesful in obtaining initial correction in the idiopathic clubfoot patient. This method corrects the neonatal congenital clubfoot in 85% without any surgery

INTRODUCTION. Computer-aided systems have been developed recently in order to improve the precision of implantation of unicompartmental knee replacement (UKR). Minimal invasive techniques may decrease the surgical trauma related to the prosthesis implantation, but there might be a concern about the potential for a loss of accuracy. Mobile bearing prostheses have been developed to decrease the risk of polyethylene wear, but are technically more demanding. Navigation might help to compensate for these difficulties. We wanted to combine the theoretical advantages of the three different techniques by developing a navigated, minimal invasive, mobile bearing unicompartmental knee prosthesis. MATERIAL AND METHODS. 160 patients have been operated on at our institution with this system. The 81 patients with more than 2 year follow-up have been re-examined. Complications have been recorded. The clinical results have been analyzed according to the Knee Society Scoring System. The subjective results have been analyzed with the Oxford Knee Questionnaire. The accuracy of implantation has been analyzed on post-operative antero-posterior and lateral long leg X-rays. The 2-year survival rate has been calculated. RESULTS. We observed 8 complications related to the implant or the operative technique: 2 cases of meniscus instability (1 revision to TKR, 1 bearing exchange); 2 cases of tibia loosening (revised to TKR), 2 cases of femoral loosening (revised to TKR), 1 case of lateral disease progression (revised to TKR), 1 case of unexplained pain syndrome (revised to TKR). The mean Knee Score was 93 points, 44% had the maximum of 100 points, and only 10% have less than 85 points. The mean pain score was 48 points/50. The mean flexion angle was 128°, and 60% had at least 130° of knee flexion. The mean Function Score was 97 points, 84% have the maximum of 100 points, and only 5% had less than 85 points. The mean Oxford Knee Questionnaire score was 19 points (best result: 12 points, worst result: 60 points). Expected limb axis correction was obtained in 77% of the cases. 62% of the cases had an optimally implanted prosthesis for all studied criteria. The 2-year survival rate was 97%. DISCUSSION. Most of the revision cases were related to technical difficulties during the development phase. Fixation of the implant has been improved, and some imprecise steps of the software have been corrected. Since these changes occurred, no severe early complication related to implant or software has been observed. The current implant is considered reliable, and the current minimal invasive navigated technique is considered reliable as well

Background. Extendable proximal femoral replacements(PFR) are used in children with bone tumours in proximity to the proximal femoral physis, previously treated by hip disarticulation. Long-axis growth is preserved, allowing limb salvage. Since 1986, survival outcomes after limb salvage and amputation have been known to be equal. Method. Retrospective review of all patients <16years undergoing extendable PFR at Royal National Orthopaedic Hospital (UK) between 04/1996 and 01/2006, recording complications, failures, procedures undertaken and patient outcomes. Results. 8 patients (mean age 8.9±3 years) underwent extendable PFR for Ewing's Sarcoma(5), Osteosarcoma(1), Chondrosarcoma(1) and rhabdomyosarcoma(1). 2 primary PFRs failed (infection of unknown source & local recurrence, both at 26months); 2 required revision for full extension (1 became infected at revision, requiring 2 stage revision). 3 patients had the original prosthesis in situ at last follow-up (mean 7.2;range 3–10.5years). 1 patient had no implant complications, but died (neutropaenic sepsis) 63 days after implant insertion. 2 were treated for recurrence but disease free at last review. 5 were continuously disease free. 5 patients were lengthened a mean 3.7cm; 2 were not lengthened.1 had incomplete data. 5 patients suffered subluxation/dislocation (mean 15.6months), 3 recurrently. Each underwent a mean 1.6 open & 1.4 closed procedures for the displaced joint. 3 patients had 4 open reductions and acetabuloplasties and 2 patients were converted to THR, with 3 major complications: 2 sciatic nerve palsies and 1 (THR) infection. The 5th patient was due for acetabuloplasty but had hip disarticulation for recurrence. Acetabular erosion occurred in 3; 2 were revised to THR (3.5 & 6.8years). 3 patients suffered peri-prosthetic supracondylar fracture (treated conservatively). 5 patients were revised to THR (mean 5.9years): 2 for dislocation, 2 for acetabular erosion & 1 for infection. 1 underwent amputation and another died. Only 1 surviving implant was not converted to THR: this patient had progressive acetabular erosion at 10.5 years & will eventually require THR. The amputee had poor hip function prior to disarticulation but went on to become an international Paralympic sportsman and had very good function 11.4 years post-disarticulation. 3 patients had fixed hip adduction deformity. 1 was isolated and treated with adductor tenotomy, whilst 2 were associated with knee flexion deformity (one required in-patient physiotherapy; the other prosthetic shortening). Conclusions. Extendable PFR permits limb salvage with psychological & functional benefits, but complications are common and some are specific to PFR. Surgery for these may result in further complications. Patients should be warned of the high conversion rate to THR. All the above should be borne in mind when selecting patients. As illustrated above, functional outcome is sometimes better with amputation

Aims

The aim of this study was to compare the incidence of anterior knee pain after antegrade tibial nailing using suprapatellar and infrapatellar surgical approaches

Introduction. Anterior Cruciate ligament reconstruction is a common operation in orthopaedics surgery. A common complication of whilst havesting the hamstring tendon is injury to the infra-patellar branch of the saphenous nerve (IPBSN), resulting in altered sensation to the anterior and lateral aspects of the knee and leg. Aim. The aim of this study was to further understand the course of this nerve in relation to surgical approach to anterior cruciate ligament reconstruction. Material and method. The nerve was traced and dissected in 25 knees from 14 different cadavers. Four paths of IPBSN in relation to the Sartorius muscle were identified: (1) a posterior path which ran round the inferior posterior border of the muscle, (2) a transmuscular path that penetrated through the muscle, (3) an anterior path that ran from the anterior border of the muscle and (4) posterior patellar path that ran round the posterior of the muscle at the same level as the patellar. Dissections were carried out with further 14 knees in a standard manner using both type of incision techniques, vertical incision or horizontal, in ten pair of knees. Using a tendon stripper, the hamstrings tendon were harvested in a standard fashion in different angles of the knee ie full extension and flexion at 90 degrees. Results. Of these paths the posterior was the most common featuring in 57% of specimens and the nerve was at higher risk of being injured due to the proximity of that pathway and the gracilis and semintendinosus muscle tendons. Horizontal incision has a higher chance of damage to the saphenous nerve and the infra-patellar branch. The saphenous nerve was injured on every occasion by this incision. Vertical incision, 1.5cm from the midline, avoided the infra-patellar branch and the saphenous nerve. Harvesting of the tendon in full extension was difficult, and it made the incision sites both horizontal and vertical at greater risk injuring the tendons. When the knee was flexed at 90 degrees these problems were overcome. Conclusions. A vertical incision with a flexed knee gave the best method to harvest the tendon with minimal risk to damaging the infra-patellar branch and the saphenous nerve when using the tendon stripper

Background. Extendable partial femoral replacements (EPFR) permit limb salvage in children with bone tumours in proximity to the physis. Older designs were extended through large incisions or minimally invasive surgery. Modern EPFR are lengthened non-invasively. Lengthening improves functional score (Futani, 2006) but has been associated with complications including infection (Jeys, 2005). This study is the first to look specifically at the relationship between EPFR lengthening and complications. Method. Retrospective review of 51 paediatric (<16 years) oncology patients undergoing primary (1 °) EPFR (minimally/noninvasive) between 06/1994 and 01/2006. Exclusions: 1 patient with 5cm extension without medical intervention and 5 patients with incomplete data. Results. There was a negative relationship between age at 1 ° operation and EPFR lengthening (p = 0.03). Mean lengthening for all (including revision) EPFR was 3cm (range 0–13.05). 28 (64%) patients were lengthened a mean 4.8cm at a mean 7 procedures each. 18 were not lengthened, of which 12 were deceased at last followup and 1 had undergone amputation. Lengthening of secondary prostheses contributed a mean 3.7cm to limb length. 2 tertiary implants were lengthened noninvasively by 1.2cm (3 lengthenings) and 1.275cm (5 lengthenings). 16 of 21 failed 1 ° femoral components had been lengthened. The 21 implants underwent a mean 4.2 lengthenings in comparison to mean 1.3 lengthenings in the 28 that did not fail. Number of 1 ° prosthetic lengthenings was positively related to risk of component failure (p = 0.035) and total number of complications (p = 0.049). Complication rate was also related to total lengthening of 1 ° prosthesis (in cm) (p = 0.004). There was a statistically insignificant (p = 0.059) trend towards increased infection rate with higher number of minimally invasive lengthening procedures. Complications were commoner in those undergoing lengthening (mean 3 vs 1.75 in non-lengthened prostheses). Number of lengthenings correlated with number of complications (p = 0.001). Total lengthening of distal EPFR correlated with incidence of knee fixed flexion deformity (FFD)(p = 0.034). Median lengthening was 3cm in those with FFD and 0cm in those without (p = 0.019). Open lengthening procedures caused 6 complications: 2 deep & 3 superficial infections and recurrent subluxation requiring acetabuloplasty in a proximal replacement. Summary/Conclusions. The inverse relationship between age at 1 ° operation and lengthening is expected if the aim of offsetting limb length discrepancy during growth is being achieved. Lengthening is associated with increased complications (particularly infection and FFD) and femoral component failure, suggesting that lengthening procedures are implicated in the cause of some complications. 5 infective complications after lengthening were theoretically avoidable if noninvasive growers were used

We have managed 21 patients with a fracture of the tibia complicated by bone and soft-tissue loss as a result of an open fracture in 10, or following debridement of an infected nonunion in 11, by resection of all the devitalised tissues, acute limb shortening to close the defect, application of an external fixator and metaphyseal osteotomy for re-lengthening. The mean bone loss was 4.7 cm (3 to 11). The mean age of the patients was 28.8 years (12 to 54) and the mean follow-up was 34.8 months (24 to 75).

All the fractures united with a well-aligned limb. The mean duration of treatment for the ten grade-III A+B open fractures (according to the Gustilo-Anderson classification) was 5.7 months (4.5 to 8) and for the nonunions, 7.6 months (5.5 to 12.5). Complications included one refracture, one transient palsy of the peroneal nerve and one equinus contracture of 10°.