Atypical femoral fracture non-union (AFFNU) is both, rare (3–5 per 1000 proximal femur fractures) and difficult to treat. Lack of standardised guidelines leads to a variability in fixation constructs, use of bone grafting and restricted weight bearing protocols, which are not evidence based. We hypothesised that there is no change in union rates without the use of bone grafting and immediate weight bearing post-operatively does not lead to increased complications. Materials & Methods. A retrospective review of all consecutively treated AFFNU cases between March 2015 to December 2019 was carried out. 9 patients with a mean age of 63.87 years and M:F ratio of 7:2 met the inclusion criteria. Primary outcome variable was radiographic union at 12 months after revision surgery. All surgeries were carried out by a single surgeon. Fixation construct, neck-shaft angle, use of bone graft and immediate postoperative weight bearing protocols were recorded. Results. Radiographic union was achieved in 7 of 9 patients (78%) after first revision surgery. 1 patient achieved union after 2nd revision surgery and 1 patient died in the early post-operative period due to pulmonary embolism. No bone grafting was used in any of the patients and weight-bearing as tolerated was allowed from the first post-operative day. The mean neck-shaft angle after non-union surgery was 136 degrees. Conclusions. In this case series, the union rate was comparable to those reported in literature previously and achieved without any form of bone grafting. To our knowledge, this is the only case series where no bone grafting was used in the management of AFFNU. Limited by a small sample size and retrospective study design, still, this study brings into question the efficacy of practice of bone grafting and restricted weight-bearing in the management of AFFNU. Bone grafting is associated with the risk of infection at donor site, postoperative pain, and morbidity, while early weight bearing is critical in elderly patients. There is no evidence supporting restricted weight-bearing and it should not be adopted as the default practice as it may even be detrimental to patients

Aim. The time to onset of symptoms after fracture fixation is still commonly used to classify fracture-related infections (FRI). Early infections (<2 weeks) can often be treated with debridement, systemic antibiotics, irrigation, and implant preservation (DAIR). Late infections (>10 weeks) typically require implant removal as mature, antibiotic-tolerant biofilms have formed. However, the recommendations for delayed infections (2–10 weeks) are not clearly defined. Here, infection healing and bone healing in early and delayed FRI is investigated in a rabbit model with a standardized DAIR procedure. Method. Staphylococcus aureus was inoculated into 17 rabbits after plate osteosynthesis in a humerus osteotomy. The infection developed either one week (early group, n=6) or four weeks (delayed group, n=6) before a standardized DAIR procedure and microbiological analysis were performed. Systemic antibiotics were administered for six weeks (two weeks: Nafcillin+Rifampin, four weeks: Levofloxacin+Rifampin). A control group (n=5) also underwent a revision operation (debridement and irrigation) after four weeks, but received no antibiotic treatment. Rabbits were euthanized seven weeks after the revision operation. Bone healing was assessed using a modified radiographic union score for tibial fractures (mRUST). After euthanasia, a quantitative microbiological examination of the entire humerus, adjacent soft tissues, and implants was performed. Results. All animals were infected at the time of revision surgery, with the bacterial load in the early group (especially in soft tissues) being greater than in the delayed group and control group. This indicates infiltration of bacteria into areas that are more difficult to reach after four weeks of debridement. The infection was eradicated in all animals in both the early and delayed groups at euthanasia, but not in the control group (CFU median (IQR): 2.1×10. 7. (1.3×10. 7. -2.6×10. 7. ). The osteotomy healed in the early group, while bone healing was significantly impaired in both the delayed group and control group (mRUST median (IQR): early group: 16 (14–16), delayed group: 7.5 (6–10), control: 7 (5.5–9); early vs. delayed: p=0.0411, early vs. control p=0.0065). Conclusion. The maturation of the infection between the first and fourth week does not affect the success of infection eradication in this rabbit FRI model. However, bone healing appears to be impaired with increasing duration of infection

The management of periprosthetic distal femur fractures is an issue of increasing importance for orthopaedic surgeons. Because of the expanding indications for total knee arthroplasty (TKA) and an aging population with increasingly active lifestyles there has been a corresponding increase in the prevalence of these injuries. The management of these fractures is often complex because of issues with obtaining fixation around implants and dealing with osteopenic bone or compromised bone stock. In addition, these injuries frequently occur in frail, elderly patients, and the early restoration of function and ambulation is critical in these patients. There remains substantial controversy with respect to the optimal treatment of periprosthetic distal femur fractures, with some advocating for Locked Plating (LP), others Retrograde Intramedullary Nailing (RIMN) and finally those who advocate for Distal Femoral Replacement (DFR). The literature comparing these treatments, has been infrequent, and commonly restricted to single-center studies. The purpose of this study was to retrospectively evaluate a large series of operatively treated periprosthetic distal femur fractures from multiple centers and compare treatment strategies. Patients who were treated operatively for a periprosthetic distal femur fracture at 8 centers across North America between 2003 and 2018 were retrospectively identified. Baseline characteristics, surgical details and post-operative clinical outcomes were collected from patients meeting inclusion criteria. Inclusion criteria were patients aged 18 and older, any displaced operatively treated periprosthetic femur fracture and documented 1 year follow-up. Patients with other major lower extremity trauma or ipsilateral total hip replacement were excluded. Patients were divided into 3 groups depending on the type of fixation received: Locked Plating, Retrograde Intramedullary Nailing and Distal Femoral Replacement. Documented clinical follow-up was reviewed at 2 weeks, 3 months, 6 months and 1 year following surgery. Outcome and covariate measures were assessed using basic descriptive statistics. Categorical variables, including the rate of re-operation, were compared across the three treatment groups using Fisher Exact Test. In total, 121 patients (male: 21% / female: 79%) from 8 centers were included in our analysis. Sixty-seven patients were treated with Locked Plating, 15 with Retrograde Intramedullary Nailing, and 39 were treated with Distal Femoral Replacement. At 1 year, 64% of LP patients showed radiographic union compared to 77% in the RIMN group (p=0.747). Between the 3 groups, we did not find any significant differences in ambulation, return to work and complication rates at 6 months and 1 year (Table 1). Reoperation rates at 1 year were 27% in the LP group (17 reoperations), 16% in the DFR group (6 reoperations) and 0% in the RIMN group. These differences were not statistically significant (p=0.058). We evaluated a large multicenter series of operatively treated periprosthetic distal femur fractures in this study. We did not find any statistically significant differences at 1 year between treatment groups in this study. There was a trend towards a lower rate of reoperation in the Retrograde Intramedullary Nailing group that should be evaluated further with prospective studies. For any figures or tables, please contact the authors directly

Introduction. Cerament, a bioresorbable hydroxyapatite and calcium sulfate cement, is known to be used as a bone-graft substitute in traumatic bone defect cases. However, its use in open fractures has not previously been studied. Materials and Methods. Retrospective, single-centre review of cases between November 2016 and February 2021. Open fractures were categorised according to the Orthopaedic Trauma Society classification (OTS). Cases were assessed for union, time to union, and associated post-operative complications. Results. Twenty-four patients were identified. Fifteen cases were classified as OTS simple open fractures, and nine cases were complex open fractures requiring soft tissue reconstruction. Four cases were lost to follow-up. Four cases had limited follow-up beyond 6 months but showed evidence of progressive radiographic union. Of the remaining 16 cases, eight cases (50%) went on to union with a mean time to union of 6.7 months (5 to 12 months). Persistent non-union remained in six cases (38%). Two cases required return to theatre due to an infected skin graft and wound dehiscence respectively. One case had the complication of persistent weeping of Cerament from the wound. This self-resolved within two weeks. Limitations of this case series include the lack of complete follow-up in eight patients (33%) and the lack of patient reported outcome measures. Conclusions. Cerament can be a useful adjunct in managing open fractures. However, it should be noted there is a high rate of non-union which may be reflective of the significant morbidity associated with open fractures with structural bone defects

Introduction. Distal femoral and proximal tibial osteotomies are effective procedures to treat degenerative disease of the knee joint. Previously described techniques advocate the use of bone graft to promote healing at the osteotomy site. In this present study a novel technique which utilises the osteogenic potential of the cambial periosteal layer to promote healing “from the outside in” is described. Materials and Methods. A retrospective analysis of a consecutive single-surgeon series of 23 open wedge osteotomies around the knee was performed. The median age of the patients was 37 years (range 17–51 years). The aetiology of the deformities included primary genu valgum (8/23), fracture malunion (4/23), multiple epiphyseal dysplasia (4/23), genu varum (2/23), hypophosphataemic rickets (1/23), primary osteoarthritis (1/23), inflammatory arthropathy (1/23), post-polio syndrome (1/23), and pseudoachondroplasia (1/23). Results. There were two cases lost to follow-up with a median follow-up period 17 months (range 1–32 months). Union was achieved in all cases, with 1/23 requiring revision for early fixation failure for technical reasons. The median time to radiographic union 3.2 months (95% Confidence Interval (CI) 2.5–3.8 95% CI). CT scans demonstrated early periosteal callus, beneath the osteoperiosteal flap, bridging the opening wedge cortex. Clinical union occurred at 4.1 months (95% CI 3.9–4.2 months). Complications included superficial surgical site infection (1/23), deep vein thrombosis (1/23), and symptomatic metalwork requiring removal (7/23). Conclusions. The osteoperiosteal flap technique was a safe and effective technique for opening wedge osteotomies around the knee with a reliable rate of union

Introduction. Management of Vancouver type B1 and C periprosthetic fractures in elderly patients requires fixation and an aim for early mobilisation but many techniques restrict weightbearing due to re-fracture risk. We present the clinical and radiographic outcomes of our technique of total femoral plating (TFP) to allow early weightbearing whilst reducing risk of re-fracture. Methods. A single-centre retrospective cohort study was performed including twenty-two patients treated with TFP for fracture around either hip or knee replacements between May 2014 and December 2017. Follow-up data was compared at 6, 12 and 24 months. Primary outcomes were functional scores (Oxford Hip or Knee score (OHS/OKS)), Quality of Life (EQ-5D) and satisfaction at final follow-up (Visual Analogue Score (VAS)). Secondary outcomes were radiographic fracture union and complications. Results. Mean OHS and OKS was 50.25, EQ-5D score was >4 for all modalities, VAS was 64.4/100. Radiographs demonstrated bony union in 58% at 3 months and 76% at 6 months. We identified no case of re-fracture however non-union occurred in 4 patients. No other operative complications were identified. Conclusion. These results suggest that TFP may be a safe, viable option for management of periprosthetic fractures around stable implants allowing the benefit of early weightbearing, satisfactory outcomes and low re-fracture risk

Background. As the number of primary or revision TKA with stem extension cases are growing simultaneously, the number of periprosthetic fracture in these cases has also increased accordingly. However, there have been few reports on the classification and treatment of periprosthetic fracture following stemmed TKA and lack of information about the treatment outcome. The purposes of this study were 1) to demonstrate classification and management of periprosthetic fractures after stemmed TKA and 2) to report treatment outcome after the periprosthetic fractures. Materials and Methods. This retrospective study included 17 knees (15 patients) with an average age of 69.7 years. All cases were revision TKA cases, and there were 13 female and 2 male patients. The patients were treated nonoperatively or underwent operation by orthopedic principle. The period of union was evaluated by confirming the formation of callus crossing fragments in radiographs. We reviewed the complications and functional outcomes after treatment of periprosthetic fracture following revision TKA by assessing FF, FC and scoring WOMAC and KSS. Results. The classification of periprosthetic fractures of stemmed TKA was based on location of fracture and stability of implant. They were classified as follows: type I, metaphyseal fracture without loosening of implant [Fig. 1]; type II, diaphyseal fracture adjacent to stem without loosening of implant [Fig. 2]; type III, diaphyseal fracture away from stem without loosening of implant [Fig. 3]; and type IV, metaphyseal or diaphyseal fracture with loosening of implant [Fig. 4]. There were 1 case of type I, 9 cases of type II, 4 cases of type III and 3 cases of type IV fractures. The mean time for gaining radiographic union of type I was 3.3 month; type II was 4.4 month; type III was 4.6 month; and type IV was 3.9 month. Most of the metaphyseal fractures were comminuted and all cases of loosening of the femoral implant were found in the metaphyseal fractures. Nine periprosthetic fractures were fixed using locking plate (single locking plate : 4 cases, dual locking plate : 5 cases). The bone union period is much shorter in patients with dual plate fixation than single plate only. Range of motion, WOMAC and KSS were not significantly different between before fracture and after management of fracture. Complications included 1 metal failure, 2 loosening of implant and 1 postoperative infection. Conclusions. Metaphyseal fractures probably cause the collateral ligament insufficiency, and loosen the implant. Therefore, rotating hinge prosthesis should be used to stabilize the ligament of knee joint. Also, Revision TKA with longer stem should be considered if the stability of implant is not sure. When we underwent operation using plate fixation, dual plating provided better stability of fracture and shortened the union period than single plating. However, we need to approach individually depending on the patient, such as using cerclage wire, bone graft and so on. This study will help to establish appropriate treatment options according to each classification. For any figures or tables, please contact the authors directly

Although most uncomplicated paediatric fractures do not require routine long-term follow-up with an orthopaedic surgeon, practitioners with limited experience dealing with paediatrics fractures will often defer to a strategy of unnecessary frequent clinical and radiographic follow-up. Development of an evidence-based clinical care pathway may help reduce unnecessary radiation exposure to this patient population and reduce costs to patient families and the healthcare system. A retrospective analysis including patients who presented to SickKids hospital between October 2009 and October 2014 for management of clavicle fractures was performed. Patients with previous clavicle fractures, perinatal injury, multiple fractures, non-accidental injury, underlying bone disease, sternoclavicular dislocations, fractures of the medial clavicular physis and fractures that were managed at external hospitals were excluded from the analysis. Variables including age, gender, previous injury, fracture laterality, mechanism of injury, polytrauma, surgical intervention and complications and number of clinic visits were recorded for all patients. Radiographs were analysed to determine the fracture location (medial, middle or lateral), type (simple or comminuted), displacement and shortening. 339 patients (226 males, 113 females) with an average age of 8.1 (range 0.1–17.8) were reviewed. Diagnoses of open fractures, skin tenting or neurovascular injury were rare, 0.6%, 4.1%, and 0%, respectively. 6 (1.8%) patients underwent surgical management. All decisions for surgery were made on the first consultation with the orthopaedic surgeon. For patients managed non-operatively, the mean number of clinic visits including initial consultation in the emergency department was 2.0 (±1.2). The mean number of radiology department appointments was 4.1 (± 1.0) where patients received a mean number of 4.2 (±2.9) radiographs. Complications in the non-operative group were minimal; 2 refractures in our series and no known cases of non-union. All patients achieved clinical and radiographic union and returned to sport after fracture healing. Our series suggests that the decision to treat operatively is made at the initial assessment. If no surgical indications were present at the initial assessment by the primary-care physician, then routine clinical or radiographic follow up is unnecessary. Development of a paediatric clavicle fracture pathway may reduce patient radiation exposure and reduce costs incurred by the healthcare system and patients' families without jeopardising patient outcomes

Reverse total shoulder arthroplasty (RSA) with glenoid bone grafting has become a common option for the management of significant glenoid bone loss and deformity associated with glenohumeral osteoarthritis. Despite the increasing utilization of this technique, our understanding of the rates of bone graft union, complications and outcomes are limited. The objectives of this systematic review are to determine 1) the overall rate of bone graft union, 2) the rate of union stratified by graft type and technique, 3) the reoperation and complication rates, and 4) functional outcomes, including range of motion (ROM) and functional outcome scores following RSA with glenoid bone grafting. A comprehensive search of MEDLINE, Embase, and CINAHL databases was completed for studies reporting outcomes following RSA with glenoid bone grafting. Inclusion criteria included clinical studies with greater than 10 patients, and minimum follow up of one year. Studies were screened independently by two reviewers and quality assessment was performed using the MINORs criteria. Pooled and frequency-weighted means and standard deviations were calculated where applicable. Overall, 15 studies were included, including nine retrospective case series (level IV), four retrospective cohort studies (level III), one prospective cohort study (level II) and one randomized control trial (level I). The entire cohort consisted of 555 patients with a mean age of 71.9±2.1 years and 70 percent female. The mean follow-up was 33.8±9.4 months. Across all procedures, 84.9% (N=471) were primary arthroplasties, and 15.1% (N=84) were revisions. The overall graft union rate was 89.2%, but was higher at 96.1% among studies that used autograft bone (9 studies, N=308). When stratified by technique, bone graft for the purposes of lateralization resulted in a 100% union rate (4 studies, N=139), while eccentric bone grafts used in asymmetric bone loss resulted in a lower union rate of 84.9% (10 studies, N=345). The overall revision rate was 6.5%, and was lowest following primary cases at 1.8% (11 studies, N=393). The pooled mean scapular notching rate was 20.1% (12 studies, N=497). Excluding notching, the pooled mean complication rate was 21.5% for all cases and 13% for primary cases (11 studies, N=393). When reported, there was significant improvement in post-operative ROM in all planes. There was also improvement in functional outcome scores, whereby the frequency-weighted mean Constant score increased from 25.9 to 67.2 (8 studies, N=319), ASES score increased from 34.7 to 75.2 (4 studies, N=142), and SST score increased from 2.1 to 7.6 (5 studies, N=196) at final follow up. This review demonstrates that glenoid bone grafting with RSA results in good mid-term clinical and radiographic outcomes. Union rate appears to depend highly on graft type and technique, whereby the highest union rates were seen following the use of autograft bone for the purposes of lateralization. Interestingly, the union rate of autograft bone for the purposes of augmentation in eccentric bone loss is considerably lower and its impact on the long-term survivorship of the implant remains unknown

Over a four year period of time, 142 consecutive hip revisions were performed with the use of an extended proximal femoral osteotomy. Twenty patients had insufficient follow-up or were followed elsewhere and were excluded from the review. The remaining 122 revisions included 83 women and 39 men. Average age at time of revision was 63.8 (26–84) years. Indications for revision were aseptic loosening (114), component failure (4), recurrent dislocation (2), femoral fracture (1) and second stage re-implantation for infection (1). The extended proximal femoral osteotomy gave easy access to the distal bone-cement or bone prosthesis interface in all cases. It allowed neutral reaming of the femoral canal and implantation of the revision component in proper alignment. Varus remodeling of the proximal femur secondary to loosening was handled with relative ease implementing the osteotomy. Average time from the beginning of the osteotomy procedure to the complete removal of prosthesis and cement was 35 minutes. There were no non-unions of the osteotomised fragments at an average post-operative follow-up of 2.6 years with no cases of proximal migration of the greater trochanteric fragment greater than 2 mm, there was evidence of radiographic union of the osteotomy site in all cases by 3 months. Stem fixation with bone ingrowth was noted in 112 (92%) of 122 hips, stable fibrous fixation was seen in 9 (7%) and 1 stem was unstable and was subsequently revised. However, there was an incidence of 7% perforation rate of the femoral canal distal to the osteotomy site during cement removal. This was most prevalent where there was greater than 2 cm of cement plug present which was well bonded. When OSCAR was used instead of hand tools or power reamers, there were no perforations in 51 cases. There has been no failure of fixation with fully porous coated stems inserted in the canals where OSCAR had removed cement. Also, the use of OSCAR has allowed us to shorten the osteotomy, thus allowing a longer, intact isthmus to remain so that shorter stems can be used. We highly recommend the use of OSCAR in conjunction with the extended osteotomy for removal of well-fixed distal cement beyond the extended osteotomy site

Background. Implants based on the polyetheretherketon (PEEK) polymer have been developed in the last decade as an alternative to conventional metallic devices. PEEK devices may provide several advantages over the use of conventional orthopedic materials, including the lack of metal allergies, radiolucency, low artifacts on magnetic resonance imaging scans and the possibility of tailoring mechanical properties. The purpose of this study was to evaluate the clinical results at mean 24-month follow-up using a new plate made of carbon-fiber-reinforced polyetheretherketon (CFR-PEEK) for the treatment of distal radius fractures. Materials and methods. We performed a prospective study including all patients who were treated for unstable distal radius fracture with a CFR-PEEK volar fixed angle plate. We included 70 consecutive fractures of AO types B and C that remained displaced after an initial attempt at reduction. The fractures were classified according to the AO classification: 35 fractures were type C1, 13 were type C2, 6 were type C3, 5 were type B1 and 11 were type B2. Results. All fractures healed, and radiographic union was observed at an average of 6 weeks. The final Disabilities of Arm, Shoulder and Hand score was 5.2 points. The average grip strength, expressed as a percentage of the contralateral limb, was 94 %. Three cases of hardware breakage were reported. Two cases were due to intraoperative plate rupture caused by the attempt to achieve the reduction of the fracture in 1 case and while inserting a distal screw in the other case. In the last case hardware breakage was caused by a fall on the injuried arm 1 week after surgery. No cases of loss of the surgically achieved fracture reduction were documented. Hardware removal was performed in 3 cases, for the occurrence of extensor tenosynovitis in 2 patients and tenosynovitis of flexor pollicis longus in 1 case. Conclusion. The major advantage of CFR-PEEK plate is its radiolucency. This characteristic allows direct visualization of osseous callus formation, allowing monitoring of the healing of the fracture, thereby improving clinical assessment and accuracy. Therefore, specific indications for this new radiolucent plate can be represented by fractures with significant metaphyseal comminution and in cases of nascent malunion where a distal radius osteotomy with bone grafting is usually performed to correct the wrong angle. At early follow-up this device showed good clinical results and allowed maintenance of reduction in complex, AO fractures. The occurrence of tendon complications related to this implant was similar to that reported in literature for the other new-generation plates. However, attention should be payed when stressing the plate to achieve the desired fracture reduction to avoid hardware failure

Aims

The timing of when to remove a circular frame is crucial; early removal results in refracture or deformity, while late removal increases the patient morbidity and delay in return to work. This study was designed to assess the effectiveness of a staged reloading protocol. We report the incidence of mechanical failure following both single-stage and two stage reloading protocols and analyze the associated risk factors.

Over a four year period of time, 142 consecutive hip revisions were performed with the use of an extended proximal femoral osteotomy. Twenty patients had insufficient follow up or were followed elsewhere and were excluded from the review. The remaining 122 revisions included 83 women and 39 men. Average age at time of revision was 63.8 (26–84) years. Indications for revision were aseptic loosening (114), component failure (4), recurrent dislocation (2), femoral fracture (1) and second stage re-implantation for infection (1). The extended proximal femoral osteotomy gave easy access to the distal bone-cement or bone prosthesis interface in all cases. It allowed neutral reaming of the femoral canal and implantation of the revision component in proper alignment. Varus remodeling of the proximal femur secondary to loosening was handled with relative ease implementing the osteotomy. Average time from the beginning of the osteotomy procedure to the complete removal of prosthesis and cement was thirty-five minutes. There were no non-unions of the osteotomised fragments at an average post-op follow up of 2.6 years with no cases of proximal migration of the greater trochanteric fragment greater than 2mm, there was evidence of radiographic union of the osteotomy site in all cases by 3 months. Stem fixation with bone ingrowth was noted in 112 (92%) of 122 hips, stable fibrous fixation was seen in 9 (7%) and 1 stem was unstable and was subsequently revised. However, there was an incidence of 7% perforation rate of the femoral canal distal to the osteotomy site during cement removal. This was most prevalent where there was greater than 2cm of cement plug present which was well bonded. When OSCAR was used instead of hand tools or power reamers, there were no perforations in 51 cases. There has been no failure of fixation with fully porous coated stems inserted in the canals where OSCAR had removed cement. Also, the use of OSCAR has allowed us to shorten the osteotomy, thus allowing a longer, intact isthmus to remain so that shorter stems can be used. We highly recommend the use of OSCAR in conjunction with the extended osteotomy for removal of well-fixed distal cement beyond the extended osteotomy site

Over a four year period of time, 142 consecutive hip revisions were performed with the use of an extended proximal femoral osteotomy. Twenty patients had insufficient follow-up or were followed elsewhere and were excluded from the review. The remaining 122 revisions included 83 women and 39 men. Average age at time of revision was 63.8 (26–84) years. Indications for revision were aseptic loosening (114), component failure (4), recurrent dislocation (2), femoral fracture (1) and second stage re-implantation for infection (1). The extended proximal femoral osteotomy gave easy access to the distal bone-cement or bone prosthesis interface in all cases. It allowed neutral reaming of the femoral canal and implantation of the revision component in proper alignment. Varus remodeling of the proximal femur secondary to loosening was handled with relative ease implementing the osteotomy. Average time from the beginning of the osteotomy procedure to the complete removal of prosthesis and cement was thirty-five minutes. There were no non-unions of the osteotomised fragments at an average post-op follow-up of 2.6 years with no cases of proximal migration of the greater trochanteric fragment greater than 2mm, there was evidence of radiographic union of the osteotomy site in all cases by 3 months. Stem fixation with bone ingrowth was noted in 112 (92%) of 122 hips, stable fibrous fixation was seen in 9 (7%) and 1 stem was unstable and was subsequently revised. However, there was an incidence of 7% perforation rate of the femoral canal distal to the osteotomy site during cement removal. This was most prevalent where there was greater than 2cm of cement plug present which was well bonded. When OSCAR was used instead of hand tools or power reamers, there were no perforations in 51 cases. There has been no failure of fixation with fully porous coated stems inserted in the canals where OSCAR had removed cement. Also, the use of OSCAR has allowed us to shorten the osteotomy, thus allowing a longer, intact isthmus to remain so that shorter stems can be used. We highly recommend the use of OSCAR in conjunction with the extended osteotomy for removal of well-fixed distal cement beyond the extended osteotomy site

Radiographic follow-up of traumatic spondylolisthesis of the axis is well documented in the literature. However, there is a paucity of studies regarding the long-term functional outcome of this type of injury. To study the population, treatment and outcome following traumatic spondylolisthesis of the axis, we reviewed 36 consecutive patients presenting to our institution, a tertiary referral spinal trauma centre, over a 6-year period. We assessed: (a) the mechanism of injury, (b) the mode of treatment, (c) the radiographic classification using the Levine and Edwards system and (d) functional outcome using the Cervical Spine Outcomes Questionnaire (CSOQ) by BenDebba. Of the 36 patients presenting there were 24 males and 12 females with a mean age of 46 (range18-82) years. The commonest mechanism of injury was road traffic accidents. There were 14 Type-I, 11 Type-II and 1 Type-IIA fractures. Twenty-seven patients were treated with halo vest immobilisation and nine were immobilised in a Minerva jacket. Four patients were converted from halo to Minerva because of pin failure. The mean duration of hospital stay was 10 (range 3-30) days. All fractures demonstrated radiographic union at a mean of 12 (range 10-16) weeks. There were no neurological complications. Upon review, all patients, whether Type-I or Type-II demonstrated low CSOQ scores approaching their pre-morbid status. However, Type-II fractures scored higher in 3 functional outcome categories when compared to Type-I fractures. This unique study of an uncommon fracture shows for the first time a difference in the functional outcome scores of Type-II fractures of the axis when compared to Type-I fractures at a mean follow-up of 3 years and 10 months

Background. Periprosthetic fracture fixation can be a difficult and complex procedure. The incidence of such fractures is increasing relative to the high prevalence of elderly patients with joint arthroplasty and osteoporosis. Locking plates were introduced for the management of complex periarticular fractures in osteoporotic bone, but there is little information on the use of these plates for the management of periprosthetic fractures. The purpose of this study was to review the early experience with these plates in managing complex Vancouver B1 and C periprosthetic fractures at our academic centre to determine the effectiveness in achieving union, and to identify any potential complications associated with their use. Methods. We evaluated the results of Vancouver B1 and type C periprosthetic fractures treated with Synthes LCP. The mean age of the patients at the time of surgery was 76 years. 5 patients were men and 10 were women. There were 8 Vancouver B1 and 7 Vancouver C fractures. 6 fractures had failed previous operative treatment. No patient was lost to follow-up. We assessed time to union, complications, and identified criteria for cortical fixation using these plates. Results. At the time of the most recent follow-up, all patients had gone on to radiographic union. Time to union was 6 months. All patients continue to have pain, and all continue to use walking aids. We discuss technical considerations, plate length, fixation and use of allograft. Conclusion. The Synthes Locking Plate system has been shown to provide good results for use in Type C and B1 periprosthetic fractures. Complications were surprisingly low considering the age group involved and associated co-morbidities. Surgery is complex requiring approximately 4 hours with expected blood loss of > 1 litre. Rehabilitation can be slow and prolonged but all patients were ambulatory at 1 year

Introduction. Ulnar shortening osteotomy has become an accepted treatment for a variety of ulnar sided wrist disorders. We have been performing ulnar shortening with an oblique osteotomy cut with the aid of a commercially available jig. The osteotomy is then fixed with a Dynamic Compression Plate. The aim of this study was to report the complications following ulnar shortening. Methods. We retrospectively analysed 56 consecutive ulnar shortening osteotomies. There were 36 female and 19 male patients. The mean age was 45 years. The mean follow-up was 399 days. 25 patients had pre-operative MRI scans and in 34 arthroscopy of the wrist had been performed. 22 tears of the triangular fibrocartilage complex were recorded on arthroscopy. In all cases shortening had been performed with the aid of a jig and bone resection performed in an oblique orientation. Dynamic Compression Plates were used for fixation and a lag screw was inserted through one of the plate-holes and across the osteotomy site. Radiographs were evaluated for pre-operative and post-operative ulnar variances and post-operatively for bony union. Results. The average post-operative ulna variance was 0.12mm. The average time for osteotomy union was 82 days. There were four delayed unions. There were three non-unions. The average time of revision surgery was ten months. All cases have gone onto radiographic union. 19 patients underwent a second operation to have their plates removed. Average time to plate removal was 494 days. There were two cases of re-fracture following plate removal. Conclusion. The rate of delayed and non-union following ulnar shortening osteotomy is higher in our series when compared to the literature. We also noted a higher incidence of plate removal and re-fracture through the osteotomy site. These complications are under-reported in the literature and more emphasis should be given when consent is taken for this procedure

Purpose. The evolution of locked anatomical clavicular plating in combination with evidence to suggest that fixation of clavicle fractures yields better outcome to conservative treatments has led to an increasing trend towards operative management. There is no evidence however to compare early fixation with delayed reconstruction for symptomatic non- or mal-union. We hypothesize that early intervention yields better functional results to delayed fixation. Methods. Between August 2006 and May 2010, 97 patients were managed with operative fixation for their clavicular fracture. Sixty eight with initial fixation and 29 delayed fixation for clavicular non- or mal-union. Patients were prospectively followed up to radiographic union, and outcomes were measured with the Oxford Shoulder Score, QuickDASH, EQ5D and a patient interview. Mean follow-up was to 30 months. All patients were managed with Acumed anatomical clavicular plates. Results. The radiographic and clinical outcomes were available for all patients. Scores were available for 62 (62/97). There were no statistically significant differences in age (p>0.05), sex (p>0.05), energy of injury (p>0.05), number of open fractures (p>0.05) between the two groups. The mean quickDASH was 8.9 early, 9.1 delayed (p< 0.05), Oxford Shoulder score was 15.7 early, 16.1 delayed (p< 0.05). In the early fixation group 5 patients had wound healing complications, and 8 went on subsequently to have removal of prominent metalwork. In the delayed fixation group 2 had wound healing complications and 4 had removal of prominent metalwork. There were no statistically significant differences in the EQ5D quality of life questionnaire. Conclusion. There are no statistically significant differences in shoulder performance, wound or operative complications between early and delayed fixation of clavicular fractures. Our series does not support early fixation of clavicular fractures, as results for delayed intervention in those who become symptomatic appear comparable

The term os-acromiale denotes the failure of fusion of acromial apophysis to the scapular spine. The prevalence of os is considered to be about 8% in the general population with higher prevalence in African Americans and males. The treatment options for a symptomatic os acromiale range from arthroscopic excision to decompression to ORIF and bone grafting. In this study, we reviewed retrospectively patients who had undergone ORIF and bone grafting for a painful os acromiale. Patients surgically treated for os acromiale from 1998 to 2009 were included in the study. All patients were diagnosed to have a symptomatic os acromiale clinically and radiologically. A pre operative MRI of the affected shoulder was done in all patients. All patients had failed conservative management. The surgical technique was standard in all patients. The rotator cuff was repaired if it was torn. Patients were followed up at 3, 6 and 12 months postoperatively. Post operative X-rays were done at 3 months to assess healing. An ASES scoring was done at the final follow up at a mean of 30.5 months post op. 16 patients with 17 shoulders which included 10 males and 6 females were available for the last follow up. 11 shoulders involved dominant hand, 15 shoulders had a history of trauma. Surgery was performed after an average of 7.2 months of conservative management. 11 out of the 17 shoulders had associated rotator cuff tears. Out of the 6 patients with intact cuff, 2 had associated clavicle fractures and 1 patient had an Acromio clavicular joint dislocation. A clinical and radiographic union was achieved in all patients. Mean ASES score in patients without rotator cuff tear was 89 whereas patients with associated rotator cuff tear had an ASES score of 74. Pain score and percentage ADL score were better in patients without rotator cuff tear (92 and 1.3) as compared to those with a cuff tear (83 and 2.2). There was no significant difference in scores in patients who had second surgery at final follow up. 15 of the 16 patients were satisfied with the surgery and would have the surgery on the other side for a similar problem. Open reduction and internal fixation of symptomatic os acromiale yields predictable clinical outcome. Bigger studies randomising treatment methods in similar group of patients may be needed to find out the superiority of one method over the other