Introduction Debonding at the cement-prosthesis interface leading to stem movement and abrasion, has been proposed as initiating events in aseptic loosening of cemented total hip arthroplasties. A polished tapered or an absolutely stable stem possibly minimises this risk. This study evaluated a cemented, precoated femoral stem for stable fixation. Methods The study included 24 patients, mean age of 64 years (48 to 78) undergoing single total hip arthroplasty for osteoarthritis. All were treated with cemented Definition (Stryker) stems which are straight, chromium-cobalt, with an integrated proximal polymethylmethacrylate mantle. One surgeon using fourth generation cementation techniques performed all surgeries. UHMWPE cups and Zirconia heads were used. At the time of surgery, tantalum markers were inserted into the femur, cement and stem for Radiostereometric analysis (RSA) of migration. Measurements were performed at two, 12 and 24 months intervals. Standard radiographs and Harris Hip Scores were obtained post-operatively and at two years. Results During the first two years post-operatively the stems were shown to be absolutely fixed within the cement mantle and the mantle itself stable with the femur. At two years the mean subsidence of the stem in relation to the femur was 0.00 mm (SD 0.1), while the cement mantle subsided 0.2 mm (SD 0.2) in relation to the femur. The femoral head mean rotation was 0.02 retroversion. Postoperative radiolucent lines of > 1 mm where present in a mean of 1.4% (0 to 5%) of the cement-bone interfaces. This remained unchanged at two years (0 to 3%). Stems were in average positioned 0.8 in varus (1.2 valgus to 4.0 varus). Harris Hip Scores improved from a mean of 46 (23 to 68) pre-operatively to 93 (57 to 100) at two years. Conclusions This is the first stem where no migration could be detected during the first two years. These results so far indicate good long-term performance of this precoated stem

Clinical Problen: the avulsion fracture of the MT V bone and the Jones fractures are typical fractures under tenssion and therefore often require osteosynthesis. Materials and Methods: to avoid soft tissue problems due to the open reduction and implant on the bone surface on the lateral foot a percutaneus technique with a 3,5mm XXS locked compression nail was developed. The fracture is reduced with the gide wire witch is also used for the canulated 3,5mm drill wich prepares the canal for the nail. The locking is performed on both sides of the fracture with one 2mm threated wire and the dynamic compression of the Fracture of the fracture is performed with a set screw in the nail. All patients are allowed to walk free with normal foot wear. From Jul 1999 to Jan.2006 77 patients were treated according to the above technique. Results: Tha OAFAS of the patients preoperativ was 22 and postoperative 96. No pseudarthrosis or implant failures occured but in 53 patients (69%) implant removal was necessary because patients had discomfort due to the implant. Conclusion: the XXS nail is a new method for minimal invasive and stable fixation of MTV fractures with full weight bearing capacity in low complication rate. However in most cases implant removal is indicated

The avulsion fracture of the V-th metatarsal and Jones fractures often show delayed and non-union. The tension belt osteosynthesis shows often soft tissue problems due to the thin soft tisshe covering. A new minimal invasive method with the 3,5mm XXS nail and the clinical results are presented. Percutaneously the fracture is reduced with a K-wire as a joy stick. This or if the direction needed is different a second K-wire as guide is introduced and with a canulated 3,5 mm drill the place for the nail is prepared. Proximal and distal to the fracture one threaded wire locking and fracture compression through the nail (proximal longitudinal holes) are performed. 77 patients with a XXS nail fixation of MT V fractures were treated from July 1999 to Jan.2006. Clinical and radiological re-examination at 1 to 6 years were performed. The AOFAS was 22 pre- and 96 postoperatively. No pseudarthrosis but in 53 patients implant removal was done in part due to local discomfort. This was strictly correlated to the length of the threaded wires to the bone surface. 95% reached pretrauma activity levels. Satisfaction was 9 from 10 points. The XXS nails allow a percutaneous stable fixation of the avulsion and Jones fractures of the V-th metatarsus. The complication rate is low

The avulsion fracture of the V-th metatarsal and Jones fractures often show delayed and non-union. The tension belt osteosynthesis shows often soft tissue problems due to the thin soft tisshe covering. A new minimal invasive method with the 3,5mm XXS nail and the clinical results are presented. Percutaneously the fracture is reduced with a K-wire as a joy stick. This or if the direction needed is different a second K-wire as guide is introduced and with a canulated 3,5 mm drill the place for the nail is prepared. Proximal and distal to the fracture one threaded wire locking and fracture compression through the nail (proximal longitudinal holes) are performed. 77 patients with a XXS nail fixation of MT V fractures were treated from July 1999 to Jan.2006. Clinical and radiological re-examination at 1 to 6 years were performed. The AOFAS was 22 pre- and 96 postoperatively. No pseudarthrosis but in 53 patients implant removal was done in part due to local discomfort. This was strictly correlated to the length of the threaded wires to the bone surface. 95% reached pretrauma activity levels. Satisfaction was 9 from 10 points. The XXS nails allows a percutaneous stable fixation of the avulsion and Jones fractures of the V-th metatarsus. The complication rate is low

There is a growing trend towards using pre-clinical models of atrophic non-union. This study investigated different fixation devices, by comparing the mechanical stability at the fracture site of tibia bone fixed by either intramedullary nail, compression plate or external fixator. 40 tibias from adult male Wistar rats' cadavers were osteotomised at the mid-shaft and a gap of 1 mm was created and maintained at the fracture site to simulate criteria of atrophic non-union model. These were divided into five groups (n=8 in each): the first group was fixed with 20G intramedullary nail, the second group with 18G nail, the third group with 4-hole plate, the fourth group with 6-hole plate, and the fifth group with external fixator. Tibia was harvested by leg disarticulation from the knee and ankle joints, the soft tissues were carefully removed from the leg, and tibias were kept hydrated throughout the experiment. Each group was then subdivided into two subgroups for mechanical testing: one for axial loading (n=4) and one for 4-point bending (n=4). Statistical analysis was carried out by ANOVA with a fisher post-hoc comparison between groups. A p-value less than 0.05 was considered statistically significant. Axial load to failure data and stiffness data revealed that intramedullary nails are significantly stronger and stiffer than other devices, however there was no statistically significant difference axially between the nail thicknesses. In bending, load to failure revealed that 18G nails are significantly stronger than 20G. We concluded that 18G nail is superior to the other fixation devices, therefore it has been used for in-vivo experiments to create a novel model of atrophic non-union with stable fixation

Aims

Early implant migration measured with radiostereometric analysis (RSA) has been proposed as a useful predictor of long-term fixation of tibial components in total knee arthroplasty. Evaluation of actual long-term fixation is of interest for cemented components, as well as for cementless fixation, which may offer long-term advantages once osseointegration has occurred. The objective of this study was to compare the long-term migration with one- and two-year migration to evaluate the predictive ability of short-term migration data and to compare migration and inducible displacement between cemented and cementless (porous metal monoblock) components at least ten years postoperatively.

Hallux valgus (HV) presents as a common forefoot deformity that causes problems with pain, mobility, footwear, and quality of life. The most common open correction used in the UK is the Scarf and Akin osteotomy, which has good clinical and radiological outcomes and high levels of patient satisfaction when used to treat a varying degrees of deformity. However, there are concerns regarding recurrence rates and long-term outcomes. Minimally invasive or percutaneous surgery (MIS) has gained popularity, offering the potential for similar clinical and radiological outcomes with reduced postoperative pain and smaller scars. Despite this, MIS techniques vary widely, hindering comparison and standardization. This review evaluates the evidence for both open Scarf and Akin osteotomy and newer-generation MIS techniques. Fourth-generation MIS emphasizes multiplanar rotational deformity correction through stable fixation. While MIS techniques show promise, their evidence mainly comprises single-surgeon case series. Comparative studies between open and MIS techniques suggest similar clinical and radiological outcomes, although MIS may offer advantages in scar length and less early postoperative pain. MIS may afford superior correction in severe deformity and lower recurrence rates due to correcting the bony deformity rather than soft-tissue correction. Recurrence remains a challenge in HV surgery, necessitating long-term follow-up and standardized outcome measures for assessment. Any comparison between the techniques requires comparative studies. Surgeons must weigh the advantages and risks of both open and MIS approaches in collaboration with patients to determine the most suitable treatment. Cite this article: Bone Joint J 2025;107-B(1):10–18

We determined the short-term clinical outcome and migration within the bone of the humeral cementless component of the Instrumented Bone Preserving (IBP) total elbow replacement in a series of 16 patients. There were four men and 12 women with a mean age at operation of 63 years (40 to 81). Migration was calculated using radiostereometric analysis. There were no intra-operative complications and no revisions. At two-year follow-up, all patients showed a significant reduction in pain and functional improvement of the elbow (both p < 0.001). Although ten components (63%) showed movement or micromovement during the first six weeks, 14 (88%) were stable at one year post-operatively. Translation was primarily found in the proximal direction (median 0.3 mm (interquartile range (IQR) -0.09 to 0.8); the major rotational movement was an anterior tilt (median 0.7° (IQR 0.4° to 1.6°)). One malaligned component continued to migrate during the second year, and one component could not be followed beyond three months because migration had caused the markers to break off the prosthesis.

This study shows promising early results for the cementless humeral component of the IBP total elbow replacement. All patients had a good clinical outcome, and most components stabilised within six months of the operation.

Cite this article: Bone Joint J 2014;96-B:229–36.

Aims. In this study, we aimed to explore surgical variations in the Femoral Neck System (FNS) used for stable fixation of Pauwels type III femoral neck fractures. Methods. Finite element models were established with surgical variations in the distance between the implant tip and subchondral bone, the gap between the plate and lateral femoral cortex, and inferior implant positioning. The models were subjected to physiological load. Results. Under a load of single-leg stance, Pauwels type III femoral neck fractures fixed with 10 mm shorter bolts revealed a 7% increase of the interfragmentary gap. The interfragmentary sliding, compressive, and shear stress remained similar to models with bolt tips positioned close to the subchondral bone. Inferior positioning of FNS provided a similar interfragmentary distance, but with 6% increase of the interfragmentary sliding distance compared to central positioning of bolts. Inferior positioning resulted in a one-third increase in interfragmentary compressive and shear stress. A 5 mm gap placed between the diaphysis and plate provided stability comparable to standard fixation, with a 7% decrease of interfragmentary gap and sliding distance, but similar compressive and shear stress. Conclusion. Finite element analysis with FNS on Pauwels type III femoral neck fractures revealed that placement of the bolt tip close to subchondral bone provides increased stability. Inferior positioning of FNS bolt increased interfragmentary sliding distance, compressive, and shear stress. The comparable stability of the fixation model with the standard model suggests that a 5 mm gap placed between the plate and diaphysis could viably adjust the depth of the bolt. Cite this article: Bone Joint Res 2022;11(2):102–111

Aims. One of the main causes of tibial revision surgery for total knee arthroplasty is aseptic loosening. Therefore, stable fixation between the tibial component and the cement, and between the tibial component and the bone, is essential. A factor that could influence the implant stability is the implant design, with its different variations. In an existing implant system, the tibial component was modified by adding cement pockets. The aim of this experimental in vitro study was to investigate whether additional cement pockets on the underside of the tibial component could improve implant stability. The relative motion between implant and bone, the maximum pull-out force, the tibial cement mantle, and a possible path from the bone marrow to the metal-cement interface were determined. Methods. A tibial component with (group S: Attune S+) and without (group A: Attune) additional cement pockets was implanted in 15 fresh-frozen human leg pairs. The relative motion was determined under dynamic loading (extension-flexion 20° to 50°, load-level 1,200 to 2,100 N) with subsequent determination of the maximum pull-out force. In addition, the cement mantle was analyzed radiologically for possible defects, the tibia base cement adhesion, and preoperative bone mineral density (BMD). Results. The BMD showed no statistically significant difference between both groups. Group A showed for all load levels significantly higher maximum relative motion compared to group S for 20° and 50° flexion. Group S improved the maximum failure load significantly compared to group A without additional cement pockets. Group S showed a significantly increased cement adhesion compared to group A. The cement penetration and cement mantle defect analysis showed no significant differences between both groups. Conclusion. From a biomechanical point of view, the additional cement pockets of the component have improved the fixation performance of the implant. Cite this article: Bone Joint Res 2022;11(4):229–238

Aim: A debonding in the stem-cement interface is often the þrst event leading to clinical failure of hip prostheses. We have tested the stability of a pre cement mantled stem were the concept of composite beam stems is taken to a new level. Methods: Twenty four patients with a mean age of 64 years (48–73), a weight of 72 kg and allocated to total hip arthroplasty due to OA were operated. All received a Deþnition stem (a straight CoCr stem proximally coated with a PMMA mantle). All poly cups, Palacos cement and 4th generation cementing technique was used in all. Tantalum markers were inserted in femur and the stem and migration measured with RSA at 2, 12 and 24 months. Radiographs and Harris hip score was obtained post op and at 2 years. Results: The subsidence of stems in relation to femur was 0.00 mm (SEM 0.02) and the cement mantle subsided 0.2 mm (SEM 0.02) in relation to femur. The femoral head rotated backward 0.02 mm.(SEM 0.07) Post op radiolucent lines of 1 mm thickness or more were present to a mean of 0.3% (0–3%) in the cement-bone interface at 2 years. Harris hip score increased from a mean of 46 (23–68) pre op to 93 (57–100) at 2 years. Conclusion: Deþnition is the þrst stem investigated with RSA were no migration at all could be recorded the þrst 2 years. Togeher with a stable cement mantle and no radiolucent lines it so far indicates a good long term performance of the Deþnition stem.

The Fixion expandable nailing system provides an intramedullary fracture fixation solution without the need for locking screws. Proponents of this system have demonstrated shorter surgery times with rapid fracture healing, but several centres have reported suboptimal results with loss of fixation. This is the largest comparative series to be reported to date.

We compared outcomes between 50 consecutive diaphyseal tibial fractures treated with a Fixion device at our institution to an age, sex and fracture configuration matched series of 57 fractures at a neighbouring hospital treated with a conventional interlocked intramedullary nail. Minimum follow up time was 2 years.

Operating time was significantly reduced in the Fixion group (mean 61 minutes, range 20–99) compared to the interlocked group (88 minutes, 52–93), p< 0.00001. The union rate was no different between the Fixion group (93.9%) and the interlocked group (96.5%), p=0.527. Time to clinical and radiological union was significantly faster in the Fixion group (median 85 days, range 42–243) compared to the interlocked group (119, 70–362), p< 0.0001. The overall reoperation rate was lower in the Fixion series (24.5% vs 38.6%, p=0.121), although the majority of reoperations in the interlocked group were more minor, for screw removal. 3 Fixion nails were revised for fixation failure and 2 manipulations were required for rotational deformities after falls; all of these patients were non-compliant with post-operative instructions. There were no fixation failures in the interlocked group. 3 fractures were noted to propagate during inflation of Fixion nails.

The Fixion nail is faster to implant and allows more physiological loading of the fracture, with a faster union time. However, these advantages are offset by a reduction in construct stability. Our results have demonstrated a learning curve with a reduction in complications as our indications were narrowed, avoiding osteoporotic, multifragmentary, unstable fractures and non-compliant patients

Displaced fractures of the radial neck in children can lead to limitation of elbow and forearm movements if left untreated. Several management techniques are available for the treatment of radial neck fractures in children. Open reduction can disturb the blood supply of the soft tissue surrounding the radial head epiphysis and is associated with more complications.

We report our experience of treating 14 children between the age of 4 and 13 years, who had severely displaced radial neck fractures (Judet type 111 and 1V). 12 patients were treated with indirect reduction and fixation using the Elastic Stable Intramedullary Nail (ESIN) technique, (3 with assisted percutaneous K-wire reduction) and 2 had open reduction followed by ESIN fixation of the radial head fragment. This method reduces the need for open reduction and thus the complication rate. Three patients had associated fractures of the same forearm which was also treated surgically at the same time. We routinely immobilised the forearm for two weeks and removed the nail in all cases in an average of 12 weeks. We had no complication with implant removal.

All 14 patients have been followed up for average of 28 months. One patient (7%) developed asymptomatic avascular necrosis (AVN) of the head of radius. Thirteen patients (93%) had excellent result on final review. One patient had neuropraxia of the posterior interosseous nerve which recovered within 6 weeks.

In conclusion we advocate ESIN for the closed reduction and fixation of severely displaced radial neck fractures in children. It remains a useful fixation method even if open reduction is required and allows early mobilisation.

Several techniques are available for the treatment of displaced fractures of the neck of the radius in children. We report our experience in 14 children treated by indirect reduction and fixation using an elastic stable intramedullary nail. The patients were followed up for a mean of 28 months. One developed asymptomatic avascular necrosis. The rest had excellent results. One had a neuropraxia of the posterior interosseous nerve, which recovered within six weeks. We advocate elastic stable intramedullary nailing for the closed reduction and fixation of these fractures in children.

Introduction: Regarding operative treatment of proximal humeral fractures no current treatment guidelines have been established so far. Angular stable implant for stabilisation of proximal humerus fractures find increased spreading. Aim of the study was the evaluation of pain, function subjective contentment and especial the surgical complications after stabilization with the Proximal Humerus Plate.

Methods: 214 patients were treated with PHP from 8/2001 to 2/2005 and documented prospectively. The humeral head fragment was fixated with four angular stable self locking screws. Neer–Classification showed 102 2-part, 71 3-part and 41 4-part fractures. Follow up (x-ray, VAS, Constant Score) was performed after 6 and 12 months respectively.

Results: Until now 154 (72%) Patients were available for follow up. Complications were seen in 31 cases (20%). Leading were perforation of self locking screws of the humeral head (10), followed by secondary dislocation (7, 3 of them with re-trauma), secondary humeral head necrosis (6), implant failure (3), malposition (varus) (3), and infection (2). In 18 cases (12%) re-operation was necessary: removal of screws (7), re-osteosynthesis (6), hemiarthroplasty (5). The constant score (compared to uninjured side) was 6 months postoperatively 61 (71%) and after 12 months 73 (82%).

Conclusion: The problems of osteosynthesis of proximal humeral fractures using an internal fixator are shown by the complications. Especially rigid self locking head screws show a high risk to perforate the humeral articular surface. On the other hand results showed good primary and secondary stability in comparison with the literature.

Complex acetabular reconstruction for oncology and bone loss are challenging for surgeons due to their often hostile biological and mechanical environments. Titrating concentrations of silver ions on implants and alternative modes of delivery allow surgeons to exploit anti-infective properties without compromising bone on growth and thus providing a long-term stable fixation. We present a case series of 12 custom acetabular tri-flange and custom hemipelvis reconstructions (Ossis, Christchurch, New Zealand), with an ultrathin plasma coating of silver particles embedded between layers of siloxane (BioGate HyProtect™, Nuremberg, Germany). At the time of reporting no implant has been revised and no patient has required a hospital admission or debridement for a deep surgical site infection. Routine follow up x-rays were reviewed and found 2 cases with loosening, both at their respective anterior fixation. Radiographs of both cases show remodelling at the ilium indicative of stable fixation posteriorly. Both patients remain asymptomatic. 3 patients were readmitted for dislocations, 1 of whom had 5 dislocations within 3 weeks post-operatively and was immobilised in an abduction brace to address a lack of muscle tone and has not had a revision of their components. Utilising navigation with meticulous implant design and construction; augmented with an ultrathin plasma coating of silver particles embedded between layers of siloxane with controlled and long-term generation of silver ion diffusion has led to outstanding outcomes in this series of 12 custom acetabular and hemipelvis reconstructions. No patients were revised for infection and no patients show signs of failure of bone on growth and incorporation. Hip instability remains a problem in these challenging mechanical environments and we continue to reassess our approach to this multifaceted problem

Aims. Refobacin Bone Cement R and Palacos R + G bone cement were introduced to replace the original cement Refobacin Palacos R in 2005. Both cements were assumed to behave in a biomechanically similar fashion to the original cement. The primary aim of this study was to compare the migration of a polished triple-tapered femoral stem fixed with either Refobacin Bone Cement R or Palacos R + G bone cement. Repeated radiostereometric analysis was used to measure migration of the femoral head centre. The secondary aims were evaluation of cement mantle, stem positioning, and patient-reported outcome measures. Methods. Overall, 75 patients were included in the study and 71 were available at two years postoperatively. Prior to surgery, they were randomized to one of the three combinations studied: Palacos cement with use of the Optivac mixing system, Refobacin with use of the Optivac system, and Refobacin with use of the Optipac system. Cemented MS30 stems and cemented Exceed acetabular components were used in all hips. Postoperative radiographs were used to assess the quality of the cement mantle according to Barrack et al, and the position and migration of the femoral stem. Harris Hip Score, Oxford Hip Score, Forgotten Joint Score, and University of California, Los Angeles Activity Scale were collected. Results. Median distal migration (y-axis) at two years for the Refobacin-Optivac system was -0.79 mm (-2.01 to -0.09), for the Refobacin-Optipac system was -0.75 mm (-2.16 to 0.20), and for the Palacos-Optivac system was -1.01 mm (-4.31 to -0.29). No statistically significant differences were found between the groups. Secondary outcomes did not differ statistically between the groups at the two-year follow-up. Conclusion. At two years, we found no significant differences in distal migration or clinical outcomes between the three groups. Our data indicate that Refobacin Bone Cement R and Palacos R + G are comparable in terms of stable fixation and early clinical outcomes. Cite this article: Bone Joint J 2024;106-B(5):435–441

Aims. The aim of this study was to evaluate the outcome of complex radial head fractures at mid-term follow-up, and determine whether open reduction and internal fixation (ORIF) or radial head arthroplasty (RHA) should be recommended for surgical treatment. Methods. Patients who underwent surgery for complex radial head fractures (Mason type III, ≥ three fragments) were divided into two groups (ORIF and RHA) and propensity score matching was used to individually match patients based on patient characteristics. Ultimately, 84 patients were included in this study. After a mean follow-up of 4.1 years (2.0 to 9.5), patients were invited for clinical and radiological assessment. The Mayo Elbow Performance Score (MEPS), Oxford Elbow Score (OES), and Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire score were evaluated. Results. Patients treated with ORIF showed significantly better postoperative range of motion for flexion and extension (121.1° (SD 16.4°) vs 108.1° (SD 25.8°); p = 0.018). Postoperative functional scores also showed significantly better results in the ORIF group (MEPS 90.1 (SD 13.6) vs 78 (SD 20.5); p = 0.004). There was no significant difference between the groups in terms of the complication rate (RHA 23.8% (n = 10) vs ORIF 26.2% (n = 11)). Implant-related complications occurred in six cases (14.3%) in the RHA group and in five cases (11.9%) in the ORIF group. Conclusion. Irrespective of the patient’s age, sex, type of injury, or number of fracture fragments, ORIF of the radial head should be attempted initially, if a stable reconstruction can be achieved, as it seems to provide a superior postoperative outcome for the patient compared to primary RHA. If reconstruction is not feasible, RHA is still a viable alternative. In the surgical treatment of complex radial head fractures, reconstruction shows superior postoperative outcomes compared to RHA. Good postoperative results can be achieved even after failed reconstruction and conversion to secondary RHA. Therefore, we encourage surgeons to favour reconstruction of complex radial head fractures, regardless of injury type or number of fragments, as long as a stable fixation can be achieved. Cite this article: Bone Joint J 2024;106-B(10):1158–1164

Introduction. The management of fracture-related infection has undergone radical progress following the development of international guidelines. However, there is limited consideration to the realities of healthcare in low-resource environments due to a lack of available evidence in the literature from these settings. Initial antimicrobial suppression to support fracture union is frequently used in low- and middle-income countries despite the lack of published clinical evidence to support its practice. This study aimed to evaluate the outcomes following initial antimicrobial suppression to support fracture union in the management of fracture-related infection. Materials & Methods. A retrospective review of consecutive patients treated with initial antimicrobial suppression to support fracture healing followed by definitive eradication surgery to manage fracture-related infections following intramedullary fixation was performed. Indications for this approach were; a soft tissue envelope not requiring reconstructive surgery, radiographic evidence of stable fixation with adequate alignment, and progression towards fracture union. Results. This approach was associated with successful treatment in 51/55 (93%) patients. Fracture union was achieved in 52/55 (95%) patients with antimicrobial suppression alone. Remission of infection was achieved in 54/55 (98%) patients following definitive infection eradication surgery. Following antibiotic suppression, 6/46 (13%) pathogens isolated from intra-operative samples demonstrated multi-drug resistance. Conclusions. Initial antimicrobial suppression to support fracture healing followed by definitive infection eradication surgery was associated with successful treatment in 93% of patients. The likelihood of remission of infection increases when eradication surgery is performed in a healed bone. This approach was not associated with an increased risk of developing multi-drug-resistant infections compared to contemporary bone infection cohorts in the published literature