Aims. Fixation techniques used in the treatment of slipped capital femoral epiphysis (SCFE) that allow continued growth of the femoral neck, rather than inducing epiphyseal fusion in situ, have the advantage of allowing remodelling of the deformity. The aims of this study were threefold: to assess whether the Free-Gliding (FG) SCFE screw prevents further slip; to establish whether, in practice, it enables lengthening and gliding; and to determine whether the age of the patient influences the extent of glide. Methods. All patients with SCFE who underwent fixation using FG SCFE screws after its introduction at our institution, with minimum three years’ follow-up, were reviewed retrospectively as part of ongoing governance. All pre- and postoperative radiographs were evaluated. The demographics of the patients, the grade of slip, the extent of lengthening of the barrel of the screw and the restoration of Klein’s line were recorded. Subanalysis was performed according to sex and age. Results. A total of 19 hips in 13 patients were included. The mean age of the patients at the time of surgery was 11.5 years (9 to 13) and the mean follow-up was 63 months (45 to 83). A total of 13 FG SCFE screws were used for the fixation of mild or moderate SCFE, with six contralateral prophylactic fixations. No hip with SCFE showed a further slip after fixation and there were no complications. Lengthening occurred in 15 hips (79%), with a mean lengthening of the barrel of 6.8 mm (2.5 to 13.6) at final follow-up. Remodelling occurred in all hips with lengthening of the barrel. There was statistically more lengthening in patients who were aged < 12 years, regardless of sex (p = 0.002). Conclusion. The FG SCFE screw is effective in preventing further slip in patients with SCFE. Lengthening of the barrel occurred in most hips, and thus allowed remodelling. This was most marked in younger children, regardless of sex. Based on this study, this device should be considered for use in patients with SCFE aged < 12 years instead of standard pinning in situ. Cite this article: Bone Joint J 2023;105-B(2):215–219

Aims. The aim of this study was to compare the peak pull-out force (PPF) of pedicle-lengthening screws (PLS) and traditional pedicle screws (TPS) using instant and cyclic fatigue testing. Materials and Methods. A total of 60 lumbar vertebrae were divided into six groups: PLS submitted to instant pull-out and fatigue-resistance testing (groups A1 and A2, respectively), TPS submitted to instant pull-out and fatigue-resistance testing (groups B1 and B2, respectively) and PLS augmented with 2 ml polymethylmethacrylate, submitted to instant pull-out and fatigue-resistance testing (groups C1 and C2, respectively). The PPF and normalized PPF (PPFn) for bone mineral density (BMD) were compared within and between all groups. Results. In all groups, BMD was significantly correlated with PPF (r = 0.83, p < 0.001). The PPFn in A1 was significantly less than in B1 (p = 0.006) and C1 (p = 0.002). The PPFn of A2 was significantly less than in B2 (p < 0.001) and C2 (p < 0.001). The PPFn in A1, B1, and C1 was significantly greater than in A2 (p = 0.002), B2 (p = 0.027), and C2 (p = 0.003). There were no significant differences in PPFn between B1 and C1, or between B2 and C2. Conclusion. Pedicle lengthening screws with cement augmentation can provide the same fixation stability as traditional pedicle screws and may be a viable clinical option. Cite this article: Bone Joint J 2018;100-B:516–21

Aims. The aim of this study was to investigate whether on-demand removal (ODR) is noninferior to routine removal (RR) of syndesmotic screws regarding functional outcome. Methods. Adult patients (aged above 17 years) with traumatic syndesmotic injury, surgically treated within 14 days of trauma using one or two syndesmotic screws, were eligible (n = 490) for inclusion in this randomized controlled noninferiority trial. A total of 197 patients were randomized for either ODR (retaining the syndesmotic screw unless there were complaints warranting removal) or RR (screw removed at eight to 12 weeks after syndesmotic fixation), of whom 152 completed the study. The primary outcome was functional outcome at 12 months after screw placement, measured by the Olerud-Molander Ankle Score (OMAS). Results. There were 152 patients included in final analysis (RR = 73; ODR = 79). Of these, 59.2% were male (n = 90), and the mean age was 46.9 years (SD 14.6). Median OMAS at 12 months after syndesmotic fixation was 85 (interquartile range (IQR) 60 to 95) for RR and 80 (IQR 65 to 100) for ODR. The noninferiority test indicated that the observed effect size was significantly within the equivalent bounds of -10 and 10 scale points (p < 0.001) for both the intention-to-treat and per-protocol, meaning that ODR was not inferior to RR. There were significantly more complications in the RR group (12/73) than in the ODR group (1/79) (p = 0.007). Conclusion. ODR of the syndesmotic screw is not inferior to routine removal when it comes to functional outcome. Combined with the high complication rate of screw removal, this offers a strong argument to adopt on demand removal as standard practice of care after syndesmotic screw fixation. Cite this article: Bone Joint J 2021;103-B(11):1709–1716

The purpose of this study was to evaluate and compare the effect of short segment pedicle screw instrumentation and an intermediate screw (SSPI+IS) on the radiological outcome of type A thoracolumbar fractures, as judged by the load-sharing classification, percentage canal area reduction and remodelling. . We retrospectively evaluated 39 patients who had undergone hyperlordotic SSPI+IS for an AO-Magerl Type-A thoracolumbar fracture. Their mean age was 35.1 (16 to 60) and the mean follow-up was 22.9 months (12 to 36). There were 26 men and 13 women in the study group. In total, 18 patients had a load-sharing classification score of seven and 21 a score of six. All radiographs and CT scans were evaluated for sagittal index, anterior body height compression (%ABC), spinal canal area and encroachment. There were no significant differences between the low and high score groups with respect to age, duration of follow-up, pre-operative sagittal index or pre-operative anterior body height compression (p = 0.217, 0.104, 0.104, and 0.109 respectively). The mean pre-operative sagittal index was 19.6° (12° to 28°) which was corrected to -1.8° (-5° to 3°) post-operatively and 2.4° (0° to 8°) at final follow-up (p = 0.835 for sagittal deformity). No patient needed revision for loss of correction or failure of instrumentation. Hyperlordotic reduction and short segment pedicle screw instrumentation and an intermediate screw is a safe and effective method of treating burst fractures of the thoracolumbar spine. It gives excellent radiological results with a very low rate of failure regardless of whether the fractures have a high or low load-sharing classification score. Cite this article: Bone Joint J 2014;96-B:541–7

Aims. Revision total hip arthroplasty in patients with Vancouver type B3 fractures with Paprosky type IIIA, IIIB, and IV femoral defects are difficult to treat. One option for Paprovsky type IIIB and IV defects involves modular cementless, tapered, revision femoral components in conjunction with distal interlocking screws. The aim of this study was to analyze the rate of reoperations and complications and union of the fracture, subsidence of the stem, mortality, and the clinical outcomes in these patients. Methods. A total of 46 femoral components in patients with Vancouver B3 fractures (23 with Paprosky type IIIA, 19 with type IIIB, and four with type IV defects) in 46 patients were revised with a transfemoral approach using a modular, tapered, cementless revision Revitan curved femoral component with distal cone-in-cone fixation and prospectively followed for a mean of 48.8 months (SD 23.9; 24 to 112). The mean age of the patients was 80.4 years (66 to 100). Additional distal interlocking was also used in 23 fractures in which distal cone-in-cone fixation in the isthmus was < 3 cm. Results. One patient (2.2%) died during the first postoperative year. After six months, 43 patients (93.5%) had osseous, and three had fibrous consolidation of the fracture and the bony flap, 42 (91.3%) had bony ingrowth and four had stable fibrous fixation of the stem. No patient had radiolucency around the interlocking screws and no screw broke. One patient had non-progressive subsidence and two had a dislocation. The mean Harris Hip Score increased from of 57.8 points (SD 7.9) three months postoperatively to 76.1 points (SD 10.7) 24 months postoperatively. Conclusion. The 2° tapered, fluted revision femoral component with distal cone-in-cone-fixation, combined with additional distal interlocking in patients with bony deficiency at the isthmus, led to reproducibly good results in patients with a Vancouver B3 fracture and Paprosky type IIIA, IIIB, and IV defects with regard to union of the fracture, subsidence or loosening of the stem, and clinical outcomes. Cite this article: Bone Joint J 2024;106-B(4):344–351

The compression produced by and the resistance to pullout of the 6.5 mm cannulated Herbert screw were compared with those of ASIF headed screws. The latter were tested with and without washers and in the following sizes: 4.5 mm cortical, 6.5 mm cancellous with a 16 mm threaded segment, and 6.5 mm cancellous with a 32 mm threaded segment. Polyurethane foam was used as a substitute for cancellous bone and ASIF artificial bone for corticocancellous bone. The compression produced by a cancellous lag screw with a washer was significantly greater than that produced by a Herbert screw of equivalent size (p < 0.05). When the screws were tested using the corticocancellous composite the ASIF cancellous screw without a washer produced significantly greater compression (p < 0.05); when used with a washer the difference was highly significant (p < 0.001). The dual pitch Herbert screw is not appropriate for the management of fractures in which compression is of greater importance than the need to avoid prominence of the screw head

Aims. Guided growth has been used to treat coxa valga for cerebral palsy (CP) children. However, there has been no study on the optimal position of screw application. In this paper we have investigated the influence of screw position on the outcomes of guided growth. Methods. We retrospectively analyzed 61 hips in 32 CP children who underwent proximal femoral hemi epiphysiodesis between July 2012 and September 2017. The hips were divided into two groups according to the transphyseal position of the screw in the coronal plane: across medial quarter (Group 1) or middle quarter (Group 2) of the medial half of the physis. We compared pre- and postoperative radiographs in head-shaft angle (HSA), Reimer’s migration percentage (MP), acetabular index (AI), and femoral anteversion angle (FAVA), as well as incidences of the physis growing-off the screw within two years. Linear and Cox regression analysis were conducted to identify factors related to HSA correction and risk of the physis growing-off the screw. Results. A total of 37 hips in Group 1 and 24 hips in Group 2 were compared. Group 1 showed a more substantial decrease in the HSA (p = 0.003) and the MP (p = 0.032). Both groups had significant and similar improvements in the AI (p = 0.809) and the FAVA (p = 0.304). Group 1 presented a higher incidence of the physis growing-off the screw (p = 0.038). Results of the regression analysis indicated that the eccentricity of screw position correlated with HSA correction and increases the risk of the physis growing-off the screw. Conclusion. Guided growth is effective in improving coxa valga and excessive femoral anteversion in CP children. For younger children, despite compromised efficacy of varus correction, we recommend a more centered screw position, at least across the middle quarter of the medial physis, to avoid early revision. Cite this article: Bone Joint J 2020;102-B(9):1242–1247

The rigidity of a sliding compression screw and three cannulated lag screws in the treatment of subcapital fractures was compared in five pairs of female cadaver femora. There were no significant differences between the compressive strength, bone density, cortical thickness or Singh index of the bones in each pair. A subcapital fracture was standardised using a perpendicular saw cut across the femoral neck. A uniaxial 'load test system' with force and length measurement facilities was used to mimic cyclical stressing applied in vivo at a frequency of 0.5 Hz from 0 to 3 times body-weight. There was no significant difference between the fixation afforded by the sliding compression screw and three lag screws. Bone quality was the single most important factor in the stability of the bone implant unit

Aims. The aim of this retrospective study was to compare the correction achieved using a convex pedicle screw technique and a low implant density achieved using periapical concave-sided screws and a high implant density. We hypothesized that there would be no difference in outcome between the two techniques. Methods. We retrospectively analyzed a series of 51 patients with a thoracic adolescent idiopathic scoliosis. There were 26 patients in the convex pedicle screw group who had screws implanted periapically (Group 2) and a control group of 25 patients with bilateral pedicle screws (Group 1). The patients’ charts were reviewed and pre- and postoperative radiographs evaluated. Postoperative patient-reported outcome measures (PROMs) were recorded. Results. The number of implants (14.5 vs 17.1) and the implant density (1.5 vs 1.9) were significantly lower in Group 2 (p < 0.001). Operating time was 27 minutes shorter in Group 2 than in Group 1, with a mean of 217 minutes (SD 50.5; 120 to 346). The duration of surgery per instrumented vertebra was reduced by 19% in Group 2 (p = 0.011). No statistical difference was found in the postoperative Cobb angle, vertebral rotation, the relative correction achieved, or postoperative PROMs. Conclusion. Despite a lower implant density and achieving correction through a convex rod, surgical correction of the Cobb angle and vertebral body rotation was similar in both groups. Periapical pedicle screws and primary correction on the concave side do not seem to be mandatory in order to achieve good surgical results in idiopathic thoracic scoliosis. The operating time was shorter in the group with lower implant density. In conclusion, the technique provided good results and has the potential to reduce complications and costs. Cite this article: Bone Joint J 2021;103-B(3):536–541

Aims. The aim of this study was to investigate whether intraoperative 3D fluoroscopic imaging outperforms dorsal tangential views in the detection of dorsal cortex screw penetration after volar plating of an intra-articular distal radial fracture, as identified on postoperative CT imaging. Methods. A total of 165 prospectively enrolled patients who underwent volar plating for an intra-articular distal radial fracture were retrospectively evaluated to study three intraoperative imaging protocols: 1) standard 2D fluoroscopic imaging with anteroposterior (AP) and elevated lateral images (n = 55); 2) 2D fluoroscopic imaging with AP, lateral, and dorsal tangential views images (n = 50); and 3) 3D fluoroscopy (n = 60). Multiplanar reconstructions of postoperative CT scans served as the reference standard. Results. In order to detect dorsal screw penetration, the sensitivity of dorsal tangential views was 39% with a negative predictive value (NPV) of 91% and an accuracy of 91%; compared with a sensitivity of 25% for 3D fluoroscopy with a NPV of 93% and an accuracy of 93%. On the postoperative CT scans, we found penetrating screws in: 1) 40% of patients in the 2D fluoroscopy group; 2) in 32% of those in the 2D fluoroscopy group with AP, lateral, and dorsal tangential views; and 3) in 25% of patients in the 3D fluoroscopy group. In all three groups, the second compartment was prone to penetration, while the postoperative incidence decreased when more advanced imaging was used. There were no penetrating screws in the third compartment (extensor pollicis longus groove) in the 3D fluoroscopy groups, and one in the dorsal tangential views group. Conclusion. Advanced intraoperative imaging helps to identify screws which have penetrated the dorsal compartments of the wrist. However, based on diagnostic performance characteristics, one cannot conclude that 3D fluoroscopy outperforms dorsal tangential views when used for this purpose. Dorsal tangential views are sufficiently accurate to detect dorsal screw penetration, and arguably more efficacious than 3D fluoroscopy. Cite this article: Bone Joint J 2020;102-B(7):874–880

Aims. The aim of this study was to explore why some calcar screws are malpositioned when a proximal humeral fracture is treated by internal fixation with a locking plate, and to identify risk factors for this phenomenon. Some suggestions can be made of ways to avoid this error. Methods. We retrospectively identified all proximal humeral fractures treated in our institution between October 2016 and October 2018 using the hospital information system. The patients’ medical and radiological data were collected, and we divided potential risk factors into two groups: preoperative factors and intraoperative factors. Preoperative factors included age, sex, height, weight, body mass index, proximal humeral bone mineral density, type of fracture, the condition of the medial hinge, and medial metaphyseal head extension. Intraoperative factors included the grade of surgeon, neck-shaft angle after reduction, humeral head height, restoration of medial support, and quality of reduction. Adjusted binary logistic regression and multivariate logistic regression models were used to identify pre- and intraoperative risk factors. Area under the curve (AUC) analysis was used to evaluate the discriminative ability of the multivariable model. Results. Data from 203 patients (63 males and 140 females) with a mean age of 62 years (22 to 89) were analyzed. In 49 fractures, the calcar screw was considered to be malpositioned; in 154 it was in the optimal position. The rate of malpositioning was therefore 24% (49/203). No preoperative risk factor was found for malpositioning of the calcar screws. Only the neck-shaft angle was found to be related to the risk of screw malpositioning in a multivariate model (with an AUC of 0.72). For the fractures in which the neck-shaft angle was reduced to between 130° and 150°, 91% (133/46) of calcar screws were in the optimal position. Conclusion. The neck-shaft angle is the key factor for the appropriate positioning of calcar screws when treating a proximal humeral fracture with a locking plate. We recommend reducing the angle to between 130° and 150°. Cite this article: Bone Joint J 2020;102-B(12):1629–1635

Aims. The aim of this study was to evaluate whether, after correction of an adolescent idiopathic scoliosis (AIS), leaving out the subfascial drain gives results that are no worse than using a drain in terms of total blood loss, drop in haemoglobin level, and opioid consumption. Methods. Adolescents (aged between 10 and 21 years) with an idiopathic scoliosis (major curve ≥ 45°) were eligible for inclusion in this randomized controlled noninferiority trial (n = 125). A total of 90 adolescents who had undergone segmental pedicle screw instrumentation were randomized into no-drain or drain groups at the time of wound closure using the sealed envelope technique (1:1). The primary outcome was a drop in the haemoglobin level during first three postoperative days. Secondary outcomes were 48-hour postoperative oxycodone consumption and surgical complications. Results. All 90 patients were included in the primary outcome analysis (no drain = 43; drain = 47). The mean total postoperative blood loss (intraoperative and drain output) was significantly higher in the group with a subfascial drain than in the no-drain group (1,008 ml (SD 520) vs 631 ml (SD 518); p < 0.001). The drop in haemoglobin level did not differ between the study groups over the postoperative timepoints (p = 0.290). The 48-hour opioid consumption was significantly higher in the no-drain group (2.0 mg/kg (SD 0.9) vs 1.4 (SD 0.6); p = 0.005). Two patients in the no-drain and one patient in the drain group developed a surgical site infection. Conclusion. Leaving the subfascial drain out after pedicle screw instrumentation for AIS is not associated with higher postoperative haemoglobin levels. Patients treated without a subfascial drain needed 30% more opioids during the first 48 hours than those who had a drain. Cite this article: Bone Joint J 2022;104-B(9):1067–1072

Bone weakness leading to refracture is a recognised complication of the removal of rigid fixation plates. We have used partially demineralised rabbit tibiae to simulate atrophic changes and to determine whether weakness is due to atrophy or to residual screw holes. Partial demineralisation and a screw hole each reduced maximum bending moment. However, energy absorbing capacity was little affected by demineralisation, but was reduced to 50% by a single drill hole. Residual screw holes are a considerably more important cause of bone weakness after plate removal than is cortical atrophy

In a prospective observational study we compared the two-year outcome of lumbar fusion by a simple technique using translaminar screws (n = 57) with a more extensive method using transforaminal lumbar interbody fusion and pedicular screw fixation (n = 63) in consecutive patients with degenerative disease of the lumbar spine. Outcome was assessed using the validated multidimensional Core Outcome Measures Index. Blood loss and operating time were significantly lower in the translaminar screw group (p < 0.01). The complication rates were similar in each group (2% to 4%). In all, 91% of the patients returned their questionnaire at two-years. The groups did not differ in Core Outcome Measures Index score reduction, 3.6 (. sd. 2.5) (translaminar screws) vs 4.0 (. sd. 2.8) (transforaminal lumbar interbody fusion) (p = 0.39); ‘good’ global outcomes, 78% (translaminar screws) vs 78% (transforaminal lumbar interbody fusion) (p = 0.99) or satisfaction with treatment, 82% (translaminar screws) vs 86% (transforaminal lumbar interbody fusion) (p = 0.52). The two fusion techniques differed markedly in their extent and the cost of the implants, but were associated with almost identical patient-orientated outcomes. Extensive three-point stabilisation is not always required to achieve satisfactory patient-orientated results at two years

Intramedullary nailing of metaphyseal fractures may be associated with deformity as a result of instability after fixation. Our aim was to evaluate the clinical use of Poller screws (blocking screws) as a supplement to stability after fixation with statically locked intramedullary nails of small diameter. We studied, prospectively, 21 tibial fractures, 10 in the proximal third and 11 in the distal third in 20 patients after the insertion of Poller screws over a mean period of 18.5 months (12 to 29). All fractures had united. Healing was evident radiologically at a mean of 5.4 ± 2.1 months (3 to 12) with a mean varus-valgus alignment of −1.0° (−5 to 3) and mean antecurvatum-recurvatum alignment of 1.6° (−6 to 11). The mean loss of reduction between placement of the initial Poller screw and follow-up was 0.5° in the frontal plane and 0.4° in the sagittal plane. There were no complications related to the Poller screw. The clinical outcome, according to the Karström-Olerud score, was not influenced by previous or concomitant injuries in 18 patients and was judged as excellent in three (17%), good in seven (39%), satisfactory in six (33%), fair in one (6%), and poor in one (6%)

Aims. The aim of this study was to investigate if there are differences in outcome between sliding hip screws (SHSs) and intramedullary nails (IMNs) with regard to fracture stability. Methods. We assessed data from 17,341 patients with trochanteric or subtrochanteric fractures treated with SHS or IMN in the Norwegian Hip Fracture Register from 2013 to 2019. Primary outcome measures were reoperations for stable fractures (AO Foundation/Orthopaedic Trauma Association (AO/OTA) type A1) and unstable fractures (AO/OTA type A2, A3, and subtrochanteric fractures). Secondary outcome measures were reoperations for A2, A3, and subtrochanteric fractures individually, one-year mortality, quality of life (EuroQol five-dimension three-level index score), pain (visual analogue scale (VAS)), and satisfaction (VAS) for stable and unstable fractures. Hazard rate ratios (HRRs) for reoperation were calculated using Cox regression analysis with adjustments for age, sex, and American Society of Anesthesiologists score. Results. Reoperation rate was lower after surgery with IMN for unstable fractures one year (HRR 0.82, 95% confidence interval (CI) 0.70 to 0.97; p = 0.022) and three years postoperatively (HRR 0.86, 95% CI 0.74 to 0.99; p = 0.036), compared with SHS. For individual fracture types, no clinically significant differences were found. Lower one-year mortality was found for IMN compared with SHS for stable fractures (HRR 0.87; 95% CI 0.78 to 0.96; p = 0.007), and unstable fractures (HRR 0.91, 95% CI 0.84 to 0.98; p = 0.014). Conclusion. This national register-based study indicates a lower reoperation rate for IMN than SHS for unstable trochanteric and subtrochanteric fractures, but not for stable fractures or individual fracture types. The choice of implant may not be decisive to the outcome of treatment for stable trochanteric fractures in terms of reoperation rate. One-year mortality rate for unstable and stable fractures was lower in patients treated with IMN. Cite this article: Bone Joint J 2022;104-B(2):274–282

The AO Foundation advocates the use of partially threaded lag screws in the fixation of fractures of the medial malleolus. However, their threads often bypass the radiodense physeal scar of the distal tibia, possibly failing to obtain more secure purchase and better compression of the fracture. We therefore hypothesised that the partially threaded screws commonly used to fix a medial malleolar fracture often provide suboptimal compression as a result of bypassing the physeal scar, and proposed that better compression of the fracture may be achieved with shorter partially threaded screws or fully threaded screws whose threads engage the physeal scar. We analysed compression at the fracture site in human cadaver medial malleoli treated with either 30 mm or 45 mm long partially threaded screws or 45 mm fully threaded screws. The median compression at the fracture site achieved with 30 mm partially threaded screws (0.95 kg/cm. 2. (interquartile range (IQR) 0.8 to 1.2) and 45 mm fully threaded screws (1.0 kg/cm. 2 . (IQR 0.7 to 2.8)) was significantly higher than that achieved with 45 mm partially threaded screws (0.6 kg/cm. 2. (IQR 0.2 to 0.9)) (p = 0.04 and p < 0.001, respectively). The fully threaded screws and the 30mm partially threaded screws were seen to engage the physeal scar under an image intensifier in each case. The results support the use of 30 mm partially threaded or 45 mm fully threaded screws that engage the physeal scar rather than longer partially threaded screws that do not. A 45 mm fully threaded screw may in practice offer additional benefit over 30 mm partially threaded screws in increasing the thread count in the denser paraphyseal region. Cite this article: Bone Joint J 2013;95-B:1662–6

Aims. In approximately 20% of patients with ankle fractures, there is an concomitant injury to the syndesmosis which requires stabilisation, usually with one or more syndesmotic screws. The aim of this review is to evaluate whether removal of the syndesmotic screw is required in order for the patient to obtain optimal functional recovery. Materials and Methods. A literature search was conducted in Medline, Embase and the Cochrane Library for articles in which the syndesmotic screw was retained. Articles describing both removal and retaining of syndesmotic screws were included. Excluded were biomechanical studies, studies not providing patient related outcome measures, case reports, studies on skeletally immature patients and reviews. No restrictions regarding year of publication and language were applied. Results. A total of 329 studies were identified, of which nine were of interest, and another two articles were added after screening the references. In all, two randomised controlled trials (RCT) and nine case-control series were found. The two RCTs found no difference in functional outcome between routine removal and retaining the syndesmotic screw. All but one of the case-control series found equal or better outcomes when the syndesmotic screw was retained. However, all included studies had substantial methodological flaws. Conclusions. The currently available literature does not support routine elective removal of syndesmotic screws. However, the literature is of insufficient quality to be able to draw definitive conclusions. Secondary procedures incur a provider and institutional cost and expose the patient to the risk of complications. Therefore, in the absence of high quality evidence there appears to be little justification for routine removal of syndesmotic screws. Cite this article: Bone Joint J 2016;98-B:1497–1504

Aims. This study aimed to compare mortality in trochanteric AO/OTA A1 and A2 fractures treated with an intramedullary nail (IMN) or sliding hip screw (SHS). The primary endpoint was 30-day mortality, with secondary endpoints at 0 to 1, 2 to 7, 8 to 30, 90, and 365 days. Methods. We analyzed data from 26,393 patients with trochanteric AO/OTA A1 and A2 fractures treated with IMNs (n = 9,095) or SHSs (n = 17,298) in the Norwegian Hip Fracture Register (January 2008 to December 2020). Exclusions were made for patients aged < 60 years, pathological fractures, pre-2008 operations, contralateral hip fractures, fractures other than trochanteric A1/A2, and treatments other than IMNs or SHSs. Kaplan-Meier and Cox regression analyses adjusted for type of fracture, age, sex, cognitive impairment, American Society of Anesthesiologists (ASA) grade, and time period were conducted, along with calculations for number needed to harm (NNH). Results. In unadjusted analyses, there was no significant difference between IMN and SHS patient survival at 30 days (91.8% vs 91.1%; p = 0.083) or 90 days (85.4% vs 84.5%; p = 0.065), but higher one-year survival for IMNs (74.5% vs 73.3%; p = 0.031) compared with SHSs. After adjustments, no significant difference in 30-day mortality was found (hazard rate ratio (HRR) 0.94 (95% confidence interval (CI) 0.86 to 1.02(; p = 0.146). IMNs exhibited higher mortality at 0 to 1 days (HRR 1.63 (95% CI 1.13 to 2.34); p = 0.009) compared with SHSs, with a NNH of 556, but lower mortality at 8 to 30 days (HRR 0.89 (95% CI 0.80 to 1.00); p = 0.043). No differences were observed in mortality at 2 to 7 days (HRR 0.94 (95% CI 0.79 to 1.11); p = 0.434), 90 days (HRR 0.95 (95% CI 0.89 to 1.02); p = 0.177), or 365 days (HRR 0.97 (95% CI 0.92 to 1.02); p = 0.192). Conclusion. This study found no difference in 30-day mortality between IMNs and SHSs. However, IMNs were associated with a higher mortality at 0 to 1 days and a marginally lower mortality at 8 to 30 days compared with SHSs. The observed differences in mortality were small and should probably not guide choice of treatment. Cite this article: Bone Joint J 2024;106-B(6):603–612

Aims. We present the results of correcting a double or triple curve adolescent idiopathic scoliosis using a convex segmental pedicle screw technique. Patients and Methods. We reviewed 191 patients with a mean age at surgery of 15 years (11 to 23.3). Pedicle screws were placed at the convexity of each curve. Concave screws were inserted at one or two cephalad levels and two caudal levels. The mean operating time was 183 minutes (132 to 276) and the mean blood loss 0.22% of the total blood volume (0.08% to 0.4%). Multimodal monitoring remained stable throughout the operation. The mean hospital stay was 6.8 days (5 to 15). Results. The mean post-operative follow-up was 5.8 years (2.5 to 9.5). There were no neurological complications, deep wound infection, obvious nonunion or need for revision surgery. Upper thoracic scoliosis was corrected by a mean 68.2% (38% to 48%, p < 0.001). Main thoracic scoliosis was corrected by a mean 71% (43.5% to 8.9%, p < 0.001). Lumbar scoliosis was corrected by a mean 72.3% (41% to 90%, p < 0.001). No patient lost more than 3° of correction at follow-up. The thoracic kyphosis improved by 13.1° (-21° to 49°, p < 0.001); the lumbar lordosis remained unchanged (p = 0.58). Coronal imbalance was corrected by a mean 98% (0% to 100%, p < 0.001). Sagittal imbalance was corrected by a mean 96% (20% to 100%, p < 0.001). The Scoliosis Research Society Outcomes Questionnaire score improved from a mean 3.6 to 4.6 (2.4 to 4, p < 0.001); patient satisfaction was a mean 4.9 (4.8 to 5). . Conclusions. This technique carries low neurological and vascular risks because the screws are placed in the pedicles of the convex side of the curve, away from the spinal cord, cauda equina and the aorta. A low implant density (pedicle screw density 1.2, when a density of 2 represents placement of pedicle screws bilaterally at every instrumented segment) achieved satisfactory correction of the scoliosis, an improved thoracic kyphosis and normal global sagittal balance. Both patient satisfaction and functional outcomes were excellent. Cite this article: Bone Joint J 2017;99-B:1080–7

Aims. This study evaluated variation in the surgical treatment of stable (A1) and unstable (A2) trochanteric hip fractures among an international group of orthopaedic surgeons, and determined the influence of patient, fracture, and surgeon characteristics on choice of implant (intramedullary nailing (IMN) versus sliding hip screw (SHS)). Methods. A total of 128 orthopaedic surgeons in the Science of Variation Group evaluated radiographs of 30 patients with Type A1 and A2 trochanteric hip fractures and indicated their preferred treatment: IMN or SHS. The management of Type A3 (reverse obliquity) trochanteric fractures was not evaluated. Agreement between surgeons was calculated using multirater kappa. Multivariate logistic regression models were used to assess whether patient, fracture, and surgeon characteristics were independently associated with choice of implant. Results. The overall agreement between surgeons on implant choice was fair (kappa = 0.27 (95% confidence interval (CI) 0.25 to 0.28)). Factors associated with preference for IMN included USA compared to Europe or the UK (Europe odds ratio (OR) 0.56 (95% CI 0.47 to 0.67); UK OR 0.16 (95% CI 0.12 to 0.22); p < 0.001); exposure to IMN only during training compared to surgeons that were exposed to both (only IMN during training OR 2.6 (95% CI 2.0 to 3.4); p < 0.001); and A2 compared to A1 fractures (Type A2 OR 10 (95% CI 8.4 to 12); p < 0.001). Conclusion. In an international cohort of orthopaedic surgeons, there was a large variation in implant preference for patients with A1 and A2 trochanteric fractures. This is due to surgeon bias (country of practice and aspects of training). The observation that surgeons favoured the more expensive implant (IMN) in the absence of convincing evidence of its superiority suggests that surgeon de-biasing strategies may be a useful focus for optimizing patient outcomes and promoting value-based healthcare. Cite this article: Bone Joint J 2021;103-B(4):775–781

Aims. We compared the accuracy, operating time and radiation exposure of the introduction of iliosacral screws using O-arm/Stealth Navigation and standard fluoroscopy. Materials and Methods. Iliosacral screws were introduced percutaneously into the first sacral body (S1) of ten human cadavers, four men and six women. The mean age was 77 years (58 to 85). Screws were introduced using a standard technique into the left side of S1 using C-Arm fluoroscopy and then into the right side using O-Arm/Stealth Navigation. The radiation was measured on the surgeon by dosimeters placed under a lead thyroid shield and apron, on a finger, a hat and on the cadavers. Results. There were no neuroforaminal breaches in either group. The set-up time for the O-Arm was significantly longer than for the C-Arm, while total time for placement of the screws was significantly shorter for the O-Arm than for the C-Arm (p = 0.001). The mean absorbed radiation dose during fluoroscopy was 1063 mRad (432.5 mRad to 4150 mRad). No radiation was detected on the surgeon during fluoroscopy, or when he left the room during the use of the O-Arm. The mean radiation detected on the cadavers was significantly higher in the O-Arm group (2710 mRem standard deviation (. sd. ) 1922) than during fluoroscopy (11.9 mRem . sd 14.8). (p < 0.01). Conclusion. O-Arm/Stealth Navigation allows for faster percutaneous placement of iliosacral screws in a radiation-free environment for surgeons, albeit with the same accuracy and significantly more radiation exposure to cadavers, when compared with standard fluoroscopy. Take home message: Placement of iliosacral screws with O-Arm/Stealth Navigation can be performed safely and effectively. Cite this article: Bone Joint J 2016;98-B:696–702

We undertook a retrospective study investigating the accuracy and safety of percutaneous pedicle screws placed under fluoroscopic guidance in the lumbosacral junction and lumbar spine. The CT scans of patients were chosen from two centres: European patients from University Medical Center Hamburg-Eppendorf, Germany, and Asian patients from the University of Malaya, Malaysia. Screw perforations were classified into grades 0, 1, 2 and 3. A total of 880 percutaneous pedicle screws from 203 patients were analysed: 614 screws from 144 European patients and 266 screws from 59 Asian patients. The mean age of the patients was 58.8 years (16 to 91) and there were 103 men and 100 women. The total rate of perforation was 9.9% (87 screws) with 7.4% grade 1, 2.0% grade 2 and 0.5% grade 3 perforations. The rate of perforation in Europeans was 10.4% and in Asians was 8.6%, with no significant difference between the two (p = 0.42). The rate of perforation was the highest in S1 (19.4%) followed by L5 (14.9%). The accuracy and safety of percutaneous pedicle screw placement are comparable to those cited in the literature for the open method of pedicle screw placement. Greater caution must be taken during the insertion of L5 and S1 percutaneous pedicle screws owing to their more angulated pedicles, the anatomical variations in their vertebral bodies and the morphology of the spinal canal at this location. Cite this article: Bone Joint J 2015; 97-B:1111–17

Aims. We aimed to retrospectively assess the accuracy and safety of CT navigated pedicle screws and to compare accuracy in the cervical and thoracic spine (C2-T8) with (COMB) and without (POST) prior anterior surgery (anterior cervical discectomy or corpectomy and fusion with ventral plating: ACDF/ACCF). Patients and Methods. A total of 592 pedicle screws, which were used in 107 consecutively operated patients (210 COMB, 382 POST), were analysed. The accuracy of positioning was determined according to the classification of Gertzbein and Robbins on post-operative CT scans. Results. High accuracy was achieved in 524 screws (88.5%), 192 (87.7%) in the cervical spine and 332 (89%) in the thoracic spine, respectively. The results in the two surgical groups were compared and a logistic regression mixed model was performed to analyse the risk of low accuracy. Significantly lower accuracy was found in the COMB group with 82.9% versus 91.6% in the POST group (p = 0.036). There were no neurological complications, but two vertebral artery lesions were recorded. Three patients underwent revision surgery for malpositioning of a screw. Although the risk of malpositioning of a screw after primary anterior surgery was estimated to be 2.4-times higher than with posterior surgery alone, the overall rates of complication and revision were low. Conclusion. We therefore conclude that CT navigated pedicle screws can be positioned safely although greater caution must be taken in patients who have previously undergone anterior surgery. Cite this article: Bone Joint J 2017;99-B:1373–80

Aims. The aim of this study was to investigate the association between the type of operation used to treat a trochanteric fracture of the hip and 30-day mortality. Patients and Methods. Data on 82 990 patients from the National Hip Fracture Database were analyzed using generalized linear models with incremental case-mix adjustment for patient, non-surgical and surgical characteristics, and socioeconomic factors. Results. The use of short and long intramedullary nails was associated with an increase in 30-day mortality (adjusted odds ratio (OR) 1.125, 95% confidence interval (CI) 1.040 to 1.218; p = 0.004) compared with the use of sliding hip screws (12.5% increase). If this were causative, it would represent 98 excess deaths over the four-year period of the study and one excess death would be caused by treating 112 patients with an intramedullary nail rather than a sliding hip screw. Conclusion. There is a 12.5% increase in the risk of 30-day mortality associated with the use of an intramedullary nail compared with a sliding hip screw in the treatment of a trochanteric fractures of the hip

The aim of this biomechanical study was to investigate the role of the dorsal vertebral cortex in transpedicular screw fixation. Moss transpedicular screws were introduced into both pedicles of each vertebra in 25 human cadaver vertebrae. The dorsal vertebral cortex and subcortical bone corresponding to the entrance site of the screw were removed on one side and preserved on the other. Biomechanical testing showed that the mean peak pull-out strength for the inserted screws, following removal of the dorsal cortex, was 956.16 N. If the dorsal cortex was preserved, the mean peak pullout strength was 1295.64 N. The mean increase was 339.48 N (26.13%; p = 0.033). The bone mineral density correlated positively with peak pull-out strength. Preservation of the dorsal vertebral cortex at the site of insertion of the screw offers a significant increase in peak pull-out strength. This may result from engagement by the final screw threads in the denser bone of the dorsal cortex and the underlying subcortical area. Every effort should be made to preserve the dorsal vertebral cortex during insertion of transpedicular screws

Ventral screw osteosynthesis is a common surgical method for treating fractures of the odontoid peg, but there is still no consensus about the number and diameter of the screws to be used. The purpose of this study was to develop a more accurate measurement technique for the morphometry of the odontoid peg (dens axis) and to provide a recommendation for ventral screw osteosynthesis. Images of the cervical spine of 44 Caucasian patients, taken with a 64-line CT scanner, were evaluated using the measuring software MIMICS. All measurements were performed by two independent observers. Intraclass correlation coefficients were used to measure inter-rater variability. The mean length of the odontoid peg was 39.76 mm (. sd. 2.68). The mean screw entry angle α was 59.45° (. sd. 3.45). The mean angle between the screw and the ventral border of C2 was 13.18° (. sd. 2.70), the maximum possible mean converging angle of two screws was 20.35° (. sd. 3.24). The measurements were obtained at the level of 66% of the total odontoid peg length and showed mean values of 8.36 mm (. sd. 0.84) for the inner diameter in the sagittal plane and 7.35 mm (. sd. 0.97) in the coronal plane. The mean outer diameter of the odontoid peg was 12.88 mm (. sd. 0.91) in the sagittal plane and 11.77 mm (. sd. 1.09) in the coronal plane. The results measured at the level of 90% of the total odontoid peg length were a mean of 6.12 mm (. sd. 1.14) for the sagittal inner diameter and 5.50 mm (. sd. 1.05) for the coronal inner diameter. The mean outer diameter of the odontoid peg was 11.10 mm (. sd.  1.0) in the sagittal plane and 10.00 mm (. sd. 1.07) in the coronal plane. In order to calculate the necessary screw length using 3.5 mm cannulated screws, 1.5 mm should be added to the measured odontoid peg length when anatomical reduction seems possible. The cross-section of the odontoid peg is not circular but slightly elliptical, with a 10% greater diameter in the sagittal plane. In the majority of cases (70.5%) the odontoid peg offers enough room for two 3.5 mm cannulated cortical screws. Cite this article: Bone Joint J 2013;95-B:536–42

Percutaneous placement of pedicle screws is a well-established technique, however, no studies have compared percutaneous and open placement of screws in the thoracic spine. The aim of this cadaveric study was to compare the accuracy and safety of these techniques at the thoracic spinal level. A total of 288 screws were inserted in 16 (eight cadavers, 144 screws in percutaneous and eight cadavers, 144 screws in open). Pedicle perforations and fractures were documented subsequent to wide laminectomy followed by skeletalisation of the vertebrae. The perforations were classified as grade 0: no perforation, grade 1: < 2 mm perforation, grade 2: 2 mm to 4 mm perforation and grade 3: > 4 mm perforation. In the percutaneous group, the perforation rate was 11.1% with 15 (10.4%) grade 1 and one (0.7%) grade 2 perforations. In the open group, the perforation rate was 8.3% (12 screws) and all were grade 1. This difference was not significant (p = 0.45). There were 19 (13.2%) pedicle fractures in the percutaneous group and 21 (14.6%) in the open group (p = 0.73). In summary, the safety of percutaneous fluoroscopy-guided pedicle screw placement in the thoracic spine between T4 and T12 is similar to that of the conventional open technique. Cite this article: Bone Joint J 2015;97-B:1555–61

We reviewed 212 consecutive patients with adolescent idiopathic scoliosis who underwent posterior spinal arthrodesis using all pedicle screw instrumentation in terms of clinical, radiological and Scoliosis Research Society (SRS)-22 outcomes. In Group 1 (51 patients), the correction was performed over two rods using bilateral segmental pedicle screws. In Group 2 (161 patients), the correction was performed over one rod using unilateral segmental pedicle screws with the second. rod providing stability of the construct through two-level screw fixation at proximal and distal ends. The mean age at surgery was 14.8 years in both groups. Comparison between groups showed no significant differences with regard to age and Risser grade at surgery, pre- and post-operative scoliosis angle, coronal Cobb correction, length of hospital stay and SRS scores. Correction of upper thoracic curves was significantly better in Group 1 (p = 0.02). Increased surgical time and intra-operative blood loss was recorded in Group 1 (p < 0.001 and p = 0.04, respectively). The implant cost was reduced by mean 35% in Group 2 due to the lesser number of pedicle screws. Unilateral and bilateral pedicle screw techniques have both achieved excellent deformity correction in adolescent patients with idiopathic scoliosis, which was maintained at two-year follow-up. This has been associated with high patient satisfaction and low complication rates

We reviewed the outcome of a retrospective case series of eight patients with atlantoaxial instability who had been treated by percutaneous anterior transarticular screw fixation and grafting under image-intensifier guidance between December 2005 and June 2008. The mean follow-up was 19 months (8 to 27). All eight patients had a solid C1–2 fusion. There were no breakages or displacement of screws. All the patients with pre-operative neck pain had immediate relief from their symptoms or considerable improvement. There were no major complications. Our preliminary clinical results suggest that percutaneous anterior transarticulation screw fixation is technically feasible, safe, useful and minimally invasive when using the appropriate instruments allied to intra-operative image intensification, and by selecting the correct puncture point, angle and depth of insertion

We investigated the static and cyclical strength of parallel and angulated locking plate screws using rigid polyurethane foam (0.32 g/cm. 3. ) and bovine cancellous bone blocks. Custom-made stainless steel plates with two conically threaded screw holes with different angulations (parallel, 10° and 20° divergent) and 5 mm self-tapping locking screws underwent pull-out and cyclical pull and bending tests. The bovine cancellous blocks were only subjected to static pull-out testing. We also performed finite element analysis for the static pull-out test of the parallel and 20° configurations. In both the foam model and the bovine cancellous bone we found the significantly highest pull-out force for the parallel constructs. In the finite element analysis there was a 47% more damage in the 20° divergent constructs than in the parallel configuration. Under cyclical loading, the mean number of cycles to failure was significantly higher for the parallel group, followed by the 10° and 20° divergent configurations. In our laboratory setting we clearly showed the biomechanical disadvantage of a diverging locking screw angle under static and cyclical loading

We compared a new fixation system, the Targon Femoral Neck (TFN) hip screw, with the current standard treatment of cannulated screw fixation. This was a single-centre, participant-blinded, randomised controlled trial. Patients aged 65 years and over with either a displaced or undisplaced intracapsular fracture of the hip were eligible. The primary outcome was the risk of revision surgery within one year of fixation. A total of 174 participants were included in the trial. The absolute reduction in risk of revision was of 4.7% (95% CI 14.2 to 22.5) in favour of the TFN hip screw (chi-squared test, p = 0.741), which was less than the pre-specified level of minimum clinically important difference. There were no significant differences in any of the secondary outcome measures. We found no evidence of a clinical difference in the risk of revision surgery between the TFN hip screw and cannulated screw fixation for patients with an intracapsular fracture of the hip. Cite this article: Bone Joint J 2014;96-B:652–7

We investigated the effects of hydroxyapatite (HA) coating on the purchase of pedicle screws. A total of 23 consecutive patients undergoing lumbar fusion was randomly assigned to one of three treatment groups. The first received uncoated stainless-steel screws, the second screws which were partly coated with HA, and the third screws which were fully coated. The insertion torque was recorded. After 11 to 16 months, 21 screws had been extracted. The extraction torque was recorded. Radiographs were taken to assess fusion and to detect loosening of the screws. At removal, the extraction torques exceeded the upper limit of the torque wrench (600 Ncm) for many HA-coated screws. The calculated mean extraction torque was 29 ± 36 Ncm for the uncoated group, 447 ± 114 Ncm for the partly-coated group and 574 ± 52 Ncm for the fully-coated group. There were significant differences between all three groups (p < 0.001). There were more radiolucent zones surrounding the uncoated screws than the HA-coated screws (p < 0.001). HA coating of pedicle screws resulted in improved fixation with reduced risk of loosening of the screws

We compared the strength of fixation of a biodegradable screw with that of two metal screws in a bone-patellar-tendon-bone (BPTB) graft in the bovine knee. We used 33 fresh BPTB specimens with a circular tibial bone plug of 9 mm in diameter which were anchored in a tibial metaphyseal bone tunnel with either an interference screw (n = 11), an AO cancellous screw (n = 11) or a fibrillated, self-reinforced biodegradable poly-L-lactide screw (n = 11). The mean force to failure (+/- SD) in the three groups was 1358 +/- 348 N, 1081 +/- 331 N and 1211 +/- 362 N, respectively. There was no significant difference in the groups with regard to the linear load or the elastic moduli of the fixation. We conclude that the biodegradable screw is as good as either of the two metal screws in the fixation of a BPTB graft in the bovine knee and can be recommended for ACL reconstruction using this type of graft

We retrospectively evaluated eight patients who underwent arthrodesis of the knee using cannulated screws. There were six women and two men, with a mean age of 53 years. The indications for arthrodesis were failed total knee arthroplasty, septic arthritis, tuberculosis, and recurrent persistent infection. Solid union was achieved in all patients at a mean of 6.1 months. One patient required autogenous bone graft for delayed union. One suffered skin necrosis which was treated with skin grafting. The mean limb-length discrepancy was 3.1 cm. On a visual analogue scale, the mean pain score improved from 7.9 to 3.3. According to the Knee Injury and Osteoarthritis Outcome score quality of life items, the mean score improved from 38.3 pre-operatively to 76.6 at follow-up. Cannulated screws provide a high rate of union in arthrodesis of the knee with minimal complications, patient convenience, and a simple surgical technique

Despite worldwide clinical use of bio-absorbable devices for internal fixation in orthopaedic surgery, the degradation behaviour and tissue replacement of these implants are not fully understood. In a long-term experimental study, we have determined the patterns of tissue restoration 36 and 54 months after implantation of polyglycolic acid and poly-laevo-lactic acid screws in the distal femur of the rabbit. After 36 months in the polyglycolic acid group the specimens showed no remaining polymer and loose connective tissue occupied 80% of the screw track. Tissue restoration remained poor at 54 months, the amounts of trabecular bone and haematopoietic elements being significantly lower than those in the intact control group. The amount of trabecular bone within the screw track at 54 months in the polyglycolic acid group was less than in the empty drill holes (p = 0.04). In the poly-laevo-lactic acid group, polymeric material was present in abundance after 54 months, occupying 60% of the cross-section of the core area of the screw track. When using absorbable internal fixation implants we should recognise that the degradation of the devices will probably not be accompanied by the restoration of normal trabecular bone

We examined the radiographs from a prospective clinical study of fixation by pedicle screws and those from an experimental study in a sheep model. In the clinical study, instruments were removed from 21 patients after implantation for 11 to 16 months and the extraction torques of the screws were recorded. A structured protocol was used for the radiological examinations. In the experimental study, loaded pedicle screw instrumentations were implanted in the sheep for six or 12 weeks. After radiological examination the pull-out resistance and the histological characteristics were studied. In the clinical study, all screws with radiolucent zones had a significantly reduced mean extraction torque compared with screws without radiolucent zones (16 ± 10 Ncm v 403 ± 220 Ncm; p < 0.0001). In the experimental study the mean maximum pull-out resistance for the screws with radiolucent zones was significantly lower than for those with no radiolucency (243 ± 156 N v 2214 ± 578 N; p = 0.0006) and the mean bone-to-screw contact was reduced for screws with zones compared with those without zones (8 ± 9% v 55 ± 29%; p = 0.0002). Our findings showed that all screws with radiolucent zones had low extraction torques or low pull-out resistance. A radiolucent zone is a good indicator of loosening of a pedicle screw

Different calcaneal plates with locked screws were compared in an experimental model of a calcaneal fracture. Four plate models were tested, three with uniaxially-locked screws (Synthes, Newdeal, Darco), and one with polyaxially-locked screws (90° ± 15°) (Rimbus). Synthetic calcanei were osteotomised to create a fracture model and then fixed with the plates and screws. Seven specimens for each plate model were subjected to cyclic loading (preload 20 N, 1000 cycles at 800 N, 0.75 mm/s), and load to failure (0.75 mm/s). During cyclic loading, the plate with polyaxially-locked screws (Rimbus) showed significantly lower displacement in the primary loading direction than the plates with uniaxially-locked screws (mean values of maximum displacement during cyclic loading: Rimbus, 3.13 mm (. sd. 0.68); Synthes, 3.46 mm (. sd. 1.25); Darco, 4.48 mm (. sd. 3.17); Newdeal, 5.02 mm (. sd. 3.79); one-way analysis of variance, p < 0.001). The increased stability of a plate with polyaxially-locked screws demonstrated during cyclic loading compared with plates with uniaxially-locked screws may be beneficial for clinical use

We compared the clinical, radiological and quality-of-life outcomes between hybrid and total pedicle screw instrumentation in patients undergoing surgery for neuromuscular scoliosis. A matched comparison using prospectively collected data was undertaken. A total of 66 patients underwent posterior or anteroposterior correction and fusion with hybrid (n = 33, mean age at surgery 15.8 years (9.10 to 19.6)) or total pedicle screw instrumentation (n = 33, mean age 14.7 years (7.0 to 20.7)) with a minimum follow-up of two years. The major curve pre-operatively was a mean of 87° (. sd. 29, 25° to 141°) and 81° (. sd. 18, 47° to 116°) in the hybrid and total pedicle screw groups, respectively (p = 0.29) and at a minimum of two years it was 33° (. sd. 20; 2° to 87°) and 20° (. sd. 12; 1° to 55°), respectively (p = 0.0016). The mean correction of the major curve was 59% (41% to 88%) in the hybrid and 75% (43% to 99%) in the total pedicle screw groups at two-year follow-up (p = 0.0011). The mean operating time was 7.45 hours (. sd. 2.18) and 6.04 hours (. sd. 1.71) in the hybrid and total pedicle screw groups, respectively (p = 0.001), and the mean intra-operative blood loss was 3760 ml (. sd.  2790) and 1785 ml (. sd. 1110), respectively (p = 0.001). Total pedicle screw instrumentation provided shorter operating times, less blood loss and better correction of the major curve compared with hybrid constructs in patients undergoing surgery for neuromuscular scoliosis

Transarticular screw fixation with autograft is an established procedure for the surgical treatment of atlantoaxial instability. Removal of the posterior arch of C1 may affect the rate of fusion. This study assessed the rate of atlantoaxial fusion using transarticular screws with or without removal of the posterior arch of C1. We reviewed 30 consecutive patients who underwent atlantoaxial fusion with a minimum follow-up of two years. In 25 patients (group A) the posterior arch of C1 was not excised (group A) and in five it was (group B). Fusion was assessed on static and dynamic radiographs. In selected patients CT imaging was also used to assess fusion and the position of the screws. There were 15 men and 15 women with a mean age of 51.2 years (23 to 77) and a mean follow-up of 7.7 years (2 to 11.6). Stable union with a solid fusion or a stable fibrous union was achieved in 29 patients (97%). In Group A, 20 patients (80%) achieved a solid fusion, four (16%) a stable fibrous union and one (4%) a nonunion. In Group B, stable union was achieved in all patients, three having a solid fusion and two a stable fibrous union. There was no statistically significant difference between the status of fusion in the two groups. Complications were noted in 12 patients (40%); these were mainly related to the screws, and included malpositioning and breakage. The presence of an intact or removed posterior arch of C1 did not affect the rate of fusion in patients with atlantoaxial instability undergoing C1/C2 fusion using transarticular screws and autograft. Cite this article: Bone Joint J 2013;95-B:972–6

Our aim was to compare polylevolactic acid screws with titanium screws when used for fixation of the distal tibiofibular syndesmosis at mid-term follow-up. A total of 168 patients, with a mean age of 38.5 years (18 to 72) who were randomly allocated to receive either polylevolactic acid (n = 86) or metallic (n = 82) screws were included. The Baird scoring system was used to assess the overall satisfaction and functional recovery post-operatively. The demographic details and characteristics of the injury were similar in the two groups. The mean follow-up was 55.8 months (48 to 66). The Baird scores were similar in the two groups at the final follow-up. Patients in the polylevolactic acid group had a greater mean dorsiflexion (p = 0.011) and plantar-flexion of the injured ankles (p < 0.001). In the same group, 18 patients had a mild and eight patients had a moderate foreign body reaction. In the metallic groups eight had mild and none had a moderate foreign body reaction (p <  0.001). In total, three patients in the polylevolactic acid group and none in the metallic group had heterotopic ossification (p = 0.246). We conclude that both screws provide adequate fixation and functional recovery, but polylevolactic acid screws are associated with a higher incidence of foreign body reactions. Cite this article: Bone Joint J 2014;96-B:548–54

Aims. In a randomized controlled trial with two-year follow-up, patients treated with suture button (SB) for acute syndesmotic injury had better outcomes than patients treated with syndesmotic screw (SS). The aim of this study was to compare clinical and radiological outcomes for these treatment groups after five years. Methods. A total of 97 patients with acute syndesmotic injury were randomized to SS or SB. The five-year follow-up rate was 81 patients (84%). The primary outcome was the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle Hindfoot Scale. Secondary outcome measures included Olerud-Molander Ankle (OMA) score, visual analogue scale (VAS), EuroQol five-dimension questionnaire (EQ-5D), range of movement, complications, reoperations, and radiological results. CT scans of both ankles were obtained after surgery, and after one, two, and five years. Results. The SB group had higher median AOFAS score (100 (interquartile range (IQR) 92 to 100) vs 90 (IQR 85 to 100); p = 0.006) and higher median OMA score (100 (IQR 95 to 100) vs 95 (IQR 75 to 100); p = 0.006). The SS group had a higher incidence of ankle osteoarthritis (OA) (24 (65%) vs 14 (35%), odds ratio (OR) 3.4 (95% confidence interval (CI) 1.3 to 8.8); p = 0.009). On axial CT we measured a significantly smaller mean difference in the anterior tibiofibular distance between injured and non-injured ankles in the SB group (–0.1 mm vs 1.2 mm; p = 0.016). Conclusion. Five years after syndesmotic injury treated with either SB or SS, we found better AOFAS and OMA scores, and lower incidence of ankle OA, in the SB group. These long-term results favour the use of SB when treating an acute syndesmotic injury. Cite this article: Bone Joint J 2020;102-B(2):212–219

Penetration of the dorsal screw when treating distal radius fractures with volar locking plates is an avoidable complication that causes lesions of the extensor tendon in between 2% and 6% of patients. We examined axial fluoroscopic views of the distal end of the radius to observe small amounts of dorsal screw penetration, and determined the ideal angle of inclination of the x-ray beam to the forearm when making this radiological view. Six volar locking plates were inserted at the wrists of cadavers. The actual screw length was measured under direct vision through a dorsal approach to the distal radius. Axial radiographs were performed for different angles of inclination of the forearm at the elbow. Comparing axial radiological measurements and real screw length, a statistically significant correlation could be demonstrated at an angle of inclination between 5° and 20°. The ideal angle of inclination required to minimise the risk of implanting over-long screws in a dorsal horizon radiological view is 15°. Cite this article: Bone Joint J 2013;95-B:1101–5

We treated 108 patients with a pertrochanteric femoral fracture using either the dynamic hip screw or the proximal femoral nail in this prospective, randomised series. We compared walking ability before fracture, intra-operative variables and return to their residence. Patients treated with the proximal femoral nail (n = 42) had regained their pre-operative walking ability significantly (p = 0.04) more often by the four-month review than those treated with the dynamic hip screw (n = 41). Peri-operative or immediate post-operative measures of outcome did not differ between the groups, with the exception of operation time. The dynamic hip screw allowed a significantly greater compression of the fracture during the four-month follow-up, but consolidation of the fracture was comparable between the two groups. Two major losses of reduction were observed in each group, resulting in a total of four revision operations. Our results suggest that the use of the proximal femoral nail may allow a faster postoperative restoration of walking ability, when compared with the dynamic hip screw

We have developed a hollow perforated cannulated screw. One or more of these was implanted percutaneously in 11 patients with an osteolytic metastasis in the femoral neck and multiple metastases elsewhere. They were supplemented by one or two additional standard 6.5 mm cannulated screws in nine patients. Polymethylmethacrylate bone cement was injected through the screw into the neck of the femur using small syringes, as in vertebroplasty. The mean amount of cement injected was 23.2 ml (17 to 30). Radiotherapy was started on the fourth post-operative day and chemotherapy, on average, was resumed a day later. Good structural stability and satisfactory relief from pain were achieved in all the patients. This technique may be useful in the palliation of metastases in the femoral neck

Fracture of a pedicle is a rare complication of spinal instrumentation using pedicular screws, but it can lead to instability and pain and may necessitate extension of the fusion. Osteosynthesis of the fractured pedicle by cerclage-wire fixation and augmentation of the screw fixation by vertebroplasty or temporary elongation of the fixation, allows stabilisation without sacrifice of the adjacent healthy segment. We describe three patients who developed a fracture of the pedicle in the most caudal instrumented vertebra early after lumbar spinal fusion. During revision surgery the pedicles were reduced and secured by a soft cerclage wire bilaterally. Fusion was obtained at the site of the primary instrumentation and healing of the pedicles was achieved. Cerclage wiring of the fractured pedicle seems to be safe and avoids permanent extension of the fusion without the sacrifice of an otherwise healthy segment

We investigated several factors which affect the stability of cortical screws in osteoporotic bone using 18 femora from cadavers of women aged between 45 and 96 years (mean 76). We performed bone densitometry to measure the bone mineral density of the cortical and cancellous bone of the shaft and head of the femur, respectively. The thickness and overall bone mass of the cortical layer of the shaft of the femur were measured using a microCT scanner. The force required to pull-out a 3.5 mm titanium cortical bone screw was determined after standardised insertion into specimens of the cortex of the femoral shaft. A significant correlation was found between the pull-out strength and the overall bone mass of the cortical layer (r. 2. = 0.867, p < 0.01) and also between its thickness (r. 2. = 0.826, p < 0.01) and bone mineral density (r. 2. = 0.861, p < 0.01). There was no statistically significant correlation between the age of the donor and the pull-out force (p = 0.246), the cortical thickness (p = 0.199), the bone mineral density (p = 0.697) or the level of osteoporosis (p = 0.378). We conclude that the overall bone mass, the thickness and the bone mineral density of the cortical layer, are the main factors which affect the stability of a screw in human female osteoporotic cortical bone

We describe the results of a prospective case series of patients with spondylolysis, evaluating a technique of direct stabilisation of the pars interarticularis with a construct that consists of a pair of pedicle screws connected by a U-shaped modular link passing beneath the spinous process. Tightening the link to the screws compresses bone graft in the defect in the pars, providing rigid intrasegmental fixation. We have carried out this procedure on 20 patients aged between nine and 21 years with a defect of the pars at L5, confirmed on CT. The mean age of the patients was 13.9 years (9 to 21). They had a grade I or less spondylolisthesis and no evidence of intervertebral degeneration on MRI. The mean follow-up was four years (2.3 to 7.3). The patients were assessed by the Oswestry Disability Index (ODI) and a visual analogue scale (VAS). At the latest follow-up, 18 patients had an excellent clinical outcome, with a significant (p < 0.001) improvement in their ODI and VAS scores. The mean ODI score at final follow-up was 8%. Assessment of the defect by CT showed a rate of union of 80%. There were no complications involving the internal fixation. The strength of the construct removes the need for post-operative immobilisation

We studied prospectively 30 patients who had a Mitchell’s osteotomy secured by either a suture followed by immobilisation in a plaster boot for six weeks, or by a cortical screw with early mobilisation. The mean time for return to social activities after fixation by a screw was 2.9 weeks and to work 4.9 weeks, which was significantly earlier than those who had stabilisation by a suture (5.7 and 8.7 weeks, respectively; p < 0.001). Use of a screw also produced a higher degree of patient satisfaction at six weeks, and an earlier return to wearing normal footwear. The improvement in forefoot scores was significantly greater after fixation by a screw at six weeks (p = 0.036) and three months (p = 0.024). At one year, two screws had been removed because of pain at the site of the screw head. Internal fixation of Mitchell’s osteotomy by a screw allows the safe early mobilisation of patients and reduces the time required for convalescence

In patients with osteoporosis there is always a strong possibility that pedicle screws will loosen. This makes it difficult to select the appropriate osteoporotic patient for a spinal fusion. The purpose of this study was to determine the correlation between bone mineral density (BMD) and the magnitude of torque required to insert a pedicle screw. To accomplish this, 181 patients with degenerative disease of the lumbar spine were studied prospectively. Each underwent dual-energy x-ray absorptiometry (DEXA) and intra-operative measurement of the torque required to insert each pedicle screw. The levels of torque generated in patients with osteoporosis and osteopenia were significantly lower than those achieved in normal patients. Positive correlations were observed between BMD and T-value at the instrumented lumbar vertebrae, mean BMD and mean T-value of the lumbar vertebrae, and mean BMD and mean T-value of the proximal femur. The predictive torque (Nm) generated during pedicle screw insertion was [-0.127 + 1.62 × (BMD at the corresponding lumbar vertebrae)], as measured by linear regression analysis. The positive correlation between BMD and the maximum torque required to insert a pedicle screw suggests that pre-operative assessment of BMD may be useful in determining the ultimate strength of fixation of a device, as well as the number of levels that need to be fixed with pedicle screws in patients who are suspected of having osteoporosis

Aims. Surgical treatment of hip fracture is challenging; the bone is porotic and fixation failure can be catastrophic. Novel implants are available which may yield superior clinical outcomes. This study compared the clinical effectiveness of the novel X-Bolt Hip System (XHS) with the sliding hip screw (SHS) for the treatment of fragility hip fractures. Methods. We conducted a multicentre, superiority, randomized controlled trial. Patients aged 60 years and older with a trochanteric hip fracture were recruited in ten acute UK NHS hospitals. Participants were randomly allocated to fixation of their fracture with XHS or SHS. A total of 1,128 participants were randomized with 564 participants allocated to each group. Participants and outcome assessors were blind to treatment allocation. The primary outcome was the EuroQol five-dimension five-level health status (EQ-5D-5L) utility at four months. The minimum clinically important difference in utility was pre-specified at 0.075. Secondary outcomes were EQ-5D-5L utility at 12 months, mortality, residential status, mobility, revision surgery, and radiological measures. Results. Overall, 437 and 443 participants were analyzed in the primary intention-to-treat analysis in XHS and SHS treatment groups respectively. There was a mean difference of 0.029 in adjusted utility index in favour of XHS with no evidence of a difference between treatment groups (95% confidence interval -0.013 to 0.070; p = 0.175). There was no evidence of any differences between treatment groups in any of the secondary outcomes. The pattern and overall risk of adverse events associated with both treatments was similar. Conclusion. Any difference in four-month health-related quality of life between the XHS and SHS is small and not clinically important. There was no evidence of a difference in the safety profile of the two treatments; both were associated with lower risks of revision surgery than previously reported. Cite this article: Bone Joint J 2021;103-B(2):256–263

Aims. To compare the outcomes for trochanteric fractures treated with a sliding hip screw (SHS) or a cephalomedullary nail. Patients and Methods. A total of 400 patients with a trochanteric hip fracture were randomised to receive a SHS or a cephalomedullary nail (Targon PFT). All surviving patients were followed up to one year from injury. Functional outcome was assessed by a research nurse blinded to the implant used. Results. Recovery of mobility, as assessed by a mobility scale, was superior for those treated with the intramedullary nail compared with the SHS at eight weeks, three and nine months (p-values between 0.01 and 0.04), the difference at six and 12 months was not statistically significant (p = 0.15 and p = 0.18 respectively). The mean difference was around 0.4 points (0.3 to 0.5) on a nine point scale. Surgical time for the nail was four minutes less than that for the SHS (p < 0.001). Fracture healing complications were similar for the two groups. There were no statistically significant differences between implants for any other recorded outcomes including the need for post-operative blood transfusion, wound healing complications, general medical complications, hospital stay or mortality. Conclusion. This study confirms the findings of a previous study that both methods of treatment produce similar results, although intramedullary fixation does result in marginally improved regain of mobility in comparison with the SHS. Cite this article: Bone Joint J 2017;99-B:1210–15

The spinal manifestations of neurofibromatosis include cervicothoracic kyphosis, in which scalloping of the vertebral body and erosion of the pedicles may render conventional techniques of fixation impossible. We describe a case of cervicothoracic kyphosis managed operatively with a vascularised fibular graft anteriorly across the apex of the kyphus, followed by a long posterior construct using translaminar screws, which allow segmental fixation in vertebral bodies where placement of the pedicle screws was impracticable

Our aim was to compare the one-year post-operative outcomes following retention or removal of syndesmotic screws in adult patients with a fracture of the ankle that was treated surgically. A total of 51 patients (35 males, 16 females), with a mean age of 33.5 years (16 to 62), undergoing fibular osteosynthesis and syndesmotic screw fixation, were randomly allocated to retention of the syndesmotic screw or removal at three months post-operatively. The two groups were comparable at baseline. . One year post-operatively, there was no significant difference in the mean Olerud–Molander ankle score (82.4 retention vs 86.7 removal, p = 0.367), the mean American Orthopedic Foot and Ankle Society ankle-hindfoot score (88.6 vs 90.1, p = 0.688), the mean American Academy of Orthopedic Surgeons foot and ankle score (96.3 vs 94.0, p = 0.250), the mean visual analogue pain score (1.0 vs 0.7, p = 0.237), the mean active dorsiflexion (10.2° vs 13.0°, p = 0.194) and plantar flexion (33.6° vs 31.3°, p = 0.503) of the ankle, or the mean radiological tibiofibular clear space (5.0 mm vs 5.3 mm, p = 0.276) between the two groups. A total of 19 patients (76%) in the retention group had a loose and/or broken screw one year post-operatively. . We conclude that removal of a syndesmotic screw produces no significant functional, clinical or radiological benefit in adult patients who are treated surgically for a fracture of the ankle. Cite this article: Bone Joint J 2014;96-B:1699–1705

Several authors have reported complications from screw removal after treatment of slipped upper femoral epiphysis by single screw fixation, and have attributed these to poor screw design. We have developed a simple and reliable method of screw removal which uses a cannulated 8.0 mm end-threaded cancellous screw (Smith & Nephew Richards Medical, Memphis, Tennessee) and a specially designed cannulated trephine. The method has been successful, with minimal complications, and a limited surgical exposure

We aimed to determine the optimal method of inserting a screw into polymethylmethacrylate (PMMA) cement to enhance fixation. We performed six groups of ten axial pull-out tests with two sizes of screw (3.5 and 4.5 mm AO cortical) and three methods of insertion. Screws were placed into 'fluid' PMMA, into 'solid' PMMA by drilling and tapping, or into 'curing' PMMA with quarter-revolution turns every 30 seconds until the PMMA had hardened. After full hardening, we measured the maximum load to failure for each screw-PMMA construct. We found no significant difference in the pull-out strengths between screw sizes or between screws placed in fluid or solid PMMA. Screws placed in curing PMMA were significantly weaker: the relative strengths of solid, fluid and curing groups were 100%, 97% and 71%, respectively. We recommend the use of either solid or fluid insertion according to the circumstances and the preference of the surgeon

We describe a method of internal fixation for femoral neck fractures which has been newly developed to reduce the frequency of early complications. Two cannulated screws are inserted in the axis of the femoral neck to reach into the subchondral bone of the femoral head. The screws are inserted over guide pins and the tip of the screw is self-tapping and designed to provide good anchorage in the femoral head. We used this method in 44 consecutive patients in a prospective study with no exclusions, followed for a minimum of 24 months. All fractures healed within 12 months, and there were no cases of early loosening or nonunion. In four cases, late segmental collapse had developed during the mean follow-up period of 30 months

Ten cases of a complication of Garden screw fixation of subcapital fracture, namely subtrochanteric fracture through the lower screw hole, are presented. Their possible aetiology, prevention and difficulties in management are discussed. It is recommended that, during the insertion of Garden screws, care should be taken to avoid multiple attempts at passing the guide wire. If subtrochanteric fracture occurs internal fixation with a nail plate or screw plate is advised. Ideally the nail or screw should be inserted along the track of one of the existing screws

We prospectively studied the use of intercostal EMG monitoring as an indicator of the accuracy of the placement of pedicle screws in the thoracic spine. We investigated 95 thoracic pedicles in 17 patients. Before insertion of the screw, the surgeon recorded his assessment of the integrity of the pedicle track. We then stimulated the track using a K-wire pedicle probe connected to a constant current stimulator. A compound muscle action potential (CMAP) was recorded from the appropriate intercostal or abdominal muscles. Postoperative CT was performed to establish the position of the screw. The stimulus intensity required to evoke a muscle response was correlated with the position of the screw on the CT scan. There were eight unrecognised breaches of the pedicle. Using 7.0 mA as a threshold, the sensitivity of EMG was 0.50 in detecting a breached pedicle and the specificity was 0.83. Thoracic pedicle screws were accurately placed in more than 90% of patients. EMG monitoring did not significantly improve the reliability of placement of the screw

We evaluated the outcome of treatment of nonunion of an intracapsular fracture of the femoral neck in young patients using two cannulated screws and a vascularised bone graft. A total of 32 patients (15 women and 17 men, with a mean age of 36.5 years; 20 to 50) with failed internal fixation of an intracapsular fracture were included in the study. Following removal of the primary fixation, two cannulated compression screws were inserted with a vascularised iliac crest bone graft based on the ascending branch of the lateral femoral circumflex artery. At a mean follow-up of 6.8 years (4 to 10), union was achieved in 27 hips (84%). A total of five patients with a mean age of 40.5 years (35 to 50) had a persistent nonunion and underwent total hip arthroplasty as also did two patients whose fracture united but who developed osteonecrosis of the femoral head two years post-operatively. Statistical analysis showed that younger patients achieved earlier and more reliable union (p < 0.001). The functional outcome, as assessed by the Harris Hip score, was better in patients aged < 45 years compared with those aged > 45 years (p < 0.001). . These findings suggest that further fixation using two cannulated compression screws and a vascularised iliac crest bone graft is an effective salvage treatment in patients aged <  45 years, in whom osteosynthesis of a displaced intracapsular fractures of the femoral neck has failed. Cite this article: Bone Joint J 2015; 97-B:988–91

We reviewed 15 consecutive patients, 11 women and four men, with a mean age of 48.7 years (37.3 to 62.6), who between July 2004 and August 2007 had undergone percutaneous sacroiliac fusion using hollow modular anchorage screws filled with demineralised bone matrix. Each patient was carefully assessed to exclude other conditions and underwent pre-operative CT and MR scans. The diagnosis of symptomatic sacroiliac disease was confirmed by an injection of local anaesthetic and steroid under image intensifier control. The short form-36 questionnaire and Majeed’s scoring system were used for pre- and post-operative functional evaluation. Post-operative radiological evaluation was performed using plain radiographs. Intra-operative blood loss was minimal and there were no post-operative clinical or radiological complications. The mean follow-up was for 17 months (9 to 39). The mean short form-36 scores improved from 37 (23 to 51) to 80 (67 to 92) for physical function and from 53 (34 to 73) to 86 (70 to 98) for general health (p = 0.037). The mean Majeed’s score improved from 37 (18 to 54) pre-operatively to 79 (63 to 96) post-operatively (p = 0.014). There were 13 good to excellent results. The remaining two patients improved in short form-36 from a mean of 29 (26 to 35) to 48 (44 to 52). Their persistent pain was probably due to concurrent lumbar pathology. We conclude that percutaneous hollow modular anchorage screws are a satisfactory method of achieving sacroiliac fusion

The spiral blade modification of the Dynamic Hip Screw (DHS) was designed for superior biomechanical fixation in the osteoporotic femoral head. Our objective was to compare clinical outcomes and in particular the incidence of loss of fixation. . In a series of 197 consecutive patients over the age of 50 years treated with DHS-blades (blades) and 242 patients treated with conventional DHS (screw) for AO/OTA 31.A1 or A2 intertrochanteric fractures were identified from a prospectively compiled database in a level 1 trauma centre. Using propensity score matching, two groups comprising 177 matched patients were compiled and radiological and clinical outcomes compared. In each group there were 66 males and 111 females. Mean age was 83.6 (54 to 100) for the conventional DHS group and 83.8 (52 to 101) for the blade group. Loss of fixation occurred in two blades and 13 DHSs. None of the blades had observable migration while nine DHSs had gross migration within the femoral head before the fracture healed. There were two versus four implant cut-outs respectively and one side plate pull-out in the DHS group. There was no significant difference in mortality and eventual walking ability between the groups. Multiple logistic regression suggested that poor reduction (odds ratio (OR) 11.49, 95% confidence intervals (CI) 1.45 to 90.9, p = 0.021) and fixation by DHS (OR 15.85, 95%CI 2.50 to 100.3, p = 0.003) were independent predictors of loss of fixation. . The spiral blade design may decrease the risk of implant migration in the femoral head but does not reduce the incidence of cut-out and reoperation. Reduction of the fracture is of paramount importance since poor reduction was an independent predictor for loss of fixation regardless of the implant being used. Cite this article: Bone Joint J 2015;97-B:398–404

We performed a retrospective study of the factors affecting the outcome of Weber type-C ankle fractures in 43 patients reviewed at two to nine years after injury. We determined the functional result in relation to the use of a diastasis screw, the accuracy of reduction, the presence of tibiotalar dislocation, and of injury to the medial side of the ankle by medial malleolar fracture or deltoid ligament rupture. We assessed the use of a diastasis screw as appropriate or inappropriate on the basis of an anatomical study performed by Boden et al (1989). The diastasis screw was used unnecessarily in 19 of the 31 patients so treated, but this did not appear to affect the final functional result. The worse functional results were in ankles dislocated at the initial injury, and in those with medial malleolar fractures as opposed to those with deltoid ligament ruptures. The best results were after accurate reduction of the fibula and the syndesmosis, and greater increase in the width of the syndesmosis was associated with a worse result. Our results suggest that an increase of more than 1.5 mm in syndesmosis width is unacceptable. We recommend that when the deltoid ligament is ruptured, a diastasis screw should be used if the fibular fracture is more than 3.5 cm above the top of the syndesmosis. When a medial malleolar fracture has been rigidly repaired a diastasis screw is required if the fibular fracture is more than 15 cm above the syndesmosis

We have reviewed 81 patients with fractures of the odontoid process treated between May 1983 and July 1997, by anterior screw fixation. There were 29 patients with Anderson and D’Alonzo type-II fractures and 52 with type III. Roy-Camille’s classification identified the direction and instability of the fracture. Operative fixation was carried out on 48 men and 33 women with a mean age of 57 years. Associated injuries of the cervical spine were present in 15 patients, neurological signs in 13, and 18 had an Injury Severity Score of more than 15. Nine patients died and 11 were lost to follow-up. Of 61 patients, 56 (92%) achieved bony union at an average of 14.1 weeks. Two patients required a secondary posterior fusion after failure of the index operation. A full range of movement was restored in 43 patients; only six had a limitation of movement greater than 25%. We conclude that anterior screw fixation is effective and practicable in the treatment of fractures of the dens

We biomechanically investigated whether the standard dynamic hip screw (DHS) or the DHS blade achieves better fixation in bone with regard to resistance to pushout, pullout and torsional stability. The experiments were undertaken in an artificial bone substrate in the form of polyurethane foam blocks with predefined mechanical properties. Pushout tests were also repeated in cadaveric femoral heads. The results showed that the DHS blade outperformed the DHS with regard to the two most important characteristics of implant fixation, namely resistance to pushout and rotational stability. We concluded that the DHS blade was the superior implant in this study

We randomly allocated 60 consecutive patients with fractures of the waist of the scaphoid to percutaneous fixation with a cannulated Acutrak screw or immobilisation in a cast. The range of movement, the grip and pinch strength, the modified Green/O’Brien functional score, return to work and sports, and radiological evidence of union were evaluated at each follow-up visit. Patients were followed sequentially for one year. Those undergoing percutaneous screw fixation showed a quicker time to union (9.2 weeks vs 13.9 weeks, p < 0.001) than those treated with a cast. There was a trend towards a higher rate of nonunion in the non-operative group, although this was not statistically significant. Patients treated by operation had a more rapid return of function and to sport and full work compared with those managed conservatively. There was a very low complication rate. We recommend that all active patients should be offered percutaneous stabilisation for fractures of the waist of the scaphoid

Intramedullary tibial nailing was performed in ten paired cadavers and the insertion of a medial-to-lateral proximal oblique locking screw was simulated in each specimen. Anatomical dissection was undertaken to determine the relationship of the common peroneal nerve to the cross-screw. The common peroneal nerve was contacted directly in four tibiae and the cross-screw was a mean of 2.6 mm (1.0 to 10.7) away from the nerve in the remaining 16. Iatrogenic injury to the common peroneal nerve by medial-to-lateral proximal oblique locking screws is therefore a significant risk during tibial nailing

The results of treatment in 242 patients with intracapsular fractures of the neck of femur treated with Garden screws are presented with reference as to whether the screws were crossed or parallel. The incidence both of nonunion and of avascular necrosis was less in those fractures treated with parallel screws. The outcome was also superior if the reduction was good

Computer-assisted frameless stereotactic image guidance allows precise preoperative planning and intraoperative localisation of the image. It has been developed and tested in the laboratory. We evaluated the efficacy, clinical results and complications of placement of a pedicle screw in the lumbar spine using this technique. A total of 62 patients (28 men, 34 women) had lumbar decompression and spinal fusion with segmental pedicle screws. Postoperative CT scans were taken of 35 patients to investigate the placement of 330 screws. None showed penetration of the medial or inferior wall of a pedicle. Registration was carried out 66 times. The number of fiducial points used on each registration averaged 5.8 (4 to 7) The mean registration error was 0.75 mm (0.32 to 1.72). This technique provides a safe and reliable guide for placement of transpedicular screws in the lumbar spine

We conducted a randomised controlled trial to compare external fixation of trochanteric fractures of the femur with the more costly option of the sliding hip screw. Patients in both groups were matched for age (mean 67 years, 50 to 100) and gender. We excluded all pathological fractures, patients presenting at more than one week, fractures with subtrochanteric extension or reverse obliquity, multiple fractures or any bone and joint disease interfering with rehabilitation. The interval between injury and operation, the duration of surgery, the amount of blood loss, the length of hospital stay and the cost of treatment were all significantly higher in the sliding hip screw group (p < 0.05). The time to union, range of movement, mean Harris hip scores and Western Ontario and McMaster University knee scores were comparable at six months. The number of patients showing shortening or malrotation was too small to show a significant difference between the groups. Pin-track infection occurred in 18 patients (60%) treated with external fixation, whereas there was a single case of wound infection (3.3%) in the sliding hip screw group

The results of a prospective multicentre study of the Herbert differential pitch bone screw used to treat 50 scaphoid fractures and non-unions are presented. All fresh fractures and four of the five fracture-dislocations united, an overall union rate of 92%. Although the technique is demanding, the Herbert screw can achieve excellent results in the management of scaphoid fractures

We reviewed 161 patients, from four centres in Switzerland, who had undergone posterior fusion of the upper cervical spine with transarticular screw fixation of the atlanto-axial joints. They were followed up for a mean 24.6 months. The vertebral artery and the medulla escaped injury and only 5.9% of the complications were directly related to the screws. The rate of pseudarthrosis was 0.6%

Sacral insufficiency fractures are traditionally treated with bed rest and analgesia. The importance of early rehabilitation is generally appreciated; but pain frequently delays this, resulting in prolonged hospital stay and the risk of complications related to immobility. We describe three women with sacral insufficiency fractures who were treated with percutaneous sacroiliac screws and followed up for a mean of 18 months (12 to 24). They had immediate pain relief, uncomplicated rehabilitation and uneventful healing

We reviewed the records of 431 patients who had open reduction and internal fixation of the scaphoid performed by one surgeon (TJH) over a 13-year period. The Herbert bone screw provided adequate internal fixation without the use of plaster immobilisation, promoting a rapid functional recovery. On average, patients returned to work 4.7 weeks after surgery and wrist function was significantly improved, even when the fracture failed to unite. Healing rates for acute fractures were better than those reported for plaster immobilisation and were independent of fracture location. In the case of established nonunions, healing depended on the stage and location of the fracture, but the progress of arthritis was halted and carpal collapse significantly improved. Internal fixation of the scaphoid using the Herbert bone screw, although technically demanding, has few complications and appears to offer significant advantages over other methods of treatment

Adult human cadaver pelves were tested to determine micromotion at the prosthesis-bone interface in cementless hemispherical acetabular components during simulated single-limb stance. The micromotion of non-press-fit components with screw fixation in response to cyclic loads to a maximum of 1500N was compressive (interface closing) at the superior iliac rim and distractive (interface opening) at the inferior ischial rim; that of press-fit components was compressive all around the acetabular rim regardless of screw fixation. Adding screws to the component decreased the micromotion at the site of the screw, but sometimes increased it at the opposite side. Two dome screws with the press-fit component decreased the micromotion at the superior iliac rim but at the inferior ischial rim there was either no change or increased movement. A press-fit cup shows less micromotion than a non-press-fit cup with screw fixation. The addition of screws to a press-fit cup does not necessarily increase the initial stability

The purpose of this study was to determine whether patients with a burst fracture of the thoracolumbar spine treated by short segment pedicle screw fixation fared better clinically and radiologically if the affected segment was fused at the same time. A total of 50 patients were enrolled in a prospective study and assigned to one of two groups. After the exclusion of three patients, there were 23 patients in the fusion group and 24 in the non-fusion group. Follow-up was at a mean of 23.9 months (18 to 30). Functional outcome was evaluated using the Greenough Low Back Outcome Score. Neurological function was graded using the American Spinal Injury Association Impairment Scale. Radiological outcome was assessed on the basis of the angle of kyphosis. Peri-operative blood transfusion requirements and duration of surgery were significantly higher in the fusion group (p = 0.029 and p < 0.001, respectively). There were no clinical or radiological differences in outcome between the groups (all outcomes p > 0.05). The results of this study suggest that adjunctive fusion is unnecessary when managing patients with a burst fracture of the thoracolumbar spine with short segment pedicle screw fixation

The augmentation of fixation with bone cement is increasingly being used in the treatment of severe osteoporotic fractures. We investigated the influence of bone quality on the mechanics of augmentation of plate fixation in a distal femoral fracture model (AO 33 A3 type). Eight osteoporotic and eight non-osteoporotic femoral models were randomly assigned to either an augmented or a non-augmented group. Fixation was performed using a locking compression plate. In the augmented group additionally 1 ml of bone cement was injected into the screw hole before insertion of the screw. Biomechanical testing was performed in axial sinusoidal loading. Augmentation significantly reduced the cut-out distance in the osteoporotic models by about 67% (non-augmented mean 0.30 mm (. sd. 0.08) vs augmented 0.13 mm (. sd. 0.06); p = 0.017). There was no statistical reduction in this distance following augmentation in the non-osteoporotic models (non-augmented mean 0.15 mm (. sd. 0.02) vs augmented 0.15 mm (. sd. 0.07); p = 0.915). In the osteoporotic models, augmentation significantly increased stability (p = 0.017). Cite this article: Bone Joint J 2013;95-B:1406–9

We hypothesised that the anterior and posterior walls of the body of the first sacral vertebra could be visualised with two different angles of inlet view, owing to the conical shape of the sacrum. Six dry male cadavers with complete pelvic rings and eight dry sacrums with K-wires were used to study the effect of canting (angling the C-arm) the fluoroscope towards the head in 5° increments from 10° to 55°. Fluoroscopic images were taken in each position. Anterior and posterior angles of inclination were measured between the upper sacrum and the vertical line on the lateral view. Three authors separately selected the clearest image for overlapping anterior cortices and the upper sacral canal in the cadaveric models. The dry bone and K-wire models were scored by the authors, being sure to check whether the K-wire was in or out. In the dry bone models the mean score of the relevant inlet position of the anterior or posterior inclination was 8.875 (standard deviation (. sd. ) 0.35), compared with the inlet position of the opposite inclination of –5.75 (. sd. 4.59). We found that two different inlet views should be used separately to evaluate the borders of the body of the sacrum using anterior and posterior inclination angles of the sacrum, during placement of iliosacral screws. Cite this article: Bone Joint J 2015;97-B:705–10

We created virtual three-dimensional reconstruction models from computed tomography scans obtained from patients with acetabular fractures. Virtual cylindrical implants were placed intraosseously in the anterior column, the posterior column and across the dome of the acetabulum. The maximum diameter which was entirely contained within the bone was determined for each position of the screw. In the same model, the cross-sectional diameters of the columns were measured and compared to the maximum diameter of the corresponding virtual implant. We found that the mean maximum diameter of virtual implant accommodated by the anterior columns was 6.4 mm and that the smallest diameter of the columns was larger than the maximum diameter of the equivalent virtual implant. This study suggests that the size of the screw used for percutaneous fixation of acetabular fractures should not be based solely on the measurement of cross-sectional diameter and that virtual three-dimensional reconstructions might be useful in pre-operative planning

Various techniques have been used for the fixation of the posterior pelvis, each with disadvantages specific to the technique. In this study, a new protocol involving the placement of posterior pelvic screws in the CT suite is described and evaluated. A total of 66 patients with unstable pelvic ring injuries was stabilised under local anaesthesia with sedation. The mean length of time for the procedure was 26 minutes per screw. There were no technical difficulties or misplaced screws and no cases of infection or nonunion. All patients stated that they would choose to have the CT scan procedure again rather than a procedure requiring general anaesthesia. The charges for the procedure were approximately £1840 ($2800) per operation. CT-guided placement of iliosacral screws is a safe, feasible, and cost-effective alternative to radiologically-guided placement in the operating theatre in selected patients

1. A series of 100 intracapsular fractures of the femoral neck treated with the Charnley compression screw is reported. 2. There were six deaths, and in patients reviewed long enough (seventy-five) there were eleven undisplaced fractures, with successful union in 8l·8 per cent, and sixty-four displaced fractures, with a union rate of 59·6 per cent. 3. If we exclude six failures of operative technique, there remain fifty-eight patients in whom the fracture was judged radiologically to have united in 65·5 per cent. 4. The Charnley compression screw is an effective method of internal fixation in such fractures, and non-union with this method is usually due to causes other than mechanical failure

Over a period of one year we treated nine fractures of the sesamoid bones of the hallux, five of which were in the medial sesamoid. All patients had symptoms on exercise, but only one had a recent history of injury. The mean age of the patients was 27 years (17 to 45) and there were six men. The mean duration of symptoms was nine months (1.5 to 48). The diagnosis was based on clinical and radiological investigations. We describe a new surgical technique for percutaneous screw fixation for these fractures using a Barouk screw. All the patients were assessed before and after surgery using the American Orthopaedic Foot and Ankle Society Hallux Score (AOFAS). There was a statistically significant improvement in the mean score from 46.9 to 80.7 (p = 0.0003) after fixation of the fracture with a rapid resolution of symptoms. All patients returned to their previous level of activity by three months. We believe that this relatively simple technique is an excellent method of treatment in appropriately selected patients

We investigated a new intramedullary locking nail that allows the distal interlocking screws to be locked to the nail. We compared fixation using this new implant with fixation using either a conventional nail or a locking plate in a laboratory simulation of an osteoporotic fracture of the distal femur. A total of 15 human cadaver femora were used to simulate an AO 33-A3 fracture pattern. Paired specimens compared fixation using either a locking or non-locking retrograde nail, and using either a locking retrograde nail or a locking plate. The constructs underwent cyclical loading to simulate single-leg stance up to 125 000 cycles. Axial and torsional stiffness and displacement, cycles to failure and modes of failure were recorded for each specimen. When compared with locking plate constructs, locking nail constructs had significantly longer mean fatigue life (75 800 cycles (. sd. 33 900) vs 12 800 cycles (. sd. 6100); p = 0.007) and mean axial stiffness (220 N/mm (. sd. 80) vs 70 N/mm (. sd. 18); p = 0.005), but lower mean torsional stiffness (2.5 Nm/° (. sd. 0.9) vs 5.1 Nm/° (. sd. 1.5); p = 0.008). In addition, in the nail group the mode of failure was either cut-out of the distal screws or breakage of nails, and in the locking plate group breakage of the plate was always the mode of failure. Locking nail constructs had significantly longer mean fatigue life than non-locking nail constructs (78 900 cycles (. sd. 25 600) vs 52 400 cycles (. sd. 22 500); p = 0.04). The new locking retrograde femoral nail showed better stiffness and fatigue life than locking plates, and superior fatigue life to non-locking nails, which may be advantageous in elderly patients. Cite this article: Bone Joint J 2014;96-B:114–21

We compared the outcome of patients treated for an intertrochanteric fracture of the femoral neck with a locked, long intramedullary nail with those treated with a dynamic hip screw (DHS) in a prospective randomised study. Each patient who presented with an extra-capsular hip fracture was randomised to operative stabilisation with either a long intramedullary Holland nail or a DHS. We treated 92 patients with a Holland nail and 98 with a DHS. Pre-operative variables included the Mini Mental test score, patient mobility, fracture pattern and American Society of Anesthesiologists grading. Peri-operative variables were anaesthetic time, operating time, radiation time and blood loss. Post-operative variables were time to mobilising with a frame, wound infection, time to discharge, time to fracture union, and mortality. We found no significant difference in the pre-operative variables. The mean anaesthetic and operation times were shorter in the DHS group than in the Holland nail group (29.7 vs 40.4 minutes, p < 0.001; and 40.3 vs 54 minutes, p < 0.001, respectively). There was an increased mean blood loss within the DHS group versus the Holland nail group (160 ml vs 78 ml, respectively, p < 0.001). The mean time to mobilisation with a frame was shorter in the Holland nail group (DHS 4.3 days, Holland nail 3.6 days, p = 0.012). More patients needed a post-operative blood transfusion in the DHS group (23 vs seven, p = 0.003) and the mean radiation time was shorter in this group (DHS 0.9 minutes vs Holland nail 1.56 minutes, p < 0.001). The screw of the DHS cut out in two patients, one of whom underwent revision to a Holland nail. There were no revisions in the Holland nail group. All fractures in both groups were united when followed up after one year. We conclude that the DHS can be implanted more quickly and with less exposure to radiation than the Holland nail. However, the resultant blood loss and need for transfusion is greater. The Holland nail allows patients to mobilise faster and to a greater extent. We have therefore adopted the Holland nail as our preferred method of treating intertrochanteric fractures of the hip

A new and simple operative technique has been developed to provide rigid internal fixation for all types of fractures of the scaphoid. This involves the use of a double-threaded bone screw which provides such good fixation that, after operation, a plaster cast is rarely required and most patients are able to return to work within a few weeks. A classification of scaphoid fractures is proposed. The indications for operation included not only acute unstable fractures, but also fractures with delayed healing and those with established non-union; screw fixation was combined with bone grafting to treat non-union. In a prospective trial, 158 operations using this technique were carried out between 1977 and 1981. The rate of union was 100 per cent for acute fractures and 83 per cent overall. This method of treatment appears to offer significant advantages over conventional techniques in the management of the fractured scaphoid

Five consecutive unstable fractures of the distal third of the clavicle were treated by indirect open reduction and internal fixation using a temporary Bosworth-type screw. Coracoclavicular fixation provided and maintained reduction of the fracture. Healing occurred uneventfully within nine weeks in all cases. The screw was removed under local anaesthesia after healing of the fracture and there were no surgical complications. Shoulder function was restored to the pre-injury level. Temporary coracoclavicular screw fixation appears to be a valuable alternative for the treatment of type II fractures of the distal third of the clavicle

Aims. We performed a retrospective, comparative study of elderly patients with an increased risk from anaesthesia who had undergone either anterior screw fixation (ASF) or halo vest immobilisation (HVI) for a type II odontoid fracture. Patients and Methods. A total of 80 patients aged 65 years or more who had undergone either ASF or HVI for a type II odontoid fracture between 1988 and 2013 were reviewed. There were 47 women and 33 men with a mean age of 73 (65 to 96; standard deviation 7). All had an American Society of Anesthesiologists score of 2 or more. Results. Patients who underwent ASF had a significantly better outcome than those who were treated by HVI. There was a rate of nonunion of 10% after ASF and 23% after HVI. Failure of reduction or fixation occurred in 11 patients (15%) but there was no significant difference between the two groups. Mortality rates were also similar: 9% (n = 3) after ASF and 8% (n = 4) after HVI. Conclusion. We conclude that ASF is the preferred method of treatment in this group of elderly patients, having a significantly higher rate of fusion, better clinical outcome and a similar rate of general and treatment-related complications. Cite this article: Bone Joint J 2016;98-B:1222–6

Fracture of the neck of the femur after resurfacing arthroplasty usually leads to failure and conversion to a total hip replacement. We describe an intracapsular fracture of the femoral neck sustained after hip resurfacing which was treated by cannulated screws, resulting in union and retention of the resurfacing implant. The result at follow-up three years later was very satisfactory with a Harris hip score of 99

Ununited fractures of the scaphoid with extensive bone resorption are usually treated by bone grafting and internal fixation, using either an open or a minimally invasive technique. We studied the feasibility of percutaneous fixation without bone grafting in a consecutive series of 27 patients with established nonunion of an undisplaced fracture of the scaphoid and extensive local resorption of bone. They were treated by a single surgeon with rigid fixation alone, using a headless cannulated screw inserted through a volar percutaneous technique. Clinical examination, standard radiographs and CT confirmed that the fracture had united in all patients at a mean of 11.6 weeks (8 to 16), and that their functional scores had improved. We concluded that extensive resorption at the fracture site is not an absolute indication for bone grafting, and that percutaneous fixation alone will eventually produce healing of ununited undisplaced fractures of the scaphoid regardless of the size of the gap

Filling the empty holes in peri-articular locking plates may improve the fatigue strength of the fixation. The purpose of this in vitro study was to investigate the effect of plugging the unused holes on the fatigue life of peri-articular distal femoral plates used to fix a comminuted supracondylar fracture model. A locking/compression plate was applied to 33 synthetic femurs and then a 6 cm metaphyseal defect was created (AO Type 33-A3). The specimens were then divided into three groups: unplugged, plugged with locking screw only and fully plugged holes. They were then tested using a stepwise or run-out fatigue protocol, each applying cyclic physiological multiaxial loads. All specimens in the stepwise group failed at the 770 N load level. The mean number of cycles to failure for the stepwise specimen was 25 500 cycles (. sd. 1500), 28 800 cycles (. sd.  6300), and 26 400 cycles (. sd. 2300) cycles for the unplugged, screw only and fully plugged configurations, respectively (p = 0.16). The mean number of cycles to failure for the run-out specimens was 42 800 cycles (. sd. 10 700), 36 000 cycles (. sd. 7200), and 36 600 cycles (. sd.  10 000) for the unplugged, screw only and fully plugged configurations, respectively (p = 0.50). There were also no differences in axial or torsional stiffness between the constructs. The failures were through the screw holes at the level of comminution. In conclusion, filling the empty combination locking/compression holes in peri-articular distal femur locking plates at the level of supracondylar comminution does not increase the fatigue life of the fixation in a comminuted supracondylar femoral fracture model (AO 33-A3) with a 6 cm gap

We studied the biomechanical behaviour of three sliding fixation devices for trochanteric femoral fractures. These were a titanium alloy sideplate and lag screw, a titanium alloy sideplate and dome plunger with cement augmentation, and a stainless-steel sideplate and lag screw. We used 18 mildly osteoporotic cadaver femora, randomly assigned to one of the three fixation groups. Four displacement and two strain gauges were fixed to each specimen, and each femur was first tested intact (control), then as a two-part fracture and then as a four-part intertrochanteric fracture. A range of physiological loads was applied to determine load-bearing, load-sharing and head displacement. The four-part-fracture specimens were subsequently tested to failure to determine maximum fixation strengths and modes of failure. The dome-plunger group failed at a load 50% higher than that of the stainless-steel lag-screw group (p < 0.05) and at a load 20% higher than that of the titanium-alloy lag-screw group (NS). All 12 lag-screw specimens failed by cut-out through the femoral head or neck, but none of the dome-plunger group showed movement within the femoral head when tested to failure. Strain-gauge analysis showed that the dome plunger produced considerably less strain in the inferior neck and calcar region than either of the lag screws. Inferior displacement of the femoral head was greatest for the dome-plunger group, and was due to sliding of the plunger. The dome plunger with cement augmentation was able to support higher loads and did not fail by cut-out through the femoral head.(ABSTRACT TRUNCATED AT 250 WORDS)

In a prospective, randomised study we have compared the pertrochanteric external fixator (PF) with the sliding hip screw (SHS) in 100 consecutive patients who were allocated randomly to the two methods of treatment. Details of the patients and the patterns of fracture were similar in both groups. Follow-up was for six months. Use of the PF was associated with significantly less blood loss, a shorter operating time, reduced postoperative pain, shorter hospitalisation (p < 0.001), earlier mobilisation (p < 0.001) and a reduced rate of mechanical complications (p < 0.01). Superficial infection was significantly more common with the PF (p < 0.01), but without long-term adverse consequences. There were no differences in the healing of the fracture, mortality or final functional outcome. Our results indicate that the external fixator is an effective and safe device for treating pertrochanteric fractures and should be considered as a useful alternative to conventional fixation with the sliding hip screw

We describe a percutaneous technique for screw fixation of all types of fractures of the scaphoid. During a 15-year period ending in 1984, 280 cases were treated by this method; 198 of them returned for evaluation in 1986 and comprise the material for this report. After a mean postoperative time of 82 months, 89% of the recent fractures had united as well as 81.8% of those with delayed or nonunion and 42.8% of those with sclerotic nonunion

In a randomised trial involving 598 patients with 600 trochanteric fractures of the hip, the fractures were treated with either a sliding hip screw (n = 300) or a Targon PF intramedullary nail (n = 300). The mean age of the patients was 82 years (26 to 104). All surviving patients were reviewed at one year with functional outcome assessed by a research nurse blinded to the treatment used. The intramedullary nail was found to have a slightly increased mean operative time (46 minutes (. sd. 12.3) versus 49 minutes (. sd. 12.7), p < 0.001) and an increased mean radiological screening time (0.3 minutes (. sd. 0.2) versus 0.5 minutes (. sd. 0.3), p <  0.001). Operative difficulties were more common with the intramedullary nail. There was no statistically significant difference between implants for wound healing complications (p = 1), or need for post-operative blood transfusion (p = 1), and medical complications were similarly distributed in both groups. There was a tendency to fewer revisions of fixation or conversion to an arthroplasty in the nail group, although the difference was not statistically significant (nine versus three cases, p = 0.14). The extent of shortening, loss of hip flexion, mortality and degree of residual pain were similar in both groups. The recovery of mobility was superior for those treated with the intramedullary nails (p = 0.01 at one year from injury). In summary, both implants produced comparable results but there was a tendency to better return of mobility for those treated with the intramedullary nail

1. A modification of the McLaughlin technique of lag screw fixation of the fractured scaphoid is described. 2. Fifty-six patients operated upon between 1956 and 1966 have been reviewed and their fractures classified under the headings recent, delayed union and non-union. 3. Plaster casts were avoided and early return to work encouraged; 95 per cent did so within two months. 4. Of twenty-two recent fractures, including three perilunar trans-scaphoid dislocations, nineteen united; of fifteen showing delayed union, eight united: and of nineteen cases of non-union, only two united. 5. The function of the wrist in the seventeen cases of persistent non-union stabilised by lag-screw was surprisingly good; only one patient has required arthrodesis to date. 6. The indications and contra-indications for the operation are discussed

Between 1993 and 2000 we treated 14 patients with nonunion of fractures of the distal humerus; 11 had already had previous fixation which had failed. The mean time to surgery was 21 months after injury. All the fractures were very low which made it difficult to obtain a firm hold of the small distal fragment. The problem of fixation was addressed by inserting a Coventry infant hip screw into the humeral condyles. The screw has a thread of wide diameter which gives excellent purchase on the small distal fragment. The condyles can then be compressed on to the humeral shaft using a 4.5 mm narrow tibial dynamic plate. Of these 14 difficult cases of nonunion, 12 progressed to union

We describe a simple method of inserting the distal screws in a locked femoral nail. The method requires no aiming device and no assistant. The only equipment needed is a 3 mm Kirschner wire and an air drill

In children, nonunion of fractures of the waist of the scaphoid is uncommon. Treatment has included bone grafting without internal fixation, bone grafting with Kirschner-wire fixation, and screw fixation without bone grafting. We report the successful use of Herbert screw fixation and iliac-crest bone grafting in five cases, all of which healed without further surgery. At an average follow-up of 3.3 years, the range of motion, grip strength, carpal stability, and radiological appearances were all excellent

We report a case of malignant fibrous histiocytoma of the hip which occurred 30 years after the insertion of a single chrome-cobalt alloy screw for a slipped femoral epiphysis. The possible aetiological association between malignant tumours and metallic implants is discussed