Sixty-one patients with 68 osteonecrotic femoral heads, at different stages of development, were treated surgically; their average age was 36 years. Necrosis followed a fracture in 43 hips and traumatic dislocation in three. It was idiopathic in 14, cortisone-induced in seven and associated with gout in one. The operation of multiple drilling, curettage of the necrotic bone and muscle pedicle bone grafting was performed in all. Cheilectomy of the superolateral part of the femoral head and adductor tenotomy were added in cases of advanced necrosis. Of the several types of muscle pedicle used, tensor fasciae latae anteriorly and quadratus femoris posteriorly were preferred. Full weight-bearing was not permitted for five to six months. The follow-up period varied from three to 12 years. Hip pain was regularly relieved and abduction and rotation of the joints were improved. Those with post-traumatic or idiopathic necrosis did better than those with cortisone-induced necrosis

We describe six patients with aggressive granulomatous lesions around cementless total hip prostheses. Two patients previously had a cemented prosthesis in the same hip. The Lord prosthesis was used in five patients, the PCA in one. Both prostheses were made of chrome-cobalt alloy. Pain on weight-bearing occurred on average 3.2 years after the cementless arthroplasty, and at that time radiography revealed aggressive granulomatosis around the proximal femoral stem and the acetabular component in five of the patients; one had a large solitary granuloma in the proximal femur. Revision was performed on average 4.8 years after the cementless arthroplasty. At that time all granulomas had grown large in size; while waiting for revision operation, two femoral stem components fractured. All the granulomas showed a uniform histopathology, which included histiocytosis; the cause for these lesions was thought to be plastic debris from the acetabular socket

The purpose of this study was to establish if the Bateman prosthesis functions as a bipolar device moving primarily at the inner metal-on-polyethylene bearing as originally proposed, or as a unipolar hemiarthroplasty moving at the outer metal-on-cartilage surface as has recently been suggested. One hundred hips were examined at one year follow-up; 78 were examined again at two to four years. The replacement was performed for arthritis in 76 hips and for femoral neck fracture in 24. Movement was assessed both with and without weight-bearing. In 80% of the arthritis group the prosthesis functioned as a bipolar hip replacement with movement occurring primarily at the inner metal-on-polyethylene surface. By contrast, in 75% of the fracture group the prosthesis functioned largely as a unipolar device with movement occurring primarily at the outer metal-on-cartilage surface. In all cases examined serially the movement pattern was the same at two to four years as it has been at one year. Clearly, the action of the prosthesis depends on the condition of the acetabular cartilage

The thalamus is the part of the calcaneus that supports the posterior articular facet and continues forward, becoming thinner towards the groove of the sinus tarsi. The main displacements after fracture depend on 1) a primary fracture line dividing the bone into anterior and posterior fragments, and 2) a semilunar fragment in the thalamic region. In the operation advised the sinus tarsi is exposed and the semilunar fragment is reduced by rotation in the opposite direction and is fixed to the medial fragment (the sustenaculum tali not being displaced) by a transverse Kirschner wire. The two main fragments are fixed by an antero-posterior wire. Plaster is applied and is retained for twelve weeks. Weight-bearing is not permitted for the first four weeks. There were no major complications in fifty-eight operations. The anatomical results were good: restoration of the tuber-joint angle by reduction of the semilunar fragment was maintained. The functional results were very satisfactory: permanent disability was slight or mild

1. Fifty-eight major injuries in the region of the talus were reviewed regarding treatment, incidence of complications and long-term results. 2. The prognosis for simple fractures of the head, neck or body was good, as was that for dislocations of the midtarsal and peritalar joints. 3. The prognosis for fracture-dislocations of the neck and body was better than has been frequently reported. It was related to the degree of initial trauma. A good result occurs only if accurate reduction is effected and maintained. Fixation with a Kirschner wire is a useful method of maintaining the reduction after unstable fracture-dislocations. 4. Avascular necrosis occurred only in the more severe injuries and its incidence was related to the degree of initial displacement. The late results were better than have been previously described. The condition is best treated conservatively by protection from weight-bearing until revascularisation is well advanced. 5. A case with an unusual pattern of fracture of the neck of the talus is described following a plantar-flexion inversion injury

1. There seem to be two distinct methods of destruction of the foot, once pain sensibility has been lost: the first is a slow erosion and shortening associated with perforating ulcers under the distal weight-bearing end of the foot. The second is a proximal disintegration of the tarsus in which mechanical forces often determine onset and progress of the condition. 2. Once the tarsus begins to disintegrate it is difficult to halt the rapid destruction of the foot. 3. It is possible to detect early stages of this condition in time to take preventive measures. Routine palpation of anaesthetic feet will reveal patches of warmth localised to bones and joints which are in a condition of strain. Radiographs of such feet and a study of posture and gait may define early changes which point to one of several possible patterns of disintegration which may follow. 4. These patterns are described and discussed and suggestions made for preventive and corrective measures

Aims

Accurate estimations of the risk of fracture due to metastatic bone disease in the femur is essential in order to avoid both under-treatment and over-treatment of patients with an impending pathological fracture. The purpose of the current retrospective in vivo study was to use CT-based finite element analyses (CTFEA) to identify a clear quantitative differentiating factor between patients who are at imminent risk of fracturing their femur and those who are not, and to identify the exact location of maximal weakness where the fracture is most likely to occur.

Aims

The use of frozen tumour-bearing autograft combined with a vascularized fibular graft (VFG) represents a new technique for biological reconstruction of massive bone defect. We have compared the clinical outcomes between this technique and Capanna reconstruction.

We have treated 42 consecutive complex ununited fractures of the femoral shaft by wave-plate osteosynthesis at five different medical centres. There were 13 with previous infection, 12 with segmental cortical defects, and 3 were pathological fractures. In 39 cases there had been previous internal fixation and 21 patients had had more than one earlier operation. Union was achieved in 41 patients at an average of six months, although three had required a second bone graft. Two patients had recurrence of infection and in one this resulted in the persistence of nonunion. There were no failures of the implant. All 41 patients with union are now fully weight-bearing, but four have a leg-length discrepancy, one has axial malalignment, and nine have residual stiffness of the knee. These results are surprisingly good, despite the complexity of the initial problem, and appear to confirm the biological and mechanical advantages of the wave plate over the conventional plate for such cases

Aims

Osteopetrosis (OP) is a rare hereditary disease that causes reduced bone resorption and increased bone density as a result of osteoclastic function defect. Our aim is to review the difficulties, mid-term follow-up results, and literature encountered during the treatment of OP.

Primary osteoarthritis of the ankle with no history of trauma is rare. We report the use of a low tibial osteotomy on 18 ankles in 18 patients, two men and 16 women. The osteotomy is designed to correct the varus tilt and anterior opening of the distal tibial joint surface where it has been shown by weight-bearing radiographs and arthroscopy that there is healthy articular cartilage on the lateral side of the ankle. An opening-wedge osteotomy was used to achieve slight overcorrection. Follow-up of the 18 ankles at an average of 6 years 11 months (2.7 to 12.10) showed the results by our own scoring system to be excellent in six ankles, good in nine, and fair in three with no poor results. Of the three patients with fair results, two had been undercorrected and the third had little residual articular cartilage. Arthroscopic examination of ten ankles showed repair by fibrocartilage in seven. We conclude that slight overcorrection of deformity by low tibial osteotomy is effective in treating intermediate-stage primary osteoarthritis of the ankle

We present the results of a prospective trial of osteotomy of the metatarsal neck for hallux valgus in 31 feet of 23 women, using a new stapling device with no plaster splintage and early weight-bearing. Surgery was performed for pain (29 feet) and difficulty with footwear (nine feet). The average time for return to light work was 3.3 weeks, and to full work 8.3 weeks after operation. Seventeen patients had full recovery within three months and 21 of the 23 patients had complete relief of pain. Shoes were more comfortable in 17 feet and 9 patients could wear narrower shoes. Only two patients were unsatisfied with the appearance of the foot. All the osteotomies united, and the average hallux valgus angle was improved on radiographs from 35 degrees to 23 degrees. The mean first metatarsal angle was reduced from 16 degrees to 11 degrees. The new technique allows more accurate surgery and easier postoperative management

Aims

This study is a prospective, non-randomized trial for the treatment of fractures of the medial malleolus using lean, bioabsorbable, rare-earth element (REE)-free, magnesium (Mg)-based biodegradable screws in the adult skeleton.

Valgus deformity of the hindfoot can occur at the subtalar joint, the ankle joint, or at both sites. In children suffering from spina bifida, the ankle is often the main site of deformity. Thirty-five ankles with valgus deformity of the hindfoot were studied in 23 children with spina bifida. A radiological triad was observed in all patients: shortening of the fibula, lateral wedging of the distal tibial epiphysis, and lateral tilt of the talus at the ankle mortise . There was a definite correlation between the severity of wedging and the degree of talar tilt, and a fair correlation between the severity of wedging and the extent of fibular shortening. The results of operation in 12 feet are presented. It is concluded that any operations performed below the ankle on these patients (subtalar fusion or triple arthrodesis) is unlikely to succeed; the deformity needs to be corrected above the ankle (by epiphysiodesis or supramalleolar osteotomy). Radiological assessment of the ankle by taking weight-bearing films in the anteroposterior plane is essential to determine the true extent of the deformity before undertaking any operation

1. Rosette strain gauges placed on the lateral surface of the right calcaneus of eight sheep allowed recordings of bone deformation to be made during walking and trotting on a moving belt. From these recordings the changing direction and magnitude of the principal strains and the maximum shear strain could be calculated. 2. The cancellous architecture of the ovine calcaneus, when viewed in lateral radiographs, is arranged in two trabecular tracts which intersect in the form of an arch. in all cases during the main weight-bearing period the direction of the principal strains varied little, and at the time of maximum deformation coincided with the direction of the underlying trabeculae. The principal compressive strain coincided with the direction of the trabeculae in the dorsal tract, The principal tensile strain with those in the plantar tract. At the point of trabecular intersection the principal strains were more nearly equal but they maintained their alignment with their respective trabecular tracts. 3. in this particular site the trajectorial theory of bone structure has found some experimental support

1. The semilunar cartilages are part of the rotator mechanism of the knee joint. 2. Movement of the weight-bearing knee comprises synchronous lateral rotation of the tibia with extension and medial rotation of the tibia with flexion. 3. When this synchrony is disturbed, injuries to the semilunar cartilages result. 4. Damage to the anterior two-thirds of the medial cartilage blocks lateral rotation of the tibia, with consequent physical signs that are pathognomonic of the retracted and the bowstring cartilage, which are the most common types of injury. 5. Each type of cartilage injury produces its own pattern of erosion of articular cartilage and its own sequence of symptoms as so-called arthritis develops. 6. The sequence of symptoms may be halted and often reversed by removal of the torn cartilage. Operation is warranted in most cases however long the history and whatever the age of the patient. 7. The development of medial retropatellar arthritis is explained. The symptoms are often relieved by removal of the medial semilunar cartilage and adequate post-operative rehabilitation

The Ankle Injury Management (AIM) trial was a pragmatic equivalence randomized controlled trial conducted at 24 hospitals in the United Kingdom that recruited 620 patients aged more than 60 years with an unstable ankle fracture. The trial compared the usual care pathway of early management with open reduction and internal fixation with initially attempting non-surgical management using close contact casting (CCC). CCC is a minimally padded cast applied by an orthopaedic surgeon after closed reduction in the operating theatre. The intervention groups had equivalent functional outcomes at six months and longer-term follow-up. However, potential barriers to using CCC as an initial form of treatment for these patients have been identified. In this report, the results of the AIM trial are summarized and the key issues are discussed in order to further the debate about the role of CCC. Evidence from the AIM trial supports surgeons considering conservative management by CCC as a treatment option for these patients. The longer-term follow-up emphasized that patients treated with CCC need careful monitoring in the weeks after its application to monitor maintenance of reduction.

Cite this article: Bone Joint J 2019;101-B:1472–1475.

Aims

Extracellular matrix (ECM) and its architecture have a vital role in articular cartilage (AC) structure and function. We hypothesized that a multi-layered chitosan-gelatin (CG) scaffold that resembles ECM, as well as native collagen architecture of AC, will achieve superior chondrogenesis and AC regeneration. We also compared its in vitro and in vivo outcomes with randomly aligned CG scaffold.

We assessed factors which may affect union in 32 patients with nonunion of a fracture of the diaphysis of the femur and 67 comparable patients whose fracture had united. These included gender, age, smoking habit, the use of non-steroidal anti-inflammatory drugs (NSAIDs) the type of fracture (AO classification), soft-tissue injury (open or closed), the type of nail, the mode of locking, reaming v non-reaming, infection, failure of the implant, distraction at the fracture site, and the time to full weight-bearing. Patients with severe head injuries were excluded. Both groups were comparable with regard to gender, Injury Severity Score and soft-tissue injury. There was no relationship between the rate of union and the type of implant, mode of locking, reaming, distraction or smoking. There were fewer cases of nonunion in more comminuted fractures (type C) and in patients who were able to bear weight early. There was a marked association between nonunion and the use of NSAIDs after injury (p = 0.000001) and delayed healing was noted in patients who took NSAIDs and whose fractures had united

We carried out radial MRI in 30 hips with moderate osteoarthritis and in ten normal hips. On a scout view containing the entire acetabular rim, 12 vertical radial slices were set at 15° intervals. Different appearances were observed in different parts of the joint. In the weight-bearing portion, from 45° anterosuperior to 45° posterosuperior, ‘attenuation’ (n = 16) and ‘disappearance’ (n = 25) were observed as abnormalities of the labrum with ‘capsular stripping’ (n = 29) and ‘extraosseous high signal lesion’ (n = 27) as capsular abnormalities, seen more often in the anterosuperior portion. In all 12 planes there were osteophytes on the acetabular edge (n = 24), femoral head (n = 22) and/or at the central acetabulum (n = 6), a bone cyst on the acetabulum (n = 18) and/or the femoral head (n = 9), irregularity of the articular cartilage (n = 30), and an effusion (n = 28). Our findings indicate that radial MRI may be a useful non-invasive diagnostic method for demonstrating pathology in moderate osteoarthritis of the hip