Between 1987 and 2006 we performed a modified Thompson’s quadricepsplasty on 40 fracture-related stiff knees and followed the patients for a mean of 7.9 years (2 to 11.1). The factors affecting the final gain of movement were investigated. A total of 15 knees required lengthening of the rectus femoris. The mean flexion gain was 70.2° (42.3° to 112.5°). According to Judet’s criteria, the results were excellent in 30 knees, good in seven, and fair in three. The range of movement which was achieved intra-operatively was related to the gain of knee flexion on univariate analysis. Five patients had complications: deep infection in one, recurrent patellar dislocation in one, and rupture of the extensor mechanism in three. This modified technique gives satisfactory results. Achieving maximum knee flexion intra-operatively seems to be the most important factor in enhancing the outcome in patients with stiffness of the knee following fracture.

Segmental resection of malignant bone disease in the femoral diaphysis with subsequent limb reconstruction is a major undertaking. This is a retrospective review of 23 patients who had undergone limb salvage by endoprosthetic replacement of the femoral diaphysis for a primary bone tumour between 1989 and 2005.

There were 16 males and seven females, with a mean age of 41.3 years (10 to 68). The mean overall follow-up was for 97 months (3 to 240), and 120 months (42 to 240) for the living patients. The cumulative patient survival was 77% (95% confidence interval 63% to 95%) at ten years. Survival of the implant, with failure of the endoprosthesis as an endpoint, was 85% at five years and 68% (95% confidence interval 42% to 92%) at ten years. The revision rate was 22% and the overall rate of re-operation was 26%. Complications included deep infection (4%), breakage of the prosthesis (8%), periprosthetic fracture (4%), aseptic loosening (4%), local recurrence (4%) and metastases (17%). The 16 patients who retained their diaphyseal endoprosthesis had a mean Musculoskeletal Tumour Society score of 87% (67% to 93%). They were all able to comfortably perform most activities of daily living.

Femoral diaphyseal endoprosthetic replacement is a viable option for reconstruction following segmental resection of malignant bone disease. It allows immediate weight-bearing, is associated with a good long-term functional outcome, has an acceptable complication and revision rate and, most importantly, does not appear to compromise patient survival.

Open reduction and internal fixation of high-energy pilon fractures are often associated with serious complications. Various methods have been used to treat these injuries, with variable results. A total of 17 consecutive patients with pilon fractures of AO/OTA type 43-B3 (n = 1), type C2 (n = 12) and type C3 (n = 4) were treated by indirect reduction by capsuloligamentotaxis and stabilisation using an ankle-spanning Ilizarov fixator. The calcaneal ring was removed at a mean of 3.7 weeks (3 to 6). A total of 16 patients were available for follow-up at a mean of 29 months (23 to 43). The mean time to healing was 15.8 weeks (13 to 23). Nine patients had pin-track infections but none had deep infection or osteomyelitis. Four patients (25%) had malunion. Fair, good or excellent ankle scores were found in 14 patients. External fixation with a ring fixator achieves stable reduction of the fractured fragments without additional trauma to soft tissues.

With minimum complications and good healing results, the Ilizarov apparatus is particularly useful for high-energy pilon fractures.

We describe the management of nonunion combined with limb-length discrepancy following vascularised fibular grafting for the reconstruction of long-bone defects in the lower limb after resection of a tumour in skeletally immature patients. We operated on nine patients with a mean age of 13.1 years (10.5 to 14.5) who presented with a mean limb-length discrepancy of 7 cm (4 to 9) and nonunion at one end of a vascularised fibular graft, which had been performed previously, to reconstruct a bone defect after resection of an osteosarcoma.

Reconstruction was carried out using a ring fixator secured with correction by half pins of any malalignment, compression of the site of nonunion and lengthening through a metaphyseal parafocal osteotomy without bone grafting. The expected limb-length discrepancy at maturity was calculated using the arithmetic method. Solid union and the intended leg length were achieved in all the patients. Excessive scarring and the distorted anatomy from previous surgery in these patients required other procedures to be performed with minimal exposures and dissection in order to avoid further compromise to the vascularity of the graft or damage to neurovascular structures. The methods which we chose were simple and effective in addressing these complex problems.

We compared the incidence and severity of complications during and after closing- and opening-wedge high tibial osteotomy used for the treatment of varus arthritis of the knee, and identified the risk factors associated with the development of complications. In total, 104 patients underwent laterally based closing-wedge and 90 medial opening-wedge high tibial osteotomy between January 1993 and December 2006. The characteristics of each group were similar. All the patients were followed up for more than 12 months. We assessed the outcome using the Hospital for Special Surgery knee score, and recorded the complications. Age, gender, obesity (body mass index > 27.5 kg/m²), the type of osteotomy (closing versus opening) and the pre-operative mechanical axis were subjected to risk-factor analysis.

The mean Hospital for Special Surgery score in the closing and opening groups improved from 73.4 (54 to 86) to 91.8 (81 to 100) and from 73.8 (56 to 88) to 93 (84 to 100), respectively. The incidence of complications overall and of major complications in both groups was not significantly different (p = 0.20 overall complication, p = 0.29 major complication). Logistic regression analysis adjusting for obesity and the pre-operative mechanical axis showed that obesity remained a significant independent risk factor (odds ratio = 3.23) of a major complication after high tibial osteotomy.

Our results suggest that the opening-wedge high tibial osteotomy can be an alternative treatment option for young patients with medial compartment osteoarthritis and varus deformity.

Proximal osteotomies for forefoot deformity in patients with rheumatoid arthritis have hitherto not been described. We evaluated combination joint-preserving surgery involving three different proximal osteotomies for such deformities. A total of 30 patients (39 feet) with a mean age of 55.6 years (45 to 67) underwent combined first tarsometatarsal fusion and distal realignment, shortening oblique osteotomies of the bases of the second to fourth metatarsals and a fifth-ray osteotomy.

The mean follow-up was 36 months (24 to 68). The mean foot function index scores for pain, disability and activity subscales were 18, 23, and 16 respectively. The mean Japanese Society for Surgery of the Foot score improved significantly from 52.2 (41 to 68) to 89.6 (78 to 97). Post-operatively, 14 patients had forefoot stiffness, but had no disability. Most patients reported highly satisfactory walking ability. Residual deformity and callosities were absent. The mean hallux valgus and intermetatarsal angles decreased from 47.0° (20° to 67°) to 9.0° (2° to 23°) and from 14.1° (9° to 20°) to 4.6° (1° to 10°), respectively. Four patients had further surgery including removal of hardware in three and a fifth-ray osteotomy in one.

With good peri-operative medical management of rheumatoid arthritis, surgical repositioning of the metatarsophalangeal joint by metatarsal shortening and consequent relaxing of surrounding soft tissues can be successful. In early to intermediate stages of the disease, it can be performed in preference to joint-sacrificing procedures.

We report the use of a free vascularised iliac bone graft in the treatment of 21 patients (19 men and 2 women) with an avascular nonunion of the scaphoid in which conventional bone grafting had previously failed. The mean age of the patients was 32 years (23 to 46) and the dominant wrist was affected in 14. The mean interval from fracture to the vascularised bone grafting was 39 months (9 to 62). Pre-operative MRI showed no contrast enhancement in the proximal fragment in any patient. Fracture union was assessed radiologically or with CT scans if the radiological appearances were inconclusive.

At a mean follow-up of 5.6 years (2 to 11) union was obtained in 16 patients. The remaining five patients with a persistent nonunion continued to experience pain, reduced grip strength and limited range of wrist movement. In the successfully treated patients the grip strength and range of movement did not recover to match the uninjured side.

Prevention of progressive carpal collapse, the absence of donor site morbidity, good subjective results and pain relief, justifies this procedure in the treatment of recalcitrant nonunion of the scaphoid.

We evaluated 31 patients with bilateral dysplastic hips who had undergone periacetabular osteotomy for early (Tönnis grade 0 or 1) or moderate (Tönnis grade 2) osteoarthritis in one hip and total hip replacement for advanced (Tönnis grade 3) osteoarthritis in the other. At a mean follow-up of 5.5 years (2 to 9) after periacetabular osteotomy and 6.7 years (3 to 10) after total hip replacement, there was no difference in the functional outcome in hips undergoing osteotomy for early or moderate osteoarthritis and those with a total hip replacement, as determined by the Merle d’Aubigné and Postel score and the Western Ontario and McMaster Universities osteoarthritis index. More patients preferred the spherical periacetabular osteotomy to total hip replacement (53% vs 23%; p = 0.029). Osteoarthritis secondary to hip dysplasia is often progressive. Given the results, timely correction of dysplasia by periacetabular osteotomy should be considered whenever possible in young patients since this could produce a favourable outcome which is comparable with that of total hip replacement.

We have evaluated the in vivo migration patterns of 164 primary consecutive Charnley-Kerboull total hip replacements which were undertaken in 155 patients. The femoral preparation included removal of diaphyseal cancellous bone to obtain primary rotational stability of the stem before line-to-line cementing. We used the Ein Bild Roentgen Analyse femoral component method to assess the subsidence of the femoral component.

At a mean of 17.3 years (15.1 to 18.3) 73 patients were still alive and had not been revised, eight had been revised, 66 had died and eight had been lost to follow-up. The mean subsidence of the entire series was 0.63 mm (0.0 to 1.94). When using a 1.5 mm threshold, only four stems were considered to have subsided. Our study showed that, in most cases, a highly polished double-tapered stem cemented line-to-line does not subside at least up to 18 years after implantation.

We evaluated the histological changes before and after fixation in ten knees of ten patients with osteochondritis dissecans who had undergone fixation of the unstable lesions. There were seven males and three females with a mean age of 15 years (11 to 22). The procedure was performed either using bio-absorbable pins only or in combination with an autologous osteochondral plug. A needle biopsy was done at the time of fixation and at the time of a second-look arthroscopy at a mean of 7.8 months (6 to 9) after surgery.

The biopsy specimens at the second-look arthroscopy showed significant improvement in the histological grading score compared with the pre-fixation scores (p < 0.01). In the specimens at the second-look arthroscopy, the extracellular matrix was stained more densely than at the time of fixation, especially in the middle to deep layers of the articular cartilage.

Our findings show that articular cartilage regenerates after fixation of an unstable lesion in osteochondritis dissecans.

We review the treatment of pelvic Ewing’s sarcoma by the implantation of extracorporeally-irradiated (ECI) autografts and compare the outcome with that of other reported methods.

We treated 13 patients with ECI autografts between 1994 and 2004. There were seven males and six females with a median age of 15.7 years (interquartile range (IQR) 12.2 to 21.7). At a median follow-up of five years (IQR 1.8 to 7.4), the disease-free survival was 69% overall, and 75% if one patient with local recurrence after initial treatment elsewhere was excluded. Four patients died from distant metastases at a mean of 17 months (13 to 23). There were three complications which required operative intervention; one was a deep infection which required removal of the graft. The functional results gave a mean Musculoskeletal Tumor Society score of 85% (60% to 97%), a mean Toronto extremity salvage score of 86% (69% to 100%) and a mean Harris hip score of 92 (67 to 100).

We conclude that ECI grafting is a suitable form of treatment for localised and resectable pelvic Ewing’s sarcoma.

A consecutive series of 23 patients (25 ankles) with osteoarthritis of the ankle and severe varus or valgus deformity were treated by open arthrodesis using compression screws. Primary union was achieved in 24 ankles one required further surgery to obtain a solid fusion. The high level of satisfaction in this group of patients reinforces the view that open arthrodesis, as opposed to ankle replacement or arthroscopic arthrodesis, continues to be the treatment of choice when there is severe varus or valgus deformity associated with the arthritis.

The results of proximal humeral replacement following trauma are substantially worse than for osteoarthritis or rheumatoid arthritis. The stable reattachment of the lesser and greater tuberosity fragments to the rotator cuff and the restoration of shoulder biomechanics are difficult. In 1992 we developed a prosthesis designed to improve fixation of the tuberosity fragments in comminuted fractures of the proximal humerus. The implant enables fixation of the fragments to the shaft of the prosthesis and the diaphyseal fragment using screws, washers and a special toothed plate. Between 1992 and 2003 we used this technique in 50 of 76 patients referred to our institution for shoulder reconstruction after trauma. In the remaining 26, reconstruction with a prosthesis and nonabsorbable sutures was performed, as the tuberosity fragments were too small and too severely damaged to allow the use of screws and the toothed plate.

The Constant score two years post-operatively was a mean of 12 points better in the acute trauma group and 11 points better in the late post-traumatic group than in the classical suture group.

We recommend this technique in patients where the tuberosity fragments are large enough to allow fixation with screws, washers and a toothed plate.

Kienböck’s disease is a form of osteonecrosis affecting the lunate. Its aetiology remains unknown. Morphological variations, such as negative ulnar variance, high uncovering of the lunate, abnormal radial inclination and/or a trapezoidal shape of the lunate and the particular pattern of its vascularity may be predisposing factors. A history of trauma is common. The diagnosis is made on plain radiographs, but MRI can be helpful early in the disease. A CT scan is useful to demonstrate fracture or fragmentation of the lunate. Lichtman classified Kienböck disease into five stages. The natural history of the condition is not well known, and the symptoms do not correlate well with the changes in shape of the lunate and the degree of carpal collapse. There is no strong evidence to support any particular form of treatment. Many patients are improved by temporary immobilisation of the wrist, which does not stop the progression of carpal collapse. Radial shortening may be the treatment of choice in young symptomatic patients presenting with stages I to III-A of Kienböck’s disease and negative ulnar variance. Many other forms of surgical treatment have been described.

Nonunion of the tibia associated with bone loss, previous infection, obliteration of the intramedullary canal or located in the distal metaphysis poses a challenge to the surgeon and significant morbidity to patients. We retrospectively reviewed the records of 24 patients who were treated by central bone grafting and compared them to those of 20 who were treated with a traditional posterolateral graft. Central bone grafting entails a lateral approach, anterior to the fibula and interosseous membrane which is used to create a central space filled with cancellous iliac crest autograft. Upon consolidation, a tibiofibular synostosis is formed that is strong enough for weight-bearing. This procedure has advantages over other methods of treatment for selected nonunions.

Of the 24 patients with central bone grafting, 23 went on to radiographic and clinical union without further intervention. All healed within a mean of 20 weeks (10 to 48). No further bone grafts were required, and few complications were encountered. These results were comparable to those of the 20 patients who underwent posterolateral bone grafting who united at a mean of 31.3 weeks (16 to 60) but one of whom required below-knee amputation for intractable sepsis.

Central bone grafting is a safe and effective treatment for difficult nonunions of the tibia.

Many orthopaedic surgeons believe that obese patients have a higher rate of peri-operative complications and a worse functional outcome than non-obese patients. There is, however, inconsistency in the literature supporting this notion.

This study was performed to evaluate the effect of body mass index (BMI) on injury characteristics, the incidence of complications, and the functional outcome after the operative management of unstable ankle fractures.

We retrospectively reviewed 279 patients (99 obese (BMI ≥ 30) and 180 non-obese (BMI < 30) patients who underwent surgical fixation of an unstable fracture of the ankle. We found that obese patients had a higher number of medical co-morbidities, and more Orthopaedic Trauma Association type B and C fracture types than non-obese patients. At two years from the time of injury, however, the presence of obesity did not affect the incidence of complications, the time to fracture union or the level of function.

These findings suggest that obese patients should be treated in line with standard procedures, keeping in mind any known associated medical co-morbidities.

We present a retrospective study of patients suffering from a variety of benign tumours in whom external fixators were used to treat deformity and limb-length discrepancy, and for the reconstruction of bone defects. A total of 43 limbs in 31 patients (12 male and 19 female) with a mean age of 14 years (2 to 54) were treated.

The diagnosis was Ollier’s disease in 12 limbs, fibrous dysplasia in 11, osteochondroma in eight, giant cell tumour in five, osteofibrous dysplasia in five and non-ossifying fibroma in two. The lesions were treated in the tibia in 19 limbs, in the femur in 16, and in the forearm in eight. The Ilizarov frame was used in 25 limbs, the Taylor Spatial Frame in seven, the Orthofix fixator in six, the Monotube in four and the Heidelberg fixator in one. The mean follow-up was 72 months (22 to 221).

The mean external fixation period was 168 days (71 to 352). The mean external fixation index was 42 days/cm (22.2 to 102.0) in the 22 patients who required limb lengthening. The mean correction angle for those with angular deformity was 23° (7° to 45°).

At final follow-up all patients had returned to normal activities. Four patients required a second operation for recurrent deformity of further limb lengthening. Local recurrence occurred in one patient, requiring further surgery.

Failure of fixation is a common problem in the treatment of osteoporotic fractures around the hip. The reinforcement of bone stock or of fixation of the implant may be a solution. Our study assesses the existing evidence for the use of bone substitutes in the management of these fractures in osteoporotic patients. Relevant publications were retrieved through Medline research and further scrutinised. Of 411 studies identified, 22 met the inclusion criteria, comprising 12 experimental and ten clinical reports. The clinical studies were evaluated with regard to their level of evidence. Only four were prospective and randomised.

Polymethylmethacrylate and calcium-phosphate cements increased the primary stability of the implant-bone construct in all experimental and clinical studies, although there was considerable variation in the design of the studies. In randomised, controlled studies, augmentation of intracapsular fractures of the neck of the femur with calcium-phosphate cement was associated with poor long-term results. There was a lack of data on the long-term outcome for trochanteric fractures. Because there were only a few, randomised, controlled studies, there is currently poor evidence for the use of bone cement in the treatment of fractures of the hip.