We treated 22 patients with type-two odontoid fractures in halothoracic vests for six to eight weeks followed by a Philadelphia collar for four weeks. Eighteen patients were reviewed by questionnaire and radiography at a mean of 40 months after injury. We assessed union, fracture position, the degree of permanent pain and stiffness, satisfaction with the treatment and the outcome. The overall union rate was 82%. Posterior malunion with residual posterior displacement or angulation was associated with a higher incidence of persisting pain. The position at union did not correlate with the residual cervical stiffness. Fractures failed to unite in four patients (18%) none of whom had late neurological sequelae, although they had more late pain. There were associations between the development of nonunion and an extension-type injury, age over 65 years and delay in diagnosis

We have compared the results and complications after closed and open reduction with internal fixation in young adults with displaced intracapsular fractures (Garden grades III and IV) of the neck of the femur. We also studied the risk factors which influenced nonunion and the development of avascular necrosis (AVN). A total of 102 patients aged between 15 and 50 years was randomised to receive either closed or open reduction. Both groups were compared for age, gender, time to surgery and posterior comminution as well as for union and complications. Using univariate and multivariate analysis the factors influencing nonunion and AVN were assessed. Of the 102 patients, 92 were available for review. There was no significant difference between the groups in terms of union (p = 0.93) and AVN at two years (p = 0.85). Posterior comminution, poor reduction and improper placement of the screws were the major factors contributing to nonunion. The overall incidence of AVN was 16.3% (15 of 92 patients) and it was not influenced by these factors. A delay of more than 48 hours before surgery did not influence the rate of union or the development of AVN when compared with operation within 48 hours of injury

Fractures of the tibial shaft are common injuries, but there are no long-term outcome data in the era of increased surgical management. The aim of this prospective study was to assess the clinical and functional outcome of this injury at 12 to 22 years. Secondary aims were to determine the short- and long-term mortality, and if there were any predictors of clinical or functional outcome or mortality. From a prospective trauma database of 1502 tibial shaft fractures in 1474 consecutive adult patients, we identified a cohort of 1431 tibial diaphyseal fractures in 1403 patients, who fitted our inclusion criteria. There were 1024 men, and mean age at injury was 40.6 years. Fractures were classified according to the AO system, and open fractures graded after Gustilo and Anderson. Requirement of fasciotomy, time to fracture union, complications, incidence of knee and ankle pain at long-term follow-up, changes in employment and the patients’ social deprivation status were recorded. Function was assessed at 12 to 22 years post-injury using the Short Musculoskeletal Function Assessment and short form-12 questionnaires. Long-term functional outcome data was available for 568 of the surviving patients, 389 were deceased and 346 were lost to follow-up. Most fractures (90.7%, n = 1363) united without further intervention. Fasciotomies were performed in 11.5% of patients; this did not correlate with poorer functional outcome in the long term. Social deprivation was associated with a higher incidence of injury but had no impact on long-term function. The one-year mortality in those over 75 years of age was 29 (42%). At long-term follow-up, pain and function scores were good. However, 147 (26%) reported ongoing knee pain, 62 (10%) reported ankle pain and 97 (17%) reported both. Such joint pain correlated with poorer functional outcome. Cite this article: Bone Joint J 2014;96-B:1370–7

The June 2012 Research Roundup. 360. looks at: platelet-rich plasma; ageing, bone and mesenchymal stem cells; cytokines and the herniated intervertebral disc; ulcerative colitis, Crohn’s disease and anti-inflammatories; the effect of NSAIDs on bone healing; osteoporosis of the fractured hip; herbal medicine and recovery after acute muscle injury; and ultrasound and the time to fracture union

In Neer type II (Robinson type 3B) fractures of the distal clavicle the medial fragment is detached from the coracoclavicular ligaments and displaced upwards, whereas the lateral fragment, which is usually small, maintains its position. Several fixation techniques have been suggested to treat this fracture. The aim of this study was to assess the outcome of patients with type II distal clavicle fractures treated with coracoclavicular suture fixation using three loops of Ethibond. This prospective study included 14 patients with Neer type II fractures treated with open reduction and coracoclavicular fixation. Ethibond sutures were passed under the coracoid and around the clavicle (UCAC loop) without making any drill holes in the proximal or distal fragments. There were 11 men and three women with a mean age of 34.57 years (29 to 41). Patients were followed for a mean of 24.64 months (14 to 31) and evaluated radiologically and clinically using the Constant score. Fracture union was obtained in 13 patients at a mean of 18.23 weeks (13 to 23) and the mean Constant score was 96.07 (91 to 100). One patient developed an asymptomatic fibrous nonunion at one year. This study suggests that open reduction and internal fixation of unstable distal clavicle fractures using UCAC loops can provide rigid fixation and lead to bony union. This technique avoids using metal hardware, preserves the acromioclavicular joint and provides adequate stability with excellent results. Cite this article: Bone Joint J 2013;95-B:983–7

1 . A series of 343 tibial shaft fractures proceeding to sound union in adults, and 192 fractures in children, was studied. Groups of fractures differing from each other only in the one particular variable under consideration were compared. 2. The severity of the injury (as assessed by the degree of displacement, of comminution and of compound wounding) was found to be an important determinant of speed of fracture union and of incidence of delayed and non-union. A simple classification of severity of injury is described. 3. Distraction delayed healing. Traction which avoided distraction had no effect on the rate of union of fractures of moderate severity compared with cases of similar severity of injury treated by immobilisation only. Major fractures subjected to traction did take longer to unite on the average, but there was no increase in the incidence of delayed or non-union

We have investigated whether assessment of blood flow to the proximal scaphoid can be used to predict nonunion in acute fractures of the scaphoid. We studied 32 fractures of the scaphoid one to two weeks after injury, by dynamic fat-suppressed T1-weighted gradient-echo MRI after the intravenous administration of gadopentetate dimeglumine (0.1 mmol/kg body-weight). Steepest slope values (SSV) and percentage enhancement values (%E) were calculated for the distal and proximal fragments and poles. All the fractures were treated by immobilisation in a cast, and union was assessed by CT at 12 weeks. Nonunion occurred in four fractures (12%), and there was no statistically significant difference between the proximal fragment SSV and %E values for the fractures which united and those with nonunion. The difference between the proximal pole SSV and %E values for the union and nonunion groups reached statistical significance (p < 0.05), but with higher enhancement parameters for the nonunion group. Our results suggest that poor proximal vascularity is not an important determinant of union in fractures of the scaphoid

Between 2005 and 2010 ten consecutive children with high-energy open diaphyseal tibial fractures were treated by early reduction and application of a programmable circular external fixator. They were all male with a mean age of 11.5 years (5.2 to 15.4), and they were followed for a mean of 34.5 months (6 to 77). Full weight-bearing was allowed immediately post-operatively. The mean time from application to removal of the frame was 16 weeks (12 to 21). The mean deformity following removal of the frame was 0.15° (0° to 1.5°) of coronal angulation, 0.2° (0° to 2°) sagittal angulation, 1.1 mm (0 to 10) coronal translation, and 0.5 mm (0 to 2) sagittal translation. All patients achieved consolidated bony union and satisfactory wound healing. There were no cases of delayed or nonunion, compartment syndrome or neurovascular injury. Four patients had a mild superficial pin site infection; all settled with a single course of oral antibiotics. No patient had a deep infection or re-fracture following removal of the frame. The time to union was comparable with, or better than, other published methods of stabilisation for these injuries. The stable fixator configuration not only facilitates management of the accompanying soft-tissue injury but enables anatomical post-injury alignment, which is important in view of the limited remodelling potential of the tibia in children aged > ten years. Where appropriate expertise exists, we recommend this technique for the management of high-energy open tibial fractures in children

1 . The arterial pattern and the histological features in the femoral head and neck were studied at necropsy in twenty-five specimens with intracapsular fractures. An improved visual-arteriographic method employing barium sulphate dyed with Prussian blue was used. Twenty-three of the fractures were from a few days to twenty-four weeks old and two were seven and ten years old. Nineteen had been nailed or nail-plated. 2. The results were divided into four groups according to the state of the femoral head. In the first group, four heads were histologically viable and had a normal vascular pattern; in the second group, four showed partial avascular necrosis with part of the head retaining a normal blood supply; in the third group, ten had avascular necrosis in all or most of the head and showed little or no revasculanisation; and in the fourth group, seven showed extensive revascularisation of grossly necrotic heads. Total or subtotal capital necrosis had occurred in 64 per cent and total or partial necrosis in 84 per cent of the specimens. The results indicated that interruption of the retinacular vessels was the cause of gross necrosis; and that in most cases an intact blood supply through the ligamentum teres cannot keep more than a part of the head alive when the other vessels are cut off. Occasionally the ligamentum teres is torn by the nail, or though intact, its blood supply is interrupted. This accounts for completion of avascular necrosis in most cases with total capital necrosis. Viability of the subfoveal area from an intact supply through the ligamentum teres was the main source of revascularisation after capital necrosis. Other sources–from across a uniting fracture line, from growth of soft tissue round the head and neck and from other small viable foci in the head and neck–were much less important and the degree of revascularisation was generally limited. Revascularisation was accompanied by fibrocellular invasion of the marrow, differentiation of cells and the formation of oil cysts whereby the necrotic fat is removed; but bony reconstitution was limited. 3. Six fractures were uniting and another had united by bone making an overall union frequency of 50 per cent considering only the nailed fractures older than two weeks. Four of them (57 per cent) showed total or subtotal capital necrosis. In fractures older than two weeks the frequency of union among the eleven nailed fractures with avascular necrosis was 36 per cent, and it was 100 per cent among the three nailed ones with viable or substantially viable heads. Necrosis of the neck side of the fracture was unrelated to non-union because it soon becomes invaded by fibrovascular tissue and new bone. 4. Fibrosis was the basis of union when the head was dead but examination of older fractures at necropsy is needed to assess the long-term results of revascularisation and union. The clinical desirability or otherwise of capital revascularisation after necrosis also needs to be studied

Aims

The aim of this study was to prepare a scoping review to investigate the use of biologic therapies in the treatment of musculoskeletal injuries in professional and Olympic athletes.

1. The processes of repair and union were studied in six fractures of the lower end of the radius, ranging in age from ten days to five and a half months. 2. The major pathway to union is medullary, through the proliferation around the fracture of vascular granulation tissue with osteogenic power. This invades and then bridges the fracture and is followed by the laying down of trabeculae of new bone. 3. Success depends on the growth of new capillaries across the fracture line, some of which mature and re-establish the meduilary circulation. 4. Indriving of the lateral cortex of the proximal fragment into the distal spongy medulla at the time of injury (in Colles's fractures) permits bridging between proximal periosteal and distal meduliary callus. Otherwise periosteal proliferation plays only a subsidiary role in union. 5. Fissure fractures of the lower articular surface were frequent and they also healed by the invasion of granulation tissue proliferating in the medulla nearby

We describe a retrospective review of 38 cases of reconstruction following resection of the metaphysiodiaphysis of the lower limb for malignant bone tumours using free vascularised fibular grafts. The mean follow-up was for 7.6 years (0.4 to 18.4). The mean Musculoskeletal Tumor Society score was 27.2 (20 to 30). The score was significantly higher when the graft was carried out in a one-stage procedure after resection of the tumour rather than in two stages. Bony union was achieved in 89% of the cases. The overall mean time to union was 1.7 years (0.2 to 10.3). Free vascularised fibular transfer is a major operation with frequent, but preventable, complications which allows salvage of the limb with satisfactory functional results

We report on the use of the Ilizarov method to treat 40 consecutive fractures of the tibial shaft (35 AO 42C fractures and five AO 42B3 fractures) in adults. There were 28 men and 12 women with a mean age of 43 years (19 to 81). The series included 19 open fractures (six Gustilo grade 3A and 13 grade 3B) and 21 closed injuries. The mean time from injury to application of definitive Ilizarov frame was eight days (0 to 35) with 36 fractures successfully uniting without the need for any bone-stimulating procedure. The four remaining patients with nonunion healed with a second frame. There were no amputations and no deep infections. None required intervention for malunion. The total time to healing was calculated from date of injury to removal of the frame, with a median of 166 days (mean 187, (87 to 370)). Minor complications included snapped wires in two patients and minor pin-site infections treated with oral antibiotics in nine patients (23%). Clinical scores were available for 32 of the 40 patients at a median of 55 months (mean 62, (26 to 99)) post-injury, with ‘good’ Olerud and Molander ankle scores (median 80, mean 75, (10 to 100)), ‘excellent’ Lysholm knee scores (median 97, mean 88, (29 to 100)), a median Tegner activity score of 4 (mean 4, (0 to 9)) (comparable to ‘moderately heavy labour / cycling and jogging’) and Short Form-12 scores that exceeded the mean of the population as a whole (median physical component score 55 (mean 51, (20 to 64)), median mental component score 57 (mean 53, (21 to 62)). In conclusion, the Ilizarov method is a safe and reliable way of treating complex tibial shaft fractures with a high rate of primary union

We treated 50 patients with fractures of the waist of the scaphoid in a below-elbow plaster cast for up to 13 weeks. Displacement of the fragments was assessed independently by two observers using MRI and radiographs performed within two weeks of injury. The MRI assessments showed that only the measurement of sagittal translation of the fragments and an overall assessment of displacement had satisfactory inter- and intra-observer reproducibility and revealed that nine of the 50 fractures were displaced. Only three of the 49 fractures with adequate follow-up failed to unite, and all were displaced with more than 1 mm of translation in the sagittal plane. If the MRI assessment of displacement of the fracture was used as the measurement of choice, assessment of displacement on the initial scaphoid series of radiographs showed a sensitivity of between 33% and 47% and a positive predictive value of between 27% and 86%. Neither observer was able correctly to identify more than 33% to 47% of the displaced fractures from the plain radiographs. Although the overall assessment of displacement and gapping and translation in the coronal plane on the plain radiographs influenced the rate of union, none of these parameters identified all three fractures which failed to unite. We conclude that the assessment of displacement of scaphoid fractures on MRI can probably be used to assess the likelihood of union although the small number of nonunions limits the power of the study. In contrast, the assessment of displacement on routine radiography is inaccurate and of less value in predicting union

We retrospectively evaluated 18 patients with a mean age of 37.3 years (14 to 72) who had undergone pelvic reconstruction stabilised with a non-vascularised fibular graft after resection of a primary bone tumour. The mean follow-up was 10.14 years (2.4 to 15.7). The mean Musculoskeletal Tumor Society Score was 76.5% (50% to 100%). Primary union was achieved in the majority of reconstructions within a mean of 22.9 weeks (7 to 60.6). The three patients with delayed or nonunion all received additional therapy (chemotherapy/radiation) (p = 0.0162). The complication rate was comparable to that of other techniques described in the literature. Non-vascularised fibular transfer to the pelvis is a simpler, cheaper and quicker procedure than other currently described techniques. It is a biological reconstruction with good results and a relatively low donor site complication rate. However, adjuvant therapy can negatively affect the outcome of such grafts

Nine patients underwent arthrodesis of the knee using a customised coupled nail (the Mayday arthrodesis nail), five after infected arthroplasty, one following failed arthrodesis, one for intractable anterior knee pain, one for Charcot instability and one after trauma. Comparison was made with 17 arthrodeses, eight undertaken using external fixation, four with dual compression plates, and five with long Küntscher nails. Union was achieved in all patients (100%) at a mean time of ten months using the customised implant. There were no complications despite early weight-bearing. No further procedures were required. This contrasted with a rate of union of 53% and a complication rate of 76% with alternative techniques. Of this second group, 76% required a further operative procedure. We compared the Mayday arthrodesis nail with other techniques of arthrodesis of the knee. The differences in the need for further surgery and occurrence of complications were statistically significant (p < 0.001), and differences in the rate of nonunion and inpatient stay of less than three weeks were also significant (p < 0.05) using Fisher’s exact test. We conclude that a customised coupled intramedullary nail can give excellent stability allowing early weight-bearing, and results in a high rate of union with minimal postoperative complications

An atypical femoral fracture (AFF), with a transverse fracture radiologically through the lateral cortex is a rare but serious condition. In order to improve our ability to identify patients with this condition, we retrospectively surveyed all subtrochanteric, peri-implant and diaphyseal femoral fractures in patients aged ≥ 65 years who underwent surgical treatment at our hospital between 2004 and 2011. We describe the incidence of atypical fractures and their characteristics, with observational data including a review of the hospital and general practitioner records. Clinical outcomes were evaluated using the Harris hip score (HHS) and the timed up-and-go (TUG) test. Atypical fractures only occurred in women with an incidence of 9.8 per 100 000 person-years. The incidence in those who were treated with bisphosphonates was 79.0 per 100 000 person-years; eight of 17 fractures occurred around metal implants. There was a high incidence of delayed union and revision surgery. A total of nine patients (ten AFFs) were available for review at a mean follow-up of 36.5 months (10 to 104). The clinical outcome was poor with a mean HHS of 58.9 (95% CI 47.4 to 70.4) and a mean TUG test of 25.7 s (95% CI 12.7 to 38.8). The delay in diagnosis and treatment of AFF may result from a lack of knowledge of this condition. Cite this article: Bone Joint J 2014; 96-B:1035–40

We present the results of 13 patients who suffered severe injuries to the lower leg. Five sustained a traumatic amputation and eight a Gustilo-Anderson type IIIC open fracture. All were treated with debridement, acute shortening and stabilisation of the fracture and vascular reconstruction. Further treatment involved restoration of tibial length by callus distraction through the distal or proximal metaphysis, which was commenced soon after the soft tissues had healed (n = 8) or delayed until union of the fracture (n = 5). All patients were male with a mean age of 28.4 years (17 to 44), and had sustained injury to the leg only. Chen grade II functional status was achieved in all patients. Although the number of patients treated with each strategy was limited, there was no obvious disadvantage in the early lengthening programme, which was completed more quickly

Cancellous inlay bone grafting for delayed union or non-union of the scaphoid bone gives good results in most cases (Table IV). The operation is easy, does not require radiological control and does not damage the dorsal arterial plexus. The indications for the operation are twofold: firstly for patients complaining of disabling symptoms in the wrist joint with an established pseudarthrosis of the scaphoid bone, with neither arthritic changes nor severe avascularity of the proximal fragment; and, secondly, for delayed union in recent fractures despite adequate immobilisation. Union may still occur if conservative treatment is continued further, but because this may take up to eighteen months (during which time most patients would be unable to work), operation is a reasonable alternative. In this series two scaphoid fractures united after operation with some collapse of the proximal fragment. This probably resulted from removal of too much bone (preliminary to inlaying the graft) from an already small fragment with a poor blood supply. The operation can be performed even in the presence of a small proximal fragment and gave a satisfactory result in two out of three such cases

1. The technique of compression-arthrodesis of the knee joint is described. 2. Fifteen consecutive cases are reported in which clinical union was detected at the first inspection from twelve days to six weeks after operation. By this method the total period of disability is reduced to three months. 3. Three mechanical factors which might be responsible for this very early clinical union are examined: compression is believed to be the main factor, although fixation is also important. 4. A fallacy is exposed in the use of bone grafts for arthrodesis of the knee; the graft is less osteogenic than the substance of the bones which form the joint, and it provides inefficient internal fixation. 5. A theory is suggested that compression, even in the presence of slight movement, acts by producing a fixed "hinge" without shearing movement; at this point a bridgehead of flexible osteoid tissue is established in which ossification inevitably takes place despite slight bending movement. 6. A second theory is suggested that high compression forces stimulate early union by liberating bone salts at points of maximum pressure through the action of osteoclasts, and that the local excess of bone salts is redeposited under cellular activity within a range of a few millimetres where there is no pressure