Aims. Clinical and radiological data were reviewed for all patients with mucopolysaccharidoses (MPS) with thoracolumbar kyphosis managed non-operatively or operatively in our institution. Methods. In all 16 patients were included (eight female: eight male; 50% male), of whom nine had Hurler, five Morquio and two Hunter syndrome. Six patients were treated non-operatively (mean age at presentation of 6.3 years; 0.4 to 12.9); mean kyphotic progression +1.5. o. /year; mean follow-up of 3.1 years (1 to 5.1) and ten patients operatively (mean age at presentation of 4.7 years; 0.9 to 14.4); mean kyphotic progression 10.8. o. /year; mean follow-up of 8.2 years; 4.8 to 11.8) by circumferential arthrodesis with posterior instrumentation in patients with flexible deformities (n = 6). Results. In the surgical group (mean age at surgery of 6.6 years; 2.4 to 16.8); mean post-operative follow-up of 6.3 years (3.5 to 10.3), mean pre-operative thoracolumbar kyphosis of 74.3. o. (42. o. to 110. o. ) was corrected to mean of 28.6. o. (0. o. to 65. o. ) post-operatively, relating to a mean deformity correction of 66.9% (31% to 100%). Surgical complications included a deep wound infection treated by early debridement, apical non-union treated by posterior re-grafting, and stable adjacent segment spondylolisthesis managed non-operatively. Thoracolumbar kyphosis > +38. o. at initial presentation was identified as predicting progressively severe deformity with 90% sensitivity and 83% specificity. Discussion. This study demonstrates that severe thoracolumbar kyphosis in patients with MPS can be effectively treated by circumferential arthrodesis. Severity of kyphosis at initial presentation may predict progression of thoracolumbar deformity. Patients with MPS may be particularly susceptible to post-operative complications due to the underlying connective tissue disorder and inherent immunological compromise. Take home message: Clinical and radiological data were reviewed for all patients with mucopolysaccharidoses with thoracolumbar kyphosis managed non-operatively or operatively in our institution. Cite this article: Bone Joint J 2016;98-B:229–37

Aims

With increasing burden of revision hip arthroplasty (THA), one of the major challenges is the management of proximal femoral bone loss associated with previous multiple surgeries. Proximal femoral arthroplasty (PFA) has already been popularized for tumour surgeries. Our aim was to describe the outcome of using PFA in these demanding non-neoplastic cases.

1. Thirty-seven cases of fracture of the dens have been studied. 2. The incidence of non-union was high: 64 per cent after apparently adequate closed treatment. 3. Possible causes of the high incidence of non-union have been studied : attention is drawn to the effect of displacement and to that of posterior displacement in particular. 4. Non-union of the dens with potential instability at the atlanto-axial joint is not acceptable in a patient who expects to lead a normal active life. 5. Atlanto-axial fusion is the method of choice in the treatment of instability ; once that has been secured, pseudarthrosis of the dens is no longer significant

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

Aims

We aimed to compare the implant survival, complications, readmissions, and mortality of Vancouver B2 periprosthetic femoral fractures (PFFs) treated with internal fixation with that of B1 PFFs treated with internal fixation and B2 fractures treated with revision arthroplasty.

Aims

The primary aim of this study was to identify independent predictors associated with nonunion and delayed union of tibial diaphyseal fractures treated with intramedullary nailing. The secondary aim was to assess the Radiological Union Scale for Tibial fractures (RUST) score as an early predictor of tibial fracture nonunion.

The uptake of 99mTc-MDP was studied in 73 patients after a tibial fracture. The image obtained five minutes after injection during a period between one and four weeks after fracture was found to be related to the incidence of non-union after six months. A ratio of 1.3 between the uptake at the fracture site and at normal bone adjacent to it predicted non-union in an individual patient with a sensitivity of about 70% and a specificity of 90%

Aims

Debate continues regarding the optimum management of periprosthetic distal femoral fractures (PDFFs). This study aims to determine which operative treatment is associated with the lowest perioperative morbidity and mortality when treating low (Su type II and III) PDFFs comparing lateral locking plate fixation (LLP-ORIF) or distal femoral arthroplasty (DFA).

The place of internal fixation in the treatment of fractures of the shafts of the radius and ulna in adults is discussed, and the results in 130 fractures treated by internal fixation are reviewed. Non-union was found to be the most frequent and serious complication after internal fixation. The incidence of non-union can be greatly reduced if operation is delayed for at least one week, and preferably two to three weeks after injury. Evidence is presented to support the value of delayed operation in the promotion of union of fractures

We have reviewed 22 patients with scaphoid fractures treated by internal fixation with the Herbert screw. Three patients had trans-scaphoid perilunar dislocations, one had an oblique displaced fracture of the waist of the scaphoid and 18 had fractures with delayed or non-union. Corticocancellous bone grafts were added in nine of the cases of non-union. Results were excellent or good in 80% of cases after a mean duration of postoperative immobilisation of four weeks. The technical difficulties are analysed and the problems of applying the jig and of operative exposure are discussed

1 . The results of transplanting the greater trochanter in 225 "low-friction" arthroplasties of the hip have been examined. 2. Non-union occurred in an average of 7 per cent of cases. 3. When non-union occurred the results still showed improvement. 4. Four different methods of fixation were used, of which that using two wires, crossed in the horizontal and coronal planes, never failed to secure union. 5. Transplantation of the greater trochanter to the best position is only possible if the neck of the femur is shortened or if the centre of motion of the arthroplasty is displaced medially by deepening the acetabulum, or by a combination of both. 6. In the best position the transplanted trochanter considerably improved active abduction against gravity

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

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

The hospital records of 222 cases of ipsilateral fractures of the femur and tibia were reviewed, and patients were grouped according to the type of fracture and the method of treatment. Thirty-five per cent of patients required late operation for delayed union or non-union, osteomyelitis, refracture and malunion, regardless of the treatment group. A disturbing factor was the 30% incidence of osteomyelitis in patients treated by fixation of both fractures, almost three times the incidence when only one fracture was fixed. A 30% incidence of delayed union or non-union occurred in patients managed conservatively. Of sixty-three patients personally examined, the worst results found were those following conservative management of both fractures. More use of rigid external fixation and of cast bracing is recommended in the management of the fractured tibia, combined with internal fixation of the femoral fracture. Examination of the knee suggested that, with ipsilateral fractures, disruption of ligaments is a common occurrence and should always be suspected

1. A series of 705 fractures of the tibia is reviewed, 674 of which were treated conservatively. 2. The factors most conducive to delayed or non-union are initial displacement, comminution, associated soft-tissue wound and infection. The extent to which these are combined in any fracture determines its "personality" and its inherent propensity for union. 3. Eight fracture types are differentiated based on the above "personality rating." The incidence of delayed union or non-union varies from 9 per cent in the most favourable type to 39 per cent in the least favourable. Infection raises the incidence to 60 per cent. Comparative statistics which fail to recognise these differences can be entirely misleading. 4. Continuous traction does not retard union. 5. The results of conservative treatment are analysed with regard to union, deformity, stiff joints and contractures and the conclusion is reached that no case has yet been made out for internal fixation as the method of choice in the treatment of this fracture

1. A simple method of internal fixation of adult forearm fractures which gives consistent good results is necessary because the closed method of treatment is of limited application. 2. Open reduction of fractures without rigid internal fixation gives a high proportion of non-union and poor results. 3. Rigid internal fixation with standard plates and screws has been shown to give a low incidence of non-union in this series. 4. A three and a half inch long plate with six screws is suitable for most fractures, but if there is moderate or severe comminution, or if there is a segmental fracture, longer plates and more screws should be used to provide sound fixation. 5. Severely comminuted fractures with large avascular bone fragments should have the addition of a bone graft at the time of the plating operation in order that union may be assured. Thin strips of iliac bone are preferred. 6. Rigid plating is considered to be the most satisfactory treatment for open fractures. 7. Immobilisation of the limb after operation is not necessary and is undesirable if the fixation is rigid. 8. The functional results of this treatment are good and seemingly better than those achieved by other methods. 9. Serious complications of the plating operation are few and avoidable

Background

Due to the overwhelming demand for trauma services, resulting from increasing emergency department attendances over the past decade, virtual fracture clinics (VFCs) have become the fashion to keep up with the demand and help comply with the BOA Standards for Trauma and Orthopaedics (BOAST) guidelines. In this article, we perform a systematic review asking, “How useful are VFCs?”, and what injuries and conditions can be treated safely and effectively, to help decrease patient face to face consultations. Our primary outcomes were patient satisfaction, clinical efficiency and cost analysis, and clinical outcomes.

A study of a collected series of femoral neck fractures in seventy-one children observed for one to nineteen years shows:. 1. This injury is rare but occurs in children of all ages from three to sixteen years old. 2. The fractures may be classified as transepiphysial, transcervical (the commonest), basal and pertrochanteric. Displacement was frequent. 3. The fracture usually followed severe violence, especially falls from a height or motor accidents. 4. Complications were frequent and included avascular necrosis, delayed union (seventeen cases), non-union (seven cases) and disturbances of growth at both the upper and lower ends of the femur. 5. Avascular necrosis occurred in thirty patients (42 per cent). Three patterns of necrosis are described : diffuse, localised and confined to the femoral neck. The radiographic appearances of avascular necrosis after this fracture are different from those of pseudocoxalgia (Legg-Calvé-Perthes' disease). 6. Non-union did not occur after adequate primary internal fixation or after primary subtrochanteric osteotomy. 7. The management of an undisplaced fracture presented no great problem and the results were good. A plaster spica is recommended for treatment of this fracture. Exceptionally, avascular necrosis developed. 8. Treatment of the displaced fractures (forty-nine cases) was less satisfactory. A good result was obtained from primary treatment in only fifteen patients. 9. The value of different methods of primary treatment is discussed, including manipulative reduction and immobilisation in a plaster spica, manipulative reduction and internal fixation, and primary subtrochanteric osteotomy. Manipulative reduction and immobilisation in a plaster spica is not recommended. 10. Salvage operations were required in nineteen patients. Late subtrochanteric osteotomy is of value in the management of some of these problems

This study attempts to establish the factors on which the prognosis of an intracapsular fracture of the femoral neck depends, and to draw attention to certain causes of non-union and ischaemic necrosis. These factors are of two kinds: those inherent in the fracture, and those produced by the surgeon. The prognosis depends largely on the nature of the fracture. Original displacement and comminution are the factors which have most influence. Fractures of Type IV with severe comminution have mainly contributed to the bad reputation of intracapsular fractures. Accurate reduction and firm fixation are necessary if the best results for the type of fracture are to be expected. Accurate reduction does not mean merely accurate apposition of the fragments. Fixation of the fracture in certain rotational malpositions such as valgus of over 20 degrees and rotation round the long axis of the neck may occlude the only remaining source of blood supply, the vessels of the ligamentum teres. If these vessels remain open they may produce revascularisation in a femoral head deprived of its blood supply. The degree of valgus can easily be measured but it is impossible to detect rotation round the long axis of the neck. In this analysis only two methods of fixation were studied. It is clear that rigid fixation is of great significance, and a nail-plate, though it may not be the ideal method of fixation, is greatly superior to a Smith-Petersen nail introduced in the usual way. From the results of this survey there is no justification for continuing the use of this method except perhaps in Type II fractures. The greater the risk of non-union the more important is the fixation, and this is true of all fractures. This study also has a bearing on the indications for primary prosthetic replacement. If the nature of the fracture and the result of the reduction make it likely that replacement by a prosthesis is going to be the ultimate solution, and if the patient is over seventy years old, it is wiser to do it as a primary measure. Finally it was shown that condensation and collapse of the femoral head are not the only radiological signs of ischaemic necrosis. An earlier sign is flattening of the weight-bearing area, which appears on an average six and a half months after injury, as compared to condensation, which may not be apparent until eighteen months after injury

Introduction

In response to the COVID-19 pandemic, there was a rapidly implemented restructuring of UK healthcare services. The The Royal National Orthopaedic Hospital, Stanmore, became a central hub for the provision of trauma services for North Central/East London (NCEL) while providing a musculoskeletal tumour service for the south of England, the Midlands, and Wales and an urgent spinal service for London. This study reviews our paediatric practice over this period in order to share our experience and lessons learned. Our hospital admission pathways are described and the safety of surgical and interventional radiological procedures performed under general anaesthesia (GA) with regards to COVID-19 in a paediatric population are evaluated.