Fractures of the hip in children have been associated with a very high rate of serious complications including avascular necrosis (up to 47%) and coxa vara (up to 32%). Over a period of 20 years, we have treated displaced fractures by early anatomical reduction, internal fixation and immobilisation in a spica cast to try to reduce these complications. We have reviewed 18 patients who had a displaced non-pathological fracture of the hip when under 16 years of age. Their mean age at the time of the injury was eight years (2 to 13). They returned for examination and radiography at a mean follow-up of eight years (2 to 17). Each patient had been treated by early (″24 hours) closed or open reduction with internal fixation and 16 had immobilisation in a spica cast. By Delbet’s classification, there was one type-I, eight type-II, eight type-III, and one type-IV fractures. There were no complications in 15 patients. Avascular necrosis occurred in one patient (type-III), nonunion in one (type-II, one of the two patients who did not have a cast) and premature physeal closure in one (type-I). There were no cases of infection or complications as a result of the cast. Our treatment of displaced hip fractures in children by early reduction, internal fixation, and immobilisation in a spica cast gave reduced rates of complications compared with that of large published series in the literature

Aims

A lack of supporting clinical studies have been published to determine the ideal length of intramedullary nail in fixation of trochanteric fractures of the hip. Nevertheless, there has been a trend to use shorter intramedullary nails for the internal fixation of trochanteric hip fractures. Our aim was to determine if the length of nail affected the outcome.

We reviewed 110 patients with an unstable fracture of the pelvic ring who had been treated with a trapezoidal external fixator after a mean follow-up of 4.1 years. There were eight open-book (type B1, B3-1) injuries, 62 lateral compression (type B2, B3-2) and 40 rotationally and vertically unstable (type C1-C3) injuries. The rate of complications was high with loss of reduction in 57%, malunion in 58%, nonunion in 5%, infection at the pin site in 24%, loosening of the pins in 2%, injury to the lateral femoral cutaneous nerve in 2%, and pressure sores in 3%. The external fixator failed to give and maintain a proper reduction in six of the eight open-book injuries, in 20 of the 62 lateral compression injuries, and in 38 of the 40 type-C injuries. Poor functional results were usually associated with failure of reduction and an unsatisfactory radiological appearance. In type-C injuries more than 10 mm of residual vertical displacement of the injury to the posterior pelvic ring was significantly related to poor outcome. In 14 patients in this unsatisfactory group poor functional results were also affected by associated nerve injuries. In lateral compression injuries the degree of displacement of fractures of the pubic rami caused by internal rotation of the hemipelvis was an important prognostic factor. External fixation may be useful in the acute phase of resuscitation but it is of limited value in the definitive treatment of an unstable type-C injury and in type-B open-book injuries. It is usually unnecessary in minimally displaced lateral compression injuries

We have reviewed our recent results with functional bracing of tibial shaft fractures in adults in order to define its role in management. We also analysed several parameters of these fractures to discover those which influence healing. A total of 780 tibial fractures treated in prefabricated functional braces were followed to union; shortening of less than 10 mm and angulation of less than 5 degrees in any plane were our parameters for successful treatment. The average time before applying a brace was 3.8 weeks for closed fractures and 5.2 weeks for open ones. Closed fractures healed in an average of 17.4 weeks and open fractures in an average of 21.7 weeks, 90% of them with 10 mm of shortening or less. Varus angulation and posterior angulation were the most common deformities encountered at union. There were 20 nonunions (2.5%) and 46 braces were discontinued during treatment. We found no association between fracture healing and the patient's age, the mechanism of injury or the fracture location. The degree of soft tissue injury appeared to have most influence on the speed of fracture healing. Fracture comminution and initial displacement, the condition of the fibula and the time from injury to bracing also appeared to affect the speed of union

We have reviewed retrospectively 80 patients who were treated for traumatic fractures of the femur with a Grosse-Kempf nail to assess the incidence and causes of persisting pain in the proximal thigh. At a mean of 21 months after operation 33 patients had residual pain severe enough to interfere with their lifestyle or mobility. This was in the region of the scar on the greater trochanter in three-quarters of the patients. Only four showed no radiological abnormality. There was nonunion of the fracture in two, Paget’s disease in one, breakage of the nail in two and prominence of the proximal locking screw in five, although we found no correlation between prominence of the nail and pain. There was a strong relationship between pain and heterotopic ossification at the proximal end of the implant; this was present in 64% of the patients with pain as compared with those without pain (p < 0.001, Mann-Whitney U test). Of the 80 patients, 27 had the implant removed after 18 months, 17 of them because of pain. In six of these 17, the pain was not relieved. Prominence of the nail proximally was not associated with pain, but protuberance of laterally-based proximal locking screws caused problems. We found a strong association between heterotopic bone formation and pain, but it is uncertain whether this is the true cause or merely an indication of some other factor such as traumatic damage to the glutei during insertion of the nail. Removal of the implant does not always cure such pain

Autogenous bone graft which has been either autoclaved or irradiated is commonly used in oriental countries as an alternative to allograft. We started to use the technique of extracorporeal irradiation of the resected specimen and reimplantation (ECIR) in 1991. There was, however, a high incidence of fracture of the irradiated bone and loss of articular cartilage. In an attempt to reduce these complications, we combined the irradiated autograft with a conventional arthroplasty. Between 1995 and 1998, 14 patients underwent limb salvage by this method. Seven had an osteosarcoma, two bony metastases, three a chondrosarcoma, one a malignant fibrous histiocytoma, and one a leiomyosarcoma. Ten tumours were located in the proximal femur, two in the proximal humerus, and two in the distal femur. One patient who had a solitary metastasis in the proximal part of the left femur died from lung metastases 13 months after operation. The remaining 13 patients were alive and without evidence of local recurrence or distant metastases at a mean follow-up of 43 months (28 to 72). Postoperative palsy of the sciatic nerve occurred in one patient, but no complications such as wound infection, fracture, or nonunion were seen. All host-irradiated bone junctions healed uneventfully within eight months. Using the Enneking functional evaluation system, the mean postoperative score for all 14 patients was 80% (57 to 93). The use of irradiated autograft prosthesis composites reduces the complications of ECIR and gives good functional results. It may be a good alternative in limb-salvage surgery, especially in countries where it is difficult to obtain allografts

Aims

To validate the Sydney Hamstring Origin Rupture Evaluation (SHORE), a hamstring-specific clinical assessment tool to evaluate patient outcomes following surgical treatment.

Aims

Severe spinal deformity in growing patients often requires surgical management. We describe the incidence of spinal deformity surgery in a National Health Service.

Aims

There is little information about how to manage patients with a recurvatum deformity of the distal tibia and osteoarthritis (OA) of the ankle. The aim of this study was to evaluate the functional and radiological outcome of addressing this deformity using a flexion osteotomy and to assess the progression of OA after this procedure.

The current standard recommendation for antibiotic therapy in the management of chronic osteomyelitis is intravenous treatment for six weeks. We have compared this regime with short-term intravenous therapy followed by oral dosage. A total of 93 patients, with chronic osteomyelitis, underwent single-stage, aggressive surgical debridement and appropriate soft-tissue coverage. Culture-specific intravenous antibiotics were given for five to seven days, followed by oral therapy for six weeks. During surgery, the scar, including the sinus track, was excised en bloc. We used a high-speed, saline-cooled burr to remove necrotic bone, and osseous laser Doppler flowmetry to ensure that the remaining bone was viable. Infected nonunions (Cierny stage-IV osteomyelitis) were stabilised by internal fixation. In 38 patients management of dead space required antibiotic-impregnated polymethylmethacrylate beads, which were exchanged for an autogenous bone graft at six weeks. Free-tissue transfer often facilitated soft-tissue coverage. These 93 patients were compared with 22 consecutive patients treated previously who had the same surgical management, but received culture-specific intravenous antibiotics for six weeks. Of the 93 patients, 80 healed without further intervention. Of the 31 Cierny-IV lesions, 27 healed without another operation, and four fractures required additional bone grafts. No more wound drainage was needed. Treatment was successful in 91% of patients, regardless of the organism involved. There was no difference in outcome in terms of these variables when the series were compared. We conclude that the long-term administration of intravenous antibiotics is not necessary to achieve a high rate of clinical resolution of wound drainage for adult patients with chronic osteomyelitis

Aims

The Precice intramedullary limb-lengthening system has demonstrated significant benefits over external fixation lengthening methods, leading to a paradigm shift in limb lengthening. This study compares outcomes following antegrade and retrograde femoral lengthening in both adolescent and adult patients.

We describe the results of treatment of open fractures of the humerus, radius and ulna in 61 children. Most were due to low-energy trauma and were rarely associated with head or other injuries; 72% were Gustilo type I, 15% type II and 13% type III. Fifteen children (25%) had open diaphyseal, supracondylar or T-shaped fractures of the humerus. Arterial injuries occurred in two (13%) and nerve injuries in 7 (47%). All nerve injuries recovered spontaneously. The long-term results in 13 children were excellent or good in 11 (85%) and fair in two (15%). Forty-six children (75%) had open forearm fractures. Arterial injuries occurred in one (2%), nerve injuries in five (11%) and a compartment syndrome in five (11%). Ruptured radial and ulnar arteries and median and ulnar nerves were repaired in one child. All other nerve injuries resolved spontaneously. Early compartment release in five children prevented Volkmann's ischaemic contracture. Normal union occurred in only 36 children (78%). Delayed union, nonunion, malunion and refracture frequently complicated type-II and type-III fractures of the shafts of the radius and ulna. The long-term results in 38 children were excellent or good in 33 (87%), fair in 4 (11%) and poor in one (2%). The short-term results for open fractures of the humerus were better than for open fractures of the forearm, but the long-term results were similar being excellent or good in 86% of the children

This retrospective study analyses the results of subtalar bone block distraction arthrodesis used in the treatment of late complications of calcaneal fractures, acute severely comminuted fractures, nonunion (and malunion) of attempted subtalar arthrodeses, avascular necrosis of the talus, and club-foot deformity. Of 39 patients (41 feet) who had this procedure, 35 (37 feet) returned for follow-up after a mean of 70 months (26 to 140). There were 24 men (25 feet) and 11 women (12 feet) with a mean age of 41 years (16 to 63). Each completed a standardised questionnaire, based on the hindfoot-scoring system of the American Orthopaedic Foot and Ankle Society and were reviewed both clinically and radiologically. Of the 37 operations, 32 (87%) achieved union. The mean hindfoot score (maximum of 94 points) increased from 21.1 points (8 to 46) preoperatively to 68.9 (14 to 82) at the final follow-up. The mean talocalcaneal and calcaneal pitch angles were 20.5° and 4.9° before operation, 25.9° and 8.3° immediately after, and 24.6° and 7.7° at the final follow-up, respectively. The mean talar declination angle improved from 6.5° (−10 to 22) before operation to 24.8° (14 to 32) at the final follow-up. The mean talocalcaneal height increased from 68.7 mm before operation to 74.5 mm immediately after and 73.5 mm at the final follow-up. Of the 37 arthrodeses available for review, 32 were successful; 29 patients (30 arthrodeses) were satisfied with the procedure. Minimal loss of hindfoot alignment occurred when comparing radiographs taken immediately after operation and at final follow-up

Abstract

The medial malleolus, once believed to be the primary stabilizer of the ankle, has been the topic of conflicting clinical and biomechanical data for many decades. Despite the relevant surgical anatomy being understood for almost 40 years, the optimal treatment of medial malleolar fractures remains unclear, whether the injury occurs in isolation or as part of an unstable bi- or trimalleolar fracture configuration. Traditional teaching recommends open reduction and fixation of medial malleolar fractures that are part of an unstable injury. However, there is recent evidence to suggest that nonoperative management of well-reduced fractures may result in equivalent outcomes, but without the morbidity associated with surgery. This review gives an update on the relevant anatomy and classification systems for medial malleolar fractures and an overview of the current literature regarding their management, including surgical approaches and the choice of implants.

Cite this article: Bone Joint J 2019;101-B:512–521.

Objectives

The aim of this study was to assess the clinical application of, and optimize the variables used in, the BACH classification of long-bone osteomyelitis.

Implant-related infection is one of the leading reasons for failure in orthopaedics and trauma, and results in high social and economic costs. Various antibacterial coating technologies have proven to be safe and effective both in preclinical and clinical studies, with post-surgical implant-related infections reduced by 90% in some cases, depending on the type of coating and experimental setup used. Economic assessment may enable the cost-to-benefit profile of any given antibacterial coating to be defined, based on the expected infection rate with and without the coating, the cost of the infection management, and the cost of the coating. After reviewing the latest evidence on the available antibacterial coatings, we quantified the impact caused by delaying their large-scale application. Considering only joint arthroplasties, our calculations indicated that for an antibacterial coating, with a final user’s cost price of €600 and able to reduce post-surgical infection by 80%, each year of delay to its large-scale application would cause an estimated 35 200 new cases of post-surgical infection in Europe, equating to additional hospital costs of approximately €440 million per year. An adequate reimbursement policy for antibacterial coatings may benefit patients, healthcare systems, and related research, as could faster and more affordable regulatory pathways for the technologies still in the pipeline. This could significantly reduce the social and economic burden of implant-related infections in orthopaedics and trauma.

Cite this article: C. L. Romanò, H. Tsuchiya, I. Morelli, A. G. Battaglia, L. Drago. Antibacterial coating of implants: are we missing something? Bone Joint Res 2019;8:199–206. DOI: 10.1302/2046-3758.85.BJR-2018-0316.