We retrospectively reviewed 101 consecutive patients
with 114 femoral tumours treated by massive bone allograft at our
institution between 1986 and 2005. There were 49 females and 52
males with a mean age of 20 years (4 to 74). At a median follow-up
of 9.3 years (2 to 19.8), 36 reconstructions (31.5%) had failed.
The allograft itself failed in 27 reconstructions (24%). Mechanical complications such as delayed union, fracture and
failure of fixation were studied. The most adverse factor on the
outcome was the use of intramedullary nails, followed by post-operative
chemotherapy, resection length >
17 cm and age >
18 years at the
time of intervention. The simultaneous use of a vascularised fibular
graft to protect the allograft from mechanical complications improved
the outcome, but the use of intramedullary cementing was not as
successful. In order to improve the strength of the reconstruction and to
advance the biology of host–graft integration, we suggest avoiding
the use of intramedullary nails and titanium plates, but instead
using stainless steel plates, as these gave better results. The
use of a supplementary vascularised fibular graft should be strongly
considered in adult patients with resection >
17 cm and in those
who require post-operative chemotherapy.
Arteriovenous fistula formation after a closed
extremity fracture is rare. We present the case of an 11-year-old
boy who developed an arteriovenous fistula between the anterior
tibial artery and popliteal vein after closed fractures of the proximal
tibia and fibula. The fractures were treated by closed reduction
and casting. A fistula was diagnosed 12 weeks after the injury.
It was treated by embolisation with coils. Subsequent angiography
and ultrasonography confirmed patency of the popliteal vein and
anterior and posterior tibial and peroneal arteries, with no residual shunting
through the fistula. The fractures healed uneventfully and he returned
to full unrestricted activities 21 weeks after his injury.
Sacral insufficiency fractures are traditionally treated with bed rest and analgesia. The importance of early rehabilitation is generally appreciated; but pain frequently delays this, resulting in prolonged hospital stay and the risk of complications related to immobility. We describe three women with sacral insufficiency fractures who were treated with percutaneous sacroiliac screws and followed up for a mean of 18 months (12 to 24). They had immediate pain relief, uncomplicated rehabilitation and uneventful healing.
We analysed 54 alumina ceramic-on-ceramic bearings
from total hip replacements retrieved at one centre after a mean
duration of 3.5 years (0.2 to 10.6)
The incidence of deep-vein thrombosis and the need for thromboprophylaxis following isolated trauma below the knee is uncertain. We have investigated this with a prospective randomised double-blind controlled trial using low molecular weight heparin with saline injection as placebo in patients aged between 18 and 75 years who had sustained an isolated fracture below the knee which required operative fixation. All patients had surgery within 48 hours of injury and were randomised to receive either the placebo or low molecular weight heparin for 14 days, after which they underwent bilateral lower limb venography, interpreted by three independent radiologists. Further follow-up was undertaken at two, six, eight and 12 weeks. A total of 238 patients fulfilled all the inclusion criteria, with 127 in the low molecular weight heparin group and 111 in the placebo group, all of whom underwent bilateral venography. There was no statistically significant difference in the incidence of deep-vein thrombosis between those patients treated with low molecular weight heparin or the placebo (p = 0.22). The number of deep-vein thromboses in the two groups was 11 (8.7%) and 14 (12.6%), respectively. Age and the type of fracture were significantly associated with the rate of deep-vein thrombosis (p = 0.001 and p = 0.009, respectively) but gender, comorbidities and the body mass index were not. The overall incidence of deep-vein thrombosis in this series was 11%. There was no clinical or statistical significant reduction in the incidence of deep-vein thrombosis with the use of thromboprophylaxis. However, we accept that owing to a cessation of funding, recruitment to this trial had to be ended prior to establishing the necessary sample size. Our results cannot, therefore, categorically exclude the possibility that low molecular weight heparin treatment could be beneficial. We recommend a further multicentre trial be undertaken to resolve this matter.
With the established success of the National
Joint Registry and the emergence of a range of new national initiatives for
the capture of electronic data in the National Health Service, orthopaedic
surgery in the United Kingdom has found itself thrust to the forefront
of an information revolution. In this review we consider the benefits
and threats that this revolution poses, and how orthopaedic surgeons
should marshal their resources to ensure that this is a force for
good.
To assess the sensitivity and specificity of self-reported osteoporosis
compared with dual energy X-ray absorptiometry (DXA) defined osteoporosis,
and to describe medication use among participants with the condition. Data were obtained from a population-based longitudinal study
and assessed for the prevalence of osteoporosis, falls, fractures
and medication use. DXA scans were also undertaken.Objectives
Methods
Controversy continues to surround the management
of patients with an open fracture of the lower limb and an associated
vascular injury (Gustilo type IIIC). This study reports our 15-year
experience with these fractures and their outcome in 18 patients
(15 male and three female). Their mean age was 30.7 years (8 to
54) and mean Mangled Extremity Severity Score (MESS) at presentation
was 6.9 (3 to 10). A total of 15 lower limbs were salvaged and three underwent
amputation (two immediate and one delayed). Four patients underwent
stabilisation of the fracture by external fixation and 12 with an
internal device. A total of 11 patients had damage to multiple arteries
and eight had a vein graft. Wound cover was achieved with a pedicled
flap in three and a free flap in six. Seven patients developed a
wound infection and four developed nonunion requiring further surgery.
At a mean follow-up of five years (4.1 to 6.6) the mean visual analogue
scale for pain was 64 (10 to 90). Depression and anxiety were common.
Activities were limited mainly because of pain, and the MESS was
a valid predictor of the functional outcome. Distal tibial fractures
had an increased rate of nonunion when associated with posterior
tibial artery damage, and seven patients (39%) were not able to
return to their previous occupation.
In the management of a pelvic fracture prompt recognition of an unstable fracture pattern is important in reducing mortality and morbidity. It is believed that a fracture of the transverse process of L5 is a predictor of pelvic fracture instability. However, there is little evidence in the literature to support this view. The aim of this study was to determine whether a fracture of the transverse process of L5 is a reliable predictor of pelvic fracture instability. We reviewed our hospital trauma database and identified 80 patients who sustained a pelvic fracture between 2006 and 2010. There were 32 women and 48 men with a mean age of 40 years (10 to 96). Most patients were injured in a road traffic accident or as a result of a fall from a height. A total of 41 patients (51%) had associated injuries. The pelvic fractures were categorised according to the Burgess and Young classification. There were 45 stable and 35 unstable fractures. An associated fracture of the transverse process of L5 was present in 17 patients; 14 (40%) of whom had an unstable fracture pattern. The odds ratio for an unstable fracture of the pelvis in the presence of a fracture of the transverse process of L5 was 9.3 and the relative risk was 2.5. A fracture of the transverse process of L5 in the presence of a pelvic fracture is associated with an increased risk of instability of the pelvic fracture. Its presence should alert the attending staff to this possibility.
Antegrade intramedullary nailing of fractures of the shaft of the humerus is reported to cause impairment of the shoulder joint. We have reviewed 33 patients with such fractures to assess how many had injuries to the ipsilateral shoulder. All had an MR scan of the shoulder within 11 days of injury. The unaffected shoulder was also scanned as a control. There was evidence of abnormality in 21 of the shoulders (63.6%) on the injured side; ten had bursitis of the subacromial space, five evidence of a partial tear of the rotator cuff, one a complete rupture of the supraspinatus tendon, four inflammatory changes in the acromioclavicular joint and one a fracture of the coracoid process. These injuries may contribute to pain and dysfunction of the shoulder following treatment, and their presence indicates that antegrade nailing is only partly, if at all, responsible for these symptoms.
In a randomised trial involving 598 patients
with 600 trochanteric fractures of the hip, the fractures were treated with
either a sliding hip screw (n = 300) or a Targon PF intramedullary
nail (n = 300). The mean age of the patients was 82 years (26 to
104). All surviving patients were reviewed at one year with functional
outcome assessed by a research nurse blinded to the treatment used.
The intramedullary nail was found to have a slightly increased mean
operative time (46 minutes ( In summary, both implants produced comparable results but there
was a tendency to better return of mobility for those treated with
the intramedullary nail.
To investigate the differences of open reduction and internal
fixation (ORIF) of complex AO Type C distal radius fractures between
two different models of a single implant type. A total of 136 patients who received either a 2.4 mm (n = 61)
or 3.5 mm (n = 75) distal radius locking compression plate (LCP
DR) using a volar approach were followed over two years. The main
outcome measurements included motion, grip strength, pain, and the
scores of Gartland and Werley, the Short-Form 36 (SF-36) and the
Disabilities of the Arm, Shoulder, and Hand (DASH). Differences
between the treatment groups were evaluated using regression analysis
and the likelihood ratio test with significance based on the Bonferroni
corrected p-value of <
0.003.Objectives
Methods
Supination-external rotation (SER) fractures of the ankle may present with a medial ligamentous injury that is not apparent on the initial radiographs. A cadaver gravity-stress view has been described, but the manual-stress view is considered to be the examination of choice for the diagnosis of medial injuries. We prospectively compared the efficacy of these two examinations. We undertook both examinations in 29 patients with SER fractures. Of these, 16 (55%) were stress-positive, i.e. and had widening of the medial clear space of >
4 mm with a mean medial clear space of 6.09 mm (4.4 to 8.1) on gravity-stress and 5.81 mm (4.0 to 8.2) on manual-stress examination, and 13 patients (45%) were stress-negative with a mean medial clear space of 3.91 mm (3.3 to 5.1) and 3.61 mm (2.6 to 4.5) on examination of gravity- and manual-stress respectively. The mean absolute visual analgoue scale score for discomfort in the examination of gravity stress was 3.45 (1 to 6) and in the manual-stress procedure 6.14 (3 to 10). We have shown that examination of gravity-stress is as reliable and perceived as more comfortable than that of manual stress. We recommend using it as the initial diagnostic screening examination for the detection of occult medial ligamentous injuries in SER fractures of the ankle.
Over the past 40 years, the management of displaced fractures of the acetabulum has changed from conservative to operative. We have undertaken a meta-analysis to evaluate the classification, the incidence of complications and the functional outcome of patients who had undergone operative treatment of such injuries. We analysed a total of 3670 fractures. The most common long-term complication was osteoarthritis which occurred in approximately 20% of the patients. Other late complications, including heterotopic ossification and avascular necrosis of the femoral head, were present in less than 10%. However, only 8% of patients who were treated surgically needed a further operation, usually a hip arthroplasty, and between 75% and 80% of patients gained an excellent or good result at a mean of five years after injury. Factors influencing the functional outcome included the type of fracture and/or dislocation, damage to the femoral head, associated injuries and co-morbidity which can be considered to be non-controllable, and the timing of the operation, the surgical approach, the quality of reduction and local complications which are all controllable. The treatment of these injuries is challenging. Tertiary referrals need to be undertaken as early as possible, since the timing of surgery is of the utmost importance. It is important, at operation, to obtain the most accurate reduction of the fracture which is possible, with a minimal surgical approach, as both are related to improved outcome.
Filling the empty holes in peri-articular locking
plates may improve the fatigue strength of the fixation. The purpose of
this A locking/compression plate was applied to 33 synthetic femurs
and then a 6 cm metaphyseal defect was created (AO Type 33-A3).
The specimens were then divided into three groups: unplugged, plugged
with locking screw only and fully plugged holes. They were then
tested using a stepwise or run-out fatigue protocol, each applying
cyclic physiological multiaxial loads. All specimens in the stepwise group failed at the 770 N load
level. The mean number of cycles to failure for the stepwise specimen
was 25 500 cycles ( In conclusion, filling the empty combination locking/compression
holes in peri-articular distal femur locking plates at the level
of supracondylar comminution does not increase the fatigue life
of the fixation in a comminuted supracondylar femoral fracture model
(AO 33-A3) with a 6 cm gap.
A displaced fracture of the scaphoid is one in
which the fragments have moved from their anatomical position or there
is movement between them when stressed by physiological loads. Displacement
is seen in about 20% of fractures of the waist of the scaphoid,
as shown by translation, a gap, angulation or rotation. A CT scan
in the true longitudinal axis of the scaphoid demonstrates the shape
of the bone and displacement of the fracture more accurately than
do plain radiographs. Displaced fractures can be treated in a plaster
cast, accepting the risk of malunion and nonunion. Surgically the
displacement can be reduced, checked radiologically, arthroscopically
or visually, and stabilised with headless screws or wires. However,
rates of union and deformity are unknown. Mild malunion is well
tolerated, but the long-term outcome of a displaced fracture that
healed in malalignment has not been established. This paper summarises aspects of the assessment, treatment and
outcome of displaced fractures of the waist of the scaphoid.
Free vascularised fibular grafting has been reported
to be successful for adult patients with osteonecrosis of the femoral
head (ONFH). However, its benefit in teenage patients with post-traumatic
ONFH has not been determined. We evaluated the effectiveness of
free vascularised fibular grafting in the treatment of this condition
in children and adolescents. We retrospectively analysed 28 hips
in 28 patients in whom an osteonecrotic femoral head had been treated
with free vascularised fibular grafting between 2002 and 2008. Their
mean age was 16.3 years (13 to 19). The stage of the disease at
time of surgery, and results of treatment including pre- and post-operative
Harris hip scores, were studied. We defined clinical failure as
conversion to total hip replacement. All patients were followed
up for a mean of four years (2 to 7). The mean Harris hip score
improved from 60.4 (37 to 84) pre-operatively to 94.2 (87 to 100)
at final follow-up. At the latest follow-up we found improved or
unchanged radiographs in all four initially stage II hips and in
23 of 24 stage III or IV hips. Only one hip (stage V) deteriorated.
No patient underwent total hip replacement. Free vascularised fibular grafting is indicated for the treatment
of post-traumatic ONFH in teenage patients.
A high rate of complications is associated with open reduction and internal fixation of Sanders type 4 fractures of the calcaneum. We assessed the long-term outcome of 83 Sanders type 4 comminuted intra-articular fractures of the calcaneum in 64 patients who underwent non-operative treatment between 1999 and 2005. Each fracture was treated by closed reduction and immobilisation in a long leg cast. Patients were reviewed every three months in the first year, and every six months thereafter. At each visit, the involved ankles were assessed by the American Orthopaedic Foot and Ankle Society (AOFAS) criteria. The degree of fracture healing and the presence of osteoarthritis were assessed. At a mean follow-up of 51 months (24 to 70) the mean AOFAS score was 72 (52 to 92). Osteoarthritis was scored radiologically using Graves’ classification and was evident in the subtalar joints of 75 ankles (90%) on x-ray and in all ankles on CT scans, of which 20 were grade 0 or 1, 39 grade 2, and 24 grade 3. A non-operative approach to treating these fractures may be simpler, less expensive, easier to administer with fewer complications, and may be better tolerated than surgery, by many patients.
This study investigated the anatomical relationship between the clavicle and its adjacent vascular structures, in order to define safe zones, in terms of distance and direction, for drilling of the clavicle during osteosynthesis using a plate and screws following a fracture. We used reconstructed three-dimensional CT arteriograms of the head, neck and shoulder region. The results have enabled us to divide the clavicle into three zones based on the proximity and relationship of the vascular structures adjacent to it. The results show that at the medial end of the clavicle the subclavian vessels are situated behind it, with the vein intimately related to it. In some scans the vein was opposed to the posterior cortex of the clavicle. At the middle one-third of the clavicle the artery and vein are a mean of 17.02 mm (5.4 to 26.8) and 12.45 mm (5 to 26.1) from the clavicle, respectively, and at a mean angle of 50° (12 to 80) and 70° (38 to 100), respectively, to the horizontal. At the lateral end of the clavicle the artery and vein are at mean distances of 63.4 mm (46.8 to 96.5) and 75.67 mm (50 to 109), respectively. An appreciation of the information gathered from this study will help minimise the risk of inadvertent iatrogenic vascular injury during plating of the clavicle.