We have investigated the benefits of patient specific instrument guides, applied to osteotomies around the knee. Single, dual and triple planar osteotomies were performed on tibias or femurs in 14 subjects. In all patients, a detailed pre-operative plan was prepared based upon full leg standing radiographic and CT scan information. The planned level of the osteotomy and open wedge resection was relayed to the surgery by virtue of a patient specific guide developed from the images. The mean deviation between the planned wedge angle and the executed wedge angle was 0° (-1 to 1, sd 0.71) in the coronal plane and 0.3° (-0.9 to 3, sd 1.14) in the sagittal plane. The mean deviation between the planned hip, knee, ankle angle (HKA) on full leg standing radiograph and the post-operative HKA was 0.3° (-1 to 2, sd 0.75). It is concluded that this is a feasible and valuable concept from the standpoint of pre-operative software based planning, surgical application and geometrical accuracy of outcome.

Cite this article: Bone Joint J 2013;95-B, Supple A:153–8.

Forty-four children, treated conservatively for fracture of the shaft of a femur, were studied radiographically to assess the consequent increase in longitudinal growth of the bone. Overgrowth averaged 8.1 mm and was shown to be significantly greater in boys than in girls. Overgrowth did not appear to be influenced by the age of the patient, the type of injury, the type or site of the fracture, the amount of overlap of the fragments or by the handedness of the patient

Objectives

The purpose of this study was to investigate whether the femoral head–neck contour, characterised by the alpha angle, varies with the stage of physeal maturation using MRI evaluation of an asymptomatic paediatric population.

We investigated prospectively the bone mineral density (BMD) of the proximal femur after implantation of a tapered rectangular cementless stem in 100 patients with a mean age of 60 years (16 to 87). It was determined using dual energy x-ray absorptiometry, performed one week after surgery and then every six months until the end-point of five years. The BMD increased significantly in Gruen zones 2, 4 and 5 by 11%, 3% and 11% respectively, and decreased significantly in Gruen zones 1, 6 and 7 by 3%, 6% and 14% respectively, over the five-year period. The net mean BMD did not change over this time period. The changes in the BMD were not confined to the first 12 months after surgery. This investigation revealed no change in the overall periprosthetic BMD, but demonstrated a regional redistribution of bone mass from the proximal to distal zones

A comparative study of methods for treating fractures of the distal half of the femur was carried out prospectively in the five-year period January 1973 to December 1977. The three methods compared were conservative treatment on a Thomas' splint, application of a knee-hinged cast-brace at five to seven weeks, and intramedullary nailing. The time in bed, in hospital and to union were compared as was the rate of functional recovery of the knee. It is concluded that the cast-brace provides a safe reliable method of treatment, combining the advantages of non-operative management with the early mobilisation possible with intramedullary fixation but without the disadvantages of surgical treatment

1. The results in 211 fractures of the shaft of the femur in adults treated by internal fixation have been reviewed. 2. A comparison has been made between the effects of early internal fixation within the first six days of injury and delayed fixation. 3. Eighty-five fractures treated by early fixation gave a rate of non-union of 23 per cent; in 126 fractures treated by delayed fixation the rate was 0·8 per cent. 4. Delayed operation is therefore advocated for the majority of femoral shaft fractures for which internal fixation is indicated

We conducted a randomised controlled trial to compare external fixation of trochanteric fractures of the femur with the more costly option of the sliding hip screw. Patients in both groups were matched for age (mean 67 years, 50 to 100) and gender. We excluded all pathological fractures, patients presenting at more than one week, fractures with subtrochanteric extension or reverse obliquity, multiple fractures or any bone and joint disease interfering with rehabilitation. The interval between injury and operation, the duration of surgery, the amount of blood loss, the length of hospital stay and the cost of treatment were all significantly higher in the sliding hip screw group (p < 0.05). The time to union, range of movement, mean Harris hip scores and Western Ontario and McMaster University knee scores were comparable at six months. The number of patients showing shortening or malrotation was too small to show a significant difference between the groups. Pin-track infection occurred in 18 patients (60%) treated with external fixation, whereas there was a single case of wound infection (3.3%) in the sliding hip screw group

The role of radiotherapy and/or surgery in the local treatment of Ewing’s sarcoma has still to be determined. The outcome of Ewing’s sarcoma may differ according to its location and a selection bias towards surgery limits the ability to compare methods of local treatment. We have carried out a retrospective review of 91 consecutive patients treated for non-metastatic Ewing’s sarcoma of the femur. They received chemotherapy according to four different protocols. The primary lesion was treated by surgery alone (54 patients), surgery and radiotherapy (13) and radiotherapy alone (23). One was treated by chemotherapy alone. At a median follow-up of ten years, 48 patients (53%) remain free from disease, 39 (43%) have relapsed, two (2%) have died from chemotherapeutic toxicity and two (2%) have developed a radio-induced second tumour. The probability of survival without local recurrence was significantly (p = 0.01) higher in patients who were treated by surgery with or without radiotherapy (88%) than for patients who received radiotherapy alone (59%). The five- and ten-year overall survival rates were 64% and 57%, respectively. Patients who were treated by surgery, with or without radiotherapy, had a five- and ten-year overall survival of 64%. Patients who received only radiotherapy had a five- and ten-year survival of 57% and 44%, respectively. Our results indicate that in patients with Ewing’s sarcoma of the femur, better local control is achieved by surgical treatment (with or without radiotherapy) compared with the use of radiotherapy alone. Further studies are needed to verify the impact of this strategy on overall survival

It is unclear whether there is a limit to the amount of distal bone required to support fixation of supracondylar periprosthetic femoral fractures. This retrospective multicentre study evaluated lateral locked plating of periprosthetic supracondylar femoral fractures and compared the results according to extension of the fracture distal with the proximal border of the femoral prosthetic component. Between 1999 and 2008, 89 patients underwent lateral locked plating of a supracondylar periprosthetic femoral fracture, of whom 61 patients with a mean age of 72 years (42 to 96) comprising 53 women, were available after a minimum follow-up of six months or until fracture healing. Patients were grouped into those with fractures located proximally (28) and those with fractures that extended distal to the proximal border of the femoral component (33). Delayed healing and nonunion occurred respectively in five (18%) and three (11%) of more proximal fractures, and in two (6%) and five (15%) of the fractures with distal extension (p = 0.23 for delayed healing; p = 0.72 for nonunion, Fisher’s exact test). Four construct failures (14%) occurred in more proximal fractures, and three (9%) in fractures with distal extension (p = 0.51). Of the two deep infections that occurred in each group, one resolved after surgical debridement and antibiotics, and one progressed to a nonunion. Extreme distal periprosthetic supracondylar fractures of the femur are not a contra-indication to lateral locked plating. These fractures can be managed with internal fixation, with predictable results, similar to those seen in more proximal fractures

One hundred and seven patients with intertrochanteric fractures of the femur treated with a Richards screw-plate were compared retrospectively with 103 patients treated with a Jewett nail-plate. The mortality and morbidity were similar in the two groups. In patients with comparable fractures, those treated with a Richards device mobilised more quickly and left hospital sooner, and more of them returned to their homes. Failures of stabilisation, both clinically and radiographically, were fewer in this group. The reliability of fixation with a correctly positioned Richards screw-plate could justify the omission of outpatient follow-up in all but a small group of patients with severe unstable fractures or grossly defective bone stock. The higher cost of a Richards implant and the slightly longer operative procedure were outweighed by savings in occupancy of acute and long-stay hospital beds

We report the use of the uncemented Kotz modular femur and tibia reconstruction system after 95 distal femoral resections performed from 1983 to 1989. The average follow-up was 51 months; 62 patients had at least 36 months' follow-up and 36 at least 60 months. Complications required reoperation in 55%. The postoperative infection rate was 5% for primary cases, 6% for revision cases, and 43% for revision of previously infected cases. The polyethylene bushes failed in 42% of cases at an average of 64 months postoperatively. Stem breakage occurred in 6% and was associated with the use of narrow stems and extensive quadriceps excision. The radiological results were excellent or good in most cases and were related to the initial screw fixation, but not to age, chemotherapy, length of resection or size of stem. The clinical results were excellent or good in 75%, failure usually being associated with a complication, especially infection

1. Volkmann’s ischaemia is a real and threatening complication of fracture of the femur, and it is more common than reports in the literature would suggest. 2. The early signs and symptoms in the calf are ominous whereas the early vascular signs of a good tibial pulse, colour and temperature are often misleading. 3. Muscle decompression with or without arterial exploration has proved to be of no value. 4. Early recognition and radical treatment are imperative. Temporary paralysis of the lumbar sympathetic outflow has been shown to be an effective measure. 5. Transfixion of the calcaneum with a Kirschner wire for traction has the advantage of eliminating all bandages, suspending the tender calf and preventing an equinovarus deformity. 6. The only essential difference between the histological appearance of muscle which recovers and that which does not appears to be degeneration of muscle nuclei. The significance of engorged blood vessels remains in doubt. 7. Histological studies suggest that despite the typical gross appearance of an infarct some regeneration of muscle may occur

Coronal plane fractures of the posterior femoral condyle, also known as Hoffa fractures, are rare. Lateral fractures are three times more common than medial fractures, although the reason for this is not clear. The exact mechanism of injury is likely to be a vertical shear force on the posterior femoral condyle with varying degrees of knee flexion. These fractures are commonly associated with high-energy trauma and are a diagnostic and surgical challenge. Hoffa fractures are often associated with inter- or supracondylar distal femoral fractures and CT scans are useful in delineating the coronal shear component, which can easily be missed. There are few recommendations in the literature regarding the surgical approach and methods of fixation that may be used for this injury. Non-operative treatment has been associated with poor outcomes. The goals of treatment are anatomical reduction of the articular surface with rigid, stable fixation to allow early mobilisation in order to restore function. A surgical approach that allows access to the posterior aspect of the femoral condyle is described and the use of postero-anterior lag screws with or without an additional buttress plate for fixation of these difficult fractures.

Cite this article: Bone Joint J 2013;95-B:1165–71.

Previously, we showed that case-specific non-linear finite element (FE) models are better at predicting the load to failure of metastatic femora than experienced clinicians. In this study we improved our FE modelling and increased the number of femora and characteristics of the lesions. We retested the robustness of the FE predictions and assessed why clinicians have difficulty in estimating the load to failure of metastatic femora. A total of 20 femora with and without artificial metastases were mechanically loaded until failure. These experiments were simulated using case-specific FE models. Six clinicians ranked the femora on load to failure and reported their ranking strategies. The experimental load to failure for intact and metastatic femora was well predicted by the FE models (R² = 0.90 and R² = 0.93, respectively). Ranking metastatic femora on load to failure was well performed by the FE models (τ = 0.87), but not by the clinicians (0.11 < τ < 0.42). Both the FE models and the clinicians allowed for the characteristics of the lesions, but only the FE models incorporated the initial bone strength, which is essential for accurately predicting the risk of fracture. Accurate prediction of the risk of fracture should be made possible for clinicians by further developing FE models.

We report a prospective study of 26 cases of fracture of the distal third of the femur treated with the Derby intramedullary nail. This new design controls rotation and allows compression of the fracture, permitting early weight-bearing. All the fractures united in good position within four months, 12 of them with minimal external callus. There were no implant failures and the only serious complication was one case of deep infection

Aim and Methods

The goals of this study were to define the risk factors, nature, chronology, and treatment strategies adopted for periprosthetic femoral fractures in 32 644 primary total hip arthroplasties (THAs).

We report a prospective study of 198 cases of subcapital fracture of the femur treated by closed reduction and fixation with a sliding compression screw-plate. This was done without regard to the patient's age or the Garden stage of the fracture. Early weight-bearing was encouraged. Of the displaced fractures 23% failed in the first year because of non-union or infection. Of the fractures which united 27% had developed avascular necrosis after three years. Despite this we believe that the sliding compression screw-plate, of proven value in the treatment of intertrochanteric fractures, is also useful for the fixation of subcapital fractures

Filling the empty holes in peri-articular locking plates may improve the fatigue strength of the fixation. The purpose of this in vitro study was to investigate the effect of plugging the unused holes on the fatigue life of peri-articular distal femoral plates used to fix a comminuted supracondylar fracture model. 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 (. sd. 1500), 28 800 cycles (. sd.  6300), and 26 400 cycles (. sd. 2300) cycles for the unplugged, screw only and fully plugged configurations, respectively (p = 0.16). The mean number of cycles to failure for the run-out specimens was 42 800 cycles (. sd. 10 700), 36 000 cycles (. sd. 7200), and 36 600 cycles (. sd.  10 000) for the unplugged, screw only and fully plugged configurations, respectively (p = 0.50). There were also no differences in axial or torsional stiffness between the constructs. The failures were through the screw holes at the level of comminution. 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

1. A report is presented of the results of a trial to compare the effects of early and late weight-bearing in patients with a transcervical fracture of the femur treated by reduction of the fracture and internal fixation with a sliding nail-plate. 2. One hundred and twelve patients have been assessed clinically and radiologically three years after operation. 3. Retrospective analysis of factors that affect the outcome of treatment suggests that the two groups were fairly evenly balanced. 4. The results show that full weight-bearing two weeks after operation did not increase the incidence of failure of fixation or of non-union. 5. The higher incidence of superior segmental collapse in patients in whom weight-bearing was deferred for twelve weeks can be explained by the greater number of high fractures in this group and the greater number with a poor reduction

Inadequate bone stock is often found in revision surgery of femoral components of total knee replacements. Our aim was to test the hypothesis that these remodelling patterns can be explained by stress shielding, and that prosthetic bonding characteristics affect maintenance of bone mass. We made a three-dimensional finite-element model of an average male femur with a cemented femoral knee component. This model was integrated with iterative remodelling procedures. Two extreme prosthetic bonding conditions were analysed and gradual changes in bone density were calculated. The long-term bone loss under the femoral knee component resembled clinical findings which confirms the hypothesis that stress shielding can cause distal femoral bone loss. Our study predicts, contrary to clinical findings, that an equilibrium situation is not reached after two years, but that bone resorption may continue. This hidden bone loss may be so drastic that large reconstructions are needed at the time of revision