The purpose of this study is to describe the use of the PHILOS plate (Synthes) in reverse configuration to treat complex distal humeral non-unions.

Non-union is a frequent complication of distal humeral fracture. It is a challenging problem due to the complex anatomy of the distal humerus, small distal fragment heavily loaded by the forearm acting as a long lever arm with powerful forces increasing the chances of displacement. Rigid fixation and stability with a device of high “pull-out” strength is required. The PHILOS plate has been used in reverse configuration to achieve good fixation while allowing central posterior placement of the implant.

11 patients with established non-union of distal humeral fractures were included in this study. No patient in whom this implant was used has been excluded. Initial fixation was revised using the PHILOS plate in reverse configuration and good fixation was achieved. Bone graft substitutes were used in all cases. Patients were followed to bony union, and functional recovery.

All fractures united. One required revision of plate due to fatigue failure. Average time to union was 8 months with excellent restoration of elbow function.

A reversed PHILOS plate provides an excellent method of fixation in distal humeral non-union, often complicated by distorted anatomy and previous surgical intervention. It has a high “pull-out” strength and may be placed in the centre of the posterior humerus, allowing proximal extension of the fixation as far as is required. It provides secure distal fixation without impinging on the olecranon fossa. It is more versatile and easier to use than available pre contoured plating systems.

The purpose of this study was to identify the prevalence of common mental disorders in patients undergoing complex limb reconstruction.

Patients undergoing limb reconstruction are vulnerable to mental health problem as they must adapt to significant and prolonged physical disability. Treatment emphasis has been on restoration and rehabilitation of physical health with little or no attention given to spectrum of psychological consequences. IMPARTS (Integrating Mental and Physical healthcare: Research, Training and Services) is a King's Health Partners initiative aiming to develop informatics to improve detection and management of common mental disorders in medical settings. IMPARTS screening in the King's College Hospital limb reconstruction clinic commenced in April 2012.

Outpatients attending between April 2012 and November 2013 were screened prior to their appointment. Patients were screened for symptoms of depression, anxiety, post-traumatic stress disorder (PTSD), alcohol dependence and drug use.

In total, 298 individual patients were screened. The prevalence of depression was found to be 21.8%, with 6.4% experiencing suicidal thoughts. Probable anxiety disorder was identified in 20.7% of patients. Symptoms of PTSD were reported by 29.2%, with 9.0% reporting severe symptoms. Probable alcohol dependence was identified in 2.7% of patients, and 3.0% screened positive for drug misuse.

The consequences of undergoing limb reconstruction stretch beyond the physical problem to mental well-being, rendering patients vulnerable to mental health problems and substance misuse. Early detection and management of such problems may have a significant effect on physical treatment outcome and rehabilitation to productive social life. There is urgent need to integrate mental health care as part of early management of severely injured patients.

The purpose of this study is to describe the use of intramedullary distraction coupled with an additional osteotomy to achieve union with simultaneous deformity correction and lengthening in femoral non-union.

Femoral non-union is a difficult problem often associated with shortening, angulation, and mal-rotation. We report the use of an intramedullary distraction device, with additional osteotomy, to achieve union, restore femoral length and alignment. Simple distraction in femoral non-union is often ineffective, possibly because the non-union site is relatively avascular. Osteotomy is known to increase blood flow and, with lengthening, promote union through distraction histiogenesis.

7 patients with posttraumatic diaphyseal femoral non-union with shortening were studied. Pre-operative planning included long leg standing views, with CT to measure mal-rotation. 6 patients were treated with the Intramedullary Skeletal Kinetic Distractor (ISKD) with an osteotomy distant from non-union site within the parameters required for the device. One patient underwent distraction without osteotomy. Patients were followed to union. Complications and adjuvant interventions were recorded.

All 7 patients with femoral non-union treated with ISKD were included and followed up. Patients treated with osteotomy united at average of 9 months with satisfactory deformity correction and lengthening. However patient who underwent pure distraction failed to unite. Complications included failure to lengthen, requiring manipulation, and delayed consolidation of regenerate requiring bone graft. The procedure was well tolerated

The initial results of the management of femoral non-union with deformity by intramedullary distraction coupled with osteotomy are encouraging. Complications were minor and readily manageable. We believe there is an important role for this method in the management of femoral non-unions associated with deformity and length discrepancy.

The results of a multi-surgeon, multi-implant series of patellofemoral joint arthroplasty performed over a ten year period are presented. All patellofemoral joint arthroplasty performed from the years 1996 to 2006 were retrospectively reviewed using case notes, radiographs and clinic appointments until their latest follow-up period.

101 arthroplasties in 91 patients were followed up for average period of 48 months (range 6–96 months). The average age was 57 years with female patients thrice as common as male patients. There were 5 (5%) complications with 1 deep infection and 4 stiff knees. 35 subsequent procedures were performed in 28 patients including arthroscopic debridement in 18, arthroscopic lateral retinacular release in 8, tibial tuberosity transfer in 3, manipulation for stiffness in 2, and revision to total knee arthroplasty in 4 patients (3 for progression of tib-iofemoral osteoarthritis and 1 for infection).

The necessity of further surgeries in one third of the study group suggests that close follow-up of these patients is needed to address any concerns that can be easily resolved.

Introduction: Authors aim to present an interesting series of calcaneal tumors accrued from Scottish Bone Tumor Registry. The available literature is largely limited to the case reports. Bony tumors of the foot account for approximately 3% of all osseous tumors (1), of which Calcaneal location is the second most common site after the metatarsals in the foot. This study describes tumors of varying aetiology with regard to epidemiology, clinical features, diagnostic findings, treatment modalities and outcome.

Material and Methods: This study is a retrospective review of the medical records and imaging modalities of forty patients with calcaneal tumors which were accrued from Scottish Bone Tumor Registry between January 1954 and December 2006. Patient demographics including presentation characteristics, and delay in the presentation from the onset of symptoms were noted. Plain radiographs followed by further imaging with CT, MR and Bone scanning were reviewed. Size, location and spread of the tumors were noted based on imaging modalities. The type of biopsy, histological diagnosis, type of resection and adjuvant therapy was noted. All patients were followed-up clinically and radiologically for a minimum of 2 yrs or until death

Results: There were 28 primary benign, 11 primary malignant and 1 secondary malignant tumors. In the cohot of 40 patients 26 were male and 14 females with mean age of 27 years. Pain (37/40), swelling (27/40) and restriction of movements (25/40) were the main presenting features. Pathological fractures were found in 4 patients. Mean duration of symptoms was 12 months. Histological diagnoses included Osteoid Osteoma (4/40), PVNS (4/40), Chondroblastoma (3/40), Simple bone cyst (3/40), ABC (3/40), GCT (3/40), Osteochondroma (2/40), Chondroblastoma, Enchondroma, Fibrous Histiocytoma and Glomus tumour (1 case each). Chondrosarcoma, Ewing’s and Paget’s sarcoma (2 cases each), Osteosarcoma, Spindle cell and Pleomorphic Sarcoma (1 case each). Thirty eight patients underwent operative management.

Summary: Current study is one of the largest reported series of calcaneal tumors. A wide variety of lesions seem to involve patients from different age groups and either sex. Presentation features include mainly pain and swelling aggravated by walking. Radiological features may differ than those reported for common locations for the given tumor type. The recurrence rate for benign bone forming as well as cartilage tumors seem to be low provided adequate curettage or excision has been carried out. Whereas most benign lesions can be managed with limb salvage, below knee amputation sees to be a standard operation for primary malignant tumors. Metastatic lesions have poor survival prognosis.

Purpose: To present results of a series of patients treated with Trapeziectomy, Ligament Reconstruction and Tendon Interposition for treatment of 1st CMC joint arthritis.

Methods: 59 patients (65 thumbs) from Single surgeons’ practice were prospectively followed by 2 independent observers who did not participate in the study. Patient demographics, occupation, handedness, symptoms and clinical findings were recorded. Objective assessment including pinch and grip strength was carried out by the Occupational therapists. Functional outcome assessment was done using questionnaire designed by senior author. Patients were asked to evaluate the operation using the subjective assessment component of Buck-Gramcko score. Radiographs were studied for Trapezial space and arthroplasty space. Analysis was carried out using SPSS statistical software.

Results: A total of 59 patients at an average age of 62 years were followed up for an average of 25 months. Six patients had bilateral procedures. Average follow up was 3.5 years with minimum follow up being 3 years. Osteoarthritis was the commonest diagnosis accounting for 53 (91%) patients and rheumatoid arthritis in 6 (9%) of patients. 48 cases (82%) were Stage IV and 15 cases (18%) Stage V. Mean duration of symptomsbefore the surgical intervention was 36 months. 3 patients developed superficial wound infection and 4 patients developed reflex sympathetic dystrophy. The results suggested pinch strength and grip strength improved to 50% and 22.5% respectively, as compared to pre-operative value.

Conclusion: Treatment options for 1st CMC joint arthritis have evolved over time. Many prospective randomized studies have shown lack of advantage of LRTI as compared to trapeziectomy alone, but these studies are not free from limitations. The present study is one of the largest reported single surgeon series and benefits from aprospectively maintained database with minimum 3 years follow up. The study rises above the existing limitations in the literature and reinforces concept of Ligament Reconstruction and Tendon Interposition.

Level of Evidence: Level II (Prospective study)

Purpose: Isolated patellofemoral joint (PFJ) osteoarthritis has long been a common observation as an important source of knee pain. Once non-operative treatment modalities have been exhausted, the surgical options available are transposition/elevation of tibial tubercle, drilling, realignment procedures, patellectomy, patellar resurfacing, patellofemoral arthroplasty (PFA) and total knee arthroplasty (TKA). Among these, PFA is an established treatment of isolated PFJ osteoarthritis. We present our multi-surgeon, multi-implant series of patellofemoral joint arthroplasty performed over a 10 year period.

Method: This study was a retrospective review of all PFA performed in the Knee Arthroplasty Unit at our hospital over a ten year period from 1997 to 2006. The unit comprises seven specialist surgeons, each with considerable experience in knee arthroplasty and numerous trainee surgeons. One hundred and one PFA performed in 91 patients were identified from the theatre records. Three different implant models were used: the Lubinus implant (Waldemar Link), the FPV system (Wright Medical) and the Avon system (Stryker Howmedica Osteonics).

Results: 101 arthroplasties in 91 patients were followed up for average period of 48.8 months (6–96 months). Of these, none were lost to follow up. The average age was 57 years with female patients thrice as common as male patients. Concomitant procedures in the form of 23 lateral retinacular release or 6 osteochondral autograft transfer system (OATS) were performed. There were 6 complications with 2 infections and 4 stiff knees. 31 arthroplasties had subsequent procedures including arthroscopic debridement (18), arthroscopic lateral retinacular release (8), tibial tuberosity transfer (3) and manipulation for stiffness (2). A total of 4 arthroplasties underwent revision to total knee arthroplasty, 2 for infection and 2 for progression of tibiofemoral osteoarthritis.

Conclusion: The necessity of revision surgeries in one third of the cases suggests that close follow-up of the patients is needed to address any concerns that can be easily resolved. A majority of the patients in our study had very good outcomes and did not need subsequent procedures in the medium term. Our study reiterates the importance of proper patient selection, surgeon experience and correct surgical technique in successful outcomes from PFA.

Introduction: Patellofemoral arthroplasty (PFA) is an established treatment of isolated patellofemoral osteoarthritis. We present our multi-surgeon, multi-implant series of patellofemoral joint arthroplasty performed over a ten year period.

Material & Results: his study was a retrospective review of all PFA performed in our unit over a ten year period from 1997 to 2006. The unit comprises seven specialist knee surgeons and numerous trainee surgeons. A total of 46 knees had the Lubinus implant (Waldemar Link), 30 knees had the FPV system (Wright Medical) and 25 knees had the Avon system (Stryker Howmedica).

101 arthroplasties in 91 patients were followed up for average period of 48.8 months (6–96 months). The average age was 57 years with female patients thrice as common as male patients. Concomitant procedures in the form of 23 lateral retinacular release or 6 osteochondral autograft transfer system (OATS) were performed. There were 6 complications with 2 infections and 4 stiff knees. Subsequent procedures included arthroscopic debridement (18), arthroscopic lateral retinacular release (8), tibial tuberosity transfer (3) and manipulation for stiffness (2). A total of 4 arthroplasties underwent revision to TKA, 2 for infection and 2 for progression of tibiofemoral osteoarthritis.

Conclusion: Thorough clinical history, physical examination and radiological investigation are essential before embarking on PFJ replacement. Other concomitant procedures like joint debridement, menisectomy or lateral retinacular release may be necessary to obtain optimum results. The necessity of revision surgeries in 31% of the cases of our study suggests that close follow-up of the patients is needed to address any concerns which can be easily resolved. PFJ replacement effectively addresses anterior knee pain, preserves the joint integrity, involves lesser surgical dissection and has good results of revision to TKA.

Introduction: Osteoarthritis of thumb CMC joint is a common pathology. Several non-prosthetic surgical options exist. There is abundant literature both in favour of and against combining trapeziectomy with ligament reconstruction and/or tendon interposition (LRTI). This study provides qualitative and quantitative outcomes assessment of a single surgeon series of consecutively operated 65 patients with trapezio-metacarpal joint arthritis using Trapeziectomy with LRTI.

Methods: 50 female and 15 male patients at an average age of 63 at the time of surgery were followed up for a mean of 3 years, 4 months. Radial half of flexor carpi radialis is dissected using a Carroll tendon retriever and passed through a transosseous hole in the thumb metacarpal base to exit on its dorsum. Patients were put in a full below elbow cast for a period of 4 weeks following which hand therapy was instituted. Patients were evaluated using quick DASH score and objective data like thumb opposition, radiographic scaphometacarpal mobility and gap, pinch and grasp strength. All operations were carried out by senior author.

Results: Good to excellent results were obtained in 59 cases with satisfactory opposition. Pinch strength was 4.3 Kg being 1 to 2 Kg less than reference range. Scoring with quick DASH did not decrease with the longevity of follow up. No complications were encountered. No correlation was found between variables like age, sex, dominance, occupation, primary diagnosis, reduced space on follow up radiographs, severity of arthritic changes and final outcome.

Discussion: Present study is one of the largest consecutive single surgeon series reported recently. All efforts were made to eliminate confounding factors like multi surgeons, modifications of technique, different patient populations etc. The study supports the concept of interposition arthroplasty in the treatment of basal joint arthritis of thumb provided strict attention to the details of surgical technique is observed.

Introduction: The C-Stem was introduced in the endeavour to achieve greater stability, improved fixation, minimise subsidence and improve loading of the proximal femur to maintain bone quality and avoid stress shielding. Since promising early results in 2001, no studies including a large patient population from a single surgeon series have been published.

Methods: Health records and imaging modalities of 260 patients, operated between 2001 and 2004 were retrospectively evaluated by 2 independent reviewers. All patients had antero-lateral approach in supine position. Clearing of the calcar was carried out to allow adequate cement mantle proximally and posteromedially. Tip of the stem was allowed to penetrate in to the intramedullary bone block. All patients were followed up regularly with clinical and radiological information being updated.

Results: 90 men and 170 women, 30 bilateral cases were identified. Mean age at the time of surgery was 61.8 years (50–91). Commonest diagnosis was primary OA (56%) followed by secondary OA due to AVN or childhood pathology (30%) and previous trauma. 43 patients had previous operations in the form of failed internal fixation, osteotomy or hemiarthroplasty. Assessment included oxford hip score. Radiographs digitalised on DICOM software were analysed for subsidence (0.7 mm), alignment (94% satisfactory), bone-cement interface changes (35% progressive improvement) and proximal femur stress shielding (2.1%). At the time of final follow up 89% were independently mobile. 4 % thigh pain, 3 revisions for recurrent dislocations, 3 nonfatal and 2 fatal pulmonary embolism. Taking death or revision for any reason as endpoints, 97.8% survivorship was noted using Kaplan-miere analysis.

Discussion: The strength of the study includes large patient population, completeness of follow up and single surgeon series eliminating compounding factors. Bone cement interface improvement was noted in younger patients with high activity level. The study consolidates the soundness of the concept of C-Stem.

We report a prospective study of the liner-metal interfaces of modular uncemented acetabular components as sources of debris. We collected the pseudomembrane from the screw-cup junction and the empty screw holes of the metal backing of 19 acetabula after an average implantation of 22 months. Associated osteolytic lesions were separately collected in two cases. The back surfaces of the liners and the screws were examined for damage, and some liners were scanned by electron microscopy. The tissues were studied histologically and by atomic absorption spectrophotometry to measure titanium content. The pseudomembrane from the screw-cup junction contained polyethylene debris in seven specimens and metal debris in ten. The material from empty screw holes was necrotic tissue or dense fibroconnective tissue with a proliferative histiocytic infiltrate and foreign-body giant-cell reaction. It contained polyethylene debris in 14 cases and metal in five. The two acetabular osteolytic lesions also showed a foreign-body giant-cell reaction to particulate debris. The average titanium levels in pseudomembranes from the screw-cup junction and the empty screw holes were 959 micrograms/g (48 to 11,900) and 74 micrograms/g (0.72 to 331) respectively. The tissue from the two lytic lesions showed average titanium levels of 139 and 147 micrograms/g respectively. The back surfaces of the PE liners showed surface deformation, burnishing, and embedded metal debris. All 30 retrieved screws demonstrated fretting at the base of the head and on the proximal shaft. Non-articular modular junctions create new interfaces for the generation of particulate debris, which may cause granulomatous reaction.