Non-unions of the supracondylar area of the humerus are uncommon but they produce profound functional disability. We have successfully treated a series of these non-unions surgically using the Coventry hip screw. This is a large metaphyseal screw which is applied through both humeral condyles and then compressed on to a single 4. 5mm narrow tibial plate applied to the lateral aspect of the humeral shaft.

Between 1993 and 2000 we operated on thirteen consecutive patients aged 20 to 81 years (mean age 51 years). All the patients had a severe functional disability. The mean time to surgery was 23 months following their accidents. The average follow up was 16 months (range 8–18 months). All but two of the thirteen patients went on to bony union. The mean time to radiological union was six months (2 to 12 months). The mean arc of flexion doubled to 90 degrees.

Until now, the recommended operative technique for stabilisation of non-unions of the distal humerus is identical to that described for primary fracture repair, and involves fixation with two 3. 5 mm plates at 90 degrees. In our experience, this was the technique usually used at the initial operation/s, and is therefore likely to fail again. This correlates with the reported 6–12% non-union rate in the literature. In this series, stable fixation was achieved by using the Coventry hip screw.

This paper describes the outcome of type III pilon fractures of the distal tibia treated primarily with an Ilizarov ring fixator.

Only patients with an intra-articular fracture of the tibial plafond on plainradiographs that corresponded to type III pattern with the system of Rfiedi andAllgower were included.

There were thirteen patients with a mean age of 45 (range 29–65), twelve males and one female. The mechanism of injury in all the patients was high-speed road traffic accident.

Operative fixation consisted of fracture reduction and stabilisation using the llizarov circular frame external fixator and olive tipped wires. Further insult to the already damaged soft tissues was avoided.

Bony union was achieved in all cases. Treatment in the frame lasted between 3 and 10 months (average 6. 3 months). Neither deep infection nor soft tissue complications occurred.

Outcome measurements included the Olerud ankle score, modified Ovadia and Beals radiological criteria, and the SF-36 Health Questionnaire.

Wound and deep infections were successfully avoided and bony union was achieved in all our patients. This compares well with other fixation techniques. The use of the llizarov circular frame external fixator without any additional internal reduction or fixation procedures is a definite option for the treatment of these high-energy injuries.

Between 1993 and 2000 we treated 14 patients with nonunion of fractures of the distal humerus; 11 had already had previous fixation which had failed. The mean time to surgery was 21 months after injury. All the fractures were very low which made it difficult to obtain a firm hold of the small distal fragment. The problem of fixation was addressed by inserting a Coventry infant hip screw into the humeral condyles. The screw has a thread of wide diameter which gives excellent purchase on the small distal fragment. The condyles can then be compressed on to the humeral shaft using a 4.5 mm narrow tibial dynamic plate. Of these 14 difficult cases of nonunion, 12 progressed to union.

Aim: to evaluate the use of large acetabular cup in revision surgery without structural bone graft.

Materials/methods: Patients who had revision hip surgery at Greenwich Hospital between 1991 and 1994 were reviewed. All patients had complete clinical and radiological follow up.

Large cup was the press fit Mathys Isoelastic cup.

No patient had any structural bone grafting.

Failure was defined as need for surgery and/or poor clinical outcome.

Objective clinical assessment was done using the Harris Hip score.

Radiological assessment was carried out using RC Johnston’s criteria for uncemented cups.

Results: 52 revised cups in 48 patients were reviewed. Mean age was 71.6yrs, 21 males and 27 females. Mean follow up was 6 years (4 to 8 years). Average cup size was 64 mm (62 to 66).

Diagnosis at index operation was 10 Rheumatoid, and 42 osteoarthrosis. Average Harris Hip Score was 85 (excellent 35, good 11, fair 3, poor 3)

Radiological assessment showed excellent bony incorporation in all but the failures. There were 3 failures, 1 due to infection (revision was for infected primary THR), and 2 due to aseptic loosening in rheumatoid patients (both had significant cup malposition at revision). The major complications included 2 intraoperative fractures.

Conclusion: Intermediate term results of acetabular revisions, using large cups, without structural bone grafting, in our hands, are encouraging. Cup position at revision appears crucial for long-term survival.