The first description in the literature, of a complication during the extraction of a retrograde expandable intra-medullary nail in three patients.

Ankle fractures in elderly people are low-energy fractures characterised by fragility. In the majority, they are unstable and challenging to manage. Retrograde expandable intra-medullary nails (Fixion®, Biomet Merck Limited) inserted through the calcaneum across the sub-talar and ankle joints into the tibia have been successfully used in the treatment of fragility fractures and non-unions of the distal tibia and ankle, where the use of an antegrade locked nail would not provide adequate fracture stability for union. Primary fracture management involves removing the nail at least 3-4 months after radiological check. In cases of treatment of non-unions a longer treatment period is often required before removal of nail is considered. We present three patients where breakage of the Fixion® nail during surgery caused problems in nail extraction.

Electrical treatment of tibial non-union: a prospective, randomised, double-blind trial.

Electrical stimulation in the treatment of bony non-union has been used in different forms for many years. However, there is still a lot of uncertainty about its efficacy. We, therefore, undertook a prospective, randomised, double-blind trial to try and determine its effect. Over a period of 5 years, 34 consecutive patients with a tibial non-union met our "criteria for inclusion". Each patient had an oblique fibular osteotomy, followed by a unilateral external fixator. They were then randomly allocated one of two machines. Group 1, the active group, received electrical stimulation from an active machine. Group 2, the dummy group, had an identical machine but without any current passing through the active coils. They were then followed up for 6 months and evaluated clinically and radiologically for bony union. Unfortunately, there was by chance, an imbalance in smoking habit between the two groups. The union rate in the subgroup that smoked was 75% (6/8) in the active group as compared to 46% (6/13) in the dummy group. The active group of non-smokers had 100% (10/10) union rate, compared to 67% (2/3) in the dummy group. Overall 24 out of the 34 patients progressed to union. Out of 18, 16 (89%) in the active group showed bony union as compared to 8/16 (50%) in the dummy. There was, thus, a statistically significant positive association between tibial union and electrical stimulation (odds ratio 8, 95% CI: 1.5-41, P=0.02).

Use of the coventry infant hip screw in the treatment of nonunion of fractures of the distal humerus.

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.

Modification of the Nicoll bone-grafting technique for nonunion of the radius and/or ulna.

We treated 19 patients with established nonunion of the radius and/or ulna by the excision of avascular bone and the grafting of blocks of corticocancellous bone from the iliac crest, augmented by rigid plate fixation under compression. This allowed early mobilisation, and bony union was achieved between three and 24 months after operation in all but one of the patients. The single failure was attributed to the excessive length of the defect (100 mm) and inadequate fixation.

Tibiocalcaneal fusion for avascular necrosis of the talus.

Between 1994 and 1999, we treated six patients with avascular necrosis of the talus by excision of the necrotic body of the talus and tibiocalcaneal fusion using an Ilizarov frame. This was combined with corticotomy and a lengthening procedure. Shortening was corrected in all patients except two, who were over 60 years of age. All patients had previous operations which had failed. All achieved solid bony fusion, with five out of six having either a good or an excellent result. We conclude that this is an effective reconstructive technique which gives a good functional result.

Nonunion of the humerus after failure of surgical treatment. Management using the Ilizarov circular fixator.

We used the Ilizarov circular external fixator to treat 16 patients with persistent nonunion of the diaphysis of the humerus despite surgical treatment. All patients had pain and severe functional impairment of the affected arm. In ten, nonunion followed intramedullary nailing. We successfully treated these by a closed technique. The nail was left in place and the fracture compressed over it. The fractures of the other six patients had previously been fixed by various methods. We explored these nonunions, removed the fixation devices and excised fibrous tissue and dead bone before stabilising with the Ilizarov fixator. In five patients union was achieved. Bone grafting was not required. In the single patient in whom treatment failed, there had been a severely comminuted open fracture. All except one patient had reduction of pain, and all reported an improvement in function.

Established nonunion of the scaphoid treated by volar wedge grafting and Herbert screw fixation.

We reviewed 26 consecutive men of mean age 28 years who had wedge bone grafting and Herbert screw fixation for symptomatic established nonunion of the waist of the scaphoid. The period between injury and operation averaged 30 months (10 to 96), and 11 of the 26 patients had had previous operations, seven with bone grafts. At a mean follow-up of 14 months (6 to 42) 25 fractures (95%) had united at a median time of four months. Symptoms were improved in all patients. The outcome was not related to the time between injury and surgery or to pre-existing degenerative changes. Previous surgery carried a worse prognosis. The technique is difficult but can achieve union even when previous surgery and bone grafting have failed. The usual result is improved function and some relief of pain.

Locked nailing for nonunion of the tibia.

We treated 24 patients with nonunion of tibial shaft fractures by locked intramedullary nailing, 18 by open and six by closed techniques. Union was achieved in 22 patients, failing only in two patients with active infection. Locked nailing prevented recurrence of deformity and allowed the patients to mobilise without external support. Supplementary bone grafting was essential only for major defects.

Free vascularised fibular grafts for congenital pseudarthrosis of the tibia.

We describe 11 patients with congenital pseudarthrosis of the tibia treated by a free vascularised fibular graft (FVFG) and followed up from 10 to 64 months (mean 38). Bony union was achieved in nine of the 11 cases: two failures required amputation. The mean time for union in the successful cases was five months. Nine of the 11 patients had had an average of four surgical procedures before the FVFG, so the graft was a salvage procedure for which the only alternative was amputation. FVFG is recommended as a primary procedure for the treatment of congenital pseudarthrosis of the tibia if there is a large tibial defect (over 3 cm) or shortening of more than 5 cm. The primary use of this operation is not advised for cases in which standard orthopaedic procedures are expected to succeed. For a small defect with a favourable prognosis (Boyd and Sage 1958), we recommend conventional bone grafting, intramedullary nailing and electrical stimulation.

Electrical stimulation in the treatment of congenital pseudarthrosis of the tibia.

A treatment regime using electrical stimulation in association with a variety of surgical procedures has improved the prognosis in congenital pseudarthrosis of the tibia--one of the most challenging of all orthopaedic disorders. The technique consists of correction of the tibial deformity, intramedullary fixation and cancellous bone grafting, augmented by electrical stimulation using an implanted bone-growth stimulator. Experience with 27 pseudarthroses in 25 patients is presented; of those, 20 have joined. The cases have been reviewed and the causes of failure analysed. These results offer encouragement to the orthopaedic surgeon treating this difficult condition.

The treatment of non-union by pulsed electromagnetic fields combined with a Denham external fixator.

Fifteen cases of non-union of a long bone were treated by pulsed electromagnetic fields in combination with a Denham external fixator. Thirteen united within a few months and a controlled trial has been established to determine the contribution made by PEMF.

Cine radiography in cervical spondylosis as a means of determining the level for anterior fusion.

A series of 75 patients who had undergone anterior cervical fusion between 1965 and 1977 were reviewed. The patients were divided into two groups: those in Group A had had the level of fusion indicated by cine radiography, whereas in Group B the level had been determined by plain radiographs and clinical symptoms and signs. Results showed that cine radiography was the more accurate diagnostic technique. Accurate diagnosis of the level to be fused, the careful clinical selection of patients and sound bony union were found to be vital to the success of anterior cervical fusion. The incidence of pseudarthrosis was significant in single-level fusions and was even greater in double-level fusions and in patients with a history of trauma, especially whiplash injuries. It was rare to develop recurrence of symptoms in adjacent levels after fusion of a level localised by cine radiography.