Introduction: Treatment of proximal humeral fractures with plate osteosynthesis or intramedullary nail fixation in humeral shaft fractures with a proximal locking bolt carries the risk of iatrogenic injury of the axillary nerve. The purpose of this anatomical study is to define a more reliable safe zone to prevent iatrogenic axillary nerve injury using the humeral head instead of the acromion as a (radiographic) reference point during operative treatment. Materials and methods: Anatomical dissection and labeling of the axillary nerve and branches was performed on 10 specially embalmed human specimens. Standard AP and straight lateral radiographs were made. The distances were measured indirectly from the cranial tip of the humerus to the axillary nerve on radiographs. Results: The median distance from the cranial tip of the humerus to the axillary nerve was 52 mm. The mean number of axillary nerve branches was 3. The distances from the cranial tip of the humerus to the nerve (branch) varied from 23 to 78 mm. The median distance from the proximal (anterior) branch was 36 mm, to the second branch 47 mm, 54 mm to the third branch and 73 mm to the fourth branch. The axillary nerve moves along with the humerus in cranial and caudal direction when the subacromial space varies. Conclusion: This study shows that the position of the axillary nerve can be better determent using the cranial tip of the humerus as a reference point instead of the acromion. Furthermore, it is unsafe to place the proximal locking bolts in the zone between 24 mm and 78 mm from the cranial tip of the humerus. The greatest chance to cause a lesion of the main branch of the axillary nerve is in the zone between 48 mm and 58 mm caudal from the tip of the humeral head.

Background: Humeral retroversion (RV) is important to the study of shoulder function and reconstruction. This study tests the hypothesis that clinically obtained computer tomography (CT) measurements for humeral RV (off-axis measurements) differ from those obtained after reformatting the image slice orientation so that the humeral shaft is perpendicular to the gantry (coaxial measurements) and explores deviations from true RV. Materials and methods: A custom-built application created in Mathematica was used to explore the effect of altering the humeral orientation on slice angle acquisition by 3D imaging technologies, on the perceived angle of RV from the 2D-projection of the reference axes. The application allows for control of humeral axis orientation relative to image slice (3D) or plain of projection (2D) and humeral rotation. The effect of rotating a virtual model of one humerus around its own axis and in discrete anatomical directions on the measured RV angle was assessed. Results: The coaxial measurement of humeral RV (31.2°) differed from off-axis measurement, with a maximum difference in measured RV of 50° in 45° of extension. The typical position of the humerus in a CT scan resulted in a difference in RV measurement up to 22°. Explorations of deviation led to the following outcomes, as divided by anatomic direction. Extension and abduction led to an underestimation, and flexion and adduction led to an overestimation of the RV-angle. Conclusion: Measurements must be done consistently about the position and orientation of the humerus. Deviation in the humeral alignment of as little as 10° can distort the measurement of version up to 15°.

Introduction: Limb lengthening using intramedullary nails is an increasingly popular method of achieving limb length equalisation. Currently, the decision regarding when to commence full weight-bearing (FWB) remains largely subjective. Objective criteria for determining the proper timing of FWB would be helpful to limb lengthening surgeons. This study examines using the pixel value ratio (PVR) as an objective method to determine the time to FWB for patients being lengthened with an intramedullary nail. Materials and methods: A retrospective chart review of 42 patients who underwent unilateral lengthening of the femur was undertaken. The PVR of all four cortices of the regenerate bone was monitored throughout the distraction and consolidation stages to determine the ratio at the time of FWB. Results: Clinically and radiologically determined FWB was achieved at a mean time of 125.7 ± 30.1 days from surgery. The mean PVR at the time of FWB was 0.94. The medial cortex healed fastest with a mean PVR of 0.96, while the posterior cortex healed slowest with a mean PVR of 0.92. Conclusion: The PVR is a quick and reliable method to objectively assess the state of healing of the regenerate bone during distraction osteogenesis. We observed that there were no adverse effects when subjects commenced FWB when three out of the four cortices had a PVR of at least 0.93.

Aim and objective: In deformity correction around the knee, the mechanical lateral distal femoral angle (mLDFA) and medial proximal tibial angle (MPTA) are used in surgical planning routinely. While plain radiographs are generally adequate, some surgeons utilise intraoperative arthrograms to visualise the articular contours and assess a younger child's true joint alignment, often with findings that these are discrepant from that measured just using bone alignment. The age cutoff for a discrepancy between the two is not defined. Materials and methods: We queried our picture archiving and communication systems (PACS) database for MRIs with a radiological read of “normal” for patients between the ages of 4 and 16 years at the time of the study. Anatomic axes were used to determine the anatomic LDFA (aLDFA) and MPTA angles using end-cartilage and end-bone landmarks independently. Results: We reviewed 116 MRIs, 56% male, with approximately 9 studies per year of age. There were no significant overall differences between aLDFA and MPTA when measured at the bone vs cartilage surfaces (p = 0.42 and p = 0.53, respectively). In the 4- to 6-year age range, there was a significant difference between bony and cartilaginous aLDFA (p = 0.02) but not MPTA (p = 0.88). Conclusion: In children 6 years of age and younger, intraoperative arthrogram should be considered while treating knee deformity, as plain films may not fully represent the true deformity of the distal femur in particular. Clinical significance: Supports the need for advanced imaging or intraoperative arthrogram for joint corrective surgery in young patients. Level of evidence: Level 3 diagnostic.

Aim and objective: Fibular autograft is a known technique for the reconstruction of traumatic and non-traumatic bone defects in both adult and paediatric populations. We aim to describe our outcomes using various stabilisation methods for non-vascularised fibular autograft to reconstruct both benign and malignant tumours in a paediatric population in a National Paediatric Centre over the past 14 years. Materials and methods: This was a retrospective review of 10 paediatric cases with non-traumatic primary bone defects in a National Paediatric Centre. Criteria for inclusion were all non-traumatic primary bone defects requiring reconstruction with a non-vascularised fibular autograft in the diaphyseal or metaphyseal regions of the bone. The primary outcome measures were union and time to union (weeks). Time to union was illustrated using Kaplan–Meier curves. Secondary outcome measures included postoperative fracture, infection (deep and superficial), time to full weight-bearing and all-cause revision surgery. Results: The mean length of follow-up was 63 months for the entire cohort (9–168, SD = 48.6). There was no loss to follow-up. Six lesions were located in the tibia, two in the femur and the remaining two were located in the ulna and third metacarpal. Union was ultimately achieved in 8 of the 10 patients using this donor autograft. The mean time to union was 28 weeks (10–99, SD = 29.8). There were four complications of autograft fracture. The mean time to fracture was 17 weeks (9–32, SD = 10.71). In all four of these cases, the patient achieved union at final follow-up. There were two superficial and two deep infections recorded. Three resolved with the use of antimicrobial therapy and one deep infection ultimately required insertion of an intercalary prosthesis to treat the infected non-union of the fibular graft site. Conclusion: The use of non-vascularised fibular autograft for the reconstruction of tumours is an effective surgical technique in a paediatric cohort. We report the largest known series of malignant paediatric tumours treated with this technique to date. Clinical significance: Non-vascularised fibular autograft is successful in the reconstruction of large bone defects secondary to malignant paediatric bone tumours.

Aim and objective: Ilizarov hip reconstruction (IHR) is a traditional method of salvaging chronic adolescent problem hips but faces practical problems from external fixators leading to reduced compliance. We present the same reconstruction utilising only internal devices with a modification in technique and aim to review early results. Materials and methods: We retrospectively evaluated eight patients between 2014 and 2017 with chronic painful hips treated by a two-stage reconstruction; stage 1 included femoral head resection and pelvic support osteotomy using double plating, while stage 2 comprised distal femoral osteotomy avoiding varus followed by insertion of retrograde magnetic nail for postoperative lengthening. Patients continued physiotherapy postoperatively while protecting from early weight-bearing. Results: At mean follow-up of 19 months (range 6–36), all osteotomies healed with bone healing index of 47 days/cm (range 30–72). Pain improved from 8.3 (range 7–9) to 2 (range 0–6), while limb length discrepancy got corrected from 4.3 cm (range 3–5) to 1.4 cm (range 0–2.5) at final follow-up. Trendelenburg sign was eliminated in three and delayed in five. No examples of infection or permanent knee stiffness were noted. One patient had plates breakage due to mechanical fall and one had 35 mm of lateral mechanical axis deviation requiring corrective osteotomy. Conclusion: Pelvic support hip reconstruction with exclusive internal devices is a technique in evolution with encouraging early results. It avoids common complications of external fixators and facilitates quick rehabilitation of joints. Refraining from distal varus can effectively eliminate Trendelenburg gait, albeit with some degree of lateral mechanical axis deviation. Unlike external fixation where there is a possibility of gradual correction, this staged procedure of internal fixation is technically demanding with a learning curve. Clinical significance: Pelvic support hip reconstruction performed by internal implants is a viable alternative to IHR with potential benefits.

Limb lengthening by distraction osteogenesis is an accepted orthopaedic surgical technique. The Precice intramedullary lengthening system is the most recent innovation in limb lengthening. Early results have been favourable in femoral lengthening but there is little reported on the outcome in tibial lengthening. The aim of this study is to present our early results of Precice tibial lengthening, and the stepwise evolution of our surgical technique. Materials and methods: A case series of 17 consecutive tibial lengthenings were prospectively analysed. Healing index, length achieved, range of motion, and complications were recorded. The initial cases followed the recommended surgical technique. Progressive regenerate deformity during lengthening required changes to the surgical method. Results: No cases were lost to follow-up. All the nails lengthened at the desired rate. There were no complications of infection or poor regenerate formation. Progressive valgus and procurvatum was prevented in later cases by the positioning of Poller blocking screws at the time of nail insertion. Conclusion: The tibial Precice nail is successful in obtaining length and good regenerate formation. The recommended technique was insufficient to control the deforming forces from the lower limb muscle compartments during lengthening. We therefore recommend the addition of multiple blocking screws in an amended technique.

Background: Bone defects remain challenging to manage. The wide array of treatment options is a testament no single strategy works in every patient. This is more complex if consideration is given to the status of the host and the soft tissues. The choice of treatment should be based on specific patient requirements after taking all variables into account. Materials and Methods: We present a comprehensive classification system and treatment algorithm to assist with decision-making in management. All potential treatment modalities including amputation are discussed with their relevant pearls and pitfalls. Conclusion: The proposed classification system may potentially assists with communication, enable patient stratification for assigning the most appropriate treatment modality and guide reporting of treatment outcomes.

Purpose: Distraction osteogenesis has been used for post-traumatic segmental bone defects. Absent or delayed callus formation in the distraction gap can lead to significant morbidity and affect the clinical outcome. Experimental evidence in animal models has demonstrated that teriparatide enhances the consolidation of regenerate and also strengthens it. This study aimed to report our experience with recombinant teriparatide therapy for patients with regenerate insufficiency. Materials and methods: Nine out of 43 patients undergoing limb lengthening using the limb reconstruction system (LRS) fixator were diagnosed with regenerate insufficiency. With informed consent, these patients received a therapeutic regime of 20 μg of teriparatide administered subcutaneously once daily for a period of 3 months. Results: The mean age in the sample was 40.22 years (SD 17.87). Regenerate insufficiency was diagnosed at a mean of 4.94 months (range 2.5–9 months) from surgery. Teriparatide injections were started at a mean of 6.94 months (range 4.5–11 months) from surgery. The sites of regenerate insufficiency were tibia (n = 5) and femur (n = 4). Favourable radiographic progress in visibility of callus was seen at a mean duration of 9.4 weeks (range 8–12 weeks) from the initiation of teriparatide therapy. No systemic complications were encountered. Conclusion: The initiation of teriparatide treatment as described in this study may be successful in triggering the osteogenic potential within poor regenerate and help in consolidation and avoid more invasive surgical procedures.

Aspergillus osteomyelitis can be a very debilitating disease with an associated mortality of up to 25%. Silver is well known for its broad antimicrobial properties including activity against fungi and the coating of orthopaedic implants with silver has been reported to be successful in complex cases. We report for the first time on a complicated case of Aspergillus osteomyelitis affecting the left knee in a patient with a chronic lymphoid leukaemia treated with appropriate surgical debridement, local and systemic antibiotic and antimycotic therapy, as well as staged surgical treatment with final limb-saving arthrodesis by using a custom-made microsilver coated arthrodesis rod.

Case description: A 58-year-old woman suffered an open displaced olecranon fracture with extensive soft tissue damage when she was involved in a car accident in Africa. Local doctors performed a debridement of the elbow. Later, she presented in our centre for further treatment. There was a possibility of active infection, for which antibiotics were given and a debridement was performed. We then applied dynamic external fixation to minimize infection risk. Physiotherapy started soon after. External fixation was removed after 2 months. On follow-up, the patient reported no pain and no signs of major instability were present. Therefore, we agreed not to perform additional surgery. Annual follow-up radiographs showed progressive remodelling of the joint. Eleven years after the initial trauma, a reversed elbow has formed. It is a fully functional neo-articulation that is shaped by osteophyte formation and erosion of ulna, radius and humerus. The patient is free of pain and shows intact flexion and supination, while extension and pronation are limited. She has regained good elbow function and can perform most of her daily activities. Conclusion: Invasive reconstructive surgery with implantation of foreign material should be avoided or postponed in heavily contaminated fractures to avoid infection. It could be valuable to consider a watchful waiting strategy, which sometimes results in a good functional end result. Nature can be kind, which has been proven in our case.