Higher rate of complications with uncemented compared to cemented total hip arthroplasty for displaced intracapsular hip fractures: A randomised controlled trial of 50 patients.

BACKGROUND: The primary aim of this study was to compare the functional outcome of uncemented with cemented total hip arthroplasty (THA) for displaced intracapsular hip fractures. The secondary aims were to assess length of surgery, blood loss, complications and revision rate between the two groups. METHODS: A prospective double-blind randomised control trial was conducted. Fifty patients with an intracapsular hip fracture meeting the inclusion criteria were randomised to either an uncemented (n = 25) or cemented (n = 25) THA. There were no differences (p > 0.45) in age, gender, health status or preinjury hip function between the groups. The Oxford hip score (OHS), Harris Hip score (HHS), EuroQol 5-dimensional (EQ5D), timed get up-and-go (TUG), pain and patient satisfaction were used to assess outcome. These were assessed at 4, 12 and 72 months after surgery, apart from the TUG which as only assessed as 6 months. RESULTS: The study was terminated early due to the significantly (n = 8, p = 0.004) higher rate of intraoperative complications in the uncemented group: three fractures of the proximal femur and five conversions to a cemented acetabular component. There were no significant (p ≥ 0.09) differences in the functional measures (OHS, HSS, EQ5D, TUG and pain) or patient satisfaction between the groups. There was no difference in operative time (p = 0.75) or blood loss (p = 0.66) between the groups. There were two early revisions prior to 3 months post-operatively in the uncemented group and none in the cemented group, but this was not significant (log rank p = 0.16). CONCLUSION: There was a high rate of intraoperative complications, which may be due to poor bone quality in this patient group. There were no ergonomic or functional advantages demonstrated between uncemented and cemented THA. Cemented THA should remain as the preferred choice for the treatment of intracapsular hip fractures for patients that meet the criteria for this procedure.

Differentiation of the 50B11 dorsal ganglion cells into NGF and GDNF responsive nociceptor subtypes.

The embryonic rat dorsal root ganglion (DRG) neuron-derived 50B11 cell line is a promising sensory neuron model expressing markers characteristic of NGF and GDNF-dependent C-fibre nociceptors. Whether these cells have the capacity to develop into distinct nociceptive subtypes based on NGF- or GDNF-dependence has not been investigated. Here we show that by augmenting forskolin (FSK) and growth factor supplementation with NGF or GDNF, 50B11 cultures can be driven to acquire differential functional responses to common nociceptive agonists capsaicin and ATP respectively. In addition, to previous studies, we also demonstrate that a differentiated neuronal phenotype can be maintained for up to 7 days. Western blot analysis of nociceptive marker proteins further demonstrates that the 50B11 cells partially recapitulate the functional phenotypes of classical NGF-dependent (peptidergic) and GDNF-dependent (non-peptidergic) neuronal subtypes described in DRGs. Further, 50B11 cells differentiated with NGF/FSK, but not GDNF/FSK, show sensitization to acute prostaglandin E2 treatment. Finally, RNA-Seq analysis confirms that differentiation with NGF/FSK or GDNF/FSK produces two 50B11 cell subtypes with distinct transcriptome expression profiles. Gene ontology comparison of the two subtypes of differentiated 50B11 cells to rodent DRG neurons studies shows significant overlap in matching or partially matching categories. This transcriptomic analysis will aid future suitability assessment of the 50B11 cells as a high-throughput nociceptor model for a broad range of experimental applications. In conclusion, this study shows that the 50B11 cell line is capable of partially recapitulating features of two distinct types of embryonic NGF and GDNF-dependent nociceptor-like cells.

Forage fish and polycyclic aromatic compounds in the Fort McMurray oil sands area: Body burden comparisons with environmental distributions and consumption guidelines.

The Fort McMurray region in northeastern Alberta (Canada) is rich in natural sources of polycyclic aromatic compounds (PACs) from exposed bitumen beds; anthropogenic sources are being released with increased oil sands industry expansion. Here we report on investigations of PACs (47 compounds) in three species of forage fish collected during the 2012-2013 Joint Oil Sands Monitoring Program (JOSMP) fish health investigations and compare results with PAC data for sediment and water collected under JOSMP and earlier programs. PAC concentrations in sediments varied three orders in magnitude and were highest at downstream tributary mouths, which flowed through the exposed McMurray Formation, and along reaches of the Athabasca River where the formation was exposed. PAC concentrations in water were less variable but with higher concentrations near exposed bitumen beds. Forage fish exhibited the weakest spatial gradients in ΣPACs concentration, which averaged 102 ±â€¯32 ng/g in trout-perch from the Athabasca River, 125 ±â€¯22 ng/g in lake chub from the Ells River, and 278 ±â€¯267 ng/g in slimy sculpin from the Steepbank, Firebag, and Dunkirk Rivers. Low-molecular weight compounds, particularly naphthalenes and fluorenes, dominated fish PACs. Phenanthrenes occurred in greater percent composition in fish caught in areas where PAC concentrations in sediments were higher due to the proximity of bitumen sources than in other areas. Dibenzothiophene, a major component of bitumen PAC, was a minor component of fish ΣPACs. Forage fish PAC concentrations were below fish consumption guidelines established by the European Commission (2011) and for the reopening of the commercial fisheries closed by the Deepwater Horizon oil spill. PAC concentrations in forage fish were similar to concentrations observed in many other studies (fish market surveys, estuaries, and marine waters) and lower than in fish sampled from highly impacted areas (near refineries, harbors, and other industrialized areas).

Avoiding, diagnosing and treating well leg compartment syndrome after pelvic surgery.

BACKGROUND: Patients undergoing prolonged pelvic surgery may develop compartment syndrome of one or both lower limbs in the absence of direct trauma or pre-existing vascular disease (well leg compartment syndrome). This condition may have devastating consequences for postoperative recovery, including loss of life or limb, and irreversible disability. METHODS: These guidelines represent the collaboration of a multidisciplinary group of colorectal, vascular and orthopaedic surgeons, acting on behalf of their specialty associations in the UK and Ireland. A systematic analysis of the available peer-reviewed literature was undertaken to provide an evidence base from which these guidelines were developed. RESULTS: These guidelines encompass the risk factors (both patient- and procedure-related), diagnosis and management of the condition. Key recommendations for the adoption of perioperative strategies to facilitate prevention and effective treatment of well leg compartment syndrome are presented. CONCLUSION: All surgeons who carry out abdominopelvic surgical procedures should be aware of well leg compartment syndrome, and instigate policies within their own institution to reduce the risk of this potentially life-changing complication.

Older age and female gender are independent predictors of early conversion to total knee arthroplasty after high tibial osteotomy.

BACKGROUND: The primary aim was to assess survival of opening wedge high tibial osteotomy (HTO) for medial compartment osteoarthritis. The secondary aim was to identify independent predictors of early conversion to total knee arthroplasty (TKA). METHODS: During the 18-year period (1994-2011) 111 opening wedge HTO were performed at the study centre. Mean age was 45 years (range 18-68) and the majority male (84%). Mean follow-up was 12 (range six to 21) years. Failure was defined as conversion to TKA. Kaplan-Meier, Cox regression and receiver operating curve (ROC) analyses were performed. RESULTS: Forty (36.0%) HTO failed at a mean of 6.3 years (range one to 15). By Kaplan-Meier analysis, the five-year survival rate was 84% (95% confidence interval (CI) 82.6-85.4), 10-year rate 65% (95% CI 63.5-66.5) and 15-year rate 55% (95% CI 53.3-56.7). Cox regression analysis identified older age (hazard ratio (HR) 1.07 for each additional year, 95% CI 1.03-1.11, p b 0.001) and female gender (HR 2.37, 95% CI 1.06-5.33, p = 0.04) as independent predictors of failure. ROC analysis identified a threshold age of 47 years above which the risk of failure increased significantly (area under curve 0.72, 95% CI 0.62-0.81, p b 0.001). Cox regression analysis, adjusting for covariates, identified a significantly greater (HR 2.49, 95% CI 1.26-4.91, p = 0.01) risk of failure in patients aged 47 years old or more. CONCLUSION: The risk of early conversion to TKA is significantly increased in females and those older than 47. These risk factors should be considered pre-operatively when planning intervention for isolated medial compartment osteoarthritis.

Native hip dislocation at acetabular fracture predicts poor long-term outcome.

AIM: The aim of this study was to evaluate the long-term clinical outcomes and complications following an acetabular fracture associated with a posterior hip dislocation compared to those without dislocation. PATIENTS & METHODS: A retrospective cohort study of 113 patients (mean age 42 (14-95), 77% male) with acetabular fracture dislocations compared to 367 patients with acetabular fractures without dislocation (mean age 54 (16-100), 66% male) treated from 1988 to 2010. Patient characteristics, complications, reoperations, and conversion to total hip arthroplasty (THA) were recorded. Long term patient reported outcomes (Oxford Hip Score and SF-12) were measured at mean follow up 9.7 years (5-26). RESULTS: At long-term follow up 12/113 (11%) patients had died and 22/113 (19%) were lost. Isolated posterior wall fracture was the most common fracture associated with dislocation. Patients with dislocation were more likely to be younger and male with higher Injury Severity Scores (ISS). There was no significant difference in radiographic post-traumatic osteoarthritis development between fractures with and without dislocation (p = 0.246). Sciatic nerve palsy (12% Vs 1%, p < 0.001) and avascular necrosis (AVN) (11% Vs 1%, p < 0.001) were more common when dislocation was present. AVN was associated with increasing age and hypotension on arrival to the emergency department. Ten-year native hip survival was worse following fracture dislocations compared to fractures without dislocation: 75.1% (65.7-84.5 95% CI) Vs 90.7% (87.0-94.4), p < 0.001. Significant predictors of THA requirement were older age, particularly age >55 years at fracture, and increased ISS. Long-term OHS was worse in fractures with dislocations (33.6 ± 13.1 Vs 37.0 ± 14.0, p = 0.016). CONCLUSION: Acetabular fractures with an associated dislocation have worse long-term functional outcomes with higher rates of complications and conversion to late THA compared to acetabular fractures without a dislocation.

Outcomes following osteosynthesis of periprosthetic hip fractures around cemented tapered polished stems.

We retrospectively reviewed outcomes of 79 patients with periprosthetic hip fractures around cemented tapered polished stem (CTPS) implants treated with osteosynthesis between January 1997 and July 2011. All patients underwent open reduction and fixation using a broad dynamic compression plate (DCP). Seventy two (91%) of fractures united. There were seven (9%) non-unions with failure of metal work, three (4%) as a result of infection and four (5%) due to mechanical failure. Significant subsidence (>5mm) of the implant was seen in seven (9%) of cases. Ten (13%) cases developed post-operative infection. Non-anatomic reduction and infection were identified as predictors of poor outcome. This is the largest series of a very specific group of periprosthetic fractures treated with osteosynthesis. Open reduction internal fixation with a broad dynamic compression plate for patients with periprosthetic hip fractures around the tip of cemented tapered polished stems is a suitable treatment provided there is no bone loss and the fracture can be precisely, anatomically, reduced and adequately fixed.

Allosensitization Following Bone Graft.

It is recognized that patients may become sensitized to donor-specific HLA antigens as a result of previous antigenic exposures, classically through previous transplantation, pregnancy, or blood transfusion. We present an unusual case of a patient who unexpectedly developed a range of anti-HLA antibodies following orthopedic surgery where a bone graft was deployed intraoperatively. We describe the case of a 52-year-old man awaiting a renal transplantation, undergoing elective orthopedic surgery requiring a small-volume bone graft. His postoperative antibody profile was found to be substantially changed compared to his previous negative samples, with the presence of HLA-DR, DQ, and DP specificities, at levels that would be likely to give a positive flow cytometry crossmatch and therefore according to local procedures required listing as unacceptable antigens for organ allocation. We perform a literature review of all previous cases of allosensitization following bone graft. This case is the first to demonstrate allosensitization following minor surgery with ;low-volume bone graft. Previous evidence is very limited and pertains only to massive osteochondral surgery for trauma or malignancy, and is confounded by potential concomitant blood transfusion. Clinicians should be aware of the risk of allosensitization where bone grafts are used.

Generalised ligamentous laxity and revision ACL surgery: Is there a relation?

BACKGROUND: The aim of the present study was to investigate the relationship between generalised ligamentous laxity (GLL) and requirement for revision anterior cruciate ligament (ACL) reconstruction. METHODS: The study cohort consisted of 139 patients undergoing primary ACL reconstruction, 44 patients undergoing revision ACL surgery and a control group of 70 patients without any knee ligament injury. A Beighton score of four or more was classified as generalised ligamentous laxity. RESULTS: The primary and revision ACL surgery groups had an increased incidence of GLL compared to the control group (p<0.05). The revision ACL surgery group also had higher incidence of GLL as compared to primary ACL surgery group (p<0.05). There was a sub group within the revision cohort, who had failure of the original surgery without an identifiable cause (biological failure). The incidence of GLL in this group was significantly higher than the primary surgery group (p<0.05). CONCLUSIONS: The findings of this study suggest that GLL may be associated with a higher risk of ACL injury and an increased risk of graft failure after primary ACL reconstruction. Based on the results of our study we feel that in the presence of GLL an autogenous graft may not be the best option for either primary or revision ACL reconstruction. LEVEL OF EVIDENCE: 3 (III).

Histologic and immunohistochemical characterization of thymic epithelial tumours in the dog.

Thymic epithelial tumour (TET) histologic subclassification has not been well described in the veterinary literature as it has in humans. The objective of this study was to identify and describe TET subtypes in dogs and to determine the utility of immunohistochemistry (IHC) in differentiating these subtypes. Samples were reviewed and classified according to a modified World Health Organization (WHO) criteria for human tumours of thymic origin. Signallment, presenting signs, treatment and survival data was collected from medical records. Histologic review confirmed the same subtypes as described in humans. Presence of high stage disease, pleomorphism, mitotic figures and capsular invasion was more common in atypical thymomas and thymic carcinomas than in thymomas. IHC was performed for GLUT-1, CD5, CD117 and CK8/18; however, this was not useful in classifying the tumours.

Exchange nailing for femoral diaphyseal fracture non-unions: Risk factors for failure.

The aim of this study was to identify risk factors for failure of exchange nailing for femoral diaphyseal fracture non-unions. The study cohort comprised 40 patients with femoral diaphyseal non-unions treated by exchange nailing, of which six were open injuries. The median time to exchange nailing from primary fixation was 8.4 months. The main outcome measures were union, number of secondary fixation procedures required to achieve union and time to union. Multiple causes for non-union were found in 16 (40%) cases, with infection present in 12 (30.0%) patients. Further surgical procedures were required in nine (22.5%) cases, one of whom (2.5%) required the use of another fixation modality to achieve union. Union was ultimately achieved with exchange nailing in 34/37 (91.9%) patients. The median time to union after the exchange nailing was 9.4 months. Cigarette smoking and infection were risk factors for failure of exchange nailing. Multivariate analysis found infection to be the strongest predictor of exchange failure (p<0.05). Exchange nailing is an effective treatment for aseptic femoral diaphyseal fracture non-union. However, 50% of patients undergoing exchange nailing in the presence of infection required at least one further procedure. It is important to counsel patients of this so that they can plan for it and do not consider that the first exchange operation has failed.

A comparison of the use of uncemented hydroxyapatite-coated bipolar and cemented femoral stems in the treatment of femoral neck fractures: a case-control study.

We performed a case-control study to compare the rates of further surgery, revision and complications, operating time and survival in patients who were treated with either an uncemented hydroxyapatite-coated Corail bipolar femoral stem or a cemented Exeter stem for a displaced intracapsular fracture of the hip. The mean age of the patients in the uncemented group was 82.5 years (53 to 97) and in the cemented group was 82.7 years (51 to 99) We used propensity score matching, adjusting for age, gender and the presence or absence of dementia and comorbidities, to produce a matched cohort receiving an Exeter stem (n = 69) with which to compare the outcome of patients receiving a Corail stem (n = 69). The Corail had a significantly lower all-cause rate of further surgery (p = 0.016; odds ratio (OR) 0.18, 95% CI 0.04 to 0.84) and number of hips undergoing major further surgery (p = 0.029; OR 0.13, 95% CI 0.01 to 1.09). The mean operating time was significantly less for the Corail group than for the cemented Exeter group (59 min [12 to 136] vs 70 min [40 to 175], p = 0.001). The Corail group also had a lower risk of a peri-prosthetic fracture (p = 0.042; OR 0.19, 95% CI 0.01 to 1.42) . There was no difference in the mortality rate between the groups. There were significantly fewer complications in the uncemented group, suggesting that the use of this stem would result in a decreased rate of morbidity in these frail patients. Whether this relates to an improved functional outcome remains unknown.

Direct effects of Bmi1 on p53 protein stability inactivates oncoprotein stress responses in embryonal cancer precursor cells at tumor initiation.

Embryonal cancer can arise from postnatally persistent embryonal remnant or rest cells, which are uniquely characterized by the absence of p53 mutations. Perinatal overexpression of the MycN oncoprotein in embryonal cancer precursor cells causes postnatal rests, and later tumor formation through unknown mechanisms. However, overexpression of Myc in adult tissues normally activates apoptosis and/or senescence signals as an organismal defense mechanism against cancer. Here, we show that perinatal neuroblastoma precursor cells exhibited a transiently diminished p53 response to MycN oncoprotein stress and resistance to trophic factor withdrawal, compared with their adult counterpart cells from the TH-MYCN(+/+) transgenic mouse model of neuroblastoma. The adult stem cell maintenance factor and Polycomb group protein, Bmi1 (B-cell-specific Moloney murine leukemia virus integration site), had a critical role at neuroblastoma initiation in the model, by repressing p53 responses in precursor cells. We further show in neuroblastoma tumor cells that Bmi1 could directly bind p53 in a complex with other Polycomb complex proteins, Ring1A or Ring1B, leading to increased p53 ubiquitination and degradation. Repressed p53 signal responses were also seen in precursor cells for other embryonal cancer types, medulloblastoma and acute lymphoblastic leukemia. Collectively, these date indicate a general mechanism for p53 inactivation in some embryonal cell types and consequent susceptibility to MycN oncogenesis at the point of embryonal tumor initiation.

The surgical treatment of knee stiffness following anterior cruciate ligament reconstruction.

Knee stiffness following anterior cruciate ligament (ACL) reconstruction remains a common complication, which can substantially impair knee function. The aim of this study was to assess the effectiveness of arthroscopic arthrolysis, in conjunction with manipulation under anaesthetic (MUA), in treating stiffness post-ACL reconstruction. We reviewed the records of 18 patients who underwent arthroscopic arthrolysis to treat established stiffness following primary isolated ACL reconstruction. Eight of these patients underwent concomitant MUA at time of arthrolysis. The median time between reconstruction and arthrolysis was nine months. Seven patients had arthrolysis performed within eight months of reconstruction, while 11 patients underwent arthrolysis greater than eight months postreconstruction. Following arthrolysis, the mean extension loss improved from 7° to 1°. In patients with mild extension stiffness (prearthrolysis extension deficits <10°), the mean improvement to extension was 3°. In patients with severe extension stiffness (prearthrolysis extension deficit ≥10°), the mean improvement to extension was 10°. Arthroscopic arthrolysis was significantly more effective in restoring extension loss if carried out within eight months of the primary reconstruction (P < 0.03). In the patients who underwent MUA at time of arthrolysis, the mean flexion loss improved from 16° to 4°. In conclusion, arthroscopic arthrolysis, in conjunction with MUA, is an effective treatment for knee stiffness post-ACL reconstruction but ideally should be carried out within eight months.

Operative versus non-operative treatment of acute rupture of tendo Achillis: a prospective randomised evaluation of functional outcome.

A total of 80 patients with an acute rupture of tendo Achillis were randomised to operative repair using an open technique (39 patients) or non-operative treatment in a cast (41 patients). Patients were followed up for one year. Outcome measures included clinical complications, range of movement of the ankle, the Short Musculoskeletal Function Assessment (SMFA), and muscle function dynamometry evaluating dorsiflexion and plantar flexion of the ankle. The primary outcome measure was muscle dynamometry. Re-rupture occurred in two of 37 patients (5%) in the operative group and four of 39 (10%) in the non-operative group, which was not statistically significant (p = 0.68). There was a slightly greater range of plantar flexion and dorsiflexion of the ankle in the operative group at three months which was not statistically significant, but at four and six months the range of dorsiflexion was better in the non-operative group, although this did not reach statistically significance either. After 12 weeks the peak torque difference of plantar flexion compared with the normal side was less in the operative than the non-operative group (47% vs 61%, respectively, p < 0.005). The difference declined to 26% and 30% at 26 weeks and 20% and 25% at 52 weeks, respectively. The difference in dorsiflexion peak torque from the normal side was less than 10% by 26 weeks in both groups, with no significant differences. The mean SMFA scores were significantly better in the operative group than the non-operative group at three months (15 vs 20, respectively, p < 0.03). No significant differences were observed after this, and at one year the scores were similar in both groups. We were unable to show a convincing functional benefit from surgery for patients with an acute rupture of the tendo Achillis compared with conservative treatment in plaster.

The Edinburgh Orthopaedic Trauma Unit and the International Trauma Symposium.

This brief annotation summarises the particular contributions made by the annual Edinburgh International Trauma Symposium in various areas of research into aspects of orthopaedic trauma and the management of acutely injured patients, during the 25 years since its establishment.

Fixation of intracapsular fractures of the femoral neck in young patients: risk factors for failure.

The aim of this study was to determine the comorbid risk factors for failure in young patients who undergo fixation of a displaced fracture of the femoral neck. We identified from a prospective database all such patients ≤ 60 years of age treated with reduction and internal fixation. The main outcome measures were union, failure of fixation, nonunion and the development of avascular necrosis. There were 122 patients in the study. Union occurred in 83 patients (68%) at a mean follow-up of 58 months (18 to 155). Complications occurred in 39 patients (32%) at a mean of 11 months (0.5 to 39). The rate of nonunion was 7.4% (n = 9) and of avascular necrosis was 11.5% (n = 14). Failures were more common in patients over 40 years of age (p = 0.03). Univariate analysis identified that delay in time to fixation (> 24 hours), alcohol excess and pre-existing renal, liver or respiratory disease were all predictive of failure (all p < 0.05). Of these, alcohol excess, renal disease and respiratory disease were most predictive of failure on multivariate analysis. Younger patients with fractures of the femoral neck should be carefully evaluated for comorbidities that increase the risk of failure after reduction and fixation. In patients with a history of alcohol abuse, renal or respiratory disease, arthroplasty should be considered as an alternative treatment.

Strength and function recovery after multiple-ligament reconstruction of the knee.

INTRODUCTION: The advent of modern arthroscopic techniques has lead to widespread surgical repair of multiligament injuries of the knee. Although functional outcomes may be linked to the recovery of strength and range of movement, studies have failed to report objective measures of strength recovery. The primary aim of this study was to describe the recovery of isokinetic quadriceps and hamstrings' strength. The secondary aims were to describe the recovery of movement and function. METHODS: Isokinetic muscle dynamomentry was performed by a research physiotherapist. Range-of-movement and patient-reported outcome measures (International Knee Documentation Committee (IKDC), Short Musculoskeletal Function Questionnaire (SMFA) and Knee injury and Osteoarthritis Outcome Score (KOOS)) were also evaluated. RESULTS: At 2 years, quadriceps peak torque had recovered to 85% of the uninjured side and hamstrings were 90%. Hamstring recovery was faster than quadriceps, but at final recovery there were no overall differences between muscle group recovery (p=0.194). Patients obtained a mean 135° of flexion. The KOOSs showed that sporting and quality of life factors recovered more slowly. Although 95% of patients returned to work, 20% had to change types of employment. Median time to return to work was 8 weeks. Nearly one-third (30%) of patients returned to their original level of sport at 2 years. CONCLUSION: Muscle strength improves after multiple ligament reconstruction. There is no difference in outcomes for different muscle groups at 2 years. Deficits persist in comparison with the uninjured limb. A proportion of patients will be unable to return to the pre-injury occupation or sporting ability.

The treatment of open femoral fractures with bone loss.

The results of the treatment of 31 open femoral fractures (29 patients) with significant bone loss in a single trauma unit were reviewed. A protocol of early soft-tissue and bony debridement was followed by skeletal stabilisation using a locked intramedullary nail or a dynamic condylar plate for diaphyseal and metaphyseal fractures respectively. Soft-tissue closure was obtained within 48 hours then followed, if required, by elective bone grafting with or without exchange nailing. The mean time to union was 51 weeks (20 to 156). The time to union and functional outcome were largely dependent upon the location and extent of the bone loss. It was achieved more rapidly in fractures with wedge defects than in those with segmental bone loss. Fractures with metaphyseal defects healed more rapidly than those of comparable size in the diaphysis. Complications were more common in fractures with greater bone loss, and included stiffness of the knee, malunion and limb-length discrepancy. Based on our findings, we have produced an algorithm for the treatment of these injuries. We conclude that satisfactory results can be achieved in most femoral fractures with bone loss using initial debridement and skeletal stabilisation to maintain length, with further procedures as required.