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Background Infection is one of the most devastating complications after primary total knee arthroplasty (TKA). Antibiotics-impregnated cement has been used and proven effective in preventing deep infection. This study was to evaluate the long-term results of using cefuroxime-impregnated cement and systemic cefazolin for one week to assess their efficacy in preventing infection of primary TKA. Methods From 1999 to 2007, 2700 cases of primary TKA were performed with cemented fixation of all patellar, tibial, and femoral components. Cefuroxime-impregnated cement for fixation and systemic cefazolin for one week were selected in all cases. The average follow-up period was 89 months (range, 40–140). The effects of this selected regime in the periprosthetic infection were evaluated. Results A total of eight infections occurred after primary TKA, including five deep infections (0.19%) and three superficial infections (0.11%) in the 2700 knees. No loosening or osteolysis was noted. Conclusion Comparable with other measurements, cefuroxime-impregnated cement, accompany by systemic cefazolin for 1 week was shown to control postoperative deep infection to 0.19% (after primary TKA was performed in an operative setting without lamina flow and body exhaust suit).

To realize the therapeutic potential of mesenchymal stem cells (MSCs), we aimed to develop a method for isolating and expanding New Zealand rabbit MSCs in a great scale. Rabbit MSCs expanded under hypoxic and normoxic conditions were compared in terms of replication capacity, differentiation potential, and the capacity for allogeneic transplantation in a calvarial defect model. The cells from all tested rabbits were expanded more rapidly when plated at low-density under hypoxic conditions compared to under normoxic conditions. Moreover, cells expanded under hypoxic conditions increased in the potential of osteoblastic, adipocytic, and chondrocytic differentiation. More importantly, radiographic analysis and micro-CT measurement of bone volume revealed the hypoxic cells when transplanted in the calvarial defects of another rabbit increased in the ability to repair bone defect compared to the normoxic cells. Six weeks after allogeneic transplantation of hypoxic MSCs, histological analysis revealed a callus spanned the length of the defect, and several bone tissues spotted in the implant. At 12 weeks, new bone had formed throughout the implant. Using BrdU labeling to track the transplanted cells, the hypoxic cells were more detected in the newly formed bone compared to the normoxic cells. For defects treated with allogeneic MSCs, no adverse host response could be detected at any time-point. In conclusion, we have developed a robust method for isolation and expansion of rabbit MSCs by combining low-density with hypoxic culture, which can be applied for the design of clinical trials in allogeneic transplantation of MSCs for bone healing.

Background: Open reduction and internal fixation with tension band wire is the standard treatment for displaced transverse patellar fractures. Recently, some minimally invasive techniques have been proposed as possible alternative methods. This retrospective study compared a newly reported percutaneous osteosynthesis with conventional open method for the treatment of displaced transverse patellar fractures. Methods: The minimally invasive technique was performed by percutaneous osteosynthesis with modified Carpenter’s (POMC) technique, using figure-eight wiring through two-paired cannulated screws under the control of arthroscopy and fluoroscopy. The conventional open surgery was performed with open modified anterior tension band (OMATB) technique. Totally 60 displaced transverse fractures were included in our study. Twenty were treated with percutaneous technique and 40 with open method. Outcome assessment included analysis of radiographic images, range of motion, Lysholm scores, complications, and reoperations. Results: Mean follow-up was 37.3 months. Comparison of POMC and OMATB groups showed statistically significant results as follows: shorter surgical time, 70.4 � 12.5 minutes for POMC group; greater degrees of flexion, 140.4 � 6.1 for POMC group; better total range of motion, 139.6 � 8.2 for POMC group; higher Lysholm scores, 93.6 � 3.1 for POMC group. Frequencies of total complications and reoperations were significantly lower in POMC group. Conclusion: POMC method was a reproducibly reliable method, offering better functional outcome, lower incidence of complications, and reoperations, as compared with standard OMATB group for transverse patellar fractures. Nevertheless, it is not recommended for severely comminuted fractures. Copyright 2011 Elsevier Taiwan LLC and the Chinese Medical Association. All rights reserved.

The purpose of this study was to evaluate retrospectively the outcomes of cementation of cross-linked polyethylene (PE) liner in a well-fixed metal shell in 23 hips with an average follow-up period of 6 years. The mean Harris hip score was 69.6 ± 12 (range, 46-83) points preoperatively. The average postoperative follow-up was 72.3 months (range, 56-100 months). At the final follow-up, the mean Harris hip score was 95.5 ± 3 (84-100) points. There was no change in the bone-shell interface. No new osteolytic lesions were identified. The lesions impacted with bone graft had united completely. The remaining osteolytic lesions had decreased in size. There was no recurrent osteolysis, hip dislocation, component migration, and failure at the cement-metal interface. The results of the current study revealed that cementation of cross-linked PE liner into a well-fixed shell provided good midterm durability. Keywords: cement, well-fixed acetabular shell, cross-linked polyethylene liner, revision total hip arthroplasty.

Background and Objectives Allograft-prosthetic composite for reconstruction of the proximal femur after tumor excision is widely used as an alternative to megaprosthesis. To achieve greater biological fixation, we employed a long-stem prosthesis that is cemented proximally into the extracorporeally irradiated autograft and press-fit distally into the host femur without any supplementary plate fixation of the junction instead of the standard all-cemented technique. Methods From 1997 to 2002, 14 patients underwent proximal femur reconstruction with extracorporeally irradiated autograft-prosthetic composite using an AML® extensively porous-coated long stem for reconstruction of the bone defect of tumor excisions. Results At the mean follow-up period of 65.7 months, only one patient (8.1%) developed non-union and another died of disease before union of the junction. The remaining 12 patients (85%) achieved union at a mean of 20.3 weeks (range, 14–40 weeks) without major complication. The mean functional Enneking score was 72.1% (range, 53–93%). Conclusions These clinical results show that this reliable and satisfactory technique promotes union through compression at the host-graft junction with weight-bearing by leaving the distal portion of the femoral stem uncemented into the host bone. J. Surg. Oncol. 2009;100:418–422. © 2009 Wiley-Liss, Inc.

Variable degrees of bony deficiencies often complicate revisional arthrolasties of acetabular components and represent challenges to orthopedic surgeons. Many solutions exist and cementless jumbo cup reconstruction had been proven to be a feasible and successful method. Our study aimed to access the results of these cementless giant cups for managing acetabular bony defect at one institute.Between March 2000 and March 2003, 47 revisions of the failed acetabular components using the so-called "Jumbo Acetabular Cups" were enrolled in our study. All cases were followed for at least 4 years. We defined the size of the jumbo cups for the Asians to be of an outside diameter of 64 mm for men and 60 mm for women, which were 2 mm smaller than the commonly used definition in the Western countries. The radiographic outcomes and the migration of hip centers were analyzed. The endurance of these giant sockets was estimated by the Kaplan-Meier analysis.After a mean follow-up of 65 months, only three implant failures requiring re-revision were identified. The estimated 5-year survival rate according to the Kaplan-Meier analysis was 94.5%. Radiographic analysis demonstrated an improvement of vertical hip center from 31 to 27 mm proximal to the interteardrop line. Eight (17%) cups exhibited radiolucent line around the bone-prosthesis interface but did not attenuate implant instability. The complication rate was not high. Dislocation happened in five (11%) patients. One deep infection was successfully reconstructed in stage surgeries after eradication of the infection.With the aid of novel implant-coating technique and materials, jumbo cup reconstruction can achieve stability and longevity through an adequate peripheral ring-contact, regardless of inadequate implant to host bone contact. We believe that this is a reliable and easily performed reconstruction for acetabular defect.

To evaluate the efficacy and safety of tapentadol immediate-release (IR) for treating acute pain following orthopedic bunionectomy surgery in a Taiwanese population.This was a phase 3, randomized, double-blind, placebo-controlled, parallel-group bridging study in which Taiwanese patients (N = 60) with moderate-to-severe pain following bunionectomy were randomized (1:1:1) to receive tapentadol IR 50 or 75 mg or placebo orally every 4-6 hours over a 72 hour period. The primary endpoint was the sum of pain intensity difference over 48 hours (SPID48), analyzed using analysis of variance.Out of 60 patients randomized (mainly women [96.7%]; median age 44 years), 41 (68.3%) completed the treatment. Mean SPID48 values were significantly higher for tapentadol IR (p ≤ 0.006: 50 mg, p ≤ 0.004: 75 mg) compared with placebo. Between-group differences in LS means of SPID48 (vs. placebo) were tapentadol IR 50 mg: 105.6 (95% CI: 32.0; 179.2); tapentadol IR 75 mg: 126.6 (95% CI: 49.5; 203.7). Secondary endpoints including SPID at 12, 24, and 72 hours, time to first use of rescue medication, cumulative distribution of responder rates, total pain relief and sum of total pain relief and sum of pain intensity difference at 12, 24, 48, and 72 hours, and patient global impression of change showed numerically better results supporting that tapentadol IR (50 and 75 mg) was more efficacious than placebo in relieving acute pain. The most frequent treatment emergent adverse events reported in ≥ 10% patients in either group were dizziness, nausea, and vomiting. A limitation of this study may possibly include more controlled patient monitoring through 4-6 hour dosing intervals, which reflects optimal conditions and thus may not approximate real-world clinical practice. However, all treatment groups would be equally affected by such bias of frequent monitoring, if any, since it was a randomized and double-blind study.Tapentadol IR treatment significantly relieved acute postoperative pain and was well tolerated in a Taiwanese population. ClinicalTrials.gov identifier: NCT01813890.

To investigate the effects of ultrasound-guided injections of hyaluronic acid (HA) versus steroid for trigger fingers in adults.Prospective, double-blinded, randomized controlled study.Tertiary care center.Subjects with a diagnosis of trigger finger (N=36; 39 affected digits) received treatment and were evaluated.Subjects were randomly assigned to HA and steroid injection groups. Both study medications were injected separately via ultrasound guidance with 1 injection.The classification of trigger grading, pain, functional disability, and patient satisfaction were evaluated before the injection and 3 weeks and 3 months after the injection.At 3 months, 12 patients (66.7%) in the HA group and 17 patients (89.5%) in the steroid group exhibited no triggering of the affected fingers (P=.124). The treatment results at 3 weeks and 3 months showed similar changes in the Quinnell scale (P=.057 and .931, respectively). A statistically significant interaction effect between group and time was found for visual analog scale (VAS) and Michigan Hand Outcome Questionnaire (MHQ) evaluation (P.05). The steroid group had a lower VAS at 3 months after injection (steroid 0.5±1.1 vs HA 2.7±2.4; P.001). The HA group demonstrated continuing significant improvement in MHQ at 3 months (change from 3wk: steroid -2.6±14.1 vs HA 19.1±37.0; P=.023; d=.78).Ultrasound-guided injection of HA demonstrated promising results for the treatment of trigger fingers. The optimal frequency, dosage, and molecular weight of HA injections for trigger fingers deserve further investigation for future clinical applications.

Fibrous dysplasia, a condition in which the skeleton fails to develop normally, is characterized by fibroblastic stroma and immature bone. Bowing of the long bones occurs frequently in the polyostotic form, and stress fractures often result. Shepherd's crook deformity is a characteristic feature of fibrous dysplasia. The goal of its treatment is to obtain normal walking ability and relieve pain due to pathologic fracture secondary to the deformity; however, correction of the deformity is a surgical challenge. We present 2 cases of shepherd's crook deformity treated with corrective osteotomy and a dynamic hip screw. Both cases showed good bone healing and no recurrent deformity. The gross deformities were corrected, and both patients were pain-free after operation.

This work presents finite-element-method-based simulations of fluid dynamics and heat transfer in a practical coffee bean roaster. The source of heat and air speed at the exhaust window were identified as critical operating parameters affecting the temperature and air speed distribution in the roaster. Quantitative analysis was conducted to elucidate the relationships among the power of heat source, air speed at the exhaust window, temperature and air speed profiles within the roaster chamber. The resulting air speed distribution values were then used to simulate the transfer of heat between the coffee beans and the surrounding air. Highly unevenly temperature distributions were observed in the coffee beans in the first 60 s of the roasting process. Nonetheless, between 100 and 720 s, the temperature in the coffee beans became increasingly uniform as it increased monotonically to approximately 200°C. Practical Applications Roasting conditions (air speed, temperature profile and duration) play a critical role in the resulting aroma and flavor of roasted coffee beans. We developed a methodology for the predictions of the air speed and temperature within the roaster. This methodology developed in this work could be used in optimizing the design of a coffee bean roaster as well as the roasting conditions.

A rare type I Monteggia equivalent lesion with a posterior dislocation associated with a diaphyseal radius and ulna fracture in an adult is described. The probable mechanisms of injury are speculated to include flexion of the elbow and pronation of the forearm. Early reduction of the dislocation and rigid fixation of the fractures helped to achieve excellent results.

Diagnosis of occult hip fractures by initial radiographs remains challenging in the emergency department. Previously, the gold standard for accurate diagnosis of occult hip fractures was magnetic resonance imaging. This study used initial radiographs obtained in the emergency department to evaluate specific signs and measurements as diagnostic references for occult femoral neck fractures in elderly patients. Initial negative radiographs were reviewed for 2 groups of patients: a group with occult femoral neck fractures (n=16) and a group without fractures (n=32). Reviews of initial radiographs and all imaging studies were performed by a senior orthopedist (C-C.C.) and a radiologist (H-T.W.). Diagnostic signs included lateral, medial, anterior, and posterior signs; measurements included elevation of the fat pad and external rotation of the femur. The prevalence of occult femoral neck fracture was 3.3%. Initial radiographs of occult femoral neck fractures were not routinely negative; 14 (87.5%) of 16 patients with fractures had at least 1 radiographic sign. Using the positive lateral or posterior sign as the diagnostic reference, the sensitivity was 0.875 and the specificity was 0.906. When elevation of the fat pad was ⩾1.5 mm, the sensitivity was 0.867 and the specificity was 0.857 for the diagnosis of occult femoral neck fracture. The lateral and posterior signs and elevation of the fat pad ⩾1.5 mm on initial radiographs are recommended as diagnostic references for occult femoral neck fracture. These references are clearly defined and may offer important information for all clinicians and radiologists in the emergency department.

Background: Human immunodeficiency virus (HIV)-infected patients are at risk for bacterial and opportunistic infections with worsening immunosuppression. Methods: From June 2000 to January 2009, six patients who were diagnosed with HIV infection underwent 10 joint replacement procedures, including six total hip arthroplasties, two total knee arthroplasties, and one shoulder hemiarthroplasty. An ordinary dose of postsurgical-empirical antibiotics was prescribed, with an average follow-up period of 38.6 months. All prostheses of total knee arthroplasty and shoulder hemiarthroplasty were fixed with vancomycin-impregnated bone cement. Results: The rate of postoperative infection for HIV infected patients is supposed to be higher than for HIV negative patients. However, in our institution, there have been no HIV- positive patients who have suffered postoperative infection. Conclusion: HIV-positive patients can have excellent outcomes after undergoing various arthroplastic surgeries. This revelation, coupled with the advances in antiviral therapy that have helped to lengthen HIV patient lifespans, strongly suggests that these patients should receive arthroplastic surgery.

A retrospective study was conducted to evaluate the role of autologous bone graft in treating atrophic nonunion of midshaft clavicle fracture with a limited-contact dynamic compression plate (LC-DCP). Between 1995 and 2008, sixty cases of atrophic nonunion of midshaft clavicle fractures were managed with open reduction and internal fixation with an LC-DCP. The cases were separated into 2 groups to evaluate the effect of autologous bone graft in the enhancement of bone union. In group 1 (n=24), autologous bone graft was not used; in group 2 (n=36), autologous bone graft was used. Pre- and postoperative management were the same in both groups. Radiographic results and functional outcomes according to the Quick Disability of Arm, Shoulder, and Hand score were evaluated. Average follow-up was 25.2 months (range, 24–48 months). No statistically significant difference was found between the 2 groups regarding demography and preoperative functional scores ( P >.05). Operative time and hospital stay were statistically significant longer in group 2 ( P P >.05). Limited-contact dynamic compression plate fixation is an effective method for treating atrophic nonunion of midshaft clavicle fractures. Autologous bone graft was not needed.

To realize the therapeutic potential of mesenchymal stem cells (MSCs), we aimed to develop a method for isolating and expanding New Zealand rabbit MSCs in a great scale. Rabbit MSCs expanded under hypoxic and normoxic conditions were compared in terms of replication capacity, differentiation potential, and the capacity for allogeneic transplantation in a calvarial defect model. The cells from all tested rabbits were expanded more rapidly when plated at low-density under hypoxic conditions compared to under normoxic conditions. Moreover, cells expanded under hypoxic conditions increased in the potential of osteoblastic, adipocytic, and chondrocytic differentiation. More importantly, radiographic analysis and micro-CT measurement of bone volume revealed the hypoxic cells when transplanted in the calvarial defects of another rabbit increased in the ability to repair bone defect compared to the normoxic cells. Six weeks after allogeneic transplantation of hypoxic MSCs, histological analysis revealed a callus spanned the length of the defect, and several bone tissues spotted in the implant. At 12 weeks, new bone had formed throughout the implant. Using BrdU labeling to track the transplanted cells, the hypoxic cells were more detected in the newly formed bone compared to the normoxic cells. For defects treated with allogeneic MSCs, no adverse host response could be detected at any time-point. In conclusion, we have developed a robust method for isolation and expansion of rabbit MSCs by combining low-density with hypoxic culture, which can be applied for the design of clinical trials in allogeneic transplantation of MSCs for bone healing.

Silibinin, an effective chemo-preventive agent in various cancer types, suppresses cancer cell growth, but its effects on cancer stem-like cells (CSLCs) remain unclear. This study aimed to examine whether silibinin inhibited the development of CSLCs and disclose the underlying signaling. The colorectal cancer spheroid culture system was used for enriching CSLCs. The effects of silibinin on CSLCs were evaluated by counting sphere numbers, and calculating the percentage of CD133+ cells by flow cytometry and immunofluorescence both in the absence and presence of different concentrations of silibinin. The results showed the sphere number of CCS was 36 ± 9.6 after 15 days of CSLC enrichment in spheroid culture, and the percentage of CD133+ cells increased to 18 ± 6.4% compared to 3 ± 0.8% before enrichment. Treatment with silibinin reduced the sphere formation to 5 ± 3.3 and decreased the CD133+ percentage to 8 ± 2.3%. Interestingly, treatment of silibinin suppressed the activation of the AKT Ser473/mTOR pathway in spheroid culture through suppressing the activity of protein phosphatase 2Ac subunit (PP2Ac). In a xenograft tumor model, treatment with silibinin also inhibited tumor formation rate and tumor growth. Silibinin, which inhibits colon CSLCs self-renewal and sphere formation by suppressing the PP2Ac/AKT Ser473/mTOR pathway, may be a compound for developing new strategies in modulating CSLCs in cancer therapy.

For treatment of displaced transverse patellar fractures, open reduction and internal fixation is the standard reconstructive method. The role of percutaneous osteosynthesis is still unclear and worth of further investigation. Our hypothesis is that satisfactory reduction and rigid fixation is possible for the treatment of displaced transverse patellar fractures with some percutaneous techniques. Here, we present and evaluate a minimally invasive technique for these patellar fractures.This is a retrospective study. Twenty-one patients with 21 transverse patellar fractures were treated with our percutaneous technique in acute phase. The minimally invasive surgery was achieved by closed reduction and fixation with modified Carpenter's technique, using figure-eight wiring through two parallel cannulated screws under the assistance of arthroscopy and fluoroscopy. The patients were followed up to an average of 38.8 months (range 26-48). Main outcome measurements included radiographic assessment, range of motion, Lysholm scores, complications, and reoperations.Radiographically, all fractures healed at a mean of 11.0 weeks (range 9-13). Mean total range of motion of knee joint was 140.1° (range 127-152). Functional assessment of Lysholm scores was 93.9 points (range 86-100). Malreduction, loss of reduction, and infection were not observed in 21 patients. Complications were three cases (14%) of hardware irritation, and needed a second operation for removal.Under the control of arthroscopy and fluoroscopy, we successfully treated 21 displaced transverse patellar fractures by percutaneously osteosynthesis. This is a safe and reproducible method for transverse patellar fractures. However, it is not indicated for severely comminuted fractures.

Allograft-prosthetic composite for reconstruction of the proximal femur after tumor excision is widely used as an alternative to megaprosthesis. To achieve greater biological fixation, we employed a long-stem prosthesis that is cemented proximally into the extracorporeally irradiated autograft and press-fit distally into the host femur without any supplementary plate fixation of the junction instead of the standard all-cemented technique.From 1997 to 2002, 14 patients underwent proximal femur reconstruction with extracorporeally irradiated autograft-prosthetic composite using an AML extensively porous-coated long stem for reconstruction of the bone defect of tumor excisions.At the mean follow-up period of 65.7 months, only one patient (8.1%) developed non-union and another died of disease before union of the junction. The remaining 12 patients (85%) achieved union at a mean of 20.3 weeks (range, 14-40 weeks) without major complication. The mean functional Enneking score was 72.1% (range, 53-93%).These clinical results show that this reliable and satisfactory technique promotes union through compression at the host-graft junction with weight-bearing by leaving the distal portion of the femoral stem uncemented into the host bone.

The purpose of this study was to evaluate retrospectively the outcomes of cementation of cross-linked polyethylene (PE) liner in a well-fixed metal shell in 23 hips with an average follow-up period of 6 years. The mean Harris hip score was 69.6 +/- 12 (range, 46-83) points preoperatively. The average postoperative follow-up was 72.3 months (range, 56-100 months). At the final follow-up, the mean Harris hip score was 95.5 +/- 3 (84-100) points. There was no change in the bone-shell interface. No new osteolytic lesions were identified. The lesions impacted with bone graft had united completely. The remaining osteolytic lesions had decreased in size. There was no recurrent osteolysis, hip dislocation, component migration, and failure at the cement-metal interface. The results of the current study revealed that cementation of cross-linked PE liner into a well-fixed shell provided good midterm durability.

Background: Refractory nonunions of the tibia or femur are physically and mentally devastating conditions for the patients, and the treatment is challenging for orthopedic surgeons. The goal of this study was to assess the feasibility and outcome of surgical treatment in recalcitrant nonunions of a lower extremity with bone graft enriched with autologous platelet gel (APG). Methods: Twelve patients with four femoral and eight tibial atrophic nonunions after multiple prior procedures were included. All of them were treated with the bone grafting procedures with autograft complex enriched with APG. They were evaluated with radiographs, bone mineral density for bony healing process, and the Short-Form 36 Health Survey for functional outcome. Results: Of the 12 patients, 11 healed at an average of 19.7 weeks after the first attempt and 1 healed after the second attempt at 21 weeks. The bone mineral density continued to increase steadily from early healing to the remodeling phase. Functional status was greatly improved at an average follow-up of 32.4 months. Conclusions: The results of this preliminary study implied the possible potential of bone graft enriched with APG in the treatment of recalcitrant nonunions of the lower extremity. More research is necessary to clarify its role in augmentation of bone graft to enhance healing of nonunion.

Between 1997 and 2004, 18 patients (8 men and 10 women, with a mean age of 73.2 years) with failed treatment of intertrochanteric hip fractures underwent hip arthroplasty as salvage procedures at our institution. Cementless, 5/8-porous coated, 6-in. primary diaphyseal locking femoral stems were used. Prospective follow-up ranging from 2 to 5 years (mean, 37.1 months) showed improvement of hip function without prosthesis loosening. Complications included 1 case of postoperative infection, 2 cases of dislocation, and 2 cases of stem subsidence. The clinical results were satisfactory. The 5/8-porous coated, 6-in. cementless femoral stems could be used in the salvage procedures for failed fixation of intertrochanteric hip fractures.

Giant cell tumors of the acetabulum are uncommon lesions. Their diagnosis is often delayed due to their slow progression, late onset symptoms and easily been obscured by bowel gas in plain pelvic radiographs. The tumor size is always very large at the time of diagnosis, with major nerve and joint involvement. Management of such tumor remains challenging to orthopedic surgeons. Between 1992 and 1999, 3 acetabular giant cell tumors were diagnosed and managed at our institution. The treatment modality was intralesional tumor excision with structural allograft reconstruction. The margin of tumor was routinely managed with high-speed burring and phenol application. All 3 patients were free of local recurrence at a mean follow-up of 89 months. Postoperative palsy of sciatic nerve occurred in 1 patient, but no complications such as wound infection or fracture were seen. The nerve palsy recovered completely 1 year later. The final functional outcome of the 3 patients was excellent. The result appears that intralesional excision with adjuvant therapy is feasible in the management of giant cell tumor of the acetabulum and is able to obtain a satisfactory outcome.

We reported a case of fracture of a polyethylene tibial post in a 44-year-old woman after 3 years of NexGen posterior-stabilized total knee arthroplasty (Zimmer, Warsaw, IN). Burnishing and delamination of the polyethylene was found around the breakage site of the post, especially over the anterior aspect of the post base. It indicated that the possible failure mechanism was the repeated anterior impingement between the metal femoral cam and polyethylene tibial post. After replacement of the broken insert, the patient obtained complete relief of previous symptoms. To our knowledge, this is the first report of post breakage of a NexGen posterior-stabilized knee prosthesis.

Metaphyseal fractures of the distal tibia near the ankle joint are difficult to manage. Poor soft tissue coverage and comminution of the fracture complicate open reduction. This prospective study aims to evaluate the practicability of using interlocking nails to treat such fractures. Using the method of closed reduction and internal fixation with a shortened tibial interlocking nail, 20 consecutive cases of distal tibial metaphyseal fractures within 4 cm of the ankle joint line were enrolled from 1997 to 2001. All patients received regular post-operative radiographic check-up and the ankle function was evaluated with the Iowa Ankle-Evaluation rating system. Our result was satisfactory and all of the fractures united solidly with a mean union time of 17.2 weeks. No major complication occurred. We conclude that tibial interlocking nailing is a reliable and safe method for managing metaphyseal fractures of the distal tibia near the ankle joint.

We report a patient who had bilateral stress fractures of proximal tibial shaft secondary to advanced osteoarthritis of knee with varus deformity. With treatment by simultaneous correction of deformity and internal fixation, the fractures healed uneventfully and the chronic knee pain was much alleviated. Due to progression of the symptom, right total knee replacement was finally performed 9 years later. Her left knee still did well after 13-year follow-up.

Background This study was conducted to evaluate the results of treating hypertrophic nonunion of mid-shaft clavicle fracture with a limited contact dynamic compression plate (LC-DCP) without autologous cancellous bone graft. Methods From 1995 to 2008, 51 cases of hypertrophic nonunion of mid-shaft clavicle fracture were managed with open reduction and internal fixation by LC-DCP without bone graft involvement. Of these 51 cases, 30 had nonunion after failure of initial surgical treatment (Group 1), and 21 had nonunion after failure of conservative treatment (Group 2). Preoperative and postoperative case management were the same for both groups, with the average follow-up period being 20.4 months (range 18–36). Our study evaluated the radiographic results and functional outcomes of these cases according to the quick disability of arm, shoulder, and hand score. Results All 51 cases resulted in uneventful unions. There was no statistically significant difference between the two groups regarding patient demography, cause of injury, preoperative and postoperative functional scores, length of operation, union time, and duration of hospitalization (p > 0.05). Conclusion LC-DCP fixation is an effective method for treating hypertrophic nonunion of mid-shaft clavicle fracture. Local bone graft is sufficient to achieve necessary union, and autologous bone graft from other sites of the body appears unnecessary.