Our aim was to analyse radiological outcome of proximal humerus fractures treated with Philos plate and to assess its usefulness in treatment of malunion and non-union.

Seventy-seven patients were treated with Philos plate (24 men and 53 women). Mean age was 61 years (15–88). There were 66 acute fractures, 6 nonunion, 4 mal-union and one periprosthetic fracture. Acute fractures included 29 two part, 30 three part and five 4 part fractures. Seven had associated dislocation. There were two head splitting fractures. Deltopectoral approach was used in all. No acute fractures were bonegrafted however all nonunions had bonegraft.

Postoperative radiographs were available for review for 59. Average union time was 12 weeks (8–24). Satisfactory union occurred in 51 (86.4%). Twenty-three (39 %) fractures had inadequate reduction. Malplacement of plate was observed in 25 (42%) leading to significant malunion in 11.8%. Satisfactory union was occurred in all of last 30 patients. Nonunion occurred in 2 with infection in one. Other complications included screw penetration into glenohumeral joint, avascular necrosis, screw backing out and tuberosity detachment. Philos plate fixation was used for treatment of 6 nonunions, 4 malunions and one periprosthetic fracture with satisfactory outcome in all.

Relatively high rate of complications was observed in early cases in this series. This could be attributed to the steep learning curve with this technique. Emphasis should be put on careful and adequate reduction of fracture and optimal placement of plate (about 8 mm from the tip of tuberosity) to avoid impingement and to achieve correct screw placement in the humeral head.

In conclusion, Philos plate has been of benefit in management of complex fractures as well as management of non-union of proximal humerus. Quality of reduction and optimal placement of plate appear to be the two most important parameters for a successful outcome.

As part of the workup long length femur radiograph may be carried out pre-operatively in patients presenting with a proximal femur fracture in order to rule out distant metastasis in patients with a history of malignancy but also in some patients in whom a suspicion of possible distal abnormality is aroused by the configuration of the proximal fracture

Using our unit’s database we identified all patients (n=689) presenting with a proximal femoral fracture between Sept 2006 and August 2007 at the Norfolk and Norwich University hospital in Norwich.

Of 689 patients, 92 patients (13.2%) had long length femur radiograph performed before surgery. Indications included history of cancer (39), subtrochantric fractures (14), spontaneous fracture without any fall(2), paget s disease(1), early onset osteoporosis(1) while no clear indication was available in 35 patients. Five patients (5.5%) were found to have some abnormality. Three of the 39 patients with a history of previous cancer were found to have a distal femur metastasis. Two of the 35 patients where a clear indication was not apparent had abnormal findings: one patient had a distal femur infarction and another was found to have a distal femoral malunion. In both cases long leg films did not influence choice of implant. Of the 39 patients with a previous history of cancer, 24 had short implants (hemi-arthroplasty, intramedullary device, DHS), 14 had long implants and one patient died before the operation.

Long length femoral radiographs appear to be indicated in patients with a documented history of a cancer as it helps to decide whether to use a long or short implant. However in patients without a history of malignancy, long leg films were of no value in decision making even if the configuration of the fracture was suspicious.

Background: Implantable grade silicon nitride (Si3N4), such as MC2 TM from Amedica, is an attractive alternative to the common bearing materials used today for spinal and orthopedic applications. Ceramic bearings used in total hip arthroplasty (THA) consist of a femoral head (ball) articulating inside an acetabular cup (socket); the ball and socket are made of alumina (Al2O3) or Al2O3-based composite materials such as zirconia toughened alumina. Extensive studies on the mechanical, imaging and tribological characteristics of MC2 for spinal implants have been conducted. This paper summarizes some of the results from these studies.

Methods: Si3N4 materials properties were evaluated per ASTM standards C-1161 for flexural strength and E-399 for toughness, using the single edge notched beam method. Strength was also measured after subjecting the ceramic to accelerated aging conditions. Imaging compatibility of the MC2, PEEK, titanium, cobalt-chromium (CoCr) and trabecular metal discs was determined under a variety of imaging methods, including MRI. Wear testing of Si3N4 acetabular cups articulating against Si3N4 and CoCr femoral heads was also conducted. Biocompatibility evaluation of the Si3N4 was conducted per ISO 10993 protocols.

Results: MC2 Si3N4 exhibits improved mechanical properties over modern Al2O3 and Al2O3-based composite THA bearings, with a flexural strength of 920 ± 70 MPa, a Weibull modulus of 19, and a fracture toughness of 10 ± 1 MPa.m1/2. Accelerated aging of Si3N4 did not adversely affect the flexural strength. The imaging comparison study showed that Si3N4 did not exhibit any MRI imaging artifacts similar to PEEK, but unlike the metallic materials used for spinal implants. In wear tests using a hip simulator, Si3N4 acetabular cups produced low volumetric wear when articulating against Si3N4 or CoCr femoral heads. The implantable grade Si3N4 material was also found to be biocompatible.

Conclusions: Si3N4 exhibits a superior combination of properties including strength, toughness, MRI compatibility, and wear resistance. This may allow spinal implants with an important combination of properties than hitherto possible, including a wider range of design options, improved anatomic fit and imaging compatibility. Additionally, spinal vertebral body replacement implants were tested in static and fatigue conditions per the ASTM F 2077 and have been cleared by the FDA. An MC2 Si3N4 based total cervical disc implant has been designed and is undergoing pre-clinical testing. The versatility of the MC2 Si3N4 ceramic may enable its use in total disc replacements owing to its combination of superior wear resistance and imaging compatibility.

Introduction: Vertebroplasty is increasingly used in the treatment of painful osteoporotic vertebral fractures, and involves transpedicular injection of bone cement into the fractured vertebral body. Effective infiltration of the vertebral body cancellous bone by the cement is determined by the cement viscosity, and by the permeability of the bone. However, it is unclear how permeability is influenced by regional variations in porosity and architecture of bone within the vertebral body. The aim of the present study was to investigate how permeability is influenced by porosity and architecture of cancellous bone mimics.

Methods: Cylindrical polyamide mimics of two types of cancellous bone structures were fabricated using selective laser sintering (SLS) techniques. Structure A had the rod-like vertical and horizontal trabeculae typical of the anterior vertebral body, while structure B had oblique trabeculae typical of the posterior-lateral vertebral body. Structure B had fewer trabeculae than A. Porosities of 80 and 90% were represented for both structures. Golden syrup, which has a viscosity similar to bone cement1, was injected into the mimics at a constant speed using a ram driven by a materials testing machine. Pressure drop measurements across the mimic, made using a differential pressure transducer, were obtained at five different injection speeds. Permeability of each mimic was calculated from these measurements2. Two more repeat permeability measurements were performed on each mimic.

Results: Repeat measurements were always within 12% of the mean value. For structure A the mean permeabilities were 1.26×10-7 and 1.82×10-7m2 for the 80 and the 90% porosity mimics respectively. The corresponding mean permeabilities for structure B were 1.92×10-7 and 2.86×10-7m2.

Discussion: These preliminary results indicate that higher permeabilities occur in structures with higher porosities, and with structures containing fewer trabeculae that are arranged obliquely. Since permeability is a determinant of cement infiltration, taking into account patient-specific bone architecture parameters may improve the safety and clinical outcome of vertebroplasty. Future experiments will clarify in more detail the architectural parameters that have greatest effect on permeability.

Compared with general anaesthesia, brachial plexus (BP) anaesthesia improves patient satisfaction and accelerates hospital discharge after ambulatory hand surgery; however, variable success rates and typical onset times up to 30 minutes have limited its widespread use. Increasing availability of high-resolution portable ultrasound has renewed interest in more proximal approaches to the BP, previously thought to carry unacceptable risk. The aim of this study was to compare the onset times of ultrasound guided supraclavicular and infraclavicular BP block in patients undergoing ambulatory hand surgery.

With ethics committee approval, patients presenting for hand surgery were prospectively randomised to either supraclavicular (trunks/divisions) or infraclavicular (cords) BP block. A single experienced operator (MF) placed all blocks using ultrasound only guidance. A blinded observer (AP, SY) assessed pinprick sensory and motor block on 3-point scale (normal=2, reduced=1, absent=0) in the median, ulnar, radial and musculocutaneous nerve territories every five minutes, or until blocks were complete. A single general anaesthesia without influence from the unblended anaesthetist.

Of the first 27 patients recruited, block placement details and Intraoperative data are presented in There was a trend to faster onset times and higher success in group infraclavicular, however, this did not reach statistical significance.

Interim results are so far inconclusive for the superiority of one approach. Both techniques were well tolerated and had a high success rate for surgical anaesthesia.

Introduction: Obesity is detrimental to the health of an individual, however does a high body mass index (BMI) actually determine post operative morbidity following hip replacement surgery?

Methods: 550 consecutive primary hip replacement patients were included in this study. Patients were followed up at four weeks, six weeks and one year following surgery. Any complication that the patient had was recorded and listed either as local or general. The complications were further sub divided into minor and major depending on the risk they posed to the patient or the joint.

Results: The average BMI of our patients was 28.3 (4.3). 56 (10%) patients had a complication following hip replacement surgery. The group who did not have any complications had an average BMI of 28.13 (SD=4.6) while the group who sustained complications had an average BMI of 29.46 (SD=5.8) with a p value of 0.104 (Student t-test). When BMI was grouped in values of 5 starting from < 25 and ending with > 35 the p value was 0.029 (chi square test). Odds ratios for grouped BMI varied from 0.086–1.61(95% CI 1.01–1.08) (p=0.086). Odds ratios for individual surgeons ranged from 0.96–2.41 (p=0.024)

Discussion: When we looked at the overall BMI there was no significant difference between the group who had a complication and the group who did not have a complication, however when the BMI was split into groups those patients in group 30–34 and 35+ experienced a higher rate of complications. The final odds of BMI was 1.05 (1.01,1.09). There was a higher complication rate in the groups other than the ideal BMI of 25–29, and even a fall in BMI caused an increase in the complication rates.

Conclusions: Obese individuals are at a higher risk of developing a complication following surgery, however the operating surgeon also has an influence on the complication rate following hip replacements.

The authors would like to present a retrospective study conducted on 178 patients having undergone a hip replacement. The aim of this study was to look at the immediate and short-term complications of hip replacement in relation to the body mass index (BMI).

Patients ranging from age 49 to 90 were included in this study with an average age of 67.5. BMI ranged from 18 to 41. Length of stay ranged from 3 days to 76 days with an average of 11.5 days. Follow up of each patient included any wound complications, time to mobilisation and time to discharge. Operative blood loss and need to transfusion were also looked at. Blood loss was found to be from 150 mls to 2400 mls.

A large number of orthopaedic surgeons use a BMI value of 35 as the upper cut off point to refuse elective surgery. Using the Null hypothesis the authors wanted to prove that a higher BMI resulted in higher complication rates. Statistical analysis of the data however did not show a significant relationship between BMI and early complications in hip replacement surgery. Parameters measured had a higher relationship to individual surgeons rather than the BMI.

The authors would like to conclude that using the BMI as a predictor of a higher rate of short-term complications and refusing surgery to patients with a higher BMI is not justified.

Introduction and Aims: To evaluate the results of humeral nailing with the new Fixion inflatable humeral nail.

Method: We retrospectively studied 42 patients with acute humeral fractures (20), delayed and non-union (12) and pathological fractures (10), who where treated with an inflatable humeral nail and had a minimum follow-up of six months. Our primary outcome measures were clinical and radiological union. Secondary outcome measures were revision of the nail, screening time and operative time. We made a clinical assessment of the patients using the Constant score of the shoulder and a measure of health-related quality of life, using the EuroQol EQ-5D questionnaire.

Results: In patients with acute fractures 16/19 (84%) went on to clinical and radiological union (1/20 patients died four weeks post-operatively from bronchopneumonia). All of the patients with delayed and non-union of humeral fractures went on to clinical and radiological union. In the patients with pathological fractures, the nail provided good palliative symptom relief. Average screening time was 40.5 seconds (21–107). Average operative time was 71 minutes (26–142). Constant score of the shoulder had a median of 67 (SIQ 46.5–77.5) in the affected arm and 87 (SIQ 74–89) in the normal arm.

Conclusion: The treatment of humeral fractures using the inflatable intramedullary nail is a simple and safe technique, avoiding the time and complications associated with distal locking. Its seems to be an appropriate technique with excellent results in those patients with delayed and non-union of humeral fractures, and provides effective palliation in patients with pathological fractures. Its efficacy in patients with acute fractures is comparable to other intramedullary nails. In our experience, it is particularly effective in the multiply injured and the infirm because of the speed and ease of insertion.

Aims: The aim of this study was to þnd out if undisplaced displaced distal radial fractures require plaster immobilisation. Methods: In this prospective study, undisplaced distal radial fractures were divided into two groups; plaster immobilisation was used for one group while removable volar splint was used for the other group. Follow up was at six weeks, three months and six months. Patients were assessed by clinical examination, grip strength, radiological assessment, EQ-5D and a Short Form 12 questionnaire. Results: At 3 months, no difference was found between the two groups in clinical evaluation, radiological assessment, the functional outcome, grip strength, and visual analogue score for pain. Conclusions: We conclude that undisplaced distal radius fractures can probably be treated with out a plaster cast and put straight into wrist orthosis.

Objective: To compare the presentation, diagnosis and treatment of spinal tuberculosis in two cities, one in the UK, and one in Malaysia

Design: Retrospective comparison over a five-year period from June 1995. The Centres studied were the Royal Orthopaedic and Queen Elizabeth Hospitals, Birmingham (UK), and the Kuala Lumpur General Hospital (KL), Malaysia.

Subjects: There were 80 patients (29 females, mean age 42) in the KL group, and 19 patients (8 females, mean age 45) in the UK group.

Outcome measures: Frankel grading before and after treatment were measured for both groups.

Results: KL patients had higher rates of immunocompromise, and had fewer spinal levels involved, 2.1 compared with 2.6 (p-−0.04). There were 65 procedures, 58 positive ZN stains, and 65 positive cultures as compared with 24, 2 and 9 in Birmingham respectively. Improvement in Frankel grading was seen in four patients in UK (5 grades), and in 17 patients in KL (29 grades).

Conclusions: Although the two groups exhibited similar demographics, the rate of immunocompromise-related tuberculosis, severity of neurological deficit, and type of surgery undertaken differed significantly. Reasons for the difficulty in identifying the tubercle bacillus in Birmingham are discussed.