The aim of this study was to establish the consensus of opinion amongst trauma surgeons for the management of displaced supracondylar fractures of the humerus in children.

We carried out a postal questionnaire involving 130 orthopaedic surgeons with an interest in paediatric trauma. They were identified as being members of the British Society for Children’s Orthopaedic Surgery.

We received a response rate of 65%. One third of respondents believe that in uncomplicated fractures, reduction should occur within 6 hours of injury and one half felt that ‘pulseless’ fractures should be treated in the same time frame. 60% said they would explore a pulseless arm after midnight, but only 20% would reduce and stabilise uncomplicated fractures. 82% of surgeons stabilise displaced grade III fractures with K wires, of these, the majority would use a‘crossed’ configuration. If after stabilisation the arm remained pulseless, only 16% said they would explore the brachial artery immediately, 23.5% would seek a vascular opinion and 60.5% of surgeons would observe for 24 hours. If the arm remained pulseless but pink after 24 hours, the majority of surgeons would continue to observe and rely on collateral circulation for distal perfusion.

The majority of surgeons would stabilise displaced supracondylar fractures as soon as possible but not after midnight unless the arm was pulseless. If the hand remained pink but pulseless, most felt that continued observation beyond 24 hours was acceptable.

Introduction: With the introduction of out-patient waiting time targets, there has been increasing pressure on clinics to accommodate both new referrals and follow-up patients. Departments have found it increasingly difficult to continue long-term follow-up of patients post arthroplasty.

We have piloted a new system of purely therapist led clinics and assessed this with an anonymous patient survey.

Method: Since 2005 and following a training program for the therapists involved, 110 arthroplasty patients have passed through the new clinics. They are seen at 6 weeks, 6 and 12 months and then 3, 5 and 10 years. Their ROM, stability and XRAY findings are documented and each patient completes Oxford Knee, SF 12 and WOMAC scores. If there are problems at any stage they are seen in the surgeon led clinic.

Results: 69% of patients responded to the survey and in general they were very satisfied with the new system. 75% felt that been seen by the therapist alone still fully addressed their needs with 79% having an overall impression of either excellent or very good. The patients rated the therapists professionalism, assessment and information delivery as good to excellent in over 80%.

Conclusion: We feel that with the introduction of this new system, we will be able to continue long-term follow-up of all our patients post arthroplasty. With their regular assessments and scoring we will be able to monitor the success of their replacements and theoretically identify early any problems.

Bone substitutes have emerged as a promising alternative in surgeries requiring bone grafting, with a large array of materials available for today’s surgeon. Unfortunately, there is currently no definitive method for comparing the potential bone-healing potential of these different materials. We have developed a novel technique for assessing the osteogenic capacity of different bone substitutes in a mechanically-stimulating perfusion bioreactor.

The Zetos(TM) bioreactor system consists of individual flow chambers connected to a low-flow perfusion pump, which recirculates media through samples. The Zetos can be programmed to apply a controlled stress or a controlled strain to each individual sample inside the flow chamber. Since bone formation has been shown to be optimal with short doses of high amplitude strains, test samples were subjected to daily loading corresponding to physiological strain experienced during a jumping exercise (maximum 3000 microStrain).

Three substitute materials representing the range of materials available clinically were tested in the Zetos system; these included collagen, calcium phosphate, and a synthetic polymer. Primary human osteoblasts were seeded onto the substitutes, which were then placed inside the Zetos system and maintained under load or non-load conditions for 14 days. No supplementary osteogenic factors were provided to the cells. The degree of bone formation in the samples was assessed using Von Kossa staining and quantified in terms of the area of new mineral relative to the surface area of the substitute.

No mineralisation was detected in the non-loaded samples. However, in the loaded samples, mineralisa-tion was detected in some of the substitutes. The degree of mineralisation depended on the material: in collagen, an average of 0.22 mm2/mm2 was mineralised; in calcium phosphate, mineralisation averaged 0.0013 mm2/ mm2; but in the loaded polymer samples, no mineralisation was detected.

This indicates that mechanical loading is a sufficient stimulus for bone formation in some materials, even in the absence of other known osteogenic factors. Further, commercial substitutes differ in their ability to support bone formation under conditions of physiological loading. Further development of this technique could allow it to be used as a screening tool for predicting the efficacy of commercial products.

We compare the management and outcome of two management stratergies for the perfused but pulseless hand following stabilisation of grade III supracondylar fractures in children.

For this study we looked at 15 patients treated in two centres (all treated by the senior author) between 1995 and 2004. The patients were designated to group I if the pulseless hand had been observed or group II if they underwent immediate exploration. Data collected included time to surgery, neurological deficit, time to return of pulse and subsequent symptoms of forearm claudication. All patients were seen at week 1,3 and followed for at least 6 months post surgery. Radiographs were reviewed to determine the adequacy of reduction of the fracture.

The mean age of patient was 3.8 years. Median time to surgery was 6 hours. 6 children had evidence of anterior interosseus nerve palsy. 12 cases were reduced anatomically, 3 had minimal fracture gap. Of the 8 patients in group I (observation) 2 had secondary exploration and one developed claudication symptoms. All had palpable radial pulse at 3 months.6 of the 7 patients in group II (exploration) were seen to have brachial artery tethering, 2 with median nerve entrapment. 5 of them had subsequent return of radial pulse within 24 hours.

Satisfactory radiological reductionof the fracture does-not exclude vessel or nerve entrapment. We would advocate early exploration of the artery if the pulse does not return within 24 hours.

Background: There is no consensus on the best treatment of complex intraarticular fractures and high energy diaphyseal fractures of the long bones. The Locking Compression Plate (LCP) and the Less Invasive Stabilization System (LISS) are the new implants with angular stability developed by the AO/ASIF. The new screw-plate systems seem to offer an excellent alternative for the operative fixation in these cases.

Patients and methods: In a prospective study the new system was used to treat 20 patients (8 women, 12 men; average age 39.3 yrs) with 23 high – energy injuries (multifragmentary shaft fractures or complex intraarticular) from december 2001. During a mean period of 20 (13–30) months, complications, clinical and radiographic findings were followed prospectively. One patient was lost to follow-up. 19 patients underwent a standardized follow-up examination. According to the AO classification, 6 were proximal tibial fractures 41-C; 4 distal tibial 43-C; 6 distal femoral 33-C; 3 humerus 12-C and 4 distal radius 23-C. Ten of the fractures were open, 6 grade II, and 4 grade III. Because of severe concomitant injuries, 4 fractures were first treated with an external fixator and definitively stabilized more than two weeks after the injury. 2 patients were operated on after failure of others implants and non-union.

Results: The outcome correlated with the severity of the fracture, anatomic reduction, exact positioning of the plate and concomitant injuries. Despite the large number of open and comminuted fractures no serious complications as deep infections, vascular lesions, DVT or non-unions were presented.

Conclusions: We found the new internal fixator system to be a safe and reliable procedure. The new system offers numerous fixation possibilities and has proven its worth in complex fracture situations and in revision operation. A good knowledge of biomechanics is essential as well as precise preoperative planning.

Background: Paediatric spinal systems made from stainless steel are effective at correcting early onset scoliosis in a non-fusion technique. The use of similar systems manufactured from titanium is an attractive alternative as it would allow Magnetic Resonance Imaging of the patient with its recognised imaging advantages.

Objective: We performed a prospective in vitro study to compare the mechanical performance of a current clinically used stainless steel construct with an identical proposed titanium alternative.

Methods: Twelve spinal constructs of each material were constructed in a typical in vivo configuration using a corpectomy model in accordance with ASTM F1798 standard. Five samples for each metal were subjected to axial compressive static loading at a rate of 1mm/s until plastically deformed. Seven samples for each metal were then subject to varying compressive cyclic loads until a 5 million cycle run out was observed. From this data a fatigue S-N curve was generated.

Results: The stiffness of each construct was then calculated and the results were statistically analysed. For steel and titanium we calculated 95% confidence intervals of 23.9 to 35.7 and 18.8 to 23.7 respectfully. Significance P(< 0.05). The fatigue strength to 5 million cycles was 179N and 150N for steel and titanium respectfully. Failure occured most commonly in the rods close to the transverse rod connector or the pedicle screw / polyethylene block interface.

Conclusions: We conclude that with identical dimensions, the stainless steel constructs had a significantly higher Modulus of Elasticity than titanium. The fatigue strength for steel was also higher than titanium. The potential use of titanium as an alternative to stainless steel in paediatric spinal systems is still an attractive alternative. Given the results, we would suggest that further re-designing and testing be carried out before clinical release and then initially be reserved for selected patients with lower body weight or physical demands.