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Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_XXX | Pages 34 - 34
1 Jul 2012
Young P Bell S Jane M Mahendra A
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Introduction

Bony tumours of foot account for approximately 3% of osseous tumours. However, literature regarding calcaneal tumours comprises individual case reports, short case series or literature reviews, with last large case series in 1973. Literature on bony tumours of the talus is limited to case reports only.

Methods

We retrospectively reviewed medical notes and imaging for all patients with calcaneal or talar tumours recorded in the Scottish Bone Tumour Registry since the 1940's. Demographics, presentation, investigation, histology, management and outcome were reviewed.


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_XXVIII | Pages 26 - 26
1 Jun 2012
Young P Bell S MacDuff E Mahendra A
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Bony tumours of the foot account for approximately 3% of all osseous tumours. However, literature regarding os calcis tumours comprises individual case reports, short case series or literature reviews, with the last large case series in 1973.

We retrospectively reviewed the medical notes and imaging for all patients with calcaneal tumours recorded in the Scottish Bone Tumour Registry since the 1940's. Demographics, presentation, investigation, histology, management and outcome were reviewed.

38 calcaneal tumours were identified. Male to female ratio 2:1, mean age at presentation 30 with heel pain and swelling, average length of symptoms 9 months. 4 cases present with pathological fracture. 24 tumours benign including 6 unicameral bone cysts, 3 chondroblastoma, 3 PVNS with calcaneal erosion, and a wide variety of individual lesions. 13 malignant tumours comprising 6 osteosarcoma, 5 chondrosarcoma and 2 Ewings sarcoma. 1 metastatic carcinoma.

Tumours of the calcaneus frequently are delayed in diagnosis due to their rarity and lack of clinician familiarity. They are more common in men and have a 1 in 3 risk of malignancy, covering a wide variety of lesions. Outcome is dependent on early diagnosis, timely surgery and most importantly neo-adjuvant chemotherapy. Diagnosis is often made on plain radiograph but MRI is the gold standard.

We present the largest case series of calcaneal tumours, from our experience with the Scottish Bone Tumour Registry. Despite their rarity clinicians should maintain a high index of suspicion as accurate and timely diagnosis is important to management and outcome.


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_XXVIII | Pages 1 - 1
1 Jun 2012
Bell S Young P Drury C Jones B Blyth M MacLean A
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Total knee arthroplasty is an established and successful operation. In up to 13% of patients who undergo total knee arthroplasty continue to complain of pain. Recently computerised tomography (CT) has been used to assess the rotational profile of both the tibial and femoral components in painful total knee arthroplasty.

We reviewed 56 painful total knee replacements and compared these to 56 matched patients with pain free total knee replacements. Patients with infection, aseptic loosening, revision arthroplasties and gross coronal malalignment were excluded. Datum gathered from case notes and radiographs using a prospective orthopaedic database to identify patients. The age, sex, preoperative and postoperative Oxford scores, visual analogue scores and treatments recorded. The CT information recorded was limb alignment, tibial component rotation, femoral component rotation and combined rotation.

The two cohorts of patients had similar demographics. The mean limb alignments were 1.7 degrees varus and 0.01 degrees valgus in the painful and control groups respectively. A significant difference in tibial component rotation was identified between the groups with 3.2 degrees of internal rotation in the painful group compared to 0.5 degrees of external rotation in the control group (p=0.001). A significant difference in femoral component rotation was identified between the groups with 3.8 degrees of internal rotation in the painful group compared to 1.1 degrees of external rotation in the control group (p=0.001). A significant difference in the combined component rotation was identified between the groups with 6.8 degrees of internal rotation in the painful group compared to 1.7 degrees of external rotation in the control group (p=0.001).

We have identified significant internal rotation in a patient cohort with painful total knee arthroplasty when compared to a control group with internal rotation of the tibial component, femoral component and combined rotation. This is the largest comparison series currently in the literature.


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_XXVIII | Pages 21 - 21
1 Jun 2012
Bell S Young P Mahendra A
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Primary bone tumours of the talus are rare. Currently the existing literature is limited to a single case series and case reports or cases described in series of foot tumours. Information regarding the patient's demographics and tumour types is therefore limited.

The aim of this study was to investigate these questions and also suggest a management protocol for suspected primary bone tumours of the talus. We retrospectively reviewed the Scottish Bone Tumour Register from January 1954 to May 2010 and included all primary bone tumours of the talus. We identified only twenty three bone tumours over fifty six years highlighting the rarity of these tumours. There were twenty benign and three malignant tumours with a mean age of twenty eight years. A delay in presentation was common with a mean time from onset of symptoms to diagnosis of ten months. Tumour types identified were consistent with previous literature. We identified cases of desmoplastic fibroma and intraosseous lipodystrophy described for the first time.

We suggest an investigatory and treatment protocol for patients with a suspected primary bone tumour of the talus. This is the largest series of primary bone tumours of the talus in the literature.


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_XXVI | Pages 82 - 82
1 Jun 2012
Maratos E King A Jones T Bell D
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Aim

To investigate the effect of intraoperative wound irrigation with povidone-iodine on surgical site infection.

Methods

Data were collected prospectively for all cases of instrumented thoracic and lumbar spine surgery undertaken by the senior author (DB) from 01/10/2008 to 1/10/2010. Variables recorded included patient factors (age, co-morbidities, drug history) and operative factors (type of operation, duration of operation, elective/emergency, in hours/out of hours, consultant/junior, perioperative antibiotic administration). Routine povidone-iodine application commenced on 1/06/2009. Surgical site infection was defined as wound infection confirmed on wound swab or blood cultures. Comparison was made between patients receiving povidone-iodine intraoperative wound irrigation and those who did not using Fisher's exact test.


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_XXIII | Pages 164 - 164
1 May 2012
Pak P Oliver R Bell D Yu Y Bellemore J Walsh W
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Posterolateral spinal fusion using autograft in adult rabbits has been reported by many groups using the Boden model. Age in general has an adverse effect on skeletal healing; although, its role in posterolateral fusion is not well understood. This study examined the influence of animal age on spinal fusion using a standard model and experimental endpoints. We hypothesised that fusion quality and quantity would be less with increasing age.

A single level posterolateral fusion between the fifth and sixth lumbar segments were performed in six-month and two-year-old New Zealand white rabbits (n=6 per group) using morcelized iliac crest autograft. All animals were sacrificed at 12 weeks following surgery. Posteroanterior Faxitron radiographs and CT scans were taken and DICOM data was analysed (MIMICS Version 12, Materialise, Belgium). Axial, sagittal, coronal and three-dimensional models were created to visualise the fusion masses. Bone mineral density (BMD) of the fusion mass was measured using a Lunar DPXL Dexa machine. An MTS Bionix testing machine was then used to assess peak load and stiffness. Sagittal and coronal plane histology was evaluated in a blinded fashion using H&E, Tetrachrome and Pentachrome stains. Assessment included overall bony response on and between the transverse processes. Radiographs and CT confirmed a more robust healing response in younger animals. Radiographic union rates decreased from 83% to 50% in the aged animals. A neo- cortex surrounding the fusion mass was observed in the younger group but absent in the aged animals. Fusion mass BMD and that of the vertebral body was decreased in the older animals (P<0.05). Tensile mechanical data revealed a 30% reduction in peak load (P=0.024) and 34% reduction in stiffness (P=0.073) in the two-year-old animals compared with the six-month-old animals. Histological evaluation demonstrated a reduction in overall biological activity in the two-year-old animals. This reduction in activity was observed in the more challenging intertransverse space as well as adjacent to the transverse processes and vertebral bodies at the decortication sites. Numerous sites of new bone formation was present in the middle of the fusion mass in the six-month-old animals while the bone graft in the two-year- old animals were less viable.

Skeletal healing is complex and mediated by both local and systemic factors. This study demonstrated that ageing leads to an impaired and delayed skeletal repair.

Where autograft is utilised, diminished graft osteoinductivity and reduced levels of growth factors and nutritional supply in the surrounding milieu explains our observations. The aged rabbit posterolateral spinal fusion model has not been previously described but would be a useful to evaluate new treatment modalities in a more challenging host environment.


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_XXIV | Pages 5 - 5
1 May 2012
Nicolaou N Padman M Bell M Fernandes J
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PURPOSE OF THE STUDY

To assess if prolonged use of Bisphosphonates in Osteogenesis Imperfecta alters the pattern of femoral fractures.

Osteogenesis Imperfecta (OI) has been treated with Bisphosphonates for many years with some clear clinical benefits. In adult cohorts there are reports of a new pattern of atraumatic subtrochanteric fractures seen with Bisphosphonate treatment.

SUMMARY OF METHODS

This study assesses the location of femoral fractures in a cohort of 176 OI patients treated with Bisphosphonates over a two year period and compares it to a historical control group of 45 managed prior to the advent of this specific treatment.


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_XI | Pages 29 - 29
1 Apr 2012
Bell S McLaughlin D Huntley J
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Forearm fractures are a common paediatric injury. This study was aimed to describe the epidemiological of paediatric forearm fractures in the urban population of Glasgow.

We reviewed of all the forearm fracture treated by the orthopaedic service in Yorkhill Children's Hospital in 2008. Datum gathered from case notes and radiographs using the prospective orthopaedic database to identify patients with forearm fractures. The age, sex, side and type of fracture, the timing and mechanism of the injury and treatment were documented for the 436 fractures. Census data were used to derive absolute age-specific incidences.

Distinction was made between torus and other types of fractures. Torus fractures require no specific orthopaedic treatment and were segregated out. For the remaining 314 fractures, the age and sex distribution, seasonal variation of fractures and treatments for each type of fracture were examined. The incidence of forearm fractures in our population is 411 fractures per 100,000 population per year. An increased number of fractures occurred during the months of May and August. A fall from less than one metre was the commonest mechanism of injury, sporting injuries were the second commonest with football the most common sport associated.

This study identifies some features which are in good agreement with studies from elsewhere in Britain, such as incidence and seasonality. However, there are also interesting differences – such as the Glasgow peak incidence for forearm fractures being at age 8, with a marked decline by 12 years. Furthermore, our findings have been extended to consideration of type of intervention, and likelihood of successful treatment.


Orthopaedic Proceedings
Vol. 93-B, Issue SUPP_IV | Pages 571 - 571
1 Nov 2011
Weiss KR Bhumbra R Al-Juhani W Griffin A Deheshi B Ferguson P Bell R Wunder JS
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Purpose: Impending and pathologic fractures of the humerus, usually due to metastatic disease, are associated with significant pain, morbidity, loss of function, and diminished quality of life. Several methods of stabilization have been described. Here we report the outcome of fixation using intramedullary poly methyl methacrylate (bone cement) and non-locking plates.

Method: A retrospective review was undertaken which included all patients treated at a tertiary musculoskeletal oncology referral center from February, 1989 to October, 2009. Patients who underwent surgical management of an impending or pathologic fracture of the humerus were included. All patients were treated using the following technique: Vascular tumors were embolized pre-operatively. Following gross tumor removal through curettage, antibiotic bone cement was placed into the humeral canal and bone defect. If there was a fracture, the bone ends were held in place as the cement cured. The humerus was stabilized using non-locking plates fixed with screws inserted through the bone and hardened bone/cement composite. Ideally, plates spanned the osseous defect by at least 2 cortical diameters and often the entire length of the bone.

Results: Clinical records were available for 67 patients who underwent the above procedure. There were 44 males and 23 females with an average age of 62.2 years. In 76% of patients there was a pathologic fracture at presentation, while in 24% it was impending. The most common histology was myeloma (21%), followed by renal (20%) and lung adenocarcinoma (20%). Forty-nine patients (73%) had one plate, 16 (24%) had two plates, one patient had three plates, and one had four plates. Complications occurred in 14 (21%) cases, and eight (12%) required reoperation of the humerus. The most common cause for reoperation was disease progression (six of eight). There were two nerve palsies, one deep infection, and one hardware failure. Interestingly, the single hardware failure occurred in a patient whose pain relief and functional status improved to the point that he fractured his construct while hammering with the affected arm in a home improvement project.

Conclusion: Intralesional tumor resection and stabilization of impending and pathologic fractures of the humerus with the described technique has several attributes. Most importantly, it provides immediate, absolute rigidity of the upper extremity and enables early pain relief and return of function without the need for osseous union. Radiation has no negative effects on the construct. The patient’s local disease burden is reduced, thus helping to alleviate tumor-related pain and slow local disease progression. Finally, this technique is user-friendly and cost-effective as it does not require any special equipment or devices that are not available to community orthopaedic surgeons. This technique provides a durable option for the treatment of impending and pathologic humerus fractures.


Orthopaedic Proceedings
Vol. 93-B, Issue SUPP_IV | Pages 551 - 552
1 Nov 2011
Ferreira LM Bell TH Johnson JA King GJ
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Purpose: Most displaced olecranon fractures can be treated with ORIF. However with severe comminution or bone loss, excision of the fragments and repair of the triceps to the ulna is recommended. The triceps can be reattached to either the anterior or posterior aspect of the ulna. The purpose of this in-vitro study was to determine the effect of triceps repair technique on elbow laxity and extension strength in the setting of olecranon deficiency.

Method: Eight unpreserved cadaveric arms were used (age 75 ± 11 years). Surface models were generated from CT images and sequential olecranon resections in 25% increments were performed using real-time navigation. Muscle tendons (biceps, brachialis, brachioradialis and triceps) were sutured to actuators of an elbow motion simulator, which produced active extension. A tracking system recorded kinematics in the varus and valgus positions. A triceps advancement was performed using either an anterior or posterior repair to the remaining olecranon in random order. Triceps extension strength was measured in the dependent position with the elbow flexed 90° using a force transducer located at the distal ulnar styloid, while triceps tension was increased from 25–200 N. Outcome variables included maximum varus-valgus elbow laxity and triceps extension strength. Two-way repeated measures ANOVAs were performed for laxity comparing resection level and repair method. Three-way repeated measures ANOVAs were performed for triceps extension strength comparing triceps tension, resection level and repair method. Significance was set at p < 0.05.

Results: Progressive olecranon resection increased elbow laxity (p < 0.001). Although the posterior repair produced slightly greater laxity for all but the 50% resection, this difference was not significant (p = 0.2). The posterior repair provided greater extension strength than the anterior repair at all applied triceps tensions and for all olecranon resections (p = 0.01). The initial 0% resection reduced extension strength for both repairs (p < 0.01), however, there was no effect of progressive olecranon resections (p = 0.09).

Conclusion: There was no significant difference in laxity between the anterior and posterior repairs. Thus even for large olecranon resections, the technique of triceps repair does not have significant influence on joint stability. Extension strength was not reduced by progressive olecranon resections, perhaps due to wrapping of the triceps tendon around the trochlea putting it in-line with the ulna and giving it a constant moment arm. Triceps extension strength was higher for the posterior repair. This is likely due to the greater distance and hence moment arm of the posterior repair to the joint rotation center. Conversely, the anterior repair brings the triceps insertion closer to the joint center, reducing the moment arm. Since there was no significant difference in laxity between the repairs, the authors favour the posterior repair due to its significantly higher triceps extension strength.


Orthopaedic Proceedings
Vol. 93-B, Issue SUPP_IV | Pages 489 - 490
1 Nov 2011
Hendrick P Hale L Bell M Milosavljevic S Hurley-Osing D McDonough S Baxter D
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Background: Activity advice and prescription are commonly used in the management of low back pain (LBP). However, no research has assessed whether objective measurements of physical activity predict outcome, recovery and course of LBP.

Methods: One hundred and one patients with acute LBP were recruited into a longitudinal cohort study. Each participant completed the Roland Morris Disability Questionnaire (RMDQ), Visual Analogue Scale and a “simple” activity question, detailing whether they had resumed full “normal” activities (Y/N), at baseline (T0) and 3 months (T1); Baecke Physical Activity Questionnaire, Fear-Avoidance Beliefs Questionnaire and the 12-item General Health Questionnaire at T0. Physical activity was measured for 7 days at T0 and T1 with an RT3 accelerometer and the seven day physical activity recall questionnaire (7d-PAR).

Results: The only significant predictor of RMDQ change was RMDQ score at T0 (p < .0001). Physical activity change did not predict RMDQ change in both univariate (p = 0.82) and multivariate analysis (p = 0.84). Paired t-tests found a significant change in RMDQ (p < .0001) and return to full “normal” activities (p < .0001) from T0 to T1, but no significant change in activity levels measured with the RT3 (p = 0.56) or the 7d-PAR (p = 0.43). RMDQ change (OR 1.72, p = 0.01) and RMDQ at T1 (OR 0.65, p = 0.04) predicted return to full “normal” activities at T1.

Conclusions: These results question the role of physical activity in LBP recovery and the assumption that activity levels change as LBP symptoms resolve.

Conflicts of Interest: None

Sources of Funding: This research was supported by a University of Otago Establishment Grant


Orthopaedic Proceedings
Vol. 93-B, Issue SUPP_III | Pages 376 - 376
1 Jul 2011
Whitehead D Hooper G Bell
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We prospectively reviewed patients who had undergone a Revision Total Knee Replacement (TKR) to a mobile-bearing arthroplasty. We wanted to assess functional outcome and survival, and to determine whether the perceived advantages of a mobile-bearing arthroplasty could be expanded to the revision situation.

We divided the patients into two groups. Group 1 consisted of 40 patients who were revised to a rotating platform, with or without stems and augments, and group 2 consisted of 41 patients revised to a varus-valgus constrained mobile-bearing device that still allowed rotation of the bearing. All were assessed with Knee Society Knee Scores, WOMAC, and New Jersey Knee Scores and standard radiographs by an independent examiner.

Group 1 had an average age of 71 years at revision and a follow-up of 5–9 years. Seventy-six percent had excellent or good results with 89% survival at 9 years. Group 2 had an average age of 71 years at revision and a follow-up of 2–5 years. The patient satisfaction score was 8/10 and the normality score was 6.8/10. There was only one case of instability in both groups in a patient with a patellar fracture.

A mobile-bearing TKR can be used in the revision situation with acceptable clinical results and patient outcome without compromising the stability or survivorship in the short-term. It has proved to be a “patellar-friendly” procedure with reduced re-operation for patellar complications; however longer-term studies are required to determine whether the rates of polyethylene wear are reduced by the use of a more congruent articulation.


Orthopaedic Proceedings
Vol. 93-B, Issue SUPP_III | Pages 310 - 310
1 Jul 2011
Craig J Damkat-Thomas L Bell P McMullan M Fogarty B
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Introduction: Open tibial fractures presenting to the 3 Northern Ireland trauma hospitals with over 36 months (2003–2006) were considered regarding the BAO/BAPS guidelines, which recommended joint orthopaedic/plastic management with definitive tissue coverage within 5 days.

Methods: Details of Gustillo-Anderson classification, method and timing of surgery, and complications were identified retrospectively from a regional database and patient notes.

Results: Of 111 patients with 115 fractures, 28 were Gustillo-Anderson grade 1, 21 were grade 2, 28 were grade 3a, 35 were grade 3b, and 3 were grade 3c. Grade 1 fractures were chiefly treated by IM nailing or cast. Most grade 2 and 3 injuries received IM nailing or external frames and primary closure within 5 days. Most grade 3b fractures were treated with external frames and tissue coverage after day 5, 46% having documented plastics referrals, and 20% receiving flaps All grade 3c fractures required amputation. Complications occurred in 42% of patients, mainly soft tissue infections (19%) and delayed union (10%) or non-union (12%). Only 42% of grade 3 injuries had documented referrals to plastics. Only 26% of patients were treated initially at the regional plastics unit (with orthpaedics on-site) but only 11% of patients required transfer for plastics input (chiefly for flaps).

Conclusions: Complications were common despite most patients meeting the guidelines regarding time to definitive surgery. With increasing Gustillo-Anderson grade the number of procedures increased and method of management changed for orthopaedic and plastics procedures. Many patients with Gustillo 3 injuries had no recorded referral to plastics.


Orthopaedic Proceedings
Vol. 93-B, Issue SUPP_III | Pages 269 - 270
1 Jul 2011
Bell TH King GJ Johnson JA Ferreira LM McDonald CP
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Purpose: The purpose of this study was to determine the effect of serial olecranon resections on elbow stability.

Method: Eight fresh, previously frozen cadaveric arms underwent CT scanning. The specimens were mounted in an in-vitro motion simulator, and kinematic data was obtained using an electromagnetic tracking system. Simulated active and passive flexion was produced with servo-motors and pneumatic pistons attached to specific muscles. Flexion was studied in the dependent, horizontal, varus, and valgus positions. Custom computer navigation software was utilized to guide serial resection of the olecranon in 12.5% increments. A triceps advancement repair was performed following each resection.

Results: Serial olecranon resections resulted in a significant increase in valgus-varus (V-V) laxity for both passive (p< 0.001) and active (p=0.04) flexion. For passive motion this increase reached statistical significance following the 12.5% resection. This corresponded to an increase in V-V laxity of 1.4 ± 0.1o and a total laxity of 7.5 ± 1.0o. For active flexion this increase reached significance following the 62.5% resection. This corresponded to an increase in V-V laxity of 5.6 ± 1.1o and a total laxity of 11.2 ± 1.5. There was no significant effect of sequential olecranon excision on elbow kinematics or stability with the elbow in the vertical or horizontal positions. The elbows became grossly unstable after resection of greater than 75% of the olecranon.

Conclusion: A progressive increase in the varus-valgus laxity of the elbow was seen with sequential excision of the olecranon. Laxity of the elbow was increased with excision of 75% of the olecranon, likely due to the loss of the bony congruity and attachment site of the posterior band of the medial collateral ligament. Gross instability resulted when 87.5% or greater was removed, likely due to damage to the anterior band of the medial collateral ligament as it inserts on the sublime tubercle of the ulna. Rehabilitation of the elbow with the arm in the dependant position should be considered following excision of the olecranon; varus and valgus orientations should be avoided. The contribution of the olecranon to elbow stability may be even more important in patients with associated ligament injuries or fractures of the elbow.


Orthopaedic Proceedings
Vol. 93-B, Issue SUPP_III | Pages 266 - 267
1 Jul 2011
Jones KB Riad S Griffin A Deheshi B Bell RS Ferguson P Wunder JS
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Purpose: The functional consequences of femoral nerve resection during soft tissue sarcoma management are not well described. Sciatic nerve resection with a sarcoma, once considered an indication for amputation, is now commonly performed during limb salvage. We compared the functional outcomes of femoral and sciatic nerve resections in patients undergoing wide resection of soft-tissue sarcomas.

Method: The prospectively collected database from a tertiary referral center for sarcomas was retrospectively reviewed to identify patients with resection of the femoral or sciatic nerve performed during wide excision of a soft tissue sarcoma. Patient demographics, treatment, complications and functional outcomes were collected.

Results: Ten patients with femoral nerve resections were identified, all women, aged 47 to 78, with large soft tissue sarcomas of varied subtypes. All patients received adjuvant radiotherapy, most pre-operatively. Six patients developed fractures with long-term follow-up, only two of which were in the prior radiation field. Musculoskeletal Tumor Society (MSTS) 1987 scores demonstrated one excellent, 4 good, and 5 fair results. MSTS 1993 scores averaged 71.4 ± 17.2 percent and Toronto Extremity Salvage Scores (TESS) averaged 61.7 ± 21.8. There were no significant differences between the functional scores for patients with femoral or sciatic nerve resections (P=1.0).

Conclusion: Femoral nerve resection appears more morbid than anticipated. The falls to which patients were prone, even years after surgery, subject them to ongoing long-term risks for fractures and other injuries. Nerve-specific functional outcomes should be considered when counseling patients prior possible resection of the femoral nerve for involvement by a soft tissue sarcoma.


Orthopaedic Proceedings
Vol. 93-B, Issue SUPP_III | Pages 266 - 266
1 Jul 2011
Jones KB Riad S Griffin A Deheshi B Bell RS Ferguson P Wunder JS
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Purpose: Few functional outcomes of total femoral endoprosthetic replacement (TFEPR) using contemporary modular systems are available. We compared functional results between TFEPR patients receiving fixed- and rotating-hinge knee componentry following oncologic resections.

Method: Eighteen TFEPR patients were identified from a prospectively gathered sarcoma database. Six were secondary procedures and 12 primary. Four patients had metastatic carcinoma, 8 osteosarcoma, 4 non-osteogenic spindle cell sarcomas of bone, 1 Ewing’s sarcoma, and 1 femur-invading soft-tissue sarcoma. All reconstructions used modular implants from a single company. Proximally, all were bipolar hip hemiarthoplasties, 12 including abductor reattachment. Distally, 8 had fixed- and 10 had rotating-hinge knee componentry. Toronto Extremity Salvage Score (TESS), and both Musculoskeletal Tumor Society Scores (MSTS) were compared between fixed- and rotating-hinge groups using the Mann-Whitney test.

Results: Complications included 1 hip dislocation, 1 femoral malrotation, and wound problems requiring 3 debridements and 1 amputation. One metastatic carcinoma patient developed local relapse. Follow-up averaged 4 years (range 1 month to 14 years). At latest follow-up, 10 patients had died of disease. Eight remained alive, 6 disease-free, 2 with distant disease. Among patients surviving 6 months, 6 used no assistive devices, 5 used a single cane, and 4 were wheelchair bound, each at least partly due to distant disease progression. TESS averaged 74.5±17.4, MSTS1987 25.2±4.4; and MSTS1993 58.6±22.9 among the 12 patients for whom functional results were available from latest follow-up. No statistically significant differences or even trends were detected between fixed-hinge and rotating-hinge patients (lowest p = 0.755), but both instability problems were in the rotating-hinge group.

Conclusion: While both rotating- and fixed-hinge TFEPR reconstructions may function well, consideration should be given to fixed-hinge knee reconstruction when massive myectomies or poorer conditioning make hip and knee stability a primary concern in the short-term.


Orthopaedic Proceedings
Vol. 93-B, Issue SUPP_III | Pages 302 - 303
1 Jul 2011
Prasthofer A Sloan R Old J Coghlan J Bell S
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Introduction: The aim of this study was to assess the outcomes of patients with recurrent antero-inferior gle-nohumeral instability with associated antero-inferior glenoid bone loss treated with a specific open stabilisation technique, using intra-substance coracoid bone grafting. It is hypothesised that this method of reconstruction produces low recurrence of instability as well potential for patients to return to high-risk sport.

Methods: 30 shoulders with recurrent anterior dislocation and glenoid bone loss were stabilised with open capsular and labral repair and intra-substance coracoid bone grafting. Motion and stability were assessed by Rowe Stability Score (RSS) with follow-up over 2 years in all cases. American Shoulder and Elbow Score (ASES) and Oxford Stability Scoring (OSS) were also recorded at follow-up. Intention to and actual return to sporting level was assessed. Union of the graft was confirmed by CT scan.

Results: For all 30 shoulders at a mean follow-up time of 2 years 11 months (range 2–5 years) the RSS improved from a mean of 32 to 78.5 post-op. 1 redislocation occurred whilst continuing high-risk sport after 2 years. ASES index at 2 years had a mean of 91.8 whilst the OSS was 18.5. Pre-operatively, 24 patients participated in high-risk sport. 20 intended to return to high-risk sport post operatively. 18 achieved this return without restriction. CT scans were available on 25 shoulders at a mean of 4.5 months after surgery. 1 showed slight resorption of the graft, union was confirmed in 23.

Conclusion: This small sample shows an overall acceptable clinical and radiological outcome at a minimum of 2-year follow-up. These results support the current literature advocating open stabilisation and bone grafting of the glenoid where loss is evident, particularly in the young contact athlete with recurrent instability and high expectations of success.


Orthopaedic Proceedings
Vol. 93-B, Issue SUPP_I | Pages 64 - 64
1 Jan 2011
Gaheer RS Bell S Dillon J Ferdinand RD
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Arthrodesis of small joints of the feet has been used for a variety of conditions. Described initially for treatment of congenital or paralytic foot deformities, arthrodesis has now been widely accepted as treatment for a range of foot disorders from inflammatory and post traumatic arthritis to acquired flat foot. A variety of fixation devices have been used to achieve compression at the Arthrodesis site.

The aim of our study is to evaluate the use of Memory compression staples in small joint fusions of the feet. The staples are made of a nickel-titanium alloy which exhibits a phenomenon called “Marmen” effect. When kept at ice-cold temperature (0–5°C), the alloy becomes plastically deformed, but, regains its original shape at body temperature. The emphasis of this study is to validate the safety of the implant for fusion of small joints of feet, as well as to determine whether the higher cost of the implant is justified by a demonstrable trend in time to fusion and period of immobilization required.

Between June 2003 and June 2008, a total of 148 feet (276 joints) had Arthrodesis using memory compression staples.

Data was collected retrospectively and clinical and radiological outcomes were assessed.

The average period of immobilization in cast was 6.8 weeks (range, 6–12). The average time to fusion was 8 weeks (range, 6–16).

The use of memory staples provides an accurate, reproducible and predictable method of achieving arthrodesis in small joints of the feet. The time to fusion is less, thereby reducing the recovery time after surgery.


Orthopaedic Proceedings
Vol. 92-B, Issue SUPP_III | Pages 376 - 376
1 Jul 2010
Kucharski RA Campbell D Bell MJ
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Aim: To evaluate the accuracy of ultrasound to locate the gastrocnemius musculotendinous junction (GMTJ) prior to surgery. There is no clear clinical method to precisely localise this junction, either in the paediatric or adult populations.

Method: Twenty calves in 12 paediatric patients with a diagnosis of spastic gastrocnemius muscle (GM) contracture underwent ultrasound examination prior to slide lengthening (Strayer). Surgeons did the ultrasound examination after only a short introduction to the method, using a portable ultrasound machine (Sonosite 180 PLUS) with a linear (5–10 MHz frequency range) transducer.

Only the GMTJ of medial head was located as it usually has a lower attachment and is thicker. The soleus muscle has short multipennate fibres running obliquely between aponeuroses overlying its anterior and posterior surfaces. GM has long parallel fibres and merges distally with the posterior aponeurosis of the soleus muscle. The GMTJ has a unique conical appearance on ultrasound. Pre operative skin markings were compared with the location of GMTJ during surgery.

Results: All ultrasound-guided locations of GMTJ were found to be accurate within 5mm at time of surgery.

Conclusions: This study indicates that ultrasound of the calf muscles by a surgeon prior to surgery is an accurate and reliable way of centering the incision over the GMTJ. The distinct morphological structure of the soleus muscle and overlying GM heads means that even surgeons with little ultrasound experience can perform the examination.


Orthopaedic Proceedings
Vol. 92-B, Issue SUPP_III | Pages 371 - 371
1 Jul 2010
Bell J Dass S Viswanathan S Donald G
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Introduction: Forearm fractures are the most common long bone fracture in the paediatric population. Associated neurological injury is a well recognized complication of these injuries yet is generally considered to beuncommon. This study sought to evaluate the incidence of neurological impairment in children referred for manipulation by the orthopaedics team in this tertiary referral hospital.

Materials & Methods: A retrospective chart analysis was performed of the first 100 children to be referred for orthopaedic assessment. This represented 43% of the total number of children presenting to the emergency department in this time period. Inclusion criteria involved a fracture of any segment of the radius and/or ulna on radiological examination. Exclusion criteria included concomitant ipsilateral upper limb fracture, and compartment syndrome.

Results: A total of 96 cases met the inclusion criteria. The cohort had a mean age of 8.04. Males were more likely to be injured as was the left forearm. The distal metaphysis was the segment most likely to be fractured and compound injuries were uncommon. The incidence of associated neurological impairment was 15.6%. The median nerve was most commonly injured, comprising 60% of nerve injuries. Distal physeal fractures were the most common fracture pattern to be associated with neurological impairment, with a rate of 37%.

Conclusions: Forearm fractures requiring manipulation in the paediatric population are commonly associated with nerve injuries, with distal physeal fractures having a particularly strong correlation. Clinicians require a high index of suspicion for nerve injury when evaluating forearm fractures to avoid underdiagnosis. Failure to recognize neurological injury at the time of initial assessment has the potential to delay time to reduction due to the injury being misclassified as non-urgent. This delay has the potential to cause a prolonged or failed recovery of nerve function.