The objective of this study is to investigate if genomic sequencing is a useful method to diagnose orthopaedic infections. Current methods used to identify the species of bacteria causing orthopaedic infections take considerable time and the results are frequently insufficient for guiding antibiotic treatment. The aim here is to investigate if genomic sequencing is a faster and more reliable method to identify the species of bacteria causing infections. Current methods include a combination of biochemical markers and microbiological cultures which frequently produce false positive results and false negative results. Samples of prosthetic fluid were obtained from surgical interventions to treat orthopaedic infections. DNA is extracted from these samples lab and nanopore genomic sequencing is performed. Initial investigations informed that a sequencing time of 15 minutes was sufficient. The resulting genomic sequence data was classified using Basic Local Alignment Tool (BLAST) against the NCBI bacterial database and filtered by only including reads with an identity score of 90 and E-value of 1e-50. An E-value of 1e-50 suggests a high-quality result and is commonly used when analysing genomic data. This data was then filtered in R Studio to identify if any species were associated with orthopaedic infections. The results from genomic sequencing were compared to microbiology results from the hospital to see if the same species had been identified. The whole process from DNA extraction to output took approximately 2 hours, which was faster than parallel microbiological cultures.Abstract
Objectives
Methods
Mirels’ score predicts the likelihood of sustaining pathological fractures using pain, lesion site, size and morphology. The aim is to investigate its reproducibility, reliability and accuracy in upper limb bony metastases and validate its use in pathological fracture prediction. A retrospective cohort study of patients with upper limb metastases, referred to an Orthopaedic Trauma Centre (2013–18). Mirels’ was calculated in 32 patients; plain radiographs at presentation scored by 6 raters. Radiological aspects were scored twice by each rater, 2-weeks apart. Inter- and intra-observer reliability were calculated (Fleiss’ kappa test). Bland-Altman plots compared variances of individual score components &total Mirels’ score. Mirels’ score of ≥9 did not accurately predict lesions that would fracture (11% 5/46 vs 65.2% Mirels’ score ≤8, p<0.0001). Sensitivity was 14.3% &specificity was 72.7%. When Mirels’ cut-off was lowered to ≥7, patients were more likely to fracture (48% 22/46 versus 28% 13/46, p=0.045). Sensitivity rose to 62.9%, specificity fell to 54.6%. Kappa values for interobserver variability were 0.358 (fair, 0.288–0.429) for lesion size, 0.107 (poor, 0.02–0.193) for radiological appearance and 0.274 (fair, 0.229–0.318) for total Mirels’ score. Values for intraobserver variability were 0.716 (good, 95% CI 0.432–0.999) for lesion size, 0.427 (moderate, 95% CI 0.195–0.768) for radiological appearance and 0.580 (moderate, 0.395–0.765) for total Mirels’ score. We showed moderate to substantial agreement between &within raters using Mirels’ score on upper limb radiographs. Mirels’ has poor sensitivity &specificity predicting upper limb fractures - we recommend the cut-off score for prophylactic surgery should be lower than for lower limb lesions.
Our rural orthopaedic service has undergone service restructure during the COVID-19 pandemic in order to sustain hip fracture care. All adult trauma care has been centralised to the Royal Shrewsbury Hospital for assessment and medical input, before transferring those requiring operative intervention to the Robert Jones and Agnes Hunt Orthopaedic Hospital. We aim to review the impact of COVID-19 on hip fracture workload and service changes upon management of hip fractures. We reviewed our prospectively maintained trust database and National Hip Fracture Database records for the months of March and April between the years 2016 and 2020. Our assessment included fracture pattern (intrascapular vs extracapsular hip fracture), treatment intervention, length of stay and mortality.Aims
Methods
Frozen section is a recognised technique to assist in the diagnosis of infection and there are standards for reporting. Our aim of this review was to assess the value of frozen section in the diagnosis of infection, as well as other variables. We performed a retrospective review of all frozen sections for suspected infection in 2016. Patient demographics, histological and microbiological investigations, laboratory and bedside tests were recorded and analysed using statistical software. 46 patients had 55 frozen sections; the majority were for lower limb arthroplasty. No sections were reported as polymorphonuclear neutrophils per high-power field. Three sections showed signs of infection and one without evidence had positive cultures. One uncertain section did not grow organisms. 10 patients had two-stage procedures, four of these were intended to be determined by frozen section but only two had evidence of infection on analysis. Evidence of infection on frozen section does correlate with microbiological growth but does not relate to intention to stage procedures in half of patients. The effect of new tests such as Synovasure is highlighted by this review. Frozen section analysis is reported subjectively but is a good predictor of infection. Clinical assessment is accurate in diagnosing infection. Histological, microbiological and additional investigations should be considered in relation to their cost-effectiveness.
In this cross sectional study, the impact and the efficacy of a surveillance programme for sarcomas of the extremities was analysed. All patients who had treatment with curative intent for a high-grade sarcoma and were diagnosed before 2014 were included and followed for a minimum of two years.Objectives
Methods
Chondroblastomas are rare bone tumours accounting for approximately 1% of all benign bone lesions. They occur in children and adolescents and are more frequent in males. The conventional treatment for chondroblastomas is surgery, however, this can be difficult and disabling due to the apo- or epiphyseal location. Surgery is curative in most cases, but recurrence rates of 10%–35% have been reported in the literature. Radiofrequency ablation is well established in the treatment of osteoid osteomas and painful bone metastases. We report our experience with the use of radiofrequency ablation in the treatment of chondroblastomas. Seven patients were identified from our Tumour database with biopsy proven chondroblastomas who were treated with Percutaneous CT Guided Radiofrequency Thermo coagulation.Introduction
Methods
Simple bone cysts are relatively common in children. When they present to a musculoskeletal oncology unit, they are usually treated by a variety of methods that range from observations following fracture to surgically curettage. The outcome is usually good. Very little is written in the literature regarding adults with a cystic bone lesion. We present 10 consecutive skeletally mature patients who presented with a benign cystic bone lesion. The mean age at diagnosis was 38 years (20–60 years). Three patients has a cyst in the foot, three in the hip, two in the knee, one in the pelvis and the remainder in the shoulder. Full work up, including biopsy, was performed in all cases. All hip lesions required internal fixation for actual or impending fractures. The average follow up was 1.5 years. The surgical outcome was good in all cases. The histological features are similar in all cases. Cementum, as found in Unicameral Bone Cysts, is not seen. This may present a new entity that is not described in the literature.
To evaluate the rise in impedance during percutaneous radiofrequency thermo coagulation (PRFTC) of osteoid osteomas as a predictor of local recurrence. A prospective study of 23 patients (24 PRFTC procedures) with minimum of 2.25-year follow-up (average 3.3 years). Average age 19.6 years (range 4–44), sex ratio 15□:□8 (male□:□female), 16 non-diaphyseal, 7 diaphyseal.Objective
Design and Patients
Enchondromas located in the phalangeal bones may be more cellular than non-digital locations necessitating clinical and radiological correlation to determine diagnosis. Atypical enchondromas have increased cellularity and atypia relative to simple enchondromas but no evidence of permeation. Chondrosarcomas of the phalanges are thought to have a more indolent course than chondrosarcomas in other locations. The aim of the study was to determine the outcome of atypical enchondromas and grade 1 chondrosarcomas of the phalanges treated surgically. Data was collected prospectively on patients with a cartilage lesion of the phalanges. Typical enchondromas, grade 2 or 3 chondrosarcomas and patients with Ollier's disease were excluded.Introduction
Methods
Periarticular metastasis may be treated with endoprosthetic reconstruction. The extensive surgery required may not, however, be appropriate for all patients. Our aim was to establish if the outcome of locking plate fixation in selected patients with periarticular metastases. Prospective data collection was performed. Twenty one patients underwent surgery for periarticular metastatic tumours. The median duration of follow-up for surviving patients was one year. There have been no cases of implant failure and no requirement for revision surgery. Pain relief was excellent or good in the majority of patients. Patients who had sustained a fracture prior to fixation had restoration of their WHO performance status. All patients had a dramatic improvement in their MSTS scores. The median pre-operative score was 15% (0%-37%) improving to a median score of 80% (75% -96%) post operatively. Locking plates provide reliable fixation and excellent functional restoration in selected patients suffering from periarticular metastatic bone disease.
Tension band wire fixation continues to be the most popular method of fixation for displaced olecranon fractures despite several biomechanical studies questioning the validity of the tension band concept. Our aim was to compare the outcome of the tension band wire (TBW) method with plate fixation. 58 consecutive olecranon fractures underwent internal fixation in 58 patients between September 2000 and December 2004. There were 30 male and 28 female with a mean age at the time of surgery of 52.5 years for the TBW group (range 19 to 88) and 46.1 for the plate group (range 19 to 72). Patients were excluded if they were less than 16 years of age. Choice of fixation was based on surgeon preference, fracture pattern and presence of associated injuries. 43 patients were managed with the AO tension band technique and 15 with plate fixation. Clinical assessment and functional analysis was performed using Helm’s scoring system. Radiographic assessment was performed to assess the quality of reduction. All fractures were displaced and classified according to Colton’s classification. Mean follow up was 13 months (range 6 to 18) and similar for the two groups. For the TBW group 41 (95 %) had a fair or good result. 27 (62.8%) patients had symptomatic metal prominence requiring implant removal. In the plate fixation group 14 (94%) had a fair or good functional result despite having more complex fractures. Only 2 (18%) patients required implant removal for symptomatic metalwork, including one failure due to a technical problem. Similar functional results were seen with plating and tension band wiring of displaced olecranon fractures. Despite meticulous technique, tension band wire fixation still has an unacceptably high complication rate with symptomatic metal prominence requiring further surgery. To avoid this problem, we recommend plating, even for the more simple olecranon fractures.
To assess the efficacy of the current surveillance programme for patients with sarcoma we undertook a prospective analysis of all patients with sarcoma treated between 1990 and 1995. The patients routinely enter a surveillance programme which consists of regular clinical evaluation, CXR and radiological imaging. We reviewed 643 cases of sarcoma with mean follow up 8. 4 years (range 6. 2–11. 3). Local recurrence occurred in 14% of cases and 34% developed metastases. The cumulative survival at 10 years was 59%. 46% of the deaths were directly attributable to metastases. For the soft tissue sarcomas 15% of the local recurrences were picked up at surveillance appointment and 70% were picked up early by the patient. For the sarcomas of bony origin 36% were picked up at surveillance and 57% were picked up early by the patient. Pulmonary metastasis was by far the common metastasis with 82% developing these. 78% were identified by surveillance CXR of which 83% were asymptomatic and 34% went on to thoracotomy and metastectomy. Of the other metastases a third were picked up during surveillance and all were symptomatic. Surveillance programmes have a role in the management of patients with sarcoma, allowing the earlier identification of local recurrence and metastasis. Clinical evaluation and CXR were found to be, in particular, valuable tools, but patient education and open access to clinics is also important.
Due to advances in the assessment and treatment of patients with metastatic bone disease, the survival has improved in recent years. It was the aim of this met-analysis to assess the outcome of patients with metastatic bone disease across Europe. Five major bone tumour treatment centres participated in the met-analyses. Data had been collected prospectively and was retrieved from the databases for the purpose of this study. All patients were referred to the bone tumour centre for assessment and possible surgical treatment. The data of almost 2500 patients were analysed. The average age at diagnosis was 60 years and the male to female ratio was 1:1.07. The overall 5-year survival was 35%, but this was significantly better in metastatic disease of the thyroid and breast as well as multiple myeloma. The number and site of metastases or the presence of a pathological fracture were not prognostic factors in terms of survival. Patients who were female or younger than 50 years of age at time of diagnosis had a better outcome. This registry will be expanded and more information analysed to try and provide useful information about prognostic factors and outcome for patients with meta-static bone disease.
