Introduction

Unstable ankle fractures are routinely managed operatively. Due to soft-tissue and implant related complications, there has been recent literature reporting on the non-operative management of well-reduced medial malleolus fractures following fibular stabilisation, but with limited evidence supporting routine application. This trial assessed the superiority of internal fixation of well-reduced (displacement ≤2mm) medial malleolus fractures compared with non-fixation following fibular stabilisation.

This single-centre prospective randomised trial aimed to assess the superiority of operative fixation compared with non-operative management for adults with an isolated, closed humeral shaft fracture.

70 patients were randomly allocated to either open reduction and internal fixation (51%, n=36/70) or functional bracing (49%, n=34/70). 7 patients did not receive their assigned treatment (operative n=5/32, non-operative n=2/32); results were analysed based upon intention-to-treat. The primary outcome measure was the DASH score at 3 months. Secondary outcomes included treatment complications, union/nonunion, shoulder/elbow range of motion, pain and health-related quality of life (HRQoL).

At 3 months, 66 patients (94%) were available for follow-up; the mean DASH favoured surgery (operative 24.5, non-operative 39.4; p=0.006) and the difference (14.9 points) exceeded the MCID. Surgery was also associated with a superior DASH at 6wks (operative 38.4, non-operative 53.1; p=0.005) but not at 6 months or 1yr. Brace-related dermatitis affected 7 patients (operative 3%, non-operative 18%; OR 7.8, p=0.049) but there were no differences in other complications. 8 patients (11%) developed a nonunion (operative 6%, non-operative 18%; OR 3.8, p=0.140). Surgery was associated with superior early shoulder/elbow range of motion, and pain, EuroQol and SF-12 Mental Component Summary scores. There were no other differences in outcomes between groups.

Surgery confers early advantages over bracing, in terms of upper limb function, shoulder/elbow range of motion, pain and HRQoL. However, these benefits should be considered in the context of potential operative risks and the absence of any difference in patient-reported outcomes at 1yr.

Introduction

Introduction: Pre-operative counselling to prepare patients for frame surgery is important to ensure expectations of recovery and rehabilitation are realistic and anxiety is reduced. The aim of the study was to ascertain whether the current clinical nurse specialist frames counselling session (CNS FCS) prepared patients adequately for life with a frame as well as to explore information patients felt was missing.

Unicompartmental knee arthroplasty (UKA) has a higher risk of revision than total knee arthroplasty, particularly for low volume surgeons. The recent introduction of robotic-arm assisted systems has allowed for increased accuracy, however new systems typically have learning curves. The objective of this study was to determine the learning curve of a robotic-arm assisted system for UKA.

Methods A total of 152 consecutive robotic-arm assisted primary medial UKA were performed by five surgeons between 2017 and 2021. Operative times, implant positioning, reoperations and patient-reported outcome measures (PROMS; Oxford Knee Score, EuroQol-5D, and Forgotten Joint Score) were recorded.

There was a learning curve of 11 cases with the system that was associated with increased operative time (13 minutes, p<0.01) and improved insert sizing over time (p=0.03). There was no difference in implant survival (98.2%) between learning and proficiency phases (p = 0.15), and no difference in survivorship between ‘high’ and ‘low’ usage surgeons (p = 0.23) at 36 months. There were no differences in PROMS related to the learning curve. This suggested that the learning curve did not lead to early adverse effects in this patient cohort.

The introduction of a robotic-arm assisted UKA system led to learning curves for operative time and implant sizing, but there was no effect on patient outcomes at early follow- up. The short learning curve was independent of UKA usage and indicated that robotic-arm assisted UKA may be particularly useful for low-usage surgeons.

The primary aim was to assess the reliability of ultrasound in the assessment of humeral shaft fracture healing. The secondary aim was to estimate the accuracy of ultrasound assessment in predicting humeral shaft nonunion.

Twelve patients (mean age 54yrs [20–81], 58% [n=7/12] female) with a non-operatively managed humeral diaphyseal fracture were prospectively recruited and underwent ultrasound scanning at six and 12wks post-injury. Scans were reviewed by seven blinded observers to evaluate the presence of sonographic callus. Intra- and inter-observer reliability were determined using the weighted kappa and intraclass correlation coefficient (ICC). Accuracy of ultrasound assessment in nonunion prediction was estimated by comparing scans for patients that united (n=10/12) with those that developed a nonunion (n=2/12).

At both six and 12wks, sonographic callus was present in 11 patients (10 united, one developed a nonunion) and sonographic bridging callus (SBC) was present in seven patients (all united). Ultrasound assessment demonstrated substantial intra- (6wk kappa 0.75, 95% CI 0.47-1.03; 12wk kappa 0.75, 95% CI 0.46-1.04) and inter-observer reliability (6wk ICC 0.60, 95% CI 0.38-0.83; 12wk ICC 0.76, 95% CI 0.58-0.91). Absence of sonographic callus demonstrated a sensitivity of 50%, specificity 100%, positive predictive value (PPV) 100% and negative predictive value (NPV) 91% in nonunion prediction (accuracy 92%). Absence of SBC demonstrated a sensitivity of 100%, specificity 70%, PPV 40% and NPV 100% (accuracy 75%). Of three patients at risk of nonunion based on reduced radiographic callus formation (Radiographic Union Score for HUmeral fractures <8), one had SBC on 6wk ultrasound (and united) and the other two had non-bridging or absent sonographic callus (both developed a nonunion).

Ultrasound assessment of humeral shaft fracture healing was reliable and predictive of nonunion, and may be a useful tool in defining the risk of nonunion among patients with reduced radiographic callus formation.

This prospective randomised trial aimed to assess the superiority of internal fixation of well-reduced medial malleolar fractures (displacement □2mm) compared with non-fixation, following fibular stabilisation in patients undergoing surgical management of a closed unstable ankle fracture.

A total of 154 adult patients with a bi- or trimalleolar fracture were recruited from a single centre. Open injuries and vertically unstable medial malleolar fractures were excluded. Following fibular stabilisation, patients were randomised intra-operatively on a 1:1 basis to fixation or non-fixation after satisfactory fluoroscopic fracture reduction was confirmed. The primary outcome was the Olerud Molander Ankle Score (OMAS) at 12 months post-randomisation. Complications were documented over the follow-up period.

The baseline group demographics and injury characteristics were comparable. There were 144 patients reviewed at the primary outcome point (94%). The median OMAS was 80 (IQR, 60-90) in the fixation group vs. 72.5 (IQR, 55-90) in the non-fixation group (p=0.165). Complication rates were comparable, although significantly more patients (n=13, 20%) in the non-fixation group developed a radiographic non-union (p<0.001). The majority (n=8/13) were asymptomatic, with one patient requiring surgical reintervention. In the non-fixation group, a superior outcome was associated with an anatomical medial malleolar fracture reduction.

Internal fixation is not superior to non-fixation of well-reduced medial malleolar fractures when managing unstable ankle fractures. However, one in five patients following non-fixation developed a radiographic non-union and whilst the re-intervention rate to manage this was low, the longer-term consequences of this are unknown. The results of this trial may support selective non-fixation of anatomically reduced fractures.

Source of the study: University of Auckland, Auckland, New Zealand

Unicompartmental knee arthroplasty (UKA) has benefits for patients with appropriate indications. However, UKA has a higher risk of revision, particularly for low-usage surgeons. The introduction of robotic-arm assisted systems may allow for improved outcomes but is also associated with a learning curve. We aimed to characterise the learning curve of a robotic-arm assisted system (MAKO) for UKA in terms of operative time, limb alignment, component sizing, and patient outcomes.

Operative times, pre- and post-surgical limb alignments, and component sizing were prospectively recorded for consecutive cases of primary medial UKA between 2017 and 2021 (n=152, 5 surgeons). Patient outcomes were captured with the Oxford Knee Score (OKS), EuroQol-5D (EQ-5D), Forgotten Joint Score (FJS-12) and re-operation events up to two years post-UKA. A Cumulative Summation (CUSUM) method was used to estimate learning curves and to distinguish between learning and proficiency phases.

Introduction of the system had a learning curve of 11 cases. There was increased operative time of 13 minutes between learning and proficiency phases (learning 98 mins vs. proficiency 85 mins; p<0.001), associated with navigation registration and bone preparation/cutting. A learning curve was also found with polyethylene insert sizing (p=0.03). No difference in patient outcomes between the two phases were detected for patient-reported outcome measures, implant survival (both phases 98%; NS) or re-operation (learning 100% vs. proficiency: 96%; NS). Implant survival and re-operation rates did not differ between low and high usage surgeons (cut-off of 12 UKAs per year).

Introduction of the robotic-arm assisted system for UKA led to increased operative times for navigation registration and bone preparation, but no differences were detected in terms of component placement or patient outcomes regardless of usage. The short learning curve regardless of UKA usage indicated that robotic-arm assisted UKA may be particularly useful for low-usage surgeons.

Abstract

Abstract

Cemented total hip arthroplasty (THA) in the younger patient has historically been associated with higher wear and revision rates. We carried out a retrospective study of a prospectively collected database of patients at Wrightington hospital undergoing cemented THA under 55 years of age to determine acetabular wear and revision rates.

Between August 2005 and December 2021 a cohort of 110 patients, 56 males and 54 females, underwent Cemented Total Hip Replacement through a posterior approach. Mean age at operation was 50yrs (35–55). The mean follow up was 6 years 9 months (0–16 years). 3 patients were lost to follow-up. Of the remaining 107 patients, Conventional and cross lined polyethylene were used in 54 and 53 patients respectively. Ceramic heads were used in 102 patients. 22.225mm and 28mm heads were used in 60 and 47 patients respectively. Clinical outcomes were assessed by Merle d'Aubigne and Postel scores which showed significant functional improvement. Linear wear was measured on plain radiographs using TRAUMA CAD and cup loosening was assessed by classification of Hodgkinson et al.

No cases were revised during the observed follow up period. The mean wear rate in conventional and crosslinked polyethylene cups were 2.31mm (0.1–4.6) and 1.02mm (0.1–2.6) respectively.

Cemented THA with both conventional and crosslinked polyethylene provides excellent survival rates in adults under the age of 55 years and crosslinked polyethylene may further improve these results due to improved wear rates.

Abstract

Acute distal biceps tendon repair reduces fatigue-related pain and minimises loss of forearm supination and elbow flexion strength. We report the short- and long-term outcome following repair using an EndoButton technique.

Between 2010 – 2018, 102 patients (101 males; mean age 43 years) underwent acute (□6 weeks) distal biceps tendon repair using an EndoButton technique. The primary short-term outcome was complications. The primary long-term outcome was the Quick-DASH (Q-DASH). Secondary outcomes included the Oxford Elbow Score (OES), EuroQol-5D-3L (EQ-5D), return to function and satisfaction.

At mean short-term follow-up of 4 months (2.0 – 55.5) eight patients (7.8%) experienced a major complication and 34 patients (33.3%) experienced a minor complication. Major complications included re-rupture (n=3, 2.9%), unrecovered nerve injury (n=4, 3.9%) and surgery for heterotopic ossification excision (n=1, 1.0%). Three patients (2.9%) required surgery for a complication. Minor complications included neuropraxia (n=27, 26.5%) and superficial infection (n=7, 6.9%). At mean follow-up of 5 years (1 – 9.8) outcomes were collected from 86 patients (84.3%). The median Q-DASH, OES, EQ-5D and satisfaction scores were 1.2 (IQR 0 – 5.1), 48 (IQR, 46 – 48), 0.80 (IQR, 0.72 – 1.0) and 100/100 (IQR, 90 – 100) respectively. Most patients returned to sport (82.3%) and employment (97.6%) following surgery. Unrecovered nerve injury was associated with a poor outcome according to the Q-DASH (p< 0.001), although re-rupture and further surgery were not (p > 0.05).

Acute distal biceps tendon repair using an EndoButton technique results in excellent patient reported outcomes and health-related quality of life. Although rare, unrecovered nerve injury adversely affects outcome.

Aims

Arthrofibrosis is a relatively common complication after joint injuries and surgery, particularly in the knee. The present study used a previously described and validated rabbit model to assess the biomechanical, histopathological, and molecular effects of the mast cell stabilizer ketotifen on surgically induced knee joint contractures in female rabbits.

Whilst emergency fasciotomy for acute compartment syndrome (ACS) of the leg is limb and potentially lifesaving, there remains a perception that such surgery may result in excessive morbidity, which may deter surgeons in providing expeditious care. There are limited long-term studies reporting on the morbidity associated with fasciotomy.

A total of 559 patients with a tibial diaphyseal fracture were managed at our centre over a 7-year period (2009–2016). Of these patients, 41 (7.3%) underwent fasciotomies for the treatment of ACS. A matched cohort of 185 patients who did not develop ACS were used as controls. The primary short-term outcome measure was the development of any complication. The primary long-term outcome measure was the patient reported EQ-5D.

There was no significant difference between fasciotomy and non-fasciotomy groups in the overall rate of infection (17% vs 9.2% respectively; p=0.138), deep infection (4.9% vs 3.8%; p=0.668) or non-union (4.9% vs 7.0%; p=1.000). There were 11 (26.8%) patients who required skin grafting of fasciotomy wounds. There were 206 patients (21 ACS) with long-term outcome data at a mean of 5 years (1–9). There was no significant difference between groups in terms of the EQ-5D (p=0.81), Oxford Knee Score (p=0.239) or the Manchester-Oxford Foot Questionnaire (p=0.629). Patient satisfaction on a linear analogue scale was reduced in patients who developed ACS (77 vs 88; p=0.039).

These data suggest that when managed with urgent decompressive fasciotomies, ACS does not appear to have a significant impact on the long-term patient reported outcome, although overall patient satisfaction is reduced.

The evidence for treatment of acute complex radial head fractures with radial head replacement (RHR) predominantly comprises short to mid-term follow-up. This study describes the complications and long-term patient reported outcomes following RHR.

From a single-centre trauma database we retrospectively identified 119 patients over a 16-year period who underwent primary RHR for an acute complex radial head fracture. We reviewed electronic records to document post-operative complications, including prosthesis revision and removal. Patients were contacted to confirm complications and long-term patient reported outcomes. The primary outcome measure was the QuickDash (QD).

The mean age at injury was 50 years (16–94) and 63 (53%) were female. Most implants were uncemented ‘loose-fit’ monopolar prostheses; 86% (n=102) were metallic and 14% (n=17) silastic. Thirty patients (25%) required revision surgery (n=3) or prosthesis removal (n=27). Five patients underwent arthrolysis and there were four cases of infection. In the long-term, 80% (80/100; 19 deceased) were contacted at a mean of 12 years (7.5–23.5). The median QD was 6.8 (IQR, 16.8), the median EQ-5D was 0.8 (IQR, 0.6) and the median Oxford Elbow Score was 46 (IQR, 7). Overall satisfaction was high with a mean of 9.4/10 (2–10). There was no significant difference in any outcome measure for those patients requiring revision or removal surgery (all p>0.05).

This is the largest series in the literature documenting the long-term patient reported outcome after RHR. Despite a quarter of patients requiring further surgery, RHR is supported by positive long-term results for the treatment of complex radial head fractures.

Implant choice was changed from cemented Thompson to Exeter Trauma Stem (ETS) for treatment of displaced intra-capsular neck of femur fractures in University Hospital Aintree, Liverpool, United Kingdom (a major trauma center), following the NICE guidelines that advised about the use of a proven femoral stem design rather than Austin Moore or Thompson stems for hemiarthroplasties.

The aim of our study was to compare the results of Thompson versus ETS hemiarthroplasty in Aintree.

We initially compared 100 Thompson hemiarthroplasties that were performed before the start of ETS use, with 100 ETS hemiarthroplasties.

There was no statistically significant difference between the two groups in terms of patients' demographics (age, sex and ASA grade), intra-operative difficulties/complications, post op medical complications, blood transfusion, in-patient stay and dislocations.

The operative time was statistically significantly longer in the ETS group (p= .0067). Worryingly, the 30 days mortality in ETS group was more than three times higher in ETS group (5 in Thompson group versus 16 in ETS group. P= .011).

To corroborate our above findings we studied 100 more consecutive patients that had ETS hemiarthroplasty. The results of this group showed 30 day mortality of 8 percent. However the operative time was again significantly longer (p= .003) and there was 18 percent conversion to bipolar hemiarthropalsty. Moreover there was statistically significant increased rate of deep infection (7%, p = .03) and blood transfusion (27%, p = .007).

This we feel may be due to longer and more surgically demanding operative technique including pressurised cementation in some patients with significant medical comorbidities.

Our results raise the question whether ETS hemiarthoplasty implant is a good implant choice for neck of femur fracture patients. Randomised control trials are needed to prove that ETS implant is any better than Thompson hemiarthroplasty implants in this group of patients.

Scheuermann's kyphosis is a structural deformity of the thoracic or thoracolumbar spine, which can result in severe pain, neurological compromise and cosmetic dissatisfaction. Modern surgical techniques have improved correction through a posterior-only or antero-posterior approach but can result in significant morbidity.

We present our results of the surgical management of severe Scheuermann's kyphosis by a single surgeon with respect to deformity correction, global balance parameters, functional outcomes and complications at latest follow-up. We included 49 patients, of which 46 had thoracic and 3 had thoracolumbar kyphosis. Surgical indications included persistent back pain, progressive deformity, neurological compromise and poor self-image. Fourty-seven patients underwent posterior-only and 2 antero-posterior spinal arthrodesis utilising Chevron-type osteotomies and hybrid instrumentation. Mean age at surgery was 16.0 years with mean postoperative follow-up of 4.5 years. Mean kyphosis corrected from 92.1o to 46.9o (p<0.001). Concomitant scoliosis was eliminated in all of the 28 affected patients. Coronal and sagittal balance was corrected in all patients. Mean blood loss was 24% total blood volume. Mean operation time was 4.3 hours with mean inpatient stay of 9 days. SRS-22 questionnaire improved from a mean preoperative score of 3.4 to 4.6 at 2 years, with high treatment satisfaction rates. Complications included one toxic septicaemia episode but otherwise no wound infections, no junctional deformity, no loss of correction and no requirement for re-operation.

Posterior spinal arthrodesis with the use of hybrid instrumentation can safely achieve excellent correction of severe Scheuermann's kyphosis helping to relieve back pain, improve functional outcomes and enhance self-image.

Aim

To assess the safety of day case lumbar decompressive surgery

There is a wide range of reports on the prevalence of neurological injuries during scoliosis surgery, however this should depend on the subtypes and severity of the deformity. Furthermore, anterior versus posterior corrections pose different stresses to the spine, further quantifications of neurological risks are presented.

Neuromonitoring data was prospectively entered, and the database between 2006 and 2012 was interrogated. All deformity cases under the age of 21 were included. Tumour, fracture, infection and revision cases were excluded.

All “red alerts” were identified and detailed examinations of the neuromonitoring records, clinical notes and radiographs were made. Diagnosis, deformity severity and operative details were recorded.

2290 deformity operations were performed: 2068 scoliosis (1636 idiopathic, 204 neuromuscular, 216 syndromic, and 12 others), 89 kyphosis, 54 growing rod procedures, and 80 operations for hemivertebra. 696 anterior and 1363 posterior operations were performed for scoliosis (8 not recorded), and 38 anterior and 51 posterior kyphosis correction.

67 “red alerts” were identified, there were 14 transient and 6 permanent neurological injuries. 62 were during posterior stage (24 idiopathic, 21 neuromuscular, 15 syndromic (2 kyphosis), 1 growing rod procedure, 1 haemivertebra), and 5 were during anterior stage (4 idiopathic scoliosis and 1 syndromic kyphosis). Average Cobb angle was 88°. 1 permanent injuries were during correction for kyphosis, and 5 were for scoliosis (4 syndromic, 1 neuromuscular, and 1 anterior idiopathic).

Common reactions after “red alerts” were surgical pause with anaesthetic interventions (n=39) and the Stagnara wake-up test (n=22). Metalwork was partially removed in 20, revised in 12 and completely removed in 9. 13 procedures were abandoned.

The overall risk of permanent neurological injuries was 0.2%, the highest risk groups were posterior corrections for kyphosis and scoliosis associated with a syndrome. 4% of all posterior deformity corrections had “red alerts”, and 0.3% resulted in permanent injuries; compared to 0.6% “red alerts” and 0.3% permanent injuries for anterior surgery. The overall risk for idiopathic scoliosis was 0.06%.

Introduction

Both intra- and post-operative radiographs are traditionally obtained after instrumented lumbar spinal surgery; however the clinical advantage of routine post operative images has not been demonstrated.

Aim

To estimate the risk of bone malignancy arising in premalignant conditions.

Introduction

The role of adjuvants in curettage for giant cell tumours (GCT) is still controversial. Our aim was to determine if adjuvant cementation lowers local recurrence (LR) rates for GCTs treated with curettage.

Aim

To investigate the effectiveness of silver coated prostheses in preventing periprosthetic infection in a high-risk group.

Introduction

The aim of this study is to evaluate the functional and oncological outcome of extracorporeally irradiated autografts as a method of pelvic reconstruction after internal hemipelvectomy.

Osteosarcomas represent a heterogeneous group of primary bone tumours that affect predominantly the long bones of patients in the first two decades of life. We aim to describe the secondary effects of a poor response (⋋90% necrosis) to chemotherapy on the effectivity of other treatment outcomes, local recurrence and survival rates.

182 cases of osteosarcoma with necrosis of less than 90% and no metastases at diagnosis have been seen at our institution over 24 years. There were 60 amputations. 122 patients underwent limb salvage, with 105 marginal margins and 17 contaminated. There was no difference in size or location between the two groups. In the 122 patients with LSS, 21 had adjuvant radiotherapy and 101 did not. In the entirety of patients with ⋋90% necrosis, survival was 64% at 2 years and 37% at 5 years. When LSS Marginal resections were compared with amputation there was a significant (P=0.006) difference in survival. LSS with a marginal margin had a 25% risk of LR. In these patients there was 25% survival, whereas the absence of a local recurrence, conferred a benefit of a 40% survival XRT was used in 21 of the 122 who underwent limb salvage. The decision to use XRT was made by the local oncologist at the treating unit. There was a 24% rate of recurrence in the XRT group and 25% with no XRT.

These data demonstrated that patients who had a poor response to chemotherapy and underwent an amputation faired poorly when compared to patients with LSS. There is a selection bias in patients selected to undergo amputation. Additionally, patients who underwent amputation had a lower rate of local recurrence, but still had a poorer survival when compared to LSS.

Introduction

Myxofibrosarcoma is described by WHO as comprising of a spectrum of malignant fibroblastic lesions with variably myxoid stoma, pleomorphism and with a distinctively curvilinear vascular pattern. They are reported to be one of the commonest sarcomas of elderly patients. It has previously been reported to have a high rate of locally recurrent disease (50-60%). The aim of the study was to investigate the ROH series of tumours to determine prognostic factors for survival and local recurrence.

The aim was to identify when primary amputation was used as primary treatment and to describe outcomes in patients managed with modern chemotherapy. A detailed review of the electronic patient records was undertaken. Statistical analysis was performed with univariate analysis using Kaplan-Meier curves and Chi² testing, whilst multivariate analysis was performed using Cox regression analysis.

There were 354 osteosarcomas. 93 patients presented with metastases and 192 subsequently developed metastases at a mean of 46 months. Amputation was performed as the primary surgical treatment in 101 patients. Endoprosthetic reconstruction was used in 253 patients. Amputation was performed as a secondary procedure on 15 patients.

The 5 and 10 year survival data for all patients, including those with metastatic disease were 60% and 60% for amputation with good chemotherapy response (>89% necrosis), 65% and 63% for limb salvage and good response, 21% and 21% for amputation and poor response (⋋90% necrosis) and 51% and 30% for limb salvage with poor response.

Local recurrence occurred both with amputation (10.8%) or limb salvage (9%), with no significant differences between the two.

Univariate analysis demonstrated that the extent of response to chemotherapy induced necrosis significantly affected survival, whether the patient had an amputation or not.

Whether or not amputation or LSS was used in the surgical management of patients, local recurrence rates where similar between the two groups. Further assessment of chemotherapy-induced necrosis is a key factor in determining subsequent limb salvage or amputation management strategies.

Raised blood pressures (BP) are associated with increased cardiovascular risks such as myocardial infarction, stroke and arteriosclerosis. During surgery the haemodynamic effects of stress are closely monitored and stabilised by the anaesthetist. Although there have been many studies assessing the effects of intraoperative stress on the patient, little is known about the impact on the surgeon.

A prospective cohort study was carried out using an ambulatory blood pressure monitor to measure the BP and heart rates (HR) of three consultants and their respective trainees during hallux valgus, hip and knee arthroplasty surgery. Our principle aim was to assess the physiological effects of performing routine operations on the surgeon. We noted if there were any differences in the stress response of the lead surgeon, in comparison to when the same individual was assisting. In addition, we recorded the trainee's BP and HR when they were operating independently.

All of the surgeons had higher BP and HR readings on operating days compared to baseline. When the trainer was leading the operation, their BP gradually increased until implant placement, while their trainees remained stable. On the other hand, when the trainee was operating and the trainer assisting, the trainer's BP peaked at the beginning of the procedure, and slowly declined as it progressed. The trainee's BP remained elevated throughout. The highest peaks for trainees were noted during independent operating.

We conclude that all surgery is stressful, and that trainees are more likely to be killing themselves than their trainers.

Chondrosarcoma of bone is a surgical disease and excision with wide margins is the optimum treatment. Sometimes the size or location of the tumour at the time of diagnosis mean that only a marginal excision can be achieved. The effect of the margin of excision on outcome is investigated.

Cardiovascular disease is now the leading cause of morbidity and mortality worldwide. Raised blood pressures (BP) are associated with increased cardiovascular risks such as myocardial infarction, stroke and arteriosclerosis. During surgery the haemodynamic effects of stress are closely monitored and stabilised by the anaesthetist. Although there have been many studies assessing the effects of intraoperative stress on the patient, little is known about the impact on the surgeon.

A prospective cohort study was carried out using an ambulatory blood pressure monitor to measure the BP and heart rates (HR) of three consultants and their respective trainees during hallux valgus, hip and knee arthroplasty surgery. Our principle aim was to assess the physiological effects of performing routine operations on the surgeon. We noted if there were any differences in the stress response of the lead surgeon, in comparison to when the same individual was assisting. In addition, we recorded the trainee's BP and HR when they were operating independently. The intraoperative measurements were compared with their baseline readings and their stress response, assessed using the Bruce protocol.

Many trends were noted in this pilot study. All of the surgeons had higher BP and HR readings on operating days compared to baseline. The physiological parameters normalised by one hour post-theatre list in all subjects. When the trainer was leading the operation, their BP gradually increased until implant placement, while their trainees remained stable. On the other hand, when the trainee was operating and the trainer assisting, the trainer's BP peaked at the beginning of the procedure, and slowly declined as it progressed. The trainee's BP remained elevated throughout. The highest peaks for trainees were noted during independent operating.

We conclude that all surgery is stressful, and that trainees are more likely to be killing themselves than their trainers.

The senior author has treated a series of patients with subtrochanteric and diaphyseal femoral stress fractures associated with long-term alendronate or other bisphosphonate usage. Several patients completely fractured their femurs prior to referral. Most patients had consulted other physicians and were referred for presumed neoplasms. All patients had been diagnosed with osteoporosis and had been treated with bisphosphonates. Their plane radiographs revealed abnormalities that are pathognomonic of bisphosphonate-associated stress fractures. However, due to the subtle nature of these new unfamiliar abnormalities, most were unrecognized as such by clinicians (including experienced ISTA member hip surgeons) and radiologists. This series is presented to illustrate this pattern of impending fracture.

The authors have reviewed and will present a series (n=17) of femoral stress fractures in bisphosphonate-treated patients to illustrate the clinical and radiographic pattern of these stress fractures, and review their treatment.

The most common lesion is a subtrochanteric lateral cortical thickening that in actuality is a horizontal plane “dreaded black line” of a stress fracture with surrounding proximal and distal cortical thickening of the endosteal and periosteal bone. The stress fracture line is obscured unless a near-perfect radiographic projection is obtained. The lesion is best seen with CT scans. MRI scans reveal the stress fracture lines with surrounding edema (Fig 1), which may be misinterpreted as a tumor. Without treatment, a low-impact completed fracture will likely occur.

Many bisphosphonate-associated impending subtrochanteric femoral stress fractures are misdiagnosed as trochanteric bursitis, leading to subsequent displaced subtrochanteric fractures [Fig. 2 - Note subtle impending fracture lesion on right, completed fracture on left]. The clinical and subtle radiographic findings must be recognized by orthopaedic surgeons, particularly hip surgeons, to prevent these complete fractures. These fractures are preventable with internal fixation. Long-term administration of bisphosphonates can have adverse effects, and alternatives to long-term continuous dosing must be investigated to determine optimal administration regimens.

The comparison between surgical outcomes of trapeziectomy versus trapeziectomy with ligament reconstruction (LRTI) is well documented in the literature. We could not find any literature comparing these two procedures from a ‘patient-based outcome scoring’ perspective.

The Patient Outcomes Of Surgery (POS) hand/arm questionnaire was used in order to assess the outcomes of 33 patients (23 Trapeziectomy and 10 LRTI). All surgery was carried out by the same hand surgeon. A telephone questionnaire was performed on each patient. The mean time post surgery was 15 months (range 1 to 27) and 20 months (range 7 to 30) for the Trapeziectomy and LRTI group respectively.

There was statistically significant improvement in both groups for symptoms, physical activities and psychological functioning/cosmetic appearance. The Trapeziectomy alone group scored higher in all groups though this did not show statistical significance. There were statistically significant higher rates of complications in the LRTI group. LRTI surgery increased the tourniquet time by 28 minutes on average. Patient overall satisfaction was higher (85/100) in the trapeziectomy alone group than that of the LRTI group (75/100)

Both trapeziectomy and trapeziectomy with LRTI offer a reliably way of treating arthritis of the carpometacarpal joint. In our study, Trapeziectomy alone resulted in better overall patient satisfaction with lower complication rates and reduced operating time.

Aim

To identify factors leading to the success or failure of extracorporeal irradiation and re-implantation of bone (ECIR).

Aim

To determine the overall survival of patients with Pelvic Ewing's Sarcoma treated in our unit and to identify prognostic factors in pelvic primaries that could be used to select patients who would most likely benefit from high intensity treatment.

Introduction

The aim of this study was to investigate the results of a series of cases from a single institution with respect to local disease control and patient survival to determine prognostic factors.

Since1986 we have monitored the actual diagnosis of all cases referred to our Unit with the diagnosis of ‘possible primary malignant bone tumour’. We have excluded all patients referred with a known diagnosis of either a benign condition or known to have bone metastases. In most cases the suspected diagnosis was based on X-rays alone, sometimes supported by further imaging.

Neoadjuvant chemotherapy for osteosarcoma improves outcomes for the majority, but if the chemotherapy does not work then the dilemma often arises as to whether to do limb salvage with a marginal (or worse) margin of excision or to do an amputation. If limb salvage is carried out with a close margin, does post operative radiotherapy make any difference? This study aims to address these questions.

The outcome for patients with Ewing's sarcoma recurrence is poor. Local recurrences occur in 8%-25%of these patients. The aim of the study was to analyze the patients who had a local recurrence to identify factors predicting the local recurrence and if it could be prevented

Introduction

The pelvis has always been a difficult area for surgeons, with high complication rates from surgery and the perception of poor oncological outcomes. The aim of the study was to look at the surgical and oncological outcomes of pelvic tumours treated at our centre.

Between 1966 and 2001, 1254 patients underwent excision of a bone tumour with endoprosthetic replacement. All patients who had radiotherapy were identified. Their clinical details were retrieved from their records.

A total of 63 patients (5%) had received adjunctive radiotherapy, 29 pre-operatively and 34 post-operatively. The mean post-operative Musculoskeletal Tumor Society scores of irradiated patients were significantly lower (log-rank test, p = 0.009). The infection rate in the group who had not been irradiated was 9.8% (117 of 1191), compared with 20.7% (6 of 29) in those who had pre-operative radiotherapy and 35.3% (12 of 34) in those who radiotherapy post-operatively. The infection-free survival rate at ten years was 85.5% for patients without radiotherapy, 74.1% for those who had pre-operative radiotherapy and 44.8% for those who had post-operative radiotherapy (log-rank test, p < 0.001). The ten-year limb salvage rate was 89% for those who did not have radiotherapy and 76% for those who did (log-rank test, p = 0.02).

Radiotherapy increased the risk of revision (log-rank test, p = 0.015). A total of ten amputations were necessary to control infection, of which nine were successful. Radiotherapy may be necessary for the treatment of a bone sarcoma but increases the risk of deep infection for which amputation may be the only solution.

We prospectively reviewed 2440 Cemented Anantomical (side specific) AGC total knee replacements performed on 2074 patients between 2002 and 2008 in our unit. The surgery was performed by a number of surgeons, both Consultant and Trainee grades. 1357 underwent PCL sacrificing surgery with implantation of Posterior Stabilised Femoral Implant (Cam and Grove) and 1083 underwent PCL retaining surgery with implantation of a Non-Stabilised Femoral Implant. The mean age at date of surgery for Posterior Stabilised prosthesis was 69 years (range 23-94) and Non-Posterior Stabilised prosthesis was 70 (range 33-97) with no significant difference p< 0.05 (C.I 95%). Follow up at present mean 4 years (range 1-6 years).

11 patients underwent secondary patella resurfaced for anterior knee pain at a mean of 1.5 years following the index procedure (range 0.5-4.1 years) with 6 patients reporting a marked improvement in anterior knee pain post operatively. 3 patients underwent removal of patella buttons for symptomatic loosening at a mean of 2.7 years follow index procedure.

A total of 17 patients underwent a revision of either tibial or femoral components (0.7%). Indications for revision were infection in 11 patients, gross instability in 1 patient, periprosthetic fracture in 1 patient, persistent stiffness in 1 patient. 3 patients underwent revision for symptomatic loosening of the tibial component at a mean of 2.9 years (range 1.1-4.0).

These short to medium term results for the Anatomic AGC total knee replacement agree with published results from other centres.

We performed a retrospective review of 98 patients with malignant tumours of the periacetabular region, treated by resection and endoprosthetic reconstruction between 1971 and 2005 at the Royal National Orthopaedic Hospital, Stanmore and The Royal Orthopaedic Hospital, Birmingham.

The mean age of the patients was 43.6 years (10 to 76). 53 patients (54%) were male. The age distribution demonstrated peaks in the 2nd and 6th decades. The mean follow up was 65 months (2 to 405. The overall 10-year survival rate was 56% (determined by the Kaplan-Meier method).

54 patients (58.1%) had one or more complications. Infection was the most common (30%) with the majority occurring in the first 2 years. Dislocation occurred in 19 (20%) of our patients all in the first year following surgery. All were recurrent with a mean of 2.9 (2 to 6) episodes. Operations performed before 1994 were associated with a dislocation rate of 40.5% and after 1996 the rate was only 3.9% (p < 0.001).

Function was assessed according the Toronto Extremity Salvage Sore (TESS). The overall TESS was 59.4. In patients that had a major complication the TESS was 37.1 but in the group that did not the TESS was 70.3 (p < 0.001).

Men experienced higher rates of death, infection and revision than women (p < 0.05). The local recurrence rate was 31% with high grade tumours associated with higher recurrence rates (p < 0.05). Tumour resection in the ilium is associated with higher rates of infection than tumours located in the periacetabular region alone (p < 0.05).

This method of reconstruction is still associated with high complication rates. Function is good if a major complication can be avoided. The lower dislocation rate more recently is probably the result of improved surgical technique and the use of larger femoral heads.

We have investigated whether improvements in design have altered the outcome for patients undergoing endoprosthetic replacement of the distal femur following tumour resection.

Survival of the implant and ‘servicing’ procedures have been documented using a prospective database and review of the implant design records and case records. A total of 335 patients underwent a distal femoral replacement with 162 having a fixed hinge design and 173 a rotating hinge with most of the latter group having a hydroxyapatite collar at the bone prosthesis junction. The median age of the patients was 24 years (range 13-82 yrs). With a minimum follow up of 5 years and a maximum of 30 years, 192 patients remain alive with a median follow-up of 11 years. The risk of revision for any reason was 17% at 5 years, 34% at 10 years and 58% at 20 years. One in ten patients developed an infection and 42% of these patients eventually required an amputation. Aseptic loosening was the most common reason for revision in the fixed hinge knees whilst infection and stem fracture were the most common reason in the rotating hinges. The risk of revision for aseptic loosening in the fixed hinges was 32% at ten years compared with nil for the rotating hinge knees with a hydroxyapatite collar. The overall risk of revision for any reason was halved by use of the rotating hinge, and for patients older than 40 years at time of implant.

EPRs are the treatment of choice following resection of tumours. These have been used for 39 years in our institution. There has been concern regarding the long term survival of endoprosthesis; this study investigates the fate of the reconstruction.

Chondroblastomas arise in the epiphyseal area of bones. In the femoral head this can cause considerable difficulty in obtaining access as the epiphysis is entirely intra-articular.

We have reviewed management and outcome of 10 patients with chondroblastoma of the femoral head to identify outcome and complications. The mean age was 14 years and all presented with pain (frequently in the knee) and a limp. All were diagnosed on plain Xray and MRI. Five younger children were treated by curettage by a lateral approach up the femoral neck (to try and minimise damage to the epiphysis) and five by a direct approach through the joint.

Two of the five patients with a lateral approach developed local recurrence whilst none of the direct approaches did. Both local recurrences were cured with a direct curettage. One patient developed overlengthening of the leg by 1cm but there was no case of growth arrest or osteoarthritis.

We recommend a direct approach to the lesion whenever possible to give the best chance of cure with a low risk of complications.

Introduction

Despite the advances in adjuvant chemotherapy and surgical techniques, the diagnosis of a bone tumour still carries with it a significant risk of mortality. This study investigates factors affecting survival, in patients treated for malignant tumours of bone using Endoprosthetic replacement (EPR).

Aim

To identify patient, tumour or treatment factors that influence outcome in patients with radiation induced sarcoma of bone.

Primary malignant bone tumours frequently arise in children close to the knee, hip or shoulder. Resection of the tumour will often require excision of the epiphysis and frequently one side of the involved joint. In these children an extendable endoprosthesis is usually required to allow for maintenance of limb length equality.

We have used 180 extendable endoprostheses in 176 children since 1975. The indication for use of an extendable prosthesis was if there was more than 30mm of growth remaining in the resected bone. The age of the patients ranged from 2 to 15 and 99 were boys. The sites of the endoprostheses used were: distal femur in 91, proximal tibia in 42, proximal femur in 11, total femur in 6 and proximal or total humerus in 26. 131 of the operations were for osteosarcoma and 34 for Ewing's.

Five types of lengthening mechanism have been used. Two designs used a worm screw gear, one type used a C collar, one type a ball bearing mechanism and the latest uses a non invasive lengthening system whereby a motor inside the prosthesis is activated by an electromagnetic field.

Of the 176 patients, 59 have died and of the remainder, 89 have reached skeletal maturity. 19 patients had an amputation, 11 due to local recurrence and 8 due to infection. The risk of infection was 19% in surviving patients. Most of the skeletally mature had equal leg lengths. The average number of operations was 11 but ranged between 2 and 29. Most operations were for lengthening but younger children always needed revisions of the prosthesis. Functional scores were 77%.

Extendable endoprostheses are demanding both for the patient and the surgeon. The high complication rate should be decreased by non invasive lengthening prostheses.

All patients referred to our unit with previously untreated metastatic renal cancer were included in this review. We investigated likely prognostic factors including age, sex, site, synchronous or metachronous metastasis, stage of the disease and the type of treatment received.

From 1976 until 2004, a total of 198 patients were treated by our unit for renal metastases. 15 patients were excluded because they were referred after failure of previous treatment or only had advice. 96 patients were already known to have renal metastasis with their diagnosis having been made between 0.2 and 17 years from the diagnosis of primary cancer (mean 4 years). 33 patients presented to us with a pathological fracture and were found to have renal cancer. A total of 54 patients had multiple metastases and 129 had a solitary metastasis. The cumulative survival from the time of diagnosis of the bone metastasis is 70 percent at 1 year, 40% at 3 years and 18% at 5 years. In patients with a solitary metastasis, the overall survival was 74% at 1 year and 45% at 3 years, whereas in patients with multiple metastases it was 55% at 1 year and 22% at 3 years. (p=0.02) In patients with a solitary metastasis treated by excision of the metastasis, the survival at 1 year was 86% as compared to 38% for those that were treated with just a local procedure. Cox multivariate analysis shows that survival was better in those with solitary metachronus metastasis who underwent a radical procedure.

Introduction: The aim of this study was to compare hip movement between normal subjects and patients with a large Metal on Metal hip replacement, undertaking the task of retrieving an object from the floor.

Methods: An electromagnetic tracker was used to measure movement as subjects retrieved an object with flexed hips and straight knees. Measurements were taken from a control group of 10 subjects with bilaterally normal hips, and 10 subjects with unilateral hip replacement. Sensors were attached over the iliac crest and the mid-shaft of the lateral thigh. Data was collected as each subject repeated the movement 3 times. The tracker recorded data at 10 hertz, with an accuracy of 0.15 degree.

Results: For the normal group the mean hip flexion was 90.8 degrees (SD 20.1). For the arthroplasty group the mean flexion on the normal and operated sides were 74.0 (SD 21) and 72.7 degrees (SD 21) respectively. This was not significant (P= 0.83). However there was a significant difference in hip movement between the operated hips and those in the normal control group (P= 0.03).

For the bilaterally normal group the mean hip rotation was 2.9 degrees internal (SD 11.8). For the arthroplasty group the mean rotation on the normal and operated sides were 9.4 degrees external (SD 9.5) and 6.9 degrees internal (SD 13.9) respectively. In this group there was a significant difference between the normal and operated side (P= 0.02).

Discussion: This study has shown that patients with a unilateral hip replacement have no significant flexion difference between hips, when retrieving an object from the floor. However there was a significant difference compared to a control group with normal hips. A significant difference was also observed when comparing the rotation of an operated hip joint to the contra-lateral normal hip in the same individual.