Desmoid tumours are a rare fibroblastic proliferation of monoclonal origin, arising in deep soft-tissues. Histologically, they are characterized by locally aggressive behaviour and an inability to metastasize, and clinically by a heterogeneous and unpredictable course. Desmoid tumours can occur in any anatomical site, but commonly arise in the limbs. Despite their benign nature, they can be extremely disabling and sometimes life-threatening, causing severe pain and functional limitations. Their surgical management is complex and challenging, due to uncertainties surrounding the biological and clinical behaviour, rarity, and limited available literature. Resection has been the first-line approach for patients with a desmoid tumour but, during the last few decades, a shift towards a more conservative approach has occurred, with an initial ‘wait and see’ policy. Many medical and regional forms of treatment are also available for the management of this condition, and others have recently emerged with promising results. However, many areas of controversy remain, and further studies and global collaboration are needed to obtain prospective and randomized data, in order to develop an appropriate shared stepwise approach.

Cite this article: Bone Joint J 2023;105-B(7):729–734.

Introduction. Chronic recurrent multifocal osteomyelitis (CRMO) is a rare condition characterised by bony pain and swelling which may be initially mistaken for bacterial osteomyelitis. The episodic course of the disease may confound the diagnosis and potentially be mistaken for a partial response to antimicrobial therapy. It is an orphan disease and consequently results in many unclear aspects of diagnosis, treatment and follow up for patients. The aim of this study is to evaluate a national tertiary centre's experience with the clinical condition and present one of the largest cohorts to date, emphasizing the vast array of clinical spectrum, course and response to treatment. Methods. We retrospectively evaluated all children identified with CRMO from the period 2000–2022 within Wales. Demographic data and clinical parameters were selectively identified through the utilisation of a national clinical platform (Welsh Clinical Portal). The diagnosis was based on clinical findings, radiological images, histopathological and microbiological studies. Results. A total of 21 patients were identified as suitable for inclusion. The mean age of diagnosis was 9.4 ±2 years. The age range of children being diagnosed was 6–14 years. Of the 21 patients, only 2 reported feeling unwell prior to their first presentation with generalized coryzal illness reported. The most common presenting site for CRMO was knee (33%) followed by back pain (28%). 19% of the included cases at initial presentation had localised warmth and had nocturnal pain. 4 of the patients went on to have dermatological conditions of which psoriasis was the most common (14%). Bilateral symptoms developed in 38% of the included patients. Biochemical investigations revealed only 19% of patients had a raised C-reactive protein level and erythrocyte sedimentation rate whilst 9/21 patients went on to have a bone biopsy to aid diagnosis. 100% of patients had MRI whilst whole body MRI was utilised in 8/21 patients. NSAID's were utilised for 81%, Pamidronate for 33% and methotrexate for 14%. Biologics were utilised for a further 24% of the total population in failed medical therapy. Surgical intervention was utilised for a single individual in this cohort of patients in the form of posterior spinal stabilisation. The most common referring speciality for these patients was Rheumatology (71%) followed by Orthopaedics (33%). Discussion. CRMO represents a challenging diagnosis to make with such varied clinical and biochemical presentations for this condition. The absence of diagnostic Radiological features on X-ray could argue over early MRI imaging. The utilisation of whole body-MRI can now identify multifocal disease burden which may facilitate a timely diagnosis and ensure that effective medical treatment is started promptly without delay. This study is the largest cohort of CRMO patients conducted in this country. Future work will serve to build upon a framework and national referral pathway so that these patients can be seen by the appropriate specialist in a timely manner

A previously fit and well 58 year old male suffered from a bilateral psoas haematoma (PH) following 52 days of veno-venous extracorporeal membranous oxygenation (VV-ECMO) for severe Coronavirus disease (COVID-19), refractory to all non-invasive and medical therapies. He developed multiple complications, including inability to walk or weight-bear, due to lumbar plexopathy triggered by bilateral PH compression, compounded by COVID-19-related mononeuritis multiplex. The patient was referred to our institution with a known diagnosis of bilateral PH and after spinal multidisciplinary team (MDT) input, was deemed not for surgical or interventional radiology treatments. The patient received extensive neurorehabilitation, coordinated by multiple MDTs. Although PH has been correlated to COVID-19, to the best of our knowledge this is the first reported case of such a complex presentation resulting in a dramatic bilateral PH. Health records from 3 large UK teaching hospitals were collected regarding treatment and follow up appointments, following patient's written informed consent. Patient's comorbidities, duration in hospital units, MDT inputs, health assessments, mobilisation progress and neurologic assessments, were all recorded. Data was collected retrospectively then prospectively due to lengthy in-patient stay. The literature review was conducted via PubMed and open access sources, selecting all the relevant studies and the ECMO guidelines. Patient received treatment from 3 different units in 3 hospitals over 212 days including 103 days in neurorehabilitation. Involvement of physiotherapy, dietitians, speech and language teams, neurologist, neurophysiotherapists, occupational therapists was required. The patient progressed from a bed-bound coma and inability to walk, to standing with lower limb backslab at discharge. Additionally, he was referred for elective exploratory surgery of the psoas region for scar debridement and potential nerve graft repair of the lumbosacral plexus. The surgery outcome is cautiously optimistic, with some improvement in nerve conduction studies, however is currently unknown regarding recovery progress and return to premorbid functional baseline. The novelty of this presentation yields significant learning points regarding early recognition of PH, requirements for vast MDT input and specialist use of VV-ECMO in severe COVID-19 patients. It also highlights the broad pathophysiology of SARS-CoV-2 causing neuropathy and coagulopathy; understanding this will optimise robust anticoagulation guidelines, required in VV-ECMO

Aim: To show the place of percutaneous vertebroplasty (PV) in the treatment of painful osteoporotic vertebral compression fractures (VCF). VCF is a common and often debilitating complication of osteoporosis. Although most fractures heal within a few weeks or months, a minority of patients continues to suffer with pain that does not respond to conservative therapy. Methods: PV is accomplished by percutaneous injection of cement into the fractured vertebral body. Reinforcing and stabilizing the fracture provides pain relief. Injection of cement is accomplished under real time using a bilateral transpedicular approach or a unilateral transpedicular or parapedicular route. Results: PV is indicated in patients with severe, persistent and often incapacitating focal back pain not responding to a standard medical therapy of 4 to 12 weeks duration and related to one or more collapsed vertebral bodies. PV should be used earlier in patients at risk of immobilization complications and requiring narcotics. The success rate exceeds 90% and the complication rate is lower than 1%. Most of the complications are transient and should be avoided using good technique. Conclusion: PV should be always considered as a good alternative treatment compared to medical therapy in painful patients with osteoporotic compression fractures

The utility of vertebroplasty in the treatment of spinal pain has been accepted worldwide. In this co-operative study we show the success and failure rates related to the pathological condition treated (porotic, metastatic or angioma), the incidence of new vertebral fractures adjiacent to the previously treated one, and the incidence of symptomatic and asymptomatic side effects. In all, 898 patients were treated from April 2001 through January 2004 for a total of 1796 vertebral bodies. Of these, 654 patients (73%) were treated for porotic abnormalities, 213 patients (24%) had neoplastic disease and 27 patients (3%) presented with compressive or painful angioma. Different types of cement were used. All patients were treated after MR and CT examination or, as an alternative to MR, bone nuclear medicine scan, always associated with clinical evaluation. The patients were treated under CT and C-arm fluoroscopy control (2 centres) or under fluoroscopy in an angiography suite (five centres). We never perfomed general anaesthesia, only local sedation or administration of neuroleptic drugs. Blood tests were always performed before the treatment to exclude coagulopathy. Only the presence of local or systemic infection was considered to be a real contraindication. We had a 93% success rate in patients with porotic abnormalities, one of 73% in patients with neoplastic disease and of 100% in patients with angioma. Asymptomatic venous leak was seen in 135 patients (15%) and CT demonstrated asymptomatic pulmonary embolus in eight patients (0.9%). No symptomatic venous and pulmonary emboli were identified. New fractures adjacent to a previously treated vertebral body developed in 14 patients (1.3%) while six patients showed radiculopathy (0.6%) due to posterior leakage in the lateral lumbar recess that was treated and resolved with medical therapy in 3 weeks. In six patients we also had psoas haematoma treated with medical therapy; no instance of cord compression was found. Mild disc leakage developed in 90 patients (10%) but we did not find any relation with new adjacent vertebral fracture. Vertebroplasty represents a safe technique in the treatment of spinal pain related to porotic, neoplastic changes or angioma. The technique must be performed with high performance technology. The incidence of symptomatic effects and new fractures related to previously treated vertebrae or disc leakage is very low

Introduction: We studied from July 1997 infected hip and knee arthroplasties treated with only antimicrobial therapy without removal of the implants. The patients enrolled were not eligible for surgical operation or refused it. We tried to understand the role of this kind of therapy for the infections at stage I, II and III. Material and Methods: We evaluated patients with hip or knee infected arthroplasties at stage I, II and III, respectively: an early infection (2–4 weeks after the prosthesis implantation), a chronic infection that appears more than one month after the operation and an hematogenous infection. The prosthetic hip infections were treated with an oral therapy for 6 months, while the prosthetic knee infections were treated for 9 months. Follow up examinations were conducted regularly for two years. Results: We observed 35 patients from July 1997: 15 with an infection at stage I, 17 at stage II: and 3 at stage III. In 23 patients the prosthesis affected was the hip, while in 12 patients it was the knee. The infections were due in most cases to Staphylococci (85.7%), while in 4 patients (3 cases of hematogenous infection) the pathogens isolated were Gram negative bacteria and 1 infection was due to Clostridium perfrigens. Only in 9 (25.6%) patients was performed a debridement before the beginning of the medical therapy. The overall success rate at one year of follow up was 72.7% (24/33), the success for the patients in stage I was 86.6%(13/15), in stage II 60% (9/15) and for stage III was 66.6% (2/3). Conclusions: In patients with arthroplasty infection at stage I and III a long-term antimicrobial treatment, without the implant removal, could be a good chance, especially when the pathogen isolated is a S. aureus or a S. coagulase negative. As we expected the success rate for infection at stage II was the lower that we observed between all the prosthetic joint infection, treated with the only antimicrobial therapy. The gold standard for the treatment of stage II should be prosthesis revision (1 or 2 stages); but in our study we enrolled patients not eligible for surgical operation, because of severe clinical conditions, or patients that refused it. With these results we cannot recommend the medical therapy alone, but we can use it as a salvage therapy. As for the infections at stage I and III, no relapse had been observed after one year of follow up; we think that, especially for infections at stage II, a one-year follow up could be sufficient for the identification of the relapses

Objectives. Bisphosphonates are widely used as first-line treatment for primary and secondary prevention of fragility fractures. Whilst they have proved effective in this role, there is growing concern over their long-term use, with much evidence linking bisphosphonate-related suppression of bone remodelling to an increased risk of atypical subtrochanteric fractures of the femur (AFFs). The objective of this article is to review this evidence, while presenting the current available strategies for the management of AFFs. Methods. We present an evaluation of current literature relating to the pathogenesis and treatment of AFFs in the context of bisphosphonate use. Results. Six broad themes relating to the pathogenesis and management of bisphosphonate-related AFFs are presented. The key themes in fracture pathogenesis are: bone microdamage accumulation; altered bone mineralisation and altered collagen formation. The key themes in fracture management are: medical therapy and surgical therapy. In addition, primary prevention strategies for AFFs are discussed. Conclusions. This article presents current knowledge about the relationship between bisphosphonates and the development of AFFs, and highlights key areas for future research. In particular, studies aimed at identifying at-risk subpopulations and organising surveillance for those on long-term therapy will be crucial in both increasing our understanding of the condition, and improving population outcomes. Cite this article: N. Kharwadkar, B. Mayne, J. E. Lawrence, V. Khanduja. Bisphosphonates and atypical subtrochanteric fractures of the femur. Bone Joint Res 2017;6:144–153. DOI: 10.1302/2046-3758.63.BJR-2016-0125.R1

Aims

Tenosynovial giant cell tumour (TGCT) is a rare benign tumour of the musculoskeletal system. Surgical management is fraught with challenges due to high recurrence rates. The aim of this study was to describe surgical treatment and evaluate surgical outcomes of TGCT at an Australian tertiary referral centre for musculoskeletal tumours and to identify factors affecting recurrence rates.

Autologous injection of platelet rich plasma (PRP) stimulates healing process in degenerated tendons. The purpose of this study is to compare the functional outcome of lateral epicondylitis treated with PRP and steroid injection. Tennis elbow patients who failed conservative medical therapy were included and were allocated randomly steroid group (n=70) and PRP group (n=63). Data were collected before procedure, at 4, 8, 12 weeks, 1 year and 2 years after procedure. The main outcome measures were visual analogue score, Mayo elbow performance score, DASH score and hand grip strength. Successful treatment was defined as more than a 25% reduction in visual analogue score or DASH score and more than 75 score in Mayo elbow performance score. We observed that 35 of the 70 patients (50%) in corticosteroid group and 47 of the 63 patients (75%) in PRP group were successful, which was significantly different (p<.001), according to DASH score 37 of the 70 patients (53%) and 47 of the 63 patients (75%) in the PRP group were successful which was also significantly different (P = .005), Mayo elbow performance score was successful in 36 of the 70 patients (51%) in corticosteroid group and 49 of the 63 patients (78%) in PRP group. The improvement in hand grip strength of hand from 24.7kg (mean) 26kg in corticosteroid group and 23.5kg (mean) to 32.9kg (mean) in PRP group. PRP injection for chronic lateral epicondylitis reduces pain, improve functionality and hand grip strength when compared to steroid injection

Transforaminal lumbar interbody fusion (TLIF) using an implanted cage is the gold standard surgical treatment for disc diseases such as disc collapse and spinal cord compression, when more conservative medical therapy fails. Titanium (Ti) alloys are widely used implant materials due to their superior biocompatibility and corrosion resistance. A new Ti-6Al-4V TLIF cage concept featuring an I-beam cross-section was recently proposed, with the intent to allow bone graft to be introduced secondary to cage implantation. In designing this cage, we desire a clear pathway for bone graft to be injected into the implant, and perfused into the surrounding intervertebral space as much as possible. Therefore, we have employed shape optimization to maximize this pathway, subject to maintaining stresses below the thresholds for fatigue or yielding. The TLIF I-beam cage (Fig. 1(a)) with an irregular shape was parametrically designed considering a lumbar lordotic angle of 10°, and an insertion angle of 45° through the left or right Kambin's triangles with respect to the sagittal plane. The overall cage dimensions of 30 mm in length, 11 mm in width and 13 mm in height were chosen based on the dimensions of other commercially available cages. The lengths (la, lp) and widths (wa, wp) of the anterior and posterior beams determine the sizes of the cage's middle and posterior windows for bone graft injection and perfusion, so they were considered as the design variables for shape optimization. Five dynamic tests (extension/flexion bending, lateral bending, torsion, compression and shear compression, as shown in Fig. 2(b)) for assessing long term cage durability (10. 7. cycles), as described in ASTM F2077, were simulated in ANSYS 15.0. The multiaxial stress state in the cage was converted to an equivalent uniaxial stress state using the Manson-Mcknight approach, in order to test the cage based on uniaxial fatigue testing data of Ti-6Al-4V. A fatigue factor (K) and a critical stress (σcr) was introduced by slightly modifying Goodman's equation and von Mises yield criterion, such that a cage design within the safety design region on a Haigh diagram (Fig. 2) must satisfy K ≤ 1 and σcr ≤ SY = 875 MPa (Ti-6Al-4V yield strength) simultaneously. After shape optimization, a final design with la = 2.30 mm, lp = 4.33 mm, wa = 1.20 mm, wp = 2.50 mm, was converged upon, which maximized the sizes of the cage's windows, as well as satisfying the fatigue and yield strength requirements. In terms of the strength of the optimal cage design, the fatigue factor (K) under dynamic torsion approaches 1 and the critical stress (σcr) under dynamic lateral bending approaches the yield strength (SY = 875 MPa), indicating that these two loading scenarios are the most dangerous (Table 1). Future work should further validate whether or not the resulting cage design has reached the true global optimum in the feasible design space. Experimental validation of the candidate TLIF I-beam cage design will be a future focus. For any figures or tables, please contact authors directly (see Info & Metrics tab above).

We report the clinical features and treatment on a rare case of Candida albicans lumbar spondylodiscitis in a non-immunocompromised patient. Its indolent course leads to delayed suspicion and diagnosis. As soon as fungal infection is suspected investigations with MRI and biopsy should be performed followed by medical therapy. Retrospective data analysis. A 58-year-old male underwent surgery for adenocarcinoma of the ampula of Vater treatment. Subsequently, the patient had a prolonged intensive care unit stay due to major complications, during his stay he developed a septicemia with Candida albicans isolated in the blood work. He received antifungal therapy anidulofungin, later changed to fluconazole during 2 weeks. Repeated blood work were negative and no vegetations on echocardiogram were seen. He was discharged from the ICU to a surgery floor. During the surgical unit stay he presented with lower back pain radiating to the lower limbs. Findings on neurological examination were normal, radiographs of the lumbar spine revealed L5-S1 antero listhesis. He was treated with oral non-steroidal anti-inflammatory drugs and an lumbar MRI and orthopaedic consultation was agended. One month later, after minor trauma he developed myelopathic symptoms with weakness of both lower limbs and severe back pain. Plain radiograph showed anterolistesis worsening. Magnetic resonance imaging showed endplate erosion at L5/S1. There also was evidence of paraspinal collection with epidural compression of the dural sac. The patient was treated surgicaly with debridement and posterior instrumented fusion from L4 to S1. Disk and end-plate material collected confirmed Candidal infection. The patient recovered most of his neurological deficit immediately after surgery. He was subsequently treated during 2 weeks with liposomal amphotericin B, later changed to fluconazole 400mg per os per day. He maintained antifungal therapy during 15 months. He remains asymptomatic with no recurrence of infection clinically or radiologically after surgery. Fungal spondylodiscitis is rare. Sub-acute or chronic low back pain in either immunocompromised or non-immunocompromised patients cronically ill and malnourished (parental nutrition) there must be high index of suspicion for fungal infections. Therefore we recommend screening for Candida osteomyelistis in these cases. Without treatment, involvement of vertebral bodies can lead to compression fractures, deformity of the spine and neurological impairment

Background and Purpose. Serum lactate has been shown to be an indicator of adverse clinical outcomes in patients admitted secondary to general trauma or sepsis. We retrospectively investigated whether admission serum venous lactate can predict in-hospital mortality in patients with hip fractures. Method and Results. Over a 38-month period the admission venous lactate of 807 patients with hip fractures was collated. Mean age was 82 years. The overall in-hospital mortality for this cohort was 9.4%. Mortality was not influenced by the fracture pattern or the type of surgery - be it internal fixation or arthroplasty (p = 0.7). A critical threshold of 3 mmol/L with respect to the influence of venous lactate level on mortality was identified. Mortality rate in those with a lactate level of less than 3 mmol/L was 8.6% and 14.2% for those whose level was 3 mmol/L or greater. A 1 mmol/L increase in venous lactate was associated with a 1.2 (1.02–1.41) increased risk of in-hospital mortality. Patients with a venous lactate of 3 mmol/L or higher had twice the odds of death in hospital compared to matched individuals. There was no statistically significant difference in ASA distribution between those with a lactate of less than or greater than 3 mmol/L. Conclusions. Patients with an elevated venous lactate following hip trauma should be identified as being at increased risk of death and may benefit from targeted medical therapy

Aim. To assess the efficacy of combined medical and surgical management in obtaining normal lower limb mechanical alignment in a patient cohort with genotypically similar hypophosphataemic rickets. Methods. A notes and radiograph audit was performed of all patients attending our institution with hypophosphataemic rickets: a subset with PHEX gene anomalies was studied further. Lower limb radiographs were assessed at two points during childhood and note made of treatment start, compliance; indication, timing and result of surgery. Standing leg alignment radiographs were measured at skeletal maturity or at latest review. Results. 35 patients (16 females, 18 skeletally mature) were identified. 10 commenced treatment at <12m. 11 patients (5 female) underwent 24 surgical procedures (13 for varus deformities). Surgery was bilateral in 10/11 patients. 5/14 osteotomies were performed after skeletal maturity. Malalignment was common: with NSA (neck-shaft angle) abnormalities in 20%, abnormal angles at distal femur and proximal tibia in 58% and 60% respectively and ankle abnormalities in 24%, prior to surgery. Surgical management led to normal mechanical alignment at skeletal maturity. At latest review, no patient had a leg length difference. 40% of non-operated, skeletally immature limbs have significant malalignment despite medical therapy. There was no statistical relationship between treatment onset and need for surgical correction. The relationship between non-compliance with medical treatment and surgical intervention was confounded by the changing emphasis on preferred method of surgical correction from osteotomy to guided growth. Conclusion. Even when medical treatment is commenced promptly and adhered to, significant lower limb malalignment can occur requiring surgical correction. Guided growth principles allow early deformity correction. Significance. Lower limb malalignment should not be considered a failure of medical treatment but more a consequence of the disease process. Earlier surgical intervention may encourage a more normal pattern of growth

Purpose: Minimally invasive surgery (MIS) knee replacement surgery has experienced a recent surge in popularity, driven by the patient concerns of a faster recovery time and a shorter, more cosmetic scar. However the evaluation of any new medical therapy must include a detailed evaluation of both efficacy and safety outcomes. The primary objective of our meta-analysis was to compare the incidence of complications between minimally invasive(MIS) and standard total knee replacement (TKR) approaches. Method: We reviewed randomized controlled trials comparing minimally invasive TKR to standard TKR. After testing for publication bias and heterogeneity, the data were aggregated by random-effects modeling. Our primary outcome was the number of complications. Our secondary outcomes were alignment outliers, Knee Society Function Scores, and Knee Society Knee Scores. Results: We had a total of 9 studies evaluating our primary outcome. Average follow up time ranged from 3 to 28 months. There was no significant publication bias in our study. The combined odds ratios for complications for the MIS group and alignment outliers were 1.58 (95% CI: 1.01 to 2.47) p< 0.05 and 0.79 (95% CI: 0.34 to 1.82) p=0.58 respectively. The standard difference in means for Knee Society scores was no different between groups. Conclusion: The results of this meta-analysis demonstrate a statistically significant increase in complication rates with MIS TKR when compared to standard TKR. There were no significant differences in postoperative alignment or KSS at 3 months between the two groups. MIS knee surgery should be approached with caution

Previously ankylosed or surgically arthrodesed hip joints can be converted successfully to a total hip replacement (THR) in order to improve patient mobility and function. We present a long term prospective cohort study of cementless revisions of previously ankylosed hips. Sixteen hips (15 patients) with a mean age of 52 years (range 16 to 75) had ankylosed hips for a mean of 36 years (range 3.5 to 65 years). They all received a cementless THR between August 1988 and January 2003 and were prospectively followed-up for a mean of 11 years (range 5.0 to 19 years). Two patients died during the study period of unrelated causes and none were lost to follow-up. All patients showed improved mobility and function following the conversion of their ankylosed hips. The Harris Hip Score improved from a pre-operative mean value of 70 (Standard Error of Mean (SEM) 3.4) to a post-operative value of 83 (SEM 4.4) at the latest review, which was statistically significant (p < 0.05). There was one acetabular cup revision at 5 years post implantation for aseptic loosening. At a mean of 11 years post THR, all other femoral and acetabular components remained clinically and radiographically well fixed. One patient with systemic ankylosing spondylitis and spontaneous bilateral bony hip ankylosis developed the unusual complication of Paget’s disease of the left hemipelvis and proximal femur two years after successful bilateral THR surgery. His symptoms resolved following medical therapy for Paget’s disease. We conclude that a previously ankylosed hip can be effectively converted to a cementless total hip replacement with good long term results

Introduction: Enchondromas are benign cartilaginous tumors, which are most often localized, in the small bones of the hand. Treatment methods fall into a broad spectrum ranging from conservative, medical therapies, to a variety of surgical procedures, which may or may not employ the use of local adjuvant treatment or bone grafting. Material & Method: We present thirty four patients with hand enchondromas treated surgically in our department during the last eleven years. Their medical records and radiographs were reviewed retrospectively and the patients were contacted and interviewed by telephone. Results: The patients were treated operatively with an intralesional approach, with meticulous curettage of the bone lesion, use of phenol 5% and grafting using coralline hydroxyapatite. X-rays taken over the first postoperative year revealed adequate bone synthesis at the site of enchondroma excavation, and there was no evidence of recurrence, fracture, infection or other complication related to the procedure. Conclusion: We conclude that the combination of curettage of the lesion with the use of phenol as local adjuvant and grafting using coralline hydroxyapatite during the surgical treatment of enchondromas, is a safe technique to reduce or prevent recurrence and allow adequate and uncomplicated local new bone formation

Historically spine surgeons have been powerless to help most patients with painful vertebral insufficiency fractures. Treatment was supportive, hoping that fractures could heal in situ, and accepting the resulting kyphosis and its consequences. Surgery was the court of last resort in instances of disabling neurologic deficits. The very same deficient skeleton that lead to the clinical issue, was simultaneously the principal limiting factor in surgical undertakings. Complications could be common and substantial. Vertebroplasty was born out necessity in the treatment of ‘inoperable’ vertebral metastases. The technique has become a widely adopted method of managing refractory painful vertebral insufficiency fractures, especially those due to osteoporosis. In skilled hands, vertebroplasty provides a high degree of pain relief and patient satisfaction. The fracture is fixed in situ as the marrow space is embolised with PMMA. Kyphoplasty is a technical evolution that enables active fracture reduction before fixation with PMMA. Much is made about the potential differences between the two treatment methods, but no direct comparative studies are available to allow objective conclusions. In any event, as medical therapies improve the treatment of osteoporosis in general, surgeons now have the opportunity to intervene when painful vertebral fractures are a primary source of functional impairment and life quality

In January 2005, NICE published their guidelines on secondary prevention of osteoporotic fractures. This audit aims to assess our compliance with these in the outpatient setting. The records of all new patients attending fracture clinic in a large teaching hospital, over a one month period, were reviewed. All patients who required screening or treatment for osteoporosis (females greater than 50 years old sustaining a fragility fracture) were reviewed at one year to assess compliance with the guidelines. Of the 454 patients reviewed, 90 females over the age of 50 (19%) were identified. These were further subdivided into females between the age of 50 to 75 years (Group A, n=62) and those over 75 (Group B, n=28). The inclusion criteria was presence of a fragility fracture (Group A, n=30 and Group B, n=15). Group A was investigated with DEXA scans in only 26.7% (n=8). Of these, only six were managed as per NICE guidelines and compliant at one-year. Seven patients in Group B were subsequently treated with medical therapies, but only three were managed as per NICE guidelines and compliant. Therefore of the 45 patients included in the audit, only nine were managed appropriately at one-year (20%). One patient suffered a further fracture – who had been fully compliant with treatment. NICE guidelines have been introduced to help the nation’s health using evidence based criteria. There has been no specific extra funding to enable the setting up of additional pathways and investigations for the targeted population. Even in a busy department where systems were implemented to follow the guidelines, the overall compliance with the pathway is less than a quarter. When new guidance is produced for healthcare, there should be advice, support and funding for their implementation

Previously ankylosed or surgically arthrodesed hip joints can be converted successfully to a Total Hip Replacement (THR) in order to improve patient mobility and function. We present a long term prospective cohort study of cementless revisions of previously ankylosed hips. Sixteen hips (15 patients) with a mean age of 52 years (range 16 to 75) had ankylosed hips for a mean of 36 years (range 3.5 to 65 years). They all received a cement-less THR between August 1988 and January 2003 and were prospectively followed-up for a mean of 11 years (range 5.0 to 19 years). Two patients died during the study period of unrelated causes and none were lost to follow-up. All patients showed improved mobility and function following the conversion of their ankylosed hips. The Harris Hip Score improved from a pre-operative mean value of 70 (Standard Error of Mean (SEM) 3.4) to a post-operative value of 83 (SEM 4.4) at the latest review, which was statistically significant (p < 0.05). There was one acetabular cup revision at 5 years post implantation for aseptic loosening. At a mean of 11 years post THR, all other femoral and acetabular components remained clinically and radiographically well fixed. One patient with systemic ankylosing spondylitis and spontaneous bilateral bony hip ankylosis developed the unusual complication of Paget’s disease of the Left hemipelvis and proximal femur two years after successful bilateral THR surgery. His symptoms resolved following medical therapy for Paget’s disease. We conclude that a previously ankylosed hip can be effectively converted to a cementless total hip replacement with good long term results

Background. Vertebral body compression fractures (VCFs) impair quality of life (QOL) and increase patient morbidity and mortality. The international, multicentre, randomised, controlled Fracture Reduction Evaluation (FREE) trial was initiated to compare effectiveness and safety of Balloon kyphoplasty (BKP) to non-surgical management (NSM) for the treatment of acute painful VCFs. We describe the primary endpoint of the ongoing 2-year study. Methods. Patients with 1-3 non-traumatic VCFs (< 3 months old) were randomised to either BKP or NSM. The primary endpoint was the change in QOL as measured by the SF-36 Health Survey Physical Component Summary (PCS) at one month, and device/procedure-related safety. Secondary endpoints included SF-36 subscales, the EQ-5D, self-reported back pain and function using the Roland Morris Disability Questionnaire (RMDQ). All patients were given osteoporosis medical therapy. Results. Among the BKP (N=149) and NSM (N=151) cohorts, mean patient age was 73 years and 77% were female. Most patients had VCFs due to primary osteoporosis; 8 patients due to corticosteroid-induced osteoporosis, and 4 had cancer-related fractures. Thirty-nine BKP (26%) and 36 NSM (24%) patients had >1 VCF treated. At one month follow-up, the mean improvement in the PCS was in favour of BKP over NSM (p<0.0001). All physical component SF-36 subscales and the total EQ-5D score were significantly improved for BKP compared to NSM. Mean improvements in back pain at 7 days and 1 month were significantly greater for BKP compared to NSM (p<0.0001 at both time points). The improvement in RMDQ for BKP over NSM was also significant (p<0.0001). There was one soft tissue haematoma and urinary tract infection, with no bone cement-related serious adverse events. Conclusions. Compared to non-surgical management, balloon kyphoplasty demonstrated superior short-term pain, function and quality of life outcomes with no difference in serious adverse events for the treatment of acute, painful vertebral compression fractures. (Clinical trials.gov number, NCT00211211)