Aims

The Edinburgh Trauma Triage Clinic (TTC) streamlines outpatient care through consultant-led ‘virtual’ triage of referrals and the direct discharge of minor fractures from the Emergency Department. We compared the patient outcomes for simple fractures of the radial head, little finger metacarpal, and fifth metatarsal before and after the implementation of the TTC.

Aims

Fracture clinics are often characterised by the referral of large numbers of unselected patients with minor injuries not requiring investigation or intervention, long waiting times and recurrent unnecessary reviews. Our experience had been of an unsustainable system and we implemented a ‘Trauma Triage Clinic’ (TTC) in order to rationalise and regulate access to our fracture service. The British Orthopaedic Association’s guidelines have required a prospective evaluation of this change of practice, and we report our experience and results.

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.

Aims

Extendible endoprostheses have been available for more than 30 years and have become more sophisticated with time. The latest generation is ‘non-invasive’ and can be lengthened with an external magnetic force. Early results have shown a worryingly high rate of complications such as infection. This study investigates the incidence of complications and the need for further surgery in a cohort of patients with a non-invasive growing endoprosthesis.

Aims

The purpose of this study was to review a large cohort of patients and further assess the correlation between the histological response to chemotherapy in patients with Ewing’s sarcoma with the overall (OS) and event-free survival (EFS).

Aims

The aim of this study was to establish what happens to patients in the long term after endoprosthetic replacement for a primary malignant tumour of bone.

Aims

Osteosarcoma of the pelvis is a particularly difficult tumour to treat as it often presents late, may be of considerable size and/or associated with metastases when it presents, and is frequently chondroid in origin and resistant to chemotherapy.

The aim of this study was to review our experience of managing this group of patients and to identify features predictive of a poor outcome.

Aims

The aims of this study were to estimate the cost of surgical treatment of fractures of the proximal humerus using a micro-costing methodology, contrast this cost with the national reimbursement tariff and establish the major determinants of cost.

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.

The aim of this study was to evaluate the prognostic and therapeutic factors which influence the oncological outcome of parosteal osteosarcoma.

A total of 80 patients with a primary parosteal osteosarcoma were included in this retrospective study. There were 51 females and 29 males with a mean age of 29.9 years (11 to 78).

The mean follow-up was 11.2 years (1 to 40). Overall survival was 91.8% at five years and 87.8% at ten years. Local recurrence occurred in 14 (17.5%) patients and was associated with intralesional surgery and a large volume of tumour. On histological examination, 80% of the local recurrences were dedifferentiated high-grade tumours. A total of 12 (14.8%) patients developed pulmonary metastases, of whom half had either a dedifferentiated tumour or a local recurrence. Female gender and young age were good prognostic factors. Local recurrence was a poor prognostic factor for survival. Medullary involvement or the use of chemotherapy had no impact on survival.

The main goal in treating a parosteal osteosarcoma must be to achieve a wide surgical margin, as inadequate margins are associated with local recurrence. Local recurrence has a significant negative effect on survival, as 80% of the local recurrences are high-grade dedifferentiated tumours, and half of these patients develop metastases.

The role of chemotherapy in the treatment of parosteal osteosarcoma is not as obvious as it is in the treatment of conventional osteosarcoma. The mainstay of treatment is wide local excision.

Cite this article: Bone Joint J 2015;97-B:1698–1703.

We conducted a case-control study to examine the merit of silver-coated tumour prostheses. We reviewed 85 patients with Agluna-treated (silver-coated) tumour implants treated between 2006 and 2011 and matched them with 85 control patients treated between 2001 and 2011 with identical, but uncoated, tumour prostheses.

In all, 106 men and 64 women with a mean age of 42.2 years (18.4 to 90.4) were included in the study. There were 50 primary reconstructions (29.4%); 79 one-stage revisions (46.5%) and 41 two-stage revisions for infection (24.1%).

The overall post-operative infection rate of the silver-coated group was 11.8% compared with 22.4% for the control group (p = 0.033, chi-square test). A total of seven of the ten infected prostheses in the silver-coated group were treated successfully with debridement, antibiotics, and implant retention compared with only six of the 19 patients (31.6%) in the control group (p = 0.048, chi-square test). Three patients in the silver-coated group (3.5%) and 13 controls (15.3%) had chronic periprosthetic infection (p = 0.009, chi-square test).

The overall success rates in controlling infection by two-stage revision in the silver-coated group was 85% (17/20) compared with 57.1% (12/21) in the control group (p = 0.05, chi-square test). The Agluna-treated endoprostheses were associated with a lower rate of early periprosthetic infection. These silver-treated implants were particularly useful in two-stage revisions for infection and in those patients with incidental positive cultures at the time of implantation of the prosthesis.

Debridement with antibiotic treatment and retention of the implant appeared to be more successful with silver-coated implants.

Cite this article: Bone Joint J 2015;97-B:252–7.

Aim

To assess the safety of day case lumbar decompressive surgery

A poor response to chemotherapy (≤ 90% necrosis) for osteosarcomas leads to poorer survival and an increased risk of local recurrence, particularly if there is a close margin of excision. We evaluated whether amputation confers any survival benefit over limb salvage surgery (LSS) with narrow margins in patients who respond poorly to chemotherapy.

We only analysed patients with an osteosarcoma of the limb, a poor response to chemotherapy and close margins on LSS (marginal/intralesional) or primary amputation: 360 patients (36 LSS (intralesional margins), 197 LSS (marginal margins) and 127 amputations) were included. Local recurrence developed in 13 (36%) following LSS with intralesional margins, and 39 (20%) following LSS with marginal margins. There was no local recurrence in patients who underwent amputation. The five-year survival for all patients was 41% (95% confidence interval (CI) 35 to 46), but for those treated by LSS with marginal margins was 46.2% (95% CI 38 to 53), 36.3% (95% CI 27 to 45) for those treated by amputation, and 28% (95 CI 14 to 44) for those treated by LSS with intralesional margins. Patients who had LSS and then developed local recurrence as a first event had the same survival as those who had primary amputation without local recurrence. Prophylactic adjuvant radiotherapy was used in 40 patients but had no discernible effect in preventing local recurrence.

Although amputation offered better local control, it conferred no clear survival benefit over LSS with marginal margins in these patients with a poor overall prognosis.

Cite this article: Bone Joint J 2015;97-B:115–20.

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%.

The aim of this study was to evaluate the functional and oncological outcome of extracorporeally irradiated autografts used to reconstruct the pelvis after a P1/2 internal hemipelvectomy.

The study included 18 patients with a primary malignant bone tumour of the pelvis. There were 13 males and five females with a mean age of 24.8 years (8 to 62). Of these, seven had an osteogenic sarcoma, six a Ewing’s sarcoma, and five a chondrosarcoma. At a mean follow-up of 51.6 months (4 to 185), nine patients had died with metastatic disease while nine were free from disease. Local recurrence occurred in three patients all of whom eventually died of their disease. Deep infection occurred in three patients and required removal of their graft in two while the third underwent a hindquarter amputation for extensive flap necrosis.

The mean Musculoskeletal Tumor Society functional score of the 16 patients who could be followed-up for at least 12 months was 77% (50 to 90). Those 15 patients who completed the Toronto Extremity Salvage Score questionnaire had a mean score of 71% (53 to 85).

Extracorporeal irradiation and re-implantation of bone is a valid method of reconstruction after an internal hemipelvectomy. It has an acceptable morbidity and a functional outcome that compares favourably with other available reconstructive techniques.

Cite this article: Bone Joint J 2014;96-B:1404–10

Bone sarcomas are rare cancers and orthopaedic surgeons come across them infrequently, sometimes unexpectedly during surgical procedures. We investigated the outcomes of patients who underwent a surgical procedure where sarcomas were found unexpectedly and were subsequently referred to our unit for treatment. We identified 95 patients (44 intra-lesional excisions, 35 fracture fixations, 16 joint replacements) with mean age of 48 years (11 to 83); 60% were males (n = 57). Local recurrence arose in 40% who underwent limb salvage surgery versus 12% who had an amputation. Despite achieving local control, overall survival was worse for patients treated with amputation rather than limb salvage (54% vs 75% five-year survival). Factors that negatively influenced survival were invasive primary surgery (fracture fixation, joint replacement), a delay of greater than two months until referral to our oncology service, and high-grade tumours. Survival in these circumstances depends mostly on factors that are determined prior to definitive treatment by a tertiary orthopaedic oncology unit. Limb salvage in this group of patients is associated with a higher rate of inadequate marginal surgery and, consequently, higher local recurrence rates than amputation, but should still be attempted whenever possible, as local control is not the primary determinant of survival.

Cite this article: Bone Joint J 2014;96-B:665–72.

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.

The purpose of this study was to assess whether the use of a joint-sparing technique such as curettage and grafting was successful in eradicating giant cell tumours of the proximal femur, or whether an alternative strategy was more appropriate.

Between 1974 and 2012, 24 patients with a giant cell tumour of the proximal femur were treated primarily at our hospital. Treatment was either joint sparing or joint replacing. Joint-sparing treatment was undertaken in ten patients by curettage with or without adjunctive bone graft. Joint replacement was by total hip replacement in nine patients and endoprosthetic replacement in five. All 11 patients who presented with a pathological fracture were treated by replacement.

Local recurrence occurred in five patients (21%): two were treated by hip replacement, three by curettage and none with an endoprosthesis. Of the ten patients treated initially by curettage, six had a successful outcome without local recurrence and required no further surgery. Three eventually needed a hip replacement for local recurrence and one an endoprosthetic replacement for mechanical failure. Thus 18 patients had the affected joint replaced and only six (25%) retained their native joint. Overall, 60% of patients without a pathological fracture who were treated with curettage had a successful outcome.

Cite this article: Bone Joint J 2014;96-B:127–31.