Over 80% of patients with advanced breast cancer will develop bone metastases for which there is no cure. Although thought to involve a complex cascade of cell-cell interactions, the factors controlling the development of bone metastases are still poorly understood. Osteoblasts may have an important role in mediating homing and proliferation of breast cancer cells to the bony environment. This study aimed to examine the potential role osteoblasts have in the migration of circulating tumour cells to bone and the factors involved in this attraction. Culture of osteoblasts and MDA-MB-231 breast cancer cells was performed. Breast cancer cell migration in response to osteoblasts was measured using Transwell Migration Inserts. Potential mediators of cell migration were detected using ChemiArray & ELISA assays. A luminometer based Vialight assay was used to measure breast cancer cell proliferation in response to factors secreted by osteoblasts. There was a 3-4 fold increase of MDA-MB-231 migration in response to osteoblasts. ChemiArray analysis of osteoblast-conditioned medium revealed a range of secreted chemokines including IL-6 & 8, TIMP 1 & 2 and MCP-1. Initially, MCP-1 was quantified at 282 pg/ml, but rose to over 9000 pg/ml when osteoprogenitor cells were differentiated into mature osteoblasts. Inclusion of a monoclonal antibody to MCP-1 in osteoblast-conditioned medium resulted in a significant decrease in breast cancer cell migration to osteoblasts. There was no significant change in proliferation of MDA-MB 231 cells when exposed to osteoblast-conditioned medium. Osteoblasts are capable of inducing breast cancer cell migration mediated at least in part by chemokine secretion. MCP-1 produced by the osteoblasts was shown to play a central role in mediating homing of the breast cancer cells. Increased understanding of the pathways involved in the development of bone metastases may provide new targets for therapeutic intervention.
Scarf osteotomy is a commonly performed method of hallux valgus correction. Release of deforming lateral soft tissue structures is an integral part of this correction. The aim of this study was to determine if there was any difference in the correction achieved by dorsal and transarticular releases as part of a scarf osteotomy. This radiological study was performed at a single institution. One surgeon utilised the dorsal first web approach for the distal soft tissue release and one the transarticular approach. There were 23 patients in each group. The same post-operative regime was used on both sets of patients. Data was collected on hallux valgus angle (HVA), intermetatarsal angle (IMA) and AFS sesamoid scoring. The pre-operative deformity as measured by hallux valgus angle and intermetatarsal angle where similar for both groups (p= 0.25, 0.79 respectively) with a significant difference in severity of AFS scoring in the dorsal group (p <
0.001). Patients who underwent a dorsal approach release had a mean improvement in IMA of 5.46 degrees compared to 3.86 in the transarticular group. The HVA improved by 17.92 degrees in the dorsal group compared to 8.08 in the transarticular group. Both these results were statistically significant (p= <
0.01,<
0.002 respectively). There was a statistically significant difference in number of patients returning to within normal limits of the HVA (p= <
0.05); 18 patients returned to a normal hallux valgus angle after undergoing the dorsal approach compared to 9 patients in the transarticular group. Our study shows that when performing a distal soft tissue release in conjunction with a scarf osteotomy for correction of hallux valgus, a dorsal first web approach is significantly better at correcting the HVA as compared to a transarticular approach. We would, therefore, recommend the use of a dorsal approach when performing this surgery.
142 patients experienced significant postoperative morbidity consisting of 24 myocardial infarctions, 46 respiratory tract infections, 33 urinary tract infections, 3 cerebral vascular accidents and 36 exacerbations of congestive cardiac failure. There was no correlation between morbidity and location or type of fracture. The mean age (86.1 yrs) and length of stay (26 days) was greater in the morbidity group (p<
0.05). The overall post operative in-patient mortality rate was 9%, rising to 50% in those who suffered a myocardial infarction and 33% in those with exacerbations of congestive cardiac failure.
Ankle arthrodesis is a common operation with published fusion rates ranging from 62–100%. The literature documents the difficulties of obtaining arthrodesis in certain patients for example with neuroarthropathy, but the risk of non union related to deformity, bone quality, bone defects and systemic disease has not previously been reported. Between 2002 and 2006 we performed an ankle arthrodesis in 154 patients, and analyzed these patients retrospectively to delineate categories of risk factors for achieving arthrodesis. From this analysis we devised a preoperative radiographic scoring system to grade complexity of pre-operative ankle arthrodesis. The scoring system is based upon 5 categories; size and plane of deformity, presence and size of bone defects, presence and area of avascular necrosis, site of previous fracture in post-traumatic arthritis and predisposing condition causing the arthritis. Each category has potential scores of 1–5, apart from the latter which is scored up to 6, with higher scores being more severe. The grade of complexity is derived from a cumulative score from all 5 categories. Statistical analysis revealed good intra and inter- observer correlation. Multivariate regression analysis demonstrated that this scoring system correlates with the techniques used for arthrodesis as well as outcome. This study demonstrated that if the method of arthrodesis is altered according to the relative risk of non –union then there is no significant difference in outcome between patients of high and low risk for non-union We present a new scoring system for severity of pre-operative condition in ankle arthrodesis patients and introduce an algorithm for surgical correction based upon this pre-operative scoring system. The surgical techniques for the arthrodesis are presented, ranging from simple screw fixation to more complex bone grafting techniques, bone stimulation and alternative methods of fixation.
Distal tibial physeal fractures are the second most common growth plate injury and the most common cause of growth arrest and deformity. This study assesses the accuracy of pre-operative planning for placement of the screws in these fractures using either standard radiographs or CT scans. We studied 62 consecutive physeal fractures over a period of four years. An outline of a single cut of the CT scan was used for each patient. An ideal position for the screw was determined as being perpendicular to and at the midpoint of the fracture. The difference in entry point and direction of the screw between the ideal and the observers’ assessments were compared using the paired Student’s We would, therefore, recommend that CT scans are routinely used in the pre-operative assessment and treatment of distal tibial physeal fractures.