Clinical evidence that patients with type 2 diabetes mellitus (T2DM) have increased risk of fractures is reported. Furthermore, thiazolidinediones, used to treat T2DM increases the risk of secondary osteoporosis & subsequent fractures. The osteogenic potency of metformin is reported in vitro, few studies have investigated the effects of metformin on bone mass and fracture healing in vivo. We aimed to investigate the effects of metformin on fracture healing in vivo.

We report the functional and socioeconomic long-term outcome of patients with pelvic ring injuries.

We identified 109 patients treated at a Level I trauma centre between 1973 and 1990 with multiple blunt orthopaedic injuries including an injury to the pelvic ring, with an Injury Severity Score (ISS) of ≥ 16. These patients were invited for clinical review at a minimum of ten years after the initial injury, at which point functional results, general health scores and socioeconomic factors were assessed.

In all 33 isolated anterior (group A), 33 isolated posterior (group P) and 43 combined anterior/posterior pelvic ring injuries (group A/P) were included. The mean age of the patients at injury was 28.8 years (5 to 55) and the mean ISS was 22.7 (16 to 44).

At review the mean Short-Form 12 physical component score for the A/P group was 38.71 (22.12 to 56.56) and the mean Hannover Score for Polytrauma Outcome subjective score was 67.27 (12.48 to 147.42), being significantly worse compared with the other two groups (p = 0.004 and p = 0.024, respectively). A total of 42 patients (39%) had a limp and 12 (11%) required crutches. Car or public transport usage was restricted in 16 patients (15%). Overall patients in groups P and A/P had a worse outcome. The long-term outcome of patients with posterior or combined anterior/posterior pelvic ring injuries is poorer than of those with an isolated anterior injury.

Cite this article: Bone Joint J 2013;95-B:548–53.

Introduction

There has been a paradigm shift in orthopaedic research, it is now recognized that the extent to which interventions really make a difference to a patient's overall life is indicated by measuring one's general health status. The primary aim of this study was to report how the methodology of current evidence in hip fracture research can improve if studies included patients with cognitive impairment.

Background

The inherently high stiffness of locked plate constructs is increasingly recognized as a potential cause of deficient healing observed in patients with periarticular locked plating systems.

The objective of this study is to perform a biomechanical comparison of distal femur locked plating systems.

Background

To establish relative fixation strengths of a single lateral locking plate, a double locking plate, and a tibial nail in treatment of proximal tibial extra-articular fractures.

There is evidence that fracture healing is delayed in severely injured patients. We recently demonstrated that a blunt chest trauma, which induced posttraumatic systemic inflammation, considerably impaired fracture healing in rats. Because the complement anaphylatoxin C5a is an important trigger of systemic inflammation, we tested the hypothesis, whether the impairment of fracture healing observed after a severe trauma resulted from systemically activated complement.

16 male Wistar rats received a thoracic trauma and a femur osteotomy stabilized by an external fixator. Immediately and 12 h after the trauma, half of the animals received a C5aR-antagonist to prevent the C5a-dependent systemic inflammation. Control rats received a nonsense peptide, which does not provoke any biological effect. The animals were killed after 35 days and the calli were analyzed by three point bending testing, μCT and histomorphometry. Statistics: Mann-Whitney U test, level of significance to p<0.05.

The treatment with the C5aR-antagonist increased flexural rigidity significantly by 55%, improved bony bridging of the fracture gap and led to a slightly larger and qualitatively improved callus as evaluated by μCT and histological measurements.

This study shows, that the immunomodulation by a C5aR-antagonist significantly reduced the deleterious effects of a thoracic trauma on fracture healing. C5a could possibly represent a target to prevent delayed bone healing in patients with severe trauma.

Secondary fracture healing processes are strongly influenced by interfragmentary motion. Shear movement is assumed to be more critical than axial movement, however experimental results are controversial. Numerical fracture healing models allow to simulate the fracture healing process with variation of single input parameters and under comparable normalized mechanical conditions. Therefore, a direct comparison of different in vivo scenarios is possible. The aim of this study was to simulate fracture healing under several axial and shear movement scenarios and compare their respective time to heal. We hypothesize that shear movement is always more critical than axial loading. For the presented study, we used a corroborated numerical model for fracture healing in sheep. Numerous variations of the movement amplitude, the fracture gap size and the musculoskeletal loads were simulated for comparable axial compressive and shear load cases. In all simulated cases, axial compressive load had less inhibitory influences on the healing process than shear load. Therefore, shear loading is more critical for the fracture healing outcome in general. Thus, our findings suggest osteosynthesis implants to be optimized to limit shear movements under musculoskeletal loading.

Reconstruction of 10mm segmental bone defects in rat by mesenchymal stem cell derived chondrogenic cells (MSC-DC)

Introduction

We investigated the usefulness of flap surgery for Gustilo type IIIB and C severe open fracture of the tibia, for which treatment is difficult.

Current dogma is that a programme of anatomic repositioning with rigid internal fixation of fractures will lead to successful healing. Failures are attributed to failures in technique, not in instruments, implants, or concepts. Current basic science research shows that in the osteoporotic skeleton, bone trabeculae, once lost, are not replaced. This is true in fractures. In a series of cases, the author will show that lost bone is indeed not replaced, and the unsuccessful clinical outcome is caused by adherence to concepts that do not solve the problem of fracture repair in the elderly. Five specific case examples will be shown to demonstrate this problem. Despite an abundance of bone graft substitutes, bone morphogenic protein preparations, and cancellous bone autografting, the problem of dependable fracture repair in the elderly skeleton still needs to be solved.

Introduction

The risk factors for new adjacent vertebral compression fracture (NAVCF) after Vertebroplasty (VP) or Kyphoplasty (KP) for osteoporotic vertebral compression fractures (VCFs) were investigated.

Introduction

Although a previous hip fracture is one of the strongest predictors for the next one this risk might be modified by other factors. The goal of this analysis was to compute a simple algorithm to assess the individual risk for a contralateral hip fracture.

Introduction

This study compares outcomes of vertebroplasty(VP) and kyphoplasty(KP) in 125 consecutive female Asian patients above 65 years with L1 osteoporotic vertebral compression fractures

Introduction

In elderly patients, the incidence of a second fracture in the contralateral hip within 2 years of a femoral neck fracture (FNF), ranges from 7 to 12%.

Introduction

Proxy assessment of health-related quality of life (HRQoL) can be an alternative to self reporting in elderly patients with cognitive or physical impairment. However, over- and underestimation by the proxies is reported. The aim of the present study was to examine the agreement of HRQoL answers between old Japanese patients and their close relatives.

Introduction

Lack of standardization of outcome measurement has hampered an evidence-based approach to clinical practice and research. We report on the progress on establishing a minimal set of core domains for outcome measurement in distal radius fracture.

Introduction

Since the concept of severely suppressed bone turnover (SSBT) after long-term bisphosphonate (BPs) use, SSBT have been believed as the major cause of low-energy femoral fractures, which are called atypical femoral fractures. Here we present several cases of stress fractures with bowing femoral shaft deformity, which can be another cause of low-energy femoral fractures in the elderly.

Introduction

The treatment of trochanteric femoral fractures with the use of short femoral nails has become an established method. The fixation is required that lag screw be centered to prevent complications. But correct positioning of the device may difficult because of anatomical feature. This study evaluated the femoral morphology three-dimensionally using computed tomography (CT) images.

Introduction

Femur neck fractures (NOF) in the young could result in mal-union, non-union and avascular necrosis of the femoral head. Osteosynthesis is the standard of management in NOFs in young patient above complications sometimes end in Arthroplasty. The aim of our study is to identify predictors of NOF failures in the young population.

In fractures electrical currents generated by piezoelectric and junctional diode effects initiate and augment healing. Conductive fixators may interfere with these currents causing delayed/nonunion which can be avoided by non conductive fixators, facilitating osteosynthesis. Null hypothesis of no difference and two tailed alternate hypothesis of any could be better was used. Impugn change in Electrical properties for demarcating union rate.

Patients of Gustillo's grade I and II tibia fractures were randomised in conductive and non conductive fixator groups in a blinded manner. Electrical and clinico-radiological properties were compared every two weeks for 20 weeks, recoding magnitude and significant difference. Capacitance(p=0.03), Impedance(p=0.002), Inductance(p=0.01) and Reactance(p=0.02) are the electrical parameters which not only demarcated union rate but orchestrated diagnosis of fracture healing. In Non-conducting group, after removal of fixator at week 10, Local Tenderness was consistently absent, Rust Score was higher at week 18 and 20(p=0.01), absence of abnormal mobility was 58% higher and 100% at week 12(p < 0.05), Presence of weight bearing was higher from week 16(OR=15, p=0.03), presence of transmitted movement was 2.4 times higher at week 10(95% CI=0.17–34.93, p=0.52) and was 100% at week 14.

Fractures heal at a faster rate if fixed by insulated non-conducting external fixators. Electrical parameters can be used to demarcate and monitor fracture healing.

Despite its clinical significance, metaphyseal fracture healing has received little attention in research and experimental models have been limited. In particular it is not known to what extent the mechanical environment plays a role in metaphyseal fracture healing. Recently, a new murine internal fixation plate has been developed to stabilise fractures in the distal femur under highly standardised conditions. Goal of the current study was to modify this design, in order to be able to evaluate the influence of the fixator bending stiffness on metaphyseal fracture healing in mice.

Adapting the existing single body design, resulting in low flexibility fixation, two new plates were developed with a decreased bending stiffness of approximately 65% and 45% of the original implant (100%). Pilot experiments were performed on 54 animals, whereas the mice were sacrificed and fracture healing assessed radiologically and biomechanically after 14 and 28 days.

MicroCT evaluation confirmed that the osteotomy was created in the trabecular, metaphyseal bone of the distal mouse femora. All bones showed progressive fracture healing over time, with decreased implant stiffness leading to increased periosteal callus formation.

These implants represent an important new research tool to study molecular and genetic aspects of metaphyseal fracture healing in mice under standardized mechanical conditions, in order to improve clinical treatment in challenging situations, such as in osteoporotic bone.

Background

pelvic fractures in elderly patients often result in poor prognosis due to immobilization associated complications. Thus, the target of the treatment in this patient group is early mobilization in order to reduce the risk of these complications. We report outcomes of 4 cases of pelvic fracture in elderly patients, who were treated with percutaneous screw fixation.

Introduction

Sacral fractures were previously treated with transiliac bars, sacroiliac screws or posterior plates. Sacroiliac screws are not as invasive, but the risk of intra-operative neurovascular damage must be considered. Posterior plate fixation is slightly invasive. In 2006, we conceived a new fixation method with spinal instrumentation system, and I will introduce it.

Introduction

Atypical femoral fracture focused on relation of bisphosphonate use, frequently. However, the mechanism of atypical femoral fracture was not yet clarified. Atypical femoral fractures have been kept femoral shaft cortical thickness and BMD, practically. We hypothesized that atypical femoral fractures were associated with impaired bone quality and curvature of femoral shaft.

Introduction

The fracture healing outcome is often evaluated via ex vivo testing of the fracture callus. However, there is only a small time window, where the callus stiffness is significantly different, i.e. a delayed fracture healing might be undetected if the time point of sacrifice is improper. The aim of this study was to develop an in vivo monitoring concept, which allows determining the fracture callus stiffness in vivo over the whole healing time in rats.

Introduction

Fracture healing is governed by biological and mechanical factors. Circular frames are one method to fix fractures. Recently, the number of frame designs that are available has increased and these different designs may have different effects on the mechanical environment created. The senior author has been concerned by the stability of the construction when a short frame is used. This study examined the stability of different frames and the possible use of additional 7th struts to aid stability.

Introduction

Tip apex distance (TAD) is reported as a predictor for cut outs of lag screws in the treatment of intertrochanteric fractures, and surgeons are adviced to strive for TAD within 20 mm. However the definition of neck axis and the limb position of lateral radiograph are not clearly described in the original literature. We propose the refined TAD by defining these factors. The objective of this study was to analyze the interobserver agreement of this refined TAD.

The Study to Prospectively Evaluate Reamed Intramedullary Nails in Tibial Shaft Fractures (SPRINT) randomised 1,226 patients treated by intramedullary nailing to reamed versus unreamed groups. We aimed to determine if there was a difference in the number of patients requiring more than one reoperation between the groups.

We hypothesised there would be differences in the number of patients with more than one reoperation in the reamed versus unreamed groups and in patients with open fractures versus closed fractures.

We identified patients requiring more than one reoperation during the 12 m follow-up. We considered those that were reamed versus unreamed, open versus closed, and those with a reoperation planned post 12 m follow-up. We also compared patient and fracture characteristics.

We identified a total of 44 patients requiring two or more reoperations. No difference between the reamed and unreamed groups was found in the risk of having more than one reoperation. Patients with two or more reoperations were older (p=0.03), had a higher frequency of open fractures (p<0.001), and had higher energy mechanisms of injury (p<0.001). The first reoperation was in response to infection for 25 patients. 12 patients had additional reoperations planned after the 12 m follow-up.

A relatively small number of tibial shaft fracture patients required more than one reoperation. Further study is required to assess consequences of needing multiple reoperations in this high risk group.

This ongoing prospective RCT compares two surgical approaches with respect to accuracy of guidewire and tibial nail position.

29 patients with tibial fractures were randomised to semi-extended (SE) or standard (S) approaches of tibial nail insertion. Fluoroscopy obtained guidewire and final nail position. The SE approach is more proximal with the guidewire inserted posterior to the patella, theoretically allowing more accurate wire and nail placement.

Measurements were taken in both planes of the nail and guidewire to determine deviation from optimum angle of insertion (relative to the long axes of the tibial shaft).

14 and 15 patients were treated with semi-extended and standard approaches respectively.

The semi-extended approach results in better guidewire and nail placement in both planes with mean deviation from the optimal angle of insertion as below:

Guidewire AP 4.5° (SE) versus 4.04° (S) Lateral 24.59° (SE) versus 33.36° (S)

Nail AP 3.21° (SE) versus 3.68° (S) Lateral 17.73° (SE) versus 24.04° (S)

Anterior knee pain may be due to excessive anterior placement of the nail. We assessed anterior placement of the guidewire and nail in the lateral plane. This was expressed as a percentage from the anterior cortex of the tibia. Mean results are below:

Guidewire 9.7% (SE) versus 9.3% (S)

Nail 19.5% (SE) versus 16.3% (S)

Semi-extended nailing may allow for better guidewire position and as such nail placement. This may reduce anterior knee pain.

Introduction

The treatment of large segmental defects of long bones, which is caused by high energy trauma, revision surgery and resection of tumor or osteomyelitis and so on, is usually difficult. Recently the usefulness of Induced membrane technique (Masquelet technique) is reported. Induced membrane technique is an alternative method to reconstruct long-bone defects, which is two-stage surgery and combines the use of induced pseudo-membranes and cancellous autografts. The mechanism of bone formation in this technique is unknown. We performed Induced membrane technique on four patients, collected their membranes, and tested osteogenic ability and multipotency of cells derived from the membrane.

Materials and method

This study included 309 patients, over the age of 60 (44 men, 256 women, mean age 85.6 years) who underwent osteosynthesis using a short femoral nail(Gamma)for femoral intertrochanteric fractures. The new reduction classification was defined, in AP view by the degree of contact between the medial cortex of the proximal fragment and that of the medial cortex of the distal fragment. The classification in AP view is divided into three Types: Anatomical Type, Medial Type, and Lateral Type. As for the ML view was defined based on the degree of anterior cortex contact between proximal and distal fragment, was divided also into Anatomical Type, Intramedullary Type, and Extramedullary Type. We assessed lag screw sliding amount at 2 weeks period after surgery as the post-operative displacement.

Introduction

The flexor carpi radialis (FCR) approach is widely used for volar plate fixation of distal radius fractures. However, patients sometimes complain of postoperative numbness at the thenar eminence. We propose this is derived from injury to the palmar cutaneous branch of the median nerve (PCBm).

Hip fracture treatment strategies continue to evolve with the goal of restoring hip fracture victims to Pre-injury Functional levels. Strategies for improved treatment have focused on fracture exposure, reduction, provisional fixation and definitive fixation with implant designs optimised for fracture union with minimal implant failure as originally proposed by Lambotte. Multiple implant designs have been conceived based on perceived inadequacies of previous generational designs. To better understand this evolutionary process, it is necessary to review the predecessors of modern fracture treatment and understand their design concepts and results. It is interesting that the modern era of surgical treatment of hip fractures actually began in 1902, when Dr Royal Whitman advocated the necessity of a closed reduction of adult hip fractures under general anesthesia and stabilisation by hip spica cast. Dr Whitman predicted the evolution of stabilisation by internal fixation and commented on this in his 1932 JBJS editorial emphasising the importance of surgical treatment of fractures. Dr Smith-Peterson, also from New York, in 1925 developed the 1st commercially successful hip implant, a tri–flanged nail. These first surgeries were performed with an open reduction, through a Smith-Petersen approach without radiographic control.

This nail device was rapidly modified in the 1930's to permit insertion over a guide wire with a radiographic controlled insertion technique, a minimally invasive procedure. Nail penetration and implant failure in pertrochanteric fractures led to the rapid development of side-plates and a refocus on reduction stability. This led to a period of primary corrective osteotomies for enhanced stability, but fell out of failure after the sliding hip screw concept took hold. Originally conceived by Godoy-Moreira and Pohl independently in the 1940s, it became rapidly accepted as a method to avoid nail penetration and implant failure, unfortunately at the expense of accepting malunion and collapse of the fracture. Even the importance of rotational stability was discarded as insignificant by Holt in 1963. The concept of reduction of the Antero-Medial cortex was forgotten in favour of the Tip-apex distance as the only important variable in reduction to avoid implant cut-out. The concept of malunion of pertrochanteric fractures was simply deleted from consideration with disregard for the possible association of impaired functional recovery.

Several recent papers that improved functional recovery is possible when these new implants are coupled with successful reduction strategies. Further studies are needed to identify the correct choice of implant for the appropriate fracture configuration, which may lead to a revision of our current fracture classification systems and our concepts of stability.

The previous bioabsorbable plates have had several issues with regard to clinical usage for fractures. The aims of this study were to demonstrate the clinical results of novel bioabsorbable plates made of hydroxyapatite/poly-L-lactide and titanium plates for metacarpal fractures and to compare mechanical properties of them in a fracture model. The subjects were 33 metacarpal diaphyseal fractures of 27 consecutive patients treated with bioabsorbable plates. The mean age was 35.8 (17–78), 22 male and 5 female was included. The mean follow up period was 7.4months (2–14). All cases achieved bone union, and there were no complication especially for aseptic swelling etc.

Furthermore, we compared the mechanical properties of bioabsorbable and titanium plates. There were no significant differences in 6 month postoperative clinical results including total range of active motion and % of the contralateral grip strength between patients receiving bioabsorbable and titanium plates. The bending strength and stiffness of one-third tubular bioabsorbable plate constructs were comparable with those of titanium plates for 1.5mm screws, and those of semi-tubular bioabsorbable plates were comparable with those of titanium plates for 2.0mm screws. The torsional strength of semi-tubular bioabsorbable plates was significantly greater than that of titanium plates for 2.0mm screws.

Introduction

In oblique olecranon fracture, fracture line begins in the trochlear notch and proceeds distally to the dorsal cortex of the ulna. We have experienced a nonunion of reverse oblique fracture.

Introduction

Over the past decade, the use of negative pressure wound therapy (NPWT) devices has increased and expanded to include a wide variety of patients. However, the safety and efficacy of NPWT over skin in open fractures is still unknown. The purpose of this study was to evaluate the complication rate and outcome of open fractures treated by NPWT over closed wounds or flaps.

Introduction

Bone tissue engineering approaches are an emerging strategy to treat bone defects, and commonly involve the delivery of osteogenic cells and/or drugs via a porous scaffold. We have been exploring an alternative injectable approach for drug delivery that would obviate the need for invasive surgery.

Objective

To determine what factors affect fracture healing with low-intensity pulsed ultrasound (LIPUS) for delayed unions and nonunions.

Introduction

The delay looks radiographically as a fracture callus not very evident or absent 6 months after osteosynthesis. Patients undergo a long period of immobilization and this fact causes the increase the social cost of the disease. The technique we suggest aims to the reduce the period of immobilization and as a consequence the management costs of the disease.

There is evidence that fracture healing is impaired in patients with chronic immune disorders the reasons remaining unclear so far. To further elucidate the role of the immune system in bone healing, this study investigated the hypothesis that fracture healing would be considerably disturbed in a mouse model with severe defects of the innate as well as adaptive immune system.

Immune deficient Nod-scidIL2Rγ^null and immune competent BALBcByJ mice were used (12 weeks, male, each n=24). The mice received a femur osteotomy stabilized by an external fixator and were sacrificed at d 21, 28, and 35. The calli were evaluated by three-point-bending testing, μCT and histomorphometry.

The flexural rigidity of the callus did not significantly differ between both genotypes after 21 and 28 days but was significantly lower in Nod-scidIL2Rγ^null mice after 35 days (31%). The maximum moment of inertia was significantly increased after 21 days (by 34%), and the callus cross section area after 21, 28 and 35 days in Nod-scidIL2Rγ^null mice. BV/TV of the callus of Nod-scidIL2Rγ^null mice was significantly decreased after 28 and 35 days (by 32% and 41%). The histological evaluation showed a significantly enhanced amount of cartilage in the fracture gap of Nod-scidIL2Rγ^null mice.

These data indicate an only moderate delay in fracture healing in Nod-scidIL2Rγ^null mice suffering on severe defects in innate and adaptive immune response.

Introduction

Failures in fracture healing are mainly caused by a lack of neovascularization. We have previously demonstrated that G-CSF-mobilized peripheral blood (GM-PB) CD34+ cells, an endothelial progenitor enriched cell population, contributed to fracture healing via vasculogenesis and osteogenesis. We postulated the hypothesis that local transplantation of culture expanded bone marrow (cEx-BM) CD34+ cells could exhibit therapeutic potential for fracture healing.

Introduction

Low-intensity pulsed ultrasound (LIPUS) has been reported to enhance healing of fracture and nonunion. Bone morphogenetic protein-7 (BMP-7) has also been reported to promote bone formation. Recently, we demonstrated progenitor cells with osteogenic/chondrogenic differentiation potential existed in human fracture hematoma and nonunion tissue.

Introduction

When translating the principle of intramedullary nailing for trochanteric femoral fractures to Asian patients, design modifications made to adjust for anatomic differences resulted in an PFNA Asia. The primary endpoint of this study was the rate of complications attributable to fracture fixation.

Fracture classification of femoral trochanteric fracture is usually based on plain X-ray. However, complications such as delayed union, non-union, and cut out are seen in stable fracture on X-ray. In this study, fracture was classified by 3D-CT and relationship to X-ray classification was investigated.

48 femoral trochanteric fractures (15 males, 33 female, average age: 82.6) treated with PFNA-II were investigated.

Fracture was classified to 2part, 3part(5 subgroups), and 4part with combination of 4 fragments in CT; Head (H), Greater trochanter (G), Lesser trochanter (L), and Shaft (S). 5 subgroups of 3 part fracture were (1) H+G (S: small fragment) + L-S, (2) H + G (B:big fragment) + L-S, (3) H + G-L + S, (4) H + G (W:whole) + S, and (5) H + L + G-S. Numbers of each group were as follows; 2 part: 11, 3 part (1) : 7, 3 part (2) : 12, 3 part (3) : 10, 3 part (4) : 2, 3 part (5) : 3, 4 part : 3. 3 part (3), (4), (5) and 4 part are considered as unstable, however, 6 cases in these groups were classified in A1–1 or A1–2 stable fracture in AO classification. 10 fractures in Evans and 5 fractures in Jensen classification classified as stable were unstable in CT evaluation.

It is sometimes very difficult to classify the femoral trochanteric fracture by plain X-ray. Classification with 3D-CT is very useful to distinguish which fracture is stable or unstable.

Hypothesis

The proximal geometry and design of trochanteric nails affects initial construct stiffness, fatigue survival, and preservation of biomechanical stability over time.

Common cell based strategies for treating bone defects require time-consuming and expensive isolation and expansion of autologous cells. We developed a novel expedited technology creating gene activated muscle grafts. We hypothesized that BMP-2 activated muscle grafts provide healing capabilities comparable to autologous bone grafting, the clinical gold standard.

Two male, syngeneic Fischer 344 rats served as tissue donors. Muscle tissue was harvested from hind limbs and incubated with an adenoviral vector carrying the cDNA encoding BMP-2. Bone tissue was harvested from the iliac crest. Segmental bone defects were created in the right femora of 12 rats and were filled with either BMP-2 activated muscle tissue or bone grafts. After 8 weeks, femora were evaluated by radiographs, microCT, and biomechanical tests.

BMP-2 activated muscle grafts and autologous bone grafts resulted in complete mineralization and healing, as documented by radiographs and microCT. Bone volume in the muscle graft defects (33+/-12mm3) was similar to autologous bone graft defects (39+/-5mm3). Torque at failure of the two groups was statistically indistinguishable (240+/-115 Nmm vs. 232+/-108Nmm).

In previous experiments we demonstrated that the large segmental defect model in this study will not heal with either empty defects or non-activated muscle grafts. Our findings therefore demonstrate that BMP-2 gene activation of muscle tissue effectively stimulates defect healing similar to autologous bone grafts.

Introduction

CXC chemokine receptor 4 (CXCR4) is a specific receptor for stromal-derived-factor 1 (SDF-1). SDF-1/CXCR4 interaction contributes to the regulation of endotherial progenitor cell (EPC) recruitment in ischemic tissues. The purpose of this study is to investigate the mechanistic function of CXCR4 on EPCs for bone fracture healing.

We have done emergency vascularized composite graft by microsurgical technique for severe open fractures. It is essential for open injury to cover bones, joints, tendons etc. Vascularized composite graft for open fracture with tissue defect covers bone etc., prevents infection and promotes subsequent early functional recovery. Eighteen patients aged 3–55year old with an average age of 23.1y.o. were treated with this methos. Traffic injuries of leg and foot in children were the most common and others were open severe fracture with tissue defects. The composite graft employed were peroneal osteocutaneous flap, latissimus dolsi flap, parascapular flap and groin flap. The advantage of these flaps to cover the damaged structure primrily facilitatrs rapid tissue repair without infection and scar formation. In fact, except one reoperation due to a skin necrosis in parascapular flap, all grafted flaps successfully repaired the severe damaged bone and joint. Sufficient perfusion of antibiotics by these vascularized flap prevents infection in all cases. Primary emergency vascularized composite graft for severe open fracture with tissue defect is shown to be extremely useful method with rapid repair and functionnal recovery.

Mechanical loading of bone is anabolic, while aseptic loosening of implants is catabolic. In a rat model of mechanically induced aseptic loosening, osteoclast differentiation is increased dramatically but the underlying mechanism is unknown. The objective was to profile molecular pathways in peri-implant bone resorption. Microarrays on cortical bone samples exposed to pressurized fluid flow were performed 3, 6, 12, 24 and 36 hrs, using time 0 as controls. Of a total of 4093 genes that underwent a 1.25-fold change (p<0.05) due to fluid flow only 21 were common for all time points. Signals linked to inflammation and apoptosis were regulated in a biphasic manner at 3 and 12 and/or 24 hrs. The acute response at 3 hrs was associated with increases in the cytokines IL-6, IL-11, LIF and STAT3. Levels of the pro-apoptotic factor TWEAK were higher while those of BOK, a second pro-survival molecule, were lower. There is an early and late rise in RIPK3, which stimulates a form of programmed necrosis. Osteoblast-related genes were clearly suppressed (osteocalcin, Col1a, PTHr1), while those regulating macrophage and osteoclast differentiation (CSF-1, Bach1, HO-1, RANKL, RANK, OPG) were enhanced. These data suggest that mechanical loading of cortical bone stimulates time-dependent expression of genes regulating the survival, necrosis and differentiation of both the myeloid and mesenchymal cell lineages, resulting in an integrated response leading to a rapid increase in osteoclast numbers.

Introduction

Plate fixations have been recommended for dislocated clavicle fractures. However, existing plates are inadequate for morphological compatibility with the clavicle. The aim of this study is to measure the anatomical shape of the clavicle and to compare the radiographical and clinical outcomes of our tree-dimensional (3D) reconstruction plate with conventional straight plate.

Introduction

Our previous study using microarray analysis showed that Rad (Ras associated with diabetes) was highly expressed in nonunion. The purpose of this study is to investigate the gene expression and immunolocalization of Rad, and other Ras-related G proteins: Rem1 and Rem2 in fracture/nonunion site using rat experimental models.

Introduction

Metatarsocuneiform (MTC) fusion is a standard treatment for arthritis, instability, and deformity of these joint. The MTC fusion achieves a good clinical outcome, but nonunion rates up to 12% have been reported. There are different methods for fixation of first MTC joint arthrodesis. Our aim was to compare the biomechanical characteristic of internal and external fixation constructs.

Introduction

The hematoma occurring at a fracture site is known to play an important role in fracture healing. Previously, we demonstrated that fracture hematoma contained multilineage mesenchymal progenitor cells. On the other hand, the process of fracture healing is associated by two different mechanisms, intramembranous and endochondral. However, there are no reports proving the details about cellular analysis in the process of endochondoral ossification.

Exercise deters systemic diseases such as osteoporosis, sarcopenia, diabetes and obesity. Brief daily periods of low intensity vibration (LIV; <0.4g) is anabolic to bone and muscle, an adaptive response achieved in part by biasing mesenchymal stem cell (MSC) fate selection towards forming higher order connective tissues. In the clinic, LIV has protected the musculoskeletal system even under severe challenges such as Crohn Disease, Cerebral Palsy, and end-stage renal disease.

Low magnitude mechanical signals also suppress adipogenesis in the mouse, with reductions in subcutaneous and visceral fat. The starkly distinct response of these tissues (augment bone & muscle; suppress fat) suggests that LIV influences the differentiation pathway of MSCs. Extending this diet induced obesity model to 7 months increased total adiposity, accelerated age-related loss of trabecular bone and severely reduced B & T-cell number in the marrow and blood, shifting hematopoietic stem cells (HSC) towards the myeloid lineage. LIV introduced at 4 months rescued bone and B-cells to those levels measured in regular diet controls.

These data emphasise why inactivity can promote osteoporosis, diabetes and obesity, and why a sedentary individual is predisposed to disease sequelae. Protection of MSC and HSC populations by mechanical signals may represent a unique strategy by which adiposity can be suppressed, the immune system protected, and a musculoskeletal system enhanced.

Introduction

The proximal femur fracture in children is rare. Furthermore osteoporotic fracture associated with bone tumor make it difficult to decide the proper management method. The treatment plan should include both the treatment of the fracture and management of the condition responsible for the fracture. However, the reported literatures are rare and vary.

Introduction

Basicervical fracture of the femur is one type of hip fracture, which is regarded as an extra and intra-capsular fracture. We experienced an atypical type of this fractures, the fracture line exist between subcapital portion at anterior aspect and base of the neck at posterior aspect, running through the neck with a shearing fracture line shown in the coronal plane. We investigate the characteristic and result of this fractures in our cases.

Objective

To investigate the outcomes of patients following the chipping procedures as an alternative to bone grafting in treatment of femoral non-unions.

The ratio of the incidence of trochanteric to cervical fractures increased with age in the elderly female population, but the reason for this fact remain unclear.

The purposes of this study were to investigate whether or not there are specificities of the local distribution of mechanical properties at the trochanteric region of the elderly female using a scanning acoustic microscope (SAM). Human proximal femurs were harvested from seven female cadavers (67–88 years) and proximal femur was coronally sectioned into halves across the center of neck. The surface of the coronal section was polished in order to achieve flat surfaces of smoothness well below the surface resolution in scanning with SAM. Bone tissue density and elastic modulus were calculated from the acquired SAM data. Mechanical properties were measured at the lateral and medial trochanter. Cortical bone tissue of the lateral trochanter had significantly lower elastic modulus than that of the medial trochanter in the all specimen over 70s(p<0.05). Trabecular bone tissue of proximal region of the lateral trochanter had significantly lower elastic modulus than that of distal region in all 80s specimens (p<0.05). Decrease of the elastic modulus of cortical bone in the lateral trochanter and low value of the elastic modulus of trabecular bone in the proximal region of the lateral trochanter may be related to the increase of the ratio of trochanteric to cervical fractures with age in the elderly female population.

Objective

We reviewed clinical results with minimally invasive method and using a new developed plate for unstable pelvic ring fractures, especially vertically unstable sacral fractures.

Introduction

For the increasing number of frail elderly patients in Japan, mobility is crucial to stay independent and maintain quality of life. After failure reports with standard implants, a prospective multicentre study was performed to evaluate whether an implant designed for Asians enables rapid recovery after unstable trochanteric fractures.

The most important issue in the assessment of fracture healing is to acquire information about the restoration of the mechanical integrity of bone. Echo tracking (ET) can noninvasively measure the displacement of a certain point on the bone surface under a load. Echo tracking has been used to assess the bone deformation angle of the fracture healing site. Although this method can be used to evaluate bending stiffness, previous studies have not validated the accuracy of bending stiffness. The purpose of the present study is to ensure the accuracy of bending stiffness as measured by ET. A four-point bending test of the gap-healing model in rabbit tibiae was performed to measure bending stiffness. Echo tracking probes were used to measure stiffness, and the results were compared with results of stiffness measurements performed using laser displacement gauges. The relationship between the stiffness measured by these two devices was completely linear, indicating that the ET method could precisely measure bone stiffness.

Improving periprosthetic bone is essential for implant fixation and reducing peri-implant fracture risk. This studied examined the individual and combined effects of iPTH and mechanical loading at the cellular, molecular, and tissue level for periprosthetic cancellous bone. Adult rabbits had a porous titanium implant inserted bilaterally on the cancellous bone beneath a mechanical loading device on the distal lateral femur. The right femur was loaded daily, the left femur received a sham loading device, and half of the rabbits received daily PTH. Periprosthetic bone was processed up to 28 days for qPCR, histology, and uCT analysis. We observed an increase in cellular and molecular markers of osteoblast activity and decrease in adipocytic markers for both treatments, with small additional effects in the combined group. Loading and iPTH led to a decrease and increase, respectively, in osteoclast number, acting through changes in RANKL/OPG expression. Changes in SOST and beta-catenin mRNA levels suggested an integral role for the Wnt pathway. We observed strong singular effects on BV/TV of both loading (1.53 fold) and iPTH (1.54 fold). Combined treatment showed a small additive effect on bone volume. In conclusion, loading and iPTH act through a pro-osteoblastic/anti-adipocytic response and through control of bone turnover via changes in the RANKL/OPG pathway. These changes led to a small additional, but not synergistic, increase in bone volume with the combined therapy.

Introduction

Nonunion is a common and costly fracture outcome. Intricate reciprocity between angiogenesis and osteogenesis means vascular cell-based therapy offers a novel approach to stimulating bone regeneration.

Introduction

The concept of “bone graft expanders” has been popularised to increase the volume and biological activity of the implanted Material.

Introduction

Many surgeons assess biological activity of fracture nonunion by the presence or absence of callus using radiograph. However, it is difficult to assess biological activity only by radiographic appearance. Bone scintigraphy reflects blood supply and bone metabolism and is possibly useful to assess biological activity in nonunion cases.

Background

Growing of the geriatric population has brought about increase of lower extremity fractures. The purpose of this study was to investigate the occurrence of surgical site infection after the surgery for lower extremity fractures, except proximal femoral fracture, in over eighty years old patients.

Failure to treat acute compartment syndrome (ACS) early leads to significant morbidity. Current practice depends on using clinical signs and intracompartmental pressure (ICP) monitoring to diagnose the syndrome but there is still debate regarding their accuracy and interpretation.

Patients admitted with injuries at risk of ACS underwent intramuscular (IM) pH and ICP monitoring combined with regular clinical assessment. Fasciotomies were performed on those with clinical and/or pressure based evidence of ACS. All patients were subsequently assessed for evidence of a missed ACS at at 6 & 12 months.

Of the 62 patients, 51 completed the protocol and were included in the analysis. They were divided into 2 groups: those who had ACS, either initially (fasciotomies; 13), or diagnosed at follow up (no fasciotomies; 7), and those with no evidence of ACS (31).

The sensitivity and specificity for the worst values for each variable were calculated and receiver operator characteristic (ROC) curves generated. The area under the curve for pH was 0.92, 0.73 for absolute pressure and 0.59 for delta pressure. To achieve a sensitivity of 95%, an absolute pressure of >30mmHg was 30% specific, a delta pressure of <33mmHg was 27%, while IM pH of 6.38 was 80% specific.

This study highlights the issues concerning current diagnostic methods for ACS. By comparison, IM pH radically out performed both the highest ICP and the lowest delta pressure, identifying patients early and accurately.

Alpine ski sports changed rapidly in the last decade. Complex fractures of the proximal tibia, typically seen in high energy trauma, has been seen more frequently and more often related to alpine skiing.

The aim of our study was to identify reasons for proximal tibia fracture in alpine skiing and observe the outcome.

All patients with proximal tibia fractures related to alpine skiing, which were treated in our two trauma centers were included. The patients received a questionnaire at the emergency department, dealing with accident details and the skiing habits. The fractures were classified according to the AO fracture classification scheme. The follow up was performed at least one year after trauma with the Lysholm, the Tegner activity, as well as the WOMAC VAS Score.

Between 2007 and 2010 a total of 188 patients with proximal tibia fractures caused by alpine skiing were treated. 43 patients had a type A, 96 patients a type B and 49 a type C injury. The incidence was increasing over the period continuously. The main trauma mechanism was an accident without a third party involvement with an increased rotational and axial compression impact. All outcome scores were related to fracture severity with significant worse results for the type C fractures.

In conclusion, proximal tibia fractures are an increasing and serious injury during alpine skiing. Further technical progress in skiing material should focus on these knee injuries in future.

Intro

Distal radial fractures are a commonly encountered fracture & anatomical reduction is the standard. Dorsal angulation is the traditional method of assessment but is inaccurate in rotated lateral xrays. Previously a relationship has been demonstrated between the dorsal cortex (DC) of the radius & the superior pole of the lunate (SL) & its sensitivity for assessing dorsal angulation & translation.

The most important issue in the assessment of fracture healing is to acquire information about the restoration of the mechanical integrity of bone. Many researchers have attempted to monitor stiffness either directly or indirectly for the purpose of assessing strength, as strength has been impossible to assess directly in clinical practice. The purpose of this study was thus to determine the relationship between bending stiffness and strength using mechanical testing at different times during the healing process. Unilateral, transverse, mid-tibial osteotomies with a 2-mm gap were performed in 28 rabbits. The osteotomy site was stabilized using a double-bar external fixator. The animals were divided into four groups (n=7/group/time point; 4, 6, 8 and 12 weeks). A series of images from micro-computed tomography of the gap was evaluated to detect the stage of fracture healing and a 4-point bending test was performed to measure stiffness and strength. Formation of cortex and medullary canal at the gap was seen in the 12-week group and would represent the remodeling stage. In addition, the relationship between stiffness and strength remained almost linear until at least 12 weeks. However, stiffness recovered much more rapidly than strength. Strength was not fully restored until the later stages of fracture healing. However, the current study demonstrated that stiffness could be monitored as a surrogate marker of strength until at least the remodeling stage.

Since osteoimmunology is gaining increasingly interest and evidence for involvement of complement in bone biology was found, the role of complement in bone biology and fracture healing was evaluated.

After characterizing the bone phenotype, a fracture healing experiment with C3- and C5- deficient mice was performed. After osteotomy of the right femur and external fixation, healing was analyzed after 1, 3, 7 and 21 days. Bone characterization revealed a reduced number of osteoclasts in C5-deficient animals with a significantly reduced resorption activity. While bone mineral density was significantly higher in complement-deficient strains, stiffness was significantly reduced. After 21 days of fracture healing, C5-deficient animals showed reduced stiffness and a smaller callus volume compared to controls. Interestingly, C3- more than C5-deficient animals showed reduced bone formation. Altogether, bone phenotype of complement-deficient animals resembles a mild form of osteopetrosis.

This might be due to the resorption defect seen in C5-deficient mice. A reason for the minor involvement of C3-deficient mice compared to the C5-deficient animals could be the cross-talk between the coagulation cascade with side activation of complement factor C5 by thrombin.

These results indicate for the first time an essential role of complement in bone biology and fracture healing. Future studies should focus on the molecular basis of complement involvement and the osteoclastic resorption defect.

Background

Although gradual bone transport may provide a large-diameter bone, complications are common with the long duration of external fixation. To reduce such complications, a new technique of bone transport with a locking plate has been done for tibial bone defect.

Infected non-union after severe open fracture or unsuitable fracture operation is frequently associated with bone defect and its treatment has been controversial. We have used microsurgical vascularised composite graft for these problematic cases. Fifty one patients aged 17∼70 year old (43.6 years old in average), including 41 men and 10 women. Follow-up has been more than 6 months. The vascularised composite graft included a free fibular osteocutaneous flap in 41 cases, a vascular pedicled fibular osteocutaneous flap in 2 cases, a free iliac osteocutaneous flap in 5 cases, a vascularised cutaneous flap in 2 cases and other in one case. All infected non-unions were united without trouble and co-existing infection was successfully eradicated. This method also enables the patients rapid bone union and subsequent early functional recovery. This success was attributed to greater transport of oxygen and good antibiotic perfusion in presence of good blood supply. We conclude that microsurgical vascularised composite graft for infected non-union is an extremely useful method with early bone union and subsidence of infection.

Introduction

Short-segment posterior instrumentation for spine fractures is threatened by unacceptable failure rates. Two important design objectives of pedicle screws, bending and pullout strength, may conflict with each other.

Backgrounds

Hip fractures have significant excess mortality, but it is unknown how long excess mortality persists. Our study was to explore the short and long term excess mortality after hip fractures, assess the impact of hip fracture on excess mortality and estimate the population attributable risk proportion (PARP) of risk factors for excess mortality.

Introduction

iPSCs represent a promising cell source for bone regeneration. To generate osteoprogenitor cells, most protocols use the generation of embryoid bodies (EBs). However, these protocols give rise to heterogeneous population of different cell lineage.

Introduction

Parathyroid hormone 1–34 (PTH) has been reported to accelerate fracture healing. Previously, we demonstrated human fracture hematoma contained osteo-/chondro-progenitor cells. To date, there has been no study investigating the effect of PTH on fracture hematoma-derived cells (HCs) in vitro.

Introduction

The therapeutic potential of hematopoietic stem cells for fracture healing has been demonstrated with mechanistic insight of vasculogenesis and osteogenesis enhancement. Lnk has recently been proved an essential inhibitory signaling molecule in SCF-c-Kit signaling pathway for stem cell self-renewal demonstrating enhanced hematopoietic and osteogenic reconstitution in Lnk-deficient mice. We investigated the hypothesis that down regulation of Lnk enhances regenerative response via vasculogenesis and osteogenesis in fracture healing.

Objective

The development of surgical site infection in the early weeks following open reduction and internal fixation (ORIF) is a challenging problem. There are no evidence-based guidelines to direct the number of surgical debridements prior to definitive wound closure. The purpose of this study was to assess the success of infection resolution, and to identify risk factors for failure, in post-operative infections treated with a single debridement and primary wound closure.

Aims

Dual SC Screw (DSCS) is a novel fixation device for the femoral neck fracture. DSCS is comprised of screw and barrel allowing sliding of the screw and preventing protrusion of the screw end. Two types of the barrels are available, threaded barrel (TB) and plate barrel (PB). Ordinarily, both barrels are implanted. Concept of the design is that the PB contributes stability to the screw against the varus force of the femoral head while the additional screw with TB prevents rotational deformity. The aim of this study was to represent clinical results after DSCS operation in patients with femoral neck fracture.

Background

The usefulness of arthroscopic reduction for the intra-articular fracture of the distal radius has been reported, although it is technically difficult.

Neurogenic heterotopic ossification (NHO) is a disorder of aberrant bone formation affecting one in five patients sustaining a spinal cord injury or traumatic brain injury. Ectopic bone forms around joints in characteristic patterns, causing pain and limiting movement especially around the hip and elbow. Clinical sequelae of neurogenic heterotopic ossification include urinary tract infection, pressure injuries, pneumonia and poor hygiene, making early diagnosis and treatment clinically compelling. However, diagnosis remains difficult with more investigation needed. Our pathophysiological understanding stems from mechanisms of basic bone formation enhanced by evidence of systemic influences from circulating humor factors and perhaps neurological ones. This increasing understanding guides our implementation of current prophylaxis and treatment including the use of non-steroidal anti-inflammatory drugs, bisphosphonates, radiation therapy and surgery and, importantly, should direct future, more effective ones.

Methicillin Resistant Staphylococcus Aureus (MRSA) screening has reduced rates of MRSA infection in primary total hip (THR) and total knee (TKR) replacements. There are reports of increasing methicillin resistance (MR) in Coagulase Negative Staphylococci (CNS) causing arthroplasty infections. We examined microbiological results of all 2-stage THR/TKR revisions in Tayside from 2001–2010.

72 revisions in 67 patients were included; 30 THRs and 42 TKRs. Mean ages at revision were 89 and 72 years respectively. Male: female ratio 1.4:1.2-year survivorship for all endpoints: 96% in THRs and 88% in TKRs. 5-year survival: 83% and 84% respectively.

The most common organisms were SA (30%) and CNS (29%). Antibiotic resistance was more common amongst CNS. 72% of CNS were resistant to Methicillin versus 20% of SA. 80% of CNS were resistant to Gentamicin OR Methicillin versus 20% of SA. 32% (8/72 cases or 11% overall) of CNS were resistant to BOTH Gentamicin AND Methicillin, the primary arthroplasty antibiotic prophylaxis in our region, versus 4% of SA.

Harris Hip Scores and Knee Society Scores were lower post primary, prior to symptoms of infection in patients who had MR organisms cultured compared with those who had methicillin sensitive organisms. One-year post revision both groups recovered to similar scores.

Our data suggest MR-CNS cause significantly more arthroplasty infections than MRSA. Patients developing MR infections tend to have poorer post-primary knee and hip scores before symptoms of infection fully develop. 32% of CNS causing arthroplasty infections in our region are resistant to current routine primary antibiotic prophylaxis.

There is substantial concern about the state of musculoskeletal knowledge of junior doctors. There are also marked differences in the locomotor curricula of medical schools, raising the possibility that students may be selectively disadvantaged from gaining appropriate knowledge and/or attaining a musculoskeletal career path. The aims of this study were to assess the musculoskeletal knowledge of newly qualified doctors in the south of Scotland, and to compare this between the two medical schools (Glasgow and Edinburgh) that have different locomotor teaching programmes.

All final year medical students, from Glasgow and Edinburgh Universities (n=158 and 221, respectively), attending the compulsory ‘Preparation for Practice’ lecture course immediately after (Glasgow) or before (Edinburgh) final exams, were assessed by the Freedman and Bernstein musculoskeletal examination, previously validated with two different pass-standards: (i) 73.1% (by orthopaedic surgeons), and (ii) 70% (by physicians).

There was a significant difference (Wilcoxon two sample test; p<0.5×10⁻⁹) in the marks obtained at the two institutions, the median being 59% (IQR 50–67%) and 68% (IQR 60–76%) at Glasgow and Edinburgh respectively. The pass-rates for the two institutions (Glasgow vs. Edinburgh) were markedly different, being 17.1% vs. 32.6% for the higher pass-mark, and 21.5% vs. 48% for the lower.

The majority of newly qualified doctors in the south of Scotland have inadequate musculoskeletal knowledge. There is a substantial and statistically significant difference in the scores attained by students from two neighbouring medical schools (Glasgow and Edinburgh). The striking difference in the pass-rates can be best explained by differences in respective musculoskeletal courses. These explicit and comparative deficits raise substantial questions for musculoskeletal curriculum planning, teaching, assessment and quality assurance.

A review of current literature describes varying 10-year survival rates for the Oxford Unicompartmental Knee Replacement (Biomet Orthopedics Inc, Warsaw, Ind). Application of rigorous indications and meticulous surgical technique are two factors considered to reduce revision rates.

A retrospective case-note review was conducted for 96 patients (128 knees) aged 42–89 (mean 57) who had an Oxford unicompartmental knee replacement for medial compartment osteoarthritis between January 2000 and January 2011. All procedures were performed, or directly supervised, by one 5 surgeons. The aim of the study was to ascertain the rate of revision to bicompartmental knee replacement and any associated contributory factors.

Of the 128 unicompartmental knees, 10.9% were revised to either mobile- or fixed-bearing total knee replacements due to septic (0.5%) and aseptic (1.5%) loosening, patello-femoral pain (3.9%), periprosthetic fracture (0.8%) and bearing dislocation (3.1%). Of those knees requiring revision, mean patient age was 73 years, 50% had wound complications and 42% were performed by senior trainees. All patients had intact ACL and medial osteoarthritis. Mean time to revision was 2.7 years.

In conclusion, revision of the unicompartmental knee was related to patient age > 65 years and early post-operative complications; grade of operating surgeon had little apparent effect.

We report the largest series of periprosthetic fractures in the literature, describing the changing epidemiology and predictors of outcome.

A retrospective search of prospectively compiled trauma and elective electronic databases identified 630 periprosthetic fractures presenting to the study centre between 1995 and 2010. Patient demographics, comorbidities, socioeconomic status, mechanism of injury, fracture type, classification, method of fixation, and outcome were recorded using the patients’ notes. The General Register Office for Scotland was used to obtain the mortality status of the patients.

There were 276 total hip replacements (THR), 123 total knee replacements (TKR), 117 hemiarthroplasty, and 114 “other” implants. The incidence of periprosthetic fractures increased significantly during the study period for all implants: THR (p<0.001), TKR (p<0.001), hemiarthroplasty (p=0.002), and other (p=0.003). The majority of fractures were fixed by open reduction and internal fixation (72%). This failed in 14% of THR, 15% of TKR, 21% of hemiarthroplasties, and 18% of “other” implants. Isolated independent predictors of failure of fixation, after multivariate regression analysis, were increasing age, deprivation, a past medical history of asthma or chronic obstructive airways disease, osteoporosis, and steroid use (p<0.05). Failure of fixation was associated with a significantly increased one year mortality rate (OR 12.5, p=0.003).

Periprosthetic fractures involving THR and TKR are becoming more prevalent. Patient demographics can be used to calculate the risk of failure of fixation, and those with an increased risk may benefit from revision of their implant, and avert the associate morbidity of failure of fixation.

The collective orthopaedic literature appears to highlight the Jones fracture of the fifth metatarsal, as being slow to heal, and having a high incidence of non-union. There remains a lot of confusion, throughout the orthopaedic literature, about the exact nature of this fracture.

The authors present the largest case series currently published of 117 patients who sustained a Jones fracture, demonstrating patient outcomes with different modalities of care.

Introduction

Massive rotator cuff tears in the patient who is too young for a reverse shoulder replacement are a challenging situation. A technique using a ‘Grammont osteotomy’ of the acromion has been developed to allow a comprehensive approach, the so called “Full Monty”.

The Global Conservative Anatomic Prosthesis (Global CAP) is an uncemented press fit humeral resurfacing implant developed by DePuy. We report a single surgeon series of Global CAP prostheses implanted in Norwich.

103 procedures were carried out between 2006 and 2011, in 93 patients. Mean age was 72 years (range 43 to 90). Patients were followed up for a mean 8 months (range 0 to 56). Pre-operative Oxford shoulder scores were recorded in a preadmission clinic and an Oxford score questionnaire was sent to patients post-operatively in December 2011. The mean score preoperatively was 19, rising to 28 postoperatively.

Two patients developed rotator cuff tears and have been revised to reverse polarity arthroplasty. One is pending revision for a cuff tear.

This prosthesis shows promise at this early stage for compensated glenohumeral arthritis when a bone preserving procedure is desirable.

Lateral malleolar plating is associated with complication rates of up to 30%. The fibular nail is an alternative fixation technique, requiring a minimal incision and tissue dissection, with the potential to reduce the incidence of complications. We reviewed our results of 105 unstable ankle fractures fixed with the Acumed fibular nail between 2002 and 2010. The mean age was 65 years and 72% of patients had significant systemic medical comorbidities.

A number of different locking screw configurations were assessed over the study period. A proximal blocking screw resulted in satisfactory stability in 93%, single locking screws in 86%, but nailing without locking in only 66%, leading to the development of our current technique. Of the twenty-one patients treated with this technique there have been no significant complications, and only two superficial wound infections. Good fracture reduction was achieved in all of these patients. The mean physical component SF12, Olerud and Molander and Foot and Ankle Outcome scores were 46, 65 and 83 respectively.

The outcomes of unstable ankle fractures managed with the fibular nail are encouraging, with good radiographic and functional outcomes and minimal complications. This technique should be considered in the management of debilitated patients with unstable ankle fractures.

Frail patients with neck of femur fracture often present to Accident & Emergency (A&E) with concomitant medical problems and are frequently fast-tracked to orthopaedic wards to achieve government waiting time targets.

This is a second cycle of audit since 2008 examining the safety of fast-tracking following several critical incidents. Data was collected prospectively between March and June 2011 by the first on-call orthopaedic doctor.

56 patients (12 male), average age 81.2y (50–97) were fast-tracked. 52 were correctly referred as having intra/extracapsular fracture; 4 patients did not have neck of femur fracture, but did have other medical problems. On arrival to the ward, 8 patients demonstrated abnormal symptoms, signs and vital observations requiring immediate review from the receiving physicians. For the 56 patients, a total of 448 mandatory points of protocol (e.g. intravenous access) should have been addressed prior to transfer; 150 were omitted (33.5%). Vital observations of patients fast-tracked after 2100h were worse (MEWS range 0 to 11) when compared with those fast-tracked prior to 2100h (MEWS range 0 to 3).

Fast-tracking is a common practice amongst many district-general and some teaching hospitals in Scotland. These data support concerns from orthopaedic surgeons and highlight the need for more complete management by A&E and, if necessary, referral to receiving medical staff prior to ward transfer. Early medical optimisation of acute and chronic comorbidities common to these patients is the main facilitator of early surgery. The evidence base demonstrates early surgery is a major variable in reducing post-operative mortality.

The aim was to perform a cost-utility analysis of total joint replacement in the current environment.

Arthritis is a disabling condition that leads to long-term deterioration in quality of life. Total joint replacement, despite being one of the greatest advances in medicine in the modern era, has come under recent scrutiny. The National Health Service (NHS) has competing demands and resource allocation is challenging in times of economic restraint.

Patients undergoing total hip (n=348) and knee arthroplasty (n=323), from January to July 2010, were entered into a prospective arthroplasty database. A health utility score was derived from the Euroqol (EQ-5D) score preoperatively, and at one year, and was combined with individual life expectancy to derive the Quality-Adujusted-Life-Years (QALYs) gained. Predicted need for revision surgery was Incorporated in the model. The 2011–12 Scottish Tariff was used. Two-way analysis of variance was used to compare QALYs gained between procedures, while controlling for baseline differences.

The number of QALYs gained was higher in THR versus TKR (6.53 vs 4.04 years, p<0.001). The cost per QALY for THR was £1371 (95% CI £1194 to £1614) compared with £2101 (£1762 to £2620) for TKR. Predictors of an increase in QALYs gained were poorer health prior to surgery (p<0.001) and younger age (p<0.001). General health (EQ-5D VAS) showed greater improvement in THR versus TKR (p<0.001).

This study provides up to date cost-effectiveness data for total joint replacement. THR and TKR are both extremely clinically and cost-effective interventions, with costs that compare favourably with other medical interventions (e.g. laparoscopic hernia repair vs open: £55,548 per QALY; CHD primary prevention with statins: £21,000).

Infection rates following arthroplasty surgery are between 1–4%, with higher rates in revision surgery. The associated costs of treating infected arthroplasty cases are considerable, with significantly worse functional outcomes reported. New methods of infection prevention are required. HINS-light is a novel blue light inactivation technology which kills bacteria through a photodynamic process. The aim of this study was to investigate the efficacy of HINS-light for the inactivation of bacteria isolated from infected arthoplasty cases.

Specimens from hip and knee arthroplasty infections are routinely collected to identify causative organisms. This study tested a range of these isolates for sensitivity to HINS-light. During testing, bacterial suspensions were exposed to increasing doses of HINS-light of (123mW/cm2 irradiance). Non-light exposed control samples were also set-up. Bacterial samples were then plated onto agar plates and incubated at 37°C for 24 hours before enumeration.

Complete inactivation was achieved for all Gram positive and negative microorganisms More than a 4-log reduction in Staphylococcus epidermidis and Staphylococcus aureus populations were achieved after exposure to HINS-light for doses of 48 and 55 J/cm2, respectively. Current investigations using Escherichia coli and Klebsiella pneumoniae show that gram-negative organisms are also susceptible, though higher doses are required.

This study has demonstrated that HINS-light successfully inactivated all clinical isolates from infected arthroplasty cases. As HINS-light utilises visible-light wavelengths it can be safely used in the presence of patients and staff. This unique feature could lead to possible applications such as use as an infection prevention tool during surgery and post-operative dressing changes.

A 7-day randomised controlled pre-clinical trial utilising an existing extremity war wound model compared the efficacy of saline soaked gauze to commercially available dressings. The Flexor Carpi Ulnaris of anaesthetised rabbits was exposed to high-energy trauma using a computer-controlled jig and inoculated with 10⁶Staphylococcus aureus 3 hours prior to application of dressing. Quantitative microbiological assessment demonstrated reduced bacterial counts in INADINE (Iodine) and ACTICOAT (Nanocrystalline Silver) groups and an increase in ACTIVON TULLE (Manuka Honey) group (2-way ANOVA p<0.05).

Clinical observations were made throughout the study. Haematology and plasma cytokines were analysed at intervals. Post-mortem histopathology included subjective semi-quantitative assessment of pathology severity using light microscopy to grade muscle injury and lymph node activation. Tissue samples were also examined using scanning electron microscopy (SEM).

There were no bacteraemias, abscesses, purulent discharge or evidence of contralateral axillary lymph node activation. There were no significant differences in animal behaviour, weight change, maximum body temperature or white blood cell count elevation nor in pathology severity in muscle or lymph nodes (Kruskal-Wallis). There was no evidence of bacterial penetration or biofilm formation on SEM. Interleukin-4 and Tumour Necrosis Factor α levels were significantly higher in the ACTIVON TULLE group (1-way ANOVA p<0.05).

This time-limited study demonstrated a statistically significant reduction in Staphylococcus aureus counts in wounds dressed with INADINE and ACTICOAT and an increase in wounds dressed with ACTIVON TULLE. There was no evidence that any of these dressings cause harm but nor have we established any definite clinical advantage associated with the use of the dressings tested in this study.

Traumatic injuries to the sternoclavicular joint (SCJ) are uncommon representing only 3% of all injuries to the shoulder girdle. Acutely, the majority are managed non-operatively with physiotherapy rehabilitation. However, if there is evidence of neurovascular compromise emergency reduction is indicated. There is no consensus on treatment of SCJ dislocations and subluxations that remain symptomatic after conservative treatment. Multiple surgical techniques have been described to alleviate this problem. These include resection of the medial end of the clavicle and various stabilization techniques using Kirschner wires, muscle tendon (subclavius, sternocleidomastoid, semi-tendinosus and palmaris longus) and synthetic materials (Dacron). However, all techniques have reported problems in terms of pain, decreased range of movement and a relatively high complication rate.

We report a new technique using a LARS® ligament (Ligament Augmentation and Reconstruction System) with good early post-operative results. 5 symptomatic SCJ dislocations were repaired over a 3 year period. The operations were conducted by the same surgeon and at the same unit. The patients were on average 20 years old (17–22). Mean follow up time was 21 months (9–41). Functional assessment was made using the DASH (Disabilities of the Arm, Shoulder and Hand) and the OSS (Oxford Shoulder Score) outcome measures. An improvement between pre- and post-operative scoring was observed in both DASH median 51.7 (24.2–75.0) v 13.7 (8.3–20.8) (p=0.024) and OSS 20.6 (15–32) v 41.8 (39–47) (p<0.001). One patient had a pneumothorax intra-operatively but this resolved with conservative treatment. There were no long term complications experienced during follow up.

Current military conflicts are characterised by the use of the Improvised Explosive Device (IED). Improvements in personal protection, medical care and evacuation logistics have resulted in increasing numbers of casualties surviving with complex musculoskeletal injuries, often leading to life-long disability. Thus, there exists an urgent requirement to investigate the mechanism of extremity injury caused by these devices in order to develop mitigation strategies. In addition, the wounds of war are no longer restricted to the battlefield; similar injuries can be witnessed in civilian centres following a terrorist attack.

Key to mitigating such injuries is the ability to deconstruct the complexities of an explosive event into a controlled, laboratory-based environment. In this study, an anti-vehicle underbelly injury simulator, capable of recreating in the laboratory the impulse from an anti-vehicle (AV) explosion, is presented and characterised. Tests were then conducted to assess the simulator's ability to interact with human cadaveric legs. Two mounting conditions were assessed, simulating a typical seated and standing vehicle passenger using instrumented cadaveric lower limbs.

This experimental device, will now allow us (a) to gain comprehensive understanding of the load-transfer mechanisms through the lower limb, (b) to characterise the dissipating capacity of mitigation technologies, and (c) to assess the biofidelity of surrogates.

The defining weapon of the conflicts in Iraq and Afghanistan has been the Improvised Explosive Device (IEDs). When detonated under a vehicle, they result in significant axial loading to the lower limbs, resulting in devastating injuries. Due to the absence of clinical blast data, automotive injury data using the Abbreviated Injury Score (AIS) has been extrapolated to define current NATO injury thresholds for Anti-vehicle (AV) mine tests. We hypothesized that AIS, being a marker of fatality rather than disability would be a worse predictor of poor clinical outcome compared to the lower limb specific Foot and Ankle Severity Score (FASS).

Using a prospectively collected trauma database, we identified UK Service Personnel sustaining lower leg injuries from under-vehicle explosions from Jan 2006–Dec 2008. A full review of all medical documentation was performed to determine patient demographics and the severity of lower leg injury, as assessed by AIS and FASS. Clinical endpoints were defined as (i) need for amputation or (ii) poor clinical outcome. Statistical models were developed in order to explore the relationship between the scoring systems and clinical endpoints.

63 UK casualties (89 limbs) were identified with a lower limb injury following under-vehicle explosion. The mean age of the casualty was 26.0 yrs. At 33.6 months follow-up, 29.1% (26/89) required an amputation and a further 74.6% (41/89) having a poor clinical outcome (amputation or ongoing clinical problems). Only 9(14%) casualties were deemed medically fit to return to full military duty. ROC analysis revealed that both AIS=2 and FASS=4 could predict the risk of amputation, with FASS = 4 demonstrating greater specificity (43% vs 20%) and greater positive predictive value (72% vs 32%). In predicting poor clinical outcome, FASS was significantly superior to AIS (p<0.01). Probit analysis revealed that a relationship could not be developed between AIS and the probability of a poor clinical outcome (p=0.25).

Foot and ankle injuries following AV mine blast are associated with significant morbidity. Our study clearly demonstrates that AIS is not a predictor of long-term clinical outcome and that FASS would be a better quantitative measure of lower limb injury severity. There is a requirement to reassess the current injury criteria used to evaluate the potential of mitigation technologies to help reduce long-term disability in military personnel. Our study highlights the critical importance of utilising contemporary battlefield injury data in order to ensure that the evaluation of mitigation measures is appropriate to the injury profile and their long-term effects.

Most fractures of the radial head are stable undisplaced or minimally displaced partial fractures without an associated fracture of the elbow or forearm or ligament injury, where stiffness following non-operative management is the primary concern. Displaced unstable fractures of the radial head are usually associated with other fractures or ligament injuries, and restoration of radiocapitellar contact by reconstruction or prosthetic replacement of the fractured head is necessary to prevent subluxation or dislocation of the elbow and forearm. In fractures with three or fewer fragments (two articular fragments and the neck) and little or no metaphyseal comminution, open reduction and internal fixation may give good results. However, fragmented unstable fractures of the radial head are prone to early failure of fixation and nonunion when fixed. Excision of the radial head is associated with good long-term results, but in patients with instability of the elbow or forearm, prosthetic replacement is preferred.

This review considers the characteristics of stable and unstable fractures of the radial head, as well as discussing the debatable aspects of management, in light of the current best evidence.

Cite this article: Bone Joint J 2013;95-B:151–9.

Staphylococcus aureus is a highly virulent pathogen and is implicated in approximately 50% of cases of septic arthritis. Studies investigating other S. aureus-related infections have suggested that alpha (Hla), beta (Hlb) and gamma (Hlg) toxins are key virulence factors. In particular, the ‘pore-forming’ alpha toxin is believed to be most potent. In this study, we have assessed the influence of alpha toxin on in situ chondrocyte viability.

Osteochondral explants were harvested from the metacarpophalangeal joints of 3-year-old cows and placed into flasks containing Dulbecco's Modified Eagle's Medium. The flasks were then inoculated with the following isogenic ‘knockout’ strains of S. aureus: DU5946 (Hla+Hlb-Hlg-) or DU1090 (Hla-Hlb+Hlg+).

The explants were incubated (37°C) and stained after 18, 24 and 40hrs with chloromethylfluorescein di-acetate and propidium iodide, labelling living chondrocytes green and dead cells red, respectively. Axial sections were imaged by confocal microscopy and the percentage cell death obtained using Volocity 4 software.

The alpha toxin-producing S. aureus caused rapid cell death, with 24.8+/−3.7% at 18hrs and 44.6+/−7.2% at 24hrs. At 40hrs, there was significantly more chondrocyte death (87.4+/−3.6%; p<0.001) compared to the alpha toxin knockout strain (4.1+/−1.7%; means +/− SEM; n=4).

In situ chondrocyte viability was significantly compromised by alpha toxin, with beta and gamma toxins having minimal effect. Further work will clarify the exact mechanism through which this important toxin induces chondrocyte death. Thereafter, it is hoped that targeted treatments can be developed to reduce the extent of cartilage destruction during, and after, an episode of septic arthritis.