We aimed to use data from a randomized controlled trial (RCT) comparing the sliding hip screw vs. intramedullary nailing (IMN) for trochanteric fractures to examine complication rates between those managed with a short vs. long IMN.

This is a secondary analysis using one arm of an RCT of patients ≥18 years with trochanteric fractures. We examined differences in fracture-related (femoral shaft fracture, implant failure, surgical site infection (SSI), nonunion, limb shortening, and pain) and medical (organ failure, respiratory distress, stroke, deep vein thrombosis [DVT] gastrointestinal upset, pneumonia, myocardial infarction, sepsis, or urinary tract infection) adverse events (AE), and readmission between short vs. long IMNs.

We included 412 trochanteric fracture patients, 339 (82.2%) of whom received a short (170mm–200mm) nail, while 73 (17.7%) received a long (260mm–460 mm) nail. Patients in the long group were more likely to be admitted from home (vs. an institution), and have comorbidities, or more complex fracture types.

Patients in the long group had higher rates of fracture-related AE (12.3%) vs. the short group (3.5%). Specifically, SSI (5.5% vs. 0.3%) and pain (2.7% vs. 0.0%) were significantly higher in the long group. Patients in the long group were also more likely to develop DVT (2.7% vs. 0.3%), and be readmitted to the hospital (28.8% vs. 20.7%).

Following covariable adjustment, long nails remained associated with a higher odds of fracture-related AE (5.11, 1.96–13.33) compared to short nails. We found no association between the adjusted odds of readmission and nail length (1.00, 0.52–1.94).

Our analyses revealed that trochanteric fracture patients managed with long IMN nails may have a higher odds of fracture-related AE compared to short nails. Future research is required to validate these findings with larger event rates, and further optimize IMN for trochanteric fracture patients.

Aims

To develop prediction models using machine-learning (ML) algorithms for 90-day and one-year mortality prediction in femoral neck fracture (FNF) patients aged 50 years or older based on the Hip fracture Evaluation with Alternatives of Total Hip arthroplasty versus Hemiarthroplasty (HEALTH) and Fixation using Alternative Implants for the Treatment of Hip fractures (FAITH) trials.

To describe the longitudinal trends in patients with obesity and Metabolic Syndrome (MetS) undergoing TKA and the associated impact on complications and lengths of hospital stay.

We identified patients who underwent primary TKA between 2006 – 2017 within the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database. We recorded patient demographics, length of stay (LOS), and 30-day major and minor complications. We labelled those with an obese Body Mass Index (BMI ≥ 30), hypertension, and diabetes as having MetS. We evaluated mean BMI, LOS, and 30-day complication rates in all patients, obese patients, and those with MetS from 2006-2017. We used multivariable regression to evaluate the trends in BMI, complications, and LOS over time in all patients and those with MetS, and the effect of BMI and MetS on complication rates and LOS, stratified by year.

270,846 patients underwent primary TKA at hospitals participating in the NSQIP database. 63.71% of patients were obese (n = 172,333), 15.21% were morbidly obese (n = 41,130), and 12.37% met criteria for MetS (n = 33,470). Mean BMI in TKA patients increased at a rate of 0.03 per year (0.02-0.05; p < 0 .0001). Despite this, the rate of adverse events in obese patients decreased: major complications by an odds ratio (OR) of 0.94 (0.93-0.96; p < 0 .0001) and minor complications by 0.94 (0.93-0.95; p < 0 .001). LOS also decreased over time at an average rate of −0.058 days per year (-0.059 to −0.057; p < 0 .0001). The proportion of patients with MetS did not increase, however similar improvements in major complications (OR 0.94 [0.91-0.97] p < 0 .0001), minor complications (OR 0.97 [0.94-1.00]; p < 0 .0330), and LOS (mean −0.055 [-0.056 to −0.054] p < 0 .0001) were found. In morbidly obese patients (BMI ≥ 40), there was a decreased proportion per year (OR 0.989 [0.98-0.994] p < 0 .0001). Factors specifically associated with major complications in obese patients included COPD (OR 1.75 [1.55-2.00] p < 0.0001) and diabetes (OR 1.10 [1.02-1.1] p = 0.017). Hypertension (OR 1.12 [1.03-1.21] p = 0.0079) was associated with minor complications. Similarly, in patients with MetS, major complications were associated with COPD (OR 1.72 [1.35-2.18] p < 0.0001). Neuraxial anesthesia was associated with a lower risk for major complications in the obese cohort (OR 0.87 [0.81-0.92] p < 0.0001). BMI ≥ 40 was associated with a greater risk for minor complications (OR 1.37 [1.26-1.50] p < 0.0001), major complications (1.11 [1.02-1.21] p = 0.015), and increased LOS (+0.08 days [0.07-0.09] p < 0.0001).

Mean BMI in patients undergoing primary TKA increased from 2006 - 2017. MetS comorbidities such as diabetes and hypertension elevated the risk for complications in obese patients. COPD contributed to higher rates of major complications. The obesity-specific risk reduction with spinal anesthesia suggests an improved post-anesthetic clinical course in obese patients with pre-existing pulmonary pathology. Encouragingly, the overall rates of complications and LOS in patients with obesity and MetS exhibited a longitudinal decline. This finding may be related to the decreased proportion of patients with BMI ≥ 40 treated over the same period, possibly the result of quality improvement initiatives aimed at delaying high-risk surgery in morbidly obese patients until healthy weight loss is achieved. These findings may also reflect increased awareness and improved management of these patients and their elevated risk profiles.

There has been a substantial increase in the surgical treatment of unstable chest wall injuries recently. While a variety of fixation methods exist, most surgeons have used plate and screw fixation. Rib-specific locking plate systems are available, however evidence supporting their use over less-expensive, conventional plate systems (such as pelvic reconstruction plates) is lacking. We sought to address this by comparing outcomes between locking plates and non-locking plates in a cohort of patients from a prior randomized trial who received surgical stabilization of their unstable chest wall injury.

We used data from the surgical group of a previous multi-centred, prospective, randomized controlled trial comparing surgical fixation of acute, unstable chest wall injuries to non-operative management. In this substudy, our primary outcome was hardware-related complications and re-operation. Secondary outcomes included ventilator free days (VFDs) in the first 28 days following injury, length of ICU and hospital stay, and general health outcomes (SF-36 Physical Component Summary (PCS) and Mental Component Summary (MCS) scores). Categorical variables are reported as frequency counts and percentages and the two groups were compared using Fisher's Exact test. Continuous data are reported as median and interquartile range and the two groups were compared using the Wilcoxon rank-sum test.

From the original cohort of 207 patients, 108 had been treated surgically and had data available on the type of plate construct used. Fifty-nine patients (55%) had received fixation with non-locking plates (primarily 3.5 or 2.7 mm pelvic reconstruction plates) and 49 (45%) had received fixation with locking plates (primarily rib-specific locking plates). The two groups were similar in regard to baseline and injury characteristics. In the non-locking group, 15% of patients (9/59) had evidence of hardware loosening versus 4% (2/49 patients) in the locking group (p = 0.1). The rate of re-operation for hardware complications was 3% in the non-locking group versus 0% in the locking group (p = 0.5). No patients in either group required revision fixation for loss of reduction or nonunion. There were no differences between the groups with regard to VFDs (26.3 [19.6 – 28] vs. 27.3 [18.3 – 28], p = 0.83), length of ICU stay (6.5 [2.0 – 13.1] vs 4.1 [0 – 11], p = 0.12), length of hospital stay (17 [10 – 32] vs. 17 [10 – 24], p = 0.94) or SF-36 PCS (40.9 [33.6 – 51.0] vs 43.4 [34.1 – 49.6], p = 0.93) or MCS scores (47.8 [36.9 – 57.9] vs 46.9 [40.5 – 57.4], p = 0.95).

We found no statistically significant differences in outcomes between patients who received surgical stabilization of their unstable chest wall injury when comparing non-locking plates versus locking plates. However, the rate of hardware loosening was nearly 4 times higher in the non-locking plate group and trended towards statistical significance, although re-operation related to this was less frequent. This finding is not surprising, given the inherent challenges of rib fixation including thin bones, comminution, potential osteopenia and a post-operative environment of constant motion. We believe that the increased cost of locking plate fixation in this setting is likely justifiable given these findings.

This study aimed to determine if multiple failed closed reductions (CRs) prior to fixation of distal radius fracture is associated with the odds of complication-related reoperation up to two years post fracture.

We identified all distal radius fracture patients aged 18 or older between the years of 2003-2016 in Ontario, Canada from linked administrative databases. We used procedural and fee codes to identify patients who underwent primary outpatient surgical fixation between 8 and 14 days post fracture, and grouped patients by the number of CRs they underwent prior to definitive fixation. We excluded patients who underwent fixation within 7 days of their fracture to exclude more complex fracture types and/or patients who required more immediate surgery. We grouped patients according to the number of CRs they underwent prior to definitive fixation. We used intervention and diagnostic codes to identify reoperations within two years of fixation. We used multi-level multivariable logistic regression to compare the association between the number of CRs and reoperation while accounting for clustering at the surgeon level and adjusting for other relevant covariables. We performed an age-stratified analysis to determine if the association between the number of CRs and reoperation differed by patient age.

We identified 5,464 patients with distal radius fractures managed with outpatient fixation between 8 and 14 days of their fracture. A total of 1,422 patients (26.0%) underwent primary surgical fixation (mean time to fixation 10.6±2.0 days), while 3,573 (65.4%) underwent secondary fixation following one failed CR (mean time to fixation 10.1±2.2 days, time to CR 0.3±1.2 days), and 469 (8.6%) underwent fixation following two failed CRs (mean time to fixation 10.8±2.2 days, time to first CR 0.0±0.1 days, time to second CR 4.7±3.0 days). The CR groups had higher proportions of female patients compared to the primary group, and patients who underwent two failed CRs were more likely to be fixed with a plate (vs. wires or pins). The unadjusted proportion of reoperations was significantly higher in the group who underwent two failed CRs (7.5%) compared to those who underwent primary fixation (4.4%), and fixation following one failed CR (4.9%). Following covariable adjustment, patients who underwent two failed CRs had a significantly higher odds of reoperation (odds ratio [OR] 1.72 [1.12-2.65]) compared to those who underwent primary fixation. This association appeared to worsen for patients over the age of 60 (OR 3.93 [1.76-8.77]). We found no significant difference between the odds of reoperation between patients who underwent primary fixation vs. secondary fixation following one failed CR.

We found that patients with distal radius fractures who undergo multiple CRs prior to definitive fixation have a significantly higher odds of reoperation compared to those who undergo primary fixation, or fixation following a single CR. This suggests that surgeons should offer fixation if indicated following a single failed CR rather than attempt multiple closed reductions. Prospective studies are required to confirm these findings.

Aims

The aims of this network meta-analysis (NMA) were to examine nonunion rates and functional outcomes following various operative and nonoperative treatments for displaced mid-shaft clavicle fractures.

Negative pressure wound therapy (NPWT) is commonly used to manage severe open fracture wounds. The recently completed X randomized controlled trial (RCT) evaluated the effect of NPWT versus standard wound management on 12-month disability and rate of deep infection among patients with severe open fractures of the lower limb and reported no differences. Using data from the Y trial of open fracture patients, we aimed to evaluate the impact of NPWT on the odds of having deep infections and health-related quality of life (HRQL).

Our analyses included participants from the Y trial who had Gustilo II and III lower extremity fractures. To adjust for the influence of injury characteristics on type of dressing received, a propensity score was developed from the dataset. A one-to-one matching algorithm was then used to pair patients with a similar propensity for NPWT.

Mixed effects logistic regression was used to evaluate the association between type of wound dressing and development of a deep infection requiring operative management (dependent variable) in the matched cohort. Gustilo type, irrigation solution, fracture location, mechanism of injury, and degree of contamination were included as adjustment variables. To determine any differences in HRQL between the NPWT and standard wound dressing groups, we conducted two multi-level models with three levels (centre, patient, and time) and included Short Form-12 (SF-12) Physical Health Component (PCS) and SF-12 Mental Health Component (MCS) as dependent variables. Gustilo type, irrigation solution, fracture location, mechanism of injury, degree of contamination, and pre-injury SF-12 scores were included as adjustment variables. All tests were 2-tailed with alpha=0.05.

After applying propensity score-matching to adjust for the influence of injury characteristics on type of dressing used, there were 270 matched pairs of patients available for comparison. The odds of developing a deep infection requiring operative management within 12 months of initial surgery was 4.22 times higher in patients who received NPWT compared to those who did not receive NPWT (Odds Ratio (OR) 4.22, 95% Confidence Interval (CI) 2.26–7.87.

1,329 participants were included in our HRQL analysis and those treated with NPWT had significantly lower SF-12 PCS at all follow-up visits (6w, 3m, 6m, 12m) post fracture (p=0.01). Participants treated with NPWT had significantly lower SF-12 MCS at 6-weeks post-fracture (p=0.03).

Unlike the X trial, our analysis found that patients treated with NPWT had higher odds of developing a deep infection requiring operative management and that being treated with NPWT was associated with lower physical quality of life in the 12 months post-fracture. While there may have been other potential adjustment variables not controlled for in this analysis, our results suggest that the use of this treatment should be re-evaluated.

Delayed management of high energy femoral shaft fractures is associated with increased complication rates. It has been suggested that there is less urgency to stabilize lower energy femoral shaft fractures. The purpose of this study was to evaluate the effect of surgical delay on 30-day complications following fixation of lower energy femoral shaft fractures.

Patients ≥ 18 years who underwent either plate or nail fixation of low energy (falls from standing or up to three steps' height) femoral shaft fractures from 2005 – 2016 were identified from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) via procedural codes. Patients with pathologic fractures, fractures of the distal femur or femoral neck were excluded. Patients were categorized into early (< 2 4 hours) or delayed surgery (2–30 days) groups. Bivariate analyses were used to compare demographics and unadjusted rates of complications between groups. A multivariable logistic regression was used to compare the rate of major and minor complications between groups, while adjusting for relevant covariables. Head injury patients and polytrauma patients are not included in the NSQIP database.

Of 2,716 lower energy femoral shaft fracture patients identified, 2,412 (89%) were treated within 1 day of hospital admission, while 304 (11.2%) were treated between 2 and 30 days post hospital admission. Patient age, American Society of Anesthesiologists (ASA) classification score, presence of diabetes, functional status, smoking status, and surgery type (nail vs. plate) were significantly different between groups (p After adjusting for all relevant covariables, delayed surgery significantly increased the odds of 30-day minor complications (p=0.02, OR = 1.48 95%CI 1.01–2.16), and 30-day mortality (p < 0 .001), OR = 1.31 (95%CI 1.03–2.14).

The delay of surgical fixation of femoral shaft fractures appears to significantly increase patients' risk of minor adverse events as well as increase mortality. With only 89% of patients being treated in the 24 hour timeframe that constitutes best practice for treatment of femoral shaft fractures, there remains room for improvement. These results suggest that early treatment of all femoral shaft fractures, even those with a lower energy mechanism of injury, leads to improved outcomes.

Increased operative time has been previously identified as a risk factor for complications following total joint arthroplasty. The purpose of this study was to evaluate the influence of surgical time on 30-day complications following Total Knee Arthroplasty (TKA) and to determine if there were specific time intervals associated with worse outcomes.

The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database was utilized to identify patients ≥18 years who underwent TKA between 2005 and 2016 using procedural codes. Patients with surgical durations >240 minutes were excluded. Patient demographics, operation length, and 30-day major and minor complication rates were captured. Multivariable logistic regression was used to determine if the rate of complications differed depending on length of operation, while adjusting for age, sex, American Society of Anaesthesiologists (ASA) class, functional status, smoking status, comorbidities, anesthesia type, and Body Mass Index (BMI). Multivariable linear regression was used to identify independent predictors of duration of surgery.

A total of 213,921 TKA patients (average age 67 ± 10 years) were identified from the database. Within 30-days of the index procedure, 3,321 (1.55%) experienced a major complication, and 6,144 (2.86%) experienced a minor complication. Mean surgical duration was 92 minutes (range 20 – 240). Underweight, or overweight/obese BMI, male sex, hypertension, cancer, dependent functional status, epidural anaesthesia, and ASA class III and IV were determined to be independent predictors of prolonged operation length, while COPD, current smoking, spinal anesthesia, and older age predicted lower operation times.

Operation lengths ≥ 90 minutes significantly increased the risk of both major and minor complications (P>0.01). Specifically, the rates of deep vein thrombosis (DVT), unplanned reintubation, surgical site infection (SSI), sepsis, and wound disruption were higher for patients whose operations lasted ≥ 90 minutes (p 0.05). With respect to specific complications, following covariate adjustment, operation lengths ≥ 90 minutes increased the risk of DVT, deep and superficial incisional SSI, and wound disruption, while operation lengths ≥ 120 minutes increased the risk of deep, non-incisional SSI, and sepsis (P < 0 .01).

Surgical times of ≥90 minutes independently increase the 30-day risk of DVT, infection, and wound disruption following TKA after controlling for other variables that influence operation length. This study confirms the importance of surgical duration on early outcomes following TKA.

The purpose of this investigation is to assess the rate of wear the effect once the “bedding in period”/ poly creep had been eliminated. Creep is the visco-elastic deformation that polyethylene exhibits in the first 6–12 weeks. We also assessed the wear pattern of four different bearing couples in total hip arthroplasty (THA): cobalt-chrome (CoCr) versus oxidized zirconium (OxZir) femoral heads with ultra-high molecular weight polyethylene (UHMWPE) versus highly-crosslinked polyethylene (XLPE) acetabular liners.

This was a randomized control study involving 92 patients undergoing THA. They were randomized to one of four bearing couples: (1) CoCr/UHMWPE (n= 23), (2) OxZir/UHMWPE (n=21), (3) CoCr/XLPE (n=24), (4) OxZir/XLPE (n=24). Patients underwent a posterior approach from one of three surgeons involved in the study. All patients received a porous-coated cementless acetabular shell and a cylindrical proximally coated stem with 28 mm femoral heads. Each patient was reviewed clinically and radiographically at six weeks, three and 12 months, two, five and 10 years after surgery. Standardized anteroposterior and lateral radiographs were taken. All polyethylene wear was measured by an independent blinded reviewer. Linear and volumetric wear rates were measured on radiographs using a validated computer software (Polyware Rev. 5). Creep was defined as the wear at 6 or 12 weeks, depending on if there was a more than 10% difference between both measurements. If a greater than 10% difference occurred than the later period's wear would be defined as creep.

72 hips were included in analysis after exclusion of seven revisions, three deaths and 10 losses to follow-up. The annual linear wear rates (in mm/y) at 10 years were (1) 0.249, (2) 0.250, (3) 0.074 and (4) 0.050. After adjusting for creep these rates become were (1) 0.181, (2) 0.142, (3) 0.040 and (4) 0.023. There is statistical differences between raw and adjusted linear wear rates for all bearing couples. The percentage of the radiographically measured wear at 10 years due to creep is (1) 30% (2) 44%, (3) 58.5% and (4) 51.5% with significant differences in couples with XLPE versus those with UHMWPE. There was no significant correlation between age, gender, cup size, tilt, planar anteversion and the linear or volumetric wear rates.

The linear wear rate of both UHMWPE and XLPE are even lower thxdsxzan previously described when creep is factored out. XLPE has again demonstrated far superior linear wear rates at 10 years than UHMWPE. There were no significant differences in wear rate at 10 years between CoCr and OxZir, this may be due to an underpowered study. XLPE exhibits proportionally more creep than UHMWPE within the first 6–12 weeks and accounts for more of the total wear at 10 years as measured radiographically at the end period.

Distal radius fractures are the most common adult fractures, yet there remains some uncertainty surrounding optimal treatment modalities. Recently, the rate of operative treatment of these injuries has been increasing, however, predictors of outcomes in patients treated surgically remain poorly understood. The purpose of this study was to evaluate independent predictors of 30-day readmission and complications following internal fixation of distal radius fractures.

Patients ≥18 years who underwent surgical intervention for distal radius fractures between 2005 and 2016 were identified from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) using procedural codes. Patient demographics, as well as 30-day readmission, complication, and mortality rates were ascertained. Multivariable logistic regression was used to determine independent predictors of 30-day outcomes while adjusting for patient age, sex, American Society of Anaesthesiologists (ASA) class, functional status, smoking status, comorbidities, and Body Mass Index (BMI).

A total of 10,051 patients were identified (average age 58 ±16). All patients received open reduction and internal fixation with no cases of external fixation identified in the data set. Included fractures were 37% extraarticular and 63% intraarticular. Within 30-days of initial fixation 143 (1.42%) patients were readmitted to the hospital, 71 patients experienced a complication, and 18 (0.18%) patients died. After adjusting for relevant covariables, current smoking increased the odds of readmission by 1.73 (95%Confidence interval [95%CI] 1.15 – 2.50), ASA class III/IV vs. I/II increased the odds of readmission by 2.74 (95%CI 1.85 – 4.06), and inpatient surgery vs. outpatient surgery increased the odds of readmission by 2.10 (95%CI 1.46 – 3.03). Current smoking also increased the odds of complications by 2.26 (95%CI 1.32 – 3.87), while ASA class III/IV increased it by 2.78 (95%CI 1.60 – 4.85), inpatient surgery increased it by 2.26 (95%CI 1.37 – 3.74), and dependent functional status increased it by 2.55 (1.16 – 5.64).

In conclusion, patients with severe systemic disease, current smokers and patients undergoing inpatient surgery are at risk for 30-day readmissions and complications following operative treatment of distal radius fractures. In addition, patients with dependent functional statuses are more likely to experience a complication within 30-days.

Fragility fractures associated with osteoporosis (OP) reduce quality of life, increase risk for subsequent fractures, and are a major economic burden. In 2010, Osteoporosis Canada produced clinical practice guidelines on the management of OP patients at risk for fractures (Papaioannou et al. CMAJ 2010). We describe the real-world incidence of primary and subsequent fragility fractures in elderly Canadians in Ontario, Canada in a timespan (2011–2017) following guideline introduction.

This retrospective observational study used de-identified health services administrative data generated from the publicly funded healthcare system in Ontario, Canada from the Institute for Clinical Evaluative Sciences. The study population included individuals ≥66 years of age who were hospitalized with a primary (i.e. index) fragility fracture (identified using ICD-10 codes from hospital admissions, emergency and ambulatory care) occurring between January 1, 2011 and March 31, 2015. All relevant anatomical sites for fragility fractures were examined, including (but not limited to): hip, vertebral, humerus, wrist, radius and ulna, pelvis, and femur. OP treatment in the year prior to fracture and subsequent fracture information were collected until March 31, 2017. Patients with previous fragility fractures over five years prior to the index fracture, and those fractures associated with trauma codes, were excluded.

115,776 patients with an index fracture were included in the analysis. Mean (standard deviation) age at index fracture was 80.4 (8.3) years. In the year prior to index fracture, 32,772 (28.3%) patients received OP treatment. The incidence of index fractures per 1,000 persons (95% confidence interval) from 2011–2015 ranged from 15.16 (14.98–15.35) to 16.32 (16.14–16.51). Of all examined index fracture types, hip fractures occurred in the greatest proportion (27.3%) of patients (Table). The proportion of patients incurring a second fracture of any type ranged from 13.4% (tibia, fibula, knee, or foot index fracture) to 23% (vertebral index fracture). Hip fractures were the most common subsequent fracture type and the proportion of subsequent hip fractures was highest in patients with an index hip fracture (Table). The median (interquartile range [IQR]) time to second fracture ranged from 436 (69–939) days (radius and ulna index fracture) to 640 (297–1,023) days (tibia, fibula, knee, or foot index fracture). The median (IQR) time from second to third fracture ranged from 237 (75–535) days (pelvis index fracture) to 384 (113–608) days (femur index fracture).

This real-world study found that elderly patients in Ontario, Canada incurring a primary fragility fracture from 2011–2015 were at risk for future fractures occurring over shorter periods of time with each subsequent fracture. These observations are consistent with previous reports of imminent fracture risk and the fragility fracture cascade in OP patients (Balasubramanian et al. ASBMR 2016, Toth et al. WCO-IOF-ESCEO 2018). Overall, these data suggest that in elderly patients with an index fragility fracture at any site (with the exception of the radius or ulna), the most likely subsequent fracture will occur at the hip in less than 2 years.

Previous studies have indicated that prolonged surgical time may lead to higher rates of infection following total hip arthroplasty (THA). The purpose of this study was to evaluate the influence of surgical time on 30-day complications following THA and to determine if there was a time interval associated with worse outcomes.

Patients ≥18 years who underwent THA between 2005 and 2016 were identified from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database using procedural codes. Patients with surgical durations >240 minutes were excluded. Patient demographics, operation length, and 30-day major and minor complications were ascertained. Multivariable regression was used to determine if the rate of complications differed depending on length of operation, while adjusting for relevant covariables, and to identify independent predictors of operation length. Covariables of interest included age, sex, American Society of Anaesthesiologists (ASA) class, smoking status, functional status, comorbidities, anesthesia type, and Body Mass Index (BMI).

A total of 131,361 THA patients (average age 65 ±12 years) were identified from the database. Of these, 2,177 (1.64%) experienced a major complication, and 3,504 (2.64%) experienced a minor complication within 30-days of the initial procedure. Average operation length was 91.9 minutes (range 20 – 240 minutes). Independent predictors of prolonged operation length included overweight/obese BMI, male sex, cancer, dependent functional status, epidural anaesthetic, lower pre-operative hematocrit, and ASA class II, III or IV vs. I Alternatively, older age, current smoking, and spinal anaesthetic were associated with shorter surgical durations.

Unadjusted rates of both major and minor complications were significantly higher for patients whose operation lengths were ≥ 120 minutes (P>0.001). Specifically, patients whose operations lasted ≥ 120 minutes had higher rates of septic shock, sepsis, pulmonary embolism (PE), deep vein thrombosis (DVT), urinary tract infection (UTI), renal insufficiency, surgical site infection(SSI) and wound disruption. After covariable adjustment, surgical durations of 90–119 minutes increased the risk of minor complications by 1.2 (95%Confidence interval [95%CI] 1.1–1.3), while surgical durations of 120–179 minutes increased the risk of major complications by 1.4 (95%CI 1.3 – 1.6), and minor complications by 1.4 (95%CI 1.2 – 1.5), and surgical durations ≥180 minutes increased the risk of major complications by 2.1 (95%CI 1.8 – 2.6), and minor complications by 1.9 (95%CI 1.6 – 2.3). There was no difference in the overall risk of complications for operation times lasting 20 – 39, 40 – 59, or 60 – 89 minutes (P>0.05).

In terms of specific complications, operation length ≥90 minutes was determined to be an independent risk factor for deep and superficial incisional SSI, as well as wound disruption, while operation length ≥ 120 minutes was an independent risk factor for sepsis, UTI, and deep, non-incisional SSI and operation length ≥ 180 minutes was an independent risk factor for PE, DVT, and cardiac arrest (p < 0 .05). These data indicate that prolonged surgical durations may be an independent predictor of major and minor complications following THA. This suggests that quality improvements could be made to improve operating room efficiency and surgical times and therefore postoperative outcomes.

The Masquelet or induced membrane technique (IMT) is a two-stage surgical procedure used for the treatment of segmental bone defects. In this technique, the defect is first filled with a polymethyl methacrylate (PMMA) spacer, which triggers the formation of a membrane that will encapsulate the defect. During the second surgery, the spacer is carefully removed and replaced by autologous bone graft while preserving the membrane. This membrane is vascularized, contains growth factors, and provides mechanical stability to the graft, all of which are assumed to prevent graft resorption and promote bone healing.

The technique is gaining in popularity and several variations have been introduced in the clinical practice. For instance, orthopaedic surgeons now often include antibiotics in the spacer to treat or prevent infection. However, the consequences of this approach on the properties of the induce membrane are not fully understood. Accordingly, in a small animal model, this study aimed to determine the impact on the induced membrane of impregnating spacers with antibiotics frequently used in the IMT.

We surgically created a five-mm segmental defect in the right femur of 25 adult male Sprague Dawley rats. The bone was stabilized with a plate and screws before filling the defect with a PMMA spacer. Animals were divided into five equal groups according to the type and dose of antibiotics impregnated in the spacer: A) no antibiotic (control), B) low-dose tobramycin (1.2 g/40 g of PMMA), C) low-dose vancomycin (1 g/40 g of PMMA), D) high-dose tobramycin (3.6 g/40 g of PMMA), E) high-dose vancomycin (3 g/40 g of PMMA). The animals were euthanized three weeks after surgery and the induced membranes were collected and divided for analysis. We assessed the expression of selected genes (Alpl, Ctgf, Runx2, Tgfb1, Vegfa) within the membrane by quantitative real-time PCR. Moreover, frozen sections of the specimens were used to quantify vascularity by immunohistochemistry (CD31 antigen), proliferative cells by immunofluorescence (Ki-67 antigen), and membrane thickness. Microscopic images of the entire tissue sections were taken and analyzed using FIJI software. Finally, we measured the concentration of vascular endothelial growth factor (VEGF) in the membranes by ELISA.

No significant difference was found among the groups regarding the expression of genes related to osteogenesis (Alpl, Runx2), angiogenesis (Vegfa), or synthesis of extracellular matrix (Ctgf, Tgfb1) (n = four or five). Similarly, the density of proliferative cells and blood vessels within the membrane, as well as the membrane thickness, did not vary substantially between the control, low-dose, or high-dose antibiotic groups (n = four or five). The concentration of VEGF was also not significantly influenced by the treatment received (n = four or five).

The addition of tobramycin or vancomycin to the spacer, at the defined low and high doses, does not significantly alter the bioactive characteristics of the membrane. These results suggest that orthopaedic surgeons could use antibiotic-impregnated spacers for the IMT without compromising the induced membrane and potentially bone healing.

Introduction

We designed this study to compare 30-day complications and length of hospital stay between patients undergoing total knee arthroplasty (TKA) with general anesthesia, to those undergoing TKA with spinal, epidural anesthesia, or Monitored Anesthesia Care (MAC, a combination of local anesthesia with sedation and analgesia provided by an anesthesiologist) with or without regional nerve blocks.

Aims

To compare complication-related reoperation rates following primary arthroplasty for proximal humerus fractures (PHFs) versus secondary arthroplasty for failed open reduction and internal fixation (ORIF).

Aims

To evaluate the influence of discharge timing on 30-day complications following total knee arthroplasty (TKA).

Aims

The aim of this study was to assess the influence of operating time on 30-day complications following total hip arthroplasty (THA).

Aims

The primary aim of this prognostic study was to identify baseline factors associated with physical health-related quality of life (HRQL) in patients after a femoral neck fracture. The secondary aims were to identify baseline factors associated with mental HRQL, hip function, and health utility.

Aims

We present the ten-year data of a cohort of patients, aged between 18 and 65 years (mean age 52.7 years; 19 to 64), who underwent total hip arthroplasty. Patients were randomised to be treated with a cobalt-chrome (CoCr) femoral head with an ultra-high molecular weight polyethylene (UHMWPE), highly cross-linked polyethylene (XLPE) or ceramic-on-ceramic (CoC) bearing surface.

Aims

One method of femoral head preservation following avascular necrosis (AVN) is core decompression and insertion of a tantalum rod. However, there may be a high failure rate associated with this procedure. The purpose of this study was to document the clinical and radiological outcomes following total hip arthroplasty (THA) subsequent to failed tantalum rod insertion.

Latissimus dorsi tendon transfer (LDTT) is technically challenging. In order to clarify the local structural anatomy, we undertook a morphometric study using six complete cadavers (12 shoulders). Measurements were made from the tendon to the nearby neurovascular structures with the arm in two positions: flexed and internally rotated, and adducted in neutral rotation. The tendon was then transferred and measurements were taken from the edge of the tendon to a reference point on the humeral head in order to assess the effect of a novel two-stage release on the excursion of the tendon.

With the shoulder flexed and internally rotated, the mean distances between the superior tendon edge and the radial nerve, brachial artery, axillary nerve and posterior circumflex artery were 30 mm (26 to 34), 28 mm (17 to 39), 21 mm (12 to 28) and 15 mm (10 to 21), respectively. The mean distance between the inferior tendon edge and the radial nerve, brachial artery and profunda brachii artery was 18 mm (8 to 27), 22 mm (15 to 32) and 14 mm (7 to 21), respectively. Moving the arm to a neutral position reduced these distances. A mean of 15 mm (8 to 21) was gained from a standard soft-tissue release, and 32 mm (20 to 45) from an extensile release.

These figures help to define further the structural anatomy of this region and the potential for transfer of the latissimus dorsi tendon.

Cite this article: Bone Joint J 2013;95-B:517–22.

Purpose

The recent emergence of autologous blood concentrates, such as platelet rich plasma (PRP), as a treatment option for patients with orthopaedic injuries has led to an extensive debate about their clinical benefit. Our objective was to determine the effectiveness of autologous blood concentrates compared with control therapy in improving pain in patients with orthopaedic bone and soft tissue injuries.

Purpose

Computer navigation for hip resurfacing has been shown to reduce the incidence of technical error during femoral head preparation and provides increased accuracy compared to conventional instrumentation for insertion of the initial femoral guidewire. Limitations to the widespread use of navigation in hip resurfacing include access and cost. A novel, patient specific nylon jig has been developed as a cost effective alternative for placement of the initial guidewire. The purpose of this study was to compare the accuracy of femoral guidewire insertion between imageless navigation, conventional instrumentation and a new type of CT-based custom jig.

Purpose

There is no clear definition of a critical sized defect of the tibia. We defined it as a fracture gap at least one centimeter in length and involving over 50% of the cortical diameter. We explored if the presence of a critical-sized defect predicted reoperation, and which other factors predict reoperation in patients with the critical defect. The patient based outcomes of these patients were compared to patients without a critical defect.

Purpose

Our hypothesis was that closed tibia fractures treated with intramedullary nails are impacted by surgeon and center volumes.

Purpose

Cross-linking of polyethylene greatly reduces its wear rate in hip simulator studies. We conducted a systematic review and meta-analysis of randomized controlled trials comparing cross-linked to conventional polyethylene liners for total hip arthroplasty to determine if there is a clinical reduction of: 1) wear rates, 2) radiographic osteolysis, and 3) need for total hip revision.

Purpose

To review prospectively collected data on patients undergoing primary total hip arthroplasty utilizing two different cementless acetabular components.

Purpose

The purpose of the study was to determine the rate of conversion from RSA to THR in a number of Canadian centers performing resurfacings

Purpose

There is increasing evidence that primary fixation of displaced mid-shaft fractures of the clavicle results in superior short-term outcomes when compared to traditional non-operative methods. However, the results from published studies are limited to relatively short-term (one year or less) follow-up. Accurate data of longer follow-up is important for a number of reasons, including patient prognostication, counseling and care, the design of future trials, and the economic analysis of treatment. The purpose of this paper was to examine the results of the two year follow up of patients enrolled in a previously published randomized clinical trial of operative versus non-operative treatment of displaced fractures of the clavicle.

Purpose

Femoroacetabular impingement (FAI) may contribute to the development of early onset hip osteoarthritis (OA). A cam lesion (or pistol grip deformity) of the proximal femur reduces head-neck offset resulting in cam type FAI. The alpha angle is a radiographic measurement recommended for diagnosis of cam type FAI. The purpose of this study was to determine if patients that develop end stage hip OA prior to 55 years of age have radiographic evidence of cam type FAI.

Purpose

Angiogenesis and osteogenesis are essential for bone growth, fracture repair, and bone remodeling. VEGF has an important role in bone repair by promoting angiogenesis and osteogenesis. In our previous study, endothelial progenitor cells (EPCs) promoted bone healing in a rat segmental bone defect as confirmed by radiological, histological and microCT evaluations (Atesok, Li, Schemitsch 2010); EPC treatment of fractures resulted in a significantly higher strength by biomechanical examination (Li, Schemitsch 2010). In addition, cell-based VEGF gene transfer has been effective in the treatment of segmental bone defects in a rabbit model (Li, Schemitsch et al 2009); Purpose of this study: Evaluation of VEGF gene expression after EPC local therapy for a rat segmental bone defect.

Purpose

Displaced midshaft clavicular fractures are a common injury with a high occurrence rate in young, active individuals. Non-operative care has traditionally been the standard of care for such fractures, but more recent studies have suggested benefits following primary operative fixation. The purpose of this study was to review the literature on displaced midshaft clavicle fractures, identify randomized controlled trials of operative versus non-operative treatment, and pool the functional outcome and complication rates (including nonunion and symptomatic malunion), to arrive at summary estimates of these outcomes.

Purpose

Femoral shaft fractures are routinely treated using antegrade intramedullary nailing under fluoroscopic guidance. Malreduction is common and can be due to multiple factors. Correct entry point identification can help minimize malreduction and the risk of iatrogenic fracture. This study aims to compare landmark identification used to guide nail entry, the piriformis fossa (PF) and the trochanteric tip (T), via computer navigation and conventional fluoroscopy.

Purpose

The SPRINT trial randomized 1226 patients with tibial shaft fractures treated by intramedullary (IM) nailing to reamed versus unreamed groups. Using data from this trial, we completed a subgroup analysis of those patients who required two or more reoperations following the initial IM fracture stabilization.

Purpose

This prospective randomised controlled trial aims to compare the clinical and radiological outcomes of ceramic on ceramic, cobalt chrome on ultra-high molecular weight polyethylene, and cobalt chrome on highly cross-linked polyethylene bearing surfaces at a minimum of five years.

Purpose

The Birmingham Mid-Head Resection (BMHR) is a bone-conserving, short-stem alternative to hip resurfacing for patients with compromised femoral head anatomy. It is unclear, however, if an uncemented, metaphyseal fixed stem confers a mechanical advantage to that of a traditional hip resurfacing in which the femoral prosthesis is cemented to the prepared femoral head. Thus, we aimed to determine if a metaphyseal fixed, bone preserving femoral component provided superior mechanical strength in resisting neck fracture compared to a conventional hip resurfacing arthroplasty.

The ideal bearing surface for young patients undergoing total hip replacement (THR) remains controversial. We report the five-year results of a randomised controlled trial comparing the clinical and radiological outcomes of 102 THRs in 91 patients who were <  65 years of age. These patients were randomised to receive a cobalt–chrome on ultra-high-molecular-weight polyethylene, cobalt–chrome on highly cross-linked polyethylene, or a ceramic-on-ceramic bearing. In all, 97 hip replacements in 87 patients were available for review at five years. Two hips had been revised, one for infection and one for peri-prosthetic fracture.

At the final follow-up there were no significant differences between the groups for the mean Western Ontario and McMaster Universities osteoarthritis index (pain, p = 0.543; function, p = 0.10; stiffness, p = 0.99), Short Form-12 (physical component, p = 0.878; mental component, p = 0.818) or Harris hip scores (p = 0.22). Radiological outcomes revealed no significant wear in the ceramic group.

Comparison of standard and highly cross-linked polyethylene, however, revealed an almost threefold difference in the mean annual linear wear rates (0.151 mm/year versus 0.059 mm/year, respectively) (p < 0.001).

Purpose: There is growing support in the medical literature that patient outcomes are adversely affected by physician fatigue in operator-dependent cognitive and technical tasks. The recent increase in total joint arthroplasty case load has resulted in longer operative days and increased surgeon fatigue. The purpose of this study was to determine if time of day predicts perioperative outcomes and complications in total hip and knee arthroplasty surgery.

Method: The records of all primary Total Hip Arthroplasty (THA) and Total Knee Arthroplasty (TKA) surgery performed for primary osteoarthritis, during 2007 at one large university hospital, were retrospectively reviewed. Complete demographic data (age, gender, Body Mass Index), start time of surgery, intraoperative complications, duration of surgery, radiographic component alignment, and functional outcome scores (SF-12 and WOMAC) for 341 THA and 292 TKA patients were collected and analyzed using linear and nonparametric rank correlation statistics. Data was corrected for gender, body mass index (BMI), surgeon, and post-call operating days.

Results: In the THA cohort, a later start time of surgery was significantly related to duration of surgery (p=0.0013). In addition, there was a trend towards significance for intraoperative femur fracture (p=0.0542) later in the day. Postoperative complications, component alignment, and functional outcome scores were not significantly affected by start time of surgery. There were no significant findings for any of the intraoperative or postoperative outcomes in the TKA cohort.

Conclusion: This study demonstrates that duration of surgery and the incidence of intraoperative complications for THA may increase as the start time of surgery becomes later in the day. These findings should be taken into consideration when planning operative days involving THA.

Purpose: Recently, there has been concern raised on the occurrence of pseudotumors after metal on metal hip resurfacing. A pseudotumor is defined as a local soft tissue mass associated with localized bony and/or tissue (muscle) destruction. The primary purpose of this study is to determine the incidence of this complication in several high volume Canadian academic centres.

Method: Nine of the 11 Canadian academic centres who perform metal on metal hip resurfacings were surveyed. The number of metal on metal hip resurfacing arthroplasties performed at each centre was first determined, as were the number of those who have presented with a pseudotumour, and subsequently gone on to revision surgery. The basic demographics of the group were recorded, as were the radiographic and implant design variables for those cases presenting with a pseudotumour.

Results: A sample of 3,400 hip resurfacing arthroplasties performed between 2002 and December 2008 were surveyed. Demographics were tabulated for a sub-sample of these patients. 76% were male, the mean length of follow-up was 3.02 years, mean BMI was 28.65, and mean age was 52.10 years. Three of 3,400 cases presented with a pseudotumour, an incidence of .09%.

Conclusion: Although pseudotumors remain a concern after metal on metal hip resurfacing, the incidence at short to mid term follow-up is very low in this multi-centre academic survey. This information is significantly lower than what other groups have recently reported. Continued close monitoring is required in order to determine what clinical factors are at play.

Purpose: Surgeons performing hip resurfacing antevert and translate the femoral component anteriorly to maximize head/neck offset and reduce impingement. The anterior femoral neck is under tensile forces during gait similarly to the superior neck [6]. This study was designed to determine the risk of femoral neck fracture after anterior or posterior notching of the femoral neck.

Method: Forty seven fourth generation synthetic femora were implanted with Birmingham Hip Resurfacing prostheses (Smith & Nephew Inc. Memphis, USA). Implant preparation was performed using imageless computer navigation (VectorVision SR 1.0, BrainLAB, Germany). The prosthesis was initially planned for neutral version and translated anterior, or posterior, to create a femoral neck notch. The femora were fixed in a single-leg stance and tested with axial compression using a mechanical testing machine. This method enabled comparison with previously published data. The synthetic femora were prepared in eight experimental groups:two mm and five mm anterior notches, two mm and five mm posterior notches, neutral alignment with no notching (control), five mm superior notch, five mm anterior notch tested with the femur in 25° flexion and five mm posterior notch tested with the femur in 25° extension We tested the femora flexed at 25° flexion to simulate loading as seen during stair ascent. [3] The posterior five mm notched femoral necks were tested in extension to simulate sporting activities like running. The results were compared to the control group in neutral alignment using a one – way ANOVA:

Results: Testing Group Mean load to failure Significance (p-value) Anterior 2mm 3926.61 ± 894.17 .843 Anterior 5mm 3374.64 ± 345.65 .155 Neutral (Control) 4539.44 ± 786.44 – Posterior 2mm 4208.09 ± 1079.81 .994 Posterior 5mm 3988.06 ± 728.59 .902 Superior 5mm 2423.07 ± 424.17 .001 Anterior 5mm in 25° flexion 3048.11 ± 509.24 .027 Posterior 5mm in 25° extension 3104.62 ± 592.67 .038 Our data suggests that anterior and posterior two mm or five mm notches are not significantly weaker in axial compression. Anterior and posterior 5mm notches are significantly weaker in flexion/extension (p=0.027/ p=0.038). The five mm superior notch group was significantly weaker with axial compression supporting previous published data (p=0.001).

Conclusion: We conclude that anterior or posterior two mm notching of the femoral neck has no clinical implications, however five mm anterior or posterior femoral neck notching significantly weakens the femoral neck. Fracture is more likely to occur with stair ascent or activities involving weight bearing in extension. Hip resurfacing is commonly performed on active patients and five mm neck notching has clinically important implications.

Purpose: Given recent evolving guidelines regarding maximum allowable work hours and emphasis on resident quality of life, novel strategies are required for implementing call schedules. The night float system has been used by some institutions as a strategy to decrease the burden of call on resident quality of life in level one trauma centres. The purpose of this study was to determine whether there are differences in quality of life, work-related stressors, and educational experience between orthopaedic surgery residents in the night float and standard call systems at two level one trauma centres.

Method: This was a prospective cohort study at two level one trauma hospitals comprised of a standard call (1 in 4) group and a night float (5pm-7am, Sunday to Friday) group for each hospital, respectively. Residents completed the Short Form 36 (SF-36) general quality-of-life questionnaire, as well as, questionnaires on stress level and educational experience before the rotation (baseline), at two, four and subsequently at six months. An analysis of covariance (ANCOVA) approach was used to compare between-group differences using the baseline scores as covariates. Wilcoxon Signed-Rank tests (non-parametric) were used to determine if the residents’ SF-36 scores were different from the age and sex matched Canadian norms. Predictors of resident quality of life were analyzed using multivariable mixed models.

Results: Seven residents were in the standard call group and nine in the night float group for a total of 16 residents (all males, mean age=35.1 yrs). Controlling for between-group differences at baseline, residents on the night float rotation had significantly lower role physical (RP), bodily pain (BP), social function (SF) subscale scores (p< 0.05).

Conclusion: Our study suggests that the residents in the standard call group had better health related quality of life in comparison with the night float group. No differences existed in subjective educational benefits and stress level between the groups. The study findings may be limited due to the small sample size. However, this sample size is substantial given the size of most orthopaedic residency programs in North America.

Purpose: We aimed to preliminarily validate a newly developed system, the radiographic union scale for tibial (RUST) fracture healing. We hypothesized that RUST would demonstrate better inter-rater reliability than assessment of the number of cortices bridged and correlate with functional outcomes at least as strongly as surgeon’s assessment of cortical bridging.

Method: Three blinded orthopaedic trauma surgeons independently assigned a RUST score and a number of cortices bridged by callus (zero to four) to each set of AP and lateral radiographs at each follow up period. RUST is scored from four (definitely not healed) to 12 (definitely healed) based on the presence or absence of callus and of a visible fracture line at the total of four cortices visible.

Results: For 549 sets of reviewed radiographs, inter-rater reliability for RUST scores were found to be substantially higher than for assessment of the number of cortices bridged (intra-class correlation coefficient=0.84; 95% CI, 0.80–0.87 versus kappa = 0.73; 95% CI, 0.64 – 0.81, respectively). Both methods of assessing radiographic healing were strongly correlated with weight-bearing status (r and ρ> 0.50), moderately correlated with patient-reported functional recovery and the SF-36 Physical Functioning component scores (r and ρ> 0.30), and minimally correlated with HUI Mark II scores, return to work, and the SF-36 Role Physical component and Physical Component Summary scores (r and ρ> 0.10). Neither assessment was correlated with patient-reported pain scores. All correlations were similar for RUST and the number of cortices bridged.

Conclusion: This study provides preliminary evidence that RUST can be used as a valid and reliable alternative assessment of tibial fracture healing.

Purpose: In recent years, there has been an increased appreciation of the importance of intimate partner violence (IPV), which is also known as domestic violence, spouse abuse, and battering, as a serious public health problem. Domestic violence is the most common cause of nonfatal injury to women in North America. As providers of musculoskeletal care and first-contact health care practitioners for many patients, orthopaedic surgeons should be knowledgeable regarding screening and possible interventions for IPV victims. The Canadian Orthopaedic Association and the American Academy of Orthopaedic Surgeons have both prepared explicit statements that orthopaedic surgeons should play a role in the screening and appropriate identification of victims of IPV. We aimed to identify the knowledge, attitudes, and beliefs about IPV among orthopaedic surgeons who are members of the Orthopaedic Trauma Association.

Method: We surveyed members of the Orthopaedic Trauma Association to identify attitudes toward IPV by posting a survey on the Orthopaedic Trauma Association website for its membership to complete. The survey consisted of three sections:

the general attitude of the orthopaedic surgeon toward intimate partner violence,

Results: One-hundred-and-fifty-three orthopaedic surgeons responded. The majority of the respondents were male (99%) with practices in North America (96%). Surgeons underestimated the prevalence of IPV in their practices and communities and manifested several key misconceptions:

victims must be getting something out of the abusive relationships (16%);

In the past year, approximately half of the surgeons (50.8%) acknowledged identification of a victim of IPV; however, only 4.0% of respondents currently screened for IPV among female patients with injuries. Surgeons expressed concerns about lack of knowledge in the management of abused women (30%) Guidelines for the detection and management of IPV were uncommon in most surgeons’ practices (7.8%).

Conclusion: There is a strong rationale for addressing IPV as an issue that is relevant to the field of orthopaedic surgery just as it has been shown to be relevant to primary care, emergency medicine, and obstetrics and gynecology. Our study found that orthopaedic surgeons underestimated the prevalence of IPV in their practices, held multiple misperceptions about IPV, and demonstrated discomfort in identifying and treating IPV. Targeted educational programs on IPV are needed for surgeons who routinely care for injured women.

Purpose: Intimate partner violence (IPV), also known as domestic violence, is a pattern of coercive behaviors that include repeated physical, sexual and emotional abuse. Musculoskeletal injuries are common manifestations of IPV. We aimed to determine the proportion of women presenting to orthopaedic fracture clinics for treatment of orthopaedic injuries that have experienced IPV defined as physical, sexual, or emotional abuse within the past 12 months.

Method: We completed a cross-sectional study of 282 injured women attending two Level I trauma centres in Canada. Female patients presenting to the orthopaedic fracture clinics completed two validated self-reported written questionnaires (Woman Abuse Screening Tool (WAST) and the Partner Violence Screen (PVS)) to determine the prevalence of IPV. The questionnaire also contained questions that pertain to the participant’s demographic, fracture characteristics, and experiences with health care utilization.

Results: The overall prevalence of IPV (emotional, physical, and sexual abuse) within the last 12 months was 32% (95% Confidence Interval 26.4% to 37.2%) (89 of 282 women). One in 12 injured women disclosed a history of physical abuse (24/282, 8.5%) in the past year. Seven women (2.5%) indicated the cause for their current visit was directly related to physical abuse, of which five were fractures. We did not identify any significant trends in ethnicity, socioeconomic status, or injury patterns as markers of domestic abuse. Of 24 women with physical injuries, only four had been asked about IPV by a physician, none of whom were their treating orthopaedic surgeons.

Conclusion: Our study confirms a high prevalence of IPV among female patients with injuries attending orthopaedic surgical clinics in Ontario. Similar to previous research our study found that women of all ages, ethnicities, social economic status, and injury patterns may experience IPV. Surgeons should consider screening all injured women for domestic violence in their clinics.

Purpose: The purpose of this study was to evaluate the accuracy and precision of 3 common methods used to produce posterior tibial slope during total knee arthroplasty.

Method: The study population consisted of 110 total knee arthroplasties in 102 patients that underwent total knee arthroplasty. All procedures were performed using a standard medial parapatellar approach and all knees were replaced using the Scorpio Knee System (Stryker, Mahwah, NJ) of implants and instruments. Three treatment groups were identified retrospectively based on the method used to produce the posterior tibial slope. Group 1 used an extramedullary guide with a 0 degree cutting block tilted by placing 2 fingers between the tibia and the extramedullary guide proximally and three fingers between the tibia and guide distally to produce a 3 degree posterior slope (N=40). Group 2 used computer navigation (Stryker Navigation System, Stryker, Mahwah, NJ) to produce a 3 degree posterior slope (N=30). Group 3 used an extramedullary guide placed parallel to the anatomic axis of the tibia with a 5 degree cutting block to produce a 5 degree posterior slope (N=40). Posterior tibial slope was measured from lateral radiographs by 2 independent reviewers that were blinded to the treatment group. The reported posterior tibial slope for each sample was an average of these two measurements. Accuracy of the treatment group was evaluated using a one sample t test. Groups 1 and 2 were tested for an ideal slope of 3 degrees, and Group 3 was tested for an ideal slope of 5 degrees. An a priori sample size calculation with α=0.05 and β=0.20 showed that at least 24 samples in each treatment group were required to determine a difference of 1.5 degrees between the treatment group mean posterior tibial slope and the ideal posterior tibial slope.

Results: The mean posterior slope measurements for treatment Group 1 (4.15±3.24 degrees) and treatment Group 2 (1.60±1.62 degrees) were both significantly different than the ideal slope of 3 degrees (p=0.03 for Group 1 and p< 0.01 for Group 2). This indicates that treatment Groups 1 and 2 failed to accurately produce the ideal posterior tibial slope of 3 degrees. The mean posterior tibia slope of treatment Group 3 (5.00±2.87 degrees) was not significantly different than the ideal posterior tibial slope of 5 degrees (p=1.00). This indicates that Group 3 accurately produced the ideal tibial slope of 5 degrees.

Conclusion: The most accurate method to produce posterior tibial slope was the 5 degree cutting block with an extramedullary guide. Computer navigation had the lowest standard deviation and therefore was the most precise method. However, computer navigation was not as accurate in producing the desired posterior tibial slope as the extramedullary guide with the 5 degree cutting block. The manual method of producing tibial slope with an extramedullary guide and a 0 degree cutting block was the least precise method and not as accurate as the extramedullary guide with a 5 degree cutting block.

Purpose: Optimal fixation for comminuted proximal humerus fractures is controversial. Complications using locked plates have been addressed by anatomic reduction or medial cortical support. The current study measured relative mechanical contributions of varus malalignment and medial cortical support.

Method: Forty synthetic humeri were divided into three groups, osteotomized, and fixed at 0, 10, and 20 degrees of varus malreduction with locked proximal humerus plates (AxSOS, Global model, Stryker, Mahwah, NJ, USA). This simulated mechanical medial support with the cortex intact. Axial, torsional, and shear stiffness were experimentally measured. Half of the specimens in each of the groups underwent a second osteotomy to create a segmental defect which simulated loss of medial support with the cortex removed. Axial, torsional, and shear stiffness experiments were repeated, followed by shear load to failure in 20 degrees of abduction.

Results: For isolated malreduction with the cortex intact, the repair construct at 0 degrees showed statistically equivalent or higher axial, torsional, and shear stiffness than other groups assessed. Subsequent removal of cortical support in half the specimens resulted in a drastic effect on axial, torsional, and shear stiffness at all varus angles. Repair constructs with the cortex intact at 0 and 10 degrees resulted in mean shear failure forces of 12965.4 N and 9341.1 N, respectively. These were statistically higher (p< 0.05) compared to most other groups tested. Specimens failed mainly by plate bending as the femoral head was pushed down medially and distally.

Conclusion: Anatomic reduction with the medial cortex intact was the stiffest construct after a simulated two-part fracture. This study also supports the practice of achieving medial cortical support by fixing proximal humeral fractures in varus if necessary. This may be preferable to fixing the fracture in anatomic alignment when there is a medial fracture gap.

Purpose: Severe fractures damage blood vessels and disrupt circulation at the fracture site resulting in an increased risk of poor fracture healing. Endothelial progenitor cells (EPCs) are bone-marrow derived cells with the ability to differentiate into endothelial cells and contribute to neovascularization and re-endothelialization after tissue injury and ischemia. We have previously reported that EPC therapy resulted in improved radiographic healing and histological blood vessel formation in a rat fracture model. The purpose of this study was to further quantify the effects of EPC therapy with microCT and biomechanical analyses.

Method: Five-millimeter segmental defects were created and stabilized in the femora of 14 fisher 344 rats. The treatment group (n=7) received 1x106 EPCs within gelfoam locally at the area of the bone defect and control animals (n=7) received only saline-gelfoam with no cells. The formation and healing of bone after 10 weeks were asessed by radiographic, micro-CT and biomechanical analyses.

Results: Radiographically all the animals in EPC-treated group healed with bridging callus formation, whereas control group animals demonstrated radiographic non-union. Micro-CT assessment demonstrated significantly improved parameters of bone volume (35.34 to 20.68 mm³, p=0.000), bone volume density (0.24 to 0.13%, p=0.001), connectivity density (25.13 to 6.15%, p=0.030), trabecular number (1.14 to 0.51 1/mm, p=0.000), trabecular thickness (0.21 to 0.26 mm, p=0.011), trabecular spacing (0.71 to 1.88 mm, p=0.002), bone surface area (335.85 to 159.43mm, p=0.000), and bone surface to bone volume ratio (9.43 to 7.82 1/mm, p=0.013) in the defect site for the EPC group versus the control group respectively. Biomechanical testing showed that the EPC treatment group had a significantly higher torsional strength compared with the control group (EPC=164.6±27.9 Nmm, Control=29.5±3.8 Nmm; p value = 0.000). Similarly, the EPC treated fractures demonstrated significantly higher torsional stiffness versus controls (EPC=30.3±5.0 Nmm/ deg, Control=0.9±0.1 Nmm/deg; p value = 0.000). When biomechanically compared to contralateral intact limbs, the EPC treated limbs had similar torsional stiffness (p=0.996), but significantly lower torsional strength (p=0.000) and smaller angle of twist (p=0.002).

Conclusion: These results suggest that local EPC therapy significantly enhances fracture healing in an animal model. The biomechanical results show that control animals develop a mechanically unstable non-union. In contrast, EPC therapy results in fracture healing that restores the biomechanical properties of the fractured bone closer to that of intact bone.

Purpose: Today, numerous functional outcome tools exist to assess the patient’s ability to carry out basic and instrumental activities of daily living. Furthermore, the increase in range of mobility measures reflect differences in rating scales, scores, administration and scoring options which make outcome results difficult to assess across trials. Because of the lack of consensus among investigators, we wanted to identify the citation patterns of the functional outcomes tools used by investigators in hip fracture RCTs. We believed that the lack of proper citation is an underlying factor in the diverse usage of outcome tools.

Method: We extracted the citations of disability tools from 59 Level 1 hip fracture RCTs. Disability was defined using the WHO classification (ICF). We excluded measures assessing body structure. The text and reference lists of the identified articles were screened in order to compile relevant literature on the instrument used in the RCT. Disability tools which were cited in the references were also compared to original development articles.

Results: Overall 68 different instruments were identified that measured disability in the hip fracture literature. According to ICF, 47 tools measured body function alone, 13 tools evaluated activity limitations and participation restriction and 8 were composite scoring systems. We found that 34.2% of the trials did not provide any citations to the tools assessing body function. In trials measuring activity and participation, 23.2% provided instrument citations. In trials using composite scoring systems, 19.4% of the trials provided instrument citations. All of the instrument citations when provided by the investigators were found to correspond to original development articles or trials.

Conclusion: The appropriate choice of a functional outcome instrument is fundamental in order to ensure that the results that are obtained reflect the patient. However, if citations of the indices and scales themselves are lacking, trial methodology and results could be informative but not replicated. In the future, we recommend that rigor in quality reporting include proper instrument citations.

Purpose: Unbiased outcome assessment in orthopedic clinical trials has the potential to improve trial validity. The approaches used to limit bias in outcome assessment in orthopaedic trials remain unclear. The objective of this systematic review was to assess the reporting and process of outcomes assessment practices in the current orthopaedic trauma literature.

Method: We searched eight high-impact-factor medical and orthopaedic journals manually and using the MED-LINE electronic database for reports of randomized controlled trials published from 2005 to 2008 pertaining to the surgical treatment of trauma-related injuries. Two reviewers independently determined study eligibility and extracted relevant data from included trials.

Results: Of the 7910 citations identified during our search, 47 randomized controlled trials, which included a total of 4706 patients, met our inclusion criteria. Of 47 studies, 39 (83%) provided a statement to describe some process of outcome assessment and 29 (74%) reported using an unblinded individual as the outcome adjudicator. Four studies (10%) reported using a second assessor to verify outcome measurements, and three studies (8%) reported the use of an adjudication committee to reach endpoint decisions via consensus. No included study provided a rationale for the use of their chosen approach to adjudication. The most commonly adjudicated outcomes included fracture healing (15 studies), reoperation rate (6 studies), and general clinical assessment of post-operative complications and limb function (30 studies), mainly by orthopaedic surgeons. Blinding of outcome assessors was not performed or unclear in 38 studies (81%).

Conclusion: Despite the importance of the outcome assessment process in orthopedic trauma trials, key aspects of outcome assessment are insufficiently reported. This limits the ability of readers to assess the validity of published trials.

Purpose: The purpose of this study was to compare the effects of two types of stem/progenitor cells on the healing of critical sized bone defects in a rat model. Endothelial Progenitor Cells (EPCs), a novel cell type with previously demonstrated effects on angiogenesis in animal models of vascular disease, were compared to both a control group of no cell therapy, and a treatment group of Mesenchymal Stem Cells (MSCs). The hypothesis was that EPCs would demonstrate both superior bone healing and angiogenesis, when compared to the control group and MSC group.

Method: EPCs and MSCs were isolated from the bone marrow of syngeneic rats by differential culture and grown ex vivo for 10 days. Subsequently the cells were harvested, seeded on a gelfoam scaffold, and implanted into a 5mm segmental defect in a rat femur that had been stabilized with a plate and screws. Bone healing was assessed radiographically and by microCT. Angiogenesis was assessed by histology and physiologically, using laser doppler to assess blood flow in the bone and soft tissues. All animal protocols were approved by and performed in accordance with the St. Michael’s Hospital Animal Care Committee. ANOVA was used to test for significant differences between the groups, and a p-value of < 0.05 was considered statistically significant.

Results: The EPC (n=14) group demonstrated radiographic evidence of healing of the bone defect as early as 2 weeks, and all specimens were radiographically healed at 6 weeks. Both the control group (n=14) and the MSC group (n=14) showed no radiographic evidence of healing at 10 weeks. MicroCT comparison of the EPC group versus the control group showed significantly greater bone volume and density at the defect site (p< 0.001). More blood vessel formation was observed in the EPC group versus the control group on histology at 2 weeks. Laser Doppler assessment showed significantly more soft tissue and bone blood flow at 2 and 3 weeks in the EPC group versus the control group (p=0.021).

Conclusion: The results of this study demonstrate that EPCs are effective as cell-based therapy for healing critical sized bone defects in a rat model. In this model EPCs demonstrated superiority to MSCs with regard to bone healing. In addition, EPCs demonstrated superior angiogenesis over controls in a rat model of fracture healing. These results strongly suggest that EPCs are effective for therapeutic angiogenesis and osteogenesis in fracture healing. There is a clinical need for effective strategies in the management of traumatic bone defects and nonunions. Investigation into the use of MSCs as an effective alternative to autologous bone grafting has failed to translate into clinical use. It is possible that EPCs are more effective at the regeneration of bone in segmental defects because of their synergistic effect on angiogenesis and osteogenesis. Further research into EPC based therapies for fracture healing is warranted.

Purpose: Failure to adequately recruit patients in orthopaedic trials has often led to early stopping and publication of research findings from smaller sample sizes than originally planned. The purpose of this study is to demonstrate the effect of sample size in a large, clinical trial by using SPRINT trial data to evaluate the results that would have been reported if the trial were stopped at various enrollments.

Method: The SPRINT trial evaluated reamed vs. unreamed nailing in 1226 tibia fractures. We analyzed the re-operation rates after various increments in sample size and compared the early results that would have been reported at smaller enrollments with those seen in the final, adequately powered study.

Results: In the final analysis of 1226 patients, there was a significant reduction in the risk of re-operation with reamed nails for closed fractures (35% reduction; p=0.02) and a trend towards an increased risk of re-operation for open fractures (23% increase; p=0.26). In stark contradiction, the results for the first 50 patients enrolled in the trial revealed a substantial increased risk for reamed nails in closed fractures (risk increase: 165%). It was not until enrollment reached 800 patients that the results reflected the final findings of an advantage for reamed nails. In open fractures, the trend favoring unreamed nails was not seen until 200 patients had been enrolled.

Conclusion: Our findings suggest that stopping the SPRINT trial early would have led to misleading estimates of the treatment effect between reamed and unreamed nails.

Purpose: To determine the effect of reamed versus non-reamed intramedullary (IM) nailing of femoral diaphyseal fractures on the rates of non-union and acute respiratory distress syndrome (ARDS).

Method: We searched the online databases of OVID, MEDLINE, EMBASE, PubMed, and the Cochrane collaboration for randomized clinical trials (RCT) from 1998 to 2009. Additional studies were identified by hand searches of major orthopaedic journals, reference lists of eligible studies, SCISEARCH, and title reviews of presentations from major orthopaedic trauma meetings. Inclusion criteria were trials evaluating the effect of reamed versus nonreamed closed interlocked intra-medullary nailing of femoral diaphyseal fractures on the rates of nonunion or acute respiratory distress syndrome (ARDS) in skeletally mature adults. Exclusion criteria included patients with pathologic fractures, skeletally immature patients, as well as observational and other non-randomized studies.

Results: Seventy-two citations were initially identified out of 1,147 studies. 6 studies matched all eligibility criteria as assessed by three independent reviewers. A total of 941 patients with 956 femoral diaphyseal fractures treated with intramedullary nailing met the eligibility criteria. The relative risk of non-union (four trials, n= 456 patients) was 0.29 [95% confidence interval (CI), 0.14 to 0.57; p< 0.00001] (ie. a 70% relative risk reduction of nonunion) in favour of a reamed intramedullary nail There was no significant difference in the rates of ARDS following reamed or non-reamed nailing, relative risk for ARDS (two trials, n=397) 1.10 [95% CI, 0.27 to 4.54, p=0.18].

Conclusion: The study suggests that reamed intramedullary nailing of femoral diaphyseal fractures significantly reduces the risk of non-union as compared to nonreaming. The risk of ARDS was not statistically significant between groups; however there was a slight trend towards ARDS iwith reamed IM fixation.

Purpose: Minimizing tip-apex distance (TAD) has been shown to reduce clinical failure of extramedullary sliding hip screws used to fix peritrochanteric fractures. There is debate regarding the optimal position of the lag screw in the femoral head when a cephalomedullary nail is used to treat a peritrochanteric fracture. Some authors suggest the TAD should be minimized as with an extramedullary sliding hip screw, while others suggest the lag screw should be placed inferior within the femoral head. The primary goal of this study was to determine which of 5 possible lag screw positions in the femoral head provides greatest mechanical stiffness and/or load-to-failure for an unstable peritrochanteric fracture treated with a cepha-clomedullary nail. The secondary goal was to determine if there is a linear correlation between implant-femur mechanical stiffness and/or load to failure (dependent variables) with a series of five radiographic measurements (independent variables) of distance from the lag screw tip to the femoral head apex.

Method: Long Gamma 3 Nails (Stryker, Mahwah, NJ) were inserted into 30 left synthetic femurs (Pacific Research Laboratories, Vashon, WA). An unstable four-part fracture was created, anatomically reduced, and repaired using one of 5 lag screw placements in the femoral head:

superior (n=6),

All specimens were radiographed in the anterioposterior and lateral planes, and radiographic measurements including TAD and a calcar referenced tip-apex distance (CalTAD) were calculated. All specimens were tested for axial, lateral, and torsional stiffness, and then loaded-to-failure in the axial position using an Instron 8874 (Canton, MA). ANOVA was used to compare means of the five treatment groups. Linear regression analysis was used to compare stiffness and load-to-failure (dependant variables) with radiographic measurements (independent variables). A post hoc power analysis was performed.

Results: The inferior lag screw position had significantly greater mean axial stiffness than superior (p< 0.01), anterior (p=0.02) and posterior (p=0.04) positions. Analysis revealed significantly less mean torsional stiffness for the superior lag screw position compared to other lag screw positions (p< 0.01 all 4 pairings). No statistical differences were noted for lateral stiffness. Superior and central lag screw positions had significantly greater mean load-to-failure than anterior (p< 0.01 and p=0.02) and posterior (p< 0.01 and p=0.05) positions.

There were significant negative linear correlations between stiffness tests with CalTAD, and load-to-failure with TAD. Power was greater than 95% for axial stiffness, torsional stiffness and load-to-failure tests.

Conclusion: Position of the lag screw in the femoral head affects the biomechanical properties of the implant-femur construct. Central placement of the lag screw with minimization of TAD may provide the best combination of stiffness and load-to-failure.

Purpose: Cephalomedullary nails rely on a large lag screw that provides fixation into the femoral head. There is an option to statically lock the lag screw (static mode) or to allow the lag screw to move within the nail to compress the intertrochanteric fracture (dynamic mode). The purpose of this study was to compare the biomechanical stiffness of static and dynamic modes for a cephalomedullary nail used to fix an unstable peritrochanteric fracture.

Method: Thirty intact synthetic femur specimens (Model #3406, Pacific Research Laboratories, Vashon, WA) were potted into cement blocks distally for testing on an Instron 8874 (Instron, Canton, MA). A long cephalomedullary nail (Long Gamma 3 Nail, Stryker, Mahwah, NJ) was then inserted into each of the femurs. An unstable four-part fracture was created, anatomically reduced, and the cephallomedullary nail was reinserted. Mechanical tests were conducted for axial, lateral, and torsional stiffness with the lag screws in:

static and

A paired student’s t test was used to compare the 2 modes.

Results: The axial stiffness of the cephalomedullary nail was significantly greater (p< 0.01) in the static mode (484.3±80.2N/mm) than in the dynamic mode (424.1±78.0N/mm) (Fig.2A). Similarly, the lateral bending stiffness of the nail was significantly greater (p< 0.01) in the static mode (113.9±8.4N/mm) than in the dynamic mode (109.5±8.8N/mm). The torsional stiffness of the nail was significantly greater (p=0.02) in the dynamic mode (114.5±28.2N/mm) than in the static mode (111.7±27.0N/mm).

A post hoc power analysis with & #945;=0.05 and & #946;=0.20 revealed that the paired t test on 30 samples was sufficiently powered to determine a difference in mean axial stiffness of 33.0N/mm (6.8% of static stiffness), a difference in mean lateral bending stiffness of 3.6N/mm (3.2% of static stiffness) and a difference in mean torsional stiffness of 3.4N/mm (3.0% of static stiffness).

Conclusion: Our results show that there is a 60N/mm reduction in axial stiffness of the cephalomedullary nail when the lag screw is changed from static to dynamic mode. This represents a 12.4% reduction in axial stiffness with a change from axial to dynamic modes which may be clinically significant. The differences in lateral (4.4N/mm, 3.9%) and torsional (2.8N/mm, 2.4%) are small enough that they are likely not clinically significant. We felt that a difference of greater than 10% in axial stiffness and a difference of greater than 5% in lateral or torsional stiffness would be clinically significant. Our study was adequately powered to detect these differences. Given the significant reduction in axial stiffness with dynamization of the cephalomedullary nail construct, we recommend use of the static mode when treating unstable peritrochanteric fractures with a cephalomedullary nail.

Purpose: Preoperative planning forces the surgeon to understand the “fracture personality” and devise an operative plan. In our experience, trainees have difficulty in preparing for complex acetabular cases; these fractures are among the most difficult fractures to conceptualize and teach. As a result, these fractures are poorly understood as demonstrated by low interobserver agreement between trainees in the classification of acetabular fractures. We sought to determine whether the use of visou-haptic technology would help trainees to appreciate the “personality” of an Associated-Both-Column (ABC)fracture more accurately than trainees taught by conventional instruction.

Method: Thirty senior medical students and PGY1 residents, were randomized into two groups. The control group studied an ABC fracture with the aid of a textbook excerpt and a 3D CT reconstruction of the fracture. The intervention group was given the same instructional materials, and a visuo-haptic CT model of the fracture. All other learning variables, including time on task were standardized. Participants were evaluated on their accuracy in drawing the fracture lines on a model pelvis.

Results: There was no significant difference in gender, visuo-spatial ability, and training level between groups. The participants taught with the visuo-haptic model recalled an additional 26% anatomic relationships (p< 0.01) compared with the control group.

Conclusion: These findings suggest that in addition to the benefits observed in the learning of motor skills, visuo-haptic input may improve the understanding of spatial relationships. This technology may be a useful adjunct for teaching anatomy, as well as preoperative planning.

Purpose: Accurate prediction of re-operation following tibial nailing may facilitate optimal patient care. We recently completed the SPRINT trial, a large, multi-centre trial of reamed versus non-reamed intramedullary nails in 1226 patients with tibial shaft fractures. Using the SPRINT data, we conducted an investigation of baseline and surgical patient characteristics to determine if they are associated with increased risk of re-operation within one year.

Method: Using multivariable logistic regression analysis, we investigated 15 characteristics for association with increased risk of re-operations. Because the primary SPRINT analysis found that reamed nailing reduced events in patients with closed but not open fractures, we considered both open and closed as well as treatment status in our model.

Results: We found an increased risk of re-operation in patients with a high energy mechanism of injury (odds ratio, OR=1.57, 95% CI 1.05 to 2.35), stainless steel versus titanium nail (OR=1.52, 95% CI 1.10 to 2.13), fracture gap (OR=2.40, 95% CI 1.47 to 3.94) and post-operative weightbearing (OR=1.63, 95% 1.003 to 2.64). Open fractures increased the risk of re-operation in patients who received a reamed nail (OR=3.26, 95% CI 2.01 to 5.28) but not in patients who received a non-reamed nail (OR=1.50, 95% CI 0.92 to 2.47). Patients with open fractures who had either wound management without any additional procedures, or delayed primary closure, had a decreased risk of re-operation when compared to patients who required subsequent reconstruction (respectively, OR=0.18, 95% CI 0.09 to 0.35; OR=0.29 95% CI 0.14 to 0.62).

Conclusion: To ensure optimal patient care surgeons should consider the characteristics identified in our analysis to reduce risk of re-operation.

Purpose: Vascular Endothelial Growth Factor (VEGF) plays an important role in promoting angiogenesis and osteogenesis during fracture repair. Our previous studies have shown that cell-based VEGF gene therapy accelerates bone healing of a rabbit tibia segmental bone defect in-vivo, and increases osteoblast proliferation and mineralization in-vitro. The aim of this project was to examine the effect of exogenous human VEGF (hVEGF) on the endogenous rat VEGF messenger RNA (mRNA) expression in a cell-based gene transfer model.

Method: The osteoblasts were obtained from the rat periosteum. The fibroblasts were obtained from the rat dermal tissue. The cells were then cultured to reach 60% confluence and transfected with hVEGF using Superfect. Four groups were:

osteoblast-hVEGF,

The cultured cells were harvested at 1, 3 and 7 days after the transfection. The total mRNA was extracted (TRIZOL); both hVEGF and rat VEGF mRNA were measured by reverse transcriptase-polymerase chain reaction (RT-PCR) and quantified by VisionWorksLS.

Results: The hVEGF mRNA was detected by RT-PCR from transfected osteoblasts after three days of gene transfection. The hVEGF mRNA expression in transfected fibroblasts increased exponentially at days 1, 3 and 7 after the transfection. We compared the endogenous rat VEGF mRNA expression level of the osteoblasts or fibroblasts that were transfected with hVEGF with the cells without the transfection. The hVEGF transfected osteoblasts had a greater rat VEGF mRNA expression than the non-transfected osteoblasts. Furthermore, when hVEGF was transfected to the rat fibroblasts, the endogenous mRNA expression level measured was also greater than that from the non-transfected fibroblasts. Rat VEGF mRNA expression increased in the first three days of the hVEGF transfection, but the expression level was reduced at Day 7.

Conclusion: These results suggest that cell-based hVEGF gene therapy enhances endogenous rat VEGF mRNA expression in both osteoblasts and fibroblasts.

Purpose: The use of UHMW polyethylene acetabular liners is known to cause polyethylene wear related osteolysis, the major limiting factor in its use in the younger active patient. Modern alumina ceramic articulations have been developed in order to reduce wear and avoid polyethylene debris. This prospective randomized long-term study aims to compare the outcome between an alumina ceramic-on-ceramic (CC) articulation with a ceramic on UHMW polyethylene articulation (CP).

Method: Fixty-six hips in 55 patients with mean age 42.2 (range 19–56) each received uncemented components (Wright Medical) and a 28mm alumina head with acetabular liner selected via sealed envelope randomization following anesthetic induction. Subsequent regular clinical and radiologic follow up measured patient outcome scores and noted any radiological changes.

Results: Twenty-six CP hips and 30 CC hips were evaluated. One failure required revision in each group. Mean St Michael’s outcome score for each group with up to 10 years follow-up (median 8 years, range 1–10) was 22.8 and 22.9 respectively (p=0.057). Radiographs with a minimum 5 years post-operative follow-up were analyzed in 42 hips (23 CC and 19 CP). The mean time of wear measurement for the CC group was 8.3 years (SD 1.3, Range 4.8–10.1 years) and for the CP group was 8.1 years (SD 0.9, Range 6.1–9.2 years)(p=0.471). Wear was identified in all but one CP hip but in only 12 of 23 CC replacements. Mean wear in the CP group was 0.11mm per year and 0.02mm per year in the CC group (p< 0.001).

Conclusion: To our knowledge this is the first long term randomized trial comparing in-vivo ceramic-on-ceramic with ceramic-on-polyethylene hip articulations. Other than significantly greater wear in the polyethylene group there was no significant difference in long-term outcome scores between the two groups with up to 10 years of follow-up. The use of a ceramic-on-ceramic bearing is a safe and durable option in the young patient avoiding the concerns of active metal ions and osteolytic polyethylene debris.

Purpose: To conduct a study to identify differences in complication rates and outcomes between previously recognized sub-groups commonly treated for limb length discrepancies (LLD).

Method: Forty-two males and 13 females were treated for LLD at two level-one trauma centres. Mean LLD was 4.4 cm (range 1.8 to 18cm). There were 44 femoral segments (in 41 patients) and 14 tibia segments lengthened. Forty were post-traumatic, and 18 congenital/ developmental. Objective data regarding complications, length achieved, and lengthening duration was collected from patient records. Two groups were compared for differences: Developmental (congenital and developmental etiology combined; LLD occurred prior to skeletal maturity and treatment involved creating new length) versus post-traumatic (restoration of previously existing length), and tibia versus femoral lengthening.

Results: A mean of 4.4 cm of length was achieved over a mean duration of 83 days, for a mean lengthening index of 18.9 days/cm. Superficial pin tract infections were the most common complication, occurring in 33 segments (56%). Deep infection occurred in six segments (10%). Three of these six had a history of open fracture, and a fourth had a history of infection during initial fracture management. All were successfully treated with irrigation and debridement, and exchange nailing. The developmental group had significantly greater incidence of flexion contracture (13% versus 78%, p< 0.001), and surgical correction for a contracture deformity (5% versus 61%, p< 0.001). The post-traumatic group had a significantly higher rate of painful hardware requiring removal following successful treatment of their LLD (45% versus 16%, p=0.04). Tibia segments had a significantly greater lengthening index (29 d/cm versus 18 d/cm, p=0.03).

Conclusion: Limb lengthening is an involved process with potential for serious complications. Patients who had limb-lengthening for congenital/ developmental discrepancies had a higher rate of adjacent joint contrac-ture and subsequent requirement for surgical release. Patients with post-traumatic lengthening had a higher rate of hardware removal, and the lengthening index was greater for tibiae than femora. Deep infection remains a significant concern. This study provides information for physicians and patients on the rate and type of complications that can be expected both overall, and within specific LLD treatment groups.

Purpose: The purpose of this study was to relate the extent of reaming to bone formation occurring around a critical sized defect in the tibia.

Method: Eleven canines were allocated into 2 groups: empty (N=5) or iliac crest autograft (N=6). All tibiae were reamed to 7.0 mm and fixed with a 6.5 mm statically locked intramedullary nail after creation of an 8.0 mm diaphyseal defect. The extent of reaming of the canal was dependent on the cross-sectional area of the tibia as all tibiae were reamed to 7.0 mm. Fluorescent markers were given at different times: calcein green (6 weeks), xylenol orange (9 weeks), and tetracycline (11 and 14 weeks). Animals were sacrificed at 15 weeks and perfused with a barium compound. Radiography, Micro CT, brightfield microscopy and fluorescent microscopy were used for analysis.

Results: Bone and vasculature volume within the defect were reported as a percentage of the total volume of the defect. Linear regression analysis of percent bone volume (dependent variable) and canal area (independent variable) provided a Pearson correlation coefficient of 0.925 (p=0.025) for the empty group and 0.244 (p=0.641) for the autograft group. Linear regression analysis of percent vasculature volume (dependent variable) and canal area (independent variable) provided a Pearson correlation coefficient of 0.784 (p=0.117) for the empty group and −0.146 (p=0.783) for the autograft group. Bone formation at osteotomy sites was defined as the distance from the original osteotomy site to the tip of newly formed bone. Linear regression analysis of bone formation at the osteotomy sites (dependent variable) and canal area (independent variable) provided a Pearson correlation coefficient of 0.132 (p=0.832) for the empty group and −0.937 (p=0.006) for the autograft group. Bone formation rates were reported as the distance between the fluorescent labels. Bone formation rate was less within the endosteum, cortex and periosteum with extensive reaming in empty samples.

Conclusion: Our results suggest that the acute management of tibia fractures with bone defects should involve limited reaming. This does not apply when the defect is autografted. Limited reaming may be defined by the cross-sectional area of the tibia in ratio to that of the reamer.

Purpose: Endothelial Progenitor Cells (EPCs) have been proven to contribute to formation of new blood vessels. The objective of this study was to evaluate the effects of local EPC therapy on the stimulation of angiogenesis at a fracture site and the promotion of bone healing by increasing osteogenesis and callus formation.

Method: Rat bone marrow EPCs were isolated and cultured. A segmental bone defect (4mm.) was created in the rat femur diaphysis and stabilized with a mini-plate. A gelfoam piece impregnated with a solution of EPCs (1x106) was placed into the fracture gap. Control animals received only saline-gelfoam with no cells. In total, 42 rats were studied: 21 in EPC and 21 in control groups. Seven animals were sacrificed from each group at one, two, and three weeks post-operatively. Plain radiographs of the operated femur were taken before sacrifice. Operated femurs were harvested and the specimens from the osteotomy site were collected for histological evaluation. The x-rays were scored in a scale from zero to five according to the percentage and the intensity of the bone filling at the osteotomy site. Hematoxylin-eosin stained slides were evaluated for new vessel formation and the amount of bone tissue.

Results: Radiographically, at three weeks, the mean score for the EPC group was 4.5 with five out of seven animals having bridging callus; whereas for the control group, the mean score was 2.2 with no bridging callus formation. At two weeks, EPC treated animals had a mean score of 2.4, and the control group had a score of 1. Bone formation was insignificant at one week in either group, however, the scores tended to be higher in the EPC group animals than the control; 0.6 to 0.3 respectively. Histological evaluation revealed that the specimens from EPC treated animals had abundant spicules of trabecular bone containing predominantly bone cells, osteoid, and new vessels. Conversely, control animals had scarce trabecular bone with markedly less bone cells and vessels.

Conclusion: Local EPC therapy stimulates angiogenesis and increases osteogenesis and callus formation post fracture. Our report encourages further investigation of the local use of EPCs as a potential therapy to promote bone regeneration.

Purpose: Identifying optimal treatment strategies in patients with traumatic foot and ankle injuries has been hampered by the variety of different measurement tools and lack of validation of generic and foot-specific functional measures. It remains plausible that the choice of functional outcome measure may influence our ability to accurately measure treatment effects. This prospective observational study aims to correlate the scores across six functional outcome measures in patients with traumatic foot and ankle injuries and to examine agreement of scores and patients’ subjective health status.

Method: Patients with traumatic foot or ankle injuries completed two generic, the SF-12 Health Survey and the Short Musculoskeletal Functional Assessment (SMFA), and four specific health outcome measures, the Foot Function Index (FFI), Foot and Ankle Ability Measure (FAAM), American Academy of Orthopedic Surgeons (AAOS) Foot and Ankle Questionnaire and the American Orthopedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale, at a single follow-up visit. Raw scores were calculated and used to assign patients to a categorical functional level (excellent, very good, good, fair or poor). Agreement between the assignments was assessed and Pearson correlation co-efficients were calculated for each pair of outcome scores. Statistical significance was determined using an α of 0.05.

Results: 52 patients (mean age 43.3 ± 16.8 years) were enrolled at a mean follow-up of 15.5 months. All correlations except for that between the AOFAS ankle-hindfoot scale and the mental component of the SF-12 were statistically significant. The strongest correlations were found between the SMFA, FFI, AAOS Foot and Ankle Questionnaire and the FAAM. Despite significant correlation between scores and patients’ subjective functional outcome, there was minimal agreement between assigned categorical functional levels.

Conclusion: The high correlations between scores on the generic and foot-specific functional measures suggest that it is likely unnecessary to use more than one instrument when examining functional outcome in patients with traumatic foot and ankle injuries. Generic tools also appear to function as well as specific scores in this population. However, assignment of patients to a categorical functional level based on raw outcome scores must be performed with caution as the results obtained may not accurately reflect functional outcome.

Purpose: While the durability of most uncemented femoral stems remains unknown, it is the aim of this study to demonstrate Echelon Primary femoral stem performance with regard patient outcome and overall implant survival.

Method: Between February 1998 and March 2007, 428 patients received the Echelon Primary stem. The mean age of each patient was 58.1 (SD 11.1, Range 20–87). Body mass index averaged 30.5 kg/m2 (SD 5.8, Range 17.7–58.2). The majority of patients received a Reflection uncemented acetabular component (91%) and an ultra high molecular weight polyethylene liner (76.5%), although the highly cross linked polyethylene is now used with increased frequency, used in 31% of hips since 2005. The majority of femoral heads were cobalt chrome (79.3%).

Results: Kaplan Meier survivorship for the Echelon Femoral stem with revision for aseptic loosening as end point at 100 months is 99.3% (95% CI 97.1–99.8). Taking revision for any reason as the end point the Kaplan Meier survivorship is 98.3% at 100 months (95% CI 95.9–99.3). A pre-operative WOMAC score was available for 345 of the 392 patients with mean score of 43.5 (95% CI 41.6–45.4). At the three-month post-operative review the mean WOMAC score was significantly increased to 74.54 (95% CI 72.7–76.3)(p< 0.001) and by 1 year 84.3 (95% CI 80.5–88.1). At subsequent years, the modified WOMAC score remained at a plateau of around 80. General health assessment using the SF-36 shows an improvement in the physical component score from 33.1 (95% CI 32.3–33.9) preoperatively to 42.6 (95% CI 41.7–43.6)(p< 0.001) at three months and 48.19 (95% CI 44.2–52.2) at latest follow up. The mental component scores increased from 48.7 (95% CI 47.6–49.9) to 51.4 (95% CI 50.3–52.4)(p< 0.001) and 53.5 (95% CI 50.3–56.6) respectively.

Conclusion: This large prospective review of the Echelon Primary femoral stems reveals an excellent survivorship of the stem with a 99.3% survival at 8 years with regard aseptic loosening and 98.3% survival including revision for any reason. Patient outcome scores are significantly improved and subsequently maintained. There have been no changes with regard to manufacture or design of the stem within the period of review.

Purpose: Hip resurfacing is a technically demanding alternative to total hip arthroplasty. Placement of the initial femoral guidewire utilizing traditional mechanical jigs may lead to preparatory errors and a high degree of variability in final implant stem-shaft angle (SSA). Intraoperative computer navigation has the potential to decrease preparatory errors and provide a reliable method of femoral component placement. The current study evaluated the accuracy and learning curve of 140 consecutive navigated hip resurfacing arthroplasties.

Method: Between October 2005 and May 2007, 140 consecutive Birmingham Hip Resurfacings were performed on 132 patients (107 male, 25 female). The mean age of the cohort was 51.2 years (range 25–82). Indications for surgery included osteoarthritis (n=136) and avascular necrosis (n=4). Preoperative templating was performed using digital AP unilateral hip radiographs. Neck-shaft angles (NSA) were digitally measured and relative implant stem-shaft angles planned. The central guidewire was drilled and verified intra-operatively using an imageless navigation system. Implant stem-shaft angles were assessed using 3 month post-operative radiographs.

Results: Pre-operative templating determined a mean NSA of 132.2 degrees (SD 5.3 degrees, range 115–160). The planned SSA was a relative valgus alignment of 9.5 degrees (SD 2.6 degrees). The post-operative SSA differed from the planned SSA by 2.5 degrees (SD 1.9 degrees, range 0–8). The final SSA measured within ±5 degrees of the planned SSA in 89% of cases. Of the remaining 11% of cases, all measurements erred in valgus. No cases of neck notching or varus implant alignment occurred in the series. The mean navigation time for the entire series was 18 minutes (SD 6.6 minutes, range 10–50). A learning curve was observed with respect to navigation time, with a significant decrease in navigation time between the first 20 cases and the remainder of the series. There was no evidence of a learning curve for implant placement accuracy.

Conclusion: Imageless computer navigation shows promise in optimizing preparation of the femoral head and reducing the introduction of mechanical preparatory factors that predispose to femoral neck fracture. Navigation may afford the surgeon an accurate and reliable method of femoral component placement with negligible learning curve.

Purpose: The aim of our study was to evaluate bone formation and angiogenesis produced within a biodegradable poly-D, L-lactide-co-glycolide acid/calcium phosphate (PLGA/CaP) scaffold when used to treat a diaphyseal tibia defect and compare this to an iliac crest autograft or an empty defect.

Method: An 8.0 mm diaphyseal defect was created in a canine tibia model. All tibiae were reamed to 7.0 mm and fixed with a 6.5 mm statically locked intramedullary nail. Eighteen canines were allotted into three treatment groups:

empty (N=5),

Fluorescent markers were given at different times: calcein green (six weeks), xylenol orange (nine weeks), and tetracycline (11 and 14 weeks). Animals were sacrificed at 15 weeks and perfused with a barium compound. Radiography, Micro CT, and brightfield and fluorescent microscopy were used for analysis.

Results: Micro CT and brightfield images of scaffold samples displayed multiple vessels (10 to 100μm) within the scaffold. The bone volume and vasculature volume (measured with Micro CT) within the tibial defect site were reported as a percentage of the total volume of the defect site. The percent bone volume within the defect site was not different between treatment groups (p=0.112). There was greater percent vasculature volume in the scaffold group than the autograft group (p< 0.001). Bone formation at the osteotomy sites was defined as the distance from the original osteotomy site to the tip of newly formed bone. Osteotomy bone formation was significantly greater in the scaffold group than the autograft group (p=0.015). Osteotomy sites associated with greater angiogenesis displayed greater bone formation. Bone formation rates were reported as the distance between the fluorescent bone labels. Autograft samples had the greatest bone formation rates within the periosteum. Autograft and scaffold samples had the greatest rate of bone formation within the cortex.

Conclusion: Our canine tibial defect model provides a satisfactory facsimile of the traumatic tibia fracture with associated bone loss. The PLGA/CaP biodegradable scaffold we have employed promotes angiogenesis within a defect and could be used in conjunction with autografting.

We conducted a systematic review and meta-analysis of randomised controlled trials comparing cross-linked with conventional polyethylene liners for total hip replacement in order to determine whether these liners reduce rates of wear, radiological evidence of osteolysis and the need for revision. The MEDLINE, EMBASE and COCHRANE databases were searched from their inception to May 2010 for all trials involving the use of cross-linked polyethylene in total hip replacement. Eligibility for inclusion in the review included the random allocation of treatments, the use of cross-linked and conventional polyethylene, and radiological wear as an outcome measure. The pooled mean differences were calculated for bedding-in, linear wear rate, three-dimensional linear wear rate, volumetric wear rate and total linear wear. Pooled risk ratios were calculated for radiological osteolysis and revision hip replacement. A search of the literature identified 194 potential studies, of which 12 met the inclusion criteria. All reported a significant reduction in radiological wear for cross-linked polyethylene.

The pooled mean differences for linear rate of wear, three-dimensional linear rate of wear, volumetric wear rate and total linear wear were all significantly reduced for cross-linked polyethylene. The risk ratio for radiological osteolysis was 0.40 (95% confidence interval 0.27 to 0.58; I² = 0%), favouring cross-linked polyethylene. The follow-up was not long enough to show a difference in the need for revision surgery.

We systematically reviewed the peer-reviewed literature to relate the survival of hybrid metal-on-metal hip resurfacing arthroplasty devices to a National Institute of Clinical Excellence (NICE) benchmark for choosing a primary total hip replacement, which is a survival rate of 90% at a follow-up of ten years.

A total of 29 articles (10 621 resurfaced hips) met the inclusion criteria. The mean follow-up ranged from 0.6 to 10.5 years and the survival of the implant ranged from 84% to 100%. Of the 10 621 hips, 370 were revised (3.5%), with aseptic loosening as the most frequent mode of failure.

None of the hip resurfacing arthroplasty implants used to date met the full ten-year NICE benchmark of survival. A total of 13 studies showed satisfactory survival compared with the three-year NICE benchmark.

Purpose: In a prospective randomized clinical trial, we have previously reported the “limb-specific” results comparing operative (plate fixation) versus non-operative (sling) treatment for completely displaced fractures of the shaft of the clavicle. We also sought to determine the effect that a fracture of the shaft of the clavicle had on general health status, as measured by the SF-36 General Health Status instrument. We then evaluated the effects of different treatment methods (operative versus non-operative), on general health scores.

Method: We performed a multi-center, randomized clinical trial of operative versus non-operative treatment of completely displaced clavicular shaft fractures in 111 patients. In addition to radiographic, surgeon-based, and limb-specific data we prospectively gathered SF-36 questionnaires at baseline, and at 6 weeks and 3, 6, 12, and 24 months post-injury.

Results: Results: Both groups had SF-36 scores equivalent to or slightly superior to population norms at baseline. A clavicular shaft fracture had a significant negative effect on SF-36 scores (especially the physical components) in both groups at 6 weeks (p< 0.01) and 3 months (p< 0.01). There was a statistically greater decrease in Physical Component Scores (PCS) in the non-operative group compared to the operative group (P< 0.05). At 6 months, scores had returned to pre-operative levels in the operative group, but remained significantly decreased in the non-operative group (p=0.04). This difference persisted at the one and two year points.

Conclusion: A displaced fracture of the clavicular shaft has a clinically significant negative effect on general health status scores. This effect can be mitigated by primary operative fixation, which restores scores to normal levels by six months post-injury. Patients treated non-operatively for a displaced fracture of the shaft of the clavicle demonstrated lower PCS scores at two years post-injury. This information is useful in counseling patients with regards to treatment options following displaced fractures of the clavicle shaft.

Purpose: Tibial shaft fractures are a common injury. Tibial nailing is the current standard of care for these injuries, yet there is little information regarding patient based outcomes after nailing. We sought to determine the 1 year patient based outcomes and return to activities for patients with tibia fractures in a randomized trial of reamed and unreamed nail insertion.

Method: Over a 5 year period 1226 patients with 842 closed and 406 open tibial shaft fractures were enrolled in a randomized trial comparing reamed with unreamed tibial nail insertion in 29 trauma centers and had one year follow-up. The average age was 39±16 years and 74% were male. Patient based outcomes were determined using the validated Short Form-36 (SF-36) Physical Component Summary, the Short Musculoskeletal Functional Assessment (SMFA) Dysfunction Index, and a published return to activity questionnaire. Questionnaires were administered during the initial hospitalization to obtain pre-injury status, and then the same outcome instruments were used at the 2 week, 3 month, 6 month, and one year follow-up. Statistical analysis was performed comparing the groups with p < 0.05 designated as significant.

Results: There was no difference in any outcome parameter for any time frame between the reamed and unreamed groups. The 1 year SF-36 PCS (a 100 point scale with a mean of 50 in the general population, higher better) was 42.9±11 for the reamed group and 43.5±11 for unreamed group as compared with 52.5±9 for the reamed group and 53.1±9 for the unreamed group pre-injury. The SMFA Dysfunction Index (100 point scale, higher is worse) at 1 year was 18.2±17 for the reamed group and 17.5±17 for the unreamed group as compared with 7.9±13 for the reamed group and 7.7±13 unreamed group pre-injury.

Conclusion: In patients with tibial shaft fractures treated with intramedullary nails, patient based outcomes are not related to reamed or unreamed insertion. Patients sustaining tibial shaft injuries do not return to their pre-injury status based on validated outcomes assessments or return to activity by one year after injury.

Purpose: Micro-CT is efficient, non-destructive, and accurate for qualitative and quantitative studies of bone microarchitecture during fracture healing. A cell-based vascular endothelial growth factor (VEGF) gene delivery system can increase fracture healing. Three dimensional structural variation of new bone formation in rabbit fracture segmental defects was studied with micro-CT to determine how VEGF affects these microarchitectural differences for bone healing in various periods.

Method: All animal procedures were approved by the Animal Care Committee at St. Michael’s hospital. Ten millimeter segmental bone defects were treated by local injection with cell-based VEGF gene transfer (n=15), or control group with fibroblasts alone or saline only (n=15), to stimulate differences in bone healing. The animals were sacrificed and fracture healing specimens collected at 4, 8 and 12 weeks post surgery. The region of interest (ROI) was set where the segmental defect was located, and was selected for analysis from the recognizable margins of the original defect. To describe the topographic pattern of bone healing, the ROI was divided into three areas of equal volume: proximal, middle and distal. The new bone formation and mineralization at the defect sites were evaluated by bone structural parameters from the 3-D reconstruction of micro-CT.

Results: Macroscopic evaluation of the interfragmentary section from reconstructed micro CT scans, in the VEGF treated rabbits, showed abundant fragmentary bone filling the gap of the osteotomy at 4 weeks and abundant callus bridging the gap at 8 and 12 weeks. In the control group, only small amounts of sparsely formed bone were seen in the gap at 4 weeks. In the control group, the regenerate bone was ovoid around the bone sites and a big gap remained in the segmental bone defects at 8 and 12 weeks. The bone healing micro-structural differences between the two groups varied with the period of treatment, with more differences seen at 4 than 8 or 12 weeks.

Conclusion: Cell-based VEGF gene therapy enhances fracture healing of segmental defects, and this effect is best seen in the early period following defect creation.

Purpose: The mechanical behavior of human scapholunate ligaments is not described well in the literature regarding torsion. Presently, intact scapholunate specimens were mechanically tested in torsion to determine if any tensile forces were generated as a result.

Method: Scapholunate specimens (n=19) were harvested and inspected visually. Scaphoid and lunate bones were potted in square chambers using epoxy cement. The interposing ligaments remained exposed. Specimens were mounted in a specially designed test jig and remained at a fixed axial length during testing. Using angular displacement control, ligaments were subjected to a torsional motion regime that included cyclic preconditioning (25 cycles, 1 Hz, triangular wave, 5 deg max), ramp-up to 15 deg at 180 deg/min, stress relaxation for 120 sec duration, ramp-down to 0 angulation at 180 deg/min, rest period for 5–10 minutes, and torsion-to-failure at 180 deg/min. Torque and axial tension were monitored simultaneously.

Results: Tests showed a coupled linear relationship between applied torsion and the resultant tensile forces generated for the ligament during ramp-up (Torsion/Tension Ratio = 38.86 +/− 29.00 mm, Linearity Coefficient R-squared = 0.89 +/− 0.15, n=19), stress relaxation (Ratio = 23.43 +/− 15.84 mm, R-squared = 0.90 +/− 0.09, n=16), and failure tests (Ratio = 38.81 +/− 26.39 mm, R-squared = 0.77 +/− 0.20, n=16). No statistically significant differences were detected between the Torsion/Tension ratios (p=0.13) or between the linearity (R-squared) of the best-fit lines (p> 0.085).

Conclusion: A strong linear relationship between applied torsion and resulting tensile forces for the ligament was exhibited during all testing phases. This may suggest that there is interplay between torsion and tension in both the stabilization of the scapholunate ligament during normal physiological motion and during resistance to injury processes. This is the first report in the literature of the coupling of torsion with tension for the scapholunate ligament.

Purpose: The choice of irrigating fluid and delivery pressure remains controversial. Identifying surgeons’ preferences in techniques and the rationale for their choices may aid in focusing educational activities to the orthopaedic community as well as planning future clinical trials. Our objective was to clarify current opinion with regard to the irrigation of open fracture wounds.

Method: We mailed and delivered a cross-sectional survey using a sample-to-redundancy strategy to members of the Canadian Orthopaedic Association and attendees of an international fracture course (AO, Davos, Switzerland) to examine surgeons’ preferences in the initial management of open fracture wounds.

Results: Of the 1,764 surgeons who received the questionnaire, 984 (55.8%) responded. In the management of open wounds, most surgeons surveyed, 676 (70.5%), favoured normal saline alone, however 16.8% used Bacitracin. Many surgeons, 695 (71%) used low pressures when delivering the irrigating solution to the wound, however variation exists in what constituted high versus low pressure lavage. Surgeons supported the need for a clinical trial evaluating outcomes following both the use of different irrigating solutions as well as irrigating pressures [803 (84.8%) and 730 (77.6%) respectively].

Conclusion: The majority of surgeons favour both normal saline and low pressure lavage for the initial management of open fracture wounds.

Purpose: Vascular Endothelial Growth Factor (VEGF) is vital for both angiogenesis and osteogenesis. The aim of this study was to investigate the effect of cell based VEGF gene delivery on the proliferation and mineralization of rabbit osteoblasts in vitro.

Method: Primary cultured rabbit osteoblasts were divided into four groups (each n=6). In Group I, osteoblasts were transfected with pcDNA3.1-VEGF; in Group II, osteoblasts were transfected with pcDNA-Efficiency Green Fluorescent Protein (EGFP); in Group III, osteoblasts were treated with the supernatant of fibroblasts that were transfected with VEGF genes; and in Group IV, osteoblasts were treated with the supernatant of fibroblasts that were transfected with EGFP. The cells were cultured in a-EME with 10% FBS, 2% penicillin/streptomycin with or without 10-^7 M dexamethasone and 50μg/ml L-ascorbic acid for 28 days. In the last 4 days, the cells were stimulated to initiate calcium mineralized nodule formation by adding 10 mM B-glycerophosphate. They were stained by the Von Kossa technique so that the number and the area of the nodules could be assessed by an imaging analysis system.

Results: The cells transfected by VEGF were indicated by the EGFP marked cells under a fluorescent microscope. There was a significant difference in the total nodule area (mean 18.38 mm² SE 3.73 and 5.07 mm² SE 0.55, p< 0.05) and count (mean 18.67 SE 3.22 and 2.17 SE 0.40, p< 0.001) between Group I and Group II (ANOVA, SPSS). More unmineralized and smaller nodules were found in Group III and Group IV. However, the nodules in Group III covered greater areas with dark brown staining in the cell culture dishes when compared with Group IV.

Conclusion: The observations indicate that cell based VEGF gene delivery has a positive effect on the proliferation and mineralization of osteoblasts. The greatest effect is seen with direct transfection of osteoblast cells. Cell-based VEGF gene therapy may be used to promote fracture healing.

Purpose: We conducted the first, multicentre, prospective cohort study to define the incidence of symptomatic venous thromboembolism (VTE) in patients with tibia and ankle fractures treated conservatively and relatively minor lower leg fractures. The reported incidence of deep vein thrombosis (DVT) using routine venography in patients with lower leg injury requiring cast immobilization is approximately 20–40%, which has lead to the routine use of anticoagulant prophylaxis for several weeks in many such patients. However the vast majority of venographically-detected DVTs are asymptomatic, distal thrombi whose clinical relevance is uncertain. Therefore venography is not the best outcome measure to assess the burden of clinically important VTE.

Method: Consecutive patients with tibia and fibula fractures (treated non-operatively) and patella and foot fractures, (treated operatively or conservatively) were assessed for eligibility at 5 Ontario hospitals. Patients were enrolled after informed consent within 96 hours of injury and were followed prospectively, by telephone, at 2, 6 and 12 weeks. Those with major trauma, active cancer, and previous VTE were excluded. Thromboprophylaxis was not allowed. Education regarding symptoms of VTE was provided at study entry and patients were asked about VTE symptoms at follow up. Suspected VTE was investigated in a standardized manner.

Results: From August 2002 to June 2005, 1200 patients were enrolled from 2446 consecutively screened patients. 98% of patients completed 3-month follow-up. The mean age was 45 years (16 to 93) and 60% were female. The most common fractures were fibular (39%) and most injuries were caused by falls (75%). 99 % of these fractures were unilateral. Most fractures did not require surgical repair (93%), and 82% of patients were immobilized by cast or splint for an average of 42 ±32 days. Overall, 7 patients had symptomatic, objectively confirmed VTE (2 proximal DVT, 3 calf DVT, 2 PE) with no fatal PE – an incidence of 0.6 % (95% CI 0.2 to 1.2).

Conclusion: Symptomatic VTE is an infrequent complication after these fractures without thromboprophylaxis. Therefore routine thromboprophylaxis is neither warranted, nor likely to be cost-effective in these patients. This study also highlights the significant discrepancy between clinical endpoint studies and studies using venography.

The computed neck-shaft angle and the size of the femoral component were recorded in 100 consecutive hip resurfacings using imageless computer-navigation and compared with the angle measured before operation and with actual component implanted. The reliability of the registration was further analysed using ten cadaver femora. The mean absolute difference between the measured and navigated neck-shaft angle was 16.3° (0° to 52°). Navigation underestimated the measured neck-shaft angle in 38 patients and the correct implant size in 11. Registration of the cadaver femora tended to overestimate the correct implant size and provided a low level of repeatability in computing the neck-shaft angle.

Prudent pre-operative planning is advisable for use in conjunction with imageless navigation since misleading information may be registered intraoperatively, which could lead to inappropriate sizing and positioning of the femoral component in hip resurfacing.

Femur fractures are a complication of hip arthroplasty. When the stem is well fixed, fracture fixation is the preferred treatment option. Numerous fixation methods have been advocated, using plates and/or allograft struts. The study was conducted to determine the biomechanical characteristics of three constructs currently used for fixation of these fractures.

Vancouver type B1 periprosthetic femur fractures were created distal to a cemented hip stem implanted in third generation composite femurs. The fractures were fixed with one of three constructs: 1- A non-locking plate and allograft strut (NLP-A) 2- A locking plate and allograft strut (LP-A) 3- A locking plate alone. (LP) The struts were held in place with cables. There were five specimens in each group. Following fixation, the constructs underwent sinusoidal cyclic loading from 200 to 1200 N for 100000 cycles. Stiffness of the constructs was determined in bending, torsion and axial compression before and after cyclic loading. Axial load to failure was also determined.

Overall, cyclic loading had little effect on the mechanical properties of these constructs. The two constructs with allografts were significantly stiffer in coronal plane bending than the construct consisting of only a locking plate. There were no significant differences in axial or torsional stiffness between the constructs. Load to failure of the NLP-A (4095 N) and LP-A (4007 N) constructs was significantly greater than the LP construct (3398 N) (p=0.023 and p=0.044 respectively).

All three constructs tested retained their mechanical characteristics following 100000 cycles of loading. Our initial concerns that the cables holding the allograft strut would loosen appear unfounded. Allograft strut-plate constructs are stiffer in bending and have a higher load to failure than a stand-alone locking plate. When an allograft plate construct is chosen, locking screws provide no mechanical advantage in this experimental model.

Early fracture stabilization has been shown to reduce morbidity and mortality in the patient who is multiply injured. Controversy exists in terms of managing multiple trauma patients who sustain thoracic injuries along with femoral shaft fractures. The purpose of the present study was to determine whether the presence and treatment of femoral shaft fractures increases morbidity in patients with pulmonary contusions and to determine the effect of patient and surgical factors on outcome.

Patients that suffered chest injuries between January 1987 and April 2006 were identified from the prospectively collected trauma databases at two hospitals. Patient records were reviewed to verify all data. The diagnosis of pulmonary contusion was confirmed with radiologic or post-mortem investigations. All relevant patient and surgical data was collected. Exclusion criteria included severely injured patients (head/abdomen AIS> 3), age sixty years, death twenty-four hours after injuries occurred.

A total of 1190 patients with confirmed pulmonary contusions met inclusion criteria; there were 113 femoral shaft fractures (five bilateral). Patients in both the isolated pulmonary contusion and pulmonary contusion with femoral fracture had similar injury severity scores (ISS) and demographic information. Fractures were reduced with intramedullary nailing in 88% of cases. Mean age was thirty-five years. There were significantly more incidences of fat embolism syndrome and acute lung injury (ALI) in patients with femoral factures (twenty-four hours following the injury had significantly greater risk of developing ARDS (p< 0.05).

The presence of femoral shaft fractures in patients with pulmonary contusions increases the duration of admittance to hospital and can lead to higher rates of fat embolism syndrome and ALI, however it does not appear to impact overall mortality or contribute to the development of other common respiratory complications. Early reduction of shaft fractures is encouraged to further decrease complications.

Fat embolism syndrome (FES) is a potentially lethal condition commonly seen in poly-traumatised patients, particularly those with multiple long-bone fractures. Treatment has centered around supportive care and early fracture fixation. Several clinical small trials have suggested corticosteroids benefit patients with FES but its use remains controversial. Our objective was to determine the effect of corticosteroids in preventing FES in patients with multiple long-bone fractures.

We conducted a meta-analysis of randomised trials, searching computerised databases for published studies from 1966–2006. Additionally, we performed hand searches of major orthopaedic journals, meeting proceedings, and texts. Our primary outcome was the rate of FES. Secondary outcomes included presence of hypoxia, petechiae, mortality, infection, and delayed union.

Of the one hundred and four studies identified, nine were potentially eligible, and only seven met all our eligibility criteria. From our pooled analysis of three hundred and eighty-nine patients, we found that corticosteroids reduced the risk of FES by 78% (95%CI: 43–92%, heterogeneity p-value=0.62, I2=10%) and that only eight patients needed to be treated (NNT=7.5) to prevent one case of FES (95%CI: five to thirteen patients). We did not find any significant differences in the rates of mortality, infection, or delayed union.

The current evidence suggests that the use of corticosteroids is beneficial in the prevention of fat embolism syndrome in patients with multiple long-bone fractures. The use of corticosteroids does not appear to significantly increase the risk of complications although a confirmatory large randomised trial is needed.

We sought to establish whether fibroblasts transfected ex vivo could be delivered via gelfoam impregnated with a solution of transfected cells to achieve local transgene expression in a fracture site.

A 10 millimeter segmental bone defect was created after 12 mm periosteal excision and plated in the middle one third of each rabbit tibia. Dermal tissues were obtained and fibroblasts were cultured with DMEM. Fibroblasts were labeled with CMTMR and 5x106 labeled fibroblasts in 1ml PBS with 1x1 cm? Impregnated gelfoam was placed into the fracture gap (n=2). Twenty four hours after cell injection, the rabbits were killed and specimens were harvested from the fractured leg. Using SuperFect (Qiagen Inc), the primary fibroblasts were transfected with pcDNA-VEGF which was generated with the full length coding sequence of the human VEGF gene. A convenient reporter gene, Efficiency Green Fluorescent Protein (EGFP), was used for monitoring transfection of VEGF by fluorescence intensity. Experimental rabbits received 5.0 X 106 VEGF transfected cells in 1 ml PBS via gelfoam at the fracture sites. The animals were sacrificed at seven days (n=4), fourteen days (n=4) and twenty-one days (n=4) post surgery and the fracture site specimens were collected for analysis.

The fluorescently labeled cells with CMTMR were found at the fracture site and surrounding tissues. It was demonstrated that the labeled cells were delivered into the fracture gap, bone marrow and muscle surrounding a segmental defect in the rabbit. In the VEGF group, visualised VEGF immunostaining (brown) was shown in the fracture site around the Gelfoam; as well VEGF was distributed at sites of endochondral ossification. Visible bone formation was shown: VEGF promoted new bone formation by VonKossa staining (dark) and produced numerous vessels by CD31 positive staining (brownish black). The VEGF protein was detected in and around the fracture by ELISA.

This data encourages the further development of genetic approaches using cell based VEGF gene transfer without viral vectors to promote fracture healing.

Gaining stable fixation in cases of recalcitrant non-unions can be challenging. These cases can be accompanied by a segmental bone defect and disuse osteopenia. One strategy to gain stable fixation is the use of allografts. Both cortical struts and intramedullary fibular allografts have been used for this purpose in the femur, tibia and humerus. The present study aims to compare the mechanical properties a locking plate, an intramedullary fibular strut allograft and a cortical strut allograft in a femur model of segmental bone defect.

A transverse mid-shaft osteotomy was performed in fifteen third generation large composite femurs. Twelve millimeters of bone was resected to create a segmental bone defect. Fixation was undertaken as follows: Construct F (Fibula): Lateral Non Locking plate and Intramedullary Fibula Allograft Construct LP (Locking Plate): Lateral Locking Plate Constrcut S (Strut): Lateral Non-Locking Plate and Medial Cortical Strut Allograft Axial, Torsional and Bending Stiffness as well as Load-to-Failure were determined using an Instron 8874 materials testing machine.

Overall, construct S was the stiffest, construct F intermediate and construct LP the least stiff. Specifically, the S construct was significantly (p< 0.05) stiffer than the two other constructs in the axial, coronal plane bending, sagital plane bending and torsional modes. Construct F was significantly stiffer than construct LP in the axial and coronal plane bending modes only. Both the S construct (6108 N) and the F construct (5344 N) had a greater Load-to-Failure than the LP construct (2855 N) (p=0.005 and 0.001 respectively).

The construct with a lateral non-locking plate and a medial allograft strut was stiffer and had a higher load-to-failure than the construct consisting of a stand-alone locking plate. An intramedullary fibular allograft with a lateral non-locking plate had intermediate characteristics. Other factors, such as anatomic and biologic considerations need to be considered before choosing one of the above constructs. The allograft procedures should only be used once soft tissue coverage has been obtained and any infection eradicated.

We have investigated the accuracy of placement of the femoral component using imageless navigation in 100 consecutive Birmingham Hip Resurfacings. Pre-operative templating determined the native neck-shaft angle and planned stem-shaft angle of the implant. The latter were verified post-operatively using digital anteroposterior unilateral radiographs of the hip.

The mean neck-shaft angle determined before operation was 132.7° (118° to 160°). The mean planned stem-shaft angle was a relative valgus alignment of 9.7° (sd 2.6). The stem-shaft angle after operation differed from that planned by a mean of 2.8° (sd 2.0) and in 86% of cases the final angle measured within ± 5° of that planned. We had no instances of notching of the neck or varus alignment of the implant in our series. A learning curve was observed in the time taken for navigation, but not for accurate placement of the implant.

Navigation in hip resurfacing may afford the surgeon a reliable and accurate method of placement of the femoral component.

A total of 20 pairs of fresh-frozen cadaver femurs were assigned to four alignment groups consisting of relative varus (10° and 20°) and relative valgus (10° and 20°), 75 composite femurs of two neck geometries were also used. In both the cadaver and the composite femurs, placing the component in 20° of valgus resulted in a significant increase in load to failure. Placing the component in 10° of valgus had no appreciable effect on increasing the load to failure except in the composite femurs with varus native femoral necks. Specimens in 10° of varus were significantly weaker than the neutrally-aligned specimens.

The results suggest that retention of the intact proximal femoral strength occurs at an implant angulation of ≥ 142°. However, the benefit of extreme valgus alignment may be outweighed in clinical practice by the risk of superior femoral neck notching, which was avoided in this study.

Thirty total hip replacements in twenty-eight patients in which a Zirconia/Polyethylene articulation was utilized were compared to a control group undergoing total hip replacement utilizing Cobalt-Chrome/Polyethylene articulation. These patients were matched for gender, BMI and pre-operative diagnosis.

At nine years after implantation there was no difference in the functional outcome between the two groups and no difference in liner wear rate on x-ray (Livermore technique). There was a 27% revision rate in the Zirconia group compared to the 11.5% revision rate in the Cobalt-Chrome group.

Bearing surfaces require long- term clinical follow-up to validate in vitro performance.

To determine the benefit of Zirconia on polyethylene versus cobalt-chrome on polyethylene in total hip articulation.

Zirconia offers no advantage over a cobalt-chrome head in decreasing in vivo polyethylene wear at ten- year follow-up.

Newer bearing surfaces require long- term clinical follow-up to validate in vitro laboratory performance.

All primary total hip replacements at this institution are entered prospectively in a database and are assessed on an annual basis. All patients in this study were followed for a mean of nine years with a range of six to thirteen years.

Thirty cementless total hip arthroplasties were performed in twenty-eight patients utilizing a Zirconia head coupled with a polyethylene acetabular component. Twenty-six hips have been followed for a mean of nine years. These were matched to a control group of twenty-six hips in twenty-six patients utilizing a cobalt-chrome head coupled with an identical polyethylene liner followed for a mean of ten years (range five to fourteen years). There was no functional difference in outcome at nine years between the two groups utilizing the Livermore technique there was no difference in the liner wear rate between the two patient groups. However, seven hips (27%) of the Zirconia group required revision due to loosening and/or extensive osteolysis around the cup and only three hips (11.5%) required revision in the cobalt-chrome group. Our study demonstrates that although changes in component designs and materials may offer theoretical advantages over current components their effect in vivo remains questionable.

This study (n=126, mean age=68.8 years, males=62) evaluated pre-operative WOMAC pain and physical function, age, gender, general health status, revision severity classification, number of revisions, comorbidity and unilateral vs. bilateral surgery as predictors of WOMAC pain and physical function at twenty-four months post revision hip arthroplasty. Pain improved from 9.3 to 3.6 and physical function improved from 35.4 to 17.1. No factors were predictive of patient function. Decreased pain was predicted by less pain pre surgery (p=0.01) and being male (p=0.04).

To determine if pre-operative WOMAC pain and physical function, age, gender, general health status (SF-36), revision severity classification, number of revisions, comorbidity and unilateral vs. bilateral surgery are predictive of WOMAC pain and physical function at twenty-four months post revision hip arthroplasty.

Physical function at twenty-four months is not independently predicted by the pre-treatment factors evaluated in this study. Male patients with less pain pre surgery and little comorbidity have less pain post surgery.

With the exception of pre-treatment pain, the pre-treatment factors tested in this study provide minimal guidance in identifying factors that might be modified to enhance patient outcome.

This prospective cohort study included one hundred and twenty-six patients (mean age=68.8 years, males: females=62:64) who had revision for other than infection or peri-prosthetic fracture. On average from pre-surgery to twenty-four months post-surgery, WOMAC pain improved 9.3 to 3.6 and physical function improved from 35.4 to 17.1. In univariate analysis (t-test, p< 0.05), males tended to have better function (19.6 vs. 14.7) and reported less pain (4.4 vs. 2.8). No other factors were significant in univariate analysis. None of the a priori factors noted above were independently predictive of patient function at twenty-four months in the multivariate model (F=2.06, p=0.04, R²=0.16). Decreased pain with activity at twenty-four months independently was predicted by having less pain pre surgery (p=0.01), being male (p=0.04) and having fewer comorbidities (p=0.07) in the multi-variate model (F=2.9. p=0.004, R²=0.21).

Funding: This work was supported by a grant from The Arthritis Society

We have evaluated the functional, clinical and radiological outcome of patients with simple and complex acetabular fractures involving the posterior wall, and identified factors associated with an adverse outcome.

We reviewed 128 patients treated operatively for a fracture involving the posterior wall of the acetabulum between 1982 and 1999. The Musculoskeletal Functional Assessment and Short-Form 36 scores, the presence of radiological arthritis and complications were assessed as a function of injury, treatment and clinical variables.

The patients had profound functional deficits compared with the normal population. Anatomical reduction alone was not sufficient to restore function. The fracture pattern, marginal impaction and residual displacement of > 2 mm were associated with the development of arthritis, which related to poor function and the need for hip replacement. It may be appropriate to consider immediate total hip replacement for patients aged > 50 years with marginal impaction and comminution of the wall, since 7 of 13 (54%) of these required early hip replacement.

A total of 179 adult patients with displaced intra-articular fractures of the distal radius was randomised to receive indirect percutaneous reduction and external fixation (n = 88) or open reduction and internal fixation (n = 91). Patients were followed up for two years. During the first year the upper limb musculoskeletal function assessment score, the SF-36 bodily pain sub-scale score, the overall Jebsen score, pinch strength and grip strength improved significantly in all patients. There was no statistically significant difference in the radiological restoration of anatomical features or the range of movement between the groups.

During the period of two years, patients who underwent indirect reduction and percutaneous fixation had a more rapid return of function and a better functional outcome than those who underwent open reduction and internal fixation, provided that the intra-articular step and gap deformity were minimised.

High-pressure lavage produces greater visible damage to bone at a macroscopic and microscopic level when compared with low-pressure lavage and can result in delay in the healing of fractures. Osteoblasts and adipocytes are derived from mesenchymal stem cells. Conditions which lead to bone loss often involve a switch from the osteoblast to adipocyte lineage. We have therefore examined the effect of high- and low-pressure irrigation on the differentiation of adipocytes.

Calvaria-derived bone cells were exposed to either low-pressure or high-pressure irrigation with normal saline. After 14 days the cells were fixed and the osteoblasts and adipocytes quantified using Oil Red O to stain cytoplasmic lipid droplets (triglycerides) in the cells. Osteoblasts were quantified using a commercially available alkaline-phosphatase staining assay.

A standard quantitative reverse transcription-polymerase chain reaction (RT-PCR) was performed. Messenger RNA levels for osteocalcin, a marker of osteoblasts, and PPARγ2, a marker of adipocytes, were measured. High-pressure lavage resulted in an increase in adipogenesis of 50% when compared with low-pressure lavage.

Our findings suggest that high-pressure lavage may promote differentiation of mesenchymal stem cells towards the adipoctye lineage. This may have clinical significance in the development of delayed and nonunion after treatment of fractures of long bones.

The reliability of the radiological assessment of the healing of tibial fractures remains undetermined. We examined the inter- and intraobserver agreement of the healing of such fractures among four orthopaedic trauma surgeons who, on two separate occasions eight weeks apart, independently assessed the radiographs of 30 patients with fractures of the tibial shaft which had been treated by intramedullary fixation. The radiographs were selected from a database to represent fractures at various stages of healing. For each radiograph, the surgeon scored the degree of union, quantified the number of cortices bridged by callus or with a visible fracture line, described the extent and quality of the callus, and provided an overall rating of healing.

The interobserver chance-corrected agreement using a quadratically weighted kappa (κ) statistic in which values of 0.61 to 0.80 represented substantial agreement were as follows: radiological union scale (κ = 0.60); number of cortices bridged by callus (κ = 0.75); number of cortices with a visible fracture line (κ = 0.70); the extent of the callus (κ = 0.57); and general impression of fracture healing (κ = 0.67). The intraobserver agreement of the overall impression of healing (κ = 0.89) and the number of cortices bridged by callus (κ = 0.82) or with a visible fracture line (κ = 0.83) was almost perfect.

There are no validated scales which allow surgeons to grade fracture healing radiologically. Among those examined, the number of cortices bridged by bone appears to be a reliable, and easily measured radiological variable to assess the healing of fractures after intramedullary fixation.

We have systematically reviewed the effect of alternative methods of stabilisation of open tibial fractures on the rates of reoperation, and the secondary outcomes of nonunion, deep and superficial infection, failure of the implant and malunion by the analysis of 799 citations on the subject, identified from computerised databases. Although 68 proved to be potentially eligible, only eight met all criteria for inclusion. Three investigators independently graded the quality of each study and extracted the relevant data.

One study (n = 56 patients) suggested that the use of external fixators significantly decreased the requirement for reoperation when compared with fixation with plates. The use of unreamed nails, compared with external fixators (five studies, n = 396 patients), reduced the risk of reoperation, malunion and superficial infection.

Comparison of reamed with unreamed nails showed a reduced risk of reoperation (two studies, n = 132) with the reamed technique. An indirect comparison between reamed nails and external fixators also showed a reduced risk of reoperation (two studies) when using nails.

We have identified compelling evidence that unreamed nails reduced the incidence of reoperations, superficial infections and malunions, when compared with external fixators. The relative merits of reamed versus unreamed nails in the treatment of open tibial fractures remain uncertain.

We reviewed 26 patients who had had internal fixation of an open intra-articular supracondylar fracture of the humerus. All operations were performed using a posterior approach, 13 with a triceps split and 13 with an olecranon osteotomy. The outcome was assessed by means of the Mayo Elbow score, the Disability of the Arm, Shoulder and Hand (DASH) score and the SF-36 Physical Function score. Patients with an olecranon osteotomy had less good results.

We randomised prospectively 44 patients with fractures of the shaft of the humerus to open reduction and internal fixation by either an intramedullary nail (IMN) or a dynamic compression plate (DCP). Patients were followed up for a minimum of six months. There were no significant differences in the function of the shoulder and elbow, as determined by the American Shoulder and Elbow Surgeons’ score, the visual analogue pain score, range of movement, or the time taken to return to normal activity. There was a single case of shoulder impingement in the DCP group and six in the IMN group. Of these six, five occurred after antegrade insertion of an IMN. In the DCP group three patients developed complications, compared with 13 in the IMN group. We had to perform secondary surgery on seven patients in the IMN group, but on only one in the DCP group (p = 0.016).

Our findings suggest that open reduction and internal fixation with a DCP remains the best treatment for unstable fractures of the shaft of the humerus. Fixation by IMN may be indicated for specific situations, but is technically more demanding and has a higher rate of complications.

Previous studies of the Ilizarov procedure have concentrated on musculoskeletal assessments rather than the opinions of patients. In a prospective trial of 25 consecutive patients, we evaluated the effect of Ilizarov reconstruction of post-traumatic deformity on general health status using the SF36 and Nottingham Health Profile (NHP).

The patients had very low preoperative scores, which remained low during treatment and correction, but increased postoperatively. The mean overall SF36 score improved from 36 ± 3 to 58 ± 7 (p = 0.031) and the NHP score from 39 ± 11 to 67 ± 10 (p = 0.002). The improvements in scores were not limited to the physical components and were equal or better than the improvements reported for other orthopaedic procedures, including total joint arthroplasty.

Ilizarov-type reconstruction of deformity of the lower limb not only restores bony configuration, but also produces a large improvement in the general health status of patients.

We examined the roles of methylmethacrylate (MMA) monomer and cementing technique in the formation, and haemodynamic outcome, of pulmonary fat emboli. The preparation of the femoral canal and the cementing technique were studied in four groups of adult dogs as follows: control (no preparation); lavage; cement pressurisation; and cement pressurisation after lavage. We measured the intramedullary pressure, pulmonary artery pressure (PAP), pulmonary capillary wedge pressure and bilateral femoral vein levels of triglyceride, cholesterol and MMA monomer at rest and after reaming, lavage, and cementing.

Femoral vein triglyceride and cholesterol levels did not vary significantly from resting levels despite significant elevations in intramedullary pressure with reaming, lavage and cementing (p = 0.001). PAP was seen to rise significantly with reaming (p = 0.0038), lavage (p = 0.0031), cementing (p = 0.0024) and cementing after lavage (p = 0.0028) while the pulmonary capillary wedge pressure remained unchanged.

MMA monomer was detected in femoral vein samples when cement pressurisation was used. Intramedullary lavage before cementing had no significant effect on the MMA level. Haemodynamic evidence of pulmonary embolism was noted with reaming and intramedullary canal preparation, irrespective of the presence of MMA monomer. We found no relationship between MMA monomer level and intramedullary pressure, PAP or pulmonary capillary wedge pressure.

Our findings suggest that the presence of MMA monomer in femoral venous blood has no effect on the formation of fat emboli or their pulmonary haemodynamic outcome during cemented hip arthroplasty.