To determine the outcome of subtrochanteric fractures treated by intramedullary (IM) nailing and identify causes for implant failure.

We performed a retrospective analysis of all subtrochanteric fractures treated by intramedullary nailing in Belfast trauma units between February 2006 and 2009. This subgroup of patients was identified using the Fractures Outcome Research Database (FORD). Demographic data, implant type, operative details, duration of surgery and level of operator were collected and presented. Post-operative X-rays were assessed for accuracy of reduction.

One hundred and twenty two (122) patients were identified as having a subtrochanteric fracture treated by IM nailing. There were 79 females and 43 males. Age range was 16 to 93 (mean 78). 95 (78%) cases were performed by training grades and 27 (22%) by consultants. Duration of surgery ranged from 73–129mins (mean 87mins). 47 patients (38.5%) were found to have a suboptimal reduction and 75 patients (61.5%) had an anatomical reduction on immediate post-operative x-ray. One year from surgery 73/122 patients were available for follow up. Of those patients with suboptimal reduction, 13/47 (27.7%) required further surgery. 8 required complete revision with bone grafting, and 5 underwent dynamisation. A further 6 patients had incomplete union. In the anatomical group, 4 patients underwent further surgery (5%). 3 required dynamisation and one had exchange nailing for an infected non-union. 3 patients had incomplete union at last follow up. 5/47 (10.6%) had open reduction in the suboptimal group compared to 25/75 (33.3%) in the anatomical group. Of the 27 cases performed by consultants, 13 (48%) were open reduction, compared to 17/93 (18%) by training grades.

This study has shown that inadequate reduction of subtrochanteric fractures, leads to increased rates of non union and ultimately implant failure. We recommend a low threshold for performing open reduction to ensure anatomical reduction is achieved in all cases.

Introduction

Although the majority of adult distal humeral fractures are successfully treated with ORIF, the management in frail patients, often elderly with multiple co-morbidities and osteoporotic bone, remains controversial. Elbow replacement is frequently recommended if stable internal fixation cannot be achieved, especially in low, displaced, comminuted fractures. The “bag-of-bones” method ie early movement with fragments accepted in their displaced position, is rarely considered as there has been little in the literature since 10 successful cases were reported by Brown & Morgan in 1971 (JBJS 53-B(3):425–428). We present the experience of three units in which conservative management has been actively adopted in selected cases.

The aim of management of an adult distal humeral fracture is to restore mobility, stability and pain-free elbow function. Good results are usually achieved in the majority of fractures treated with ORIF, but the management of comminuted fractures in elderly, frail patients with osteoporotic bone remains controversial. The literature focuses on elbow replacement if stable internal fixation cannot be achieved, with “bag-of-bones” management now rarely discussed eg. key-note paper - 10 successful cases reported by Brown RF & Morgan RG in 1971 (JBJS 53-B(3):425-428). We present the experience in two units in which conservative management has been actively adopted in selected cases by consultants with a subspecialty interest in the elbow.

All patients over the age of 60 with distal humeral fractures (2007 – 2009) who had been treated conservatively were reviewed clinically and radiologically. Duration of follow-up and outcome, including the Oxford and quick DASH scores, were recorded, with the fractures classified using the AO system.

There were 25 patients, 19 female and 6 male. 19/25 patients have been successfully treated conservatively with a mean Range Of Movement: Extension/Flexion: 45/125, Pronation/Supination 74/70. Only 5 underwent subsequent total elbow replacement and one delayed ORIF. There is a significant complication rate following surgical treatment with ORIF or elbow replacement in elderly, frail patients, including infection, painful non-union and/or stiffness. We believe that there is a role for initial conservative treatment in selected patients with low, displaced, comminuted humeral fractures in osteoporotic bone. Initial early mobilisation as pain allows can give good functional results without the risks of operation. It does not preclude future surgery if conservative treatment fails, but this is not required in the majority of cases.

Introduction: Magnetic Resonance Imaging (MRI) is the gold standard for imaging muscle and fatty infiltrate has featured in low back pain. However, there is little knowledge about in vivo features of neck muscles in chronic WAD. The purpose of this study was to quantitatively compare fatty infiltrate in the cervical extensors in patients with chronic WAD and controls across muscle and segmental level.

Methods: Volunteer subjects were gained through referral from local practitioners and the local university fraternity. A previously established MRI measure was performed in 113 female subjects (79- WAD & 34 healthy controls). Subjects with chronic WAD (> three months – < three years) were included if, classifiable as WAD II per the Quebec Task Force. The cohort was restricted to females (18–45 years) as they best represent those with chronic WAD. Volunteers were excluded when

classified as WAD I, III or IV

The measure was performed for the rectus capitis minor/major, multifidus, semispinalis cervicis/capitis, splenius capitis and upper trapezius. The values for all muscles were plotted for level and side and linear regression analysis was used to determine segmental trends (C3-7). A multi-factorial analysis of variance (MANOVA) was applied to investigate group means of whiplash and controls for fat indices across muscle, side and level. Bonferroni post-hoc comparisons were used to compare group by muscle interactions at each level. Multiple regression analyses were performed to determine if the score on the Neck Disability Index (NDI), age, Body Mass Index (BMI), compensation status and duration influenced fatty infiltrate. Significance was set at p < 0.05. Data presented as mean ± SD.

Results: The demographic characteristics of the two groups are: WAD (n = 79): age: 29.7 ± 7.8 years, BMI (kg/m2): 25.1 ± 5.7; duration: 20.3 ± 9.6 months and NDI: 45.5 ± 15.9. Healthy Controls (n = 34): Age: 27.0 ± 5.6 years, BMI: 23.0 ± 4.4.. NDI was not collected in controls.

MANOVA revealed significant main effects for group, muscle, segmental level and side (p < 0.0001), and significant interactions between Group:Muscle, Group:Level, Muscle:Level and Group:side (p < 0.0001). Sides were averaged for each muscle and level for post-hoc analysis.

There was a linear decrease in the fat indices from C3 – C7 for each muscle in both groups. No significant differences in fat indices across muscle, levels and side were noted in controls (p = 0.09). For the WAD subjects, the multifidus muscle had significantly higher fat content at each level compared to the other segmental muscles (p < 0.0001) and was highest at C3 (p < 0.0001).

There were higher fat indices in the whiplash group compared to the controls for the rcpmin and rcpmaj muscles (p < 0.0001).

No relationship was found for fat indices in all WAD muscles and NDI scores (p = 0.81), age (p = 0.14), duration (p = 0.99), compensation (p = 0.37) or BMI (p = 0.74).

Discussion: There is significantly greater fatty infiltration in neck extensors, especially in the deeper muscles, in females with chronic WAD when compared with controls. Future studies are required to investigate relationships between muscular degeneration and symptoms.

Effective cryopreservation of articular cartilage (AC) could improve clinical results of osteochondral allografting and provide a useful treatment alternative for large cartilage defects. Vitrification (a form of cryopreservation) incorporates high concentrations of cryoprotectant agents (CPAs) and rapid cooling rates to preserve cells in suspended animation without detrimental ice formation. Effective vitrification requires high concentrations of CPAs within the cartilage matrix but the time-dependent toxicity of CPAs hinders their usefulness. The objective of this experiment was determine the CPA permeation parameters for four commonly used CPAs. This data will enable the use of mathematical models to develop novel vitrification procedures to preserve AC. We hypothesised that the time dependency of CPA permeation into intact AC can be determined by exposing AC to CPAs for specific times and then allowing the CPA to be removed into a known volume of PBS, the osmolarity of which is then measured.

Full thickness 10mm diameter osteochondral dowels were harvested from the medial femoral condyles of sexually mature pigs. The dowels were randomly immersed in one of four CPAs (DMSO, propylene glycol, ethylene glycol, and glycerol) for various lengths of time (1–15 min). The cartilage was then immersed in 4ml of 1X PBS in a sealed container for twenty-four hours. The equilibrated solution was measured for osmolarity. The cartilage was weighed before and after treatment and this data was used to calculate the CPA concentration within the AC. This will be repeated in triplicate.

Preliminary results (minimum n=2) indicated a marked difference in permeation for the four CPAs. Ethylene glycol had the most rapid permeation with almost complete permeation (84%) within 15 min. Conversely, glycerol had the least permeation (29%) after 15 min most of which occurred within the first minute. DMSO (63%) and propylene glycol (40%) had intermediate rates of permeation that gradually increased over time.

Cryoprotectant agent permeation into intact porcine AC can be calculated using the method described in this study. This will allow us to successfully document the permeation kinetics of four commonly used CPAs within intact AC. This valuable data will markedly improve our ability to create novel vitrification solutions using mathematical models to add and remove CPAs to limit their toxic effects at high concentrations.

Cryoprotectant toxicity has become more relevant because of increased use of high concentrations of cryoprotectants for vitrification of biologic tissues. A single toxicity model that integrates cryoprotectant concentration, time and temperature is essential to optimize the cryopreservation of tissues. The Weibull probabilistic distribution has been used in environmental toxicology research. This objective of this study was to fit the Weibull model to experimental data for chondrocyte recovery from articular cartilage exposed to various concentrations of dimethyl sulfoxide at different temperatures as a function of time. This study indicated that the Weibull model is an appropriate model to describe cryoprotectant toxicity to chondrocytes in articular cartilage.

This study was designed to examine the toxicity of dimethyl sulfoxide (DMSO) on chondrocytes in porcine articular cartilage (AC) as a function of time, temperature and concentration.

The Weibull model is suitable for modeling cryoprotectant toxicity in cartilage and can be further extended to other cellular and tissue systems.

The model provides a simple method to predict toxicity and to assess the feasibility of cryopreservation protocols.

The model proved to be a good fit for the entire data set of concentration, temperature and time, yielding an R2 value of 0.87 and a maximum discrepancy of 20% between the experimental data and the model. Estimates of the model’s parameters within a confidence interval of 95% were found to be: _=30±2, _=0.67±0.05, _C=0.38±0.03, _T=−2300±300 and _CT=700±100.

Sliced porcine AC was exposed to DMSO (1, 3, 5, 6M) at different temperatures (0, 22, 37°C) for various durations. Cellular viability was determined by membrane integrity stains. Experimental data for chondrocyte recovery was fit to the global Weibull probabilistic distribution model using SPSS SigmaPlot 2000 to estimate the five parameters.

A model integrating concentration, time, and temperature of exposure is required to optimize addition and removal protocols of high concentrations of cryoprotectant for cryopreservation. The Weibull distribution is a simple and flexible model used to describe similar processes. In the current study, chondrocyte viability decreased with increased concentration, temperature and time of exposure. The model indicated a significant interaction between the toxic effects of concentration and temperature.

Introduction: Hip fractures affects more than 65,000 people in the UK each year and this number is increasing. The standard treatment is insertion of either a dynamic hip screw or hemiarthroplasty depending on fracture configuration. Because of their advanced age, associated co-morbid factors as well as having had an implant inserted, hip fracture patients are at increased risk of developing post-operative wound infections. The infection rate for hip fracture surgery is quoted at 0.6 – 3.6%¹.

Methods: We carried out a retrospective study of the readmission rate due to wound infection following treatment of their fractured neck of femur. 20 patients (16 females and 4 males) were identified over a 24 month period out of a total 1786 femoral neck fractures treated (1.1%).

Results: 11 patients re-admitted with a wound infection had had a hemiarthroplasty fixation, 9 following insertion of a DHS. 7 patients (0.4%) had a superficial wound infection (3 hemi, 4 DHS) and 13 (0.7%) a deep wound infection (8 hemi, 5 DHS). Treatment for the superficial wound infections included 6 patients requiring IV antibiotics and 1 requiring washout and resuturing of the wound.

Treatment of deep wound infections included 6 who had a Girdlestone procedure, 2 had wound washout, debridement and 2 who had removal of DHS. All received IV antibiotics. 2 patients were deemed unfit for surgery and received IV antibiotics only.

3 patients with a deep wound infection (23%) died (2 deemed unfit for surgery, and 1 Girdlestone) during their admission. 85% of the readmissions had an ASA score of three or over. We looked at the length of operation time and found that 15 took less than 45 minutes, 4 took between 45 and 60 minutes and one took over 60 minutes. Three of the operations which took over 45 minutes developed deep infections.

Conclusion: Fractured neck of femur accounts for a large proportion of fracture admissions. Accepted methods of treatment carry significant infection rates. Superficial wound infections can in the majority be treated with IV antibiotics. Deep wound infections carry a significant mortality rate. Operating time should be within 45 minutes where possible to reduce the risk of deep infection. Post-operative wound infections are associated with an ASA grade of 3 or greater.

Aims: To establish the results of elbow arthrolysis for the post-traumatic stiff elbow. Methods: A retrospective review of 20 patients undergoing open arthrolysis of the elbow under brachial plexus block followed by continuous passive motion between 1994 and 2002. Results: Eighteen patients were reviewed independently at an average follow up of 35 months (6–84 months). The range of motion improved in all patients from a mean preoperative arc of ßexion of 59.7û (5û–85û) to a mean postoperative arc of ßexion of 99.3û (55û–120û). However, the range of motion achieved intra-operatively was rarely maintained at review. The greatest improvement was seen in those with the most severe restriction in movement preoperatively. A functional range of movement (30û–130û) was achieved in 14 patients (77.7%). According to the Mayo Elbow Performance Score, measuring functional outcome, 17 patients (94%) had a good or excellent result. Arthrolysis had the added beneþt of relieving chronic post-traumatic elbow pain in 10 patients (56%). We recorded no signiþcant complications and no evidence of contracture recurrence. Conclusions: The results of conservative treatment for elbow stiffness are often disappointing. Although open elbow arthrolysis can be technically challenging a functional range of motion is readily achievable. It has been shown to be a safe procedure with a high level of patient satisfaction.

Objective: To assess the factors which result in increased mortality following a femoral neck fracture.

Design: Patients were sequentially recruited on admission to the fracture units and followed up at 2 weeks, 3 months, 6 months and 1 year.

Setting: The fracture units of two major Belfast teaching hospitals, The Royal Victoria and Belfast City Hospital (which have since amalgamated)

Subjects: All patients over the age of 65 years between 27th October 1997 and 30th November 1998 and who were admitted to the fracture units within 28 days of having sustained a fracture.

Outcome measures: Patients were assessed by: Barthel score, mental score, home circumstances. Mobility and mortality

Results: 748 patients (male/female 153/595). Mean age 82.1 years ± s.d. 7.4 years.

The overall 1-year mortality was 31.4% (235/748) and the sex distribution (male 73/153 [47.7%] female 162/595 [27.2%]).

27/748 patients who did not undergo surgical intervention had a 1-year mortality of 85.2%.

Factors which were associated with an increased 1 year mortality were: male sex (p< 0.0005), High ASA score (p< 0.0005), low Barthel score (p< 0.0005), poor mental score (p< 0.0005), decreased mobility (p< 0.0005), increased dependency in home circumstances (p< 0.0005), increased age (p< 0.0005), increased delay to surgery (p< 0.0005) and living alone (p< 0.0005).

Marital status, fracture type and type of operative intervention had no statistical effect on mortality.

Using logistic regression male sex, high ASA score, increased age, increased delay to surgery and poor mental score all remained independently associated with an increased mortality at 1 year.

Conclusion: The majority of factors which are associated with increased mortality following a femoral neck fracture are outside our control, namely age, sex and mental score. It should however be possible to reduce surgical delay and improve the patients pre-operative medical status (ASA score). A balance has to be struck between optimisation of the patient and delaying surgery unduly. The optimal timing of surgery requires further investigation.

We have reviewed a series of 56 consecutive patients treated by the Ilizarov circular fixator for various combinations of nonunion, malunion and infection of fractures. We used segmental excision, distraction osteogenesis and gradual correction of the deformity as appropriate.

Treatment was effective in eliminating 40 out of 46 nonunions and all 22 infections. There were two cases of refracture some months after removal of the frame, both of which healed securely in a second frame. Correction of malunion was good in the coronal plane but there was a tendency to anterior angulation, often occurring in the regenerate bone rather than at the original fracture site, after removal of the frame. This was associated with very slow maturation of regenerate bone in some patients, occurring largely, but not exclusively, in those who smoked heavily.

Patients expressed high levels of satisfaction with the outcome, despite relatively modest improvements in pain and function, presumably because their longstanding and intractable nonunion had been treated. None the less, the degree of satisfaction correlated strongly with the degree of improvement in pain and function.

We emphasise the importance of a multidisciplinary team in the assessment and support of patients undergoing long and demanding treatment. The Ilizarov method is valuable, but research is needed to overcome the problems of delayed maturation of the regenerate and slow or insecure healing of the docking site.