Higher than expected rates of tibial loosening with the ATTUNE® total knee arthroplasty (TKA) implant has been reported. Component loosening can be associated with the development of radiolucency lines (RLL) and our study aim was to systematically assess the reported rates of these. A systematic search was undertaken using the Cochrane methodology in four online databases. Identified studies were assessed and screened against predetermined inclusion criteria. Meta-analysis was conducted using a random-effects model.Abstract
Introduction
Methodology
In March 2020, the World Health Organisation declared the COVID-19 outbreak a pandemic. Multiple new guidelines were proposed and existing models of social, domestic and hospital care altered. Most healthcare systems were largely unprepared for this and this pandemic has tested their adaptability. This study is aimed at assessing the impact of covid-19 on the demographics, presentation and clinical management of patients with proximal femoral (hip) fractures. This retrospective multi-centre cohort study compared all patients admitted with hip fractures, between 1st March and 30th May 2019 (Group PC: Pre-Covid) with hip fracture patients admitted over the same time period during the pandemic in 2020 (Group C: Covid). The data was obtained from the hospitals' local and National Hip Fracture Databases. Mortality data was checked with the Office for National Statistics (ONS). Primary outcomes were time to theatre, in-patient length of stay and 30-day mortality. 580 patients were included (304 PC, 276 C). Patient Charlson comorbidity index and Nottingham Hip Fracture scores were broadly similar across the two cohorts. There was a significant reduction in percentage of total hip replacements in Group C (11% to 5%, p=0.006). There was an increase in conservative management in group C (1% to 5%, p=0.002). The time to theatre was significantly delayed in Group C (43.7 hours C versus 34.6 hours PC, p<0.001). Overall length of hospital stay was similar in both groups (16.6 days PC versus 15 days C, p=0.089). 30-day mortality rate in Group C was 9.8% compared to 8.2% in Group PC (p=0.431), but for covid (+) patients it was significantly higher at 38.2% versus 5.8% in covid (−) patients (p<0.001). This is one of the largest multi-centre comparative cohort study in the literature to date, examining the impact of the covid-19 pandemic on the management of hip fracture patients. Whilst mortality rates were similar in both groups, covid patients were almost seven times more likely to die, reflecting the seriousness of the covid-19 infection and its sequelae in such elderly, vulnerable patients.
The current ‘gold’ standard surgical intervention for critical size bone defect repair involves autologous bone grafting, that risks inadequate graft containment and soft tissue invasion. Here, a new regenerative strategy was explored, that uses a barrier membrane to contain bone graft. The membrane is designed to prevent soft tissue ingrowth, whilst supporting periosteal regrowth, an important component to bone regeneration. This study shows the development of a collagen-based barrier membrane supportive of periosteal-derived mesenchymal stem cell (P-MSC) growth. P-MSC-homing barrier membranes were successfully obtained with nonaligned fibres, via free-surface electrospinning using type I collagen and poly(E-caprolactone) in 1,1,1,3,3,3-Hexafluoro-2-propanol. Introduction of collagen in the electrospinning mixture was correlated with decreased mean fibre diameter (d: 319 nm) and pore size (p: 0.2–0.6 μm), with respect to collagen-free membrane controls (d: 372 nm; p: 1–2 μm). Consequently, as the average MSC diameter is 20 μm, this provides convincing evidence of the creation of a MSC containment membrane. SEM-EDX confirmed Nitrogen and therefore collagen fibre localisation. Quantification of collagen content, using Picro Sirius Red dye, showed a 50% reduction after 24 hours (PBS, 37 °C), followed by a drop to 25% at week 3. The collagen-based membrane has a significantly higher elastic modulus compared to collagen-free control membranes. P-MSCs attached and proliferated when grown onto collagen-based membranes, imaged using confocal microscopy over 3 weeks. A modified transwell cell migration assay was developed, using MINUSHEET® tissue carriers to assess barrier functionality. In line with the matrix architecture, the collagen-based membrane proved to prevent cell migration (via confocal microscopy) in comparison to the migration facilitating positive control. The aforementioned results obtained at molecular, cellular and macroscopic scales, highlight the applicability of this barrier membrane in a new ‘hybrid graft’ regenerative approach for the surgical treatment of critical size bone defects.
The management of upper limb nonunions can be challenging and often with unpredictable outcomes. In the study we present the results of treatment of upper limb nonunions treated in our institution with BMP-7 biological enhancement. Between 2004 and 2011 all consecutive patients who met the inclusion criteria were followed up prospectively. Union was assessed with regular radiological assessment. At the final follow up clinical assessment included the disabilities of the Arm, Shoulder and Hand (DASH) score, range of movement and patient satisfaction. The mean follow up was 12 months (12–36). In total 42 patients met the inclusion criteria with a mean age of 47. Anatomical distribution of the nonunion sites included 19 cases of mid/proximal radius/ulna, 14 humerus, 6 distal radius and 3 clavicles. 5 patients had septic nonunion, 35 had atrophic nonunion, 11 had previous open fractures, and 10 had bone loss (range 1–3 cm). The mean number of operations performed and the mean time from injury to BMP application was 1.5 and 26 months, respectively. 40 patients had both clinical and radiological union whereas 2 had partial radiological union but a pain free range of motion. BMP was applied in isolation in 1 case and 41 cases the application was combined with autologous bone grafting. The range of movement of the affected limb, DASH score and patient satisfaction were optimum at the final follow up. This study supports the use of BMP-7 as a bone stimulating adjunct for the treatment of complex and challenging upper limb nonunions.
The aim of this study was to investigate PDGF release in the peripheral circulation following trauma and to correlate it with the numbers of MSCs in iliac crest bone marrow (BM) aspirate. Trauma patients with lower extremity fractures (n=18, age 21–64 years) were recruited prospectively. Peripheral blood was obtained on admission, and at 1, 3, 5 and 7 days following admission. The serum was collected and PDGF was measured using ELISA. Iliac crest (BM) aspirate (20ml) was obtained on days 0–9 following admission. MSCs were enumerated using standard colony-forming unit fibroblasts (CFU-F) assay.Objective
Methods
Pelvic fractures are indicators of severe trauma and high energy absorption. They are associated with multiple local or distant concomitant injuries, which explain their high mortality and morbidity. The aim of this study is to investigate the late sequel of traumatic-pelvic-fractures (PFX) focusing on quality-of-life and sexual-function. From a database of prospectively documented data, patients who had suffered a PFX and had been treated operatively in our institution from January 2008–2009 were recruited. Exclusion criteria were patients less than one-year post-injury, pathological-fractures, patients < 18 or >65, and patients with co-morbidities linked to sexual dysfunction. Demographics, injury-mechanisms, fracture-patterns (Young-Burgess classification), injury-severity-score (AIS/05-ISS), urogenital injuries and clinical outcome were recorded and analysed. Health-related-quality-of-life was assessed using the (EuroQol-5D) and sexual-function using the international-index-of-erectile-function and the female-sexual-function-index. The minimum follow-up was 12 months (12–30).Introduction
Methods
Reaming of the canal is an important step in the debridement phase of treating intramedullary infections. Numerous techniques of radical canal debridement have been successfully reported. The use of the Reamer-Irrigation-Aspiration system (RIA-Synthes) is currently expanding to include this clinical scenario. Prospective collection of data related to infected cases treated with the use of the RIA in a tertiary referral centre referring to a 3 year period. Peri-operative details, microbiology results, and follow-up outcome over a minimum period of 12 months post-surgery are reported.Introduction
Materials and methods
The management of non-unions of subtrochanteric femoral fractures with associated implant failure is challenging. This study assessed the outcome of a cohort of patients treated according to the diamond concept. Between 2005–2010 all patients with subtrochanteric aseptic non-unions presented post implant failure (Gamma Nail breakage) were eligible in the absence of severe systemic pathologies and comorbidities. Demographics, initial fracture pattern, method of stabilisation, mode of failure of metal work, time to revision of fixation, complications, time to union, and functional outcome were recorded over a minimum period of follow-up of 12 months. The revision strategy was based on the “diamond concept;” optimising the mechanical and biological environment (revision of fixation, osteoinduction/BMP-7, osteoconduction/RIA harvested graft, and osteogenicity/concentrate of bone marrow aspirate).Background
Methods
To evaluate management, direct-medical-costs and clinical outcome profile of a large trauma unit with respect to simple elbow dislocations. All simple elbow dislocations that were defined as not requiring acute surgical intervention, post-reduction, were considered between Jan-2008 and Dec-2010. Inclusion criteria consisted of age greater than 13; absence of major associated fractures, successful closed reduction, and follow-up as an outpatient. The management of these patients was classified in terms of immobilisation time into: short (< 2weeks), standard (2–3weeks) and prolonged (>3weeks). Direct-medical-costs were calculated based on current tariff rates associated with radiology, admission, theatre time (for reductions and recovery) and outpatient attendances. Clinical outcome was evaluated with respect to complications, secondary procedures, and time before discharge from clinic.Objectives
Methods
MSCs have long promised benefits of synthesising bone/cartilage, treating non-unions and potentially accelerating fracture repair. This potential has been tempered by MSC scarcity in the ‘gold-standard’ iliac crest bone marrow aspirate (ICBMA) and the resulting need to expand numbers via cell-culture. Culture of MSCs is time-consuming, expensive and results in cells with a reduced differentiation capacity. The reamer-irrigator-aspirator (RIA) is an innovation designed to reduce intra-medullary (IM) pressures during reaming of long-bones via continuous irrigation and suction. Aspirated contents are passed via a coarse filter, which traps bony-fragments before moving into a ‘waste’ bag - from which MSCs have been previously isolated. We examined liquid and solid phases found in this ‘waste’, performed a novel digestion of the solid phase and made a comparative assessment in terms of number, phenotype and differentiation capacity with matched ICBMA. The filtrate ‘waste’ bag from RIA reaming (6 patients) was filtered (70μm) and the solid fraction digested for 60min (37°C) with collagenase. MSCs were isolated from liquid & solid fractions and from 10ml matched ICBMA. Enumeration of MSCs was achieved via colony-forming-unit-fibroblast (CFUF) assay and flow-cytometry on fresh sample using CD45low, CD271+. MSCs were cultured by virtue of their plastic adherence and passaged in standard, non-haematopoietic media. Passage (P2) cells were differentiated towards osteogenic, adipogenic and chondrogenic lineages with their phenotype assessed with flow cytometry CD33 CD34 CD45 CD73 CD90 CD105.Introduction
Methods
The purpose of this study was to prospectively evaluate the rehabilitation outcome of children following operative and non-operative stabilisation of long bone fractures sustained in conjunction with an acquired brain injury (ABI). Between 1996 and 2002, children up to 16 years of age who were admitted to the Paediatric Intensive Care Unit (PICU) with an ABI and concomitant tibial or femoral shaft fractures were considered eligible for inclusion. Children who died or were unable to walk before the accident were excluded. All data relating to the sustained injuries, the duration of PICU inpatient stay, the fracture treatment and the functional outcome were collected prospectively. The severity of the injuries was assessed using the Injury Severity Score (ISS) and the Glasgow Coma Score (GCS). The duration of time was taken from admission to reaching rehabilitation milestones; the ability to sit, stand and walk was then assessed. Total duration of hospital inpatient stay and mobility on discharge were also recorded. Operative skeletal stabilisation included external or internal fixation, as well as flexible intramedullary nailing. Statistical analysis was performed using the Mann-Whitney U Test.Purpose
Materials and Methods
The aim of this study was to evaluate the health quality of life and return to sports activities following pelvic ring injuries. Between January 2006–2007 patients treated in our institution with pelvic fractures were eligible to participate. Inclusion criteria were adult patients. Exclusion criteria were children and pathological fractures. Data recorded included demographics, injury mechanism, fracture pattern, Injury severity score (ISS), associated injuries, method of fixation, complications and functional outcome. Health related quality of life was assessed using the (EuroQol) and return to sports activities was evaluated using a return to sports questionnaire. The minimum follow up was 24 months (24–39)Introduction
Patients and Methods
In children presenting with irritable hip symptoms we wished to determine the incidence of hip septic arthritis, pathogen characteristics and the functional outcome. Between May 2007 and January 2010, children presenting to our institution with irritable hip symptoms were eligible to participate. Exclusion criteria were history of trauma to the hip, systemic inflammatory diseases. Data collected included; demographics, clinical symptoms, temperature, haematological profile, ultrasound and culture reports, microorganism isolated and outcome. The minimum follow up was 6 months (6–24).Purpose
Methods
Iliac crest bone marrow aspirate (ICBMA) is frequently cited as the ‘gold-standard’ source of MSCs. Mesenchymal stem cells have been shown to reside within the intramedullary (IM) cavities of long-bones and a comparative assessment with ICBMA has not yet been performed. Aspiration of the IM cavities of 6 patients' femurs with matched ICBMA was performed. The long-bone-fatty-bone-marrow (LBFBM) aspirated was filtered (70μm) and the solid fraction digested for 60min (37°C) with collagenase. Enumeration was performed via the colony-forming-unit-fibroblast (CFU-F) assay and using the CD45low CD271+ phenotype via flow-cytometry. Passaged (P2) cells were differentiated towards osteogenic, adipogenic and chondrogenic lineages with their phenotype assessed using flow-cytometry CD33 CD34 CD45 CD73 CD90 CD105.Introduction
Methods
The clinical and functional outcome following simultaneous fractures of the acetabulum and pelvic ring represent a challenge for the clinician and are currently obscure in the existing literature. Between January 2003 and July 2009 all patients with combined pelvic and acetabular fractures were included in this prospectively study. Demographic details, mechanism of injury, ISS, surgical procedures, post-operative course, length of hospital stay, and radiological (Matta's score) and functional outcomes (The Merle d' Aubigne hip score) were recorded. The minimum follow up was 12 months (12–72).Introduction
Patients and Methods
Fracture healing represents a physiological process regulated by a variety of signalling molecules, growth factors and osteogenic progenitor cells. Bone healing following trauma is associated with increased serum concentrations of several pro-inflammatory and angiogenic growth factors1. Platelet-derived growth factor (PDGF) has been shown to stimulate mesenchymal stem cell (MSC) proliferation in vitro. However, the in vivo relationship between the levels of PDGF and the numbers of MSCs in humans has not yet been explored. The aim of this study was to investigate PDGF release in the peripheral circulation following trauma and to correlate it with the numbers of MSCs in iliac crest bone marrow (BM) aspirate and in peripheral blood. Trauma patients with lower extremity fractures (n=12, age 18-63 years) were recruited prospectively. Peripheral blood was obtained on admission, and at 1, 3, 5 and 7 days following admission. The serum was collected and PDGF was measured using the enzyme-linked immuno-sorbent assay (ELISA) technique. Iliac crest (BM) aspirate (20ml) and peripheral blood (PB) (20ml) was obtained on days 0-9 following admission. MSCs were enumerated using standard colony-forming unit fibroblasts (CFU-F) assay.Background and objectives
Methods
Iliac crest bone marrow aspirate (ICBMA) is frequently cited as the ‘gold-standard’ source of MSCs. MSCs have been shown to reside within the intramedullary (IM) cavities of long-bones [Nelea, 2005] however a comparative assessment with ICBMA has not yet been performed and the phenotype of the latter compartment MSCs remains undefined in their native environment. Aspiration of the IM cavities of 6 patients' femurs with matched ICBMA was performed. The long-bone-fatty-bone-marrow (LBFBM) was filtered (70μm) to separate liquid and solid fractions and the solid fraction was briefly (60min, 37oC) digested with collagenase. MSC enumeration was performed using the colony-forming-unit-fibroblast (CFU-F) assay and quantification of cells with the CD45low CD271+ phenotype by flow-cytometry. [Jones 2002, Buhring 2007] MSCs were cultured and standard expansion media and passage 2 cells were differentiated towards osteogenic, adipogenic and chondrogenic lineages.Introduction
Methods
Therapeutic exploitation of MSCs in orthopaedics has been tempered by their scarcity within ‘gold-standard’ iliac crest bone marrow aspirate (ICBMA) and the resulting need to expand cells in vitro. This is time-consuming, expensive and results in cells with a reduced differentiation capacity. [Banfi 2000] The RIA is a device that provides continuous irrigation and suction during reaming of long bones. Aspirated contents pass via a filter, trapping bony-fragments, before moving into a ‘waste’ bag, from which MSCs have been previously isolated. [Porter 2009] We hypothesised that ‘waste’ RIA bag contains more MSCs than a standard aspirated volume of ICBMA (30 ml). We further hypothesised than a fatty solid phase within this ‘waste bag’ contains many MSCs trapped within the adipocyte-rich stromal network and hence requiring an enzymatic digestion for their efficient release [Jones 2006]. The discarded filtrate ‘waste’ bag that contained saline from marrow cavity irrigation procedure from RIA reaming (7 patients) was filtered (70μm) and the solid fraction digested for 60min (37oC) with collagenase. MSC enumeration was performed using the colony-forming-unit-fibroblast (CFU-F). Following culture in standard expansion media, passage 2 cells were differentiated towards osteogenic, adipogenic and chondrogenic lineages and their phenotype was assessed using flow cytometry. ICBMA from the same patients was used as controls.Introduction
Methods
With the ever increasing rate of total hip replacement and life span of these patients, there has been an upward trend towards the incidence of peri-prosthetic fractures. Previous studies does suggest the implant cost to as high as 30% of the total reimbursement in primary hip arthroplasty but this figure is much higher in periprosthetic fractures where long stem revisions are commonly used A prospective comparative study analyzing the total cost of hospital stay for a cohort of 52 consecutive patients with peri-prosthetic fractures of long bones treated in two hospitals from October 2007 to march 2009 was conducted. Demographic data, fracture classification and method of surgical treatment along with the length of hospital stay were recorded in detail. The total cost calculated was then compared to the range of reimbursement price based on HRG (human Resource Group) coding. The implant cost was determined from the buying cost by each institution. 52 patients were available for review. Average age of the patients operated was 78.5 years. 69 percent of the peri-prosthetic fractures in our series were around the proximal femur. The average cost of stay was £ 16453 (£ 1425- 26345). The reimbursement to the hospital ranged from £ 1983 to £ 8735. Hospital source utilization for peri prosthetic fractures is quite high compared to the reimbursement being given to hospitals for treating such patients. This can be as low as £ 1500 as acute phase tariff to £ 9100 for elective revisions and the implant cost can vary from 50% to 200% of the total reimbursement cost. Current recording system for peri-prosthetic fracture is unclear resulting in discrepancy between resource utilization and reimbursement thus resulting in substantial financial losses for hospitals that perform these procedures.
To evaluate efficacy and outcome of embolisation following pelvic ring injuries in patients presented with ongoing hypovolaemic shock. Between 2000 and 2003, 200 poly-trauma patients presented in our institutions following pelvic ring injuries. Those with ongoing hypovolaemic shock who were treated within 24h of admission with embolisation were included in this study. Demographics, mechanism of injury, ISS, type of pelvic ring fracture, arterial source of bleeding, hours from injury to embolisation, and outcome were all recorded prospectively. Out of the 200 treated in our institutions 17 (8.5%) underwent angio-embolisation. The mean age of the patients was 37 (14-70) and the mean ISS was 29. Distribution of pelvic ring injuries included: 3LC, 7APC, 7VS. The mean time from injury to embolisation was 15 hours. 8/17 patients were initially treated with an external fixator. The distribution of arterial injuries was: 7 superior gluteal arteries, 8 internal iliac arteries, 1 obturator artery and 1 internal pudental artery. The mean number of units transfused prior to embolisation was 22 (range 6-50). Mortality rate was 4 (23%) out of 17 embolised patients. Angio-embolisation for pelvic ring injuries occurred in 8.5% of our study population. This study indicates that only a small proportion of patients required embolisation secondary to arterial bleeding. The overall survival rate was in accordance to published international experience. Embolisation should be considered as a valid adjunct in some selected group of patients with pelvic fractures where ongoing bleeding refractory to other treatment modalities is present.
Surgery for pelvic or acetabular fractures carries a high risk of deep-vein thrombosis (DVT). Reports indicate that fondaparinux is a more effective thromboprophylactic agent than low molecular weight heparin (LMWH) after major orthopaedic surgery. We prospectively evaluated a new protocol for DVT prophylaxis using fondaparinux. One hundred and eight patients with pelvic or acetabular fractures were randomised to receive either fondaparinux or enoxaparin. Specific review points included the primary end-point of clinical deep vein thrombosis (DVT) or pulmonary embolism (PE) and any evidence of adverse effects such as bleeding or allergic reactions. Two patients that received enoxaparin were found to have a DVT (3%) and one patient died from a PE (1%). There was no documented DVT or PE in patients that received fondaparinux. The mean number of units of blood transfused was significantly higher in the enoxaparin group and this was significant post-operatively (p<0.05). The current study supports that post-operative fondaparinux, in patients with pelvic and acetabular fractures, is more effective and equally safe to enoxaparin.Patients and methods
Results
The aim of this study was to investigate the differences between open vs closed femoral fractures with regard to the epidemiology, classification and outcome. Data collected prospectively from MTOS and TARN-UK. Between 2001 and 2005, 67,665 trauma patients found and 8,591 were identified having sustained femoral shaft fractures. Demographics, pre and in-hospital data were recorded. The AIS and ISS were calculated. Outcomes and mortality rates were recorded. Four groups of patients were identified namely isolated/open (IO), polytrauma/open (PO), isolated /closed (IC), polytrauma/closed (PC). ANOVA analysis was contacted to determine the effect of fracture classification and severity of trauma to mortality using SPSS 11.0 software.Introduction
Patients & methods
The aim of this study was to investigate whether growth factors essential for fracture healing are released in the immediate aftermath following fracture and whether reaming of IM cavity causes increased liberation of these autocoids. Consecutive adult patients with femoral shaft fractures forming two groups (a group who received unreamed nail (n=10) and a second group who received reamed nail (n=10) were recruited for this study. Peripheral blood samples and samples from the femoral canal before and after reaming and before and after the solid nail insertion were collected. Serum was extracted and using Elisa colorimetric assays the concentration of Platelet Derived Growth Factor (PDGF), Vascular Endothelial Growth Factor (VEGF), Insulin-like Growth Factor I (IGF-I) Transforming Growth Factor beta 1 (TGF-21) and BMP-2 levels was measured.Purpose
Methods
The timing of definitive fixation for major fractures in polytrauma patients is controversial. To clarify this aspect of trauma management, we randomised patients with blunt multiple injuries to either initial definitive stabilisation of the femur shaft with an intramedullary nail or an external fixator which was converted to an intramedullary nail at a secondary procedure and documented the post-operative clinical condition. Multiply injured patients with femoral shaft fractures were randomised to either initial (<24 hours) intramedullary femoral nailing or to initial external fixation and conversion to an intramedullary nail at a later phase. Inclusion criteria: New Injury Severity Score >16 points, or 3 fractures and Abbreviated Injury Scale score >2 points and another injury (Abbreviated Injury Scale score >2 points), and age 18 to 65 years. Exclusion criteria: unstable or patients in extremis. Patients were graded as stable or borderline (increased risk of systemic complications). OUTCOMES: Incidence of acute lung injuries.Purpose
Methods
To estimate and compare the cost implications of the first attempt of treatment of tibial fracture non-unions treated with either autologous bone grafting or BMP-7. Patients who were successfully treated for fracture non-unions between 2001 and 2005 were included. Exclusion criteria included infected non-union, children, malignancy, or chronic debilitating disease. The decision to use BMP-7 or autogenous bone graft was guided by the defect size and the surgeon's preferred method of treatment. Group 1 (n = 12) received iliac crest bone grafting (ICBG) and group 2 (n=15) received recombinant human Bone Morphogenetic Protein-7 (BMP-7). The total costs incurred during treatment including hospital stay, implants, theatre costs, drains, antibiotics, investigations and outpatient appointments were documented and analysed.Aim of the study
Materials and methods
Grade IIIa/b open tibial fractures (OTF) result mostly following high energy trauma and may be accompanied by significant associated injuries. Aim of this study was to compare the characteristics and the outcome of OTF between patients of different injury severities. Retrospective analysis of the records of patients admitted to a level I centre in a 4 year period with an OTF. Epidemiologic data, AO-ASIF classification, method of treatment, complication rates and time to fracture-union have been statistically analysed. An AIS98-ISS threshold (ISS 16) was used to separate OTF in 2 groups (A<16, B>16).Introduction
Materials and methods
To compare a variety of commercially available bone graft substitutes (BGS) in terms of promoting adherence, proliferation and differentiation of osteoprogenitor cells. A fixed number of porcine mononuclear cells obtained from cancellous bone of the proximal femur was mixed with a standard volume of BGS and then cultured for one week in media followed by two weeks in osteogenic media. BGS included commercially available β-Tricalcium Phosphate (□-TCP), highly porous β-TCP, Hydroxyapatite/Tricalcium phosphate composite, calcium sulphate (CS), Hydroxyapatite (HA), Demineralised bone matrix (DBM), polygraft, and polymers (PGA, PLGA). Staining for live/dead cells as well as scanning electron microscopy (SEM) were carried out on all samples to determine viability and cellular binding. Further outcome measures included alkaline phosphatase assays with normalisation for DNA content to quantify osteogenic potential. Negative (BGS without cells) and positive (culture expanded osteoprogenitors) control experiments were carried out in parallel to validate the results.Aim
Materials and methods
The purpose of this study was to evaluate the efficacy of human recombinant osteogenic protein 1 (rhBMP-7) for the treatment of fracture non-unions and to estimate the health economics aspect of its administration. Twenty-four patients (18 males, mean age 39.1 (range 18-79)) with 25 fracture non-unions were treated with rhBMP-7 in our institution (mean follow-up 15.4 months (range 6-29)). Successful completion of treatment was defined as the achievement of both clinical and radiological union. The cost of each treatment episode was estimated including hospital stay, theatre time, orthopaedic implants, drug administration, investigations, clinic attendances, and physiotherapy treatments. The total cost of all episodes up to the point of receiving BMP-7 and similarly following treatment with BMP-7 were estimated and analysed. Of the 25 cases, 21 were atrophic (3 associated with bone loss) and 4 were infected non-unions. The mean number of operations performed prior to rhBMP-7 application was 3.4, including autologous bone graft in 9 cases and bone marrow injection in one case. In 21 out of the 25 cases (84%), both clinical and radiological union occurred. Mean hospital stay before and after receiving rhBMP-7 was 26.84 days per fracture and 7.8 days per fracture respectively. Total cost of treatments prior to BMP-7 was £346,117 [£13,844.68 per fracture]. Costs incurred following BMP-7 administration were estimated as £183,460 [£7,338.4 per fracture]. rhBMP-7 was used as a bone stimulating agent with or without conventional bone grafting with a success rate of 84% in this series of patients with persistent fracture non-unions. The average cost of its application was £7,338 [53.0% of the total costs of previous unsuccessful treatment of non –unions, p<0.05). Treating non-union is costly, but the financial burden could be reduced by early rhBMP-7 administration when a complicated or persistent non-union is present or anticipated. Therefore, this study supports the view that rhBMP-7 is a safe and power adjunct to be considered in the surgeon's armamentarium for the management of such difficult cases.
Acetabular or pelvic ring injuries are invariably associated with high-energy trauma that could lead to a significant degree of disability. The purpose of this study was to investigate whether patients who had surgical treatment of isolated acetabular or pelvic injuries were able to return to their previous sporting activities. Between January 2001 and January 2002 90 patients were treated in our institution with pelvic (PF) and acetabular (AF) fractures. We excluded 22 of them who had sustained other associated injuries in order to eliminate the potential bias that the associated injuries could have on the results. Demographics, fracture classification, rehabilitation, outcome and complications were documented prospectively. Frequency, level of activity and sports participation before and after surgery, as well as EuroQol (EQ-5D) were also recorded.Background
Patients and method
The effect of head injury on systemic physiology, including bone healing is still a topic of vivid discussion. We aimed to investigate whether in patients with long bone fractures the presence of head injury is associated with excessive callus formation. Data on patients with head injury and femoral diaphyseal fracture admitted to our trauma unit between 1997- 2002 were collected and analysed. Patients with factors that could influence bone healing such as smoking, NSAIDs and hormonal disorders were excluded. The severity of head injury was quantified using GCS, AIS and CT scan reports. Patients matched for age, sex and ISS with femoral shaft fractures and no head injury formed the control group of the study. All the fractures were stabilised with reamed femoral nail. The quantification of fracture healing response was estimated by taking the radiological ratio of the largest diameter of callus formed into two planes and the adjacent normal diameter of femoral canal. The minimum follow-up of the patients was 12 months. In total 42 patients were studied, 17 with head injury and femoral fracture and 25 with an isolated femoral fracture, (control group). Both groups were comparable in terms of age, sex, ISS. The difference between the mean callus to diaphyseal ratio was statistically significant for both the AP and Lateral projections (AP – mean difference 0.462, 95% CI 0.312 to 0.602, p<0.0001, LAT – mean difference 0.289, 95% CI 0.142 to 0.436, p<0.001) with the head injured patients having more florid callus compared to the control group. This study supports the view that head injury leads to exuberant callus formation in patients with long bone fractures. The mechanisms of this response could be both central and local. Research is ongoing to elucidate the pathways involved in this biological phenomenon.
To analyse and compare long-term functional outcome of combined spino-pelvic injuries to an isolated pelvis and spinal fractures, the outcome of matched 30 patients with combined pelvic and spinal fractures was compared with 32 patients with isolated pelvic fractures and 30 patients with isolated spinal fractures. Functional outcome was measured using the self-report questionnaire EuroQol EQ-5D, a generic outcome tool. The functional outcome was compared with the average UK population scores. The mean age, median ISS and demographic profile were similar in all 3 groups. Neurological injuries were seen in 10 patients in the combined injury group, 5 patients in the pelvic injury group and 3 patients in the spinal fracture group. 1 patient had sexual dysfunction in the combined injury group. The EuroQol EQ-5D descriptive scores for the combined group were 0.67±0.11 (0.71±0.12 for spine fracture, 0.61±0.18 for pelvic fracture) and Valuation scores for the combined injury were 69.6±11.4 (65.1±19.4 for spine fracture, 61.5±21.9 for pelvic fracture), which are p=0.004 and p=0.003 for the combined injury compared to the average UK population. Duration of hospital stay was a mean of 13 days in spine injury group compared to 49 days in the combined injury group. 70% of patients with spinal injuries returned to the same level of employment in a mean duration of 5.3 months with only 10% retired due to injury; compared to 56.6% returned to work in the combined injury group after a mean duration of 12.8 months with 23.3% retired due to injury. Long-term functional outcome is significantly better with isolated spinal injuries compared to pelvic injury or combined injury. There is no significant long-term difference between the combined spino-pelvic group and the isolated pelvic injury group. We feel that the spinal injuries in a patient with coexisting pelvic fracture do not contribute towards the overall functional outcome in those patients.
The aim of this study was to identify and quantify any benefits of early active treatment of paediatric femoral shaft fractures for patients, their families, and the hospital. Our protocol (1999-2002) uses flexible intramedullary nails for children older than five, early hip spica (within one week of injury) for the under five year olds, and external fixation for polytrauma (Early Active Group[EAG], n = 25). Prior to this (1999-2002), treatment consisted of late application of a hip spica (3-4 weeks following injury) or inpatient traction (Traditional Group [TG], n = 41). Outcome measures were length of hospital stay, degree of malunion, knee and hip movements, and leg length discrepancy. The financial burden to the family including waged and non-waged time lost, transport, childminder, and other extra costs were estimated. Hospital costs including inpatient stay, theatre, and implant costs were analysed.Background
Patients and methods
We aimed to investigate the treatment and outcome of patients over 65 years of age with tibial Pilon fracture. Patients were treated by primary open reduction and internal fixation or external fixation (EF) as determined by local soft tissue conditions. Patient course, incidence of radiological osteoarthritis and functional outcome using the SF-36 questionnaire were recorded. All patients were evaluated serially until discharge from final follow-up. The mean follow-up time was 28 months (12-45). Statistical analysis was performed using Analyse-it(tm) software for Excel. In total 25 patients were studied. Two patients died before completion of treatment and were excluded from the final analysis. Therefore, 23 patients (10 male) were included with a mean age of 70.9 years (range 66-89) and a mean ISS of 10.25 (range 9-22). There were 4 grade IIIb open injuries. Three patients suffered superficial tibial wound infection. Two patients underwent early secondary amputation due to deep bone sepsis within 8 weeks of injury. One patient in the ORIF group underwent primary arthrodesis, which was subsequently revised due to non-union. 3 patients underwent secondary bone grafting to enhance healing, performed at 2, 6 and 9 weeks. 2 patients with metal work failure underwent subsequent revision of ORIF and progressed to union; the mean time to union was 33.8 weeks. At final follow-up 7 (28%) patients had radiological features of osteoarthritis but none had symptoms severe enough to warrant ankle arthrodesis. There were significant differences from the USA norm in physical function score, role physical score, and physical component score, (p< 0.01). In older patients local complications are relatively common and clinical vigilance must be maintained in order to allow appropriate intervention during their post-operative course. Despite the incidence of radiological post-traumatic arthrosis, none of the patients progressed to ankle fusion.Conclusion/Significance
Guidelines on the care of the seriously injured have led to widespread changes in clinical practice. The ‘hub and spoke’ model of trauma care means increasing numbers of patients with complex problems are concentrated into regional centres. Though providing the highest standards of treatment, this has cost implications for the receiving unit, particularly given the Department of Health's move towards a ‘Payment by Results’ model of health provision. We undertook an economic evaluation of complex limb reconstruction within our tertiary referral unit. Patients referred to the complex trauma service were identified. Patients were assigned to either a ‘complicated’ or ‘straightforward’ group by two consultant surgeons, based on the nature of their treatment. 5 cases from each group were randomly selected for further analysis. Data pertaining to the direct healthcare costs for these patients was analysed. Costs per investigation/intervention were obtained relating to hospital stay, outpatient care, operative interventions and investigations. Overall 26 patients were referred to our complex trauma service from other units over 6 months. A mean of £8,375 (6,163) per patient was recouped using current Service Level Agreements. This amounts to a £26,587 deficit per patient, or £1,394,905 per year assuming current referral rates. Those planning a service treating complex trauma must allow for the considerable costs involved and make provisions to recoup this from the referring Primary Care Trust.
We aimed to quantify the health related quality of life in a series of patients suffering a variety of different tibial injuries. Patients with previous tibial injury, randomly selected from our trauma database, who successfully completed their entire course of treatment at our institution, were recalled for final assessment. Mean time to final follow-up was 37.4 months. Statistical analysis was performed using SPSS computer software. Overall, 130 patients were evaluated. There was no significant difference in the self-care dimension between the groups. Psychological problems were common in patients with IIIb and IIIc fractures, as well as amputees, with the highest incidence in those with IIIc fractures. Patients who had undergone amputation and those with IIIb open fractures reported problems with mobility significantly more frequently than those who had IIIc type injuries. However, this could be partially attributed to the significant difference in mean age between groups, with patients sustaining IIIc injuries being younger (31.9 vs 46.9). Patients with IIIb and IIIc type fractures reported significantly more problems with pain compared with those who had undergone amputation. Interestingly, patients who had undergone fasciotomy reported pain as frequently as amputees. Regarding the VAS, only patients with closed fractures reported significantly different scores from the mean of all the other groups. These data represent the health related quality of life of patients having suffered the full spectrum of tibial injury and should be considered when determining the treatment options for these patients.
Femoral fracture non-unions are considered to be rare, and are usually treated successfully with exchange nailing. However, recalcitrant aseptic cases often require additional bone grafting. The efficacy of BMP-7 in the treatment of recalcitrant aseptic femoral non-unions was studied. Since 2003 a multicenter registry (bmpusergroup.co.uk) was created collecting details of BMP7 application in general, between different university hospitals across Europe. Demographic data, intraoperative details, complications, clinical outcome parameters, radiological healing, VAS pain score, EuroQol-5D, and return-to-work were prospectively recorded. Radiological healing was defined as the presence of callous in two planes over 3 cortices. The minimum follow up was 12 months. Seventeen patients, who had undergone a median of 1(1 to 4) prior revision operations, over a median period from the injury of 17 months(9 to 42), were included in this observational study. In 76.4%(13/17) the BMP7 was combined with revision of the fixation. Non-union healing was verified in 14/17 cases(82.3%) in a median period of 6.5 months(3–15). Over 80% of these patients returned to their pre-injury level of activities, the median overall health state score was 82.5(35 to 100). No adverse events or complications were associated with the BMP7 application over the median follow-up of 24 months(12–68).
The purpose of this study was to investigate the outcome of acetabular fractures treated in our institution with marginal impaction. Over a 5 year period consecutive acetabular cases treated in our institution with marginal impaction were eligible for inclusion in this study. Exclusion criteria were patients lost to follow up and pathological fractures. A retrospective analysis of prospectively documented data was performed. Demographics, fracture types according to the Judet-Letournel classification, radiological criteria of intra-operative reduction (Matta) and secondary collapse, complication rates, and the EuroQol-5D questionnaire were documented over a median period of follow-up of 40 months (12–206). Out of 400 cases, eighty-eight acetabular fractures met the inclusion criteria. The majority (93.2%) involved males with a median age of 40.5 years (16–80). Half of them were posterior-wall fractures, 21.6% bicolumn, 14.7 %posterior-wall and column, 6.8% transverse, 5.7% anterior-column, 1.1% anterior-column posterior hemi-transverse. In 75% of the cases anatomical intra-operative reduction was achieved. Structural-bone-graft was used in 73.9%, and two-level reconstruction in 61%. At the last follow-up, the originally achieved anatomical reduction was lost in 17/66 (25.8%), (10 PW, 4 PC+PW, 1 PC, 1 Transverse, 1 Bicolumn fracture). Avascular necrosis developed in 9.1% and heterotopic ossification in 19.3%. Full return to previous activities was documented in 48.9% of cases, the EuroQol general heath state score had a median of 80% (30–95%), full recovery was recorded as to the patients’ mobility in 51.1%, as to pain in 47.7%, as to self-care in 70.5%, as to work-related activities in 55.7%, and as to emotional parameters in 65.9%. Reoperation (heterotopic-ossification excision, total-hip-arthroplasty, removal of metalwork) was necessary in 19.2% of cases. Utilising different techniques of elevation of the articular joint impaction leads to joint preservation with satisfactory overall functional results. Secondary collapse was noted in 25.8% of the patients predisposing to a poorer outcome
Anterior wall and/or column acetabular fractures (AW/ C) have a low incidence rate. Paucity of information exists regarding the clinical results of these fractures. We present our experience in treating AW/C at a tertiary referral centre. Between Jan-2002 and Dec-2007, 200 consecutive patients were treated in our institution with displaced acetabular fractures. All AW/C fractures according to the Letournel classification were included in the study. All patients underwent plain radiography and CT investigations. Retrospective analysis of the medical notes and radiographs was performed for type of associated injuries, operative technique, peri-operative complications. Radiological assessment of fracture healing was determined by Matta’s criteria and functional hip scores were assessed using Merle-d’-Aubigne scoring. The mean follow up was 44.5 months (28–64). 15 patients (10 males) met the inclusion criteria (mean age 55.5 years). Four had associated anterior dislocation. Associated injuries included pneumothorax, splenic rupture, tibial and distal radius fractures. Five were treated by percutaneous methods, 8 with plate-screw fixation, and 2 with circlage wire, (10 ilioinguinal approaches). Mean time-to-surgery was 14 days(10–21 days). The average operative time for the percutaneous group was 75min vs. 190min in the orif group. Mean postoperative-in-patient-stay was 4 days(3–7 days), and 21 days(14–37 days). One patient developed chest infection post-operatively, two loss of sensation over the distribution of lateral cutaneous nerve. None of them developed incisional hernia, deep venous thrombosis and pulmonary embolism. At the last follow-up radiological outcome was excellent in 11 and good in 4 patients; clinical outcome was excellent in 12 and good in 3 patients, and none of the patients has developed heterotopic calcification or early osteoarthritis. Our results on management of these fractures are comparable to the early results reported by Letournel. Operative treatment for the rare anterior wall and anterior column fractures yields a favourable outcome resulting in early mobilization with limited patient morbidity
To evaluate the effectiveness of Pulsed-Lavage and of Versajet-hydrosurgery in removing two Staphylococcus aureus strains from porcine tissue and graphite powder from simulated fractures. Overnight broth cultures (NCTC-6571) and S.aureus strains were diluted to yield inocula containing 1x103c. f.u. ml-1. Initially 8 porcine legs were used; porcine tissues were inoculated with 10ml of either of the two S.aureus strains. Control tissues were inoculated with PBS. All inoculated samples were irrigated with 300ml of saline using the pulsed-lavage system or using the Versajet. 10ml of each of the following were plated out in triplicate:
inoculum pre-incubation inoculum post-incubation, each left over inoculum following removal of tissue and dilutions of 10-1 and 10-2 and Wash from all samples. Eight additional porcine legs were used where 2 incisions were made down to bone in a cross-hatch pattern. 1g of graphite powder was infiltrated into each fracture site to simulate a contaminated open fracture. Each fracture site was irrigated with 500ml saline through pulsed-lavage or Versajet. The average microbiological reduction using Pulsed-Lavage or Versajet was 2% and 15% respectively. The clinical S.aureus strain was more adherent than the laboratory strain. The Versajet maintained a 12–16% reduction of S.aureus, whereas pulsed-lavage did not reduce contamination. The number of graphite particles was significantly reduced with the use of the Versajet system compared with the pulsed-lavage. Versajet system was more effective in removal of foreign particles and more effectively reduced the micro-biological load of both examined S.aureus strains in a porcine model. Further studies are indicated to evaluate the efficacy of this system in clinical practice
To estimate the prevalence of clavicular fractures, number of cases required operative treatment, and whether removal of the implant is a frequent necessity. Between November 2005 and Nov 2007 all patients presenting in our institution with clavicular fractures were eligible for participation. Patients below 18 years of age, and pathological fractures were excluded. Retrospective review of clinical notes and radiographs. Demographic details, mode of injury, treatment protocol, operative procedures performed, time to union, complications post-surgery stabilization, and the number of cases that required implant removal were documented and analysed in a computerized database. The mean time of follow up was 24 weeks (12–48). Out of 16,280 adult fractures that presented to our institution, 200 (1.23%), (137 males) patients met the inclusion criteria with a mean age of 43 years (19–95) and a mean ISS of 9 (4–38). There were 4 of the medial, 153 of the middle and 43 of the lateral clavicle fractures (3 were open). 178 (89%) patients were treated non-operatively and 22 (11%) operatively. Indications for surgery included open fracture, bony spike/skin threatened, grossly displaced/comminuted fracture, polytrauma and non-union. Mean time to radiological union was 14 weeks (5–38 weeks). Out of the 200 patients 12 (6%) developed non-union. Out of the 22 operated patients, 7 (32%) required plate removal and 1 had screw removal. Indications for removal of implant included, periprosthetic fracture (1), prominent metal work through skin (3), pain in shoulder (2), pressure symptoms (1). Post removal of implant, 6 (75%) patients claimed improvement in symptoms. Functional outcome was excellent/good in 90% of cases. The incidence of clavicular fractures was 1.23%. A small number of patients (11%) required operative treatment out of which one third had metal work removal. The majority of clavicular fractures can be treated non-operative with good functional results.
The role of the pro-inflammatory cytokine HMGB1 (alarmins) has not been investigated in the clinical setting. This study aims to assess its relationship to IL-6 release, ISS, and to quantify the second hit phenomenon after femoral nailing. 22 (13 males, mean age 37.5y) consecutive patients entered in this prospective randomised trial. All patients underwent stabilisation of the femoral shaft fracture with reamed (10 patients) or unreamed nailing. Patient demographics, ISS, and complications were recorded prospectively. Peripheral blood samples were collected on admission, induction of anaesthesia, entry into femoral canal, wound closure and on day 1, 3, and 6. Serum HMGB1 and IL-6 concentrations were measured using ELISAs. 6 healthy volunteers formed the control group. The median ISS was 14.5 (9–29). Admission median HMGB1 and IL-6 concentrations were 7.2 ng/ml and 169 pg/ml respectively. A direct correlation was observed between ISS and IL-6 and HMGB1 concentrations. HMGB1 concentrations reached to peak levels on day-6. On the contrary, the median concentration of IL-6 peaked around day 1 postoperatively (reamed: 780 vs. unreamed: 376 pg/ml) and then showed a downward trend. The median increase of HMGB1 by day 6 was 4.21ng/ml in the reamed and 2.98ng/ml in the unreamed population; the median increase of IL-6 by day 1 measured 462 pg/ml and 232 pg/ml in the respective groups. Day 6 concentration of HMGB1 in patients with an ICU stay >
5 days (n=4), compared to the rest of the patients (n=16), was 11.04ng/ml (6.13 – 35.84) vs. 7.14ng/ml (4.06 – 12.8), (p=0.03). Femoral nailing and reaming induces a second hit as supported by the post-operative increased levels of both IL-6 and HMGB1. While IL-6 has been suggested as a marker of assessment of the early inflammatory response, alarmins can provide useful information at the later stage of an evolving immuno-inflammatory process.
An increased incidence of systemic inflammatory response syndrome was associated with three variables: presence of borderline condition, hemothorax and requirement of blood transfusion. This may have important treatment implications, including the management of major fractures.
Our aim was to assess the outcome of the treatment of Segmental fracture of the humerus in adult patients. From January 1994 to December 2003, 24 (17 females) consecutive adult patients with segmental humeral fractures were treated in our unit. Segmental fracture was defined as a two-level humeral fracture with at least one intermediate segment (AO type 12C). The mean age of the patients was 56.5 years(range 29–95) and the mean ISS was 14.1(range 9–29). The causes of injury included 8 vehicular accidents, 15 falls from heights, and 1 skiing injury. Thirteen patients had associated injuries. Three fractures were open (1 grade II, and 2 grade IIIA). At final follow up all patients were assessed in terms of radiological result and functional capacity (range of motion). The mean follow up was 36 months (range 24–60). There were 5 radial nerve palsies. Seven cases involved 4 fracture segments. The mean length of segment was 7 cm (range 5–16). All fractures but 5(20.8%) progressed to union (1 infected non-union, 1 hypertrophic after ex-fix, 1 atrophic after stabilization with rush pins, one was associated with failure of fixation proximally and required hemiarthroplasty). The mean number of procedures to achieve union in total was 1.6(range 1–3). There was one implant failure and one persistent non-union. At final follow up, the mean abduction was 1100 (900–1400) and the mean forward flexion was 1200 (1000–1500). Internal external rotation was 700 (50–90) and 250 (20–45). The risk of non-union is as high as 20.8 % and additional procedures often required to achieve union of the fragments. The method of stabilization depends on several factors including fracture configuration, the available bone stock and the surgeons’ expertise. Despite the severity of this injury a satisfactory outcome can be expected.
