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The Bone & Joint Journal
Vol. 100-B, Issue 12 | Pages 1535 - 1541
1 Dec 2018
Farrow L Ablett AD Mills L Barker S

Aims

We set out to determine if there is a difference in perioperative outcomes between early and delayed surgery in paediatric supracondylar humeral fractures in the absence of vascular compromise through a systematic review and meta-analysis.

Materials and Methods

A literature search was performed, with search outputs screened for studies meeting the inclusion criteria. The groups of early surgery (ES) and delayed surgery (DS) were classified by study authors. The primary outcome measure was open reduction requirement. Meta-analysis was performed in the presence of sufficient study homogeneity. Individual study risk of bias was assessed using the Risk of Bias in Non-Randomised Studies – of Interventions (ROBINS-I) criteria, with the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) criteria used to evaluate outcomes independently.


Orthopaedic Proceedings
Vol. 100-B, Issue SUPP_8 | Pages 7 - 7
1 May 2018
Tsang S Mills L Frantzias J Baren J Keating J Simpson A
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Aim

The aim of this study was to determine whether the absence of periosteal reaction on plain radiographs was predictive of exchange nail failure in lower limb diaphyseal fracture non-unions.

Methods

A consecutive cohort of 20 femora and 35 tibiae undergoing exchange nailing for diaphyseal aseptic (n=39) and septic (n=16) fracture non-union at a single centre from 2003 to 2010. Multiple causes of non-union were found in 29 patients (53%) with infection present in 16 cases (29.1%). Of this cohort 49 fracture non-unions had complete radiographic records (19 femora and 30 tibiae) allowing evaluation of the periosteal callus. The primary outcome was the number of number of revision procedures required to achieve union. Failure was defined was as the requirement of >two revision procedures to achieve union.


Bone & Joint Research
Vol. 5, Issue 10 | Pages 512 - 519
1 Oct 2016
Mills L Tsang J Hopper G Keenan G Simpson AHRW

Objectives

A successful outcome following treatment of nonunion requires the correct identification of all of the underlying cause(s) and addressing them appropriately. The aim of this study was to assess the distribution and frequency of causative factors in a consecutive cohort of nonunion patients in order to optimise the management strategy for individual patients presenting with nonunion.

Methods

Causes of the nonunion were divided into four categories: mechanical; infection; dead bone with a gap; and host. Prospective and retrospective data of 100 consecutive patients who had undergone surgery for long bone fracture nonunion were analysed.


Orthopaedic Proceedings
Vol. 97-B, Issue SUPP_4 | Pages 8 - 8
1 May 2015
Tsang S Mills L Frantzias J Baren J Keating J Simpson A
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The aim of this study was to identify risk factors for failure of exchange nailing for femoral diaphyseal fracture non-unions. The study cohort comprised 40 patients with femoral diaphyseal non-unions treated by exchange nailing. The main outcome measures were union, number of secondary fixation procedures required to achieve union and time to union. Univariate analysis and multiple regression were used to identify risk factors for failure to achieve union.

The mean age of the patients at exchange nail surgery was 37 years. The median time to exchange nailing from primary fixation was 8.4 months. Multiple causes for non-union were found in 14 (35.0%) cases, with infection present in 12 (30.0%) patients. Further exchange procedures were required in nine (22.5%) cases, one patient (2.5%) required the use of another fixation modality, to achieve union. Union was ultimately achieved in 35 (94.5%) patients. The median time to union was 9.4 months after the exchange nail procedure. Univariate analysis confirmed that cigarette smoking and infection were predictive of failure (p<0.05). Multi-regression analysis found that Gustilo-Anderson grade, presence of dead bone or a gap and infection were predictive of exchange nail failure (p <0.05).

Exchange nailing is an effective treatment for aseptic femoral diaphyseal fracture non-union. Patients with infection required more than one procedure. Smoking, infection and the presence of dead-bone or a gap at the fracture site were associated with an increased risk of further fixation surgery.


Orthopaedic Proceedings
Vol. 96-B, Issue SUPP_14 | Pages 1 - 1
1 Oct 2014
Tsang S Mills L Frantzias J Baren J Keating J Simpson A
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The aim of this study was to identify risk factors for failure of exchange nailing in tibial diaphyseal fracture non-unions. The cohort comprised 99 tibial diaphyseal fracture non-unions treated by exchange nailing. The mean age of the patients at exchange nail surgery was 36 years. The median time from primary fixation to exchange nailing was 6.4 months. The main outcome measures were union, number of secondary fixation procedures required to achieve union and time to union. Univariate analysis and multiple regression were used to identify risk factors for failure to achieve union.

Multiple causes for non-union were found in 31.3% cases, with infection present in 32.3%. Further exchange procedures were required in 35.4%, 7.1% required the use of other fixation modalities. Union was ultimately achieved in 97.8%. The median time to union was 8.7 months. Univariate analysis revealed that cigarette smoking, an atrophic pattern of non-union and infection were predictive for failure of exchange nailing (p<0.05). Multi-regression analysis found that only infection was statistically significantly predictive (p<0.05) of exchange nail failure.

Exchange nailing is an effective treatment for tibial diaphyseal non-unions even in the presence of infection. Smoking, atrophic pattern of non-union and infection are associated with an increased risk of further fixation surgery.


Orthopaedic Proceedings
Vol. 95-B, Issue SUPP_11 | Pages 8 - 8
1 Feb 2013
Mills L Simpson A
Full Access

Aim

Although non-union is a devastating and costly consequence of trauma for the child, family and society it is felt to be a rare complication in children. Currently there is no data available in the literature regarding its incidence either per fracture or per head of population. Should we be taking paediatric fracture non-union more seriously regarding research, resource allocation and informed consent? Our aim was to determine the incidence of non-union per child and per fracture.

Method

In Scotland Information Services Division (NHS Scotland) records every inpatient admission by ICD-10 diagnosis. As almost all fracture non-unions require intervention ISD provides accurate non-union figures by site and age. However, many fractures are treated as outpatients. Using local data of overall fracture numbers we were able to calculate a ratio of inpatient to total fracture numbers and apply this nationally.


Orthopaedic Proceedings
Vol. 95-B, Issue SUPP_1 | Pages 225 - 225
1 Jan 2013
Mills L Tsang J Hopper G Keenan G Simpson H
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Introduction

Fracture non-union is a devastating cause of patient morbidity. The cost of NU treatment ranges from £7,000 to £79,000. With an estimated 11,700 cases in the UK pa the financial implications are huge, potentially costing several hundreds of million of pounds annually.

Successful outcome in the management of non-union is based upon correctly identifying the underlying cause(s) and addressing them appropriately.

Aim

The aim of this study was to assess the causative factors in non-union in order to optimize the management of non-union. The causes of NU were categorized into 4 groups (infection, dead bone/gap, host factors, mechanical).


Orthopaedic Proceedings
Vol. 91-B, Issue SUPP_III | Pages 403 - 403
1 Sep 2009
Mills L Phillips J
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Introduction: The Scottish Arthroplasty Project (SAP) publishes an annual report including infection rates post-arthroplasty having obtained their results from the patients’ ICD-10 codes. The aim of this project was to validate the THR infection rate for one unit as published in the 2006 Scottish Arthroplasty Project (SAP) Report.

Method: The details of the SAP results were obtained. The BGH keeps its own record of post-operative THR infections; only those that met the dates and criteria of the SAP 2006 report were included and compared. The ICD-10 coding status was analysed in more detail.

Results: Published rate of infection in the 2006 SAP report after total hip replacement is three times lower than the unit recorded. 12 patients were eligible (1.49% infection rate), the SAP report recorded 4 cases of infection.

The SAP searches for infection only using three ICD-10 codes. Six ICD-10 codes had been used to classify these 12 patients.

Discussion: A recent cardiac surgery study comparing postoperative mortality rates from hospital statistics with the central cardiac database statistics found an over reporting by the national central database.* We have found the reverse with a threefold under calculation in the national report. However the unreported figures still do not place BGH as an outlier. The reasons for the discrepancy are multifactorial; but include poor coding practice, narrow range of code searching and difficulties in diagnosing infection. This audit shows that investigating the results of not only the outlying units but also randomly picking those who appear to have excellent results is worthwhile.


Orthopaedic Proceedings
Vol. 90-B, Issue SUPP_II | Pages 391 - 391
1 Jul 2008
Mills L Noble B Fenwick S Simpson H
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Introduction: Atrophic nonunion is a well recognised complication of long bone fractures. Clinical trials show that BMP-2 accelerates healing and reduces nonunion in open tibial fractures. We are interested in a natural small molecule that has been previously demonstrated to stimulate angiogenesis in vivo. Our aim is to assess the two treatments in the prevention of nonunion. The small animal model we used is a non-critical size defect of the tibia deprived it of its blood supply by surgical stripping of the periosteum and curetting of the local endosteum thus closely reflecting the clinical situation. The outcomes were measured by radiographic assessment and histology.

Methods: Wistar rats were treated with either the angiogenic molecule (0.1% or 0.003%), BMP-2 or vehicle alone (PBS) soaked in a type I collagen sponge. All animals underwent a 2mm osteotomy, stripping of the periosteum and endosteum proximally and distally for the length of the diameter of the tibia. Fluorescent markers were injected at 2 weekly intervals. The rats were sacrificed at 8 weeks. Both tibiae were disarticulated; fixator and soft tissues were removed and AP and lateral X-rays were taken. Subjective assessment of the healing on X-ray was carried out in two ways; using a radiographic scoring system and by grey scale analysis. The samples were embedded, sectioned and stained for new bone formation.

Results: Bridging or potential to bridge was seen in a number of animals on x-ray. Bridging or potential to bridge was judged to be present in 72.22% of the BMP-2 group and 66.67% of the high dose group compared to 22.22% of the control group. Histological analysis is being performed to confirm these findings.

Discussion: Atrophic nonunion is a serious clinical complication, unfortunately BMP-2 is a highly costly treatment option and therefore alternative molecular therapies are much sought after. We describe here an angiogenic molecule has some potential in preventing formation of nonunion.


The Journal of Bone & Joint Surgery British Volume
Vol. 88-B, Issue 6 | Pages 701 - 705
1 Jun 2006
Simpson AHRW Mills L Noble B