This study investigates the experience of one treatment centre with routine surveillance MRI following excision of sarcoma. Casenotes, MRI and histology reports for fifty-nine patients were reviewed. The primary outcome was the presence of local tumour recurrence and whether this was identified on surveillance or interval scanning. Forty-eight patients had a diagnosis of soft tissue sarcoma, the remaining 11 a primary bone tumour. Fifteen patients had local recurrence (25%). Eight were identified on surveillance scan, and the remaining 7 required interval scans.

Surveillance scanning has a role in the early detection of local recurrence of bone and soft tissue sarcoma.

The NZ Standards of Service Provision for Sarcoma patients were developed by the NZ Sarcoma working group and published by the Ministry of Health (MOH) in 2013. Although not formally enacted by the MOH we aimed to determine the impact of these published standards and referral pathways on disease-specific survival of patients with soft-tissue sarcoma in NZ. The Middlemore Musculoskeletal Tumour Unit database was searched. Patients referred for treatment in our centre with a diagnosis of soft tissue sarcoma in the five-year period before (n=115) and after (n=155) were included. We excluded patients with bone sarcomas and retroperitoneal soft tissue sarcomas. The rate of referral after inappropriate treatment reduced after implementation of the Standards (24% vs 12%, p=0.010). The number of patients referred with tumours larger than 50mm decreased (74.8% vs 72.3%, p=0.021) and fewer had metastases at diagnosis (11.3% vs 3.2%, p=0.017). Mortality was lower in the group after introduction of the Standards (45% vs 30%, p=0.017). The estimated disease-specific survival curve between the two groups shows a trend towards increased survival in the post-standards group, although not reaching statistical significance. Local recurrence rate and metastasis rate after definitive treatment were similar between the two groups. Patients had a shorter duration of symptoms before referral in the post-Standards group although this was not statistically significant. Since implementation of the Standards, patients have been referred more promptly, with fewer inappropriate treatments. The time to mortality curve indicates a trend towards improved disease-specific survival. We conclude that the pathway for investigation and referral for this condition has become clearer, supporting the ongoing use of the Sarcoma Standards, and that these should be formally implemented by the MOH

Introduction. Management of complex fractures poses a significant challenge. Evolving research and changes to national guidelines suggest better outcomes are achieved by transfer to specialist centres. The development of Major Trauma Networks was accompanied by relevant financial arrangements. These do not apply to patients with closed fractures referred for specialist treatment by similar pathways. Despite a surge in cases transferred for care, there is little information available regarding the financial impact on receiving institutions. Materials & Methods. This retrospective study examines data from a Level 1 trauma centre. Patients were identified from our electronic referral system, used for all referrals. Transferred adult patients, undergoing definitive treatment of acute isolated closed tibial fractures, were included for a 2-year period. Data was collected using our clinical and Patient Level Information and Costing (PLICS) systems including coding, demographics, treatment, length of stay (LOS), total operative time, number of operations, direct healthcare costs, and NHS reimbursements. Results. 104 patients were identified, 23 patients were treated by internal fixation and 81 with circular frames. Patients required a median of 190 minutes of total operative time and 6 days of hospital stay at a median cost of £16,233 each, median reimbursement was £10,625. The total cost of treatment for all 104 patients was £2,205,611 and total reimbursement was £1,391463, the median deficit per patient being £5825. The overall deficit over the 2 years was £814,148. Conclusions. This study reveals a considerable economic burden associated with treating complex tibial fractures. It should be emphasised that these do not include patients referred for fracture-related infection or non-union, who may also incur similar deficits in recovered costs. These findings emphasise the importance of understanding and addressing the financial implications of managing tertiary referral orthopaedic trauma patients to ensure efficient and sustainable resource allocation

Aim. Current standard of care in the management of bone and joint infection commonly includes a 4–6 week course of intravenous (IV) antibiotics but there is little evidence to suggest that oral antibiotic therapy results in worse outcomes. The primary objective was to determine whether oral antibiotics are non-inferior to IV antibiotics in this setting. Method. This was a parallel group, randomised (1:1), open label, non-inferiority trial across twenty-six NHS hospitals in the United Kingdom. Eligible patients were adults with a clinical diagnosis of bone, joint or orthopaedic metalware-associated infection who would ordinarily receive at least six weeks of antibiotics and who had received ≤7 days of IV therapy from the date of definitive surgery (or the start of planned curative treatment in patients managed non-operatively). Participants were randomised to receive either oral or IV antibiotics for the first 6 weeks of therapy. Follow-on oral therapy was permitted in either arm. The primary outcome was the proportion of participants experiencing definitive treatment failure within one year of randomisation. The non-inferiority margin was set at 7.5%. Results. Of 1054 participants randomised (527 to each arm) endpoint data were available for 1015 (96.30%). Definitive treatment failure was identified in 141/1015 (13.89%) participants, 74/506 (14.62%) of those randomised to IV therapy and 67/509 (13.16%) of those randomised to oral therapy. In the intention to treat analysis, the imputed risk difference (PO-IV) for definitive treatment failure was −1.38% (90% CI: −4.94, 2.19), thus meeting the non-inferiority criterion (i.e. the upper limit of 95%CI being <7.5%). A complete cases analysis, a per-protocol analysis and sensitivity analyses for missing data confirmed this result. With the exception of intravenous catheter complications, there was no significant difference between the two arms in the incidence of serious adverse events (SAEs). Health economic analysis suggests that the non-surgical treatment costs over one year for patients randomised to oral therapy were approximately £2,700 less than those of IV therapy. Conclusions. Oral antibiotic therapy is non-inferior to IV therapy when used during the first six weeks in the treatment for bone and joint infection, as assessed by definitive treatment failure within one year of randomisation. These findings challenge the current standard of care and provide an opportunity to realise significant benefits for patients, antimicrobial stewardship and the health economy. Funding. The OVIVA study was funded by the National Institute for Health Research Health Technology Assessment programme (Project number 11/36/29)

Introduction. Infected big gap non-union of femur and tibia are difficult to treatment because of infection, bone loss, shortening, poor sift tissue over and deformity. Step by step management and definitive treatment by Ilizarov fixator was achieved in our cases. Materials and Methods. A long defect which is more than 10cm in femur and tibia because of infection and gap, tumor resection, traumatic loss, which is very difficult to treat by conventional method and that's why we treated that type defect by Tibialization of fibula with Ilizarov technique. Management of infected big gap non-union of the femur include debridement and bone transport by Ilizarov technique by using Ilizarov fixator we can correct deformities, regenerate new bone without bone grafting, correct LLD and patient can weight bear during the course of treatment. We retrospectively reviewed records of 246 consecutive patients who underwent distraction osteogenesis using Ilizarov compression-distraction device for infected big gap INU of femur and tibia from 2000 to 2020. Results. All healed with the application of Ilizarov fixator, 5 needed reapplications of Ilizarov to achieve 100% union. 210 were excellent, 25 good and 6 were fair by ASAMI criteria. Mean Ilizarov duration was 366 days (130–250). Mean 8.2 cm length was achieved in the regenerate. Conclusions. A well plan step by step Ilizarov technique to cover infected gap non-union of femur and tibia is an excellent method in challenging cases. Excellent results cannot be achieved with conventional methods but can be easily achieved with Ilizarov technique within 1–2 years

Grade III Open fractures of the tibia represent a serious injury. It is recognised that combined management of these cases by experienced orthopaedic and plastic surgeons improves outcomes. Previous studies have not considered the timing of definitive soft tissue cover in relation to the definitive orthopaedic management. We reviewed medical notes of 73 patients with 74 Grade III Open tibia fractures (minimum 1 year follow up), to compare deep infection rates in patients who had a) a single-stage definitive fixation and soft tissue coverage vs. those who had separate operations, and b) those who had definitive treatment completed in < 72 hours vs. > 72 hours. Of subjects that underwent definitive fixation and coverage in a single procedure, 4.2% developed deep infections, compared with 34.6 % deep infection(p<0.001) in those who underwent definitive treatment at separate operations. Of patients who had definitive treatment completed in < 72-hours, 20.0% developed deep infections a compared with 12.2%(p=0.4919) in the >72-hour group. Patients with Gustilo III open tibial fractures have lower rates of deep infection if definitive fixation and coverage are performed in a single-stage procedure. Emphasis should be placed on timely transfer to a specialist centre, aiming for a single-stage combined orthoplastic surgery

When compared to magnetic resonance imaging (MRI), ultrasound (US) performed by experienced users is an inexpensive tool that has good sensitivity and specificity for diagnosing rotator cuff (RC) tears. However, many practitioners are now utilizing in-office US with little to no formal training as an adjunct to clinical evaluation in the management of RC pathology. The purpose of our study was to determine if US without formal training is effective in managing patients with a suspected RC tear. This was a single centre prospective observational study. Five fellowship-trained surgeons each examined 50 participants referred for a suspected RC tear (n= 250). Patients were screened prior to the consultation and were included if ≥ 40 years old, had an MRI of their affected shoulder, had failed conservative treatment of at least 6 months, and had ongoing pain and disability. Patients were excluded if they had glenohumeral instability, evidence of major joint trauma, or osteonecrosis. After routine clinical exam, surgeons recorded their treatment plan (“No Surgery”, “Uncertain”, or “Surgery”). Surgeons then performed an in-office diagnostic US followed by an MRI and documented their treatment plan after each imaging study. Interrater reliability was analyzed using a kappa statistic to compare clinical to ultrasound findings and ultrasound findings to MRI, normal and abnormal categorization of biceps, supraspinatus, and subscapularis. Following clinical assessment, the treatment plan was recorded as “No Surgery” in 90 (36%), “Uncertain” in 96 (39%) of cases, “Surgery” in 61 (25%) cases, and incomplete in 3 (2%). In-office US allowed resolution of 68 (71%) of uncertain cases with 227 (88%) of patients having a definitive treatment plan. No patients in the “No Surgery” group had a change in treatment plan. After MRI, 16 (6%) patients in the “No Surgery” crossed-over to the “Surgery” group after identification of full-thickness tears, larger than expected tears or alternate pathology (e.g., labral tear). The combination of clinical examination and in-office US may be an effective method in the initial management of patients with suspected rotator cuff pathology. Using this method, a definitive diagnosis and treatment plan was established in 88% of patients with the remaining 12% requiring an MRI. A small percentage (6%) of patients with larger than expected full-thickness rotator cuff tears and/or alternate glenohumeral pathology (e.g., labral tear) would be missed at initial evaluation

The appearance of a tumor as a result of chronic osteomyelitis is a relatively rare complication and of late-onset, with a low frequence in the modern world. For the majority of patients, the interval between the onset of primitive osteomyelitis and malignant degeneration is of several decades. We present our cases and the protocol of treatment used. From January 1977 to December 2014 we treated 36 patients (33M, 3F) suffering from squamous cell tumor out of a series of 247 tibial and 74 calcaneal osteomyelitis. 26 patients had chronic osteomyelitis of tibia, 10 of the calcaneus. Based on the functional needs of patients after resection of the tumor, in 18 we applied the Ilizarov apparatus, in 14 we opted for a two steps surgery, with the help of plastic surgeon; four required amputation. 29 patients healed. After 2-years of follow up 3 patients underwent to an amputation in the proximal third of the leg, 4 had a local recurrence. All patients were assessed by SF32 and the QoL test. Squamous cell tumor is the most common malignant tumor in chronic osteomyelitis. For the diagnosis of malignant transformation from a chronic ulcer there is a thorough process. Serial biposies must be performed, especially with the emergence of new clinical signs (increased pain, a bad smell, and changes in secretion by the wound). The definitive treatment is often amputation proximal to the tumor or wide local excision in combination with adjuvant chemotherapy and radiotherapy in selected patients. Early detection can sometimes allow limb salvage. However, the most effective treatment is prevention with the definitive treatment of osteomyelitis, including appropriate debridement, wide excision of the affected area, and early reconstruction

It is unclear whether combat casualties with complex hindfeet fractures would have an improved outcome with reconstruction or amputation. This study aimed to determine the outcomes of British military casualties sustaining calcaneal fractures. In the 12 years of conflict in Iraq and Afghanistan there were 116 calcaneal fractures in 98 patients. Seventy-four patients (74/98 76%) were contactable, providing follow up data for 85 fractures (85/116 73%). Median follow up was 5-years (64 months, IQR 52–79). Thirty limbs (30/85 35%) had undergone trans-tibial amputation at time of follow-up: there was no association between open fractures and requirement for amputation (p=0.06). Definitive treatment choice had a significant association with later requirement for amputation (p=0.0479). Fifty-two patients (52/74 70%) had been discharged from the military due to their injuries: there was a significant association between amputation and military discharge (p=0.001). Only 17 patients (17/74 23%) had been able to complete a military fitness test since their injury. The median physical component score of the SF-12 quality of life outcome tool for those undergoing amputation was 51.9 (IQR 48.1–54.3). The median for those retaining their limb was 44.1 (IQR 38.6–53.8). The difference between the two cohorts was not statistically significant (p=0.989)

Deep peri-prosthetic infection after partial or total knee arthroplasty is a disconcerting problem for patient and surgeon alike. The diagnosis of infection is sometimes obvious but frequently requires that the surgeon maintain a substantial index of suspicion for infection as the cause of pain or poor outcome after any joint arthroplasty. While surgical debridement with component retention is appropriate in a subgroup of patients with an acute peri-prosthetic infection, most delayed and chronic infections are best treated with component resection. With carefully selected patients and very aggressive debridement protocols some success has been demonstrated in Europe with single-stage exchange for infection. Most surgeons in North America, however, are unfamiliar with the very aggressive debridement techniques employed at European centers that promote single stage replant; and few surgeons in North America are currently comfortable in cementing a hinged total knee replacement in place for the typical infected TKA nor do they have the patience to re-prep and drape with an entirely new OR setup after debridement and prior to the insertion of the new implant − 2 steps that are often mentioned as important to the success of single stage exchange. The pre-eminent role of two-stage exchange as the definitive treatment was established over 30 years ago. Two-stage exchange remains the gold-standard in treatment with an established track record from multiple centers and with multiple different types of infecting organisms. Some of the historical problems with two-stage exchange, such as limited mobility during the interval stage, have been mitigated with the development of effective articulating spacer techniques. Further, the emergence of drug resistant bacteria and the possibility of fungal infection make two-stage exchange the best choice for the majority of patients with deep periprosthetic joint infection in 2017

Aims. Spontaneous osteonecrosis of the knee (SONK) mainly affects the medial femoral condyle, would be a good indication for UKA. The primary aim of this study was to assess the clinical, functional and radiographic outcomes at middle to long-term follow-up, of a consecutive series of fifty UKA used for the treatment of SONK. The secondary aim was to assess the volume of necrotic bone and determine if this influenced the outcome. Patients and Methods. We reviewed 50 knees who were treated for SONK. Patients included ten males and 38 females. The mean age was 73 years (range, 57 to 83 years). The mean height and body weight were, respectively 153 cm (141 ∼171 cm) and 57 kg (35 ∼75kg). All had been operated on using the Oxford mobile-bearing UKA (Zimmer-Biomet, Swindon, United Kingdom) with cement fixation. The mean follow-up period was 8.4 years (range, 4 to 15years). We measured the size (width, length and depth) and the volume to be estimated (width x length x depth) of the necrotic bone mass using MRI in T1-weighted images. The clinical results were evaluated using the Knee Society Scoring System (KSS) and Oxford Knee Score (OKS). The flexion angle of the knee was evaluated using lateral X-ray images in maximum flexion. Results. There were no implant failures, but there were 4 deaths (from causes unrelated to UKA) mean 6.6 years after surgery(5∼8), 3 cases were lost mean 3.3 years after surgery(2∼5). The mean size of the necrotic lesion were 17.2mm (14.7∼25.3) in width, 28.2mm (6.2∼38.3) in length and 11.3mm (3.2∼14.3) in depth. The mean volume of it was calculated to be approximate 5.4 cm. 3. (0.7∼11.1). The mean flexion of the knee, KSS Knee Score, Function Score and OKS increased from a preoperative 128.7 degrees (110 ∼ 140 degrees) to 137.5 degrees (110 ∼ 153 degrees), 52.3 (30 ∼ 64) to 91.3 (87 ∼ 100), 39.7 (15∼ 55) to 90.2 (65 ∼ 100) and 21.6 (12∼ 28) to 40.2 (34∼ 48), respectively at the latest follow-up. At last follow-up all patients had good or excellent OKS. Conclusions. There was a 100% survival rate of the Oxford Phase 3 UKA for SONK in the middle to long-term (up to 15 years after surgery) in this independent study. All patients had good/excellent results at last follow-up and there were no reoperations or major complications. This suggests that Oxford mobile-bearing UKA is a good and definitive treatment for medial femoral SONK, whatever the size of the lesion

The orthopaedic surgeon is often consulted to manage pathologic fractures due to metastatic disease, even though he or she may not be an orthopaedic oncologist. A good understanding of the principles of management of metastatic disease is therefore important. The skeleton remains a common site for metastasis, and certain cancers have a predilection for bone, namely, tumors of the breast, prostate, lung, thyroid, and kidney. Myeloma and lymphoma also often involve bone. The proximal femur and pelvis are most commonly affected, so we will focus on those anatomic sites. The patient may present with pain and impending fracture, or with actual fracture. Careful preoperative medical optimization is recommended. If the lesion is solitary, or the primary is unknown, the diagnosis must be made by a full workup and biopsy before definitive treatment is planned. For patients with known metastasis (the most common situation), the options for treatment of pathologic lesions of the proximal femur generally center on internal fixation versus prosthetic replacement. Patients with breast or prostate metastasis can live for several years after pathologic fracture, so constructs must be relatively durable. If fixation is chosen, it must be stable enough to allow full weight bearing, since the overwhelming majority of pathologic fractures will never heal. In general, long constructs are chosen to protect the entire length of the bone. Nails should protect the femoral neck as well, so cephalomedullary devices are typically chosen. Megaprostheses can be useful in situations where bony destruction precludes stable internal fixation. Postoperative radiation is recommended after wound healing. Acetabular involvement typically requires reinforcement rings or cement augmentation with the Harrington technique. Careful multi-disciplinary medical management is recommended to minimise complications

Aim. Septic arthritis of the hip is a rare entity among the adult population, but with a potential severe repercussion. The most accepted treatment is the hip debridement, even though a notorious proportion of the cases need further hip replacement owing to the cartilage destruction. The aim of this study is to analyse all our cases of septic arthritis of the hip treated with a 2-stage strategy using an antibiotic-loaded cement spacer. Method. We present a retrospective review of all our cases of septic arthritis of the hip diagnosed between 2004 and 2016 that were treated with an antibiotic-loaded cement spacer. We analysed age, gender, comorbidities, aetiology, duration of symptoms, C-reactive protein values, erythrocyte sedimentation rate, initial treatment, cultures, definitive treatment and evolution. Results. A total of 14 cases were included with a mean age of 47 years: 8 men and 6 women. The aetiology of the arthritis was: haematogenous in 8 cases, after osteosynthesis in 5 cases and after arthroscopy in 1 case. An initial debridement was performed in 6 cases whereas the spacer was directly implanted in 8 cases. The cultures were positive for: Staphylococcus aureus (4 cases), Candida albicans (2 cases), Staphylococcus epidermidis (1 case), Pseudomonas aeruginosa (1 case), Enterococcus faecium (1 case), Serratia marcescens (1 case), Streptococcus dysgalactiae (1 case), Salmonella spp (1 case) and negative in 2 cases. The evolution was: total hip arthroplasty in 10 cases, spacer preserved in 2 cases, pending of hip replacement in 1 case and exitus in 1 case. All cases presented negative cultures at the moment of implantation of the definitive prosthesis. Conclusions. A 2-stage strategy using an antibiotic-loaded cement spacer prior to the definitive hip prosthesis is a good treatment for the septic arthritis of the hip in cases with important cartilage destruction

Deep periprosthetic infection after hip or knee arthroplasty is a disconcerting problem for patient and surgeon alike. The diagnosis of infection is sometimes obvious but frequently requires that the surgeon maintain a substantial index of suspicion for infection as the cause of pain or poor outcome after any joint arthroplasty. While surgical debridement with component retention is appropriate in a subgroup of patients with an acute periprosthetic infection most delayed and chronic infections are best treated with component resection. The pre-eminent role of two-stage exchange as the definitive treatment was established over 30 years ago. Two-stage exchange remains the gold-standard in treatment with an established track record from multiple centers and with multiple different types of infecting organisms. Some of the historical problems with two-stage exchange, such as limited mobility during the interval stage, have been mitigated with the development of effective articulating spacer techniques. Further, the emergence of drug resistant bacteria and the possibility of fungal infection make two-stage exchange the best choice for the majority of patients with deep periprosthetic joint infection in 2015

Evaluation of the effectiveness of biodegradable bone substitute with high doses of antibiotics in cavitary osteomyelitis and infected nonunions. The authors evaluated 8 cases, 5 of them related to osteomyelitis with bone sequestration and other 3 regarding infected nonunions. All of them had in common the persistence of infection after antibiotic therapy. All infections were confirmed by microbiological studies. In all cases the surgeons conducted a thorough surgical debridement and filling of bone defects with Herafill®. Later a tight clinical, analytical and imagiological control was performed. Five of the cases were a success with simultaneous healing of the bone loss and treatment of the infection. These corresponded to the cases of cavitary osteomyelitis. In the remaining 3 cases, despite infection eradication, union was not achieved and additional surgical procedures were required for definitive treatment of nonunion. In the treatment of bone infection, use of high doses of antibiotics at the site is a consensus as it allows eradication of the infection with lower systemic effects. With the emergence of biodegradable bone substitutes, the need for a new surgical intervention for their removal can be avoided. Properties of calcium sulfate and calcium carbonate stimulate osteogenesis at the site, allowing their absorption and replacement by bone matrix. These properties make them ideal to usage in cases of cavitary bone defects. Our experience supports the idea that the use of high doses of antibiotics locally permits remission of the infection. However, when this is implemented through a bone substitute, it is possible to achieve osteogenesis in bony cavities. Nevertheless, when applied to infected nonunions, their role seems to be limited to the eradication of the infection

Postoperative infection is a difficult complication affecting total hip arthroplasty. It is painful, disabling, costly and it lacks definitive treatment guidelines. Klebsiella spp. are uncommon causes of Total Hip Arthroplasty. The aim of this case report was to document an effective treatment algorithm for a multidrug resistant Klebsiella spp infection after THA. We report a case of a 56-year-old male who has performed a THA in 2007 at our institution. After 4 admissions due to posterior hip dislocations it was performed an Acetabular Revision in May 2014. The periprothesic infection was suspected by delayed wound healing with inflammatory signals and both abnormal values of Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP). The patient was submitted to two hip arthrocenteses, one before and the other after antibiotic therapy (EV). The intra-articular cultures revealed a Klebsiella Pneumoniae infection only carbapenem-sensitive. We decided to performed a two-stage total hip arthroplasty revision approach. After the First Acetabular revision, ESR and CRP were augmented. X-rays and CT scans were performed, but inconclusive for infection. The patient completed longterm ertapenem therapy after the results of intra-articular cultures. We repeated arthrocentesis and the result was positive for the same bacteria. After 3 months of the Acetabular procedure we performed a Girldstone. We continued with Ertapenem and after 4 months we performed a Total Revision Arthroplasty. Final intra-articular cultures were negative for infection and ESR and CRP were both normal. After 5 months of follow-up the patient is pain-free and has good ROM. The infection risk is greater with the number of revision surgeries. Our institution has good outcomes with 2-stage procedure for multi drug infections. The best diagnosis tools were ESR and CRP, and intra-articular cultures. Two-stage revision surgery is a good choice for multi-resistent infections, and proper indications must be followed

Introduction. Total knee arthroplasty (TKA) is the definitive treatment for osteoarthritis of the knee. The primary goal of the operation is to minimize or eliminate pain associated with osteoarthritis and secondarily to regain functional mobility and stability around the knee joint in order improve overall quality of life. The vast majority of techniques utilized for this procedure involves removal of the anterior cruciate ligament (ACL). In a native knee the ACL is a primary stabilizing ligament and essential for providing proprioceptive feedback. In the absence of the ACL, the kinematics of the knee are compromised. In an effort to more accurately replicate normal knee stability, new implant designs have emerged which maintain an intact ACL. Described herein is a cadaveric study looking at ACL competency after implantation of a TKA in which the cruciate ligaments are preserved. Methods. Twenty fresh, frozen cadaveric knees were utilized in which the ACL was intact. Specimens were excluded if there was concern for ACL stability as determined by physical examination, direct visualization during the arthrotomy and a KT-1000 measurement of anterior tibial translation in millimeters at 67N and 89N of anterior force. Each KT-1000 measurement was repeated three times using three individual examiners at both force values for a total of six data points. Bicruciate retaining components were implanted into each knee using a medial parapatellar approach. After adequate sagittal and coronal balancing was obtained, the knee was reexamined using the KT-1000 protocol described above to assess for any changes in ACL competency. The ACL was then transected and the knee was examined for a third time with the same KT-1000 protocol. For statistical analysis, a 2-way repeated-measures ANOVA was utilized. Pairwise differences were assessed utilizing Fisher's least significant difference method. Results. The KT-1000 measurement in millimeters of anterior tibial translation in relation to the femur provided the primary data points. The anterior translation of the tibia of the cadaveric knees before insertion of the components averaged 2.2mm at 67N of force and 3.6mm at 89N of force. After insertion of the components, the anterior tibial translation averaged 3.6mm at 67N of force and 5.0mm at 89N of force. After the ACL was transected, the averaged KT-1000 measurements were 6.8mm at 67N and 9.2mm at 89N of force. Discussion and Conclusion. Significant debate remains regarding which knee implant provides the optimum outcome in patients undergoing total knee arthroplasty. As the indications for TKA continue to expand and younger more active patients, with higher post-operative performance expectations pursue surgical intervention for degenerative knee osteoarthritis, bicruciate-retaining designs have re-emerged as potential alternative to traditional implants. While this study does demonstrate an increase in anterior translation after implantation of the components, the amount of increased laxity is unlikely to be of clinical significance. Overall ACL integrity is maintained and joint stability preserved

The purpose of this study was to review the long term functional results of patients undergoing treatment for high energy tibial plateau fractures. Between January 1994 and June 2013 our unit managed 105 high energy tibial plateau fractures (Schatzker IV-VI) with an Ilizarov frame. All cases were treated via ligamentotaxis and percutaneous fine wire fixation or with a limited open reduction of the joint surface. A retrospective analysis of all patients that have undergone Ilizarov fixation of a tibial plateau fracture was performed with radiological and clinical functional outcome measurements. We analysed 105 patients with a mean follow up of 93.5 months (range 5–200). The patient group had an average age of 49 years (range 15–87) with 62 patients being male. Fracture pattern was analysed with Schatzker's classification showing 18 type IV, 10 type V and 77 type VI tibial plateau fractures. All fractures had an average time to union of 145 days. Patients had and average range of movement of 117 degrees. Patients undergoing Ilizarov treatment for high energy tibial plateau fractures achieve successful results long term. Definitive treatment should be decided with respect to fracture pattern and the soft tissue envelope. The management aim should be to achieve anatomical reduction and stable fixation to enable early mobilization. Our study confirms the good functional outcomes and low morbidity that can be achieved in high energy fractures treated with Ilizarov fixation

Introduction. Segmental tibia fractures are high-energy injuries that are difficult to treat. We report on the use of the Ilizarov Method to treat 40 consecutive AO42C (35) and AO42B3 (5) fractures by a single surgeon. Fractures with bone loss requiring transport were excluded, as were fractures initially treated with nail or plate. Patients. 28 adult males, 12 adult females, average age 43. The most common mechanism of injury was RTA (50%). 12 (30%) had associated injuries. 19 (48%) fractures were open (6 3A, 13 3B) and 21 closed. 24 (60%) had temporary monolateral external fixation before definitive treatment. The mean time from injury to definitive Ilizarov frame was 8 days. Results. 37 (93%) healed without the need for any bone-stimulating procedure. The 3 non-unions subsequently healed with a second frame. There were no amputations and no deep infections. All injuries healed within ten degrees of anatomical alignment radiologically. The total time to healing was calculated from date of injury to frame removal. Open fractures (mean 214 days, median 182) took longer to heal than closed fractures (mean 177 days, median 177). Minor complications included snapped wires (2) and minor pinsite infections treated with oral antibiotics (9). Conclusion. The Ilizarov Method is a very safe technique to successfully treat segmental tibia fractures with high union rates (93%)

Introduction. Dislocation is one of the most common complications following total hip arthroplasty. The literature suggests a frequency of 1–3% for primary total hip replacement (THR) and 7–10% for revision procedures. No definitive treatment algorithm exists for their management, with some surgeons attempting to constrain hip motion with casting or bracing initially. The evidence for this practice is limited. The purpose of this study was to determine the current practice for managing THR dislocation within our unit, and to determine the effectiveness of abduction bracing. Method. A retrospective case-note analysis was performed on all patients admitted with a dislocated THR between 01/01/08 and 31/12/10. Patients were categorised into three groups: first time dislocators, recurrent dislocators, or dislocation occurring following revision surgery. The following data was collected; time from original surgery, closed or open reduction, surgical approach, prescription of abduction brace post-operatively, and the number of subsequent dislocations. Any patients who underwent open reduction were excluded from the study. Results. A total of 45 patients were included in the study. Of the first time dislocators, 75% treated with abduction brace re-dislocated, and 26% of patients treated without bracing re-dislocated. In the recurrent group 63% had been braced after their initial dislocation. Conclusion. Based on this study the benefit of abduction braces is limited and patient compliance tends to be poor. The cost of these appliances is significant (£450/£525) and patients typically have a prolonged hospital stay for ordering and application. Our unit has subsequently discontinued the use of such braces. Goals to reducing THR dislocation remain; meticulous preoperative planning and patient selection, accurate component positioning with intraoperative stability testing, good soft tissue repair, and early patient education