Abstract. Objectives. The role of MSCs in enhancing healing has been examined with allogeneic and xenogeneic cells in transplantation models. However, certain factors might limit the use of allogeneic cells in clinical practice, (e.g. disease transmission, ethical issues and patient acceptance). Adipose tissue represents an abundant source for autologous cells. The aim of this study was to evaluate adipose-derived autologous cells for preventing non-union. Methods. Adults male Wistar rats (n=5) underwent a previously published surgical procedure known to result in non-union if no treatment is given. This consisted of a mid-shaft tibial osteotomy with peri/endosteal stripping stabilized by intramedullary nail fixation with a 1mm gap maintained by a spacer shown to have minimal effect on fracture healing. During the same operation, ipsilateral inguinal subcutaneous fat was harvested and processed for cell isolation. After three weeks in culture, the cell number reached 5 million and were injected into the fracture site. Results. At the end of the experiment, all tibias (injected with autologous fat-MSCs) developed union, 5/5. These were compared with a control group injected with PBS (n=4) and with allogenic (n=5) and xenogeneic (n=6) cell transplantation groups. The amount of callus was noticeably large in the autologous cell group and the distal-callus index was significantly greater than that of the other groups, P-value < 0.05, unpaired t-test, corrected by Benjamini & Hochberg. Conclusion. We report a novel method for autologous MSCs implantation to stimulate fracture healing. Local injection of autologous fat-MSCs into the fracture site resulted in a solid union in all the tibias with statistically significantly greater amounts of callus. Xenogeneic Bone Marrow and Fat derived MSCs have previously been shown to have similar effects (Tawonsawatruk et al. 2014), we show here that autologous MSCs were significantly better than the xenogenic MSCs at producing union. Declaration of Interest. (b) declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported:I declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research project

Introduction and Objective. Lower limb fractures are amongst the most common surgically managed orthopaedic injuries, with open reduction and internal fixation (ORIF) as the conventional method of treatment of the fibula. In recent years, dedicated intramedullary implants have emerged for fibula fixation in tandem with the move towards minimally invasive surgery in high-risk patients. This is the largest multicentre review to date with the aim of establishing the clinical outcomes following intramedullary nail (IMN) fixation of the fibula and to identify the absolute indication for fibula IMN fixation. Materials and Methods. A retrospective study of adult patients in all UK hospitals, who underwent fibula nail fixation between 01/01/2018 and 31/10/2020 was performed. Primary outcome measures included time to union, infection rate, other post-operative complications associated with the fixation and length of hospital stay. The secondary outcome measure was to identify the indication for fibula nailing. Data tabulation was performed using Microsoft Excel and analysis was performed using SPSS Version 23 (SPSS Statistics). Results. 2 Major Trauma Centres (MTCs) and 9 Trauma Units (TUs) were eligible for inclusion. 102 patients were included and 91% were classified as ankle fractures of 68% (n=69) were Weber B, 24% (n=24) Weber C and 8% (n=9) were either distal tibial fractures with an associated fibula fracture or pilon fractures. The mean age was 64 years of which 45 were male patients and 57 were female. The average BMI was 30.03kg/m. 2. and 44% of patients were ASA 3. 74% of patients had poor pre-op skin condition including swelling and open wounds. The calculated infection rate for fibula nail was 4.9% and metal-work complication rate was 4.9%. The average time to union was 13 weeks and length of inpatient stay was 15 days (SD +/− 12 days). Conclusions. MEFNO has demonstrated that fibula nail is an ideal implant in patients who have a physiologically higher risk of surgery, poor skin condition and a complex fracture pattern. The time to union, complication and infection risks are lower than that reported in literature for ankle ORIFs

Surgical training in the UK is under increasing pressure with a high demand for service provision. This raises concerns about the resultant negative impact this is having on training opportunities for surgical trainees in theatre due to a high demand for surgical procedures to be performed expediently by consultants. This is due to the assumption that trainee take significantly longer time to operate in theatre and thus result in a slow progress of theatre lists. Our study evaluated the differences in operative time between orthopaedic trainees and orthopaedic consultants, as well as provide realistic timings for each stage encompassed within the entire duration a patient is in theatre. From our trauma unit electronic theatre database, we retrospectively collected data for six Joint Committee of Surgical Training (JCST) mandatory procedures. Information collected included patients' ASA grading, total surgical time and grade of surgeons. A total of 956 procedures were reviewed: 71.8% hip procedures, 14.2% intramedullary nail fixations and 14.2% ankle fixations. 46.2% and 53.8% of the procedures were performed by consultants and trainees as first surgeon, respectively. On average, consultants were found to be 13 minutes quicker in performing the hip procedures and this difference was found to be statically significant (p < 0.05). However, trainees were found to be quicker in performing intramedullary femoral nailings and simple ankle fixations, but consultant were faster at performing intramedullary tibial nailings and complex ankle fixations. However, the differences were not found to be statistically significant (p > 0.05)

Background. The approach to Intramedullary (IM) fixation of long bone fractures remains a controversial issue. Early reports demonstrated less favourable results of retrograde nailing as compared with antegrade options due to higher non-union rates. The aim of this audit was to evaluate the outcomes of practice within the Trauma and Orthopaedic department with relation to IM nail fixation of diaphyseal femur fractures. Methodology. The Trauma database between February 2010 and September 2013 was used to identify all femur IM nailing procedures. Picture Archiving and Communication System (PACS) software was used to classify the fractures according to the Muller AO classification. All 3–2 (Diaphyseal femur fractures) were included in the audit. PACS imaging together with outpatient documentation was evaluated for radiological and clinical outcome. Results. A total sample size of 23 patients was identified (13 antegrade vs. 10 retrograde approach fixations). Mean patient age was 67 years and male to female ratios were similar (11M vs. 12F). Antegrade nailing was performed in a younger population as compared to retrograde nailing (mean age 60 vs. 73 respectively). Mean time to union was somewhat more protracted in the retrograde group (7 vs. 5 months), although all fractures united. The most common complication with relation to antegrade nailing was due to distal locking screws backing out. I case of infection was reported in the retrograde nail group, which was treated successfully with antibiotic therapy. There were 2 cases of nonunion observed in the antegrade group. Conclusions. The results of our practice were comparable to those published in recent literature. Overall, union rates for the two groups of fixation were similar. Each fixation technique is associated with its own specific set of complications. As a general rule antegrade nailing was reserved for a younger population so as to prevent trauma to the native knee joint

The aim is to report a rare technique for correction of intramedullary nail acute angular deformity. Intramedullary tibial nail fixation of diaphyseal tibial fractures is the gold standard treatment allowing early mobilisation whilst preserving the soft tissues around the fracture site. Most commonly, intramedullary nails fail by metal fatigue secondary to non union, without significant deformity of the metalwork. Plastic deformity of the nail can result following new acute trauma, particularly before bone union has occurred. This is a clinical challenge as a reamed intramedullary nail is designed to achieve three point fixation with close anatomical fit, such that removal of a bent nail is technically difficult and also risks further damage to bone and soft tissues. We report a case of a 20 year old patient treated with intramedullary nail fixation of a diaphyseal right tibial fracture who was subsequently assaulted 4 weeks post operatively. This produced an unacceptable deformation of the nail into 25 degrees valgus and procurvatum. To remove the nail, the authors used a previously reported but rare technique of partial (up to 50%) nail division on the convex surface of the apex using Midas Rex High Speed Drill to weaken the nail then manipulation to correct deformity with minimal stress. The technique produced minimal metal debris and allowed simple exchange nail replacement without further complication. The authors believe this is the first reported use of the technique from the United Kingdom

Displaced proximal Humeral fractures at Inverclyde Royal Hospital prior to 2008 were previously treated with the antegrade Acumed Polaris Proximal Humeral, predominantly in 2 part fractures. The Philos plate was introduced in 2008, initially being used to treat select non unions, and then expanded to acute fractures. The aim of this study was to assess time to union and complications in the lower volume District General setting comparing to published outcomes. From February 2008 – January 2011, 20 patients were identified. Age range 49–75 (mean 61.2) years, 8 male; 12 female. Left 9, Right 11 Neers 2 part 35%; 3 35%; 4 30%. 16 (80%) were performed in acute fractures with 4 for non-unions, 3 of which were previous polaris nail fixations. 2 patients were lost to follow up after 6/52 but were progressing well. Union was confirmed radiologically and clinically in all but 2 remaining patients (10%), one of whom suffered a significant complication of plate fracture, the second treated with revision for painful non union. 2 other significant complications were observed: transient axillary nerve palsy and deep infection. Both of these patients recovered with delayed union observed in the infection case (52 weeks). Time to union range was 8–52 weeks (mean 17.1). The literature shows a high failure rate of up to 45% with intramedullary nail fixation and limited predominantly to 2 part fractures with risk of damage to the rotator cuff. This study shows a satisfactory union rate using the Philos of 90% with only 3 (15%) requiring further surgery for non-union, plate fracture and infection. 3 and 4 part fractures composed 65% of case load. Early results indicate satisfactory outcomes compared to current published literature

INTRODUCTION. Intramedullary nail fixation has been used for successful treatment of long bone fracture such as humerus, tibia and femur. We look at the experience of our trauma unit in treating long bone fracture using the AO approved Expert femoral/tibial nail and proximal femoral nail antirotation (PFNA). We look at the union and complication rates in patients treated with AO approved nailing system for pertrochanteric, femoral and tibial shaft fracture. METHODS. We carried out retrospective case notes review of patients that underwent femoral and tibial nailing during the period of study- October 2007 to August 2009. All patients were treated using the AO approved nailing system. We identified all trauma patients that underwent femoral and tibial nailing through the trauma register. Further information was then obtained by going through medical notes and reviewing all followed-up X-rays stored within the online radiology system. RESULTS. 149 patients, 85 male and 64 female were included into the study. 150 procedures were carried out during period of study as 1 patient underwent conversion of lateral entry femoral nail to PFNA due to refracture. Patients' age ranged from 14-96 with mean of 55. 140 patients had isolated long bone fracture (either femur or tibia) compared to 9 patients with multiple bone fractures. Our unit performed 64 Expert tibial nail, 36 PFNA, 31 Expert lateral entry femoral nail and 19 Expert retrograde femoral nail during period of study. 13 patients treated with intramedullary nail sustained open fracture, 9 of them were compound tibial fracture compared to 4 compound femoral fractures. All patients were followed-up between 2 to 24 months or until death. 9 out of 17 patients that died in this study had diagnosis of tumour. Complication rates were 17% for Expert tibial nail (1 patient with valgus deformity, peroneal nerve palsy and delayed union, 3 with delayed union, 4 with broken locking screw, 2 with wound infection and 1 with abscess over wound site), 4% for lateral/retrograde femoral nail (1 each for pulmonary embolism and broken locking screw) and 4% for PFNA (1 each for delayed union and deep vein thrombosis). The overall complication rates were 10% from this study. DISCUSSION & CONCLUSIONS. We conclude that the AO approved nailing system used for treating pertrochanteric, femoral and tibial fractures were effective with high union rate. The overall complication rates were 10% from this study. Complication rates for tibial nail were as high as 17% compared to 4% for femoral nail or PFNA. The complication rates for PFNA in our study were lower compared to 29% in PFN that was reported in one literature

Objectives

We investigated the effects on fracture healing of two up-regulators of inducible nitric oxide synthase (iNOS) in a rat model of an open femoral osteotomy: tadalafil, a phosphodiesterase inhibitor, and the recently reported nutraceutical, COMB-4 (consisting of L-citrulline, Paullinia cupana, ginger and muira puama), given orally for either 14 or 42 days.