Background. Rapid mobilisation programs, or “fast track” protocols, are aimed at shorter hospital stays. We found a limited local experience with these programs in total hip arthroplasty in South Africa, and decided to introduce a pilot study at our institution. Purpose. This pilot study is aimed at the feasibility and safety of a RM program in the private sector setting, as well as a review of the pertinent literature. Methods. 40 patients who met inclusion criteria underwent THR and TKR according to a specific protocol. Key aspects of the protocol included: minimum use of opiates, high volume pericapsular local block at time of surgery, no urinary catheter, mobilisation within 6 hrs of surgery and no high care admission. Target Discharge was 3 days. Patients were followed up retrospectively and outcomes included; length of stay, intra- and post-operative complications, subjective patient experience, re-admissions and re-operations. Results. 36 patients, (90 %), were discharged by day 3, 4 patients were discharged at day 4. Mean stay 2,8 days, shortest 2 days, and longest 4 days. 3 elderly female patients required catheterization for urinary incontinence, on the first night post surgery. No complications were experienced. The problems that prevented discharge within 3 days were post operative pain and orthostatic hypotension. There were no re-admissions or re-operations. One TKR required manipulation at 6 weeks. 5 patients required changes of dressings at home within one week post surgery. All the patients in this study were extremely satisfied. Conclusion. A rapid mobilisation program is relatively easy to implement although extra paramedical staff input is required. The results of this pilot study show that the protocol was effective and safe, as well as showing a significant hospital cost reduction. The obvious saving of costs are encouraging us to implement the protocol on a wider scale. Appendix. Lorem ipsum dolor sit amet, ligula suspendisse nulla pretium, rhoncus tempor placerat fermentum, enim integer ad vestibulum volutpat. Nisl rhoncus turpis est, vel elit, congue wisi enim nunc ultricies sit, magna tincidunt. Maecenas aliquam maecenas ligula nostra, accumsan taciti. Sociis mauris in integer, a dolor netus non dui aliquet, sagittis felis sodales, dolor sociis mauris, vel eu libero cras. Interdum at. Eget habitasse elementum est, ipsum purus pede porttitor class, ut adipiscing, aliquet sed auctor, imperdiet arcu per diam dapibus libero duis. Enim eros in vel, volutpat nec pellentesque le. NO DISCLOSURES

Introduction and Aims: To perform a pilot study to compare regional infiltration with standard (patient cotrolled or epidural) analgesia following total knee arthroplasty.

Method: Visual Analogue (VAS) scale assessment of peri-operative pain and nausea, analgesic consumption, time to mobilise from bed and range of motion at four days post-operation were compared between the two groups. Complications were documented. All operations were performed by the same surgeon (RB) and the first 79 cases were compared with an historical control group comprising the 73 cases immediately preceeding the study group. There were no exclusions from either group.

Results: The mean visual analogue score (VAS) for pain in the peri-operative period was of 3.19/10 (vs. 4.1 in controls) (p=0.02). Only four RAMP patients (5.1%) required any post-operative parenteral opiate analgesia (vs. 93.2% of controls) (p=< 0.0001). Early rehabilitation was more rapid in the RAMP patients; the mean time from return to the ward to walking was five hours 25 minutes compared to 63 hours 58 minutes in the controls (p=< 0.0001). The mean inpatient stay for RAMP patients was 6.5 days and 9.6 in controls (p=0.01). No RAMP patient required urinary catheterisation which was necessary in 42 (57%) of control patients.

Conclusion: Despite a lower incidence of patella resurfacing in the study group and a significant difference in implants, (study group mostly ‘Profix’ and controls mostly ‘Natural Knees’, regional infiltration appears to be safe and to confer substantial benefit in reducing acute morbidity.

Aims

The authors present the results of a cohort study of 60 adult patients presenting sequentially over a period of 15 years from 1997 to 2012 to our hospital for treatment of thoracic and/or lumbar vertebral burst fractures, but without neurological deficit.

Purpose of the study: The purpose of this study was to evaluate and compare the functional and radiographic results of these two surgical techniques using a prospective study. Material and methods: This study involved two consecutive series of 70 patients with a posterior fracture of the distal radius. Mixed multiple pinning (MMP) consisted in the combination of two styloid pins and two infrafocal dorsal pins. The anterior plate was a locked ITS. The patients decided when it was appropriate to wear a brace postoperatively. Functional assessment used the range of motion, the Quick DASH score, and a self-evaluation of the number of days the brace was worn. Ulnar variance, sagittal and frontal inclination of the radial epiphysis were measured pre- and postoperatively at 45 days. Results: At mean follow-up of 11.8 months (3–34), the functional outcome was comparable in the two groups but the patients with a plate fixation wore the brace less. Radiographically, there was no loss of final reduction with the plate fixation whereas with the pinning, there was a progressive loss of ulnar variance and less than 2% over-reduction. Major complications (tendon tears, nerve injury) were less frequent with pinning. Conclusion: Globally, plate fixation enabled more rapid mobilisation of the wrist. Nevertheless this method has its drawbacks (duration of the operation, material availability, cost). In our opinion the mixed multiple pinning method is the treatment of choice for fractures free of major instability or anterior or circumferential comminution

The aim of this retrospective study was to compare the rate of recovery and eventual level of function following total hip arthroplasty (THA) and hip resurfacing. Participants were 47 patients who had undergone THA and 43 who had undergone hip resurfacing. In all cases medical records were reviewed and function assessed, using the Harris hip score, visual assessment of gait and a functional score. The rate of recovery, as measured by functional activities and range of motion, was notably better in patients who underwent hip resurfacing than in patients who underwent THA. No significant discrepancy was found in the presence of deformity and the levels of postoperative pain following either procedure. We conclude that the hip resurfacing procedure may have important advantages over conventional THA, including more rapid mobilisation, higher levels of final function, increased range of motion, less physical limitation and shorter hospital stays. An important advantage is that the hip resurfacing procedure allows patients to resume work and sport earlier

8 patients with cervical myelopathy treated by French-door laminoplasty and internal fixation. A novel technique of fixation is employed to provide immediate stability, pain relief and rapid mobilisation. To report the clinical and radiological outcomes of this new fixation device for French–door laminoplasty with minimum follow-up of 30 months. Hardware assisted laminoplasty has the potential advantage of instant stability and prevention of recurring stenosis. The use of titanium mini-plates has been described in open-door laminoplasty and now we describe this technique in French–door laminoplasty. 8 patients with cervical myelopathy secondary to congenital stenosis (2) and multi-level spondylotic myelopathy (6) underwent 2-4 level French–door laminoplasty and mini-plate fixation. The average follow-up was 46.5 months. Autogenous iliac crest bone graft was interposed between the sagittally split spinous processes and 16-18 holed titanium mini-plates were contoured into a trapezoidal shape and secured to the posterior elements with screws. Patients then mobilised without external support. The mean follow-up was 46.5 months. The mean improvement in NDI at final follow-up was 35% and mean improvement in VAS was 4 points. JOA score improved from a mean of 10 to a mean of 14.8 post-operatively. All patients had achieved a significant neurological improvement and pain relief. There were no post-operative hardware related complications, pseudarthrosis or neurological deterioration. French-door laminoplasty is an excellent alternative to laminectomy for treatment of young patients with cervical myelopathy. The use of titanium mini-plates not only provides instant stability and pain relief but also seems to minimize the risk of C5 nerve root palsy. Internal fixation appears to provide instant stability, early mobilisation and therefore reduces hospital stay and associated costs

Background: Circulating endothelial precursor cells (CEPS) are thought to play a role in postnatal angiogenesis. We investigated the angiogenic stress of musculoskeletal trauma on CEP kinetics in trauma patients and their bone marrow progenitor populations in a murine model. Methods: Peripheral blood mononuclear cells (PB-MNCs) were isolated from patients (n=12) on consecutive days following closed lower-limb diaphyseal fractures. CEP levels, defined by the surface expression patterns of VEGFR2, CD34 and AC133 were determined and cytokine analysis of collected serum was performed. Bone marrow precursors defined by Ly-6A/E and c-Kit expression were harvested following traumatic insult from the murine model and quantified on flow cytometry. Human and murine progenitor populations were cultured on fibronectin and examined for markers of endothelial cell linage (Ulexeuropaeus- agglutinin- 1 binding and acetylated-LDL uptake) and cell morphology. Statistical analysis was performed using variance analysis. Results: A consistent increase in human CEPs levels was noted within 72 hours of the initial insult, the percentage increase over day 1 reaching 300%. Conclusion: We propose that musculoskeletal trauma through the release of chemokines such as VEGF, promotes rapid mobilisation of CEP from born marrow, which have the potential to contribute to reparative neovascularisation. Strategies to enhance CEPs kinetics may accelerate this process and offer a therapeutic role in aberrant fracture healing

One of the most commonly cited advantages of hip resurfacing is the technical ease of revision surgery on the femoral side of the joint. It is therefore reasonable to suggest that such surgery ought to be associated with reduced operative times, reduced blood loss and more rapid mobilisation than conventional hip revision. However, there is little objective evidence in the literature to support this view. In our own unit, 6 consultants have now revised 15 hip resurfacings (13 Corins and 2 MMT Birmingham Hip Resurfacings). A retrospective study of the hospital records was performed to compare three well recorded parameters 1) On table operative times 2) Post Operative blood transfusion requirement 3) In patient length of stay. Average on table time was 195 minutes for conventional THR revision and 120 minutes for revision of resurfacing i.e. a 1 third reduction in theatre time for resurfacing with attendant advantages in costs and risks. However, post operative length of stay was little different between the two groups. Average blood transfusion requirement was 4.6 units for conventional THR revision (n=190) and 0.9 units for revision of resurfacing. However, these crude figures do not take into account the difference in physiological state between the two groups of patients. A more complex comparison of age matched revision THR patients shows and average transfusion requirement of 1.8 to 2.2 units for revision of THR versus 0.9 units for revision resurfacing. In conclusion, there is now objective evidence of the advantages of resurfacing in the revision situation but that these advantages are more modest than those anticipated

A wide variety of intra- and extramedullary devices for the treatment of trochanteric fractures has been described. The Percutaneous Compression Plate is a minimally invasive and extramedullary device, which requires two 2–2.5 cm long incisions with minimal dissection oft soft tissue on the lateral aspect of the proximal femur. Earlier studies indicated that internal fixation using the PCCP is associated with a decreased perioperative blood loss, reduced transfusion requirements, with less postoperative pain, more rapid mobilisation, and with a reduced incidence of collapse of the fracture when compared with the standard device Dynamic Hip Screw. Aim of this study is to analyze the risk factors for the occurrence of local complications after internal fixation of intertrochanteric fractures of the femur using a Percutaneous Compression Plate. In a retrospective cohort study patients with trochanteric fractures who underwent internal fixation with a PCCP were included. We investigated the potential risk factors age, gender, experience of the surgeon as indicated by the numbers of surgical procedures with the PCCP device, stability of the fracture according to the AO/OTA classification, and co-morbidities of the patients according to the ASA classification. The operations were performed by ten different surgeons. All local complications which required re-operation were recorded. They included cutting out of the screw, loosening of the screw barrels, local haematoma, and infections. Logistic regression analysis was carried out to determine the risk factors for local complications. The mean age of the 122 patients included in this study was 78.5 years. 87 patients were female (70.7 %), 36 patients were male (29.3 %). With respect to the stability of the fracture 64 trochanteric fractures (52.5%) were classified as stable according to the AO/OTA classification, whereas 58 (47.5%) were considered to be unstable. Of the total of 122 patients with 122 trochanteric fractures eleven underwent re-operation due to local complications (9 %). The most frequent complication was complete or imminent cutting out of the upper cervical screw (N=5; 4 %). In the multivariate logistic regression model the only statistically significant risk factor was the experience of the surgeon (p=0.0316; odds ratio=4.7; CI 1.1–19.4). Our data indicate that the experience of the surgeon is a significant risk factor for the occurrence of local complications. The frequent use of this device seems to lower the re-operation rate

Introduction Unicompartmental knee arthroplasty (UKA) is well established in the treatment of OA of the knee, but has not been performed in large numbers compared with total knee arthroplasty. However, with the development of minimally invasive surgery, numbers of procedures are increasing rapidly. This study examines the results of minimally invasive UKA performed by one surgeon since august 1998. Methods A consecutive series of 388 knees in 360 patients operated between August 1988 and February 2003 were evaluated using a prospective database. All surgeries were performed by the senior author using a minimally invasive technique in a day surgery unit. General anaesthesia was used in all cases with local anaesthesia intra-operatively, combined with an anaesthetic infusion pump. No patient received parenteral narcotics. Ninety-seven percent were medial and three percent were lateral arthroplasties. Results Post-operatively no patients were lost to follow-up which ranged from two months to 4.5 years. Average age was 66 years. The average IKS score improved from 75 to 158 post-operatively. Most patients retained their pre-operative range of motion which averaged 120°. Average length of stay was 1.57 days with 41% of patients discharged the same day. There were five failures, due in part to osteoporosis and overcorretion. These were revised successfully to a ‘primary’ type knee prosthesis. Satisfaction rate subjectively was 98%. Conclusions Mid term results of UKA using the Repicci technique of minimally invasive surgery with rapid mobilisation and early discharge has ahcieved excellent results for unicompartmental OA of the knee. The procedure is better tolerated with a low complication rate and higher patient satisfaction than total knee replacement in this gourp of patients

Purpose of the study: Fractures of the metacarpals are common injuries generally observed in young males. Nailing, either with a centromedullary configuration or intermetacarpal construction is generally proposed. The nailing procedure nevertheless has its drawbacks: fracture instability, secondary displacement, pin migration, infection, requirement to remove material, injury to the cutaneous dorsal branch of the ulnar nerve, and most importantly, immobilisation for several weeks which is a major inconvenience for these young active patients. In this context, we wanted to compare two fixation systems: a locked plate versus centromedullary nailing. Material and methods: This was a retrospective comparison of consecutive patients from September 2007 to December 2008. The series included 39 cervical fractures of the fifth metacarpal in 39 patients aged 31 years on average. The first 19 patients were treated with a locked plate (Médartis. ®. ) (group A) and the 20 others with descending centromedullary nailing (group B). In group A, a dorsal approach respecting the dorsal cutaneous branch of the ulnar nerve was used. The technique consisted in insertion of distal locking screws enabling fracture reduction on the plate. No postoperative immobilisation was proposed and rapid mobilisation was encouraged. In group B, classical centromedullary nailing was performed with immobilisation with a short Thomine brace and syndactylisation of the last two fingers. Outcome was based on objective criteria (Jamar. ®. force, joint motion, duration of sick leave) and subjective assessment (DASH, VAS). Results: Mean follow-up was 12 months in group A and 8 months in group B. Depending on the type of fracture, plates with different shapes and lengths were used in group A; a single pin was used in group B (16/10 or 20/10). Secondary displacement was more frequent in group B, but the results in recovered motion were better in group B. The only parameter better in group A was length of sick leave; four patients in group A underwent reoperation to remove the plate and for tenoarthrolysis. In all, the outcomes for cervical fractures of the fifth metatarsal were better in group B. Discussion: Our preliminary results in group A show lesser complications and earlier return to work compared with better motion at last follow-up in group B. Centromedullary nailing remains the better treatment for cervical fractures of the fifth metatarsal. The extra cost of the plates does not appear to be warranted for the treatment of neck fractures of the fifth even though the patient can resume occupational activities earlier

Purpose. To study the initial presentation and subsequent investigation and management of acute knee dislocations at a regional trauma centre. Introduction. Knee dislocation requires high energy trauma, and often affects young working adults. The high incidence of associated arterial, neurological, ligamentous, and other soft tissue injuries, can produce potentially devastating outcomes. Rapid mobilisation of traditionally distinct surgical teams, with urgent vascular imaging and emergency surgery are often necessary. The extent and severity of ligamentous damage may require multiple operations to repair. Methods. A retrospective nine-year study of knee dislocations managed in the Trauma and Orthopaedic Department of the Royal Hospitals, Belfast was performed using a Fractures Outcomes Research Database (FORD), a chart review, and a review of relevant radiology. Demographic data, mechanisms of injury, associated neurovascular injuries, ligamentous damage, and operative intervention were recorded. Results. 15 patients were identified over 9 years (2000-2008 inclusive). Mean age at injury was 38 years, median 37. 14 (93%) of patients were male, 1 (7%) was female. 6 injuries (40%) were sport-related, 3 (20%) occurred as a result of road traffic collisions, 5 (33%) were accidents in the workplace, and 1 (7%) was a result of a fall while intoxicated with alcohol. 5 (33%) patients experienced a common peroneal nerve palsy. 10 (67%) received vascular imaging, and 2 (13%) underwent vascular surgery as part of the initial theatre episode. All 15 dislocations led to some degree of structural soft tissue knee injuries. These included 12 (80%) anterior cruciate ligaments, 8 (53%) posterior cruciate ligaments, 7 (47%) lateral collateral ligaments, and 5 (33%) medial collateral ligaments. 3 posterolateral corner injuries required repair. Of the 15 patients, 2 (13%) underwent no operative procedures following closed reduction, and the remaining 13 patients had 21 distinct theatre episodes recorded between them. 2 fasciotomies for compartment syndrome, and 2 common peroneal nerve decompression/explorations were performed in the initial theatre episode. 3 patients (20%) were managed with an external fixator initially. 1 patient (7%) developed complications and required trans-femoral amputation. Conclusions. Knee dislocation remains uncommon, and even major centres may receive only a few injuries per year. Orthopaedic, Vascular and Plastic surgeons, as well as Emergency Physicians and Radiologists must remain vigilant to the challenge which this injury can present, and the opportunity for excellent outcomes through a coordinated approach with close communication, awareness of injury patterns, and availability of theatre and imaging resources

Minimally invasive approaches to the hip may be divided into two categories: single mini-incisions derived from standard approaches and two-incision approaches designed specifically for minimally invasive total hip replacement. The authors have a number of specific concerns about the latter based on its apparent transgression of basic surgical principles and favour a mini-lateral approach to the hip which they describe and review. The two-incision approach requires two short (2–5cm) incisions from two different directions. Unlike other minimally invasive techniques, these incisions run close to the major neurovascular structures, which have been damaged. Visibility is limited as demonstrated by the need for navigation systems and illuminated retractors by some groups. Accurate resection of the femoral neck is obscured by the presence of the femoral head. Precise siting of the socket may be compromised by poor visibility. Most series accomodate only the use of uncemented components. Claims for more rapid mobilisation appear to depend more on anaesthetic rather than surgical technique. We have developed the mini-lateral approach to the hip, in parallel with others, over the last five years. It is a scaled-down version (< 10cm) of the Hardinge approach which has been used successfully for 25 years. It relies on a precise appreciation of the regional anatomy requires no additional equipment and avoids the problems posed by the two-incision approach. A short video presentation will be given. We present a consecutive retrospective series of 99 patients having 103 cemented C-stem THA for OA over a three-year period. Patients were assessed for duration of surgery, blood loss and length of postoperative stay. At follow-up (mean 18/12) they were assessed using the Oxford Hip Score, radiographic analysis and their incisions were measured. No hips have been revised and none are considered to be at risk. No nerve or vascular injuries have been reported

Aims: Circulating endothelial precursor cells (CEPs) are thought to play a role in angiogenesis. We investigated the angiogenic stress of musculoskeletal trauma on CEP kinetics in trauma patients and their bone marrow progenitor populations in a murine model. Methods: Peripheral blood mononuclear cells (PB-MNCs) were isolated from patients (n=12) on consecutive days following closed lower-limb diaphyseal fractures. CEP levels, deþned by the surface expression patterns of VEGFR2, CD34 and AC133 were determined and cytokine analysis of collected serum was performed. Bonemarrow precursors deþned byLy-6A/E and c-Kit expression were harvested following the traumatic insult from the murine model and quantiþed on ßow cytometry. Human and murine progenitor populations were cultured on þbronectin and examined for markers of endothelial cell lineage (Ulexeuropaeus- agglutinin-1 binding and acetylated-LDL uptake) and cell morphology. Statistical analysis was performed using variance analysis. Results: A consistent increase in human CEPs levels was noted within 72 hours of the initial insult, the percentage increase over day 1 reaching 300% (p=0.008) and returning to normal levels by day 10. Murine bone marrow precursors were mobilisd within 24 hrs peaking at 48hrs (900% p=0.035). On culture, morphologically characteristic endotheliallike cells binding UEA-1 and incorporating LDL were identiþed. Serum VEGF levels increased signiþcantly within 24 hrs of the insult, (p=0.018) preceeding the peak in CEP mobilisation. Conclusion: We propose that musculoskeletal trauma through the release of chemokines such as VEGF, promotes rapid mobilisation of CEPs from born marrow, which have the potential to contribute to reparative neovascularisation. Strategies to enhance CEPs kinetics may accelerate this process and offer a therapeutic role in aberrant fracture healing

It is important to optimise not only the operative treatment, but also the general medical condition of hip fracture patients to achieve the best rehabilitation result. Patients with a hip fracture are old and often suffer from concomitant diseases. They are prone to be affected by complications such as pneumonia, urinary tract infection and pressure ulcers. The total treatment situation with sufficient intake of food and drink, pain management, prevention of pressure ulcers and a rapid handling from arrival at the Acute and Emergency unit until the patient has been operated is crucial. We have studied the nutrition and drink in patients with a hip fracture and in spite of repeated instructions to eat and drink sufficiently the patients with the hospital standard food achieve only 54% of their optimum energy needs and 64% of the fluid necessary. With an extra addition of nourishment to the hospital food the total energy and fluid intake reach almost the calculated level of need for these patients. The amount of complications, particularly infections, were significantly lower in the well nourished group. We have also started to optimise the immediate acute treatment and already in the ambulance the patients now receive pain treatment, intravenous fluid and oxygene administration. The patients receive 3 litres of oxygene/min preoperatively and the first days postoperatively. The waiting time on hard surfaces has diminished through change of mattresses, but also with a much more rapid handling time through the X-ray department and the Emergency department. Routines have changed so the patients will not have to return to the Acute and Emergency after X-ray. Instead they are transported directly to the orthopaedic ward. Furthermore, the patients are given a higher priority in the waiting list among the acute surgery cases. All patients are evaluated for the risk of development of pressure ulcers and those at risk get special mattresses. With these measures the development of pressure ulcers during the time in hospitals has diminished by half. Special attention is also given to the patients’ mental status. At admission to hospital one third of the patients are not lucid. All these factors are of major importance for the rapid mobilisation of the patient in the acute ward and the continued rehabilitation

Introduction and Aims: Orthopaedic oncologists are often consulted regarding problems involving salvage of the distal femur due to bone loss, non-unions, infections. In young patients, extensive bony reconstruction is often necessary; in elderly, low demand patients, replacement with an endoprosthetic device results in decreased surgical time and more rapid mobilisation. Method: Since 1991, 27 patients underwent reconstruction with a custom modular distal femoral replacement and rotating hinged knee joint (DFR). Twenty-two (81%) were revised to a DFR from an existing knee arthroplasty. Diagnoses included fracture, non-union, osteomyelitis, osteolysis or deformity. Average age was 66 (25–85); 83% were female. Most patients had undergone multiple prior surgeries. Patients with a history of infection had undergone aggressive resection and insertion of spacers with prolonged antibiotic administration, however they had no infection at the time of DFR reconstruction. All endoprostheses were cemented. Patients were allowed immediate weight-bearing and rehabilitation similar to patients undergoing TKA. Results: One elderly patient died in the immediate peri-operative period of respiratory failure and one was lost to follow-up after placement in a nursing home. Average follow-up on 25 evaluable patients was 47 months (7–122). Reoperations were for recurrent infection (six) and tibial component loosening (three). Five of the six with infection were treated with synovectomy, antibiotic beads and suppressive oral antibiotics, and all five devices are still in place at an average of 54 months (range, 25–100). One severely diabetic patient had had multiple episodes of sepsis unrelated to the prosthesis which eventually seeded the distal femur and required a hip disarticulation. MSTS functional scores at last follow-up averaged 49% (13–80%) and HSS knee scores averaged 71% (37–90%). Conclusion: DFR is a useful salvage procedure in low demand patients. Initially, six patients were scheduled for transfemoral amputation and three were confined to wheelchairs. Patients other than the hip disarticulation were at minimum household ambulators at last follow-up. In spite of problems with infection, most patients improved in overall function

Introduction: The management of thoraco-lumbar burst fractures remains controversial. Different authors have advocated immobilisation, external bracing or internal fixation by either anterior or posterior approaches. Advocates of posterior fixation have in general performed stabilisation one level above and one level below the site of the fracture, resulting in fixation of two motion segments. It is known that multi-segmental spinal fusion produces undesirable biomechanics. To stabilise the site of the fracture and avoid unnecessary fixation of an uninjured segment the senior author (T.S.) for selected patients has been using a novel technique of monosegmental fixation with placement of pedicle screws directly into the fractured vertebral body. Methods: All patients with thoraco-lumbar burst fractures admitted to St Vincents and Concord Hospitals between January 2001 and October 2003 were considered for monosegmental fixation. Patients with severe osteoporosis or complete loss of vertebral body height (“vertebra plana”) were excluded. All patients underwent surgical decompression and fixation within 10 days of injury. Fixation was obtained with 4 titanium pedicle screws and a single transverse connector (Xia System Stryker Spine). Reduction of kyphotic deformity was carried out in selected patients. Average blood loss for the procedure was 250 ml with no patients requiring transfusion. All patients had a minimum of 6 months radiological and clinical follow-up. Results: Since January 2001, 18 patients with thoracolumbar burst fractures (T10-L2) were treated with single-level pedicle screw fixation. All patients were mobilised within 10 days of surgery. One patient experienced a minor superficial wound infection. There were no other postoperative complications. All patients had a stable fusion construct at 6 weeks following surgery. No patient experienced neurological deficit or have developed a delayed kyphotic deformity. There were no instances of instrument failure. 17 out of 18 patients report no significant back pain with any limitation of function by three months following surgery. One patient reports mild mechanical lower back pain 12 months following the injury. Discussion: Single level fixation for selected cases of thoracolumbar burst fracture is a safe and effective procedure to decompress the neural elements and obtain fixation and fusion of the fractured segment. It allows for rapid mobilisation and avoids a two-level fusion procedure with its subsequent detrimental effect on spinal biomechanics. It is considerably less invasive than anterior/lateral approaches which require extensive muscle dissection, rib removal and even diaphragmatic division

Objectives

We have observed clinical cases where bone is formed in the overlaying muscle covering surgically created bone defects treated with a hydroxyapatite/calcium sulphate biomaterial. Our objective was to investigate the osteoinductive potential of the biomaterial and to determine if growth factors secreted from local bone cells induce osteoblastic differentiation of muscle cells.

A national, multi-centre study was designed in which a questionnaire quantifying the degree of patient satisfaction and residual symptoms in patients following total knee replacement (TKR) was administered by an independent, blinded third party survey centre. A total of 90% of patients reported satisfaction with the overall functioning of their knee, but 66% felt their knee to be ‘normal’, with the reported incidence of residual symptoms and functional problems ranging from 33% to 54%. Female patients and patients from low-income households had increased odds of reporting dissatisfaction. Neither the use of contemporary implant designs (gender-specific, high-flex, rotating platform) or custom cutting guides (CCG) with a neutral mechanical axis target improved patient-perceived outcomes. However, use of a CCG to perform a so-called kinematically aligned TKR showed a trend towards more patients reporting their knee to feel ‘normal’ when compared with a so called mechanically aligned TKR

This data shows a degree of dissatisfaction and residual symptoms following TKR, and that several recent modifications in implant design and surgical technique have not improved the current situation.

Cite this article: Bone Joint J 2014;96-B(11 Suppl A):96–100.