Introduction. Distal femur fractures around a total knee arthroplasty (TKA) are a growing problem for orthopaedic surgeons. The purpose of this study was to identify risks of reoperation for nonunion following open reduction and internal fixation of TKA periprosthetic distal femur fractures (PDFF). Method. Patients with PDFF (AO 33A-C[VB1, C1, D1], Su types 1-3) managed operatively with open reduction and internal fixation (ORIF) were retrospectively reviewed. Exclusion criteria were acute management with a distal femur replacement, less than 6 months of follow-up, and lack of injury or follow-up radiographs. The primary outcome measure was reoperation to achieve bony union. Comparisons were made between cases that did and did not require a reoperation to achieve union. Univariate analysis was used to identify factors to be analyzed in multivariate analysis to determine independent risk factors for the primary outcome. Result. A total of 77 patients met inclusion criteria. Union rate was 69/77 (89.6%). There were no differences between the groups for age, sex, BMI, comorbidities, Su classification, open injury, or mechanism of injury. Multivariate analysis identified risks for nonunion including post-operative malalignment (OR 1.41; CI 1.20-1.64; p<0.001), notching pre-operatively (OR 1.22; CI 1.04-1.42; p=0.012), presence of screws through fracture line (OR 1.28; CI 1.17-1.39; p<0.001), plate length <12 holes (OR 1.16; CI 1.02-1.33; p=0.024) and screw density greater than 0.4 (OR 2.18; CI 1.25-3.78; p=0.006). Conclusion. The reoperation rate to promote union was 10.4%. The study identified post-operative malalignment, notching pre-operatively, presence of screws through fracture line, plate length <12 holes, and proximal screw density greater than 40% as independent risk factors for nonunion

A hot swollen joint is a commonly encountered condition in clinical practice. With a broad range of differentials, septic arthritis (SA) is perhaps one of the most concerning. Treated by culture-specific antibiotics and arthroscopic lavage, some patients require multiple washouts. We aimed to determine:. (1) What are the risk factors for development of SA?. (2) What are the risk factors for repeat washout in SA patients?. (3) What are the important clinical differences between a periprosthetic joint infection (PJI) and SA cohort?. All patients presenting to the emergency department, orthopaedic, and rheumatology clinics between January 2020 to January 2021 with a hot, swollen joint were retrospectively evaluated. Patients with previous trauma on the ipsilateral joint, with data missing from their medical records in any of the variables required for analysis, <24 months follow-up were excluded. Variables of interest in the three-month period preceding the diagnosis of SA were compared between SA and non-SA patients. Factors with a p-value of p<0.100 in univariate analysis were included in a stepwise multivariate logistic regression model. Similar analyses were performed to compare SA patients with multiple washouts with those needing one washout. Demographical and clinical data for PJI patients were collected to delineate important differences with SA cohort. 211 patients were included (SA:28;PJI:24;pseudogout:32;gout:26;others:101). Multivariate analysis showed rheumatoid arthritis (RA), skin infection, and liver disease were risk factors for SA. Amongst patients with septic arthritis, multivariate analysis showed that WBC levels above normal limits (3.6-10.5×109 cells/L) and RA were risk factors for multiple washouts. Between the SA and PJI cohorts, BMI (p=0.002) was significantly lower in the former, whilst WBC level (p=0.023) and CRP (p<0.0001) was significantly higher in the former. Early diagnosis of septic arthritis requires understanding the risk factors, namely RA, skin infection, and liver disease. Considering PJI and septic arthritis as the same entity can lead to wrong clinical judgement, and clinicians should be aware of important differences. We believe that the models in this study are of prognostic value to clinicians who are presented with the common presenting compliant of a hot swollen joint

Fracture related infections (FRI) are debilitating complications of musculoskeletal trauma surgery that can result in permanent functional loss or amputation. This study aims to determine risk factors associated with FRI treatment failure, allowing clinicians to optimise them prior to treatment and identify patients at higher risk. A major trauma centre database was retrospectively reviewed over a six-year period. Of the 102 patients identified with a FRI (66 male, 36 female), 29.4% (n=30) had acute infections (onset <6 weeks post-injury), 34.3% (n=35) had an open fracture. Open fractures were classified using Gustilo-Anderson (GA) classification (type 2:n=6, type 3A:n=16, type 3B:n=10, type 3C:n=3). Patients with periprosthetic infections of the hip and knee joint, those without prior fracture fixation, soft tissue infections, diabetic foot ulcers, pressure sore infections, patients who died within one month of injury, <12 months follow-up were excluded. FRI treatment failure was defined as either infection recurrence, non-union, or amputation. Lifestyle, clinical, and intra-operative data were documented via retrospective review of medical records. Factors with a P-value of p<0.05 in univariate analysis were included in a stepwise multivariate logistic regression model. FRI treatment failure was encountered in 35.3% (n=36). The most common FRI site was the femoral shaft (16.7%; n=17), and 15.7% (n=16) presented with signs of systemic sepsis. 20.6% (n=21) had recurrent infection, 9.8% (n=10) had non-union, and 4.9% (n=5) required an amputation. The mean age at injury was 49.71 years old. Regarding cardiovascular risk factors, 37 patients were current smokers (36.3%), 31 patients were diabetics (30.4%), and 32 patients (31.4%) were obese (BMI≥30.0). Average follow-up time was 2.37 (range: 1.04-5.14) years. Risk factors for FRI treatment failure were BMI>30, GA type 3c, and implant retention. Given that FRI treatment in 35.3% (36/102) ended up in failure, clinicians need to take into account the predictive variables analysed in this study, and implement a multidisciplinary team approach to optimise these factors. This study could aid clinicians to redirect efforts to improve high risk patient management, and prompt future studies to trial adjuvant technologies for patients at higher risk of failure

Treatment of tibial osteomyelitis can be challenging and lengthy, with numerous complications possible during rehabilitation. We report on the usage of the Taylor Spatial Frame (TSF) for a large cohort of patients, and analyse factors that affect outcomes. Between 2015-2020, 51 patients were treated with TSF for osteomyelitis at a major trauma centre. Demographic, infection and treatment factors of: age, smoking status, diabetes, and BMI, acute (<6 weeks post injury) or chronic (>6 weeks) osteomyelitis, bacteria isolated, time to debridement, therapy/surgery number of TSF, time TSF was in, antibiotic treatment period, time to partial weight bear (PWB) and full weight bear (FWB) prescriptions, were collected. Outcomes of complications and time to union were obtained. Radiological union was achieved at mean 11.0 months. Mean follow up was 24.1 months. Six and three patients were further treated with fusion and amputation respectively. Mean treatment time with TSF was 12.1 months. 78% had some complications, with pin site infection, malunion, and non-union being most prevalent. Univariate factor analysis, multicollinearity diagnostics, then multivariate model construction were performed. Staphylococcus Epidermidis in bone debridement microbiology was significantly negatively associated with pin site infection (OR 0.093, 95% CI 0.011-0.828) and malunion (OR 0.698, 95% CI 0.573-0.849), and enterococcus with non-union (OR 0.775, 95% CI 0.656-0.916), during the treatment period. Time to union was significantly positively associated with time from admission to debridement (p=0.035), time TSF was in (p=0.021), presence of complications (p=0.045), bone loss complication(p=0.037), time to FWB prescription(p=0.001). We have analysed the effectiveness of TSF in the treatment of tibial osteomyelitis, and elucidated important injury, treatment and rehabilitation factors that affect outcome. The negative bacterial-complication cross associations could be due to successful eradication as culture specific antibiotics were used postoperatively. Earlier patient full weight bearing could enhance callous formation leading to faster union

Introduction. Postoperative total shoulder arthroplasty (TSA) blood tests cost the National Health Service in the UK more than £72000 annually without definite evidence of their impact on outcomes. This study aimed to ascertain if these blood tests can be implemented on a per-patient basis. Methods. A retrospective review of one centre TSA patients over 6 years. Primary outcomes were interventions to abnormal postoperative blood tests. Secondary outcomes were the length of stay (LOS), and readmission within 30 and 90 days. Results. 193 patients underwent 216 TSAs; 72 % were females and 18% males. The mean age was 78 ± 7.2 years. Completed procedures included 134 reverse, 64 anatomical and 18 revision TSAs. 136 patients (63%) had an abnormal postoperative blood test, however, only 8 (3.7%) required intervention. The average postoperative Hb drop was 19 g/L with 94 patients (43.5%) having Hb <109g/L. 4 patients (1.8%) dropped Hb < 80g/L; only 2 (0.9%) were symptomatic and received RBC transfusion. 6 patients (2.8%) developed acute kidney injury and treated by IV fluids. The mean LOS was 3.2 ± 2.9 days .5 patients (2.3%) were readmitted within 30 days and 6 patients (2.8%) within 90 days. Univariate analysis showed association only between abnormal Creatinine and LOS (p<0.05) and of these patients, all had abnormal preoperative Creatinine baseline. No statistical correlation detected between age (p=0.287), postoperative Hb (p=0.230) and LOS nor readmission at 30 or 90 days. Conclusions. Routine postoperative blood tests are not required as no detected meaningful clinical impact and should be requested on an individual justified basis

Abstract. Objectives. Routine blood test following total shoulder arthroplasty (TSA) cost the NHS more than £72000 in 2018 without definite evidence of their impact on patients’ management or outcomes. This study aimed to ascertain if routine laboratory tests are a necessity post TSA or can be implemented on a per-patient. Methods. A retrospective review of the electronic records completed for 251 patients underwent TSA over 6 years. 193 patients were eligible for analysis. Primary outcomes were interventions to the abnormal postoperative blood tests. Secondary outcomes were the length of stay (LOS), and readmission within 30 days and 90 days. Results. 193 patients underwent 216 TSAs; 72 % were females and 18% males. The mean age was 78 ± 7.2 years. Completed procedures included 134 reverse, 64 anatomical and 18 revision TSAs. 136 patients (63%) had an abnormal postoperative blood test, however, only 8 (3.7%) required intervention. The average postoperative haemoglobin (Hb) drop was 19 g/L with 94 patients (43.5%) having Hb <109g/L. 4 patients (1.8%) dropped Hb < 80g/L; only 2 patients (0.9%) were symptomatic and received RBC transfusion . 6 patients (2.8%) developed acute kidney injury and treated by IV fluids. The mean LOS was 3.2 ± 2.9 days .5 patients (2.3%) were readmitted within 30 days and 6 patients (2.8%) within 90 days. Univariate analysis showed association only between abnormal Creatinine and LOS (p<0.05) and of these patients, all had abnormal preoperative Creatinine baseline. No statistical correlation detected between age (p=0.287), postoperative Hb (p=0.230) and LOS nor readmission at 30 or 90 days. Conclusions. Routine postoperative blood tests are not required as they have not shown to produce a meaningful clinical impact in this cohort of patients nor on the re-admission rate, causing unnecessary costs. We recommend assessing each patient and request for investigations in a coherent and justified manner. 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

Background and aim. Recent proposals have been introduced to modify stem design and/or femoral fixation in total hip replacement (THR). New designs need to consider previous design features and their results. The aim of this study has been to evaluate the clinical and radiological results of six different designs of tapered uncemented stems implanted in our Institution. Methods. 1918 uncemented hips were prospectively assessed from 1999 to 2011 (minimum follow-up of five years for the unrevised hips). All hips had a 28 or 32 mm femoral head and metal-on-polyethylene or alumina-on-alumina bearing surface. Six uncemented femoral designs that shared a femoral tapered stem incorporating a coating surface were included in the study. The different design features included the type of coating, metaphyseal filling, and sectional shape. Results. Intra-operative proximal femoral crack was 6.7% in one of the designs (p=0.01), univariate analysis showing a lower risk of crack in the other designs. The position of the stem was neutral in 80% of the cases for all designs. Femoral canal filing was related to the stem design (p<0.001 at the three levels) and to the femoral level assessed (subset alpha=0.005). Twelve stems were revised for aseptic loosening (6 from two different designs). The survival rate for femoral aseptic loosening at 15 years was 96.6% (95% CI 93.8 to 99.4) for one of these two designs ad 97.4% (95% CI95.5 to 99.6) for the other. Regression analysis showed that stem design was the only factor related to aseptic loosening when adjusted for femoral canal filling (at the three levels) stem position (neutral or not) and femoral type (cylindrical or not). Conclusion. Tapered uncemented stems consistently provide excellent bone fixation. New designs need to avoid changing successful features and concentrate on the less successful aspects

Metastatic osteosarcoma is seen in 10-20% of patients at initial presentation with the lung the most common site of metastasis. Historically, prognosis has been poor. We studied trends in survival in our small developed nation and aimed to identify correlations between the survival rate and three factors: newer chemotherapy, advances in radiological imaging and a more aggressive approach adopted by cardiothoracic surgeons for lung metastases. Our national bone tumour registry was used to identify patients at the age of 18 or under, who presented with metastatic disease at initial diagnosis between 1933 and 2006. There were 30 patients identified. Kaplan-Meier analysis was used to determine survival rates and univariate analysis was performed using the Cox regression proportional hazards model. Median survival has improved over the last 50 years; highlighted by the ‘Kotz’ eras demonstrating incremental improvement with more effective chemotherapy agents (p=0.004), and a current 5-year survival of 16%. Aggressive primary and metastatic surgery also show improving trends in survival. Three patients have survived beyond 5 years. The introduction of computerised tomography scanning has led to an increase in the prevalence of metastases at initial diagnosis. Metastatic osteosarcoma remains with a very poor prognostic factor, however, aggressive management has been shown to prolong survival

Patient reported outcome measures (PROMs) are important for assessing the results of lower limb arthroplasty. Unrealistic or uneducated expectations may have a significant negative impact on PROMs even when surgery is technically successful. This study's aim was to quantify pre-operative expectations of Scottish patients undergoing total hip and knee replacement (THR/TKR). 100 THR and 100 TKR patients completed validated questionnaires (from the Hospital for Special Surgery) prior to their operation after receiving standard pre-operative information (booklet, DVD, consultations). Each patient rated expectations from very important to not having the expectation. A total score was calculated using a numerical scale for the grading of each expectation. Univariate regression analysis was used to investigate the relationship between demographics and expectation score. The THR cohort had mean age 66.2 (SD 10.5), 53% female, mean BMI 29.0 (SD 5.1) and mean Oxford score 44 (SD 7). The TKR cohort had mean age 67.6 (SD 8.5), 59% female, mean BMI 32.8 (SD 5.8) and mean Oxford score 44 (SD 8). 100% THR and 96% TKR patients had 10 or more expectations of their operation. All expected pain relief. Other improvements expected were: walking for 100% THA and 99% TKA patients; daily activities for 100% THAs and 96% TKAs; recreational activities for 96% THAs and 93% TKAs; sexual activity for 66% THAs and 59% TKAs; psychological well-being for 98% THAs and 91% TKAs. Regression analysis showed increasing age lowered expectations in both THR (p=0.025) and TKR (p=0.031) patients but that gender, BMI and Oxford score were not significantly related to expectations. This study highlights that patients expect far more than pain relief and improved post-operative mobility from their operation. It is important to discuss and manage these expectations with patients prior to surgery. By doing so, patient satisfaction and PROMs should further improve

Objectives

To review the systemic impact of smoking on bone healing as evidenced within the orthopaedic literature.

External fixation of distal tibial fractures is often associated with delayed union. We have investigated whether union can be enhanced by using recombinant bone morphogenetic protein-7 (rhBMP-7).

Osteoinduction with rhBMP-7 and bovine collagen was used in 20 patients with distal tibial fractures which had been treated by external fixation (BMP group). Healing of the fracture was compared with that of 20 matched patients in whom treatment was similar except that rhBMP-7 was not used.

Significantly more fractures had healed by 16 (p = 0.039) and 20 weeks (p = 0.022) in the BMP group compared with the matched group. The mean time to union (p = 0.002), the duration of absence from work (p = 0.018) and the time for which external fixation was required (p = 0.037) were significantly shorter in the BMP group than in the matched group. Secondary intervention due to delayed healing was required in two patients in the BMP group and seven in the matched group.

RhBMP-7 can enhance the union of distal tibial fractures treated by external fixation.