Fixation techniques used in the treatment of slipped capital femoral epiphysis (SCFE) that allow continued growth of the femoral neck, rather than inducing epiphyseal fusion in situ, have the advantage of allowing remodelling of the deformity. The aims of this study were threefold: to assess whether the Free-Gliding (FG) SCFE screw prevents further slip; to establish whether, in practice, it enables lengthening and gliding; and to determine whether the age of the patient influences the extent of glide. All patients with SCFE who underwent fixation using FG SCFE screws after its introduction at our institution, with minimum three years’ follow-up, were reviewed retrospectively as part of ongoing governance. All pre- and postoperative radiographs were evaluated. The demographics of the patients, the grade of slip, the extent of lengthening of the barrel of the screw and the restoration of Klein’s line were recorded. Subanalysis was performed according to sex and age.Aims
Methods
A national screening programme has existed in the UK for the diagnosis of developmental dysplasia of the hip (DDH) since 1969. However, every aspect of screening and treatment remains controversial. Screening programmes throughout the world vary enormously, and in the UK there is significant variation in screening practice and treatment pathways. We report the results of an attempt by the British Society for Children’s Orthopaedic Surgery (BSCOS) to identify a nationwide consensus for the management of DDH in order to unify treatment and suggest an approach for screening. A Delphi consensus study was performed among the membership of BSCOS. Statements were generated by a steering group regarding aspects of the management of DDH in children aged under three months, namely screening and surveillance (15 questions), the technique of ultrasound scanning (eight questions), the initiation of treatment (19 questions), care during treatment with a splint (ten questions), and on quality, governance, and research (eight questions). A two-round Delphi process was used and a consensus document was produced at the final meeting of the steering group.Aims
Methods
Though the pathogenesis of Legg-Calve-Perthes disease (LCPD) is unknown, repetitive microtrauma resulting in deformity has been postulated. The purpose of this study is to trial a novel upright MRI scanner, to determine whether any deformation occurs in femoral heads affected by LCPD with weightbearing. Children affected by LCPD were recruited for analysis. Children received both standing weightbearing and supine scans in the MROpen upright MRI scanner, for coronal T1 GFE sequences, both hips in field of view. Parameters of femoral head height, width, and lateral extrusion of affected and unaffected hips were assessed by two independent raters, repeated at a one month interval. Inter- and intraclass correlation coefficients were determined. Standing and supine measurements were compared for each femoral head.Aims
Methods
The aim of this study was to establish the incidence of developmental dysplasia of the hip (DDH) diagnosed after one-year of age in England, stratified by age, gender, year, and region of diagnosis. A descriptive observational study was performed by linking primary and secondary care information from two independent national databases of routinely collected data: the United Kingdom Clinical Practice Research Datalink and Hospital Episode Statistics. The study examined all children from 1 January 1990 to 1 January 2016 who had a new first diagnostic code for DDH aged between one and eight years old.Aims
Patients and Methods
The aim of this study was to quantify the risk of developing cancer from the exposure to radiation associated with surgery to correct limb deformities in children. A total of 35 children were studied. There were 19 girls and 16 boys. Their mean age was 11.9 years (2 to 18) at the time of surgery. Details of the radiological examinations were recorded during gradual correction using a Taylor Spatial Frame. The dose area product for each radiograph was obtained from the Computerised Radiology Information System database. The effective dose in millisieverts (mSv) was calculated using conversion coefficients for the anatomical area. The lifetime risk of developing cancer was calculated using government-approved Health Protection Agency reports, accounting for the age and gender of the child.Aims
Patients and Methods
Forearm deformity is common in Hereditary Multiple Exostoses, for which multiple surgical treatments exist. Acute ulnar lengthening has been described in the literature, though in small numbers and not independent of adjunctive procedures. We hypothesise that acute ulnar lengthening as a primary procedure is safe and effective in correcting forearm deformity. Seventeen ulnas in 13 patients had acute ulnar lengthening for HME associated forearm deformity, over an eight-year period. Radiographic parameters were assessed and compared preoperatively and postoperatively. Mean follow-up was 27 months. Complications and revisions were noted. The mean pre-operative ulnar variance, 12.4mm (range 6.1 – 16.5), was significantly reduced post-operatively to a mean 4.6mm (p=<0.00001). A significant acute difference was achieved in carpal slip, (mean change of −2.2mm, p=0.02) but no significant change was seen with regard to radial bowing (p=0.98) or radial articular angle (p=0.74). There were three episodes of recurrence requiring revision. There were no major complications. Significant radiographic improvements in forearm and wrist alignment were seen with acute ulnar lengthening. Complications were infrequent. Recurrence rates in the skeletally immature patients are comparable to that reported with gradual lengthening techniques. Acute ulnar lengthening for forearm deformity associated with HME, has been demonstrated to be a safe, reproducible and effective surgical procedure.
This pilot study aims to investigate the utility and feasibility of a unique upright MR scan for imaging hips affected by Legg-Calve-Perthes Disease (LCPD) with patient standing up, in comparison to the standard supine scans. Protocol development using this unique upright MRI included healthy adult and child volunteers. Optimum patient positioning in a comparable way between supine to standing was assessed. The balance between shorter scan time (to what a child can tolerate) and longer scan time (for better image acquisition). The study protocol has begun in 2 children with LCPD. Patient recruitment continues. Early results indicate a dynamic deformity of the femoral head in early stage LCP disease. Femoral epiphysis height decreased on standing (7.8 to 6.8mm), width increased on standing (16.6 to 20.9mm) and lateral extrusion increased (3.5 to 4.1mm). Overall epiphyseal shape changed from trapezoidal (LCP femoral head when supine) to flattened triangular (LCP femoral head when standing). Differences were thus demonstrated in all parameters of bony epiphyseal height, width, extrusion and shape of a femoral head with LCP Disease when the child stood and loaded the affected hip. Satisfactory image acquisition was possible with Coronal T1 GFE sequences, with both hips in the Field of View. 2.5min scans were performed with the child standing first, then supine. Hip position was comparable when standing and supine. Longer scans were not tolerated by younger children, more so those with LCP disease. To our knowledge this is the first reported use of standing MRI in LCPD. A dynamic deformity has been demonstrated, with flattening, widening and worsened lateral extrusion when the child is standing compared to supine. This proof of concept investigation demonstrates the feasibility of upright MRI scanning and may demonstrate previously undetected deformity.
To evaluate effectiveness and safety of acute ulnar lengthening osteotomy in Madelung's deformity associated with Hereditary Multiple Exostoses (HME) Seventeen ulnas in 13 patients had acute ulnar lengthening for HME associated forearm deformity. Defined radiographic parameters were compared pre- and post-operatively using student's t-test; ulnar variance, carpal slip, radial bowing, radial articular angle. All complications were noted. Mean follow-up was 27 months (range 1.5 – 72months). An increase in ulna length by a mean of 15.4mm (range 4.5 – 29.3mm) was achieved acutely, corresponding to an increase of 9.3% of total ulnar length. Negative ulnar variance was improved from a pre-operative mean of 12.4mm (range 6.1–16.5mm) to a post-operative mean of 4.6mm (range 0–11.25mm) (p=<0.00001). Carpal slip was significantly improved by a mean of 2.2mm (p=0.02). No significant change in radial bowing (p=0.98) or radial articular angle (p=0.74) was observed. Inter-rater reliability was excellent (r=0.96, Pearson Correlation). Three patients required second procedures for recurrence of deformity at 18 months – 6 years following their primary operation. There were no incidences of compartment syndrome, neurovascular injury nor infection. One ulna fractured intra-operatively requiring a longer plate. One patient had a non union which united on revision surgery. Significant radiographic improvements in forearm and wrist alignment were seen with acute ulnar lengthening. The procedure is safe, with no compartment syndrome nor neurovascular injury and low complications rate. Recurrence rates in the skeletally immature patients are comparable to that reported with gradual lengthening. Acute ulnar lengthening for forearm deformity associated with HME has been demonstrated to be a safe, reproducible and effective surgical procedure.
As hallux valgus (HV) worsens clinical and radiological signs of arthritis develop in metatarsophalangeal joint due to incongruity of joint surfaces. The purpose of this prospective study was to determine if intraoperative mapping of articular erosion of the first metatarsal head, base of the proximal phalanx, and tibial and fibular sesamoids can be correlated to clinical and/or radiographic parameters used during the preoperative assessment of the HV deformity We analysed 50 patients prospectively who underwent surgery between Jan 2009-Jan 2010. Patients with a known history of previous first metatarsophalangeal joint surgical intervention, trauma, or systemic arthritis were excluded from analysis. Preoperative demographics and AOFAS score were recorded. Intraoperative evaluation and quantification of the first metatarsal head, base of the proximal phalanx, and sesamoid articular cartilage erosion was performed. Cartilage wear was documented using International Cartilage Research Society grading.Background
Materials and methods
Recently, the osteoregenerative properties of allograft have been enhanced by addition of autogenous skeletal stem cells to treat orthopaedic conditions characterised by lost bone stock. There are multiple disadvantages to allograft, and trabecular tantalum represents a potential alternative. This metal is widely used, although in applications where there is poor initial stability, or when it is used in conjunction with bone grafting, loading may need to be limited until sound integration has occurred. Strategies to speed up implant incorporation to surrounding bone are therefore required. This may improve patient outcomes, extending the clinical applications of tantalum as a substitute for allograft. To use tissue engineering strategies to enhance the reconstructive properties of tantalum, as an alternative to allograft. Human bone marrow stromal cells (5×105 cells/ml) were cultured on blocks of trabecular tantalum or allograft for 28 days in basal and osteogenic media. Molecular profiling, confocal and scanning electron microscopy, as well as live/dead staining and biochemical assays were used to detail cell adherence, proliferation and phenotype.Aim
Methods
Impaction bone grafting with milled human allograft is the gold standard for replacing lost bone stock during revision hip surgery. Problems surrounding the use of allograft include cost, availability, disease transmission and stem subsidence (usually due to shear failure of the surrounding allograft). Aims. To investigate various polymers for use as substitute allograft. The ideal graft would be a composite with similar mechanical characteristics as allograft, and with the ability to form de novo bone. High and low molecular weight (MW) forms of three different polymers (polylactic acid (PLA), poly (lactic-co-glycolic) acid (PLGA) and polycaprolactone (PCL)) were milled, impacted into discs, and then tested in a custom built shear testing rig, and compared to allograft. A second stage of the experiment involved the addition of skeletal stem cells (SSC) to each of the milled polymers, impaction, 8 days incubation, and then tests for cell viability and number, via fluorostaining and biochemical (WST-1, DNA) assays.Background
Methods
Replacing bone lost as a consequence of trauma or disease is a major challenge in the treatment of musculoskeletal disorders. Tissue engineering strategies seek to harness the potential of stem cells to regenerate lost or damaged tissue. Bone marrow aspirate (BMA) provides a promising autologous source of skeletal stem cells (SSCs) however, previous studies have demonstrated that the concentration of SSCs required for robust tissue regeneration is below levels present in iliac crest BMA, emphasising the need for cell enrichment strategies prior to clinical application. To develop a novel strategy to enrich skeletal stem cells (SSCs) from human BMA, clinically applicable for intra-operative orthopaedic use.Background
Aims
Skeletal stem cells (SSCs) have been used for the treatment of osteonecrosis of the femoral head to prevent subsequent collapse. In isolation SSCs do not provide structural support but an innovative case series in Southampton, UK, has used SSCs in combination with impaction bone grafting (IBG) to improve both the biological and mechanical environment and to regenerate new bone at the necrotic site. Analysis of retrieved tissue-engineered bone as part of ongoing follow-up of this translational case series.Background
Aims
Controversy exists as to whether the short external rotator tendons and capsule of the hip should be repaired after posterior approach primary total hip arthroplasty (THA). Recent studies using radiopaque markers have demonstrated that reimplantation of these muscle tendons fail early and may not prevent post operative dislocation. Using dynamic ultrasound examination we evaluated the patency of repair in 68 tendon groups (piriformis/conjoint tendon and obturator externus). We demonstrate short and medium term success in the reimplantation of these tendons using the double transosseous drill hole technique of reattaching the tendons and capsule to the greater trochanter. We followed up 21 of our total hip replacements and 13 hip resurfacings and undertook a dynamic ultrasound examination of the external rotators by an experienced musculoskeletal radiologist to assess their integrity at a minimum of 60 days and 100 days and an average of 213 days after the operation.Introduction
Methods
Disease transmission, availability and economic costs of allograft have resulted in significant efforts into finding an allograft alternative for use in impaction bone grafting (IBG). Biotechnology offers the combination of skeletal stem cells (SSC) with biodegradable polymers as a potential solution. Recently polymers have been identified with both structural strength and SSC compatibility that offer the potential for clinical translation. The aim of this study was to assess whether increasing the porosity of one such polymer via super critical CO2 fluid foaming (SCF) enhanced the mechanical and cellular compatibility characteristics for use as an osteogenic alternative to allograft in IBG. High molecular weight PLA scaffolds were produced via traditional (solid block) and SCF (porous) techniques, and the differences characterised using scanning electron microscopy (SEM). The polymers were milled, impacted, and mechanical comparison between traditional vs SCD created scaffolds and allograft controls was made using a custom shear testing rig, as well as a novel agitation test to assess cohesion. Cellular compatibility tests for cell number, viability and osteogenic differentiation using WST-1 assays, fluorostaining and ALP assays were determined following 14 day culture with SSC's.Aims
Methods
Impaction bone grafting with milled human allograft is the gold standard for replacing lost bone stock during revision hip surgery. Problems surrounding the use of allograft include cost, availability, disease transmission and stem subsidence (usually due to shear failure of the surrounding allograft). The aim of this study was to investigate various polymers for use as substitute allograft. The ideal graft would be a composite with similar mechanical characteristics as allograft, and with the ability to form High and low molecular weight (MW) forms of three different polymers (polylactic acid (PLA), poly (lactic co-glycolic) acid (PLGA) and polycaprolactone (PCL)) were milled, impacted into discs, and then tested in a custom built shear testing rig, and compared to allograft. A second stage of the experiment involved the addition of skeletal stem cells (SSC) to each of the milled polymers, impaction, 8 days incubation, and then tests for cell viability and number, via fluorostaining and biochemical (WST-1) assays.Aims
Methods
The osteo-regenerative properties of allograft have recently been enhanced by addition of autogenous skeletal stem cells to treat orthopaedic conditions characterised by lost bone stock. There are however, multiple disadvantages to allograft, including cost, availability, consistency and potential for disease transmission, and trabecular tantalum represents a potential alternative. Tantalum is already in widespread orthopaedic use, although in applications where there is poor initial implant stability, or when tantalum is used in conjunction with bone grafting, loading may need to be limited until sound integration has occurred. Development of enhanced bone-implant integration strategies will improve patient outcomes, extending the clinical applications of tantalum as a substitute for allograft. The aim of this study was to examine the osteoconductive potential of trabecular tantalum in comparison to human allograft to determine its potential as an alternative to allograft. Human bone marrow stromal cells (500,000 cells per ml) were cultured on blocks of trabecular tantalum or allograft for 28 days in basal and osteogenic media. Molecular profiling, confocal and scanning electron microscopy, as well as live-dead staining and biochemical assays were used to characterise cell adherence, proliferation and phenotype. Cells displayed extensive adherence and proliferation throughout trabecular tantalum evidenced by CellTracker immunocytochemistry and SEM. Tantalum-cell constructs cultured in osteogenic conditions displayed extensive matrix production. Electron microscopy confirmed significant cellular growth through the tantalum to a depth of 5mm. In contrast to cells cultured with allograft in both basal and osteogenic conditions, cell proliferation assays showed significantly higher activity with tantalum than with allograft (P<0.01). Alkaline phosphatase (ALP) assay and molecular profiling confirmed no significant difference in expression of ALP, Runx-2, Col-1 and Sox-9 between cells cultured on tantalum and allograft. These studies demonstrate the ability of trabecular tantalum to support skeletal cell growth and osteogenic differentiation comparable to allograft. Trabecular tantalum represents a good alternative to allograft for tissue engineering osteo-regenerative strategies in the context of lost bone stock. Such clinical scenarios will become increasingly common given the ageing demographic, the projected rates of revision arthroplasty requiring bone stock replacement and the limitations of allograft. Further mechanical testing and in vivo studies are on-going.
Skeletal stem cells can be combined with human allograft, and impacted to produce a mechanically stable living bone composite. This strategy has been used for the treatment of femoral head avascular necrosis, and has been translated to four patients, of which three remain asymptomatic at up to three year follow-up. In one patient collapse occurred in both hips due to widely distributed and advanced AVN disease, necessitating bilateral hip arthroplasty. However this has provided the opportunity to retrieve the femoral heads and analyse human tissue engineered bone. Analysis of retrieved human tissue-engineered bone in conjunction with clinical follow-up of this translational case series.Background
Aims
Recent approaches have sought to harness the potential of stem cells to regenerate bone lost as a consequence of trauma or disease. Bone marrow aspirate (BMA) provides an autologous source of skeletal stem cells (SSCs) for such applications, however previous studies have demonstrated that the concentration of SSCs present in iliac crest BMA is below that required for robust bone regeneration. Here we present a novel acoustic-facilitated filtration strategy to concentrate BMA for SSCs, clinically applicable for intra-operative orthopaedic use. The aim of this study was to demonstrate the efficacy of this strategy in concentrating SSCs from iliac crest bone marrow, as well as femoral canal BMA from older patients. Iliac crest BMA (Lonza, Rockville, MD, USA) and femoral canal BMA was obtained with informed consent from older patients during total hip replacement. 5 to 40ml of BMA was processed via the acoustically-aided exclusion filtration process to obtain 2-8 fold volume reductions. SSC concentration and function was assessed by flow-cytometry, assays for fibroblastic colony-forming units (CFU-F) and multi-lineage differentiation along chondrogenic, osteogenic and adipogenic pathways examined. Seeding efficiency of enriched and unprocessed BMA (normalised to cell number) onto allograft was assessed. Iliac crest BMA from 15 patients was enriched for SSCs in a processing time of only 15 minutes. Femoral BMA from 15 patients in the elderly cohort was concentrated up to 5-fold with a corresponding enrichment of viable and functional SSCs, confirmed by flow cytometry and assays for CFU-F. Enhanced osteogenic (P<0.05) and chondrogenic (P<0.001) differentiation was observed using concentrated aspirate, as evidenced by biochemical assay and semi-quantitative histological analysis. Furthermore, enhanced cell seeding efficiency onto allograft was seen as an effect of SSC concentration per ml of aspirate (P<0.001), confirming the utility of this approach for application to bone regeneration. The ability to rapidly enrich BMA demonstrates potential for intra-operative application to enhance bone healing and offers immediate capacity for clinical application to treat many scenarios associated with local bone stock loss. Further in vivo analysis is ongoing prior to clinical tests.
