The purpose of this study was to evaluate the efficacy of human recombinant osteogenic protein 1 (rhBMP-7) for the treatment of fracture non-unions and to estimate the health economics aspect of its administration.

Twenty-four patients (18 males, mean age 39.1 (range 18-79)) with 25 fracture non-unions were treated with rhBMP-7 in our institution (mean follow-up 15.4 months (range 6-29)). Successful completion of treatment was defined as the achievement of both clinical and radiological union. The cost of each treatment episode was estimated including hospital stay, theatre time, orthopaedic implants, drug administration, investigations, clinic attendances, and physiotherapy treatments. The total cost of all episodes up to the point of receiving BMP-7 and similarly following treatment with BMP-7 were estimated and analysed.

Of the 25 cases, 21 were atrophic (3 associated with bone loss) and 4 were infected non-unions. The mean number of operations performed prior to rhBMP-7 application was 3.4, including autologous bone graft in 9 cases and bone marrow injection in one case. In 21 out of the 25 cases (84%), both clinical and radiological union occurred. Mean hospital stay before and after receiving rhBMP-7 was 26.84 days per fracture and 7.8 days per fracture respectively. Total cost of treatments prior to BMP-7 was £346,117 [£13,844.68 per fracture]. Costs incurred following BMP-7 administration were estimated as £183,460 [£7,338.4 per fracture].

rhBMP-7 was used as a bone stimulating agent with or without conventional bone grafting with a success rate of 84% in this series of patients with persistent fracture non-unions. The average cost of its application was £7,338 [53.0% of the total costs of previous unsuccessful treatment of non –unions, p<0.05). Treating non-union is costly, but the financial burden could be reduced by early rhBMP-7 administration when a complicated or persistent non-union is present or anticipated. Therefore, this study supports the view that rhBMP-7 is a safe and power adjunct to be considered in the surgeon's armamentarium for the management of such difficult cases.

The effect of head injury on systemic physiology, including bone healing is still a topic of vivid discussion. We aimed to investigate whether in patients with long bone fractures the presence of head injury is associated with excessive callus formation. Data on patients with head injury and femoral diaphyseal fracture admitted to our trauma unit between 1997- 2002 were collected and analysed. Patients with factors that could influence bone healing such as smoking, NSAIDs and hormonal disorders were excluded. The severity of head injury was quantified using GCS, AIS and CT scan reports. Patients matched for age, sex and ISS with femoral shaft fractures and no head injury formed the control group of the study. All the fractures were stabilised with reamed femoral nail. The quantification of fracture healing response was estimated by taking the radiological ratio of the largest diameter of callus formed into two planes and the adjacent normal diameter of femoral canal. The minimum follow-up of the patients was 12 months.

In total 42 patients were studied, 17 with head injury and femoral fracture and 25 with an isolated femoral fracture, (control group). Both groups were comparable in terms of age, sex, ISS. The difference between the mean callus to diaphyseal ratio was statistically significant for both the AP and Lateral projections (AP – mean difference 0.462, 95% CI 0.312 to 0.602, p<0.0001, LAT – mean difference 0.289, 95% CI 0.142 to 0.436, p<0.001) with the head injured patients having more florid callus compared to the control group.

This study supports the view that head injury leads to exuberant callus formation in patients with long bone fractures. The mechanisms of this response could be both central and local. Research is ongoing to elucidate the pathways involved in this biological phenomenon.

Guidelines on the care of the seriously injured have led to widespread changes in clinical practice. The ‘hub and spoke’ model of trauma care means increasing numbers of patients with complex problems are concentrated into regional centres. Though providing the highest standards of treatment, this has cost implications for the receiving unit, particularly given the Department of Health's move towards a ‘Payment by Results’ model of health provision. We undertook an economic evaluation of complex limb reconstruction within our tertiary referral unit.

Patients referred to the complex trauma service were identified. Patients were assigned to either a ‘complicated’ or ‘straightforward’ group by two consultant surgeons, based on the nature of their treatment. 5 cases from each group were randomly selected for further analysis. Data pertaining to the direct healthcare costs for these patients was analysed. Costs per investigation/intervention were obtained relating to hospital stay, outpatient care, operative interventions and investigations. Overall 26 patients were referred to our complex trauma service from other units over 6 months.

A mean of £8,375 (6,163) per patient was recouped using current Service Level Agreements. This amounts to a £26,587 deficit per patient, or £1,394,905 per year assuming current referral rates.

Those planning a service treating complex trauma must allow for the considerable costs involved and make provisions to recoup this from the referring Primary Care Trust.

Aims: To investigate adequacy of temporary ex-fix in grade III open fractures of the tibia, prior to definitive treatment by Flap & Frame at 2 UK trauma centres.

Methods: Between 2000 and 2006 all open fractures of the tibia treated by the Ilizarov Method at our two institutions were entered onto the Flap & Frame database. The database was searched for all temporary external fixators placed prior to definitive Ilizarov fixation. Data collected – ex-fix type, whether revision was necessary, reasons for revision.

Results:

97 grade III open fractures in 95 patients

Discussion: Recently Naique and Pearse showed a revision rate of skeletal fixation of 48% in grade IIIb open fractures referred to their tertiary centre. In our series 34% of temporary external fixators needed revision. Modular systems such as Hoffman II and AO required no revision, irrespective of whether they were applied at trauma centre or DGH.

All Hoffman hybrids needed revision, due to both instability and plastics access. Significantly more non modular (Orthofix) ex-fixes required revision compared to modular (Hoffmann II/AO), due to poor plastics access.

Conclusion: We recommend modular external fixation systems such as Hoffman II or AO if problems of temporary external fixation of open tibial fractures are to be avoided. Hybrid temporary external fixation should be abandoned as temporary fixation in such an injury

Introduction: To assess the effectiveness of a regional basic external fixation trauma course.

Methods: Effectiveness of an annual, low-cost, Royal College of Surgeons of England approved, regional basic ex-fix course, led by consultant trauma experts from Yorkshire, UK, covering anatomy, surgical techniques, biomechanics, early management of open fractures and temporary external fixation placement was assessed. Pre- and post-course questionnaires asking grade, current hospital, previous experience, and a mini-test to design a temporary ex-fix construct for four fracture patterns (IIIb open tibia, open book pelvis, Schatzker 6, and total articular pilon) were used. Designs were assessed for stability, safe corridors and plastics assess.

Results:

- 10/22 participants had not previously attended an ex-fix course.

Discussion: Recently Pearse and Naique reported a 48% fixation revision rate in open tibial fractures transferred for tertiary care, suggesting that improved core skills are required to ensure appropriate packaging of patients prior to transfer with open, complex articular and pelvic fractures.

Participation in a simple ex-fix course improves knowledge of ex-fix design. Retention of knowledge must be reassessed after several months.

This course fills a gap in education of basic external fixation for orthopaedic trainees. We recommend every region with a tertiary referral system for complex trauma utilises this course.

Introduction: The hub and spoke model of trauma describes fracture stabilisation prior to referral. Many arrive at tertiary centres with inadequate temporary external fixation. This study investigates ex-fix availability, training and awareness of referral protocols in two regions.

Methods: Hospitals feeding two regional trauma centres were targeted with two telephone questionnaires, one for on-call orthopaedic SpRs and one for theatre nursing staff ascertaining ex-fix availability, training, knowledge of regional referral protocols, and clinical scenarios to establish common practice in each unit.

Results: 16 hospitals: 15 SpRs, 16 nurses responded

Equipment: 0/31 aware guidelines for ex-fix stock

- Ex-fix trays per unit (all manufacturers) mean = 4.14 (1–9)

SpRs:

- mean year of training = 2.2

Referral Protocols:

- 7/31 aware of transfer protocol

Discussion: A deficiency of ex-fix equipment for DCO/ polytrauma exists across many units in both regions. No accepted advice on equipment level requirement exists.

All trainees had attended ex-fix teaching. Those who had only attended generic courses were less confident in DCO scenarios.

Most favoured a specific regional ex-fix course.

Tertiary care protocols have been distributed, but many units are unaware of their existence. A regular regional audit of trauma referrals would provide protocol reinforcement and opportunity for feedback.

Introduction: To investigate adequacy of temporary ex-fix in grade III open fractures of the tibia, prior to definitive treatment by Flap & Frame at 2 UK trauma centres.

Methods: From 2000 – 2006 all open fractures of the tibia treated by the Ilizarov Method at our two institutions were entered onto the Flap & Frame database. The database was searched for all temporary external fixators placed prior to definitive Ilizarov fixation. Data collected - ex-fix type, whether revision necessary, reasons for revision.

Results:

- 97 grade III open fractures in 95 patients

Discussion: Naique and Pearse described a revision rate of skeletal fixation of 48% in grade IIIb open fractures referred to their tertiary centre. In our series 34% of temporary external fixators needed revision. Modular systems (Hoffman II and AO) required no revision, irrespective of application at a trauma centre or DGH.

All Hoffman hybrids needed revision, due to instability and plastics access. Significantly more non modular (Orthofix) ex-fixes required revision compared to modular, for poor plastics access.

We recommend modular external fixator application (Hoffman II or AO) to avoid problems with temporary external fixation of open tibial fractures. Hybrid temporary external fixation should be abandoned in such injuries.

Introduction: Although the functional outcomes after severe lower limb injury ( Gustilo grade IIIb and IIIc ) managed with various surgical techniques is well described in the literature, there is limited information on appearance related psychological impact after complex lower limb reconstruction. We sought to determine the aesthetic problems in patients with open tibial fractures with extensive soft tissue injury.

Materials and methods: Data on patients with open tibial fractures managed with free flaps between 1999–2003 admitted to our trauma unit was collected and analysed. Patients who had finished their treatment at least one year ago with isolated leg injury were identified, patients with surgery related disability were excluded. we used Derriford Scale (DSA24) with additional questionnaire for analysis .

Results: In total 31 patients were contacted out of which 18 provided with completed questionnaires, 14 male and 4 female with mean age of 41.8(17–69) year. Appearance of the leg following surgery significantly effected relationships (3 divorced, 2 split up, 3 worse, 8 same and 2 better). Nine (56.2%) patients experienced poor sexual relationship following surgery and four (22.2%) reported to avoid undressing in front of partners. Five patients (27.7%) requested debunking and two under went surgery. Twelve (66.6%) patients were still taking pain killers. Ten (55.5%) patient complained of donor site weakness or painful scar. Six (33.3%) patients required to change jobs. Thirteen (72.2%) were unconfident in themselves, (66.6%) were distressed to see there legs in mirror. Nine (50%) felt hurt and irritable at home, (61.1%) patients avoided going to beach. Nine (50%) disliked using communal changing areas or even going for shopping and felt closed in a shell. Eight (44.4%) patients felt rejected and chose not to attend social events.

Conclusion: The psychological impact of trauma is generally neglected, sudden and unexpected nature of events and interventions have significant effect on post operative quality of life.

Introduction: Some centres in the UK have recently seen a shift away from internal fixation and free tissue transfer (Fix and Flap), towards temporary monolateral external fixation, soft tissue coverage and definitive Ilizarov frame fixation (Flap and Frame).

Methods: Patients sustaining open fractures were identified prospectively and followed up beyond frame removal. After open wound debridement a monolateral ex-fix was applied. Soft tissue coverage was then achieved by our plastic surgeons. As the soft tissues settled, the temporary ex-fix was exchanged to an Ilizarov frame for definitive fixation. Open fractures with bone loss were similarly treated, with either acute shortening or bone transport, depending on the extent of bone loss and state of soft tissues.

Results: Between July 2002 and June 2004, 21 grade 3 open fractures in 18 patients were treated by Flap and Frame. There were 15 male and 3 female patients, with mean age 36. Segment involved was 19 tibias and 2 femurs. There was associated bone loss (mean 9cm) in 6 fractures. 8 had other associated injuries.

Gustilo grade, 3A/3B/3C = 6/13/2. Both 3C fractures required early amputation.

Wound closure, 5/6 fractures with bone loss required free tissue transfer (FTT); however only 3/15 fractures without bone loss required FTT to achieve soft tissue cover, most requiring fasciocutaneous flap or split skin graft only.

Median time in Ilizarov frame was 160 days for patients without bone loss. For those fractures with bone loss frame time ranged from 180–540 days, with some patients still requiring ongoing Ilizarov treatment.

All fractures without bone loss united. At mean 14 month follow up only one fracture of 21 had clinical evidence of deep sepsis. 1 tibial fracture showed a 12 degree malunion, while 7/18 patients had a superficial pinsite infection requiring a course of oral antibiotics. One free tissue transfer failed in a grade 3C fracture, leading to early amputation (in conjunction with the recognised vascular injury).

Conclusions: Grade 3 open fractures remain a significant treatment challenge. This was particularly true of those with associated bone loss, where without exception the treatment time in an Ilizarov frame was prolonged. A deep sepsis rate of 1/21 fractures treated by Flap and Frame compares favourably with other published series. In the 15 fractures without bone loss, times to union also compared very favourably. Unlike in previous series, many fractures did not require free tissue transfer, as there was no internal fixation device present at the fracture site requiring coverage.

Flap and Frame appears to be a very satisfactory method of treating grade 3 open fractures, with low deep sepsis rate, high union rate, satisfactory times to union, and reduced requirement for free tissue transfer to obtain soft tissue coverage.

Introduction and Aims: Congenital femoral deficiency (CFD) can be managed by femoral lengthening using callotasis with external fixation. A common complication is fracture with angular deformation soon after fixator removal. We developed a novel technique to overcome this complication using intermedullary stabilisation. Special hand reamers are needed to re-establish medullary canal blocked by cortical plates around previous external fixator pin sites and not yet recanalised regenerate bone.

Method: Since 2000, we treated nine of these fractures in children with an average age of 5.4 years. The children had spent an average of 22 weeks in a fixator, gaining a mean of 7cm of length. Most fractures occurred as ‘spontaneous’ events at a mean of three weeks after fixator removal, resulting in a transverse fracture through the regenerate bone, host-regenerate interface, or proximal pin sites. All were stabilised with intermedullary nailing.

Results: Union was achieved satisfactorily in approximately six weeks. No serious complications, such as infection, avascular necrosis, or non-union, occurred. All bones were successfully realigned, and the mean loss of length was only 0.7cm.

Conclusion: Careful surgical technique, using specific operative steps described (including use of flexible hand reamers to create canal, small percutaneous osteotomies to allow proper reduction, and Rush pins for stabilisation) has achieved good results. We recommend this approach to surgeons involved in the management of fractures occurring after fixator removal.

Objective : The valgus angle of the distal femur determines the axial alignment of limb. It is used to plan the realignment osteotomies in limb reconstruction surgery and to determine the angle of resection of the distal femur in total knee arthroplasty. The objective of this study was to analyse the variation of the valgus angle of the distal femur in a random Caucasian population with osteoarthritic knees presenting for total knee arthroplasty.

Method : A prospective study was undertaken involving a review of pre-operative CT scout films of osteoarthritic knees in 83 consecutive patients (44 males and 39 females; mean age 70.2 years) presented for total knee arthroplasty between May 1999 and October 2002. The valgus angle was calculated from the difference between the anatomical and mechanical axes of femur plotted on CT scanogram films.

Results : Mean valgus angle was 5.4 degrees (range 3.3 to 7.6 degrees) with a standard deviation of 1.1 degrees. Estimated 95% confidence interval of the mean for the population was 3.6 – 7.4 degrees. There were no significant differences for age, gender or laterality of the limb.

Conclusion : The value of mean valgus angle of the distal femur in osteoarthritic knees was found to be significantly lower than the one quoted in the literature in normal disease-free knees. This may have important implications on the preoperative planning of appropriate surgical planes for total knee arthroplasty or corrective osteotomies.