Introduction

We examined the effect on blood loss of two standardised intravenous bolus doses of 500 mg of Tranexamic Acid, a fibrinolytic inhibitor that reduces blood loss following Knee Arthroplasty (KA).

Purpose of the Study

This study aims at investigating the effect of application time of bone cement on the cement-bone interface strength in two types of commercially available bone cements, Cement-A and Cement-B.

BACKGROUND

In our institution we use the Winklestabile volar locking plate for operative fixation of distal radius fractures. This study aims to assess subjective and objective outcomes using this method of treatment.

Aim of the study

To estimate and compare the cost implications of the first attempt of treatment of tibial fracture non-unions treated with either autologous bone grafting or BMP-7.

Aim

To compare a variety of commercially available bone graft substitutes (BGS) in terms of promoting adherence, proliferation and differentiation of osteoprogenitor cells.

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.

Background

The aim of this study was to identify and quantify any benefits of early active treatment of paediatric femoral shaft fractures for patients, their families, and the hospital.

Aim: Assessment of a new protocol, were acute soft tissue knee injuries are referred initially to a physiotherapy led knee assessment clinic.

Patients and methods: Patients reviewed in the acute knee assessment clinic (KAC) over a 6 month period were included. Patient demographics, specialist referrals, investigations, surgical interventions, and clinical outcomes were analysed.

Patients who were managed by the KAC only, were followed up for a minimum of 6 weeks and were asymptomatic at discharge.

Patients referred to a specialist were followed up prospectively in order to identify the accuracy of the initial diagnosis made in the KAC.

Results: The study included 191 patients (125 males, 66 females) with a mean age of 34.6 years.

Patients were seen in the KAC after an average 10.5 days from injury. Initial diagnoses included 35 patelo-femoral pathologies, 30 non-specific soft tissue injuries, 28 collateral ligament injuries, 27 cruciate ligament injuries, 21 combined meniscal and ligamentous injuries, 19 meniscal injuries, 17 patients with knee arthritis, 2 combined cruciate and collateral ligament injuries, 5 patellar dislocations, and 7 non-specific knee effusions.

Overall, only 52 patients (27.2%) were referred to a rheumatologist (n=6) or an orthopaedic surgeon (n=46). A total of 25 patients were referred for further investigation (Magnetic resonance imaging (MRI) n=14, Arthroscopy n=10, or both n=2). Patients who missed > 2 appointments and had no further episodes were excluded from further analysis (n=20).

The initial diagnosis correlated positively with that of the specialist in 26 out of 32 patients (81.3%) who completed a full treatment episode. The diagnosis by the physiotherapist and the specialist correlated with MRI or arthroscopy findings in 85.0% and 95.0% of cases respectively.

Conclusion: We believe that our physiotherapy led acute knee assessment clinic is effective and safe as a first referral point for acute knee injuries.

Purpose: To estimate and compare the direct medical cost implications of the first attempt of treatment of tibial fracture non-unions treated with either autologous bone grafting or BMP-7.

Methods: Patients who were successfully treated for fracture non-unions between 2001 and 2005 were enrolled. Exclusion criteria included a diagnosis of an infected nonunion, children, malignancy, or chronic debilitating disease. The decision to use BMP-7 or autogenous bone graft was guided by the defect size as well as the treating surgeon’s preferred method of treatment. Group 1 received iliac crest bone grafting (ICBG) and Group 2 received recombinant human Bone Morphogenetic Protein-7 (BMP–7) as the first line of treatment. The direct medical costs of treatment – including hospital stay, implants, theatre costs, drains, antibiotics, investigations and outpatient appointments were documented and analysed.

Results: The study sample consisted of 27 patients (14 females). Group 1 and Group 2 included 12 patients (4 females) and 15 patients (5 females) respectively. The mean age was 41.4 and 38.5 years respectively. The average hospital stay was 7.66 for the ICBG and 5,66 for the BMP7 patients (p=0.051). The follow-up period for Group 1 was 2.84 and 2.4 years for Group 2. The average time to union was 15.3 and 10.6 weeks respectively and this was statistically significant (p< 0.05). The overall direct medical costs on average reached the sum of £6,830.73 and £7,294.1 respectively. The hospital’s, operating theatre’s and outpatient’s direct medical costs were statistically significant (p< 0.05) more for the ICBG group. The implants costs did not significantly differ between the 2 groups and the second group’s costs were mostly raised due to the actual cost of the BMP7 (£3,002.2).

Conclusion and Significance: In this study, the average cost of treatment of a tibial fracture non-union with BMP7 was 6.7% higher than the cost incurred with autologous bone grafting. Most of the costs incurred (41.1%) in the BMP7 group were related to the actual price of BMP7. The direct medical cost difference between the two groups of patients wasn’t statistically significantly higher.

The aim of this study was to compare the modern treatments for femoral fractures in children to see if they have any advantages over traditional treatments. The modern treatments are mainly operative with the objective is to get the children mobilising early and to minimise the time spent in hospital. We studied 66 children who had sustained a traumatic femoral shaft fracture, over a six-year period with a minimum follow up of two years. A protocol using early hip spicas for under 5 year olds, flexible intramedullary nails for over 5 year olds, and external fixation for the polytrauma cases was started in 1999. Over a three-year period there were 25 children who sustained a fracture (Early active group). These were prospectively reviewed with a minimum follow up of 24 months. The outcome measures being, length of hospital stay, degree of mal-union, range of movement of the hip and knee, leg length discrepancy, pain and functional restrictions. This modern patient group was compared with all the fractures in the three years prior to the new protocol commencing. This group were treated usually with in patient traction (Traditional group). There were 41 children in this group who had sustained a fracture between 1996 and 1999.

The mean length of hospital stay was 32 nights in the traditional group and 19 nights in the early active group (p less than 0.001). If we exclude the children who were severely injured with multiple injuries the mean stay is 29 nights and 10 nights (p less than 0.001). There was no significant difference in the mal-union rate between the two groups. Very few had pain and at 2 years they all had good clinical and functional results. The only significant complication rate was with the fractures that were treated with an external fixator. These were mainly pin site infections. In our population there has been a 40% reduction in the incidence of femoral fractures over the six-year period for which we have no explanation.

These modern treatments have resulted in a shorter hospital stay that has many advantages for the child and family as well as financial savings.