Skeletal metastases are an increasing sequaelae for patients with a wide range of neoplastic lesions owing to the increasing incidences of cancer. The diagnosis of a skeletal metastasis is, however, at present a terminal diagnosis representing uncontrolled tumour dissemination. The metastatic destruction of the bone reduces its load bearing capabilities progressing to the principle orthopaedic complication, that of complete loss of cortical integrity.

Aim: We examine the population suffering a complication of skeletal metastasis in terms of their mortality and morbidity. We compare patients who underwent surgical stabilization as a result of a fracture through a metastatic lesion against those who underwent prophylactic stabilization.

This is a retrospective study of all patients within the Cardiff centre who underwent an operation for a metastatic bone lesion over a 10 year period (n=140). The patients were identified using pathological records created when samples were sent at the time of the operations. The patients were all followed up for a minimum of 24 months. The demographics of the patients were collected and a detailed analysis of the primary tumour, the surgical procedure, the mobility, and survival of the patients was undertaken. The patients data was then cross referenced with the database at the regional cancer centre and the post operative radiotherapy treatment regimen were collected.

Patients who underwent prophylactic surgical stabilization had a significant survival advantage compared to those stabilized following a fracture (p=0.002). The morbidity postoperatively, defined by the patients functional mobility, also shows the benefits of prophylactic stabilization with significantly improved mobility when compared to the mobility following fracture stabilization (p=0.033). It has also been shown that there is a significant postoperative survival benefit for those patients who were able to regain mobility (p< 0.01).

Our results show a significant survival benefit of prophylactic fixation rather than fixation following fracture which is in line with previous studies We have also, for the first time in a large number study, shown that there is a survival benefit for patients who are able to mobilize following surgery and if prophylactic stabilization was undertaken patients were significantly more mobile postoperatively.

Activated leukocyte cell adhesion molecule (ALCAM) has been shown to be involved in cell migration and in both homotypic/homophilic adhesion and heterotypic/heterophilic adhesion. It has been shown that a decreased level of ALCAM expression in human breast cancer tissue correlated with a significantly poor prognosis.

Aim: Previous studies have looked at nodal and general metastasis; in this analysis using an expanded tumour cohort, we, for the first time, specifically identified patients who went on to develop skeletal metastasis.

Primary breast cancer tissues (n=234) and non-neoplastic mammary tissue (n=34) were collected and patients were routinely followed up clinically after surgery. The immunohistochemical distribution and location of ALCAM was assessed in the normal breast tissue and carcinoma and the level of ALCAM transcripts in the frozen tissue was determined using real-time quantitative PCR. The results were analysed against the clinical data looking principally at the levels in patients with skeletal metastasis but also in relation to the nodal involvement, ER status, Nottingham Prognostic Index and survival.

The immunohistochemical staining intensity shows that the cytoplasmic staining in normal breast tissue is significantly stronger than that in breast cancer tissue (p=0.023) and also the breast cancer tissue from patients who went onto develop skeletal metastasis (p=0.048). The ALCAM transcript levels were the lowest in patient with skeletal metastasis (p=0.0048) compared to those who were disease free. Significantly lower transcript levels were also found the patients who developed local recurrence (p=0.040), and who died from breast cancer (p= 0.0075). Other indicators of poor prognosis show a significant difference: patients with moderate and poor NPI prognosis lower levels than those with a good prognosis (p=0.05, p=0.0089 respectively); and lower in patients with a positive ER status than those ER negative patients (p=0.043).

This study has for the first time shown that the patient who went on to develop skeletal metastasis tended to have the lowest levels of ALCAM transcript in their breast cancers. This fact could be used to provide patient with a more accurate prognosis and identify those who may benefit enhanced monitoring and early medical and orthopaedic treatment.

Objective: To evaluate the outcomes following percutaneous insertion of angle stable plate for operative management of distal Tibial fractures and the incidence of complications associated with this procedure.

Method: A retrospective analysis of all patients who underwent percutaneous plating of distal tibia was performed. Of 51 cases 3 were holiday makers who returned to their local hospitals, leaving 48 who were followed up until union. These were all the cases treated in our units using this technique from January 2002 – September 2005.

Results: The mean time to callus formation was 9 weeks (7–12), full weight bearing was 4 weeks (0–20) and solid union was 23 weeks (18–29). The mean hospital stay was 9 days (2–31). The overall complication rate was 18%. Significant complications included problems with union (6%) and deep infection (4%).

However 2 surgeons operated on 40 of the patients with a complication rate of 10% (1 non union, 1 superficial infection and 2 delayed removal of plate).

Conclusions: We found the use of percutaneous angle stable plates in operative treatment of distal Tibial fractures very effective with acceptable complication rates. Our data suggests that with greater experience of this fixation method complication rates can be reduced.

Introduction: Bone cements produced by different manufacturers vary in their mechanical properties and antibiotic elution characteristics. Small changes in the formulation of a bone cement, which may not be apparent to surgeons, may also affect these properties. The manufacturing method of Palacos bone cement with added gentamicin has recently changed. We have carried out a study to examine the mechanical characteristics and antibiotic elution of Schering-Plough Palacos (‘old’ version), Heraeus Palacos (‘new’ version) and Depuy CMW Smartset bone cements.

Methods: Schering-Plough Palacos R40G (contains 0.5g gentamicin per 40g mix), Heraeus Palacos R+G (contains 0.5g gentamicin per 40g mix) and Depuy-CMW Smartset GHV (contains 1g gentamicin per 40g mix) were used. 40g samples of the three cements with no additional vancomycin, 1g and 2g vancomycin were prepared by a standard method using vacuum mixing in a syringe. Antibiotic elution over a five week period was measured using an immunoassay method. Standard mechanical testing was carried out according to methods defined in ISO 5833.

Results: Both Heraeus Palacos and Smartset bone cements performed significantly better than Schering-Plough Palacos in terms of mechanical characteristics both with and without additional antibiotics. All cements show a deterioration in flexural strength with increasing addition of vancomycin although staying above ISO minimum levels. Both Heraeus Palacos and Smartset elute significantly more gentamicin cumulatively than Schering-Plough Palacos. Smartset elutes significantly more vancomycin cumulatively compared with Heraeus Palacos.

Discussion: Both Heraeus Palacos and Smartset Bone cements elute significantly more gentamicin than Schering-Plough Palacos with no deterioration in mechanical characteristics. Smartset also elutes significantly more vancomycin than Heraeus Palacos without adverse affect on mechanical characteristics. Although marketed as the ‘original’ Palacos, Heraeus Palacos has significantly altered mechanical and antibiotic elution characteristics compared with previous versions.

Introduction: The correct identification of the infecting micro-organism in prosthetic joint infections is difficult and there is no single method that is wholly reliable. We report a novel method intended to improve accuracy by disrupting the biofilm surrounding the prosthesis and transferring samples rapidly to culture medium.

Method: Explanted prostheses from 20 revision operations were sampled by pressing a microbiology swab or by passing a No.10 surgical blade along it. The sample so obtained was plated immediately in the operating theatre onto horse-agar petri dishes. These were incubated in aerobic conditions in the laboratory. Culture results were compared with those obtained from our standard detection method using multiple tissue samples with are plated or grown in prolonged aerobic and anaerobic culture broth.

Results: The method proved practical to perform in practice. When compared with multiple tissue samples as the standard, the Positive Predictive Value was 90%, Negative Predictive Value 80%, sensitivity 82%, specificity 89%. In 4 of the 10 true positive samples, the theatre-inoculated samples yielded early results within 3 days, while conventional method yielded positives only later on prolonged culture.

Discussion: The above pilot is to continue and has started to alter our practice in sample taking. Blade-scrape does appear to penetrate the biofilm successfully. Growing confidence in interpretation and ease in reading the plates mean that in certain cases, we consider the results to be more reliable than traditional tissue culture. Direct plating also reduces the chance of bacterial overgrowth in broth inhibiting colonies of secondary infective organisms. Further refinement is needed, particularly with regard to anaerobic bacteria. Inaccuracies have resulted when agar plates are allowed to go out of date.

Bone cements produced by different manufacturers vary in their mechanical properties and antibiotic elution characteristics. Small changes in the formulation of a bone cement, which may not be apparent to surgeons, can also affect these properties. The supplier of Palacos bone cement with added gentamicin changed in 2005. We carried out a study to examine the mechanical characteristics and antibiotic elution of Schering-Plough Palacos, Heraeus Palacos and Depuy CMW Smartset bone cements.

Both Heraeus Palacos and Smartset bone cements performed significantly better than Schering-Plough Palacos in terms of mechanical characteristics, with and without additional vancomycin (p < 0.001). All cements show a deterioration in flexural strength with increasing addition of vancomycin, albeit staying above ISO minimum levels. Both Heraeus Palacos and Smartset elute significantly more gentamicin cumulatively than Schering-Plough Palacos. Smartset elutes significantly more vancomycin cumulatively than Heraeus Palacos.

The improved antibiotic elution characteristics of Smartset and Heraeus Palacos are not associated with a deterioration in mechanical properties. Although marketed as the ‘original’ Palacos, Heraeus Palacos has significantly altered mechanical and antibiotic elution characteristics compared with the most commonly-used previous version.

Introduction: Unstable fractures of the distal tibia that are not suitable for intramedullary nailing are commonly treated by open reduction and internal þxation and/or external þxation techniques. Treatment of these injuries using minimally invasive plate osteosynthesis (MIPO) techniques may offer the advantage of achieving adequate þxation whilst minimising soft tissue injury and damage to the vascular integrity of the fracture fragments. Purpose: We report our experience using MIPO techniques for the treatment of unstable fractures of the distal tibia. Method: A review of all patients who sustained an unstable fracture of the distal tibia treated by MIPO between 1998 and 2001 was undertaken. Twenty patients were identiþed. The mean age was 38.3 years (17 Ð 71). All fractures were closed, and were classiþed according to the AO system. Intra-articular fracture extensions were classiþed according to RŸedi and Allgšwer. Results: Sixty percent of patients achieved callus by 8 weeks. All patients achieved callus by 3 months. The mean time to full weight bearing was 12 weeks (8 Ð 17). By 6 months 18/20 patients had achieved union. The two remaining patients achieved union by 7 months without further surgery. There were no deep infections and only one malunion. There were no cases of failure of þxation. Conclusion: MIPO appears to offer a reliable method of þxation of fractures of the distal tibia that are unsuitable for intramedullary nailing. Our results suggest that this technique is associated with a lower risk of signiþcant complications than encountered with more traditional methods of þxation of such fractures.

INTRODUCTION: Unstable distal and proximal tibial fractures that are not suitable for intramedullary nailing are often treated by open reduction and internal fixation (ORIF) and/or external fixation techniques. Discuss the treatment of these injuries with Percutaneous Plating technique which offers advantages over standard external fixation and/or ORIF as it minimises soft tissue trauma and does not disturb the osteogenic fracture haematoma.

PURPOSE: We report on the experience using percutaneous plating of unstable distal fractures in a district General Hospital setting and discuss the technique used and the applicability of this method to military personnel with high functional demands.

METHOD: a retrospective review of all patients treated with percutaneous plating technique for an unstable distal tibial fracture between 1998 and 2001 was undertaken. Fractures were classified to the AO system Reudi and Allgower. Indications for use of the percutaneous plate technique were distal tibial fractures which were initially managed in plaster until definitive fixation. No external fixation was used. The operation consisted of supine position on a radiolucent table. The fracture was reduced by closed methods and a DCP was shaped to fit the tibia. This was then positioned on the medial tibia in an extraperiosteal, subcutaneous tunnel. 4.5mm screws were fitted via stab incisions as appropriate to hold the plate in position. No splinting was used other than the plaster itself unless the patient was felt to be unable to comply with a touch weight bearing regime. Clinical and radiological follow up was 6–8 weeks, 3 months and 6 months post injury.

RESULT: 22 patients were identified, 20 of whom were available to follow up. Mean age was 38.3 years (range 17–71). There were 18 males and 4 females. Mechanism of injury was a fall in 12, motorcycle RTA in 6, and rugby/ football injury in 4. Most fractures were 42-A1/42-B1. 4 fractures had distal intra-articular fracture extensions. All were closed injuries. Over 50% of patients underwent fixation within 24 hours of the injury. Mean hospital stay was 6.5 days (2–31). There were no deep infections (one superficial infection which resolved with oral antibiotic treatment). Most patients achieved callus by 8 weeks, all by 3 months. Mean time to full weight bearing was 12 weeks (8–17). By 6 months only 2 fractures had not united. These united at 7 months. There were no non-unions and only one mal-union. There were no cases of failure of fixation.

Sickle-cell disease (SCD) is probably the commonest cause of avascular necrosis worldwide, and its prevalence appears to be rising in developed countries. Avascular necrosis of the humeral head is a common complication but has not been previously studied in detail. We have reviewed 138 patients with SCD for clinical, radiological and functional abnormalities of the shoulder, using a radiological classification designed for avascular necrosis of the shoulder. Radiographic lesions, frequently bilateral, were found in 28% and only 53% of patients had normal shoulder function. The management of this relatively common complication is difficult. Joint replacement is likely to fail and early diagnosis is important.

We report five patients with tibia vara due to focal fibrocartilaginous dysplasia of the medial aspect of the proximal tibia. In three patients spontaneous correction occurred, while in one of the remaining two treated by operation, a valgus deformity and neurological complications resulted. Conservative management is therefore recommended.

Ten children who had clinically stable hips at birth were radiographed at one month because they had factors predisposing to hip dislocation. In all cases one or both hips gave rise to a suspicion of dysplasia, though clinical abnormalities were slow to appear. Four of these hips subsequently dislocated. We believe that infants with late presentation of acetabular dysplasia and clinical abnormality belong to a different aetiological group from those with neonatal instability due to ligamentous laxity. The significance of this differentiation is that some infants presenting late have only recently dislocated, and the diagnosis has not necessarily been "missed" at neonatal examination.