Type IIIB open tibial fractures are devastating high-energy injuries. At initial debridement, the surgeon will often be faced with large bone fragments with tenuous, if any, soft-tissue attachments. Conventionally these are discarded to avoid infection. We aimed to determine if orthoplastic reconstruction using mechanically relevant devitalized bone (ORDB) was associated with an increased infection rate in type IIIB open tibial shaft fractures. This was a consecutive cohort study of 113 patients, who had sustained type IIIB fractures of the tibia following blunt trauma, over a four-year period in a level 1 trauma centre. The median age was 44.3 years (interquartile range (IQR) 28.1 to 65.9) with a median follow-up of 1.7 years (IQR 1.2 to 2.1). There were 73 male patients and 40 female patients. The primary outcome measures were deep infection rate and number of operations. The secondary outcomes were nonunion and flap failure.Aims
Patient and Methods
The aim of this study was to investigate the association between the type of operation used to treat a trochanteric fracture of the hip and 30-day mortality. Data on 82 990 patients from the National Hip Fracture Database were analyzed using generalized linear models with incremental case-mix adjustment for patient, non-surgical and surgical characteristics, and socioeconomic factors.Aims
Patients and Methods
Angular deformity in the lower extremities can result in pain, gait disturbance, cosmetic deformity and joint degeneration. Up until the introduction of guided growth in 2007, which has since become the gold standard, treatment for correcting angular deformities in skeletally immature patients had been either an osteotomy, a hemiepiphysiodesis, or the use of staples. We reviewed the surgical records and diagnostic imaging in our childrens hospital to identify all patients who had guided growth surgery since 2007. All patients were followed until skeletal maturity or until their metalwork was removed.Purpose
Methods
Canonical Wnt inhibitor Sclerostin (SOST) may be a key mechanotransduction regulator. Unloading/loading 10 week old Sost−/− and WT mice. Unloading: Quads and calf muscles injected each with 0.5U botulinum toxin (BTX, Allergan) caused tibial unloading. Loading: 1200 cycles of tibial axial loading, 1200μe on mid-shaft, 4Hz, 5 days/week. Treated and control tibiae μCT scanned (Skyscan 1174) at 2 weeks.Introduction
Methods
Femoroacetabular impingement (FAI) is a significant cause of osteoarthritis in young active individuals but the pathophysiology remains unclear. Increasing mechanistic studies point toward an inflammatory component in OA. This study aimed to characterise inflammatory cell subtypes in FAI by exploring the phenotype and quantification of inflammatory cells in FAI versus OA samples. Ten samples of labrum were obtained from patients with FAI (confirmed pathology) during open osteochondroplasty or hip arthroscopy. Control samples of labrum were collected from five patients with osteoarthritis undergoing total hip arthroplasty. Labral biopsies were evaluated immunohistochemically by quantifying the presence of macrophages (CD68 and CD202), T cells (CD3), mast cells (mast cell tryptase) and vascular endothelium (CD34). Labral biopsies obtained from patients with FAI exhibited significantly greater macrophage, mast cell and vascular endothelium expression compared to control samples. The most significant difference was noted in macrophage expression (p<0.01). Further sub typing of macrophages in FAI using CD202 tissue marker revealed and M2 phenotype suggesting that these cells are involved in a regenerate versus a degenerate process. There was a modest but significant correlation between mast cells and CD34 expression (r=0.4, p<0.05) in FAI samples. We provide evidence for an inflammatory cell infiltrate in femoroacetabular impingement. In particular, we demonstrate significant infiltration of mast cells and macrophages suggesting a role for innate immune pathways in the events that mediate hip impingement. Further mechanistic studies to evaluate the net contribution and hence therapeutic utility of these cellular lineages and their downstream processes may reveal novel therapeutic approaches to the management of early hip impingement.
Mortality rates following hip fracture are high. There are several scoring systems which aim to predict morbidity and mortality in hospital in-patients. The Nottingham Hip Fracture Score (NHFS) was devised to predict 30 day mortality following hip fracture. All patients with hip fractures admitted over a 6 month period were reviewed. The NHFS was calculated for each patient and any associations between patient factors, NHFS, and outcome were investigated.Introduction
Methods
The aim of this study was to evaluate the health quality of life and return to sports activities following pelvic ring injuries. Between January 2006–2007 patients treated in our institution with pelvic fractures were eligible to participate. Inclusion criteria were adult patients. Exclusion criteria were children and pathological fractures. Data recorded included demographics, injury mechanism, fracture pattern, Injury severity score (ISS), associated injuries, method of fixation, complications and functional outcome. Health related quality of life was assessed using the (EuroQol) and return to sports activities was evaluated using a return to sports questionnaire. The minimum follow up was 24 months (24–39)Introduction
Patients and Methods
Tightrope fixation has been suggested as an alternative to screw stabilisation for distal tibiofibular joint diastasis that provides stability but avoids the problems of rigid screws across the joint. Recent case series (of 6 and 16 patients) have however, reported soft tissue problems and infections in 19–33% of patients. This study aims to review treatment and complications of distal tibiofibular diastasis fixation in our unit with the use of Tightrope or diastasis screws. Retrospective review of all patients undergoing primary ankle fixation between May 2008 and October 2009. Exclusions included revision procedures, or ankle fixation prior to the current fracture. Those undergoing Tightrope or diastasis screw fixation were studied for any complications or further procedures. Clinical records and XRAYs were reviewed, family practitioners of the patients were contacted and any consultations for ankle related problems noted.Background
Methods
Oxidized zirconium (OxZr) is used as a ceramic surface for femoral components in total knee arthroplasty (TKA). The aim of this study was to investigate its performance by examining retrieved femoral components and their corresponding PE inserts in matched comparison with conventional chrome/cobalt/molybdenum alloy (CrCoMo). 11 retrieved posterior stabilized (PS) TKA with an OxZr femoral component were included. From a cohort of 56 retrieved TKA with CrCoMo femoral components, pairs were matched according to duration of implantation, patient age, reason for revision, and BMI. The retrieved tibial polyethylene (PE) inserts were analyzed for wear using the Hood classification. Femoral components were optically viewed at 8–32x magnification and screened for scratching, pitting, delamination, and striation. Profilometry was performed to measure surface roughness of the OxZr components using a non-contact white light profiler.Introduction
Methods
Early failure of metal-on-metal (MoM) total hip replacements (THR) is now well established. We review 93 consecutive patients with CPT¯ stems MoM THR. Our series demonstrates a new mechanism of failure, which may be implant combination specific. Between January 2005 and June 2009, 93 consecutive MoM total hip replacements were preformed using CPT stems by 3 surgeons at our unit. 73 CPT¯ stems, Metasul¯ Large Diameter Heads (LDH) with Durom¯ acetabulae and 20 CPT¯ stems, Metasul¯ 28mm diameter heads in Allofit¯ shells (zimmer). Clinical outcomes were collected prospectively before surgery, at 3 months, 1 year, 2 years, 3 years, and at 5 years post surgery. Revision for any cause was taken as the primary endpoint and the roentgenograms and explanted prostheses were analyzed for failure patterns. In the LDH/Durom¯ group a total of 13 (18%) patients required revision (figs. 1) at a median of 35 months (range 6-44). 6 (8%) for periprosthetic fracture. All 6 periprostethic fractures were associated with minimal or no trauma and all had ALVAL identified histologically. To date there have been no failures in the CPT¯/28mm head Allofit¯ group. Several failures demonstrated bone loss in Gruen zones 8 ± 9 ± 10 (fig. 2). We demonstrate an unacceptably high rate of failure in CPT¯ MoM LDH hip replacements, with a high failure secondary to periprosthetic fracture and postulate a mechanism associated with local toxicity to metal ions. We strongly advise against this combination of prosthesis.
Current evidence suggests that we should be moving away from Thompson's hemiarthroplasties for patients with intracapsular hip fractures. Furthermore, the use of cement when inserting these prostheses is controversial. We aim to show the Inverness experience. We performed a retrospective review of all NHS Highland patients who underwent a hemiarthroplasty for an intracapsular neck of femur fracture over the last 15 years. Demographics and the use of cement were documented. Further analysis of this group was performed to identify any of these patients who required revision. Patients requiring revision had their case-notes reviewed to identify the cause for further surgery. 2221 patients from the Highland area had a hemiarthroplasty for an intracapsular neck of femur fracture since 1996. 1708 female (77%) and 513 male (23%). Ages ranged from 28 years to 104 years (mean 80). 2180 of this group had their operations in Raigmore with the remaining 41 at various centres throughout Scotland. 623 (28%)had a cemented hemiarthroplasty, with the remaining 1578 (72%) having an uncemented Thompson's hemiarthroplasty. The revision rate for the cemented group was 2% (13 of 623 patients). In the uncemented group it was 0.4% (6 of 1578). Reasons from revision included dislocation, periprosthetic fracture, infection and pain. Current evidence from some joint registers regarding the use of Thompson's hemiarthroplasty in the elderly is discouraging. The use of bone cement in this group with multiple co-morbidities is not without it's risks. Our data suggests that uncemented Thompson's hemiarthroplasties in low demand elderly patients with multiple co-morbidities can yield excellent results with less risk to the patients.
Specific radiological features identified by Brandser and Marsh were selected for the analysis of acetabular fractures according to the classification of Letournel and Judet. The method employs a binary approach that requires the observer to allocate each radiological feature to one of two groups. The inter- and intra-observer variances were assessed. The presence of articular displacement, marginal impaction, incongruity, intra-articular fragments and osteochondral injuries to the femoral head were analysed by a similar method. These factors were termed ‘modifiers’ and are generally considered when planning operative intervention and, critically, they may influence prognosis. Six observers independently assessed 30 sets of plain radiographs and CT scans on two separate occasions, 12 weeks apart. They were asked to determine the presence or absence of specific radiological features. This simple binary approach to classification yields an inter- and intra-observer agreement which ranges from moderate to near-perfect (κ = 0.49 to 0.88 and κ = 0.57 to 0.88, respectively). A similar approach to the modifiers yields only slight to fair inter-observer agreement (κ = 0.20 to 0.34) and slight to moderate intra-observer agreement (κ = 0 to 0.55).
Recent reports have suggested that a delay in the management of type-III supracondylar fractures of the humerus does not affect the outcome. In this retrospective study we examined whether the timing of surgery affected peri-operative complications, or the need for open reduction. There were 171 children with a closed type-III supracondylar fracture of the humerus and no vascular compromise in our study. They were divided into two groups: those treated less than eight hours from presentation to the Accident and Emergency Department (126 children), and those treated more than eight hours from presentation (45 children). There were no differences in the rate of complications between the groups, but children waiting more than eight hours for reduction were more likely to undergo an open reduction (33.3%
Existing classifications of fractures of the head of the humerus are inadequate in terms of interobserver reliability and the predictability of the clinical outcome. From a combined study of 73 fracture specimens in museums and 84 CT-three-dimensional reconstructions in patients, we have devised a classification which appears to be more useful clinically. Common patterns of fracture and a plausible mechanism of injury were observed. In 3-D most proximal humeral fractures can be organised into five basic types. These correspond in some degree to the Codman/Neer classification, but differ significantly in regard to the more complex patterns of fracture. We observed a logical progression from simple to complex fractures. An interobserver reliability study was carried out which indicated the improved usefulness of this new 3-D concept in providing a common language among clinicians for classifying these injuries. When surgery is indicated, the 3-D concept is also invaluable in guiding the restitution of anatomy through either open or percutaneous means.
