Introduction and aims

Robotic Assisted Arthroplasty (RAA) is increasingly proliferative in the international orthopaedic environment. Traditional bibliometric methods poorly assess the impact of surgical innovations such as robotic technology. Progressive Scholarly Acceptance (PSA) is a new model of bibliographic analysis which quantitatively evaluates the impact of robotic technology in the orthopaedic scientific community.

Introduction and aims

The International Orthopaedic community is eagerly adopting Robotic Assisted Arthroplasty (RAA) technology. However, the evidence for the benefits of this technology are unproven and at best equivocal. This study is a comprehensive bibliometric analysis of all published research in the field of RAA.

More than half of patients with neck of femur (NOF) fractures report their pain as severe to very severe in the first 24hrs. Opioids remain the most commonly used analgesia and are effective for static pain but not dynamic pain. Opioids provide suboptimal analgesia when patients are in a dynamic transition state and their side-effects are a source of morbidity in these patients. The Fascia Iliaca Compartment Block (FICB) involves infiltration of the fascia iliaca compartment with a large volume of low concentrated local anaesthetic to reduce pain by affecting the femoral and lateral cutaneous nerve of the thigh. The London Quality Standards for Fractured neck of femur services (2013) stated that the FICB should be routinely offered to patients. We performed an audit of patient outcomes following the introduction of the FICB across three centres.

We performed a two-cycle audit across two hospitals in 2014/15. The first cycle audited compliance with the NICE guidance in the management and documentation of pain and AMTS (Abbreviated Mental Test Scores) in patients. The second cycle was conducted following the integration of the FICB into the multidisciplinary NOF fracture protocol across three hospital sites. Data was collected on numeric pain scores, pre and post-op AMTS and opioid requirements.

There were 40 patients audited with 20 in the first cycle prior to the introduction of the FICB and 20 following this. In the second cycle, there was a statistically significant improvement (p<0.001) in the difference between the pre and post-op AMTS.

The preliminary findings in this audit support the use of the FICB adjunct to analgesia in the pre-operative management of NOF fracture patients. The FICB is a safe procedure and the organisational learning of this procedure through a multidisciplinary approach can significantly improve the outcomes of NOF fracture patients.

Unique progenitor cells have been identified recently and successfully cultured in vitro from human articular cartilage. These cells are able to maintain chondrogenic potential upon extensive expansion. In this study, we have developed a sheep, ex-vivo model of cartilage damage and repair, using these progenitor cells. This study addresses the question can such a model be used to determine factors required for progenitor cell proliferation, differentiation and integration of matrix onto bone. The hypothesis was that sheep allogenic cartilage derived progenitor cells could regenerate artificially damaged sheep articular cartilage in an osteochondral culture model. Progenitor cells were derived from ovine articular cartilage using a differential adhesion assay to fibronectin and expanded clonally. These clonal cells were marked with lentiviral vectors derived from the Human Immunodeficiency Virus-1. When a self-inactivating lentiviral vector encoding a ubiquitous phosphoglycerate kinase promoter, driving a Green Fluorescent Protein (GFP) reporter gene, was used to transduce these cells, up to 80% of these progenitor cells expressed GFP. Normal sheep medial femoral condyles containing about 2mm thick sub-condral bone were obtained and 4mm circular defects created on the cartilage surface using a biopsy punch. Condyles were cultured for two weeks in vitro with GFP labelled progenitor cells within a fibrin glue scaffold (Tisseel Lyo) and matrix production (collagen) as determined by spatially offset Raman spectroscopy and immunohistochemistry was demonstrated. Progenitor cells were able to proliferate and differentiate into collagen producing cells. Such an ex-vivo model system is an effective tool for the analysis of cartilage repair from various sources of stem cells. These ex-vivo experiments and variations on defect type, size, titration of scaffold and progenitor cell numbers requirements can further be used as a basis for screening prior to in vivo experiments.

Introduction

Ischaemia reperfusion injury (IRI) is a very common metabolic insult in orthopaedics. It is often a subtle clinical event such as after brief tourniquet use, however severe injury, even multi-organ failure or death may result from prolonged tourniquet-use, crush injuries, vascular trauma or the release of compartment-syndrome. IRI is mediated by leukocyte infiltration and oxidatively-induced endothelial disruption. Antioxidants clearly attenuate or prevent this effect in animal models.

Background

Presentations at national meetings provide an important forum to relay research findings in all areas of Orthopaedic surgery. Orthopaedic surgical trainees are encouraged throughout the training process to participate, present and ultimately publish their research. Indeed the well known mantra ‘Publish or Perish’ signifies the pressure trainees are sometimes placed under in order to achieve professional success. The number of original published papers is often the yardstick by which professional appointments are made. We aimed to determine the overall publication rates of presentations from the 2001 and 2002 Irish Orthopaedic Association meetings and to determine whether publication rates differed among other national Orthopaedic meetings and amongst the subspecialties.

Background

70% of Breast Cancer patients develop metastatic bone deposits, predominantly spinal metasases. Adult Mesenchymal Stem Cells (MSCs) are multiprogenitor stem cells found within the bone marow which have the ability to self renew and differentiate into multiple cell types. MSCs home specifically to tumour sites, highlighting their potential as delivery vehicles for therapeutic agents. However studies show they may also increase tumour metastatic potential.

Background

Author credibility and creativity is often gauged by the number of scientific papers published, with the frequency of citations for particular articles reflecting the impact of published data on the area of practice.

Background

Meticillin-resistant Staphylococcus aureus (MRSA) are endemic in hospitals throughout Ireland and present a major concern in hospital hygiene causing significant morbidity, mortality and imposing a significant financial burden. This is particularly true in the field of orthopaedic surgery where a nosocomial MRSA infection can prove catastrophic to a patient's recovery from surgery. Much has been made of the possibility of healthcare workers acting as vectors for the transmission of MRSA and other pathogenic bacteria in the hospital setting. This focus has led to the implementation of strict hand decontamination policies in hospitals in order to counter the possibility of staff - patient transmission of such bacteria. Investigations have also attempted to assess the bacterial contamination of work uniforms such as white coats, ties and scrubs. An area that has been generally overlooked however, is the assessment of the bacterial contamination some of the most commonly handled items of many healthcare workers, namely pagers and mobile phones. In this study we aimed to assess the potential for these items to act as reservoirs for MRSA contamination and thus propagate its transmission in the hospital setting.

Prenatal androgen exposure has important organising effects on brain development and influences future behavioural patterns. Second to fourth digit ratio (2D:4D) is a marker for prenatal androgen exposure and as such is a sexually dimorphic trait. Smaller, more masculine second digit (index finger) to fourth digit (ring finger) ratio’s are associated with higher exposure to prenatal testosterone levels or greater sensitivity to androgens, or both. People with smaller finger ratios, a longer fourth finger than second finger, have been shown to be more successful in competitive sports, exhibit increased visuo-spatial ability, more fertile and are perceived as being more masculine and dominant by female observers. Smaller ratios have also been associated with an increased propensity to engage in aggressive behaviour. We examined the relationship between Boxer’s fractures, a traditional injury of aggression and finger length ratio.

We reviewed 1123 patient records and/or hand x rays over a seven month time frame showing 123 fifth metacarpal (Boxer’s) fractures. We then measured, using recorded radiological data, the distance in millimetres from the base of the proximal phalanx to the tip of the distal phalanx for the second, third and fourth fingers. We also recorded sex, side of injury, site of injury and mode of injury.

One hundred and twenty three Boxer’s fractures were found over a seven month time period, 110 male and 13 female; 67.27% were right sided. The average age was 27.6 yrs ±14.2. The average finger length ratio (proximal phalanx to distal phalanx) for males was 0.9 and for females was 0.94. Both ratios were smaller than the published normal digit ratio for the general population.

Smaller second digit to fourth digit ratios are positively associated with persons presenting with fifth metacarpal fractures, thereby indicating increased aggressive tendancies independently of gender

Introduction: Ischaemia-reperfusion-injury (IRI) is one of the most common metabolic insults in orthopaedic practice. It is often a mild insult after brief tourniquet use with minimal clinical implications; but much more severe insults may result from excessive tourniquet-times, vascular trauma or release of compartment-syndrome. It is mediated largely by oxidatively-induced endothe-lial disruption and leukocyte infiltration. Antioxidants attenuate or prevent this effect in animal models.

Hypothesis: That IRI can be attenuated using established antioxidant medications (ascorbate and n-acetyl-cysteine) in the controlled setting of elective knee arthroscopy.

Methods: A EudraCT registered, prospective, randomized-controlled trial was performed. Patients (n=24) undergoing elective knee arthroscopy were randomized to one of 3 groups (IV NAC/oral ascorbate/placebo). Full blood counts, a broad array of cytokines and adhesion molecules, physiological response, pain scores and analgesia were recorded pre-operatively and at 3 postoperative time-points (10mins, 2hours, 4hours).

Results: Physiological response, analgesia and VAS did not differ. Systemic leukocytes and neutrophils were increased (p=0.001) indicating a measurable reperfusion injury. Ascorbate tended to inhibit ICAM-1 (p=0.10) and IFN-gamma (p=0.080). NAC inhibited VCAM-1 (p=0.003) and tended to inhibit ICAM-1 (p=0.094). Selectins responded in a similar pattern but not significantly. NAC tended to increase circulating leukocytes (0.093), neutrophils (0.12) and monocytes (0.04) and also induced a transient early increase in IFN-gamma (p=0.022).

Conclusions: Elevated circulating leukocytes indicate reduced leukocyte trapping and infiltration due to reduced adhesion molecule expression. NAC attenuates IRI resulting from tourniquet use in knee arthroscopy. The study was underpowered to confirm the efficacy of ascorbate in this setting. Further studies are necessary on the effects of these substances in more extreme ischaemic insults in which they may confer significant local and systemic benefits for the patient. Ascorbate and NAC act at different points in the inflammatory cascade and their potential synergistic effects warrant investigation.

Introduction: The high prevalence and associated morbidity of the hallux valgus deformity has lead to a myriad treatment options being developed. These range from conservative to operative interventions, including many different forms of osteotomy. The various interventions have met with mixed success, with some operative options suffering a high level of recurrence or patient dissatisfaction. Both outcomes have been shown to correlate to inadequate correction of one or other component of the deformity. High recurrence rates result most frequently from the failure to correct for both the intermetatarsal (IMA) and the distal metatarsal-articular (DMAA) angles, instead focusing on the IMA alone. In most techniques, the use of a two-dimensional osteotomy with a concentric axis of rotation allows only for the correction of one of the involved angles, therefore is not appropriate for the correction of this geometrically complex condition. This most often results in failure to adequately correct the DMAA. The scarf osteotomy is a triplanar osteotomy with the potential to correct both the DMAA and IMA in the same procedure, thereby performing a more anatomical correction.

Hypothesis: Even in experienced hands the accuracy of the correction can be improved, and the limitations of attainable correction identified, with simple calculations based on pre-operative radiographs.

Methods: We generated a formula to calculate the appropriate proximal and distal translations required for a given length of osteotomy to accurately correct the deformities. Two groups, of 20 patients each, were included in the study. One group prior to introduction of the formula and a second group after the introduction of the formula. Pre and post-operative weight bearing radiographs were assessed by blinded observers pre and post-operatively to determine the accuracy of the formula. Groups were compared using the independent samples T-test.

Results: There were no differences between the pre-operative IM and DMA angles between the groups. Post operative DMAA was improved by 6.1 degrees when using the formula (p=0.02). The frequency of post-operative IMA correction to within normal limits improved from 75% to 100% and the average IMA correction was improved by 2.5 degrees (p=0.003). Post operative IM and DMA angles correlated well with the calculated results from the formula. This formula has altered procedure selection in our institution for certain patients with combined large DMA and IM angles due to the easy pre-operative identification of the limits of correction.

Discussion and Conclusion: The formula allows more precise, reproducible correction of both the IMA and DMAA. The formula also clarifies the limits of the scarf osteotomy and therefore improves appropriate patient selection.

Background: 70% of Breast Cancer patients develop metastatic bone deposits, predominantly spinal metasases. Adult Mesenchymal Stem Cells (MSCs) are multiprogenitor stem cells found within the bone marow which have the ability to self renew and differentiate into multiple cell types. MSCs home specifically to tumour sites, highlighting their potential as delivery vehicles for therapeutic agents. However studies show they may also increase tumour metastatic potential.

Aims: The aim of this study was to investigate interactions between MSCs and breast cancer cells to further elucidate their role in the tumour microenvironment and hence understand factors involved in stimulating the formation of bone metastases.

Methods: MSCs harvested from the iliac crest of healthy volunteers were grown for collection of conditioned medium (CM), containing all factors secreted by the cells. Breast cancer cell lines (T47D, SK-BR3) were then cultured in MSC CM +/− antibodies to TGFβ, VEGF, MCP-1 and CCL5 for 72hrs. Cell proliferation was assessed using an Apoglow^® assay and RNA harvested for analysis of changes in Epithelial Mesenchymal Transition specific gene expression: N-Cadherin, E-Cadherin, Vimentin, Twist, Snail.

Results: A significant down regulation of breast cancer cell proliferation in the presence of MSC secreted factors was observed (p< 0.05). There was a dramatic increase in expression of EMT specific genes in both cell lines following exposure to MSC-secreted factors. Inclusion of antibodies to TGF, VEGF, MCP-1 and CCL5 inhibited the effect seen, suggesting these paracrine factors played a role in the elevated expression levels.

Conclusion: MSCs clearly have a distinct paracrine effect on breast cancer epithelial cells, mediated at least in part through secretion of growth factors and chemokines. These factors play an important role in the metastatic cascade and may represent potential therapeutic targets to inhibit MSC-breast cancer interactions, helping to prevent the formation of bone metastases in cancer.

Background: MRSA is a major economic and health issue in Ireland and as such is of particular importance in the appropriate management of orthopaedic patients. Bone, joint and implant infection can lead to unfavourable outcomes with a long protracted in hospital stay inevitable. The cost for the patient, the hospital and society are substantial. Numerous protocols have been proposed internationally to aid in the management of MRSA infection in orthopaedic patients with pre assessment and ring fencing of patients shown to have a favourable impact.

Aims: To analyse the impact of a series of infection control measures on the infection and prevalance of MRSA in both elective and trauma orthopaedic patients.

Methods: We conducted a prospective study of our unit over three time points from 2005 to 2008. All elective and trauma orthopaedic surgery was based in Merlin Park Hospital up until December 2006. Since then all elective orthopaedic surgery has remained based in Merlin Park Hospital with all trauma surgery being moved to University Hospital Galway and all trauma patients based in an exclusively ring fenced orthopaedic ward. We recorded total rates of MRSA infection and colonisation in all orthopaedic patients over nine months of each year from 2005 to 2008, pre and post separation of trauma and elective services. Of note a pre admission screening protocol was implemented in March of 2006. We also prospectively recorded all MRSA data in patients treated through our ring fenced trauma ward from its opening date in November 2006.

Results: 12259 patients were reviewed between 2005 and 2008. The mean age of all admitted patients was 46 with th emean age of all MRSA positiv epatients being 71(p=0.000). There was no statistical difference for gender distribution between MRSA positive patients, but more women were positive than men.

The rates of MRSA infection for 2005, 2006 and 2007 were 0.49%, 0.28% and 0.24% respectively (binomial comparison, 2005 to 2006, p< 0.005 and 2005 to 2007, p< 0.005). Again when trauma and elective units were seperated there was a corrected rate of infection of 0.14% and 0.33% respectively. In 2005 there was 9 Superficial Incisional (SI), 8 Organ Space Infection(OSI) and 4 Deep Incisional (DI), 2006 had 7 SI, 4 OS and 4 DI and in 2007 there was 9 SI, 9 OS and 1 DI seen in the elective unit There was no Deep MRSA infection seen in the new ring fenced trauma unit. MRSA infection was found to cause a considerable increase in length of stay with normal orthopaedic patients staying a mean of 5 days whilst MRSA patients staying 23.4 days (p=0.000).

Conclusion: The separation of emergency and elective orthopaedic services coupled with effective preoperative screening has resulted in a reduction of MRSA infection and improved patient outcome.

Objectives: Ischaemia reperfusion injury (IRI) is one of the most common metabolic insults in orthopaedic clinical practice. Oral ascorbate and both oral and intravenous n-acetylcysteine (NAC) have shown definitive beneficial effects in animal skeletal muscle IRI models. The authors hypothesized that a similar protective effect could be demonstrated in a well designed clinical trial.

Materials and Methods: A EudraCT registered, prospective, randomized, controlled, double blind trial was performed to assess the hypothesis. Ethical approval was obtained from the competent authority. Patients (n=18) undergoing elective knee arthroscopy were randomised to one of 3 groups. The NAC group received IV NAC and preoperative oral placebo. The ascorbate group received oral ascorbate and IV placebo. The placebo group received both oral and IV placebo. Anaesthetic protocols were standardized across all groups. Phlebotomy was performed preoperatively and at 3 post-operative time points. IL-1, 2, 6 and 10, ICAM, VCAM, Selectins, TNF-alpha and malondialdehyde (MDA) were measured in systemic and local blood samples. Physiological parameters were recorded in the peri-operative period. Post-operative analgesic requirements and visual analogue scores were recorded. Leg oedema was measured using volumetric analysis and figure-of-eight tape measurement.

Results: There were no differences between the groups pre-operatively. In the post-operative period the analgesic requirements were lower in the NAC group compared to ascorbate and placebo groups. CRP and d-dimers were found to peak in the early post operative period. White cell counts decreased in all groups in the early post-operative period, with a lesser reduction in the NAC and ascorbate groups. Elevation of MDA was noted in all groups but was significantly less in the NAC group. There was a trend towards increasing IL-6 and IL-8. There was a trend towards decreasing TNF-alpha and IL-1.

Conclusions: Ascorbate and NAC appear to attenuate the inflammatory response to IRI in a clinical model. These cheap, readily available medications which are acceptable to patients and doctors alike appear offer a potential benefit to patients. Further studies are required to clarify the extent of the benefit and to examine the role of these medications in trauma and in the setting of more extensive ischaemic insults.

Introduction: Patients can vary widely in their illness perceptions and subsequently, the manner in which they respond and adapt to health threats. A patient’s perception about his/her hand injury may explain their health behaviours such as adherence to post-operative therapy, coping, emotional response and eventual clinical outcome.

Aims: To examine illness beliefs in patients with hand injuries in the acute trauma setting.

Methods: The disability and severity of injury were determined using the DASH questionnaire and HISS score. The revised Illness Perception Questionnaire(IPQR) was used to explore the patient’s illness perception.

Results: Fifty seven patients were recruited. There was no correlation between the DASH and HISS scores, or their correlation with the different components of the IPQ-R scores. The cohort was optimistic about their treatment and duration of recovery. There was some evidence to suggest that patients with more severe injury were over-optimistic about recovery. Beliefs of negative consequences, chronic, cyclical duration and low illness coherence were linked with negative emotional response. Female patients and dominant hand injuries reported higher subjective disability.

Conclusions: The lack of correlations suggests that illness perceptions were not influenced by the severity of the injury. Patients in this cohort were optimistic about recovery, particularly in those with more severe injury (over-optimistic). These findings suggest that there could be a role for psychological intervention in hand injury. Longitudinal research is needed to evaluate illness beliefs in hand injury during the post-operative period.

Introduction: Finger length ratio (2d:4d) is a sexually dimorphic trait. Smaller, more masculine second digit (index finger) to fourth digit (ring finger) ratio’s are associated with higher exposure to prenatal testosterone levels or greater sensitivity to androgens, or both. People with smaller finger ratios are perceived as being more masculine and dominant by female observers. Smaller ratios have also been associated with an increased propensity to engage in aggressive behaviour. We examined the relationship between Boxer’s fractures, a traditional injury of aggression and finger length ratio.

Methods: We reviewed 1123 patient records and/or hand x-rays over a seven month time frame showing 123 fifth metacarpal (Boxer’s) fractures. We then measured, using recorded radiological data, the distance in millimetres from the base of the proximal phalanx to the tip of the distal phalanx for the second, third and fourth fingers. We also recorded sex, side of injury, site of injury and mode of injury.

Results: 123 Boxer’s fractures were found over a seven month time period, 110 male and 13 female. 67.27% were right sided. The average age was 27.6 yrs ±14.2. The average finger length ratio (proximal phalanx to distal phalanx) for males was 0.9 and for females was 0.94.

Conclusion: Smaller second digit to fourth digit ratios are positively associated with persons presenting with fifth metacarpal fractures, thereby indicating increased aggressive tendancies independently of gender.

Aim: To compare strength the to failure of Silversjold type B repair (SJBR) using bites two, four and six millimetres from the repair site of an ex-vivo porcine flexor tendon model.

Methods: Seventy freshly harvested procine flexor tendons were transected and randomised to repair using either SJBR or simple running epitendinous repair with and without a two strand Modified Kessler repair (MKR), repairs also performed spanning four and six millimetres from the repair site.

Biomechanical testing was performed with a Zwig tensinometer using a one neuton preload and a distraction rate of 20mm/min. Bulking was measured with a digital micrometer and each repair group was tested for mean load to repair failure and mean load to 2mm gap formation. In each case the mechanism of failure was recorded.

Results: The addition of an epitendonous suture statistically increases strength to failure over a core suture alone. The SJB with MKR at all distances was stronger than the the standard epitendonous suture with MK. Optimal strength was obtained at a distance of 6mm from the repair site. Data was assesed using an ANOVA analysis. Repairs failed in all repairs by suture breakage.

Conclusion: The use of an epitendonous suture adds valuable strength to a flexor tendonn repair. The SJBR is somewhat more complicated that a standard running suture however the augmentation in strength makes this worthwhile. The placement of IHM is optimal at 6mm from the repair site and did not statistically increase the tendon bulk.

Twenty-two patients with cysts of the lateral meniscus have been treated by operation. A modified operative procedure is described whereby the meniscus is inspected for a concomitant tear. A tear of the meniscus was found in ten patients and these were treated by meniscectomy. The remaining twelve cases were treated by excision of the cyst only. The rehabilitation period was considerably less in these patients. Recurrence of the cyst did not occur. The rationale for local excision is based on the similarity between the cyst of a meniscus and a simple ganglion, and also on the desirability of preserving the meniscus.