The burden of metastatic disease presenting with axial skeleton lesions is exponentially rising predominantly due to advances in oncological therapies. A large proportion is these lesions are located in the proximal femora, which given its unique biomechanical architecture is problematic.

These patients are frequently comorbid and require prompt and concise decision making regarding their orthopaedic care in line with recent British Orthopaedic Association guidelines.

We present data detailing the outcomes for patients with proximal femoral metastatic disease referred and treated over a three year period in an Regional Cancer Centre.

We retrospectively reviewed a prospectively maintained database of all patients referred for discussion at MDT with axial skeletal metastatic disease. From this we isolated patients with femoral disease. Demographic data along with primary tumour and metastatic disease site were assessed. Treatment regimens were analysed and compared. Finally predicted and actual mortality data was collated.

331 patients were referred over the analysed time period, of which 99 had femoral disease. 66% of patients were managed conservatively with serial monitoring while 34% underwent operative treatment. 65% of those received an intramedullary fixation while 35% had arthroplasty performed. There was a 51:49 split male to female with Prostate, Lung and Breast being the predominant primary tumours. Concurrent spinal metastatic disease was noted in 62% of patients while visceral mets were seen in 37%. Mortality rate was 65% with an average prognosis of 388 days (1.06years) while average mortality was noted within 291 days (0.8 years).

Proximal femoral metastatic disease accounts for a large volume of the overall mets burden. There is an overall tendency towards conservative management and of those requiring surgery IM nailing was the treatment of choice. The data would indicate that outcomes for these patients are guarded and on average worse than those predicted.

Orthopaedic surgical site infections (SSI's) prolong total hospital stays by a median of 2 weeks per patient, approximately double re-hospitalization rates, and increase healthcare costs by more than 300%. Patients with orthopaedic SSI's have significant reductions in their health-related quality of life. We performed a systematic review and meta-analysis to compare differences in outcomes between use of sutures and non-absorbable staples for closure of orthopaedic surgical wounds in adults. The primary outcomes were rates of superficial and deep SSI. Secondary outcomes included wound dehiscence, length of hospital stay, patient satisfaction and pain during removal of closure material. Data sources including PubMed, EMBASE, Scopus, Web of Science, Cochrane Library, clinicaltrials.gov, National Institute for Health and Research, UK clinical trials gateway were searched for randomised controlled trials (RCT's) meeting inclusion criteria. Sixteen RCT's published between 1987 and 2017 were included. Overall, wound infection outcomes (superficial and deep infections combined) showed no statistically significant difference between closure with staples compared with sutures with arelative risk of 1.17 (95% CI 0.59–2.30, p=0.66). A subgroup was performed specific to hip wound infection outcomes. Interestingly, a sensitivity analysis demonstrated sutures to be statistically favourable (p=0.04) in terms of hip wound infection outcomes. There was no statistically significant difference among secondary outcomes between sutures and staple groups. Overall it appears the choice of sutures or staples in closure of orthopaedic wounds has no effect on wound complications. However, caution is needed in applying the findings to different population groups due to heterogeneity across studies.

Aim

The purpose of our study was to see what the microbiological epidemiology of our discitis biopsy specimens were. In doing this we could identify if biopsy served a strategic and necessary purpose in the management of this potentially serious pathology.

Introduction

MRI imaging is carried out to identify levels of degenerative disc disease, and in some cases to identify a definite surgical target at which decompression should take place. We wanted to see if repeat MRI scans due to a prolonged time between the initial diagnostic MRI scan of the lumbar sacral spine, and the MRI scan immediately pre-operatively, due for the desire for a ‘fresh’ MRI scan pre-operatively, altered the level or type of procedure that they would have.

Objective

Our aim is to assess the use of the cervical nerve root block (CNRB) in the treatment of radicular pain associated with degenerative cervical spine disease and its potential to limit the need for surgical intervention.

Introduction

Trauma is the leading cause of death and disability in children. Pelvic fractures although rare, with a reported incidence of one per 100,000 children per year are 2^nd only to skull fractures with respect to morbidity. The objectives of this study were to improve understanding of paediatric pelvic fractures through a concise review of all aspects of these fractures and associated injuries. Understanding the patterns in which paediatric pelvic fractures and their associated injuries occur and the outcome of treatment is vital to the establishment of effective preventative, diagnostic and therapeutic interventions.

Background: Early failure of morselized impaction bone allograft is usually due to shear forces. Soil mechanics tells us that in aggregates such as bone allograft, the resistance to these shear forces can be increased by altering the fluid concentration, varying the particle size, and improving the morphology of the graft particle. Finding an idealized concentration of fat and water in bone graft could improve the resistance to interparticle shear and therefore decrease the failure rate of impaction bone graft. Ensuring the quality of the bone source is adequate can also improve the initial strength the bone graft. Furthermore optimizing the graft can be achieved by screening methods and simple intra-operative techniques.

Methods: Human femoral heads were retrieved from both total hip arthroplasty and hemiarthroplasty procedures. Bone mineral density was determined by DEXA scanning. The fat and water content of the graft was varied by combinations of squeezing and drying the graft and also by washing the graft using pulse lavaged water and 1:1 mixture of chloroform: methanol. The amount and characteristics of the fat and water in human morselized cancellous bone was quantified by the Karl Fischer extraction techniques, and gas chromatography. The overall shear strength of each graft preparation was determined by the direct shear test, adapted from an accepted protocol in soil mechanics and the optimum mixture which would resist shear forces was determined.

Results: An optimum level of fat and water was determined which was 50% stronger than unaltered bone graft. This is most closely approximated in an operating theatre situation by washing the graft with pulse lavaged normal saline and subsequently squeezing the bone graft in a vice with a force of 335kPa for 5 minutes. Whereas osteoarthritic and osteoporotic bone were similar in their fat and water content and initial resistance to shear forces, after processing, the resistance to shear forces of osteoarthritic bone improved by 147% and that of osteoporotic bone only improved by 12% (p< 0.001) Conclusions: Optimizing the fat and water content of bone graft and closely choosing the source of graft produces a stronger graft which is more resistance to shear stresses, protecting the surgical construct until bone growth can occur.

Background: The advent of locking plates used in the treatment of fractures of the surgical neck of the humerus has led to an increased use of internal fixation for these injuries. At present there are few large studies which have evaluated their success and potential factors which may contribute to any negative result.

Materials and Methods: We retrospectively reviewed 57 consecutive patients who were treated with internal fixation of 2,3 and 4-part fractures of the proximal humerus over a 3 year period with a minimum follow-up of 6 months. The MacKenzie (antero-superior) approach was used in all cases and fixation was achieved using either the PHILOS or Arthrex locking plates. Patients were assessed by a thorough chart review and at regular post-operative clinics for pain, range of motion, return to work/activity, smoking and alcohol intake and overall compliance with rehabilitation regime. X-rays were graded on the quality of initial reduction and maintenance of position. Primary end-points included union of fracture and need for additional operative procedures.

Results: The average age of patients was 63 years (range 19–91) with a preponderance of women (29:18 female: male). Average follow-up was 8 months. Ten (18%) patients were classified as problem drinkers, and 13 (22%) were smokers. Four patients were initially treated by a trial of conservative management which later failed, necessitating surgical intervention. Fifty three fractures (93%) went on to achieve union within 6 months of injury. Nine patients (15%) required an additional operation: 5 conversions to hemiarthroplasty for pain relief and 4 removals of metal for loss of screw fixation or impingement. There was no increased need for re-operation in alcoholics, but there was a 50% increase in the need for additional operations in smokers.

Discussion: To our knowledge, this study represents the largest cohort of patients treated with a fixed-angle locking plate for a fracture of the surgical neck of humerus. The use of the locking plate has led to improved union rates and good functional outcomes in the treatment of these often problematic fractures. Although these fractures tend to occur more often in alcoholics, union rates and need for re-operation are not affected. Smoking is a significant a risk factor for the need for re-operation and non-union.

Necrotising fasciitis is a rare but severe infection of soft-tissue associated with rapid progression, systemic toxicity and high mortality. Monomicrobial necrotising fasciitis caused by Pseudomonas aeruginosa is exceptionally uncommon with only 12 cases reported in the literature. We describe a fatal case with an atypical presentation in a patient following spinal decompression for a metastasis from prostate cancer.

Background: Infection remains the single most devastating complication of joint arthroplasty. In cases of established prosthetic infection, where implant retention is not feasible, there is limited consensus on an optimum management protocol.

Aim: To assess the outcome of revision for infected hip prostheses using a novel treatment regimen.

Materials and Methods: Retrospective study of a consecutive case series of 40 patients with late chronic hip joint prosthetic infection treated by a single surgeon over a 4 year period. The mean interval between index arthroplasty and revision for infection was 40 months, with patients having prior symptoms of infection for a mean of 22 months.

The treatment protocol consisted of a two stage exchange with removal of infected components via a posterior approach incorporating an extended trochanteric osteotomy, insertion of an interim antibiotic eluting cement spacer and re-implantation of an extensively coated uncemented prosthesis on the femoral side. Systemic antibiotic treatment following each stage consisted of an abridged course of 5 days post operative intravenous administration followed by complete cessation of anti-microbial therapy. The mean interval between implant removal and re-implantation was 111 days.

Results: At a mean follow up of 29.6 months (minimum 12 months), there were 2 cases of recurrent prosthetic infection. Dislocation following the second stage occurred in 7 patients. There was one mortality and one case of post operative sciatic nerve palsy. The Harris hip score increased from a pre-operative mean of 43.8 to a post operative mean of 83.9. At follow up, no patient had required revision for aseptic loosening or mechanical instability on the femoral side

Conclusion: The combination of effective staged surgical joint debridement, a shortened post operative course of systemic antibiotic treatment and an adequate latent period before re-implantation has led to encouraging early results in this series of revised chronic hip joint prosthetic infections.

Aim: The clinical and radiological outcomes of a prospective randomised controlled trial comparing Femoral Ring Allografts (FRA) to Titanium Cages (TC) for circumferential fusion are presented.

Methods: Eighty-three patients were recruited fulfilling strict entry requirements (> 6 months chronic discogenic Low Back Pain (LBP), failure of conservative treatment, one or two level discographically-proven discogenic pain). Five patients were excluded on technical infringements (unable to insert TC or FRA). From 78 patients randomised, 37 received FRA and 41 received TC. Posterior stabilisation was achieved with translaminar or pedicle screws. Patients completed the Oswestry Disability Index (ODI), Visual Analogue Scale (VAS) for back and leg pain, the Short-Form 36 (SF-36) pre-operatively and 6, 12 and 24 months post-operatively. Assessment of fusion was made by a panel of 6 individuals examining radiographs taken at the same specified time points.

Results: Clinical outcomes were available for all 83 patients (mean follow-up 28 months, range 24–75). Baseline demographic data showed no statistical difference between groups (p< 0.05). For patients receiving FRA, mean VAS (back pain) improved 2.0 points (p< 0.01), mean ODI improved 15 points (p=< 0.01), and mean SF-36 scores improved by > 11 points in 6 of 8 domains (p< 0.03). For patients receiving TC, mean VAS improved 1.1 points (p=0.004), mean ODI improved 6 points (p=0.01), and SF-36 improved significantly in only two of eight domains. Revision procedures and complications were similar in both groups. For the FRA group, 27 levels were fused from a total of 42 assessed (64.2%). For the TC group, 33 levels were fused from a total of 55 assessed (60%). This difference was not statistically significant p> 0.2.

Conclusion: The use of FRA in circumferential lumbar fusion was associated with superior clinical outcomes when compared to those observed following the use of TC. Both groups had similar fusion rates.