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.

Abstract

Innominate Osteotomy first described by Salter is one of the commonest procedures performed for treatment of Developmental Dysplasia of the Hip (DDH) in children. We recently described a less invasive technique for Innominate Osteotomy, which significantly reduces the operation time without compromising outcome (J Pediatr Orthop B. 2010 Jul;19(4):318–22). As part of the evolution of this procedure we now routinely use bioabsorbable pins (INION OTPS PIN, made from co-polymers of L-lactic acid, D-lactic acid and trimethylene carbonate) instead of K-wires to secure the graft.

We prospectively followed-up 120 consecutive cases done using bioabsorbale pins over a 2 year period. The surgical technique was as described in our less invasive innominate osteotomy paper. Average age at surgery was 24 months (18–52) with mean follow-up period of 15 months (6–24 months). The mean preoperative acetabular index was 36.2^o. Our results show a mean acetabular index of 18.7^o (P< 0.0001) at latest follow-up with no loss of correction. We recorded three superficial wound infections (one MRSA), all resolved uneventfully. There was no foreign body reaction.

The use of bioabsorbable pins eliminates the need for a second anaesthetic to remove the pins with significant cost benefit without compromising outcome.

Introduction

Ischaemic preconditioning (IPC) is a phenomenon whereby a tissue is more tolerant to an insult if it is first subjected to short bursts of sublethal ischaemia and reperfusion. The potential of this powerful mechanism has been realised in many branches of medicine where there is an abundance of ongoing research. However, there has been a notable lack of development of the concept in Orthopaedic surgery. The routine use of tourniquet-controlled limb surgery and traumatic soft tissue damage are just two examples of where IPC could be utilised to beneficial effect in Orthopaedic surgery.

Introduction: Ischaemic preconditioning (IPC) is a well recognised and powerful phenomenon where a tissue becomes more tolerant to prolonged ischaemia when it is first subjected to short bursts of ischaemia/reperfusion. IPC has been most comprehensively studied in cardiothoracic surgery, to date there has been little use of this powerful phenomenon in orthopaedic surgery. In this study, we report on the first clinical trial of IPC on human skeletal muscle, and show the potential of IPC in orthopaedics using global gene expression analysis.

Methods: After local ethics committee approval and informed consent, patients undergoing primary knee arthroplasty were randomly assigned into an IPC group and a control group. Diabetic patients or patients with an ankle/brachial index of less than 1 were excluded.

The IPC consisted of three five-minute periods of tourniquet insufflation on the operative limb, interrupted by five minute periods of reperfusion. The tourniquet was again insufflated and the operation started. The control group simply had tourniquet insufflation as normal prior to the start of surgery.

Muscle samples were taken from the operative knee of all patients at the immediate onset of surgery (t=0), and again, at one hour into the surgery (t=1). Total RNA was extracted from the muscle samples, and the gene expression profiles were determined using microarray technology.

Results: Comparison of IPC and control samples identified 702 transcripts with differences of ≥1.5-fold in their expression. Of these, 137 were altered at t=0 while 565 were altered at t=1. Amongst these changes was an up-regulation in the expression of a number of heat shock proteins (HSPs) in the IPC group as compared to the control group. Notably, there was up-regulation of the well known cytoprotective/anti-apoptotic gene, HSP72, at one hour post IPC (1.5-fold, p=0.039). There was also up-regulation of important oxidative stress defense genes, such as glutathione-S-transferase (1.6-fold, p = 0.021) and superoxide dismutase 2 (3.6-fold, p= 0.048). Microarray analysis also revealed a down-regulation in the expression of genes involved in metabolism, down-regulation of pro-apoptotic genes and up-regulation of genes necessary for transformation to a hypoxia-tolerant state.

Discussion: We present convincing evidence that IPC is beneficial to human skeletal muscle and for the first time show that IPC of human skeletal muscle works in the clinical setting. In this study, the protective effect of IPC involved a down-regulation in the expression of genes associated with metabolism, and an up-regulation in the expression of genes that provide protection from cell stress, oxidative stress and apoptosis. HSPs, and especially HSP72, have well documented roles in cell stress protection. Their presence has been cited by other studies as an indicator of cell adaptation to stress.

Abstract: Many former high level Gaelic Athletic Association (GAA) players present later in life with disabling hip arthritis requiring surgery. Many of these have evidence of the recently recognised condition of femoro-acetabular impingement (FAI). This condition results from abnormal abutment of the femoral head-neck junction with the acetabulum resulting in pain and progressive hip dysfunction. The prevalence is estimated at 10–15% in the general population, however it appears to be more common in young athletic males, and patients in their 20’s and 30’s with increased sporting activity. There has been an increase in the number of current players presenting with often poorly understood hip symptoms. We aimed to determine its prevalence in current top flight GAA players and in a cohort of past players.

92 current players and 8 retired players from the 1970’s were recruited. Questionnaires were distributed at training sessions and via e-mail. These consisted of a general questionnaire aimed at symptoms of interest, the Oxford Hip Scale and the Tegner Activity Level Scale.

Over half of current players experience hip symptoms with the majority being groin and hip pain but also a significant number complained of stiffness. Up to half of those with symptoms trained at reduced intensity and a further 20% missing training on a regular basis. 5 players in particular ceased playing for a period of between 3 and 36 months. Only 59 of 92 current players scored zero on the Oxford Hip Scale indicating a significant proportion have problems on a daily basis. The mean oxford hip score was 5.43 with a range of 0–29. The average Tegner Activity score was 10 despite having a number of players with significant symptoms indicating their desire to continue to play. 12 of the 92 underwent surgical procedures varying from Gilmore’s groin repairs and adductor tenotomies to hip arthroscopy.

It is evident that there is a link between hip symptoms in current players and FAI. Many hip conditions were previously unrecognized and thus left untreated, resulting in premature retirement of players. We therefore propose that it is vital that players are assessed for FAI at a young age and that training regimes should be altered and closely monitored in order to prevent the exacerbation of such a serious condition.

Introduction: Chronic stiffness is an uncommon complication of total knee arthroplasty (TKA) with reports in the literature citing an incidence of 1–5%. Surgical options to manage this debilitating condition include manipulation under anaesthesia (MUA) and arthrolysis; there is concern regarding revision surgery given the potential for stiffness recurrence.

Methods: Patients undergoing revision TKA for stiffness were prospectively identified. Inclusion criteria required a flexion contracture greater than 10 degrees and/or less than 70 degrees arc of motion. WOMAC and SF-36 self-report questionnaires were completed by all patients’ pre and post revision surgery.

Results: Between July 2005 and Dec 2006, 7 consecutive, aseptic, primary TKA’s were revised to address limited range of motion. Five female and 2 male patients (mean age: 57.6 years) underwent revision TKA 17.1 months (range, 7–25 months) after index TKA. All patients had attempted MUA, with additional open arthrolysis unsuccessful in 1 case. A medial parapatellar approach was performed although 3 required additional quadriceps snip for exposure. Five cases were revised with the Scorpio TS system and 2 with posterior stabilised components. Femoral augmentation was required in 2 cases and tibial in 1. Gap imbalance with increased soft tissue tension was noted intra-operatively in 5 cases with arthrofibrosis found in the remainder. At 6 months follow-up, arc of motion increased from a mean of 41.3° preoperatively to 81.4° (p=0.001) while mean flexion contracture decreased from 17.4° to 2.1° (p=0.004). Subjective improvement was also demonstrated: mean WOMAC decreased from 46.5 to 22.5 (p=0.023) and SF-36 scores increased by a mean of 35.8 points (p=0.001).

Conclusion: When conservative, implant preserving measures fail, revision surgery can be considered a viable option in addressing restricted movement following primary TKA. Aggressive physiotherapy and good patient compliance is required to minimise the recurrence of stiffness.

Introduction: A critical technical and economic challenge in total knee arthroplasty revision (TKAR) is bone loss management. Easily applied, valid pre-operative measurements of bone loss are essential to allow accurate planning and meaningful comparisons between series. We compared 2 radiographic measurement ment systems with actual intra-operative bone loss in order to determine their validity.

Methods: A prospective IRB approved cohort study of 290 consecutive TKAR patients was utilized to assess the Anderson Orthopaedic Research Institute (AORI) system and the University of Pennsylvania (UPenn) assessment system. These preoperative measures were performed on standardized antero-posterior and lateral knee radiographs by 31 orthopaedic surgeons trained in their use. The validity and reproducibility of both systems was determined versus the gold standard measure of actual intra-operative bone loss.

Results: 215 patients (74.1 percent) were assessed to have bone loss pre-operatively versus 222 (76.4 percent) intra-operatively. Using the AORI classification system agreement between preoperative and intraoperative classification was moderate for the femur (K = 0.50) and good for the tibia (K = 0.63). The UPenn system gave resultant mean scores of 0.137 for femur and tibia versus intraoperative findings of resultant mean scores of 0.14 and 0.143 for the femur and tibia, respectively. These differences were not statistically significant (p < 0.02).

Discussion: This study demonstrates a high incidence of bone loss among TKAR patients, emphasizing the importance of effective measurement tools. Both the AORI and UPenn systems are valid tools for pre-operative estimation of actual bone loss facilitating planning and clinically successful, cost effective management of bone loss in TKAR.