Introduction: Recombinant human bone morphogenic protein-2 (rhBMP-2) eliminates the need for iliac crest bone graft and has superior fusion rates in anterior interbody fusion1. Post-operative neck swelling has precluded its use in cervical fusion2. Peri-rhBMP-2 oedema is a proposed cause of neuropathic leg pain in posterolateral lumbar fusion. We aimed to compare the incidence of leg pain in a rhBMP-2 treated cohort with a control group following posterolateral lumbar fusion and to determine radiological evidence of a mechanical cause for leg pain in either group.

Methods and Results: A single surgeon, multi-centre elective practice was retrospectively reviewed over a four-year period. All rhBMP-2 treated patients were included. Control patients included all primary instrumented lumbar fusions. Endpoints included single observer recorded leg pain. There were 64 and 40 patients in the rhBMP-2 treated and control group respectively. Pre-operative demographics and diagnoses were similar. Inter-body cages were used equally. Three patients had non-mechanical leg pain in the control group versus eleven in the rhBMP-2 group of which 6 were revision surgeries. None of the control group had previous lumbar fusion (p< 0.05). Within the rhBMP-2 group, cage use was similar for leg pain (31%) and non-leg pain (29%).

Conclusion: In primary lumbar fusion surgery, there is no significant difference in post-operative MRI-identifiable mechanical leg pain between rhBMP-2 treated and non-treated groups. RhBMP-2 loaded cages do not increase the risk of leg pain. Recombinant hBMP-2 is safe to use in posterolateral lumbar surgery.

Conflicts of Interest: None

Source of Funding: None

Introduction: Vascular injuries associated with limb bone fractures are relatively uncommon.

Aim: To determine the mechanisms of injury and evaluate the outcome of combined orthopaedic and vascular injuries.

Method: A retrospective review of all patients with vascular injury associated with limb bone fractures between January 1992 and July 2006 was performed. Data collected included demographic details, clinical presentation, assessment, management and outcome.

Results: Of 22,340 fractures treated during the 14 years period 36 patients sustained a vascular injury that required surgical intervention. Of those, 18 patients (50%) had a concomitant fractures or other orthopaedic injury this group form the basis of the audit. The median age was 31.1 (range 3–80) years, and 66% were male.

Road traffic accidents accounted for 12 injuries (66%), other accidents 4(22%), iatrogenic injury 1(6%), and 1 gunshot injury (6%). Four patients had an associated nerve injury with varying severity. Skeletal fixation preceded vascular repair in most of the cases. Peroperative arterial shunting was not used in any patient. The primary vascular procedures included end-to-end anastamosis 2(11%), bypass grafting 1(6%), interposition vein grafts 8(43%), vein patch 1(6%), direct arterial repair 2(11%), ligation 2(11%), primary amputation 1(6%), reposition of normal course of artery 1(6%).

During a 17 months follow-up period, the upper and lower limb preservation rate was 100 and 89%, respectively. Nine patients (50%) were symptom free; three patients (16.6%) had a neurological deficit.

Conclusion: Vascular injury is uncommon in the orthopaedic patients. High suspicion and early intervention is essential to optimise outcome and function.

Introduction: Historically, arthrodesis of the knee was accepted as a primary procedure in patients with extensive joint destruction, usually in the elderly arthritic population. Since the significant advances in arthroplasty, knee arthrodesis has mainly become an uncommon salvage procedure for failed and infected arthroplasty. However, when all other surgical options in reconstruction post-trauma have failed, arthrodesis remains an alternative to amputation.

Patients and Methods: Six patients who had unilateral knee arthrodesis with the Ilizarov frame for traumatic destruction of their knee were assessed by physical examination, radiology review and clinical questionnaires.

The Lower Extremity Functional Scale (LEFS) and the AMA Criteria for Impairment Associated with Station and Gait Disorders were used to evaluate their functional levels of impairment. The Short-Form-36 (SF-36) Health Survey was also used as a general survey of their health.

Results: The patient group ranged from 24 – 47 years of age (mean 32.5 years), and are between 1 – 10 years after unilateral knee arthrodesis. All were satisfied with the outcome of their procedure, and half are able to work full time. 80% of those who drive report actually driving while being treated with the Ilizarov frame. Those who score lowest on the SF-36 also had significant other post-trauma injuries (e.g. upper limb amputation). Significantly, while the average level of whole person impairment was 10–19%, patients perceived their ability to walk on the flat as normal, and only have mild difficulty in rising to stand.

Conclusion: Knee arthrodesis is a realistic and acceptable alternative to amputation, and is therefore an option which should be offered to patients in the non-acute setting. It has successfully enabled salvage of otherwise “unsalvageable” limbs in our young patient group.

Introduction: With a worldwide aging population, and an expected doubling in numbers of people older than 65 between 1990 and 2020, we are in the midst of a predicted increase in osteoporosis and resultant fractures. The International Osteoporosis Foundation recently surveyed consultant orthopaedic surgeons in mainland Europe and New Zealand to determine how patients with osteoporotic fractures were managed. Their conclusion was that treatment patterns were varied, and the findings supported the need to improve fragility fracture services to reduce the risk of recurrent fractures.

Aim: The aim of our study was to see how Irish practices and opinions related to the IOF survey, in anticipation of a formal protocol being established in our unit.

Methods: A modification of the International Osteoporosis Foundation survey used in 2002 was sent to 85 Consultant Orthopaedic Surgeons listed in the Irish Medical Directory. The questionnaire evaluated the surgeon’s education and knowledge of osteoporosis management, as well as estimated numbers of patients being treated with osteoporosis and the investigations available to their service. Treatment and referral patterns were also established. All responses were anonymous.

Results: The Irish response rate to the survey of nearly 50% was higher than that of our European colleagues, and showed that only 25% of surgeons felt they received sufficient training in the area of osteoporosis, but only a minority were not confident managing the disease. One-quarter of those surveyed would treat a patient with a fragility fracture for osteoporosis themselves, while over half would refer the patient on to a General Practitioner for further management. 50% of Irish Consultants would first order bone mineral densitometry, and nearly three-quarters believe the General Practitioner is the most appropriate professional to follow up these patients. Significantly, 15% of Orthopaedic surgeons did not have any access to densitometry. The most popular treatment modality is a combination of calcium and vitamin D supplementation in conjunction with Alendronate.

Conclusion: There is currently a lack of standarisation in the management and follow up of patients with osteoporosis. While the disease and its treatment is an internationally important topical issue, our study showed that at a national level there is a lack of consistency between the need for specialised services and implementation of treatment algorithms, due in part to lack of investigative facilities and organised management teams.

Introduction Magnetic resonance imaging (MRI) is important in non-invasive evaluation of osseous and soft-tissue structures in the post-traumatic knee. However, it is sometimes impossible to determine if a focus of high signal intensity in the meniscus is confined to the substance, or extends to involve the joint surface. This is a critical differentiation as the latter represents menisci tears that can be found and treated arthroscopically, whereas the former represents degradation, intra-substance tears or normal variants not amenable to arthroscopic intervention.

The aim of this study was to investigate occurrence of altered signal intensity in the posterior horn of the medial meniscus and correlate with arthroscopic findings.

Materials and Methods 64 patients with suspected post-traumatic internal derangement of the knee who underwent MRI prior to arthroscopy were evaluated. All patients initially had MR imaging of the symptomatic knee using a standard protocol in a Siemens Symphony 1.5 Tesle Magnetom. MR images were then interpreted and reported by 2 radiologists experienced in MR and skeletal radiology. Meniscal tears were graded according to the system validated by Lotysch. A Grade 3 signal was considered unequivocal evidence of a meniscal tear. Equivocal tears (Grade 2/3 signal) were diagnosed if it was unclear if there was a small portion of normal intact meniscal tissue between a linear high signal in the meniscus and the articular surface abutting the meniscus.

Arthroscopy was subsequently performed by senior surgeons aware of the MR findings within 2 weeks of imaging.

Patients were re-assessed clinically and evaluated functionally at a mean follow-up time of 5 months. Radiographic, arthroscopic and clinical results were then correlated and evaluated.

Results There were 48 males and 16 females in the group, with a mean age of 28.2 years.. Tears of the posterior horn of the medial meniscus were reported on MRI unequivocally (Grade 3 signal) in 18 patients and equivocally (Grade 2/3 signal) in 10 patients. Subsequent arthroscopic correlation revealed 16 tears (89%) in the unequivocal group and only one tear (10%) in the equivocal group.

Discusion The finding that only 10% of patients with an equivocal tear in the posterior horn of the medial meniscus on MRI were subsequently found to have a tear on arthroscopy would suggest that early arthroscopic intervention is not warranted in these cases. We suggest that unless symptoms persist over the course of 3 to 6 months, or if a more compelling symptom complex develops, only then should arthroscopic evaluation be considered.

Conclusion Equivocal tears on MRI of the posterior horn of the medial meniscus have a low rate of arthroscopically detected tears and a trial of conservative therapy may be prudent in such cases.