Introduction

Bone transport and distraction osteogenesis have been shown to be an effective treatment for significant bone loss in the tibia. However, traditional methods of transport are often associated with high patient morbidity due to the pain and scarring caused by the external frame components transporting the bone segment. Prolonged time in frame is also common as large sections of regenerate need significant time to consolidate before the external fixator can be removed. Cable transport has had a resurgence with the description of the balanced cable transport system. However, this introduced increasingly complex surgery along with the risk of cable weave fracture. This method also requires frame removal and intramedullary nailing, with a modified nail, to be performed in a single sitting, which raised concern regarding potential deep infection. An alternative to this method is our modified cable transport system with early intramedullary nail fixation. Internal cables reduce pain and scarring of the skin during transport and allow for well controlled transport segment alignment. The cable system is facilitated through an endosteal plate that reduces complications and removes the need for a single-stage frame removal and nailing procedure. Instead, the patients can undergo a pin-site holiday before nailing is performed using a standard tibial nail. Early intramedullary nailing once transport is complete reduces overall time in frame and allows full weight bearing as the regenerate consolidates. We present our case series of patients treated with this modified cable transport technique.

Introduction

The use of the Taylor Spatial Frame (TSF) in the management of tibial fractures and deformity correction is well established in the literature, however the majority of published papers are small in patient number. The aim of the project was to evaluate clinical and radiographic outcomes of patients with tibial fractures treated with a TSF.

We evaluated the top 13 journals in trauma and orthopaedics by impact factor and looked at the longer-term effect regarding citations of their papers.

All 4951 papers published in these journals during 2007 and 2008 were reviewed and categorised by their type, subspecialty and super-specialty. All citations indexed through Google Scholar were reviewed to establish the rate of citation per paper at two, four and five years post-publication. The top five journals published a total of 1986 papers. Only three (0.15%) were on operative orthopaedic surgery and none were on trauma. Most (n = 1084, 54.5%) were about experimental basic science. Surgical papers had a lower rate of citation (2.18) at two years than basic science or clinical medical papers (4.68). However, by four years the rates were similar (26.57 for surgery, 30.35 for basic science/medical), which suggests that there is a considerable time lag before clinical surgical research has an impact.

We conclude that high impact journals do not address clinical research in surgery and when they do, there is a delay before such papers are cited. We suggest that a rate of citation at five years post-publication might be a more appropriate indicator of importance for papers in our specialty.

Cite this article: Bone Joint J 2014;96-B:414–19.

Pelvic ring fractures usually result from significant trauma, frequently requiring operative stabilisation. The use of an anterior internal fixator (INFIX) is a new technique. This temporary construct is quick and easy to apply using pre-existing spinal implants. No reports of functional outcomes or compartive studies with existing surgical techniques exist in indexed literature.

We present a prospective comparative case matched series of 21 patients treated with pelvic INFIX. 1:1 matching was achieved to a cohort of patients treated with open reduction and internal fixation (ORIF) based on fracture pattern. All patients with rotationally and/or vertically unstable pelvic ring fractures treated within our level 1 trauma centre were considered for inclusion. Patients were prospectively followed up with health outcome measures (SF-36, EQ-5D) and joint specific outcome scores (Oxford and Harris hip scores).

Symptomatic venous thromboembolism (SVTE) is a potentially significant complication which may occur following injury or surgery. Recent NICE guidelines, and clinical targets have all focused on decreasing in hospital death from acquired SVTE. Despite these guidelines there are no large studies investigating the risk factors for or incidence of SVTE in acute trauma admission.

Data from a prospective series of 9167 consecutive patients with a diagnosis of fractured neck of femur (NOF) at a single institution was used to construct a risk score for SVTE. Twenty three factors were screened with pairwise analysis. The cohort had an event rate of 1.4%. A multiple logistic regression model was used to construct a risk score and correct for confounding variables from nine significant factors identified by the pairwise analysis. Four factors; length of stay; chest infection; cardiac failure and transfusion were used to produce the final risk score. The score was statistically significant (p< 0.0001) and highly predictive (ROC analysis, AUC=0.76) of SVTE.

The score was separately validated in two cohorts from different Level 1 trauma centres. In one prospective consecutive cohort of 1000 NOF patients all components of the Nottingham SVTE score were found to be individually statistically significant (p< 0.0045). The score was further validated in a separate cohort of 3200 patients undergoing elective hip surgery. The score was found to be statistically significantly predictive of SVTE as a whole, and three of the four components were individually predictive in this patient cohort.

Balancing risks and benefits for thromboprophylaxis is key to reducing the risk of thromboembolic events, minimising bleeding and other complications associated with the therapy. Our study of 13,367 prospective patients is the largest of its type and we have successfully constructed and validated a scoring system that can be used to inform patient treatment decisions.

Patients presenting with a fractured neck of femur are a fragile group with multiple co-morbidities who are at risk of post-operative complications. As many as 52% of patients are reported to suffer a urinary tract infection post hip fracture surgery. There are little data surrounding the effects of post-operative urinary tract infections on mortality and deep prosthetic infection.

We prospectively investigated the impact of post-operative urinary tract infection (UTI) in 9168 patients admitted to our institution with a diagnosis of proximal femoral fracture over an eleven year period in a prospective population study. We examined the effects of post operative UTI on the incidence of deep infection, survivorship and length of stay.

Post-operative UTI occurred in 6.1% (n=561) and deep infection in 0.89% (n=82). Deep infection was significantly more common in patients complicated with a UTI (3.2% vs 0.74% p< 0.001) with a relative risk of 3.7:1. In 58% of patients the same organisms was cultured in the urine and hip samples. A postoperative UTI did not adversely effect 90 day survival, however was associated with an increased length of stay (ROC analysis AUC=0.79). Delays to surgery and age were not predictive of a post operative UTI.

Recognition of the risks posed by post operative UTI, the risk factors for development of infection and early treatment is essential to reduce the risks of increased subsequent periprosthetic infection.

Aims

Bone is a common site of metastatic disease. Skeletal complications include disabling pain and pathological fractures. Palliative surgery for incurable metastatic bone lesions aims to preserve quality of life and function by providing pain relief and stable mobility with fixation or replacement.

Current literature has few treatment studies. We present a 5 year longitudinal cohort study of surgery for metastatic bone disease at our large teaching hospital reviewing our complication and mortality rates.

Purpose

The evolution of locked anatomical clavicular plating in combination with evidence to suggest that fixation of clavicle fractures yields better outcome to conservative treatments has led to an increasing trend towards operative management. There is no evidence however to compare early fixation with delayed reconstruction for symptomatic non- or mal-union. We hypothesize that early intervention yields better functional results to delayed fixation.

Introduction

Pre-operative urine screening is accepted practice during pre-operative assessment in elective orthopaedic practice. There is no evidence surrounding the benefits, effects or clinical outcomes of such a practice.

The most frequent cause of failure after total hip replacement in all reported arthroplasty registries is peri-prosthetic osteolysis. Osteolysis is an active biological process initiated in response to wear debris. The eventual response to this process is the activation of macrophages and loss of bone.

Activation of macrophages initiates a complex biological cascade resulting in the final common pathway of an increase in osteolytic activity. The biological initiators, mechanisms for and regulation of this process are beginning to be understood. This article explores current concepts in the causes of, and underlying biological mechanism resulting in peri-prosthetic osteolysis, reviewing the current basic science and clinical literature surrounding the topic.