Introduction

Periprosthetic fractures of the femur are potentially catastrophic injuries associated with significant morbidity and mortality. Surgical treatment comprises revision arthroplasty or internal fixation. It is well established that a delay in treating patients with hip fracture leads to higher mortality rates, however there is limited evidence regarding mortality rates and the time to surgery in patients with lower limb periprosthetic fractures.

To examine the relationship between obesity (BMI> 30) and the incidence of peri-operative complications, outcome of surgery and return to work in patients undergoing elective less invasive posterior lumbar inter-body fusion of the lumbar spine for low back pain and leg pain (“LI-PLIF”).

15 patients with BMI> 30 who underwent (“LI-PLIF”) were identified by reviewing the clinical notes and the pre-operative admission sheet from April 2005- to March 2007. All had suffered chronic low back pain for a minimum of 2 years that had proven unresponsive to conservative treatment. All patients underwent pre- and postoperative evaluations for Oswestry Disability Index (ODI), short-form 36 (SF-36), and visual analogue scores (VAS). Minimum follow-up was for 12 months.

Blood loss was dependent on BMI, number of levels, and surgical time. Post operative complication was more in the morbidly obese group than the in the obese. 10 patients (66.6%) returned to their normal pre-operative employment within the 12 months of the index procedure. There was a significant improvement in the ODI and in the VAS for back pain. Length of hospital stay was a mean of 3.3 days

Although surgery is technically more demanding our experience with less invasive posterior inter-body fusion has shown less incidence of post operative complication, less intra-operative blood loss and short in-patient hospital stay.

We conclude that a high BMI should not be a contraindication to surgery in patients with degenerative low back pain.

Ethics approval: None: Audit Interest Statement None

Introduction: Arthrodesis of the knee nowadays is used as a salvage procedure, commonly for patients with a failed TKR or in infected trauma cases. We present 4 patients with extensive bone defects following septic sequelae of trauma treated by Arthrodesis of the knee joint.

Materials and Methods: Four patients (avg. 46.5 years; range 37–57 years; three male and one female) with longstanding infected non-union fractures (3 months–2 years) at the knee joint (three Tibial plateau and one distal femur) were treated by initial debridement and removal of dead or infected bone. This led to substantial bone defects (6–12 cm) of the debrided bone at the knee joint. The patients then underwent bone transport with a circular frame to compensate for this bone defect before achieving an Arthrodesis of the knee joint. Three patients also had a free muscle flap for soft tissue coverage before bone transport was begun.

Results: Arthrodesis of the knee was achieved in all patients at an average time of 26 months (20–32 months). None of the patients have any active infection of the limb.

Discussion and Conclusions: Knutson et al (1984) said that massive bone loss may substantially reduce the success rate of Arthrodesis of the knee. Wilde and Stearns (1989) noted decreased fusion rates with greater degrees of bone loss. In our series the bone defects were a sequelae of infective non-union, this further complicates the healing process. However, using circular frame for Bone transport to overcome the defect and to achieve compression at the Arthrodesis site is a useful technique for such challenging cases.

Introduction: Uncemented sockets have been used for revision with good results in the literature. Tantalum coated acetabular uncemented implant is the next generation implant. We used Tritanium (Stryker Corp. Kalamazoo, USA) for revision of acetabulum and present the early results.

Aim: To determine early results of porous tantalum coated modular acetabular cups in revision hip arthroplasty.

Patients and methods:41 acetabular revisions in 41 patients were performed using Tritanium acetabular uncemented sockets between March 2007 and March 2008. Posterior approach was used for all procedures. AAOS system for acetabular bone deficiency and Harris hip score for function was used for assessment.

Results: Mean age of the patients was 67 yrs (range 45–88). 95% of cups were fixed with screws for initial stability. AAOS classification showed there were 17 % Type 1, 49 % Type 2, 24% Type 3 and 5% Type 4 defects and 5 % had no defect. Bone graft was used to in 70% of patients, mostly autograft from the reamings. Mean Harris Hip Score improved from 68 pre-operatively to 84 at the last follow-up. Cup integration was seen in 93% patients. In two patients with pelvic discontinuity there was migration and in one loosening of the implant. One patient was treated for deep vein thrombosis and one patient for infection.

Conclusion: Early results of tantalum coated acetabular socket are encouraging, in providing adequate initial stabilisation for biologic fixation in segmental, cavitatory and combined defects. Facility to use locking screws in multiple directions may help in addressing pelvic discontinuity.

Introduction: Classification systems are useful in research and clinical practise as it provides a common mode of communication and evaluation. Tibial pilon injuries are a complex group of fractures, whose classification and radiological assessment in clinical practise remains undetermined.

Methods: 50 CT scans and radiographs of tibial pilon fractures were evaluated independently by 6 orthopaedic surgeons, comprising 3 consultants, 2 registrars and 1 research fellow. Fractures were classified according to ruedi allgower, AO, Topliss et al. Each surgeon was given a period of 48 hours to review copy of the original article as well as written and diagrammatic representations. Assessment was done on two occasions, 4 weeks apart. The kappa coefficient of agreement was calculated with SPSS to determine interobserver reliability and intraobserver reproducibility of the classification systems. The evaluator was blinded as to treatment and functional outcome. Each evaluator was also asked to decide upon the fracture management based on the classification types and was compared with the actual management.

Result: The interobserver agreement for ruedi allgower, Ao and Topliss et al., was fair, moderate and poor respectively. The intraobserver agreement for ruedi allgower, AO and Topliss et al., classifications was moderate at best. There was poor agreement amongst observers regarding definite management plan based on these classification systems.

Discussion: The interobserver agreement was directly proportional to the familiarity and inversely proportional to the specificity of the classification system. The intraobserver agreement improved with experience. CT scan helped in delineating the fracture segments accurately but did not significantly affect inter or intraob-server agreement.

Conclusion: Existing classification systems help in understanding the pathoanatomy of osseous part of tibial pilon fracture complex. However, Soft tissue injury forms an integral part of this complex. Without inclusion of soft tissue injury, these classification systems have limited role in definitive management.

Introduction: Infected non-union in the forearm is a rare and challenging situation. It can result in persistent deformity, shortening, bone loss, joint stiffness and disability. Secondary procedures are often required for correction of bone defects and deformity. Bone transport may be the only realistic method of treatment.

Case presentation: 56-year-old gentleman referred with an infected non-union of left distal radius. He underwent bone debridement with ilizarov frame application for distraction osteogenesis. After a period of one month, a longitudinal transport wire was inserted through the distal segment to the proximal segment and distraction was carried using this wire. This was supplemented by iliac crest bone graft and OP-1 substitute at docking stage. The frame was removed at 18 months, following which he sustained a refracture. ORIF with bone graft was performed. Finally a good consolidation was achieved. There was about 50% loss in pronation and supination and about 15 degrees short of full extension at the final followup.

Another 57-year-old gentleman referred for an infected non-union of the ulna with a severe bone defect. He was treated with a TSF application and corticotomy for distraction osteosynthesis. There has been a satisfactory progress in the bone transport and recently underwent a docking procedure with bone graft insertion.

Discussion: Post traumatic infected non-union with segmental bone defect in the forearm can be successfully managed with bone transport. Unlike tibia, where this procedure is commonly done, forearm bones have a complex soft tissue envelope which can rule out the use of external transport, especially in the radius. We found the longitudinal wire technique useful for transport of radius. Internal fixation can be used to salvage initial failures, provided that infection and substantial bone defects have been eliminated. This treatment is intensive and difficult for patient and surgeon.

Introduction: Periprosthetic infection with extensive bone loss is a complex situation. The appropriate management of large bone defects has not been established. Without reconstruction amputation/disarticulation is the likely outcome.

Aim: To Analyse preliminary results of direct exchange endoprosthetic reconstruction for periprosthetic knee infection associated with segmental bone defects.

Methods: Study of patients with periprosthetic knee infection and severe osteolysis treated by direct exchange tumour prostheses between June, 2005 and May, 2008 (4 - Distal femoral & 2 - Total femoral Replacements). Exclusion criteria included polymicrobial infection, resistant organisms, depressed immunity and poor peripheral perfusion. At each clinical visit they were monitored for clinical, microbiological, haematological and radiological evidence of infection. Community based antibiotic therapy was provided by specialist microbiologists. All patients were counselled and consented by the operating surgeon and specialist microbiologist prior to surgery.

Results: The mean age and follow up were 70.2 years and 30.5 months respectively. The most common infecting organism was Staphylococcus epidermidis (four), followed by Streptococcus species. Mean duration of antibiotics was 6 weeks intravenous(community based) and 8 weeks oral. 1 patient required intervention by plastic surgeons at index procedure. Radiographs showed no changes at final followup. One patient had superficial wound infection, which was successfully debrided. Knee range of movements averaged full extension to 95 degrees. The mean oxford knee scores pre and post operatively were 58 and 39.4 respectively.

Conclusion: Salvage direct exchange endoprosthetic reconstruction has provided effective pain relief, stability and improved mobility in our experience. Isolation of sensitive organism, specialist microbiologist input, availability of specialist physiotherapy and plastic surgery service, appropriate community care, good patient compliance and surgeon’s experience are key to success in these patients. Morbidity was significantly reduced due to early mobilisation.

Introduction: Arthrodesis of the knee nowadays is used as a salvage procedure, commonly for patients with a failed TKR or in infected trauma cases. We present 4 patients with extensive bone defects following septic sequelae of trauma treated by Arthrodesis of the knee joint.

Materials and Methods: Four patients (avg. 46.5 years; range 37–57 years; three male and one female) with longstanding infected non-union fractures (3 months–2 years) at the knee joint (three Tibial plateau and one distal femur) were treated by initial debridement and removal of dead or infected bone. This led to substantial bone defects (6–12 cm) of the debrided bone at the knee joint. The patients then underwent bone transport with a circular frame to compensate for this bone defect before achieving an Arthrodesis of the knee joint. Three patients also had a free muscle flap for soft tissue coverage before bone transport was begun.

Results: Arthrodesis of the knee was achieved in all patients at an average time of 26 months (20–32 months). None of the patients have any active infection of the limb.

Discussion and Conclusions: Knutson et al (1984) said that massive bone loss may substantially reduce the success rate of Arthrodesis of the knee. Wilde and Stearns (1989) noted decreased fusion rates with greater degrees of bone loss. In our series the bone defects were a sequelae of infective non–union, this further complicates the healing process. However, using circular frame for Bone transport to overcome the defect and to achieve compression at the Arthrodesis site is a useful technique for such challenging cases.

Periprosthetic infection with extensive bone loss is a complex situation. The appropriate management of large bone defects has not been established. Without reconstruction amputation/disarticulation is the likely outcome.

Aim of the study was to Analyse preliminary results of direct exchange endoprosthetic reconstruction for periprosthetic infection associated with segmental bone defects.

Study of patients with periprosthetic infection and severe osteolysis treated by direct exchange tumour prostheses between June, 2005 and May, 2008 (4 – Distal femoral & 2 – Total femoral Replacements). Microbiological evidence of infection was confirmed with regular monitoring of radiograph, crp, esr and wcc. Community based antibiotic therapy was provided by infectious disease team based in our institution.

The mean age and follow up were 74.2 years and 26.5 months respectively. Mean duration of antibiotics was 6 weeks intravenous(community based) and 3.5 months oral. 1 patient required intervention by plastic surgeons at index procedure. Radiographs at 6, 12 & 24 months showed no changes from immediate post-op. CRP, ESR and WBC count were within normal limits at the end of antibiotic therapy. One patient required prolonged pain relief with poor mobility due to instability in the opposite knee. One patient had infection recurrence. Knee range of movements averaged full extension to 95 degrees. The mean oxford knee scores pre and post operatively were 58 and 39.4 respectively.

We conclude that salvage endoprosthetic reconstruction has provided effective pain relief, stability and improved mobility in our experience. It has provided an oppourtunity to avoid amputation. Multidisciplinary support from plastic surgeons and specialist microbiologists is essential.

Introduction: Sniff nasal inspiratory pressure has become a valuable tool in assessing respiratory muscle weakness. Its role in the scoliosis population is still being defined.

Aim: To assess significance of Sniff nasal inspiratory pressure in paediatric patients with scoliosis. Eighty-nine paediatric patients were investigated with SNIP at the time of preoperative assessment for scoliosis surgery from Jan, 2000 to Dec, 2006. Patients were divided into neuromuscular(24) and idiopathic(55). Other causes and revision were excluded(10). SNIP was evaluated with respect to curve pattern and curve degree. This included radiograph and case note review.

The mean SNIP value for the idiopathic and neuromuscular groups was 70cmH2O and 44cmH2O respectively. This was significantly different (P=0.006). The mean cobb angle for idiopathic pattern was 58°. For the neuromuscular group it was 73°. There was no correlation between SNIP value and curve severity in either the idiopathic or neuromuscular group.

SNIP value does not correlate with cobb angle severity. SNIP can differentiate idiopathic from neuromuscular scoliosis. Low SNIP values are found in neuromuscular scoliosis. Its role in non neuromuscular scoliosis does not appear to be significant.

Background: Sniff nasal inspiratory pressure (SNIP) has become a valuable tool in assessing respiratory muscle weakness. Its role in the scoliosis population is still being defined.

Purpose: To assess significance of Sniff nasal inspiratory pressure value in paediatric patients with scoliosis.

Methods: Eighty-nine paediatric patients were investigated with SNIP at the time of preoperative assessment for scoliosis surgery from Jan, 2000 to Dec, 2006. Patients were divided into neuromuscular (24) and idiopathic (55). Other causes and revision were excluded (10). SNIP was evaluated with respect to curve pattern and curve degree. This included radiograph and case note review.

Results: The mean SNIP value for the idiopathic and neuromuscular groups was 70cmH2O and 44cmH2O respectively. This was statistically significantly different (0.006). The mean cobb angle for idiopathic pattern was 58 degree. For the neuromuscular group it was 73 degree. There was no correlation between SNIP value and curve severity in either the idiopathic or neuromuscular group.

Conclusion: SNIP is a valuable test when used in conjunction with vital capacity and overnight oxygen saturation, height, comorbidities in the neuromuscular population. It is a sensitive indicator of respiratory muscle weakness. It does not appear to reflect increasing curve severity. It does not appear relevant in scoliosis without a neuromuscular disorder.

Significance: SNIP combined with vital capacity, overnight oxygen saturation, height and co morbidities can be used to assess severity of neuromuscular scoliosis. SNIP value alone has little relevance.

Segmental bone defects with complex fractures or chronic infections comprise a very special subset of patients. Modular endoprosthetic reconstruction is an operative solution. Without reconstruction amputation/disarticulation is the likely outcome.

Aim of the study was to analyse preliminary results of modular endoprosthetic reconstruction in nonneoplastic limb salvage.

11 patients(9 – distal femoral replacement, 2 – total femoral replacement) underwent salvage reconstruction between January 2005 and March 2008 for chronic periprosthetic infections(6 – single stage revision; 2 – two stage revision) and complex periprosthetic fractures(3) with segmental bone defects. Microbiological and haematological evidence of infection was confirmed in the infection group and treated with concomitant community based antibiotic therapy as per guidance from specialist team.

The mean age and follow up were 74.2 years and 27.5 months respectively. No intraoperative complications identified. Average post operative mobilisation was with frame at 5 days, 2 sticks at 2 weeks. 1 patient required plastic surgical intervention at index operation. 1 patient had recurrence of infection.

Radiographs at 6, 12 & 24 months showed no changes from immediate post-op. Microbiological and haematological evidence of infection eradication was considered as successful treatment. Knee range of movements averaged full extension to 95 degrees. Oxford knee scores showed maximal improvement in the single stage revision group.

We conclude that salvage endoprosthetic reconstruction has provided an oppourtunity to avoid amputation. A significant improvement in overall range of motion, knee scores, pain relief and stability was achieved in this highly complex subset of patients. Multidisciplinary support from plastic surgeons and specialist microbiologists is essential.