The posterior midline approach used in spinal surgery has been associated with a significant rate of wound dehiscence. This study investigates anatomical study of the arterial supply of the cervical and thoracic spinal muscles and overlying skin at each vertebral level. It aimed to provide possible anatomical basis for such wound complications.

A dissection and angiographic study was undertaken on 8 cadaveric neck and posterior torso from 6 embalmed and 2 fresh human cadavers. Harvested cadavers were warmed and hydrogen peroxide was injected into the major arteries. Lead oxide contrast mixture was injected in stepwise manner into the subclavian and posterior intercostal arteries of each specimen. Specimens were subsequently cross-sectioned at each vertebral level and bones elevated from the soft tissue. Radiographs were taken at each stage of this process and analysed.

The cervical paraspinal muscles were supplied by the deep cervical arteries, transverse cervical arteries and vertebral arteries. The thoracic paraspinal muscles were supplied by the superior intercostal arteries, transverse cervical arteries and posterior intercostal arteries. In the thoracic region, two small vessels provide the longitudinal connection between the segmental arteries and in the cervical region, deep cervical arteries provide such connection from C3 to C6. The arterial vessels supplying the paraspinal muscles on the left and right side anastomose with each other, posterior to the spinous processes in all vertebral levels. At cervical vertebral levels, source arteries travel near the surgical field and are not routinely cauterised; Haematoma is postulated to be the cause of wound complications. At thoracic levels, source arteries travel in the surgical field and tissue ischemia is a contributing factor to wound complications, especially in operations over extensive levels.

Post-operative wound complications is a multi-factorial clinical problem, the anatomical findings in this study provide possible explanations for wound dehiscence in the posterior midline approach. It is postulated that drain tubes may reduce the incidence of haematoma in the cervical level.

Shoulder girdles of 20 cadavers (68–94yrs) were harvested. The anterior (ACHA) and posterior circumflex humeral arteries (PCHA) were injected with ink and the extra and intraosseous courses of the dyed vasculature dissected through the soft tissues and bone to the osteotendinous junctions of the rotator cuff. The ink injection and bone dissection method was newly developed for the study.

Rates of cross-over at the osteotendinous juntion were 75% in the supraspinatus, 67% in subscapularis, 33% in infraspinatus and 20% in teres minor. The supraspinatus and subscapularis insertions were vascularised by the arcuate artery, a branch of the ACHA. The insertions of the infraspinatus and teres minor were supplied by an unnamed terminal branch of the PCHA.

The insertions of the rotator cuff receive an arterial supply across their OTJ's in 50% of cases. This may explain observed rates of AVN in comminuted proximal humeral fractures. The terminal branch of the PCHA supplying the infraspinatus and teres minor insertions was named the “Posterolateral Artery”. Finally, the new method employed for this study which allowed for direct visualisation of intraosseous vasculature, will enhance our understanding of skeletal vascular anatomy and have clinical applications in orthopaedic and reconstructive surgery.

To identify factors that predict poor patient-reported outcomes in patients with traumatic vertebral body fracture(s) of the thoracic and/or lumbar spine without neurological deficit.

There is a paucity of information on factors that predict poor patient-reported outcomes in patients with traumatic vertebral body fracture(s) of the thoracic and/or lumbar spine without neurological deficit.

Patients were identified from the Victorian Orthopaedic Trauma Outcomes Registry (VOTOR). VOTOR includes all patients with orthopaedic trauma admitted to the two adult Level 1 trauma centres in Victoria, Australia. Patient-reported outcomes and data on possible predictive factors, including demographic details, injury-related and treatment-based factors, were obtained from the VOTOR database.

Patient-reported outcomes were measured at 12 months post-injury using the 12-Item Short-Form Health Survey (SF-12), a Numerical Rating Scale (NRS) for pain, global outcome questions and data was collected on return to work or study. For the identification of predictive factors, univariate analyses of outcome vs. each predictor were carried out first, followed by logistic multiple regression.

344 patients were eligible for the study and data were obtained for 264 (76.7%) patients at 12 months follow-up. Patients reported ongoing pain at 12 months post-injury (moderate–severe: 33.5%), disability (70.1%) and inability to return to work or study (23.3%). A number of demographic, injury-related and treatment-based factors were identified as being predictive of poor patient-reported outcomes. Patients who had associated radius fracture(s) were more likely to have moderate to severe disability (odds ratio (OR) = 3.85, 95% confidence interval = 1.30–11.39), a poorer physical health status (OR = 3.73, 1.37–10.12) and moderate to severe pain (OR = 3.23, 1.22–8.56) at 12 months post-injury than patients without radius fracture. Patients who did not receive compensation for work-related or road traffic-related injuries were less likely to report moderate to severe pain (OR = 0.45, 0.23–0.90) or have a poorer mental health status (OR = 0.17, 0.04–0.70) at 12 months post-injury than those who received compensation.

The prognostic factors identified in this study may assist clinicians in the identification of patients requiring more intensive follow-up or additional rehabilitation to ultimately improve patient care.

Delayed union and non-union are complications of fracture healing associated with pain and with functional and psychosocial disability. This study compares the effect on self-reported health outcomes of delayed union or non-union of femoral and tibial shaft fractures treated at two major metropolitan trauma centres in Victoria.

Patients admitted to the Royal Melbourne Hospital and The Alfred with extra- articular femoral and tibial shaft fractures during 2003-2004 and 2005-2006, and followed up by the Victorian Orthopaedic Trauma Outcomes Registry (VOTOR) were included. Hospital medical records were reviewed to identify the outcome of each fracture. Fracture healing was assessed by the need for unplanned revision surgery for delayed union or nonunion, and clinical and radiological evidence of union. Prospectively-gathered VOTOR health outcome measurements included the Short Form 12-Item Health Survey (SF-12), and return to work and pain status at 6 and 12 months post injury.

Of the 520 patients, 260 femoral and 282 tibial shaft fractures were included. In total, 285 fractures progressed to union, 138 fractures developed delayed union or non-union and 119 fractures had an unknown outcome. Factors that were significantly different between the union and delayed union or non-union groups included: fund source, mechanism of injury, other injuries, wound and Gustilo type, and fixation method. On linear regression modelling, an inverse relationship was demonstrated between delayed union or nonunion and the Physical and Mental Component Summary scores of the SF-12. This was statistically significant at both 6 and 12 months post injury unadjusted and adjusted for age, gender and other injuries. On logistic regression modelling, patients with delayed union or non-union showed unadjusted and adjusted risk ratios of 0.85 and 0.82, respectively at 6 months, and 0.82 and 0.76, respectively at 12 months to return to work. Similarly, patients with delayed union or nonunion had unadjusted and adjusted risk ratios of 1.09 and 1.11, respectively at 6 months, and 1.33 and 1.37, respectively at 12 months to have pain. Both were statistically significant at 12 months post injury unadjusted and adjusted for age, gender and other injuries.

Patients with delayed union or non-union of femoral and tibial shaft fractures have poorer physical and mental health at 6 and 12 months post injury. In addition, they are less likely to have returned to work and more likely to still have pain at 12 months post injury.

Background: Hip fractures are a common cause of hospitalisation amongst elderly patients, imposing a burden on resources and resulting in significant morbidity and mortality. Despite the high incidence questions remain surrounding the efficacy of current treatment protocols. There has also been relative neglect, within current literature, of the ‘young’ hip fracture patient.

Objectives: To analyse clinical and patient-reported outcomes for patients with hip fractures treated at two Australian level-1 trauma centres, and, to highlight key differences between the ‘typical’ patient (age> 60 years) and those aged 60 years or less.

Methods: Patients with traumatic proximal femoral fractures treated at The Royal Melbourne and Alfred hospitals between 2003 and 2006 were identified via the Victorian Orthopaedic Trauma Outcomes Registry. Patient-reported outcomes were prospectively measured at 6 and 12 months post-injury using the 12-Item Short-Form Health Survey (SF-12) and a Numerical Pain Scale. A priori defined clinical outcomes were also determined by reviewing medical records and X-rays.

Results: A total of 695 patients were identified with similar distribution between institutions. The male: female ratio was 1:2 and 13.8% were aged 60 years or less at presentation. ‘Community-dwellers’ accounted for 69.9% with 25.6% presenting from an institutional setting. Displaced subcaptial fractures (AO-31B3) occurred most commonly.

Median hospital length of stay was 12 days. Inpatient mortality reached 5.5% whilst mortality at 6 and 12 months post-injury was 17.1% and 22.6% respectively. Upon discharge 16.1% returned to the community and 60.5% required rehabilitation. At 6 months 48.0% were residing at home and 30.5% at an institutional setting. Institutionalisation decreased to 27.7% at 12 months, approaching pre-injury levels. Mean physical SF-12 scores remained well below population norms at 12 months (36.4 vs 48.9). Younger patients demonstrated significantly different results with reference to presentation, management and outcomes. Several factors were highlighted as predictors of mortality and/or functional recovery.

Conclusions: Mortality following hip fracture treatment at an Australian level-1 trauma centre is comparable to statistics achieved by similar international institutions. The rise in mortality is greatest within the initial 6 months representing a period during which close medical attention is paramount. The Mortality predictors highlighted may be useful in guiding this resource allocation. Patient-reported health status also plateaus following the initial 6 months, warranting a review of current protocols to ascertain whether this represents a golden ‘window-period’ for successful rehabilitation or whether appropriate care is not being provided beyond 6 months. Patients aged 60 years or younger represent a significant and unique group. Approach to management and goals of treatment should be tailored accordingly.

Frozen Shoulder (FS) is a debilitating musculoskeletal condition with an uncertain aetiology and poorly understood pathogenic mechanism. This study aimed to investigate the pathology of FS. We hypothesised that an altered expression of cytokines may disrupt the normal tissue remodeling process, leading to FS, which would be apparent histologically.

Patients undergoing arthroscopic treatment of FS were prospectively recruited, along with control patients being treated for subacromial impingement. Synovial biopsies were taken from all subjects. Synovial RNA levels were analysed using quantitative Polymerase Chain Reaction (qPCR). Inflammatory cytokines and growth factors thought to play a role in the pathogenesis of FS were assessed. These included metalloproteases (MMP, ADAMTS) involved in tissue remodeling and fibrosis, inflammatory cytokines such as interleukins (IL), and growth factors such as colony stimulating factors (MCSF, GMCSF, CSF1R). Samples underwent histological analysis, to assess inflammation and fibrosis.

Thirteen patients with FS and ten control patients with subacromial impingement were recruited. Arthroscopic inspection revealed greater levels of synovitis (2.63+ vs 0.40+, p< 0.01) and papillary proliferation (50% vs 10%, p=0.02) in FS patients compared with the control group, confirming the initial clinical diagnosis of FS. Histological analysis of the synovium revealed samples from the FS group were more likely to demonstrate a fibrotic, focally nodular collagen morphology (53.8% vs 10%, p=0.03). There were similar levels of chronic inflammatory cells present in those with FS and control patients (53.8% vs 30%, p=0.25). There was no evidence of acute inflammation in any of the samples. Immunohistochemical staining revealed a high level of AGEs present in the synovium and smooth muscle tissue in all samples. There was no observed difference between diabetic and non-diabetic samples. Cytogenetic analysis using qPCR revealed fibrogenic factors MMP3 (p=0.068), and ADAMTS4 (p=0.083) to be elevated in FS cases, as were inflammatory cytokines IL6 (p=0.062) and IL8 (p=0.075)

We have quantified the level of inflammatory cytokines and growth factors in FS, demonstrating that these factors are elevated in FS. This indicates that altered levels of inflammatory cytokines may be associated with the pathogenesis of inflammation evolving into fibrosis, the characteristic feature of FS. We have also shown the histology of this fibrosis to be different to that observed in normal synovium.

Traditionally autologous bone graft is the standard treatment for non-union of fractures. More recently osteo-inductive agents with or without allograft have been utilised. A trial of Autologous Mesenchymal Precursor Cells has been completed at the Royal Melbourne Hospital to investigate their potential for the treatment of nonunion of long bone fractures.

With the approval of the ethics committee at the Royal Melbourne Hospital a human safety trial was commenced for the treatment of fracture non-union. Bone marrow cells were harvested from patients approximately six weeks before surgery and cultured in a laboratory. The cells were expanded in a culture medium. At the time of definitive surgery the stem cells were implanted on a hydroxy apatite/tricalcium phosphate matrix to the non-union site. Any further fixation that was required at the time of the union was performed by the treating surgeon. Investigations were performed at regular intervals to assess for union and for any reaction to the stem cells and growth medium.

The trial has been completed and eleven patients have been entered into the study. There were eight patients with non-union of femoral fractures and four patients with tibial non-unions (one patient with ipsilateral injuries to both bones). The average age was 41.9 years and the mean time to surgery from the initial injury was 15.2 months. Eight patients have united at a mean time of 24 weeks. One is well on the way to union and of the remaining two patients one is listed as uncertain and one a declared non union. The patient who has failed to unite is currently awaiting further surgery. One patient withdrew from the trial after ceasing smoking and finally uniting prior to stem cell implantation. There has been one adverse event with possible infection at a screw site though this was thought not to be related to stem cell therapy.

This is a phase one safety trial of a new development for the treatment of a nonunion of long bone fractures. The results are promising with the regards to achieving bone union without any significant complications. This paves the way for a trial involving allogeneic stem cells.

Introduction and Aims: Currently, multiple femoral component types and sizes exist for primary total hip arthroplasty. However, component sizes for small femoral geometry are generally not available. The purpose of this study is to present the short-term use of a femoral component with sizes that extend into small femoral morphometry applications.

Method: Between November 2001 and December 2003, 20 primary THA cases and three revision THA cases were performed utilising a non-cemented, dual threaded, cone shaped (DTCS) modular femoral component manufactured in off-the-shelf sizes, which include those sizes for small femora. The components are made of CoCr and include a size ‘Z’ (19mm proximal, 9mm distal) and a size ‘Y’ (17mm proximal, 8mm distal). Both components have hydroxyapatite coating for stimulating increased bone on-growth and a modular neck allowing intra-operative adjustments of leg length, version, offset and neck length.

Results: The average patient follow-up was 10 months (range 64 days to 27 months). There were 19 (83%) hips in which the ‘Z’ component was used, and four (17%) hips with the ‘Y’ component. Radiographic evaluation revealed well-fixed and positioned components with evidence of bone densing in areas in intimate contact with the DTCS component. Radiographic evidence of minor stress shielding was observed in the greater trochanter (Gruen Zone 1) and the proximal calcar/neck cut region (Gruen Zone 7). Two revision cases (8%) required the additional use of a 6cm modular extension component (MEC) to bridge a proximal femoral deficiency. Two cases (8%) required adjunctive strut allografting at the time of surgery to protect a thin or deficient femoral cortex. There were no reported postoperative complications related to the femoral component. There was no disassociation of the modular neck from the femoral stem and there was no incidence of femoral component fracture.

Conclusion: While expanding component profile offerings into larger sizes is common, developing similar component designs for abnormally small femora is uncommon, beyond the scope of the materials used and only done as a ‘custom’ order. The DTCS modular femoral component used affords a versatile option when presented with cases involving small femoral morphometry. We conclude that the DTCS component in smaller sizes is promising and warranted for continued use.