Proximal Femoral Nail Antirotation (PFNA) I one of the implants commonly used to stabilise subtrochanteric fractures or communited inter/pertrochanteric fractures. The aim of this project was to assess the outcome of PFNA in a busy District General Hospital. Between November 2009 to November 2012, 76 patients underwent PFNA. These patients were identified from the local hip fracture database, which is prospectively collected.

The mean age of the patients was 80.11 years (range of 26.83 to 98.53). 27 were male and 49 female. Right hip was involved in 36 cases and left hip in 40. 9 patients required revision surgery due to failure of the primary surgery. 2 patients died due to other causes. 5 out of the 9 patients who underwent revision surgery had their primary surgery performed by a trainee under consultant supervision and a consultant surgeon performed the other 4 cases. In our series failure rate was 11.8%. We conclude that although PFNA is an excellent device to fix subtrochanteric or communited intertrochanteric fractures of the proximal femur one needs to be cautious and follow the correct operative technique to avoid failures.

The PFNA is used routinely at the RUH for unstable peri-trochanteric and femoral fractures. Failure of operative treatment is associated with increased morbidity and financial burden. We analysed surgical and fracture factors, aiming to identify those associated with fixation failure.

Retrospective analysis of 76 consecutive patients treated with a PFNA between 2009–2012 was performed. Patient demographics were assessed, along with fracture classification, adequacy of reduction, tip apex distance (TAD) and grade of surgeon. Failure was defined as metal work failure, non-union or need for repeat procedure.

The mean age was 78.9 years (25.9–97.4). 21 were male and 49 female. There were 17 failures (24.3%) (7 required further surgery). 10 failures were per-trochanteric, 2 sub-trochanteric and 5 mid-shaft fractures. Complications included 4 broken and 6 backed-out distal locking screws, 2 blade cut-outs, 1 nail fracture and 4 non-unions. All per-trochanteric were adequately reduced with a TAD <25 mm. 11/17 had consultant supervision.

A high rate of backed-out distal locking screws was identified. We found no concerns with adequacy of reduction, TAD or consultant supervision.

Background

The available treatments for NSLBP (Non-Specific Low Back Pain) provide, typically, small to moderate average benefits to patients. The aim of this pilot cluster RCT was to test the hypothesis that the use of a patient decision aid together with an informed shared decision making consultation would produce better outcomes in satisfaction with treatment at four month follow-up.

In this retrospective study 27 patients who had undergone revision discectomies for recurrent lumbar disc herniations were surveyed to assess their clinical outcomes. The patients chosen for the study were compared to a control group of 30 matched patients who had undergone only a primary discectomy. The spine module of the MODEMS® outcome instrument was used to evaluate the patients’ satisfaction, their pain and functional ability following discectomy, as well as their quality of life. All patients were also asked whether they were improved or worsened with surgery. Those undergoing revision surgery were asked whether the improvement following the second surgery was more or less than the improvement following the first surgery. Differences in residual numbness/tingling in the leg and/or the foot as well as in frequency of back and/or buttock pain were identified. Nevertheless improvement due to the repeat discectomy was not statistically different from those who underwent just the primary operation. Based upon patient derived outcome data with a validated instrument, revision discectomy is as efficacious as primary discectomy in selected patients.

Hip Resurfacing is now an established treatment option for young active patients with osteoarthritis. However, there is slow uptake of hip resurfacing by some surgeons, with concern regarding failure from femoral neck fracture, a small but significant risk. Femoral neck fracture may follow notching of the neck, which occurs upon preparing the femoral head after inserting the femoral head/neck guide-wire. The placement of the femoral head/neck guide-wire is a concern for even experienced surgeons routinely, and in difficult cases of femoral head/neck deformity this is especially so.

For the first time a preliminary series of Durom hip resurfacings, based on the successful Metasul bearing, were implanted using a computer image guidance system. The aim of computer navigation is to optimally place the femoral prosthesis in the correct degree of valgus with good underlying bone coverage, without notching the femoral neck or over-sizing the femoral component. Preoperative CT scanning was not required. A standard posterior approach to the hip was utilised, and a navigation reference frame was applied to the proximal femur. Then using an image intensifier and the computer navigation system, a guide-wire was passed quickly and easily into the femoral head/neck with a navigated drill guide. The femoral head was then prepared safely for the femoral component of the resurfacing, with minimal risk of femoral neck fracture.

Computer navigation systems have an important role to play in hip resurfacing with respect to femoral head/neck preparation, as demonstrated from our preliminary study. This series shows the use of computer navigation in hip resurfacing to be both SAFE and SIMPLE with a quick learning curve. It was shown to be FASTER and MORE ACCURATE in the process of guide-wire placement in the femoral head/neck as compared to conventional jigs. Crucially, femoral neck fractures may even be potentially ELIMINATED using this technique.

In the future, hip resurfacing in conjunction with computer navigation systems may allow;

- SAFER hip resurfacing, with reduced rates of femoral neck fractures

Introduction: Although knee athroplasty is a very successful operation, British knee surgeons have a wide variation in their methods of patient management. Aims: To determine current knee practice within the United Kingdom. Material and Methods: A postal survey was conducted of all members of the British Association of Knee Surgery. They were asked about pre-operative assessment, type of prosthesis used, antibiotic prophylaxis, DVT prophylaxis, bilateral arthroplasty, preferred anaesthetic, urinary catheter, patella replacement, autologous blood transfusion, mobilisation, duration of hospital stay and patient follow up. Results: 71% (221) members replied. The results and implications will be presented in full at the presentation. Some of the more interesting findings included: 18% did not have a pre-admission clinic, 18% use thromboprophylaxis for medicolegal reasons only (do not believe it works), 19% never replace the patella, 48% perform unicondlyar arthroplasty, 41% follow up patients indefinitely, one discharges patients at 6 weeks, 77% perform bilateral arthroplasty. Discussion and Conclusion: Comparison with a 1996 study of UK knee practice shows that most techniques are unchanged although slightly more surgeons routinely use an uncemented implant. (4.8% 1996, 12% 2001). There remains a wide variation in UK practice. The authors would be grateful if colleagues from other countries would contact them so that comparable studies of practice could be performed in their countries. This data may be used to compare international attitudes to knee arthroplasty.

Aims: To establish whether the Ôidealñ concentric positioning of acetabular components within the acetabular cement mantle is achieved during routine cemented total hip arthroplasty.

In vitro studies recommend concentric placement of the acetabular component. There are however no in vitro studies on acetabular component positioning.

Methods: Radiographs of 100 primary cemented total hip replacements were studied. Acetabular component positioning and cement mantles were assessed with respect to implant type, grade of surgeon and operated side.

Results: 78% of the components were eccentrically placed, with increasing cement mantle thickness from zones 1 to 3. Concentricity occurred in only 13% of the Charnley Ogee, and 28% of the IP Lubinus components. The Charnley Ogee was more superiorly eccentric than the IP Lubinus (p< 0.001). The IP Lubinus was generally more open than the Charnley Ogee and Stanmore (p=0.053). Surgical grade affected neither cement mantle nor opening angle.

Conclusions: This study indicates that the ideal component position in the acetabulum is very difþcult to achieve consistently in most patients, using the two commonly used cemented prostheses in this study. The practical difþculty of concentric component positioning while obtaining simultaneous pressurisation is illustrated.

Nitric oxide (NO) is a free radical labile gas which has important physiological functions and is synthesised by the action of a group of enzymes called nitric oxide synthases (NOS) on L- arginine. We have shown that nitric oxide modulates fracture healing¹. Bone morphogenic proteins (BMP) are potent differentiating factors that augment the process of new bone formation. Recombinant human BMP-2 (rhBMP-2) enhances spinal fusion². With progression of fusion there is a remodelling of the fusion mass bone accompanied with a decrease in the fusion mass size. It is not known whether nitric oxide has a role in spinal fusion or rhBMP-2 enhanced spinal fusion.

We studied this in a novel rat intertransverse fusion model using a defined volume of bone graft (7 caudal vertebrae) along with 157 mm3 of absorbable Type-1 collagen sponge (Helistat®) carrier, which was compacted and delivered using a custom jig for achieving a similar graft density from sample to sample. The control groups consisted of a sham operated group (S, n=20), an autograft + carrier group (AC, n=28) and a group consisting of 43 μg of rhBMP-2 (Genetics Institute, Andover, MA) mixed with autograft + carrier (ACB, n=28). Two experimental groups received a nitric oxide synthase (NOS) inhibitor, N^G-nitro L-arginine methyl ester (L-NAME, Sigma Chemicals, St Louis, MO) in a dose of 1 mg/ml ad lib in the drinking water (ACL, n=28) and one of these experimental groups had rhBMP-2 added to the graft mixture at the time of surgery (ACLB, n=28). Rats were sacrificed at 22 days and 44 days, spinal columns dissected and subjected to high density radiology (faxitron) and decalcified histology. The faxitrons were subjected to image analysis (MetaMorph).

On a radiographic score (0–4) indicating progressive maturation of bone fusion mass, no difference was found between the AC and ACL groups, however, there was a significant enhancement of fusion when rhBMP-2 was added (ACB group, 3.3±0.2) when compared to the AC group (1±0) (p< .001). However, on day 44, the ACLB group (3.3±0.2) showed significantly less fusion progression when compared to the ACB group (4±0) (p< 0.01). There was a 25% (p< 0.05) more fusion-mass-area in day 44 of ACLB group (297±26 mm³) when compared to day 44 of the ACB group (225±16 mm³) indicating that NOS inhibition delayed the remodelling of the fusion mass. Undecalcified histology demonstrated that there was a delay in graft incorporation whenever NOS was inhibited (ACL and ACLB groups).

Our results show that the biology of autograft spinal fusion and rhBMP-2 enhanced spinal fusion can be potentially manipulated by nitric oxide pathways.

Purpose: Interbody fusion cages have met with great success as an adjunct in the treatment of painful degenerative disc disease. One of the limitations is the need for the use of autogenous cancellous bone graft. In preclinical studies recombinant human bone morphogenetic protein-2 (rhBMP-2) delivered in a variety of carriers has been shown to be an effective substitute for autogenous bone, resulting in more rapid and reliable healing than that seen in control groups. The goal of this study was to report the early results of the first human trial attempting to use rhBMP-2 in interbody fusion cages.

Methods: This study was an FDA approved IDE multicenter pilot study. From 1/97 to 4/97, 14 patients were entered into a prospective, randomized trial. All patients had single level lumbar degenerative disc disease that was refractory to prolonged nonoperative care and were candidates for anterior interbody fusion of L4-5 or L5-S1. After consent, patients were randomized to either the control group (N-3) and received autogenous bone inside tapered titanium fusion cages (NOVUS LT, Sofamor Danek Memphis, TN) or to the investigational group (N = 11) and received rhBMP-2 (1.5 mg/ml)(Genetics Institute, Cambridge MA) delivered in a collagen sponge (Helistat, Integra Life Sciences, Plainsboro, NJ) inside the fusion cages. Depending on the size, the sponge in each cage was soaked with from 1.3 to 2.6 ml of the rhBMP2 solution. Patients were followed at regular intervals with plain x-ray, CT scan with reconstruction, and a full panel of blood tests. Radiographs were reviewed by an independent blinded radiologist with fusion defined as < 5 degrees of sagittal motion, absence of radiolucent lines, and presence of continuous bone through the cages. Clinical results were assessed using an outcomes questionnaire including the SF-36 general health status and Oswestry low back specific instruments.

Results: All 14 patients were available for 1-year follow-up. No cages displaced and no further surgeries were required. Mean hospital stay was 2.0 days for the rhBMP-2 patients compared to 3.3 days for the autograft controls. Of the 11 rhBMP2 patients, 10 of 11 were judged to be fused at 3 months. At 6 months and 1-year all 11 rhBMP-2 patients were noted to have a solid arthrodesis. Of the 3 control patients, 2 had solid arthodesis and one had an apparent nonunion at 1 year. On sagittal CT scan reconstruction new bone growth was seen throughout and anterior to the cages that were filled with rhBMP-2. No patients had bone formation outside of the desired area. The control patient with the nonunion had a halo surrounding the cage on the sagittal CT reconstruction. This patient had persistence of low back pain. Compared to preop, the Oswestry scores at 3 months were decreased in the rhBMP-2 group (39 to 30) compared to controls which were increased (35 to 43) and both mean scores were similar at 6 months (28 and 27). Conclusion: The preliminary results from this clinical trial with rhBMP-2 inside interbody fusion cages were excellent and support a larger pivotal trial. The arthrodesis was found to occur more rapidly and reliably than in the controls, although the sample size was limited. In addition to faster bone healing, a major advantage was the elimination of bone graft donor site morbidity and realization of decreased hospital stay. No evidence of excessive bone formation or systemic complications occurred. Moreover, this study provides one of the first demonstrations of consistent and unequivocal osteoinduction by a recombinant growth factor in humans.

Introduction: Knee arthroscopy is one of the most commonly performed orthopaedic procedures. All orthopaedic surgeons have heard anecdotal stories of thermal injury and drape combustion, yet a literature search has failed to find any papers reviewing the nature of such risks.

Materials and methods: A thermocouple attached to a laptop computer was used to record the temperature at the arthroscope tip, the light cable end and the light source generator. All potentially flammable materials commonly used during arthroscopic surgery (various disposable drapes, cotton drapes, gowns, paper towels and swabs), were placed at measured distances from a) the light cable end and b) the arthroscope tip.

Results: The arthroscope tip reached a maximum temperature of 41.90° in 200 seconds. The light cable tip reached 80° at 100 seconds and a maximum temperature of 110°C in 342 seconds. The light source generator reached a temperature of 153°C. All materials tested (except cotton swabs) underwent signs of combustion. The disposable drapes burnt most rapidly. None of the materials considered had any evidence of thermal damage when placed at distances of 2.5 cm beyond the light cable and 0.5 cm beyond the arthroscope tip. Combustion was most rapid at a distance of 5mm from the instruments.

Most surgeons consider the arthroscope tip or light cable end to be the site most likely to induce combustion. Fuel, heat and oxygen are required to produce combustion. Direct contact with the tip results in greater exposure to heat but lower oxygen availability. The fasted combustion occurred at 5mm due to higher oxygen availability despite a lower temperature.

Conclusions and Recommendations:

Disposable drapes will burn with the light cable and the arthroscope tip.