Heterotopic ossification is the formation of lamellar bone in soft tissues and is a common complication of high-energy combat injury. This disabling condition can cause pain, joint ankylosis, and skin ulceration in the residua of amputees. This project is aimed at developing a novel treatment to dissolve hydroxyapatite in heterotopic ossification and prevent the crystallisation of this this mineral at sites of ectopic bone formation. Previously reported results demonstrated that hexametaphosphate could dissolve hydroxyapatite at physiological pH. Further work has been undertaken to investigate the mechanism of this dissolution and establish a means of temporal control of action. In addition, physicochemical analyses of samples of human heterotopic ossification have yielded important insights into the nature of this pathological tissue. Techniques include mapped micro X-ray fluorescence, mapped Raman spectroscopy, scanning electron microscopy, and micro computed tomography. Formulation engineering work has begun in order to develop an appropriate delivery vehicle for this agent. This includes rheological testing and hexametaphosphate elution profiles. Finally, micro CT analysis has shown that hexametaphosphate is able to dissolve human heterotopic ossification tissue. In summary, this work has moved us closer towards our goal of a novel injectable agent for the treatment and prevention of heterotopic ossification.

At first-stage revision surgery for infection of total knee arthroplasties, antibiotic-impregnated cement spacers are frequently implanted. Two types of cement spacers are commonly used, “static” and “articulating” cement spacers. Advocates of cement spacers state that they deliver high doses of antibiotics locally, increase patient comfort, allow mobility and provide joint stability. They also minimize contracture of collateral ligaments, thereby facilitating re-implantation of a definitive prosthesis at a later stage. The use of these cement spacers, however, are not without significant complications, including patella tendon injuries.

We describe a series of three patients who sustained patella tendon injuries in infected total knee arthroplasties following the use of a static cement spacer at first-stage knee revision.

The patella tendon injuries resulted in significant compromise to wound healing and knee stability requiring multiple surgeries. The mid-term function was poor with an Oxford score at 24 months ranging from 12–20

Based on our experience, we advise caution in the use of static cement spacer blocks. If they are to be used, we recommend that they should be keyed in the bone to prevent patella tendon injuries.

Honey has been used as a topical antiseptic for at least 5,000 years. SurgiHoney is a CE licensed sterile product, which has been proven to be non-toxic and effective when used topically in the treatment of chronically infected wounds. The key difference from other medical grade honey is the broad spectrum antimicrobial characteristics with activity against Gram +ve, Gram –ve and multi-resistant organisms. Its novel role against the bacterial bioburden and biofilm associated with periprosthetic infections around total knee arthroplasties (TKA's) is therefore considered.

SurgiHoney was used as an implant coating immediately prior to wound closure after implantation of salvage endoprosthesis for multiply revised, infected TKA's undergoing staged reconstruction.

We report a consecutive series of multi-revised, infected revision TKA's where SurgiHoney was used as an active antimicrobial coating. We discuss its intra-operative application and early clinical outcomes.

The use of Surgihoney as a novel anti-microbial is established in the management of complex wound infections. This is the first reported use of SurgiHoney as a deep, implant coating in the salvage of prosthetic joint infection.

Joint degeneration may make a total knee arthroplasty (TKA) a requirement for pain relief and function. However, the presence of ipsilateral limb osteomyelitis (OM) makes surgical management extremely challenging.

We report the experience of a high volume revision knee surgeon managing ipsilateral limb multi resistant OM and the outcome of subsequent TKA.

Four consecutive patients were identified who had either ipsilateral femoral or tibial chronic osteomyelitis treated prior to undergoing TKA. Surgery to eradicate the osteomyelitis involved a Lautenbach compartmental debridement, and where necessary, healing by secondary intention. The decision to proceed to a TKA was based on history, clinical examination and radiological findings of advanced osteoarthritic change.

The patients had a mean age of 50 years. They had a background of multi-organism OM and underwent single-stage TKAs at an average of 63 months following eradication of the underlying OM.

Three patients did well but had complications associated with poor skin and soft tissues, and abnormal bone anatomy. One patient developed an infection and following a re-revision had an arthrodesis.

The results for the four cases are summarised in Table 1.

We have highlighted that patients with ipsilateral limb multi resistant OM are a difficult cohort to manage.

A common step to revision surgery for infected total knee replacement (TKR) is a thorough debridement. Whilst surgical and mechanical debridement are established as the gold standard, we investigate a novel adjuvant chemical debridement using an Acetic Acid (AA) soak that seeks to create a hostile environment for organisms, further degradation of biofilm and death of the bacteria.

We report the first orthopaedic in vivo series using AA soak as an intra-operative chemical debridement agent for treating infected TKR's. We also investigate the in vitro efficacy of AA against bacteria isolated from infected TKR's.

A prospective single surgeon consecutive series of patients with infected TKR were treated according to a standard debridement protocol. Patients in the series received sequential debridement of surgical, mechanical and finally chemical debridement with a 10 minute 3% AA soak.

In parallel, we isolated, cultured and identified bacteria from infected TKR's and assessed the in vitro efficacy of AA. Susceptibility testing was performed with AA solutions of different concentrations as well as with a control of a gentamicin sulphate disc. The effect of AA on the pH of tryptone soya was also monitored in an attempt to understand its potential mechanism of action.

Physiological responses during the AA soak were unremarkable. Intraoperatively, there were no tachycardic or arrythmic responses, any increase in respiratory rate or changes in blood pressure. This was also the case when the tourniquet was released. In addition, during the post-operative period no increase in analgesic requirements or wound complications was noted. Wound and soft tissue healing was excellent and there have not been any early recurrent infections at mean of 18 months follow up.

In vitro, zones of inhibition were formed on less than 40% of the organisms, demonstrating that AA was not directly bactericidal against the majority of the clinical isolates. However, when cultured in a bacterial suspension, AA completely inhibited the growth of the isolates at concentrations as low as 0.19%v/v.

This study has shown that the use of 3% AA soak, as part of a debridement protocol, is safe. Whilst the exact mechanism of action of acetic acid is yet to be determined, we have demonstrated that concentrations as low as 0.19%v/v in solution in vitro is sufficient to completely inhibit bacterial growth from infected TKR's.

The simple dictum of the late Prof. Alf Nachemson was that ‘surgery should very rarely, if ever, be performed in adult scoliotic patients for lumbar curves when pain is the most serious problem’. Today, the complexity of intercurrent neural symptoms, the advancing age of the population and the increasing demands and expectations of modern living require a somewhat more flexible approach to this increasingly common problem.

Treatment of adult deformity has improved along with our understanding of the radiological features of the condition most likely to be associated with disabling pain and also with our appreciation of the adverse significance of patient co-morbidity. In those patients where conservative measures have failed and where an acceptable quality of life has been lost, surgical management may be undertaken, but must address all the symptomatic aspects of the deformity in one episode of care.

Primary objectives include the restoration of satisfactory sagittal plane correction using the minimum number of operated levels whilst providing adequate spinal stability. Meticulous preoperative planning from a clinical and radiological perspective maximises the possibility of a satisfactory outcome and in this regard patient expectation is of prime importance. The questions of operative approach and levels of fixation are ever present and recent advances in our understanding of distal end fixation are worthy of consideration.

Finally, exemplary cases and our series of 23 patients undergoing surgical treatment of adult scoliosis will be presented. Mean coronal curve correction by anteroposterior approach was 60.4% and by posterior only approach 40.3%.

Patient satisfaction was 77.8% by combined approach and 58.9% by posterior only approach. The rate of reoperation was 66.7% for posterior surgery alone and 11.1% for combined approach corrections.