Aims

COVID-19 represents one of the greatest global healthcare challenges in a generation. Orthopaedic departments within the UK have shifted care to manage trauma in ways that minimize exposure to COVID-19. As the incidence of COVID-19 decreases, we explore the impact and risk factors of COVID-19 on patient outcomes within our department.

Bone metastases are common and severe complications of cancers. It is estimated to occur in 65–75% of breast and prostate cancer patients and cause 80% of breast cancer-related deaths. Metastasised cancer cells have devastating impacts on bone due to their ability to alter bone remodeling by interacting with osteoblasts and osteoclasts. Exercise, often used as an intervention for cancer patients, regulates bone remodeling via osteocytes. Therefore, we hypothesise that bone mechanical loading may regulate bone metastases via osteocytes. This provides novel insights into the impact of exercises on bone metastases. It will assist in designing cancer intervention programs that lowers the risk for bone metastases. Investigating the mechanisms for the observed effects may also identify potential drug targets.

MLO-Y4 osteocyte-like cells (gift of Dr. Bonewald, University of Missouri-Kansas City) on glass slides were placed in flow chambers and subjected to oscillatory fluid flow (1Pa; 1Hz; 2 hours). Media were extracted (conditioned media; CM) post-flow. RAW264.7 osteoclast precursors were conditioned in MLO-Y4 CM for 7 days. Migration of MDA-MB-231 breast cancer cells and PC3 prostate cancer cells towards CM was assayed using Transwell. Viability, apoptosis, and proliferation of the cancer cells in the CM were measured with Fixable Viability Dye eFluor 450, APOPercentage, and BrDu, respectively. P-values were calculated using Student's t-test.

Significantly more MDA-MB-231 and PC3 cells migrated towards the CM from MLO-Y4 cells with exposure to flow in comparison to CM from MLO-Y4 cells not exposed to flow. The preferential migration is abolished with anti-VEGF antibodies. MDA-MB-231 cells apoptosis rate was slightly lower in CM from MLO-Y4 cells exposed to flow, while proliferation rate was slightly higher. The current data showed no difference in cancer cells viability and adhesion to collagen between any two groups. On the other hand, it was observed that less MDA-MB-231 cells migrated towards CM from RAW264.7 cells conditioned in CM from MLO-Y4 cells stimulated with flow in comparison to those conditioned in CM from MLO-Y4 cells not stimulated with flow. TRAP staining results confirmed that there were less differentiated osteoclasts when RAW264.7 cells were cultured in CM from MLO-Y4 cells exposed to flow.

Overall, this study suggests that when only osteocytes and cancer cells are involved, osteocytes subjected to mechanical loading can promote metastases due to the increased secretion of VEGF. However, with the incorporation of osteoclasts, mechanical loading on osteocytes seems to reduce MDA-MB-231 cell migration. This is likely because osteocytes reduce osteoclastogenesis in response to mechanical stimulation, and osteoclasts have been shown to support cancer cells. Animal studies will also be conducted to verify the pro- or anti-metastatic effect of mechanical loading that is observed in the in vitro part of this study.

Aims

We wished to assess the feasibility of a future randomised controlled trial of parathyroid hormone (PTH) supplements to aid healing of trochanteric fractures of the hip, by an open label prospective feasibility and pilot study with a nested qualitative sub study. This aimed to inform the design of a future powered study comparing the functional recovery after trochanteric hip fracture in patients undergoing standard care, versus those who undergo administration of subcutaneous injection of PTH for six weeks.

We sought to evaluate the impact of a dedicated weekly ortho-plastics operating list on our ability to provide definitive soft tissue cover of open lower limb fractures within 72 hours.

We reviewed all open lower limb fractures at our centre before and after the introduction of an ortho-plastics list to determine whether definitive soft tissue coverage was achieved within 72 hours.

There were 23 open lower limb fractures at our centre in 2012 before the introduction of the ortho-plastics operating list of which only 7 (30%) had definitive soft tissue coverage within 72 hours. We hypothesised that the main reason for this was not patient or injury related factors but rather the logistical difficulties of coordinating theatre time on a routine trauma list with senior orthopaedic and plastic surgeon availability. To test this hypothesis we re-audited our time to soft tissue cover six months after the introduction of the ortho-plastics list and 70% of cases achieved coverage within 72 hours.

Achieving definitive soft tissue coverage of open lower limb fractures within 72 hours of injury is a challenge. A dedicated weekly ortho-plastics operating list significantly improves our ability to deliver this service.

Metatarsal fractures are extremely common injuries accounting for 10% of all fractures seen in our accident and emergency departments (3). The vast majority can be treated conservatively. There is no standardised treatment, but it is commahplace to immobilise the foot and ankle joint in a below-knee back-slab, full cast or functional brace for a period of up to 6 weeks, weight-bearing the patient as pain allows. This practice is time-consuming and expensive, not to mention debilitating, and carries a morbidity risk to the patient.

We describe a simple, effective and cheap treatment method for metatarsal fracture management using the functional forefoot-offloading shoe (FOS). This is clinically proven to offload pressure on the metatarsals and is commonly used in both elective forefoot surgery and in diabetic patients.

Between January and September 2009, we identified 57 patients attending our fracture clinic with new metatarsal fractures. 28 met our inclusion criteria.

All patients reported a significant improvement in their pain

At Injury – mean 8.21 out of 10 (range 4-10)

After FOS fitting - mean 2.92 out of 10 (range 0-6)

The forefoot-offloading shoe is an excellent alternative to plaster casting or functional boot immobilisation, offering high patient satisfaction, an excellent outcome and a considerable cost-saving to the hospital trust.

In revision hip surgery, a solidly cemented femoral component may obstruct access to the acetabulum, may be poorly orientated, or may have inadequate offset and head diameter. These problems can be addressed by revising the femoral component. The object of this study was to determine the outcome of cementing a polished, tapered, modular implant into the retained cement mantle. Benefits of cement within cement revision of a femoral stem include simplicity, reduced theatre time, and potentially reduced complication rates.

A consecutive series of 36 patients (11 men, 25 women) age range 35 to 90 years (mean age 70) underwent c stem cement in cement revision hip arthroplasty between June 2000 and April 2006. Indications for revision arthroplasty included 20 patients with aseptic acetabular loosening and 13 patients with recurrent instability. Follow up (12–84 months, mean 48 months) was annual and the outcome for every implant was known. Outcome measures included the shortened WOMAC score, Orthowave patient satisfaction survey, radiographic analysis, and assessment of the records for perioperative complications.

No patients were lost to follow up, 2 patients died with their hip in situ. The mean post operative WOMAC score at latest follow up was 10.89 (median 11, range 0 to 29). There has been no clinical or radiological signs of prosthesis loosening or failure on follow up. Complications included: one sacral plexus palsy which had a partial recovery, and one intra-operative periprosthetic fracture identified and treated at the time of the revision procedure. One patient underwent a further cup revision for recurrent dislocation.

Cement within cement revision hip arthroplasty using a highly polished tapered stem in the short to medium term provides satisfactory functional outcomes and is associated with low complication rates and good survivorship. Longer term results are awaited.

Patient satisfaction has only recently gained attention as an outcome measure in orthopaedics, where it has been reported for joint replacement surgery. Little has been published regarding predictors of patient satisfaction in orthopaedic trauma. This study aims to explore the predictors of patient satisfaction, and of surgeon satisfaction, after orthopaedic trauma.

Adult patients admitted to hospital with fractures after motor vehicle trauma were surveyed on admission, and at six months. Demographic, injury, socio-economic and compensation-related factors were measured. The two outcomes were satisfaction with progress of the injury, and satisfaction with recovery. The treating surgeons were also surveyed at six months to determine surgeon satisfaction with progress, and recovery (using the same questions), and the presence or absence of fracture union and any complications. Multivariate analysis was used to determine significant predictors of satisfaction for both groups, and satisfaction rates were compared between surgeons and patients using multivariable analysis.

Of 306 patients recruited, 232 (75.8%) returned completed questionnaires, but only 141 (46.1%) surgeons responded. Patients rated their satisfaction with progress and recovery as 74.6% and 44.4%, respectively, whereas surgeon-rated satisfaction with progress and recovery was 88.0% and 66.7%, respectively (p< 0.0001). Significant predictors of patient dissatisfaction were: blaming others for the injury, being female, and using a lawyer. Patient-rated outcome was not significantly associated with objective injury or treatment factors. The only significant predictor of surgeon dissatisfaction was fracture non-union.

Orthopaedic surgeons overestimated the progress of the injury and the level of recovery compared to patients’ own ratings. Surgeons’ ratings are influenced by objective, treatment-related factors, whereas patients’ ratings were not. Measures of outcome commonly used b y orthopaedic surgeons, such as fracture union, do not predict patient satisfaction.