Acute Achilles tendon (AT) rupture management remains debatable but non-operative functional regimes are beginning to dominate current treatment algorithms. The aim of this study was to identify predictors of functional outcome in patients with AT ruptures treated non-operatively with an immediate weight bearing functional regime in an orthosis. Analysis of prospectively gathered data from a local database of all patients treated non-operativelyat our institution with anAT rupture was performed. Inclusion criteria required a completed Achilles Tendon Rupture Score (ATRS) at a minimum of 8 months post rupture. The ATRS score was correlated against age, gender, time following rupture, duration of treatment in a functional orthoses (8- and 11-week regimes) and complications. 236 patients of average age 49.5 years were included. The mean ATRS on completion of rehabilitation was 74 points. The mean ATRS was significantly lower in the 37 females as compared to the 199 males, 65.8 vs 75.6 (p = 0.013). Age inversely affected ATRS with a Pearsons correlation of −0.2. There was no significant difference in the ATRS score when comparing the two different treatment regime durations. There were 12 episodes of VTE and 4 episodes of re-rupture. The ATRS does not change significantly after 8 months of rupture. Patients with AT ruptures treated non-operatively with a functional rehabilitation regime demonstrate good function with low re-rupture rates. Increasing age and female gender demonstrate inferior functional outcomes.
The number of total hip replacements taking place across the UK continues to grow. In an ageing population, with people living longer and placing greater strain on their prostheses, the number of peri-prosthetic femoral fractures is increasing. We studied the economic impact this has on a large university teaching hospital. All patients with a peri-prosthetic femoral fracture between 24/11/2006 and 31/5/2014 were identified using theatre databases. Radiographic and case note analysis was performed for each case. Costings from finance department for implants and in-patient stay were obtained.Introduction
Method
The K2M MESA Rail is a new implant with a unique beam-like design which provides increased rigidity compared with a standard circular rod of equivalent diameter potentially allowing greater control and maintenance of correction. The aim of this study was to review our early experience of this implant. We retrospectively reviewed the case notes and radiographs of all consecutive cases of spinal deformity correction in which at least one rail was used. All radiological measurements were made according to the Scoliosis Research Society definitions. Since June 2012 thirty-three cases of spinal deformity correction were performed using the K2M Rail system. One case was excluded as there were no pre-operative radiographs. Median age was 15 years; there were 23 females. There were 26 scoliosis cases of which two had associated Chiari malformation, three were neuromuscular, and the remainder were adolescent idiopathic cases. Six patients had kyphotic deformity secondary to Scheuermann's disease. Mean length of follow-up was 16 months. In the scoliosis cases the mean pre-operative Cobb angle of the major curve was 58.6° with a mean correction of 35.6°. The mean post-operative thoracic kyphosis was 21.1°. The median number of levels included in the correction was 13. Bilateral rails were used in four cases, the remainder had one rail on the concave side and a contralateral rod. No patients required an anterior release or staged surgery. All kyphosis cases had posterior apical corrective osteotomies. The mean pre-operative thoracic kyphosis was 75.5° with a mean correction of 31°. The median number of levels included in the correction was 11. Four patients had bilateral rails. No patients required anterior release. Complications: two patients had prominent hardware. One patient had a malpositioned screw causing nerve root irritation, which was removed. There were three superficial infections, which settled with antibiotics. There were no cases of implant breakage, screw pull-out, or loss of correction. The K2M MESA Rail is a powerful new implant design which helps to achieve and maintain satisfactory correction of complex spinal deformity, and is particularly strong at correcting kyphotic deformity. It also enables restoration of normal thoracic kyphosis, particularly in idiopathic thoracic curves, which tend to be lordosing. This may prevent thoracic flat back and potential long-term sequelae. Early results show that the system is as safe and effective as other posterior deformity correction implants on the market, however, it requires further prospective follow-up to ascertain its outcomes in the long-term.
To determine the efficacy and safety of the Magec system in early onset scoliosis (EOS). In 2011, 6 males and 2 females had Magec rods, with an average age of 8.5 years (2.9–12.7 years), 7 patients had dual rods, and 1 had single. The main cause of EOS was idiopathic scoliosis (n=6), followed by Congenital (n=1), and Syndromic (n=1). Average follow up was 19.4 months (14–26 months). 4 of these patients had their previous Paediatric Isola growing rods exchanged to Magec, and 1 patient had an exchange from single to Dual Magec rods.Aim:
Methods:
To measure truncal parameters for patients treated with growing rod systems for early onset scoliosis (EOS). 44 patients underwent growth rod surgery for EOS between 1999 and 2013 (24 females and 20 males). 27 patients had idiopathic scoliosis, 13 congenital, 3 syndromic and 1 neuromuscular. 26 patients had Paediatric Isola, 8 had Paediatric Expedium, 4 had dual growth rods with domino's and 9 each had VEPTR and MAGEC rods systems. Medical records and radiographs were analysed. Cobb angle, T1-T12 and T1-S1 length, coronal and sagittal balance, apical vertical translation (AVT), space available for the lung (SAL) and shoulder balance were measured.Aim:
Methods:
Low back pain is a common complaint, affecting up to one third of the adult population costing over £1 billion to the NHS each year and £3.5 billion to the UK economy in lost production. The demand for spinal injections is increasing allowing for advanced spinal physiotherapists to perform the procedure. The objective of this study was to investigate outcome following spinal injections performed by consultant spinal surgeon (n=40) and advanced spinal physiotherapists (ASP) (n=40) at our centre. Data on 80 patients who had received caudal epidural (n=36), nerve root block (n=28) and facet joint injections (n=16) form August 2010 to October 2011 consented to be in the study. 40 patients in each group completed Oswestry Disability Index (ODI), Visual Analogue Scores (VAS) before and 6 weeks after the procedure and patient satisfaction questionnaire investigating their experience and any complications related to the spinal injection retrospectively. The study included 32 males and 48 females. Mean age 57 years, range 21–88. [Consultant group M:17, F:23 mean age: 55, range 21–81. ASP group M:15, F:25 mean age 59, range 22–88]. Measures of patient satisfaction and outcome were obtained; using 2 tailed independent samples Introduction and aims
Method and Materials
Fractures of the femoral head are a challenging problem. The most often performed head preserving procedure worldwide is closed reduction and insertion of cannulated screws under fluoroscopic control. The use of navigation is still experimental in general trauma since rigid reference markers must be attached to all fragments. The examined system (Surgix®, Tel Aviv, Israel) is a fluoroscopy based image analysing system. It consists of a workstation and X-ray opaque markers in surgical tools. When the tool is visible in a C-arm shot a trajectory is displayed as additional layer in the image to serve as guidance for the surgeon. Forty synthetic femurs (Synbone®, Malans, Switzerland) were used and placed inside foam to simulate the soft tissue of the thigh. The models were equipped with 4.5mm radio-opaque markers at the fovea capitis femoris as target point. The aim was to bring the tip of a K-wire as close as possible to the target point entering the bone at the lateral base of the greater trochanter in a center-center position. Twenty were done under image guidance and 20 were operated the conventional way. Outcome measures included the accuracy (the distance between the tip of the wire and the target in a CT), the number of guide wire insertions, procedure duration, radiation exposure and learning curve. In the image guided group optimal guide wire placement was accomplished on first pass in 65% of the cases as compared to 5% in the conventional group (p = < 0.0001). The average number of trial and error was significantly lower in the guided group (1.7 vs. 5.8, p = < 0.0001). Consequently the average duration of the guided procedure was significantly shorter (p = 0.0008) along with radiation exposure time reduced by over 70% (p = 0.0002). The guidance system hit averaged 5.8 mm off target as compared to 5.3 mm for the freehand method (p = 0.3319). Image based guidance significantly shortened the procedure, reduced the radiation exposure and the number of trials without changing the surgeons workflow and can be used in trauma cases were reference marker based navigation is not applicable.
Computer assisted surgery (CAS) is used in trauma surgery to reduce radiation and improve accuracy but it is time consuming. Some trials for navigation in small bone fractures were made, but they are still experimental. One major problem is the fixation of the dynamic reference base for navigation. We evaluated the benefit of a new image based guidance-system (Surgix®, Tel Aviv, Israel) for fracture treatment in scaphoid bones compared to the conventional method without navigation. The system consists of a workstation and surgical devices with embedded radio opaque markers. These markers as well as the object of interest must be on the same C-arm shot. If a tool is detected in an image by the attached workstation additional information such as trajectories are displayed in the original fluoroscopic image to serve the surgeon as aiming device. The system needs no referencing and no change of the workflow. For this study 20 synthetic hand models (Synbone®, Malans, Switzerland) were randomised in two groups. Aim of this study was a central guide-wire placement in the scaphoid bone, which was blindly measured by using postoperative CT-scans. Significant distinctions related to the duration of surgery, emission of radiation, radiation dose, and trials of guide-wire positioning were observed. By using the system the surgery duration was with 50 % shortened (p = 0.0054) compared to the conventional group. One reason might be the significant reduction of trials to achieve a central guide-wire placement in the bone (p = 0.0032). Consequently the radiation exposure for the surgeon and the patient could be shortened by reduction of radiation emission (p = 0.0014) and radiation dose (p = 0.0019). By using the imaged based guidance system a reduction of surgery duration, radiation exposure for the patient and the surgeon can be achieved. By a reduced number of trials for achieving a central guide-wire position the risk of weakening the bone structure can be minimised as well by using the system. The system seems helpful where navigation is not applicable up to now. The surgical workflow does not have to be chanced.
Replacing bone lost as a consequence of trauma or disease is a major challenge in the treatment of musculoskeletal disorders. Tissue engineering strategies seek to harness the potential of stem cells to regenerate lost or damaged tissue. Bone marrow aspirate (BMA) provides a promising autologous source of skeletal stem cells (SSCs) however, previous studies have demonstrated that the concentration of SSCs required for robust tissue regeneration is below levels present in iliac crest BMA, emphasising the need for cell enrichment strategies prior to clinical application. To develop a novel strategy to enrich skeletal stem cells (SSCs) from human BMA, clinically applicable for intra-operative orthopaedic use.Background
Aims
Skeletal stem cells (SSCs) have been used for the treatment of osteonecrosis of the femoral head to prevent subsequent collapse. In isolation SSCs do not provide structural support but an innovative case series in Southampton, UK, has used SSCs in combination with impaction bone grafting (IBG) to improve both the biological and mechanical environment and to regenerate new bone at the necrotic site. Analysis of retrieved tissue-engineered bone as part of ongoing follow-up of this translational case series.Background
Aims
Skeletal stem cells can be combined with human allograft, and impacted to produce a mechanically stable living bone composite. This strategy has been used for the treatment of femoral head avascular necrosis, and has been translated to four patients, of which three remain asymptomatic at up to three year follow-up. In one patient collapse occurred in both hips due to widely distributed and advanced AVN disease, necessitating bilateral hip arthroplasty. However this has provided the opportunity to retrieve the femoral heads and analyse human tissue engineered bone. Analysis of retrieved human tissue-engineered bone in conjunction with clinical follow-up of this translational case series.Background
Aims
Recent approaches have sought to harness the potential of stem cells to regenerate bone lost as a consequence of trauma or disease. Bone marrow aspirate (BMA) provides an autologous source of skeletal stem cells (SSCs) for such applications, however previous studies have demonstrated that the concentration of SSCs present in iliac crest BMA is below that required for robust bone regeneration. Here we present a novel acoustic-facilitated filtration strategy to concentrate BMA for SSCs, clinically applicable for intra-operative orthopaedic use. The aim of this study was to demonstrate the efficacy of this strategy in concentrating SSCs from iliac crest bone marrow, as well as femoral canal BMA from older patients. Iliac crest BMA (Lonza, Rockville, MD, USA) and femoral canal BMA was obtained with informed consent from older patients during total hip replacement. 5 to 40ml of BMA was processed via the acoustically-aided exclusion filtration process to obtain 2-8 fold volume reductions. SSC concentration and function was assessed by flow-cytometry, assays for fibroblastic colony-forming units (CFU-F) and multi-lineage differentiation along chondrogenic, osteogenic and adipogenic pathways examined. Seeding efficiency of enriched and unprocessed BMA (normalised to cell number) onto allograft was assessed. Iliac crest BMA from 15 patients was enriched for SSCs in a processing time of only 15 minutes. Femoral BMA from 15 patients in the elderly cohort was concentrated up to 5-fold with a corresponding enrichment of viable and functional SSCs, confirmed by flow cytometry and assays for CFU-F. Enhanced osteogenic (P<0.05) and chondrogenic (P<0.001) differentiation was observed using concentrated aspirate, as evidenced by biochemical assay and semi-quantitative histological analysis. Furthermore, enhanced cell seeding efficiency onto allograft was seen as an effect of SSC concentration per ml of aspirate (P<0.001), confirming the utility of this approach for application to bone regeneration. The ability to rapidly enrich BMA demonstrates potential for intra-operative application to enhance bone healing and offers immediate capacity for clinical application to treat many scenarios associated with local bone stock loss. Further in vivo analysis is ongoing prior to clinical tests.
Periprosthetic femoral fractures can occur as a complication of total hip arthroplasty and are often challenging to treat as the mechanical scenario is influenced by the presence of the metal prosthesis within the bone. This research focuses on finding the optimum fixation for transverse, Vancouver type B1 periprosthetic fractures, stabilised using locking plates and secured using screws. The aim of this study was to experimentally validate a computer model of a human femur, develop that model to represent a periprosthetic femoral fracture fixation and show how the model could be used to indicate differences between plating techniques. In the first development stage, both a laboratory model and a finite element model were developed to evaluate the mechanical behaviour of an intact composite femur under axial loading. Axial strains were recorded along the medial length of the femur in both cases and compared to provide validation for the computational model predications. The computational intact femur model was then modified to include a cemented total hip replacement, and further adapted to include a periprosthetic fracture stabilised using a locking plate, with unicortical screws above, and bicortical screws below the transverse fracture. For the intact femur case, the experimental and computational strain patterns correlated well with an average difference of 16%. Following the inclusion of the stem, there was a reduction in the strain in the region of the prosthesis reducing by an average of 45%. There was also a large increase in bulk stiffness with the introduction of the prosthesis. When the fracture and plate fixation were included, there was little difference in the proximal strain where the stem dominated, and the strains in the distal region were found to be highly sensitive to the distribution of the screws. The results of this study indicate that screw configuration is an important factor in periprosthetic fracture fixation. A laboratory model of the periprosthetic facture case is now under development to further validate the computational models and the two approaches will then be used to determine optimum fixation methods for a range of clinical scenarios.
Retrospective review of growth sparing spinal instrumentation. Medical records of 30 children with spinal deformity treated were evaluated. There were 14 male and 16 female patients at an average age of 4.9 years (1-14) at the time of presentation. These included 18 idiopathic, 11 congenital and a 14 year old with delayed growth having GH treatment. All patients underwent dual growing rod construct using hook and pedicle screw instrumentation. Extensions were carried out at approximately 6 monthly intervals. Average follow up was 4.2 years (2-8.5) with an average of 7.3(3-15) extension/exchange procedures per patient. Average immediate postoperative Cobb angle was 29(15-55) from a preoperative Cobb of 68(55-100) and this was maintained to a final mean Cobb angle of 30(15-60). Average gain in T1-S1 length was 5.7(3.5-9.8) cm. Five patients had final fusion at an average age of 15.5 years. There were no infections following primary operation. Out of 249 procedures including extensions/exchange, there were 9(4.5%) episodes of deep infection in 7 patients requiring debridement. Four patients (13%) had revisions for rod breakage/screw loosening/hook pullout/junctional kyphosis and three(10%) had prominent implants.Purpose
Methods and results
To evaluate efficacy of blood conservation strategies on transfusion requirements in adult scoliosis surgery and establish a protocol for cross matching. Retrospective review of 50 consecutive adult scoliosis patients treated using anterior only(14,28%), posterior only(19,38%) or combined(17,34%) approaches. All patients were anaesthetised by the same anaesthetist implementing a standard protocol using cell salvage, controlled hypotension and antifibrinolytics. Mean age was 24.6 years. BMI was 21.9. On an average 9.5(6-15) levels were fused, with an average duration of surgery of 284.6(130-550) minutes. Antifibrinolytics were used in 31(62%) of the patients which included Aprotinin in 21(42%) and Tranexamic acid in 10(20%). Patients on antifibrinolytics had a significantly (p<0.05) lower blood loss (530ml) as compared to other patients (672ml). Mean volume of the cell saved blood re-transfused was 693.8 ml and mean postoperative HB level dropped to 10.7 g/dl(7.7-15) from a mean preoperative of 13.3 g/dl(10-17). 7(42%) with combined approaches and 3(15.8%) with posterior only approach required blood transfusion, 4/50(8%) of which required intra while 6/50(12%) required intra and postoperative transfusion. None of the patients having anterior surgery alone required blood transfusion.Purpose
Methods and Results
Avascular necrosis (AVN) of the femoral head is a potentially debilitating disease of the hip in young adults. Impaction bone grafting (IBG) of morcellised fresh frozen allograft is used in a number of orthopaedic conditions. This study has examined the potential of skeletal stem cells (SSC) to augment the mechanical properties of impacted bone graft and we translate these findings into clinical practice. We have examined the effect of SSC density on augmentation of bone formation. An in vitro model was developed to replicate the surgical IBG process. Plain allograft was used as the control, and the SSC's seeded at a density of 5×103, 5×104 and 2×105 cells per cc of allograft for the experimental groups. All samples were cultured for 2 weeks and mechanically tested to determine shear strength using the Mohr Coulomb failure curve. The approach was translated to 3 patients with early avascular necrosis (AVN) of the femoral head. The patient's bone marrow was concentrated in theatre using a centrifugation device and the concentrated fraction of SSC's were seeded onto milled allograft. The patient's necrotic bone was drilled, curetted and replaced with impacted allograft seeded with SSC's. Osteogenic potential of concentrated and unconcentrated marrow was simultaneously compared in vitro by colony forming unit assays.AIM
STUDY DESIGN
“Increases in reconstructive orthopaedic surgery, resulting from advances in surgical practice and the ageing population, have lead to a demand for bone graft that far exceeds supply.”…Traditional bone grafting methods have been linked with a number of negative issues including increased morbidity due to secondary operation site and action as a vector for spread of disease. (Hing 2004). A solution to these insufficiencies would be the creation of a synthetic osteoinductive bone graft material. This would vastly improve bone graft surgery success rates and expedite post-op recovery times. The aim of this study was to classify then explore the dissolution rates of three experimental hydroxyapatite/silicate apatite synthetic bonegrafts in physiological solutions, (phosphate buffered saline, (PBS) +/− serum proteins, (PBS +FCS). The overall objective being to identify whether there is an explainable significant difference in ion exchange that could be behind the osteoinductive phenomena. Classification of the apatite samples, (HA, SA1 and SA2), was conducted via X-Ray diffraction, FTIR-PAS Spectroscopy and SEM with EDS analysis. A dissolution experiment of the experimental apatites was conducted in PBS and PBS + FCS solutions, over time periods of 1, 2 and 4 hours, and at 1, 2, 4 and 8 days, with repeat measures.Background, Context and Motivation
Methods Used
Spinal cord injury following trauma is initially dealt with by acute hospitals. The early management including stabilization is usually performed by these centres. This is followed by onward referral to one of the Regional Spinal Injury Units. There is concern of both sides of the fence regarding mobilization following spinal cord injury. The acute hospitals want to avoid the problems of prolonged recumbency and the Regional Spinal Injury Units wish to avoid the problems of early aggressive mobilization. Therefore, we set out to discover if there was a standard approach to mobilising these patients following surgical stabilization, because of the oversubscribed resources of the spinal injury units and the wish to start mobilizing the injured as soon as possible. A comparative audit of the Regional Spinal Injury Units in the UK and North American Units. Regional Spinal Injury Units in United Kingdom and North America Clear Management Plan Mobilisation Schedule We had replies from all Regional Spinal Injury Units in the UK and from seven in North America. The Regional Spinal Injury Units all had differing approaches. Only a few were able to convey a clear management plan and mobilization schedule. Whereas the North American Units provided a ‘mobilize as able’ plan in all cases. The North American Units had a ‘mobilize as able’ policy, whereas the UK units had a mixed approach. A coherent collaboration between the spinal surgeons stabilizing these injuries and the spinal injury units providing rehabilitation would improve patient management.
To assess adverse events related to XLIF approach in lumbar degenerative disease. Recently novel minimally disruptive spine procedure eXtreme lateral Interbody Fusion i.e XLIF has been developed. It is 90 (off the midline true lateral approach, which allows large graft placement, excellent disc height restoration and indirect decompression at the stenotic motion segment. We describe our experience in 28 patients. Retrospective review of records of patients undergoing surgery between July 2008- Jan 2010. Presenting complaints, number of levels performed and complications (medical, approach, or implant related) were audited. Results: 28 patients (17 female: 11 male) with median age of 47 yrs, range (38-75) formed the study group. Average stay was 4 days. All patients had MRI of lumbar spine. 2/3 rd patients had low back pain as their presenting complaint. All patients had nerve monitoring through out the procedure. There were 12 single, 15 two level and 1 three level cases (total 45 levels). 14/28 patients underwent plating at the same time. EBL was 100ml. There were 11/45 adverse events (24.4%). 6 events were approach, 4 were implant bone interface and 1 medical related. Major complication occurred in 1 patient (3.6%). 2/3 rd of patients, were better after the surgery. Almost negligible blood loss, low infection rate and short average stay seemed to work in favour of this approach. Complications are there as (with any new procedure) our results indicate, but these are manageable and less common with this technique. This did not require Ethics approval and there was no grant or industry support for the above.
To assess the accuracy of posterior and anterolateral methods of injection into the subacromial space (SAS) of the shoulder. Ethical approval was obtained and 50 patients (23 women and 27 men) with mean age of 64.5 years (42-87 years) and clinical diagnosis of subacromial impingement were recruited. Patients with old or recent shoulder fracture, bleeding disorders, and allergy to iodine were excluded. All injections were given by the consultant or an experienced registrar after obtaining informed consent. Patients were randomised into posterior and anterolateral groups and the method of injection was revealed by opening sealed envelopes just before the injection. A combination of 3mls 0.5% bupivacaine and 2mls of radiographic dye (Niopam) was injected in the subacromial space (SAS) using either anterolateral (n-22) and posterior approaches (28). AP and lateral radiographs of shoulder were taken after injection and were reported by a Consultant Radiologist blinded to the method of injection. Visual analogue scale (VAS) and Constant-Murley shoulder score was used to assess pain and function respectively. Both scores were determined before and 30 minutes after the injection.Aims
Patients and methods
