Superior teamwork in the operating theatre is associated with improved technical performance and clinical outcomes. Yet modern rota patterns, workforce shortages, and increasing complexity of surgery, means that there is less familiarity between staff and the required choreography. Immersive Virtual Reality (iVR) can successfully train surgical staff individually, however iVR team training has yet to be investigated. We aimed to design a multiplayer iVR platform for anterior approach total hip arthroplasty (AA-THA) and assess if multiplayer iVR training was superior to single player training for acquisition of both technical and non-technical skills.

An iVR platform with choreographed roles for the surgeon and scrub nurse was developed using Cognitive Task Analysis. Forty participants were randomised to individual or team iVR training. Individually- trained participants practiced alongside virtual avatar counterparts, whilst teams trained live in pairs. Both groups underwent five iVR training sessions over 6-weeks. Subsequently, they underwent a real-life assessment in which they performed AA-THA on a high-fidelity model with real equipment in a simulated theatre. Teams performed together and individually trained participants were randomly paired up. Videos were marked by two blinded assessors recording the NOTSS, NOTECHS II and SPLINTS scores - validated technical and non-technical scores assessing surgeon and scrub nurse skills. Secondary outcomes were procedure time and number of technical errors.

Teams outperformed individually trained participants for non-technical skills in the real-world assessment (NOTSS 13.1 ± 1.5 vs 10.6 ± 1.6, p =0.002, NOTECHS-II score 51.7 ± 5.5 vs 42.3 ± 5.6, p=0.001 and SPLINTS 10 ± 1.2 vs 7.9 ± 1.6, p = 0.004). They completed the assessment 28.1% faster (27.2 minutes ± 5.5 vs 41.8 ±8.9, p<0.001), and made fewer than half the number of technical errors (10.4 ± 6.1 vs 22.6 ± 5.4, p<0.001).

Multiplayer training leads to faster surgery with fewer technical errors and the development of superior non-technical skills for anterior approach total hip arthroplasty. The convention of surgeons and nurses training separately, but undertaking real complex surgery together, can be supplanted by team training, delivered through immersive virtual reality.

Current evidence suggests that superior surgical team performance is linked to fewer intra-operative errors, reductions in mortality and even improved patient outcomes. Virtual reality has demonstrated excellent efficacy in training surgeons and scrub nurses individually, however its impact on training teams is currently unknown. This study aimed to assess if training together (scrub nurse and surgeon) in an innovative multiplayer virtual reality program was superior to single player training for novices learning anterior approach total hip arthroplasty (AA-THA).

40 participants (20 novice surgeons (CT1-ST3 level) and 20 novice scrub nurses) were enrolled in this study and randomised to individual or team virtual reality training. Individually-trained participants played with virtual avatar counterparts, whilst teams trained live in pairs (surgeon and scrub nurse). Both groups underwent 5 VR training sessions over 6 weeks. Subsequently, they underwent a real-life assessment in which they performed AA-THA on a high-fidelity model with real equipment in a simulated operating theatre. Teams performed together and individually-trained participants were randomly paired up with a solo player of the opposite role. Videos of the assessment were marked by two blinded expert assessors. The primary outcome was team performance as graded by the validated NOTECHs II score. Secondary outcomes were procedure time and number of technical errors from an expert pre-defined protocol.

Teams outperformed individually-trained participants for non-technical skills in the real-world assessment (NOTECHS-II score 50.3 ± 6.04 vs 43.90 ± 5.90, p=0.0275). They completed the assessment 28.1% faster (31.22 minutes ±2.02 vs 43.43 ±2.71, p=0.01), and made close to half the number of technical errors when compared to the individual group (12.9 ± 8.3 vs 25.6 ± 6.1, p=0.001).

Multiplayer, team training appears to lead to faster surgery with fewer technical errors and the development of superior non-technical skills.

Evidence supporting the use of virtual reality (VR) training in orthopaedic procedures is rapidly growing. However, the impact of the timing of delivery of this training is yet to be tested. We aimed to investigate whether spaced VR training is more effective than massed VR training.

24 medical students with no hip arthroplasty experience were randomised to learning the direct anterior approach total hip arthroplasty using the same VR simulation, training either once-weekly or once-daily for four sessions. Participants underwent a baseline physical world assessment on a saw bone pelvis. The VR program recorded procedural errors, time, assistive prompts required and hand path length across four sessions. The VR and physical world assessments were repeated at one-week, one-month, and 3 months after the last training session.

Baseline characteristics between the groups were comparable (p > 0.05). The daily group demonstrated faster skills acquisition, reducing the median ± IQR number of procedural errors from 68 ± 67.05 (session one) to 7 ± 9.75 (session four), compared to the weekly group's improvement from 63 ± 27 (session one) to 13 ± 15.75 (session four), p < 0.001. The weekly group error count plateaued remaining at 14 ± 6.75 at one-week, 16.50 ± 16.25 at one-month and 26.45 ± 22 at 3-months, p < 0.05. However, the daily group showed poorer retention with error counts rising to 16 ± 12.25 at one-week, 17.50 ± 23 at one-month and 41.45 ± 26 at 3-months, p<0.01. A similar effect was noted for the number of assistive prompts required, procedural time and hand path length. In the real-world assessment, both groups significantly improved their acetabular component positioning accuracy, and these improvements were equally maintained (p<0.01).

Daily VR training facilitates faster skills acquisition; however weekly practice has superior skills retention.

Abstract

Abstract

Abstract

Hip fracture principally affects the frailest in society, many of whom are care dependent, and are disproportionately at risk of contracting COVID-19. We examined the impact of COVID-19 infection on hip fracture mortality in England.

We conducted a cohort study of patients with hip fracture recorded in the National Hip Fracture Database between 1st February 2019 and 31st October 2020, in England. Data were linked to Hospital Episode Statistics to quantify patient characteristics and comorbidities, Office for National Statistics mortality data, and Public Health England's SARS-CoV-2 testing results. Multivariable Cox regression examined determinants of 90-day mortality. Excess mortality attributable to COVID-19 was quantified using Quasi-Poisson models.

Analysis of 102,900 hip fractures (42,630 occurring during the pandemic) revealed that amongst those with COVID-19 infection at presentation (n=1,120) there was a doubling of 90-day mortality; hazard ratio (HR) 2.05 (95%CI 1.86–2.26), while for infections arising between 8–30 days after presentation (n=1,644) the figure was even higher at 2.52 (2.32–2.73). Malnutrition [1.44 (1.19–1.75)] and non-operative treatment [2.89 (2.16–3.86)] were the only modifiable risk factors for death in COVID-19 positive patients. Patients with previous COVID-19 initially had better survival compared to those who contracted COVID-19 around the time of their hip fracture; however, survival rapidly declined and by 365 days the combination of hip fracture and COVID-19 infection was associated with a 50% mortality rate. Between 1st January and 30th June 2020, 1,273 (99.7%CI 1,077–1,465) excess deaths occurred within 90 days of hip fracture, representing an excess mortality of 23% (20%–26%), with most deaths occurring within 30 days.

COVID-19 infection more than doubled early hip fracture mortality; the first 30-days after injury were most critical, suggesting that targeted interventions in this period may have most benefit in improving survival.

Aims

Golf is a popular pursuit among those requiring total hip arthroplasty (THA). The aim of this study was to determine if participating in golf is associated with greater functional outcomes, satisfaction, or improvement in quality of life (QoL) compared to non-golfers.

Abstract

Abstract

Abstract

The management of primary malignant bone tumors with metastatic disease at presentation remains a challenge. While surgical resection has been shown to improve overall survival among patients with non-metastatic malignant bone tumors, current evidence regarding the utility of surgery in improving overall survival in metastatic patients remains limited.

The 2004–2016 National Cancer Database (NCDB) was queried using International Classification of Diseases 3rd Edition (ICD-O-3) topographical codes to identify patients with primary malignant bone tumors of the extremities (C40.0-C40.3, C40.8 and C40.9) and/or pelvis (C41.4). Patients with malignant bone tumors of the axial skeleton (head/skull, trunk and spinal column) were excluded, as these cases are not routinely encountered and/or managed by orthopaedic oncologists. Histological codes were used to categorize the tumors into the following groups - osteosarcomas, chondrosarcomas, and Ewing sarcomas. Patients who were classified as stage I, II or III, based on American Joint Commission of Cancer (AJCC) guidelines, were excluded. Only patients with metastatic disease at presentation were included in the final study sample. The study sample was divided into two distinct groups – those who underwent surgical resection of the primary tumors vs. those who did not receive any surgery of the primary tumor. Kaplan-Meier survival analysis was used to report unadjusted 5-year overall survival rates between patients who underwent surgical resection of the primary tumor, compared to those who did not. Multi-variate Cox regression analyses were used to assess whether undergoing surgical resection of the primary tumor was associated with improved overall survival, after controlling for differences in baseline demographics, tumor characteristics (grade, location, histological type and tumor size), and treatment patterns (underwent metastatectomy of distal and/or regional sites, positive vs. negative surgical margins, use of radiation therapy and/or chemotherapy). Additional sensitivity analyses, stratified by histologic type for osteosarcomas, chondrosarcomas and Ewing sarcomas, were used to assess prognostic factors for overall survival.

A total of 2,288 primary malignant bone tumors (1,121 osteosarcomas, 345 chondrosarcomas, and 822 Ewing sarcomas) with metastatic disease at presentation were included – out of which 1,066 (46.0%) underwent a surgical resection of the primary site. Overall 5-year survival rates, on unadjusted Kaplan-Meier log-rank analysis, were significantly better for individuals who underwent surgical resection vs. those who did not receive any surgery (31.7% vs. 17.3%; p<0.001). After controlling for differences in baseline demographics, tumor characteristics and treatment patterns, undergoing surgical resection of primary site was associated with a reduced overall mortality (HR 0.42 [95% CI 0.36–0.49]; p<0.001). Undergoing metastectomy (HR 0.92 [95% CI 0.81–1.05]; p=0.235) was not associated with a significant improvement in overall survival. On stratified analysis, radiation therapy was associated with improved overall survival for Ewing Sarcoma (HR 0.71 [95% CI 0.57–0.88]; p=0.002), but not for osteosarcoma (HR 1.14 [95% CI 0.91–1.43]; p=0.643) or chondrosarcoma (HR 1.08 [95 % CI 0.78–1.50]; p=0.643). Chemotherapy was associated with improved overall survival for osteosarcoma (HR 0.50 [95% CI 0.39–0.64]; p<0.001) and chondrosarcoma (HR 0.62 [95% CI 0.45–0.85]; p=0.003), but not Ewing sarcoma (HR 0.79 [95% CI 0.46–1.35]; p=0.385).

Surgical resection of the primary site significantly improves overall survival for primary malignant bone tumors with metastatic disease at presentation. Physicians should strongly consider surgical resection of the primary tumor, with adjunct systemic and/or radiation therapy (dependent on tumor histology), in patients presenting with metastatic disease at presentation.

Acute metatarsal fractures are a common extremity injury. While surgery may be recommended to reduce the risk of nonunion or symptomatic malunion, most fractures are treated with nonoperative management. However, there is significant variability between practitioners with no consensus among clinicians on the most effective nonoperative protocol, despite how common the form of treatment. This systematic review identified published conservative treatment modalities for acute metatarsal fractures and compares their non-union rate, chronic pain, and length of recovery, with the objective of identifying a best-practices algorithm.

Searches of CINAHL, EMBASE, MEDLINE, and CENTRAL identified clinical studies, level IV or greater in LOE, addressing non-operative management strategies for metatarsal fractures. Two reviewers independently screened the titles, abstracts, and full texts, extracting data from eligible studies. Reported outcome measures and complications were descriptively analyzed. Studies were excluded if a rehabilitation program outlining length of immobilization, weight-bearing and/or strengthening approaches was not reported.

A total of 12 studies (8 RCTs and 4 PCs), from the 2411 studies that were eligible for title screening, satisfied inclusion criteria. They comprised a total of 610 patients with acute metatarsal fractures, with a mean age of 40.2 years (range, 15 – 82). There were 6 studies that investigated avulsion fractures, 2 studies on true Jones fractures, and 4 studies with mixed fracture types. Studies assessed a variety of treatment modalities including: WB and NWB casts, elasticated support bandages, hard-sole shoes, plaster slippers, metatarsal shoe casts, and air cast boots. Most studies investigated the outcomes of NWB casts and elasticated support bandages.

The NWB short leg cast had no reported non-unions, delayed-unions, or refractures for avulsion fractures. In true Jones fractures, there was an average non-union rate of 23.6% (range, 5.6 – 27.8%), delayed-union rate of 11.8% (range, 5.6 – 18.8%), and refracture rate of 3% (range, 0 – 5.6%). Overall, the average AOFAS score was 87.2 (range, 84 – 91.7) and the average VAS score was 83.7 (range, 75 – 93).

The elasticated support bandage had an average non-union rate of 3.4% (range, 0 – 12%), and delayed-union rate of 3.8% for acute avulsion fractures, with no reported refractures. No included study arm investigated outcomes of elasticated support bandages for the true Jones fracture. The average AOFAS score for elasticated support bandages was 93.5 (range, 90 – 100). The average VAS score was 88.9 (range, 90 – 100).

Most acute metatarsal fractures heal well, with good-to-excellent functional outcomes and moderate-to-high patient satisfaction. Conservative strategies for avulsion fractures are highly successful and based on this data the authors recommend patients undergo a schedule that involves 3 – 4 weeks in an elasticated support bandage, short leg cast, or equivalent, and WB thereafter as tolerated, with return-to-activity after clinical union. Despite poorer conservative outcomes for true Jones fractures, patients should undergo 8 weeks in a NWB short leg cast, followed by a walking cast or hard-sole shoe for an additional 4 – 6 weeks, or until clinical union. However, surgical consultation is recommended.

Aims

It has been generally accepted that open fractures require early skeletal stabilization and soft-tissue reconstruction. Traditionally, a standard gauze dressing was applied to open wounds. There has been a recent shift in this paradigm towards negative pressure wound therapy (NPWT). The aim of this study was to compare the clinical outcomes in patients with open tibial fractures receiving standard dressing versus NPWT.

Deep infection occurs in 2–4% of lower limb arthroplasty resulting in increasing cost, co-morbidity and challenging revision arthroplasty surgery. Identifying the potential sources of infection helps reduce infection rates. The aim of our study is to identify the impact and potential for contamination of our hands and gowns whilst scrubbing using SSHS.

A colony-forming unit (CFU) is a pathogenic particle of 0.5 micrometers to 5 micrometers. Concurrent particle counts and blood agar exposure settle plates for 3 subjects and 1 alcohol cleaned mannequin; testing a standard arthroplasty hood, a SSHS with and without the fan on for a 2 minute exposure to represent scrubbing time. Microbiological plates were incubated using a standard protocol by our local microbiology department.

All SSHS were positive for gram-positive cocci with a mean colony count of 410cfu/m². Comparing background counts for laminar flow (mean 0.7 particle/m³; 95% CI 0–1.4) versus scrub areas (mean 131.5 particle/m3; 95% CI 123.5–137.9; p=0.0003), however neither grew any CFU's with a 2-minute exposure. For the mannequin, the only significant result was with the fan on with a 1.5× increase in the particle count (p=0.042) and a correlating positive organism (13CFU/m²). With human subjects, however, the particle count increased by 3.75× the background count with the fan on (total p=0.004, CFU p=0.047) and all had positive cultures, mean 36 CFU/m². There were no positive cultures with the standard arthroplasty hood or the SSHS with no fan on. If repeated in laminar flow, there was only a statistically significant increase with the fan on (p=0.049), but with negative cultures following a 2-minute exposure.

Sterile gloves and gowns can be contaminated when scrubbing with the SSHS fan on. We recommend having the fan switched off when scrubbing until the hood and gown is in place, ideally in a laminar flow environment.

Aim

This study aimed to identify risk factors for development of deep periprosthetic joint infection (PJI) in patients following surgical treatment of neck of femur fracture.

Over the last 10 years atypical femoral fractures (AFFs) have become recognised as a complication of standard-dose bisphosphonate use. In 2014 the American Society for Bone and Mineral Research published updated diagnostic criteria for AFF. We undertook a 5-year retrospective analysis of the trauma admission database at a major trauma centre to establish the incidence of this problem in our patient population. Initial screening was performed using keyword-matching methodology to produce a shortlist of patients with low-energy femoral fractures. These patients’ case notes, radiographs, and electronic discharge summaries were reviewed to discriminate AFF from typical femoral fractures. Initial filtering identified a total of 112 low energy femoral fractures. Of these, 12 were confirmed as AFFs. 58% (7/12) of the AFF group were on bisphosphonates compared to 15% (15/100) of the typical femoral fracture group. This finding was statistically significant (p = 0.0004). These data show that there is a link between bisphosphonate use and AFF. However, a causal relationship cannot be inferred. The incidence of AFF in our study is broadly in line with the published data.

Introduction:

Non-invasive extendible endoprostheses (NIEE) were primarily developed for salvage after musculo-skeletal tumour surgery in the immature skeleton. However, they may also have a unique application to manage complex limb reconstruction in revision surgery to address limb-length inequality in the mature skeleton. The aim of this study is to present the minimum 2 –year results of using non-invasive extendible endoprostheses for complex lower limb reconstruction.

Aim:

To review the use of traction x-rays under anaesthesia in Late Onset Scoliosis to correlate traction x-ray flexibility and postoperative correction using posterior nonsegmental all pedicle screw constructs.

Introduction:

Pigmented Villonodular Synovitis (PVNS) is a rare inflammatory disorder of the synovium, bursa and tendon sheath. The objective of this study was to evaluate the long-term outcomes and morbidity associated with operative management of PVNS of the hand.

Introduction:

Endoprosthetic replacement of the proximal femur is common in the management of bone tumours and failed revision arthroplasty. This study seeks to compare those patients undergoing acetabular resurfacing at the time of femoral replacement with those patients where the native acetabulum was preserved.

Introduction:

Distal femoral replacement is recognised as the optimum treatment for malignant distal femoral tumours. Aseptic loosening is known to be a major cause for failure in these implants. Studies have indicated that the HA coated collar promotes osteointegration and bony in growth. This study compares long term aseptic loosening in implants with HA coated collars to those without in the immature skeleton.

Introduction:

Instability and synovitis of the lesser metatarsalphalangeal (MTP) joints is a significant cause of forefoot pain. Plantar plate imaging traditionally has been through MRI and fluoroscopic arthrography. We have described ultrasound arthrography as a less resource-intensive technique without radiation exposure. We report the correlation between ultrasound arthographic and surgical findings.

In patients with a tumour affecting the distal ulna it is difficult to preserve the function of the wrist following extensive local resection. We report the outcome of 12 patients (nine female, three male) who underwent excision of the distal ulna without local soft-tissue reconstruction. In six patients, an aggressive benign tumour was present and six had a malignant tumour. At a mean follow-up of 64 months (15 to 132) the mean Musculoskeletal Tumour score was 64% (40% to 93%) and the mean DASH score was 35 (10 to 80). The radiological appearances were satisfactory in most patients. Local recurrence occurred in one patient with benign disease and two with malignant disease. The functional outcome was thus satisfactory at a mean follow-up in excess of five years, with a relatively low rate of complications. The authors conclude that complex reconstructive soft-tissue procedures may not be needed in these patients.

Cite this article: Bone Joint J 2014;96-B:1392–5.

INTRODUCTION

Leg length discrepancy following total hip arthroplasty (THA) can be functionally disabling for affected patients and can lead on to litigation issues. Assessment of limb length discrepancy during THA using traditional methods has been shown to produce inconsistent results. The aim of our study was to compare the accuracy of navigated vs. non navigated techniques in limb length restoration in THA.

Statement of purpose

Circular frames treatment for limb reconstruction involves repeated follow up visits, and a substantial number of these appointments are for pin site review only, and incur a significant cost to the NHS. We advocate ‘Telemedicine’ as a logistically and economically viable option for routine post-operative review of pin-sites.

Background

Collagenase represents a novel non-surgical treatment for Dupuytrens disease. Xiapex (Injectable collagenase, Pfizer pharmaceuticals) was recently approved by the MHRA for clinical use. The main objective of this study was to assess the proportion of patients with Dupuytrens disease that are suitable for treatment with collagenase and the financial implications of its introduction.

Introduction

Renal homeostasis has been shown to influence mortality after hip fractures; this is true for patients with both chronic kidney disease, and those who develop acute renal dysfunction after surgery. We have examined the influence of impaired renal function upon mortality and length of stay. We investigated this relationship through accurate mathematical modelling of available biochemistry data on a cohort of hip fracture patients.

Purpose

We report our surgical management of a series of primary and metastatic tumours of the lumbosacral junction, highlighting different methods of fixation, outcome and complications.

Purpose

To report a retrospective study of 103 cases of primary spinal infection, the largest ever such series from the UK, analysing presenting symptoms, investigations, bacteriology and the results of treatment.

Introduction: Lesser metatarsophalangeal joint (MTPJ) instability is a common cause of forefoot pain. Instability is probably caused by tears of the plantar plate and collateral ligaments. We prospectively compared MRI and ultrasound with and without arthrography in the assessment of patients with MTPJ instability.

Materials and Methods: MTPJ instability was diagnosed by the draw test. Nineteen patients underwent imaging with consent. One musculoskeletal radiologist performed MRI arthrography and a different musculoskeletal radiologist performed ultrasonography supplemented with arthrography. Each radiologist reported his own study, blinded to the results of the other modality. Where possible, the radiological diagnosis was evaluated at surgery.

Results: MRI identified four full thickness plantar plate tears. In five studies no contrast was seen in the MTP joint and in 10 contrast was contained within the joint.

Ultrasound identified six full thickness plantar plate tears as hypoechoic zones that extended through the whole thickness of the plate. Eleven studies showed partial thickness tears. Two studies showed thinning of the plate. Ultrasound arthrography identified seven full thickness tears by extravasation of injected fluid into the flexor tendon sheath. Eleven studies showed partial thickness tears and one was normal. Ultrasound and ultrasound arthrography agreed in 14/19 patients. MRI agreed with ultrasound on 3 of 6 full thickness tears and with ultrasound arthrography in 4 of 6 full thickness tears. MRI gave additional information about the articular surfaces in four patients. Surgical comparison was available in 11/19 patients. Ultrasound with and without arthrography correctly predicted four partial thickness tears. Ultrasound arthrography correctly predicted 6/7 full thickness tears, MRI 3/7 and ultrasound 3/7.

Discussion: Ultrasound with arthrography appears the best modality to distinguish between partial and full-thickness tears. It is cheaper, simpler and can be performed in the outpatient setting. Larger studies with surgical confirmation are required to assess its value more precisely.

Introduction: Nonunion is a relatively common complication seen in orthopaedic practice. The treatment of nonunion has traditionally been revision fixation with autogenic bone grafting. Here we present our results of nonunion treatment using Osteogenic Protein -1 (OP1) and allograft paste.

Material and Methods: Forty Eight Patients with resistant nonunion including atropic, hypertrophic and infected nonunion were treated with a composite of osteogenic protein-1 and allograft paste. The series consisted of 28 males and twenty females. Average age was 54 years. The average duration of preoperative symptoms was 26 months (range 4 to 52). 28 of 48 patients had an average of three prior failed surgical attempts at union (range 1 to 6). There were thirty seven atrophic, four hypertrophic and seven infected nonunions (bone transport docking site nonunion).18 patients in the series had previous autogenic cancellous bone grafting to the fracture site for attempted union. 39 patients had revision internal fixation with application of OP-1 and allograft paste to the nonunion site. Average healing time was 6.5 months (Range 3.5–19). Three patients in this series had OP-1 insertion twice, one patient simultaneously had autogenic cancellous bone grafting with OP-1.

Results: Average follow-up was 16 months (range 4 to 38). Functional and radiological outcome was excellent in 33 patients, good in five patients and fair in three. 3 cases were ongoing. Three patients went on to non-union requiring revision surgery and are under review. One patient died during follow-up.

Conclusion: Results in our series indicate OP-1 (BMP-7) implanted with Opteform allograft paste are as effective as autogenic cancellous bone grafting in treating resistant bone nonunions.

Introduction: The Taylor spatial frame (TSF) (Smith & Nephew) is a hexapod ring fixator that utilises the Ilizarov principles. The TSFs design is based on the Stewart-Gough platform, the use of which was originally described in mechanical engineering. Due to its unique design the TSF is extremely versatile in limb reconstruction surgery, allowing six degrees of freedom bone fragment manipulation with a high degree of precision that is aided by correction planning software.

Methods: Between October 2003 and December 2008 66 consecutive patients were treated using the TSF by a single consultant surgeon. Median patient age was 45 (range 20–69). The original pathology included 18 mal-unions, 13 acute fractures, 10 medial compartment osteoarthritis (OA) of the knee with varus deformity, 8 infected nonunions, 7 limb length discrepancies, 5 nonunions, 3 ankle OA, 3 post traumatic posterolateral corner of the knee instability, 1 multiple epiphyseal dysplasia, 1 lateral compartment OA of the knee with valgus deformity, 1 deformity secondary to Polio. There were 10 ankles, 19 knees (1 femur, 18 tibiae) and 37 tibiae.

Results: The procedures performed were 16 high tibial osteotomies, 2 frame assisted platings, 8 bone transports, 32 deformity corrections, 14 Ankle arthrodesis (9 primary, 5 revision after nonunion), 9 limb lengthening and 1 derotation. The median bone transport distance and lengthening achieved is reported.

The median time spent in the frame was 21 weeks (range 9–81), including 8 patients who required 2 frames to complete their treatment.

54 cases had a satisfactory outcome in terms of union and deformity correction using only the TSF, 5 cases were ongoing. Complications included 1 below knee amputation, 2 docking site nonunions requiring ORIF, 2 nonunions after ankle arthrodesis requiring T2 nails. 2 frames were removed due to compliance issues. 2 patients developed deformity requiring Tendo-achilles lengthening. There were 2 DVTs and 2 non-fatal PEs. 1 patient suffered a fracture at a femoral pin-site after TSF removal which was treated with external fixation. The median Otterburn grade of pin-site infection was 2 (range 0–4).

Conclusion: The Taylor spatial frame was used successfully in several different pathologies ranging from acute trauma to chronic deformity. The TSF provides the surgeon with a reliable treatment strategy that is both versatile and accurate.

Introduction: Abnormal hip morphology, seen with conditions such as slipped capital femoral epiphyses and femoral head necrosis, can lead to repetitive contact between the femoral neck and the acetabular rim. Impingement is a significant cause of hip pain in young adults and may be a mechanism for the development of early osteoarthritis. The senior surgeon has modified a technique to debride the pathology responsible for femoroacetabular impingement through a mini anterior approach, obviating the need to dislocate the hip. We describe this technique and present early clinical outcomes.

Method: Between Jan 2006 and June 2008, ‘notchplasty’ for the surgical treatment of femoroacetabular impingement was performed by the senior author (AHN) or directly under his supervision in 38 hips. There were 17 male patients and 21 female patients with an average age of 31 years. Patients have been followed according to a prospective protocol with Oxford and Iowa hip scores obtained pre-operatively, at 3 months and at 1 year.

Results: This study is still in progress. Twenty nine patients have had 3 month follow up and 13 of these have now been followed up to one year. Four patients are still less than 3 months post op. Data was unobtainable for 5 patients. 1 patient was excluded from the study.

The overall Oxford hip score improved significantly from a mean pre-operative value of 35 to a mean post operative value of 22.9 at 3 months (p< 0.001).

The mean score at 1 year increased slightly to 27.3 points but this remains lower than the pre operative average.

We report no cases of osteonecrosis. One patient has since been scheduled to undergo resurfacing arthroplasty.

Conclusions: The technique described is a new method for managing these patients whilst avoiding the pit-falls of current operative methods. The method avoids detaching the straight head of rectus, thereby tremendously improving postoperative mobilisation. However, the long term benefit of debridement of the head-neck junction for Cam-type femoroacetabular impingement remains to be seen.

Introduction: The treatment of isolated medial compartment osteoarthritis (OA) in the young or physically active patient is a challenging problem for the orthopaedic surgeon.

The rationale for high tibial osteotomy (HTO) in medial compartment OA with varus deformity is to correct varus malalignment and to redistribute load to the non-diseased lateral compartment of the knee. Here we present our early to mid-term clinical and radiological findings.

Methods: Between October 2005 and April 2007 9 patients underwent HTO and TSF application. Pre-operative OA grade was recorded using the Ahlbäck classification. Radiographs were used to calculate the pre and post operative measurements for the tibiofemoral angle, the mechanical axis deviation and the tibial slope. Correction planning was carried out using the Spatialframe software package. All operations were performed by a single experienced consultant orthopaedic surgeon specialising in Ilizarov and limb reconstruction surgery. Pre and post-operative Oxford knee scores were collected for each patient.

Results: Median follow-up was 19 months (range 15–35). Median age at operation was 49 years (range 37–59). On preoperative radiographic examination eight knees were Ahlbäck grade 1 and one knee was Ahlbäck grade 2. The median time spent in the frame was 18 weeks (range 12–37). The median total angle of correction according to correction program given was 14 degrees (range 10–22) and the median duration of correction was 18 days (range 14–36) with 6 patients requiring an additional correction program.

2 patients subsequently underwent matrix induced autologous chondrocyte implant (MACI) for osteochondral defects.

In the primary OA group we found an improvement in mean Oxford knee score after HTO from 28.3 to 37.8/48 post-operatively. 1 patient was non-compliant with the correction and required a total knee replacement (TKR) for continued pain at 36 weeks post frame removal. 1 patient required fibular osteotomy during their correction.

6 (67%) of the 9 patients had a documented pin site infection. The median Otterburn grade was 3 (range 0–4). There were no cases of chronic bone infection.

Conclusions: High tibial osteotomy performed with the Taylor spatial frame presents a viable treatment option in active patients with early medial compartment OA. With TKR as an end point the survival rate of HTO for treatment of OA was 88.9% at a median of 19 months follow-up. Our results also indicate successful use of the technique in combination with MACI.

Background: Numerous researchers have documented posterior comminution to confer an increased incidence of non-union and avascular necrosis after internal fixation of both displaced and undisplaced intracpasular hip fractures. This prospective study of 1247 patients questions this association and shows that comminution does not cause a statistically significant increase in these complications of fracture healing.

Methods: Twelve hundred and forty-seven patients with 1247 intracapsular hip fractures (568 undisplaced and 679 displaced fractures) were treated with open reduction and internal fixation. All these had preoperative radiographs, which were evaluated for posterior comminution. All of them were followed up post-operatively for clinical and radiographic evidence of non-union and avascular necrosis. The incidence of complications in comminuted versus non-comminuted fractures was calculated in both undisplaced and displaced groups. These rates were then compared for statistical significance (p value =0.05).

Results: The undisplaced cases (n=568) comprised 557 non-comminuted and 11 comminuted fractures. The complication rates were 10.9% and 18.2% respectively. The difference was not significant, with a p value of 0.38. Displaced fractures (n=679) consisted of 588 non-comminuted and 91 comminuted cases. In this group, complication rates were 33% and 35% respectively, with a p value of 0.82.

Conclusions: For the 1247 patients studied, there was no association between the observation of comminution of the fracture on the pre-operative x-rays and the later development of fracture healing complications.

A neck of femur fracture is known to be a high risk factor for the development of pressure sores with an associated morbidity, mortality and cost. We have attempted to identify risk factors in these patients for the development of pressure sores by analysing prospectively collected data of 4654 consecutive patients (1003 males/3473 females). 3.8% developed pressure sores in the sacral, buttock or heel areas.

Patients factors that increased the risk of pressure sores were increased age (82.1 years versus 76.6 years), lower mental test score (4.65 versus 5.76), diabetes mellitus (pressure sore incidence 10.4%), higher ASA score (3.0 versus 2.7) and lower admission haemoglobin concentration (120gms versus 124gms). Those patients with an extracapsular fracture were more likely to develop pressure sores compared to patients with an intracapsular fracture (4.5% versus 3.1%). Being male was not a risk factor.

While the time interval between fall and admission was not significant, the time interval between admission and surgery was found to be an extremely significant risk factor. A fall in blood pressure during surgery (5.6%) was found to increase risk. Patients who underwent a dynamic hip screw were more likely to develop pressure sores (incidence 4.7%). Patients with an intracapsular fracture treated with internal fixation were less likely to develop pressure sores in comparison to those fractures treated with a hemiarthroplasty or a sliding hip screw (2.0% versus 4.7 versus 4.4%). No relationship was seen related to length of surgery or type of anaesthesia. Our incidence of pressure sores is lower than previously reported (30%). Whilst determining factors that increase the risk of pressure sores may not be sufficiently reliable to be used for the individual patient, taking appropriate preventative measures can reduce the incidence, particularly with reference to (optimising the patient pre-operatively and) reducing delays to surgery.

Hip fractures are one of the leading causes of morbidity in the elderly population. A large reduction in morbidity can be achieved if these individuals can have definitive treatment rapidly. However, this is not always achievable to a multi factorial host of contributing factors. Therefore, to enable us to understand some aspect of why these delays, if any occur, the following study was undertaken.

The purpose of the study is to relate the place at which the patient fell, to the time of day for admission to casualty. This will enable us to ascertain whether there is a relationship between the location of injury and the time taken to admission into hospital; if there is such a correlation, then it will enable us to identify factors which will expedite an individuals attendance to hospital.

Designs: Retrospective analysis of prospectively collected data for 5273 consecutive admission to one centre with a confirmed proximal femoral fracture from January 1989 to November 2006.

Setting: Peterborough District Hospital

Results: Individuals who sustained an injury inside their own home living alone were more likely to suffer a delay in attendance to the hospital with a fracture (Median 8 hours), compared to individuals who live in there own home living with one or more individual (Median 3 hours) or those who fell indoors at other locations (Median 5 hours) or outside (Median 2 hours) were their falls were witnessed. Also it was noticed that patients living in there own homes fell during the early hours of the day, while patients who had a fall outside fell mainly during ‘working hours’ where as patients in hospital mainly had a fall during night time or mid day.

Conclusion: There is a quantifiable correlation demonstrated between place of injury and the delay in attendance to hospital.

Loss of blood is inevitable during knee replacement surgery, sometimes requiring transfusion. Allogenic blood leads to a risk of disease transmission and immunological reaction. There are various practices used. There is still a risk of bacterial transmission with stored blood and haemolytic transfusion reactions can still occur. Data was collected between 1998 and 2006. There was data on transfusion in 1532 patients undergoing primary knee replacements. There were 1375 unilateral TKRs and 157 bilateral TKRs. After reducing the bilateral cases to one record per patient, it was agreed to restrict the main analysis to 1532 patients. Data was collected prospectively at a pre-admission clinic 3 weeks prior to surgery. Haemoglobin was checked and body demographics including BMI were obtained. Each patient also had a knee score assessed. All patients received a LMWH pre-op until discharge. A tourniquet was used in each case and all patients had a medial para-patellar approach. No drains were used and operation details such as a lateral release were recorded. As per unit protocol, patients with a post-op haemoglobin less than 8.5g/dl were transfused as were symptomatic patients with haemoglobin between 8.5g/dl and 10g/dl. Each of the possible predictive factors was tested for significant association with transfusion using chi-squared or t-tests as appropriate. Multiple logistic regression was used to test for the independent predictive of factors after adjusting for one another. Results show that transfusion was more likely if the patient was older, female, short, light or thin. Among peri-operative factors, the chance of a transfusion was increased for bilateral patients, those with low knee scores and those with high ASA scores. Also patients undergoing a lateral release, those with low pre-op haemoglobin and those with a large post-op drop were more likely to be transfused. All the significant variables were entered into a forward stepwise multiple logistic regression. Transfusion was significantly more likely in those undergoing a bilateral procedure, with a low BMI, low pre-op haemoglobin and those with a large post-op drop (> 3g/dl). Allogenic transfusion is associated with immune-related reactions, from pyrexia to urticaria to haemolytic transfusion reactions, which can be life threatening. There is also the risk of viral pathogen transmission. Women were shown to be almost twice as likely to need transfusion. This has been shown in previous studies and is thought to be due to women having a lower weight and pre-op haemoglobin, both of which were shown to be significant independent factors in increasing the risk of transfusion. A pre-operative haemoglobin of less than 13g/dl, a BMI less than 25, and undergoing a bilateral procedure were shown to have an increased risk of transfusion. For patients falling into these categories, measures can be planned to try and reduce this risk.

Introduction: Extent of fibular resection dramatically alters limb function. Aim of our study was to evaluate the functional outcome following resections for 23 malignant tumors of fibula.

Methods: 23 biopsy proven malignant tumors of fibula were included in the study. There were 11 cases of Ewings sarcoma (PNET), 8 osteosarcomas, 2 malignant fibrous histiocytoma and 1 each of synovial sarcoma and chondrosarcoma. Following chemotherapy (wherever indicated) limb salvage surgery was done in all cases. There were 9 proximal, 6 middle and 9 cases of distal third of fibula. Type I resection was done in all proximal and 4 tumors of middle third fibula. Type II fibular resection with reconstruction of ankle joint was done in 10 cases. Reversal of contralateral fibula to reconstruct the ankle was done in 7 cases. Allograft was used in 3 patients.

Results: Average follow up was for 4.5 years (2 to 7 years). 17 patients (68%) were alive after 4 years of surgery. Local recurrence was seen in 3 cases and these were treated by above knee amputation. 3 patients died within 1 year of surgery. 82% of survivors had a good to excellent functional outcome according to the MSTS functional evaluation criteria and 65% were able to bear full weight and had unlimited activity. Recurrence was commonest in patients with PNET. All patients undergoing reversed fibular grafting showed good functional outcome.

Discussion and Conclusion: Results of limb salvage in malignant fibular lesions is infrequently reported. Site of fibular lesion is critical in salvage surgery and need for further reconstruction. Good results are obtained with reversed contralateral fibular reconstruction of the ankle.

In the last few decades pedicle screw placement has brought in a genuine scientific revolution in the surgical care of spinal disorders. The technique has dramatically improved the outcomes of spinal reconstruction requiring spinal fusion. Short segment surgical treatments based on the use of pedicle screws for the treatment of neoplastic, developmental, congenital, traumatic and degenerative conditions have been proved to be practical, safe and effective.

The reported incidence of nerve root damage after the use of pedicle screws ranges from 2% to 32%. The utilization of computerized image-guided technology in lumbosacral spinal fusion surgery offers increased accuracy of pedicle screw placement. We decided to review our x-rays of pedicle screw placement, and to assess the percentage misplacement of pedicle screws inserted without computer assistance. This is a retrospective study and our results are compared with those in the literature.

80 Post operative radiographs of patients operated on for trauma and degenerative conditions of the thoracolumbar spine were studied. Initially these were looked at independently by 2 orthopaedic spinal surgeons and a radiologist, and subsequently all x-rays were reviewed together to see where consensus could be reached where there was any disagreement.

The percentage of misplaced screws inserted under fluoroscopy was obtained, and compared to the percentage of misplaced screws inserted under image guidance reported in the literature. Our study shows that there is no significant difference between the 2 techniques.

Objective: To assess the correlation between the side of the annular pathology and the radicular symptoms, in the absence of a compressive root lesion.

Materials and Methods: 121 patients underwent MRI scan fro axial back and radicular symptoms. The mean age was 49.9 yrs (24–80). The sex distribution was equal. We excluded the patients that had a compressive lesion, previous operations, spinal deformity, spondylolyses, an underlying pathology (tumour, trauma or infection) or a peripheral neuropathy. Annular pathology was documented as annular tear or a non-compressive disc bulge with its location and side. We also recorded marrow endplate changes and facet arthrosis.

Results: Bilateral radicular symptoms were reported in 16 (13.2%): right side in 33 (27.3%) and left in 47 (38.8%) patients. Additionally, 82 patients (67.8%) had axial back pain. 33 patients (27.3%) were noted to have a right sided annular pathology (tear or bulge) and 72 (59.5%) had a left sided annular lesion. 21 patients (17.4%) had a central annular tear and 43 (35.5%) had a generalised disc bulge. 14 patients (11.6%) with right sided symptoms also had annular pathology, while 38 patients (31.4%) with left sided symptoms had a left sided annular lesion. There was no statistical correlation between the side of symptoms and the side of the lesion (r = −0.00066, p=0.994), any particular annular pathology (annular tear r=0.085, p=0.35; disc bulge r-0.083, p=0.36). There was no correlation between the axial back pain and the annular pathology (r=0.004; p=0.97) and facet joint or marrow end plate changes (r= −,29, p=0.76).

Conclusions: Although annular pathology can cause the radicular symptoms, our results suggest that they do not influence the side of the symptoms.

Introduction: Rotation is becoming an increasingly important consideration in the management of scoliosis yet it is difficult to measure reliably. The Perdriolle technique is a widely used and validated technique for estimating the rotation of the apical vertebra. The landmarks required to measure vertebral rotation using this technique are frequently obscured following instrumentation and the application of bone graft. We propose that the Perdriolle technique cannot be applied reliably in the presence of pedicle screw constructs.

Method: This was a manual radiographic measurement analysis comparing intraobserver and interobserver reliability of the Perdriolle “Torsiometre” and the Cobb angle measurement in scoliosis prior to and after pedicle screw instrumentation.

Results: Mean difference and 95% limits of agreement between pre-operative intra-observer readings was 2.5° (−15° and 20°). This suggests on average there was little systematic disagreement between the two readings (2.5° on average). There were large discrepancies between individual pairs of readings.

29.6% of post-operative films (17%–39%) were judged to have sufficient landmarks visible to enable measurement of vertebral rotation compared to 10% of pre-operative films.

Marked increase in systematic bias between consultants with post-operative radiographs to pre-operative films was observed.

Conclusion: We question the validity in measuring the rotation of the curve using the Perdriolle technique on post-operative films following pedicle screw instrumentation. The predominant factors for the obscuration of landmarks include the presence of bone graft, pedicle screws and rods.

Background data: The Paediatric Isola system uses the philosophy of torsion-countertorsion force as a means of scoliosis correction. It aims to maintain this correction till such time that definitive fusion can be carried out.

Aim: This is a retrospective case series of our experience with the Paediatric Isola system and we evaluated the results of this system in the treatment of Scoliosis of various etiologies.

Methods: Twenty –one children,5 with neuromuscular,1 with Ehler-Danlos,5 with idiopathic,3 syndromic and 7 congenital treated with the Isola Instrumentation were studied.

Average age was 6.5 years(2–12). Average follow-up was 24 months (6m-36m).

Results: The average Cobb angle was 52° before surgery, 33.7° after surgery (64 % correction) and 32.5° (62.5% correction) at latest follow-up. The mean apical vertebral translation was 86% and 84% at post-op and latest follow-up. Stabilisation was most commonly perfomed from T2 to L4/L5. Three patients had implant complications, two had deep seated wound infections which necesssiated removal of implants in one case. Five of these patients have gone on to definitive fusions. Curve correction was best for primary thoracolumbar curves and lumbar curves. 2 patients with thoracic curves did not maintain correction.

Conclusion: The Paediatric Isola system is a safe and effective instrumentation in early management of a difficult and challenging sub group of scoliosis patients.

The lumbar spine consists of a mobile segment of 5 vertebrae, which are located between the relatively immobile segments of the thoracic and sacral segments. The bodies are wider and have shorter and heavier pedicles, and the transverse processes project somewhat more laterally and ventrally than other spinal segments. The laminae are shorter vertically than are the bodies and are bridged by strong ligaments. The spinous processes are broader and stronger than are those in the thoracic and cervical spine.

Internal fixation as an adjunct to spinal fusion has become increasingly popular in recent years. Stainless steel or titanium plates or rods are longitudinally anchored to the spine by hooks or pedicle screws. Powerful forces can be applied to the spine through these implants to correct deformity. Implants provide immediate rigid spinal immobilization, which allows for early patient mobilization, and provides a more optimal environment for bone graft incorporation. Numerous clinical and experimental studies demonstrate higher fusion rates in patients with rigid internal fixation than in controls without instrumentation. Although various implants are available, pedicle fixation systems are the most commonly used implant type in the lumbosacral spine. The large size of the lumbar pedicles minimizes the number of instrumented motion segments required to achieve adequate stabilization.

Many authors have reported loss of postoperative deformity correction after transpedicular screw fixation, ranging from 2.5 degrees to 7.1 degrees. The general preference is to stabilize the fractured vertebra by fusing one level above and one level below. With this technique, the rate of loss of correction is high. At our institution, we routinely stabilize the unstable thoracolumbar fractures by fusing one level above and one level below. In addition, we put screws into the pedicle(s) of fractured vertebrae. The reason for this is the following:

To correct the deformed body of the fractured vertebra for better load sharing.

Plain radiographs were analysed post operatively and compared for reduction of the fracture fragments and correction of kyphotic deformity to pre-operative films. 74 Patients were admitted with thoracolumbar spine fractures to our hospital. 48 Patients were surgically treated, and 34 patients were available for follow up. We found that inserting the pedicle screws into the fractured vertebra provided good stabilization for very unstable fractures. No loss of correction was seen in the follow up x-rays. We conclude that including the fractured vertebra into the fracture fixation device not only provides better fracture reduction, but also gives improved rotatory stability.

Purpose: We describe a technique using orthoganol imaging on a radiolucent table that allows reliable, safe and reproducible insertion of thoracic pedicle screws.

Method: The popularity of pedicle screws for spinal fixation in deformity surgery has increased. Studies have shown lumbar pedicle screws to be safe and effective. The biomechanical superiority of pedicle screws has also been demonstrated. Nonetheless, reluctance to apply the technique to thoracic vertebra remains, most likely because of perceived technical difficulties and a reported high complication rate.

We describe a technique using orthoganol imaging on a radiolucent table, used in a series of patients in whom we have inserted a total of over 2000 screws.

Results: We have inserted over 2000 thoracic pedicle screws without neurological injury. In addition, this technique has allowed us to use pedicle screw to the exclusion of other, less mechanically favourable, methods of fixation to the spine; over the same time period we used only three sublaminar hooks.

Furthermore, the lateral to medial or ‘toeing in’ of screw placement gives greater pull out strength to each screw by increasing the ‘volume’ of bone that has to be overcome before failure by pull out occurs. In addition this trangulation technique allows insertion of :screws of greater diameter than the pedicle and decreases the chance of broaching medially.

Conclusion: Using the technique described, we achieve accurate screw placement ‘first time, every time’, giving us a biomechanically superior construct, allowing more powerful derotation of the spine and thus greater correction of deformity. We recommend its use for all thoracic pedicle screws.

Purpose: We report our surgical management of a series of primary and metastatic tumours of the lumbosacral junction, highlighting different methods of fixation, outcome and complications.

Method: Seven patients with primary and four with secondary tumours involving the lumbosacral junction underwent surgery. After tumour resection, iliolumbar fixation was performed in all but one case, using Galveston rods (4) or iliac screws (6). All constructs were attached proximally with pedicle screws. Cross links were used in all instrumented cases and autologous and allogenic bone graft applied.

Results: There were no perioperative deaths. Mean operating time was 7.3 hours (range 3–18) and there was extensive blood loss (mean transfusion requirement 7.5 units, range 0–20). We estimate a transfusion requirement of approximately one unit per hour operating time. However, we noted no complications attributable to either blood loss or transfusions.

Ambulation improved in 5, was unchanged in 5 and deteriorated in one. Neurological status deteriorated in 4 and remained static in the others. However in all but one case the neurological deficit was defined by the nature of proposed surgery. Mean survival from surgery for patients with metastatic disease was 9.5 months (3–18). At mean follow up of 10 months (1–19 months), all patients with primary tumours were still alive without evidence tumour recurrence.

Extralesional excision, and therefore potentially curative surgery, was achieved in 4 cases where this was the primary goal of surgery (osteosarcoma, osteoblastoma, chordoma, embryonic rhabdomyosarcoma). There were no cases of metalwork failure. One patient has undergone revision surgery for pseudathrosis.

Conclusion: Sacral resection and iliolumbar reconstruction is a feasible treatment option in selected patients, offering potential cure. The fixation methods used by the authors restored lumbosacral stability, sufficient for pain relief and preserving ambulation and usually the predicted level of neurological function.

The Ilizarov technique of distraction osteogenesis is becoming a more common way of treating complicated fractures. It has been shown that shear IFMs will delay bone healing whilst axial IFMs are beneficial to the bone healing. Therefore to measure IFMs in conditions of mobility will provide critical information for research and clinic diagnosis. Such data are not provided by static measurements. Traditionally the IFMs were measured by implanting transducers to the bone or using radiological methods. However, these methods are not suitable for either clinic utilization or measurement of IFMS when patients are doing movements which simulate their daily activities. We have designed a dynamic IFMs measuring device.

It includes a displacement transducer array, which is connected to the Ilizarov wires. This transducer array consists of 6 parallel linear displacement transducers, each of which is attached to the fixing wires of the fix-ator. This arrangement of transducers can fit into the configuration of Stewart Platform. The Reverse Stewart Platform algorithm was employed to calculate IFMs. Without measuring the bone fracture segments directly, the two segments were fitted into two planes virtually. By studying the relative movements of the two virtual planes, the algorithm transfers the relative movement to relative axial & shear translation, and relative bending & torsion rotation, between the two fracture segments. Wireless interface was used to transfer the displacement readings from the transducer array to the computer. This setup allows patient perform activities which represent their routine activities.

In laboratory studies, we found the error of this system to be related to the IFMs. For small movements around 100 micron, the absolute error was 50 micron, whereas for larger movements around 1 mm, the error was within 0.22mm.

This real time monitoring method will allow kinematical and kinetic studies on fracture patients treated with Ilizarov frame. Measurements obtained using this novel device will reflect the natural pattern of IFMs during the patients’ daily life. Since use of the device requires no additional pin, wire or operative procedure, it will be clinically applicable. The accurate real-time IFMs measurements will help elucidate the complex interplay between movement and bone formation.

Back pain is a major cause of disability and absence from work. 80% of the population will experience back pain at some point in their lives. In our study we looked at 2 randomised groups of patients. Group 1 patients had only epidural steroid injections (ESI) and group 2 patients had ESI plus radiofrequency (RF). We hypothesized that there is no difference in outcome between group 1 and 2 patients. The 2 groups were sent out a retrospective questionnaire which had 5 parts to it, including SF-36 health survey, pain drawing chart, visual analogue scale (VAS), oswestry disability score (ODS) and a patient satisfaction questionnaire. The patients had treatment between 2002 and 2003 and the post-treatment questionnaires were sent out in May 2004. The SF-36 was scored giving a physical component score (PCS) and a mental component score (MCS) using an online scoring website. The groups studied were from 2 different referral hospitals. The patients were randomised by GP referral being sent to the 2 different hospitals. 115 questionnaires with stamped addressed envelopes were sent out to group 1 patients, out of which 71 were returned (61.7%) and 113 to group 2 patients out of which 55 were returned (48.7%). Statistical analysis was done using the SPSS software programme. As there was some evidence of non-normality Mann-Whitney test was carried out, and for the patient satisfaction questionnaire, chi-squared and fisher’s exact test was used. We found that there was a significant difference among the 2 groups in the PCS (p< 0.0005) and MCS (p=0.017). There was a statistically significant difference among the 2 groups in their pain draw score, VAS and ODS with p values of < 0.0005. In the patient satisfaction questionnaire, 8 questions were asked. Patients were asked to assess how successful the spinal injection was. 35 (67%) patients from group 2 said it was successful, compared with 25 (37%) patients from group 1. 9 (17%) patients from group 2 said it was not successful compared with 27 (40%) patients from group 1. 8 (15%) patients were not sure from group 2 and 16 (24%) were not sure from group 1. The difference was statistically significant with a p value of 0.003. When asked whether they would recommend this type of injection, more patients from group 2 said they would (p=0.029). When asked about the duration of effectiveness of the injection, group 2 noticed an increased duration of benefit compared with group 1 (p< 0.0005). There was no significant difference between the groups when asked how many injections were required (p=0.089) or when asked whether or not they required painkillers (p=0.062). However, more patients from group 2 said that painkillers controlled their pain (p=0.001). When asked if they were able to return to work and do housework/gardening after injection, there were significantly more patients from group 2 being able to do so (p< 0.0005). We conclude that in the patients studied, the group who had radiofrequency treatment and epidural steroid injection did better as compared with patients who had epidural steroid injection alone.

Personal injury claims following whiplash injury currently cost the British economy more than £3 billion a year, yet only a minority of patients have radiologically demonstrable pathology. Patients sustaining fractures of the cervical spine have been subjected to greater force and might reasonably be expected to have worse symptoms than those with whiplash injuries.

Using the Neck Disability Index, we compared pain and functional disability in four groups of patients who had suffered cervical spine injuries. The four groups were: patients with stable cervical fractures treated conservatively, patients with unstable cervical fractures treated by internal fixation, patients with whiplash injuries seeking compensation, and patients with whiplash injuries not involved in litigation.

After a mean follow-up of 3½ years, patients who had sustained cervical spine fractures had significantly lower levels of pain and disability than those who suffered whiplash injuries and were pursuing compensation (p< 0.01), but had similar level to those whiplash sufferers who had settled litigation or had never sought compensation.

Functional recovery following neck injury is unrelated to the physical insult. The increased morbidity in whiplash patients is likely to be psychological and is associated with litigation.

Traditionally clubfoot in South Africa is treated by manipulation, serial casting and, at the age of 3 to 4 months, posteromedial release. Revision surgery, with its attendant problems, is often necessary.

In November 2003 we started using the Ponseti technique. To date we have treated 61 feet, most of which are type-III according to the Harold and Walker classification. Serial castings are done according to Ponseti technique. Initially the forefoot is manipulated into supination to align it with the hindfoot. The talonavicular joint is gradually reduced until 75° of abduction is achieved. Then percutaneous tenotomy is done to correct hindfoot equinus. Manipulation is done weekly and an above-knee cast is applied. Following tenotomy, the cast remains in place for 3 weeks, after which a Denis Brown splint is worn continually (except at bath time) for 3 months and then at night for 3 years. Parent compliance has been good.

We have had six failures to date. One foot was found to have tarsal coalition and another was an arthrogrypotic foot, which was successfully corrected.

Our results suggest that most operations for clubfoot are avoidable. The Ponseti manipulation technique is simple and can easily be taught to the staff of peripheral hospitals, making it ideal for treatment of clubfoot in Africa.

Aims: The purpose of this study was to investigate the number and type of complications following external þxation of pelvic fractures. Methods: We carried out a retrospective review of all patients treated at Frenchay Hospital with external þxation for fractures of the pelvic ring between August 1996 and September 2002. Patientsñ details were collected prospectively; outcome data was collected by casenote review. Results: 74 patients were treated with external þxation for pelvic fractures. In 41 patients, the þxator was used to achieve pelvic stability temporarily, whilst in 33 it was retained as part or all of the deþnitive treatment. 30 patients were haemodynamically unstable when the þxator was applied. Of these patients, two patients died of retroperitoneal haemorrhage, three had pelvic angiography and arterial embolisation and þve required a laparotomy, of which three were negative. Of the þxators used temporarily, four (10%) had pin-site infections. In only one case did this change the plan for the deþnitive treatment. Two of the temporary þxators required revision; one for loss of reduction secondary to pin loosening and one for pin penetration of the femoral head after using the low anterior approach. Six (8%) of all the þxators required repositioning due to impingement on the skin. Of the deþnitive þxators, 53% required antibiotics and 18% required pin removal for sepsis. Three (9%) of the deþnitive þxators required revision; there was one loss of reduction, one re-displacement after removal and one non-union of the pelvic fractures. Conclusions: Temporary application of external þxation to the fractured pelvis, using high iliac crest pin placement to restore pelvic stability, is a safe procedure with few complications. Haemodynamic stability is restored in the majority of patients. When used as part of the deþnitive treatment, pin site infection is common and may require pin removal but rarely leads to loss of fracture reduction or revision of þxation.

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.

Gunshot injuries to large joints are increasing in South Africa. If the bullet is in contact with the synovial fluid of the joint, it must be removed to prevent a foreign body effect and lead poisoning.

We devised a new extra-articular approach to removing the bullet from the joint. We used a reamer to make a tract in the bone towards the joint, and then removed the bullet and irrigated the joint through the same tract. Postoperatively patients were mobilised immediately. At follow-up they had good functional outcome.

Of 586 employed patients with a whiplash injury 40 (7%) did not return to work. The risk was increased by three times in heavy manual workers, two and a half times in patients with prior psychological symptoms and doubled for each increase of grade of disability. The length of time off work doubled in patients with a psychological history and trebled for each increase in grade of disability. The self-employed were half as likely to take time off work, but recovered significantly more slowly than employees.