Abstract

Fewer delays in starting a trauma list can reduce cancellations. A novel system has been previously described where a patient is identified the day before and optimised for theatre. The patient is listed first and designated “Golden Patient”. This project aimed to assess the impact of introducing a “Golden Patient” system on trauma list start times in a district general hospital.

Two months of first case sending and anaesthetic start times were recorded retrospectively (43 cases). The “Golden Patient” system was introduced with a multi-disciplinary implementation group. Target send time of 0830 hours (hrs) and anaesthetic start time of 0900hrs was agreed. First patients on trauma lists were noted in two cycles, two months apart (Cycle 1: 46, Cycle 2: 38).

Prior to implementation: Mean Send Time (MST) of 0855hrs, Mean Anaesthetic Start Time (AST) of 0921hrs.

Cycle 1: MST fell by 9 minutes (p = 0.03) and AST by 11 minutes (p = 0.023). Lists labelled with a “Golden Patient” (47.8%) were sent 14 minutes earlier (p = 0.004) and started 12 minutes earlier (p = 0.02) than those not labelled “Golden”.

Cycle 2: Implementation produced a 13-minute reduction in send times (p = o.oo3) and start times (p = 0.008) overall. “Golden Patient” cases (42.1%) showed an improved MST of 0836hrs and AST of 0902hrs, 10 minutes earlier than those not designated “Golden”.

Implementation of the “Golden Patient” produced a significant improvement in trauma list starts overall. Specifically, “Golden Patients” help to improve efficiency in sending and anaesthetic start times, by up to 19 minutes on average.

Aims

Rates of mortality as high as 25% to 30% have been described following fractures of the odontoid in the elderly population. The aim of this study was to examine whether easily identifiable variables present on admission are associated with mortality.

Aim

To evaluate the efficacy of bone marrow derived stromal cells (BMSC) for the treatment of non-unions in fractures.

Introduction

Neck of femur (NOF) fractures are one of the predominant reasons for hospital admissions in patients >65 year. These fractures are associated with a poor outcome; end to independent living in 60% of patients and a 6 month mortality of 30%. Previous studies have shown show elements of under/mal-nutrition on admission. In addition, their nutritional status shows some deterioration thereafter. The aim of this present study is to examine if the nutritional status of patients with NOF fracture admitted at our institution is associated with a larger post-operative haemoglobin drop. This is compared to an independent living age matched control group from the same geographical area.

Introduction

Regenerative medicine is a rapidly expanding discipline. However due to a lack of validated outcome measures, clinical trials have been far few. This study aims to assess the validity, inter-observer reliability and intra-observer reproducibility of experimental fracture healing assessment on plain radiographies. This technique involves implantation of mesenchymal stem cell (MSC) seeded constructs on only one side of the fracture after randomisation.

The treatment of femoral non-union, especially femoral exchanged nailing, has had mixed results in the recent literature. A review of the literature has suggested that exchanged nailing may be the gold standard for the treatment of femoral non-union. Is femoral exchange nailing an acceptable method of treatment of femoral fracture non-union? What is the evidence? In this systematic review we compare four different methods for the treatment of femoral non-union.

English speaking literature from 1970 to 2007 was searched using Pubmed^® and OVID™ databases and a manual reference search to reveal the original research, presenting the results of the treatment of femoral non-union with exchange nailing, plating, external fixation, and isolated bone grafting. Outcome parameters chosen were union rate and speed of union. The baseline variables chosen were age, number of surgeries, infection and the type of non-union.

In total, fifty six case series were identified containing 861 patients treated with exchange nailing (31 studies), 214 patients treated with plating (11 studies), 140 patients treated with external fixation (13 studies), 81 patients treated with bone grafting (4 studies). The average union rate was 89% for exchange nailing, 93% for plating and external fixation and 62% for bone grafting. Speed of union was 7.3 months for exchange nailing, 8.6 months for plating and 9.15 months for external fixation.

Study of baseline variables showed patients to be older in plating and external fixation groups (range 32–44 years, P< 0.001). There were more previous operations performed in the external fixation and plating groups (3 and 1.8 vs. 1.2, P< 0.001), significantly more infected non-unions in the plating and external fixation groups as compared to the exchange nailing group (40% vs. 11.5% P< 0.001) and significantly more atrophic non-unions in the plating and external fixation groups as compared to the exchange nailing group (85% vs. 65%, P< 0.001).

The literature suggests that femoral exchange nailing has an equivalent or poorer outcomes when compared to external fixation and plating in spite of having been performed in potentially less complex cases. Plating of non-union in the literature has a higher rate of associated bone grafting than femoral exchange nailing which may be responsible for marginally better union rate in the external fixation and plating groups.

Isolated bone grafting without revision of fixation does not provide adequate union rate and hence may be of questionable treatment value.

The aim of this study was to document the thickness of the patellofemoral joint before and after unicompart-mental joint replacement and to correlate these data with knee outcome scores.

Seventeen patients (22 knees) who underwent Patello-femoral replacement with FPV (Wright Medical) prosthesis between 2006 and 2008 were identified retrospectively and analyzed using chart and radiological review. Oxford and AKSS knee scores were gathered prospectively pre-operative and at follow-up.

Trochlear height was measured using lateral radiograph of the knee by measuring the distance between anterior distal femoral cortex and the highest point of trochlea. Trochlear height was compared pre and postoperatively. The range of movement and the Oxford and American knee society knee scores at six weeks postoperatively were noted. Association between increased trochlear height and improved range of motion was studied.

All but two patients regained full knee extension. Postoperative mean range of flexion of the knee joint was 114 degrees. The mean Oxford knee score at 6 weeks postoperatively was 21 points. The mean American Knee Society Knee Score was 85 points and function score 60 points.

We found the average trochlear height to be 6.2 mms pre and 9.7 mms post operatively with an average increase of 3.5 mms. We found no relationship between range of motion of the knee and knee function and trochlear height. This is important because there has been concern that ‘overstuffing’ of the patellofemoral joint can lead to stiffness and failure of resolution of pain post-operatively. Rather it appears that the FPV prosthesis restores the previous anatomical thickness of this compartment.

We conclude that FPV Patello-femoral replacement results in correct anatomical reconstruction of the trochlear height. This should in turn result in durable improvements in pain and function

Non-union is poorly understood. It is unknown if multipotent cells are present in non-union tissue or whether the activity of such cells is dysfunctional. Clinically, this is important as it may predict the success of novel therapies such as BMP treatments and cell-transplantation. This study aimed to study the characteristics of cell types present in human fracture non-union tissue, in comparison with bone marrow stromal cells (BMSC) from the patient and other healthy patients.

Non-union tissue was harvested (n=8) from long bones. Cells were isolated enzymatically and cultured in monolayer. BMSC were isolated by density gradient centrifugation of iliac crest biopsies. Their phenotype was assessed by FACS analysis for CD34, 45 and 105 markers. Their comparative growth kinetics was examined, as was their osteogenic and adipogenic capacity following extended culture in defined medium. Cell differentiation status was evaluated using alkaline phosphatase, von Kossa and oil-red O staining. Cell senescence was assessed via cell morphology, senescence associated Beta-galactosidase (SA-Beta)-Gal) activity.

Non-union cells grew in monolayer, but showed different morphologies; many non-union cells contained stress filaments (typical of senescent cells) or were of stellate appearance. In addition, significantly more non-union cells were positive for SA-Beta-Gal activity compared to BMSC (P=0.0006). Growth kinetics showed longer doubling times for cells isolated from non-union tissue when compared to BMSC isolated from the patient. Long term culture of non-union cells showed early growth arrest at passages 3–8. FACS analysis showed isolated cells to be CD34/45 negative and CD105 positive. Both non-union cells and BMSC differentiated along osteogenic and adipogenic lineages to varying extents.

Our novel results show that cells from non-union tissue exhibit senescence in culture. Hence, cell senescence is potentially involved in the aetiopathogenesis of non-unions. Whether or not this senescence has arisen through cell division (during failed repair attempts) or via abnormal biomechanical loading warrants further study. The influence of senescent cells on the healing process also requires investigation. Clearly these cells are able to differentiate into osteoblasts in vitro but may have an aberrant influence on union in vivo.

Introduction: This research aims to study the efficacy and effect of Bone Marrow Stromal Stem Cell (BMSSC) implantation on healing of refractory fracture non-union.

Methods: Approved by the local Ethics Committee, twelve patients (9M and 3F), age range 38 to 76 years (mean 49.9) with non-union resistant to multiple previous attempts of treatment (mean 3.75 procedures) were treated. Four tibial and eight femoral non-union.

The patients were admitted for harvesting of stromal stem cells by bone marrow aspiration from the iliac bone. BMSSC were expanded in tissue cultures for three weeks to an average of 5 x 10⁶ cells. After successful culture the non-union site underwent decortication and BMSSC added to synthetic bone substitute (different types) on one side of the fracture (medial or lateral) according to randomisation. The side of treatment was blinded to patient, surgeons and radiologist.

Standard radiographs were taken and evaluated independently by three experienced musculoskeletal radiologists. The extent of callus formation on each side was recorded. In equivocal cases computerized tomography (CT) was also obtained.

Results: No patient developed systemic complications related to the procedure. On follow-up callus formation was present in 9 of 12 patients. Callus was more marked on the cell implantation side in 6/12 patients (50%), control side in 1/12 (8.3%) and on both sides in 2 patients. 3 patients showed no change.

Discussion: These findings suggest that implantation of BMSSC can enhance bone formation in persistent non-union. A larger randomized controlled trial will follow to test this new treatment.

Successful healing of a nine-year tibial nonunion resistant to six previous surgical procedures was achieved by tissue engineering. We used autologous bone marrow stromal cells (BMSCs) expanded to 5 × 10⁶ cells after three weeks’ tissue culture. Calcium sulphate (CaSO₄) in pellet form was combined with these cells at operation. The nonunion was clinically and radiologically healed two months after implantation.

This is the description of on healing of a long-standing tibial nonunion by tissue engineering. The successful combination of BMSCs and CaSO₄ has not to our knowledge been reported in a clinical setting.