Objectives

Platelet-rich fibrin matrix (PRFM) has been proved to enhance tenocyte proliferation but has mixed results when used during rotator cuff repair. The optimal PRFM preparation protocol should be determined before clinical application. To screen the best PRFM to each individual’s tenocytes effectively, small-diameter culture wells should be used to increase variables. The gelling effect of PRFM will occur when small-diameter culture wells are used. A co-culture device should be designed to avoid this effect.

The femur is a common site for skeletal bony metastases. The aim of this study is to evaluate the outcomes of femoral intramedullary nailing in prophylactic versus therapeutic treatment in femoral metastases.

All femoral nails between April 2011 and November 2015 at a district general hospital were assessed. Intramedullary nailing performed for prophylactic or therapeutic management were included. Outcomes include mortality, survival time and length of stay in hospital.

A total of 40 cases were included. In the prophylactic group there were 25 patients and in the therapeutic group there were 15 patients. In the prophylactic group, mean age was 70 years (range 41–91); male to female ratio is 23:17 and 26 patients of this group was deceased. In the therapeutic group, mean age was 76 years (range 56–92); male to female ratio 15:10 and 10 patients were deceased in this group. The most common primary was prostate carcinoma followed by breast carcinoma. In the prophylactic group, mean survival was 25 weeks (range 2–147) and in the therapeutic group mean survival was 20 weeks (range 2–39). The length of stay was 21 days (range 3–80) in the prophylactic group and 28 days (range 7–63) in the therapeutic group.

Femoral nailing for metastases helps improve quality of life and we observed a mean survival time of 20–25 weeks postoperatively in both therapeutic and prophylactic nailing.

Tranexamic acid (TXA) is an antifibrinolytic that can prevent clot breakdown. Trauma patients often have coagulopathy which can cause mortality due to bleeding. The purpose of this review is to investigate the efficacy of TXA in reducing mortality in major trauma and secondly to look at patient's outcomes when using TXA in trauma.

Searches were performed in PUBMED, EMBASE and other databases for randomised controlled trials (RCT) and observational studies. The author searched for all relevant evidence on the use of TXA in major trauma. Relevant studies were assessed for quality using the Cochrane's Collaboration's tool for assessing risk of bias.

Eight relevant studies were identified from the search, 3 randomised controlled trials (RCTs) and 5 observational studies were identified. Five of the 8 studies found a significance in mortality with TXA use. Three showed TXA reduced mortality including the high quality level I evidence, CRASH 2 study. Three studies found no significance on mortality. There appears to be no increased risk of VOE with TXA however results from the studies varied. No study reported any adverse events due to TXA use. There does not appear to be any significant benefit of TXA use in TBI but a trend towards lower mortality. There is a role in paediatric trauma despite evidence from only 2 observational studies.

There is a high quality RCT to suggest the use of TXA in trauma patients with supporting evidence from observational studies. The outcomes in TBI are unclear. It may be beneficial in paediatric use but there is currently no level 1 evidence in paediatrics to support this. Further prospective studies looking specifically at role in TBI and paediatric trauma are required to support routine use in these specific populations.

Background:

The outcomes of open tibial fractures in a paediatric population are reported.

We attempted to investigate the incidence, the treatment modalities used and the outcome of Osteosarcoma (OS) patients treated at the two major Pediatric Oncology Hospitals in Singapore. A comprehensive list of patients with OS treated at the National University Hospital and KK Women’s and Children’s Hospital Singapore between April 1980 and May 2006 was generated. During the study interval, patients received neoadjuvant chemotherapy followed by definitive surgery consisting of either limb salvage or amputation followed by adjuvant chemotherapy. Chemotherapy was as per the European Osteosarcoma Intergroup (EOI) and as per the Memorial Sloan-Kettering Cancer Center’s (MSKCC) T12 protocols. Treatment of subsequent relapses consisted of various combinations of Methotrexate, ifosfamide, etoposide, other, and/or surgery.

Of the total 49 patients with OS, 30% presented with metastatic OS. Median age of diagnosis of OS was 12.4 years. For the cohort, two and five-year overall survival were 71% and 55% respectively. The two-year overall survival was 73% for patients who were treated as per the MSKCC protocol. At last follow-up, median 4.3 years (range, 0.3 – 21.6 years), 25 were alive with no evidence of disease and 16 were dead of disease.

Survival from OS in Singapore appears to be improving. Rarity and complexity of OS makes it crucial for patients to seek a centralized multi-disciplinary Musculoskeletal Oncology team involving surgeons and Pediatric Oncologists dedicated to the care of these young patients with the intent to cure.

Multiple drilling is reported to be an effective treatment for osteonecrosis of the head of femur, but its effect on intra-osseous pressure has not been described. We undertook multiple drilling and recorded the intra-osseous pressure in 75 osteonecrotic hips in 60 patients with a mean age of 42 years (19 to 67). At a mean follow-up of 37.1 months (24 to 60), 42 hips (56%) had a clinically successful outcome. The procedure was effective in reducing the mean intra-osseous pressure from 57 mmHg (SD 22) to 16 mmHg (SD 9). Hips with a successful outcome had a mean pressure of 26 mmHg (SD 19). It was less effective in preventing progression of osteonecrosis in hips with considerable involvement and in those with a high intra-osseous pressure in the intertrochanteric region (mean 45 mmHg (SD 25)). This study is not able to answer whether a return of the intra-osseous pressure to normal levels is required for satisfactory healing.

Introduction Thoracic pedicle screws are increasingly being used for internal fixation. Surgeons and radiologists are often required to make decisions about the position of the screws in relation to the pedicle based on AP and lateral plain radiographs alone. We ventured to assess the value of orthogonal radiographs in determining the position of thoracic pedicle screws in 23 cadaveric thoracic vertebrae

Methods Disarticulated cadaveric thoracic vertebrae were used in this study. Pedicle screws were inserted in three positions: 1) within the pedicle, deliberately violating the 2) lateral cortex of the pedicle and 3) medial cortex of the pedicle. AP (antero-posterior) & lateral radiographs were obtained and presented to 6 readers (4 surgeons & 2 radiologists) in booklets consisting of AP views alone, lateral views alone and both AP & lateral views together in a sequential manner. The readers were asked to indicate the position of the screws and the results of the evaluation were compared to the actual position (axial views).

Results On AP views alone, the accuracy in detecting screws placed out of the pedicle laterally and medially were 93% and 76% respectively, while the accuracy for screws placed inside the pedicle was 85% . On LATERAL views alone, the accuracy for the same screw positions were 69%, 58% and 64% respectively. When AP + LATERAL views were considered together, the accuracy for the same screw positions were 93%, 80% and 87% respectively. Comparing the three groups, it was observed that screw positions were read more accurately in AP + LATERAL views (87%) compared to AP views alone (85%), or LATERAL views alone (64%). The sensitivity of correctly identifying screws placement is highest in AP + LATERAL (90%) views with a specificity of 94%. The specificity of detecting screws placed inside the pedicle is highest in AP (94%). The positive predictive value (PPV) of radiographs in general (AP +LATERAL) in detecting screws placed inside the pedicle, out of the pedicle laterally and medially were 73%, 92% and 86% respectively. The negative predictive value (NPV) of radiographs in general for the same screw locations were 90%, 96% and 76% respectively. On AP and AP + LATERAL views respectively, 25% and 23% of screws placed inside the pedicle were read as medially ‘out’. 10% of screws placed medially ‘out’ were read as ‘in’ on both AP and AP + LATERAL views. Inter-observer difference was substantial. In general, surgeons appeared to have consistently higher accuracy, sensitivity, specificity, PPV and NPV values compared to radiologists and fellows in determining screw position.

Discussion The positions of the screws appear to be most accurately detected when both AP and lateral x-rays are provided compared to AP or lateral alone. Screws that perforated the lateral cortex were the easiest and those that were medially out were the most difficult to identify. Screws passed inside the pedicle may create an unnecessary apprehension that they may be medial and screws passed medially may give a false sense of security that the screw is inside the pedicle. Radiographs are just one component in ensuring accurate pedicle screw placement and surgeon’s experience, in the use of tactile skills and anatomical knowledge continue to be vitally important in the safe placement of thoracic pedicle screws.

We undertook a comparative study of magnetic resonance imaging (MRI) vertebral morphometry of thoracic vertebrae of girls with adolescent idiopathic thoracic scoliosis (AIS) and age and gender-matched normal subjects, in order to investigate abnormal differential growth of the anterior and posterior elements of the thoracic vertebrae in patients with scoliosis. Previous studies have suggested that disproportionate growth of the anterior and posterior columns may contribute to the development of AIS. Whole spine MRI was undertaken on 83 girls with AIS between the age of 12 and 14 years, and Cobb’s angles of between 20° and 90°, and 22 age-matched controls. Multiple measurements of each thoracic vertebra were obtained from the best sagittal and axial MRI cuts. Compared with the controls, the scoliotic spines had longer vertebral bodies between T1 and T12 in the anterior column and shorter pedicles with a larger interpedicular distance in the posterior column. The differential growth between the anterior and the posterior elements of each thoracic vertebra in the patients with AIS was significantly different from that in the controls (p < 0.01). There was also a significant positive correlation between the scoliosis severity score and the ratio of differential growth between the anterior and posterior columns for each thoracic vertebra (p < 0.01). Compared with age-matched controls, the longitudinal growth of the vertebral bodies in patients with AIS is disproportionate and faster and mainly occurs by endochondral ossification. In contrast, the circumferential growth by membranous ossification is slower in both the vertebral bodies and pedicles.

We report a case of systemic Penicillium marneffei infection in a Chinese woman who presented with multiple osteolytic lesions and radiographic changes similar to those seen in other fungal osteomyelitides. This infection is often misdiagnosed as tuberculosis and has a high mortality rate. The correct diagnosis is important since early antifungal therapy is life-saving.