High-energy proximal tibia fractures are complicated by soft tissue compromise and this may resul... more High-energy proximal tibia fractures are complicated by soft tissue compromise and this may result in sub-optimal outcomes. There is a high association of open injuries, compartment syndromes, and vascular injuries with these bony disruptions. Surgical treatment of these injuries has been associated with significant complications such as infection, knee stiffness, malunion, loss of fixation, soft tissue failure, and amputations. The loss of fixation is an issue especially in the elderly, with failure associated with age more than sixty years, premature weight bearing, preoperative displacement, fracture fragmentation, and severe osteoporosis. The use of two-stage reconstruction for the treatment of distal tibia fractures has been successful in decreasing the complication rates, including wound compromise. The two stages involve: 1. stabilization of the injured limb with a bridging external fixator to allow the soft tissues to improve and recover and 2. definitive fixation for reconstruction of the articular surface and meta-diaphyseal fractures. The use of such a protocol has been proposed for high-energy proximal tibia fractures to decrease the high rate of soft tissue compromise associated with traditional open methods of treatment. The choice of definitive fixation may include plates, nails, or non-bridging external fixation.
Aim The current literature indicates that hip arthroscopy is safe in both adolescents and adults ... more Aim The current literature indicates that hip arthroscopy is safe in both adolescents and adults with good early outcomes but there are no available studies that directly compare the outcomes of this procedure for mixed indications between these two groups. Method This was a prospective cohort study of 102 consecutive supine hip arthroscopies in 96 patients (48 adolescent ( 18 hips), mean age 33.8 years) at a tertiary referral paediatric and adult university hospital followed-up for a minimum of two years. Patient demographics, indications for surgery, Modified Harris Hip (MHHS) and Non-Arthritic Hip (NAHS) scores, operative interventions and complications were recorded. Results At two-year follow-up, the MHHS improved from a mean of 55.3 to 87.5 (p Conclusion This study confirms that hip arthroscopy for mixed indications leads to good early outcomes with low complication rates in adolescent and adult patients. The incidence of pudendal nerve palsy in the adolescent group is however noted and is of concern.
Background ELR+ CXC chemokine production is studied in arthritis and is thought to contribute to ... more Background ELR+ CXC chemokine production is studied in arthritis and is thought to contribute to inflammation leading to articular cartilage breakdown and arthritis pathology. However, healthy articular chondrocytes express their own chemokine receptors and ligands. The function of CXC chemokine receptors in these cells is puzzling as chondrocytes are encased in a dense extracellular matrix and are not known to migrate in vivo. Objectives This study aims to investigate the function of the CXCR1/2 signaling pathway in articular cartilage. Methods CXCR1/2 expression in adult human articular chondrocytes was confirmed by semi-quantitative RT polymerase chain reaction (RT-PCR), Western blot and immunohistochemistry. Combined and individual functionality of CXCR1 and CXCR2 was tested using an in vitro calcium mobilisation assay. Validated blocking antibodies and siRNA were used to inhibit CXCR1/2 signaling at receptor level. Pertussis toxin, PI3K inhibitors and intracellular calcium chelators were used to block signaling at intracellular levels. The highly sulphated proteoglycan content of chondrocyte micromasses was analysed using Alcian blue staining and spectrophotometric quantification. Chondrocyte gene expression was assessed using real time RT-PCR. CXCL6 and CXCL8 were detected in heparitinase digested, chondroitinase ABC digested and undigested paraffin sections of human articular cartilage from healthy and osteoarthritic donors by immunohistochemistry. Finally, 8 week old CXCR2-/- mutant BALB/C mouse knee joint paraffin sections were analysed using Safranin Orange staining, Chambers scoring and ImageJ histomorphometry. Results CXCR1/2 expression was confirmed in normal human articular cartilage. Individual blockade of either CXCR1 or CXCR2 did not inhibit downstream calcium mobilisation, indicating that CXCR1 and CXCR2 have more functional redundancy than that observed in neutrophils. CXCR1/2 signaling disruption at receptor level or by downstream blockade in chondrocytes resulted in reduced extracellular matrix sulphated glycosaminoglycan content and reduced expression of the chondrocyte differentiation markers COL2A1, Aggrecan, and SOX9. CXCL6 and CXCL8 were found in cartilage extracellular matrix in healthy tissue in distinct localisation patterns, which were disrupted in osteoarthritic tissue and following heparitinase digestion. In vivo analysis of 15 knockout and 15 wild type knees revealed that CXCR2-/- mice have significantly thinner epiphyseal growth plates and medial tibial plateaus, with a reduced sulphated proteoglycan content found in medial condyle articular cartilage. Conclusions Our findings indicate that CXCR1/2 signaling is in fact required for maintenance of phenotypic stability in articular chondrocytes. Interactions with heparan sulphate proteoglycans and distribution patterns of ligands within the ECM, and their disruption during pathology, indicate the presence of a homeostatic mechanism whereby CXC chemokines are retained within the articular cartilage matrix via interactions with heparan sulphate proteoglycans, where they maintain chondrocyte phenotypic stability via an autocrine/paracrine signaling mechanism. In vivo analysis suggests that CXCR1/2 signaling may be specifically required during periods of high chondrocyte turnover, including within the growth plate. Disclosure of Interest None Declared
Intramedullary Nailing is now accepted as the standard treatment for most femoral diaphyseal frac... more Intramedullary Nailing is now accepted as the standard treatment for most femoral diaphyseal fractures. Most intramedullary nails are designed for proximal and distal locking with screws. We describe our experience with the Brooker Wills femoral nail. This nail is unique as distal fixation is achieved with as transverse fixator deployed through slots in the nail, a concept first enunciated by deCamargo in 1952. The fins of the fixator pierce the distal cortex when deployed thereby conferring rotational stability. The entire nail (including the proximal and distal fixation devices) can be inserted through a single proximal incision in the skin. We treated 17 patients with femoral shaft fractures using this system. 93% of the patients were males. Motor vehicle accidents accounted for 80 % of the fractures. Most fractures involved the middle third of the femur (54%), followed by distal third (33%) and proximal third (13%). 67 % of the fractures showed Winquist and Hansen Grade 3 or 4 comminution. All the nailings were performed in the supine position. Static locking was done in 16 cases. Post operative weight bearing was individualized with 86% of the patients bearing full weight before the end of 16 weeks. The average time to full weight bearing was 14 weeks. The mean time to union was 17.1 weeks, with proximal, middle and distal third fractures showing average healing times of 19, 15.6 and 18.8 weeks respectively. All the fractures united. There was one case of delayed union. Intra-operative complications included–inability to deploy the distal fixator in one case and unwinding of the reamer in another case. There was one case of superficial infection where a patient developed a sinus over the metallic fin of the distal fixation device, which had penetrated the cortex. This healed after the distal fixation device was removed. There was one case of proximal nail migration, but the fracture went onto union with some limb shortening. Results were evaluated using the scoring system devised by Sanders etal (1991). The functional criteria in their scoring system include- knee flexion, presence of pain, femur deformity, walking distance, stair climbing and pre injury functional status. We achieved excellent results in 53% of patients, good- 27%, fair–13 % and poor-7%. We feel that the main advantage of the Brooker Wills Nail is the ease of distal locking. This saves time and also leads to lower level of radiation exposure, as the image intensifier is sparingly used for distal locking. In fact, this nail is an attractive option in centres which lack an image intensifier. We achieved good results with this nailing system and feel that it is an acceptable alternative to other nailing systems with conventional locking systems with screws.
The aim of our study was to assess the use of the Clavicular Hook Plate in treating acromio–clavi... more The aim of our study was to assess the use of the Clavicular Hook Plate in treating acromio–clavicular joint dislocations and fractures of the distal clavicle. The prospective study was carried out at two hospitals- a teaching hospital and a district general hospital. Between 2001 and 2004 a total of 37 patients with AC joint injuries and distal clavicle fractures were treated surgically with this device. Four of the patients had sustained a Neers Type 2 fracture of the distal clavicle, while 33 patients had acromio-clavicular joint dislocation (Rockwood Type 3 or higher). Mean age of the study group was 35.2 years. Post operatively, shoulder pendulum exercises were commenced on the second day and all patients discharged within 48 hours. During the first few weeks, we restricted shoulder abduction to 90 degrees. At the first postoperative follow up appointment at 2 weeks, average shoulder abduction was 30 degrees and forward elevation −40 degrees. This improved at 6 weeks to 85 degrees and 105 degrees respectively. The plates were removed at an average time interval of 11 weeks for the ACJ dislocations (range 8–12 weeks) and 15 weeks for the clavicle fractures (range 12–16 weeks). At three months after plate removal, we evaluated patients to measure the Visual Analogue Score(VAS) and Constant Score. The mean VAS was 1.4 (range 0–6) and the mean Constant score was 92 (range 72 to 98). Wound healing problems occurred in two patients, while two had a stress riser clavicle fracture. These had to be subsequently fixed with a Dynamic Compression Plate. One patient developed a superficial wound infection. Seven patients had problems due to impingement between the hook and the under surface of the acromion. A 45 year old female patient developed ACJ instability after plate removal. Radiographs revealed widening of the AC joint and some osteophyte formation. She went on to develop frozen shoulder which was treated with intensive physiotherapy. The AO hook plate represents an improvement over previous implants in treating injuries around the AC Joint. However, the need for a second operation to remove the plate remains a significant problem. Complications resulting from impingement were common in our patients and represent a major drawback of this implant.
Aims: To compare the cost of intra-medullary implants used stabilising paediatric diaphyseal frac... more Aims: To compare the cost of intra-medullary implants used stabilising paediatric diaphyseal fractures with the clinical outcome. Methods: Between March 1994 and August 2001, at two centres, The WomenOs and ChildrenOs Hospital, Adelaide, Australia and The Royal London Hospital, London UK 60 children were surgically treated for diaphyseal forearm fractures using Elastic Stable Intramedullary Nails (ESIN) or 2.5mm Kirschner wires. Having established no difference in the clinical outcome or subjective disability of either technique we compared the implant cost directly. Results: The two treatments both resulted in an excellent outcome with all fractures leading to union with no subjective disability. The Kirscner wires cost £3.00 per wire while the ESI Nails cost between £57.50 and £ 113.30 per wire, depending on the dimensions. Conclusions: We were not able to demonstrate any difference in outcome between ESIN and K-Wiring, although the nails do offer theoretical advantages. The cost ...
Journal of the American Academy of Orthopaedic Surgeons, 2006
The incidence of chronic renal disease is increasing, and the pattern of renal osteodystrophy see... more The incidence of chronic renal disease is increasing, and the pattern of renal osteodystrophy seems to be shifting from the classic hyperparathyroid presentation to one of low bone turnover. Patients with persistent disease also live longer than previously and are more physically active. Thus, patients may experience trauma as a direct result of increased physical activity in a setting of weakened pathologic bone. Patient quality of life is primarily limited by musculoskeletal problems, such as bone pain, muscle weakness, growth retardation, and skeletal deformity. Chronic renal disease also increases the risk of comorbidity, such as infection, bleeding, and anesthesia-related problems. Current treatment strategies include dietary changes, plate-and-screw fixation, and open reduction and internal fixation.
High-energy proximal tibia fractures are complicated by soft tissue compromise and this may resul... more High-energy proximal tibia fractures are complicated by soft tissue compromise and this may result in sub-optimal outcomes. There is a high association of open injuries, compartment syndromes, and vascular injuries with these bony disruptions. Surgical treatment of these injuries has been associated with significant complications such as infection, knee stiffness, malunion, loss of fixation, soft tissue failure, and amputations. The loss of fixation is an issue especially in the elderly, with failure associated with age more than sixty years, premature weight bearing, preoperative displacement, fracture fragmentation, and severe osteoporosis. The use of two-stage reconstruction for the treatment of distal tibia fractures has been successful in decreasing the complication rates, including wound compromise. The two stages involve: 1. stabilization of the injured limb with a bridging external fixator to allow the soft tissues to improve and recover and 2. definitive fixation for reconstruction of the articular surface and meta-diaphyseal fractures. The use of such a protocol has been proposed for high-energy proximal tibia fractures to decrease the high rate of soft tissue compromise associated with traditional open methods of treatment. The choice of definitive fixation may include plates, nails, or non-bridging external fixation.
Aim The current literature indicates that hip arthroscopy is safe in both adolescents and adults ... more Aim The current literature indicates that hip arthroscopy is safe in both adolescents and adults with good early outcomes but there are no available studies that directly compare the outcomes of this procedure for mixed indications between these two groups. Method This was a prospective cohort study of 102 consecutive supine hip arthroscopies in 96 patients (48 adolescent ( 18 hips), mean age 33.8 years) at a tertiary referral paediatric and adult university hospital followed-up for a minimum of two years. Patient demographics, indications for surgery, Modified Harris Hip (MHHS) and Non-Arthritic Hip (NAHS) scores, operative interventions and complications were recorded. Results At two-year follow-up, the MHHS improved from a mean of 55.3 to 87.5 (p Conclusion This study confirms that hip arthroscopy for mixed indications leads to good early outcomes with low complication rates in adolescent and adult patients. The incidence of pudendal nerve palsy in the adolescent group is however noted and is of concern.
Background ELR+ CXC chemokine production is studied in arthritis and is thought to contribute to ... more Background ELR+ CXC chemokine production is studied in arthritis and is thought to contribute to inflammation leading to articular cartilage breakdown and arthritis pathology. However, healthy articular chondrocytes express their own chemokine receptors and ligands. The function of CXC chemokine receptors in these cells is puzzling as chondrocytes are encased in a dense extracellular matrix and are not known to migrate in vivo. Objectives This study aims to investigate the function of the CXCR1/2 signaling pathway in articular cartilage. Methods CXCR1/2 expression in adult human articular chondrocytes was confirmed by semi-quantitative RT polymerase chain reaction (RT-PCR), Western blot and immunohistochemistry. Combined and individual functionality of CXCR1 and CXCR2 was tested using an in vitro calcium mobilisation assay. Validated blocking antibodies and siRNA were used to inhibit CXCR1/2 signaling at receptor level. Pertussis toxin, PI3K inhibitors and intracellular calcium chelators were used to block signaling at intracellular levels. The highly sulphated proteoglycan content of chondrocyte micromasses was analysed using Alcian blue staining and spectrophotometric quantification. Chondrocyte gene expression was assessed using real time RT-PCR. CXCL6 and CXCL8 were detected in heparitinase digested, chondroitinase ABC digested and undigested paraffin sections of human articular cartilage from healthy and osteoarthritic donors by immunohistochemistry. Finally, 8 week old CXCR2-/- mutant BALB/C mouse knee joint paraffin sections were analysed using Safranin Orange staining, Chambers scoring and ImageJ histomorphometry. Results CXCR1/2 expression was confirmed in normal human articular cartilage. Individual blockade of either CXCR1 or CXCR2 did not inhibit downstream calcium mobilisation, indicating that CXCR1 and CXCR2 have more functional redundancy than that observed in neutrophils. CXCR1/2 signaling disruption at receptor level or by downstream blockade in chondrocytes resulted in reduced extracellular matrix sulphated glycosaminoglycan content and reduced expression of the chondrocyte differentiation markers COL2A1, Aggrecan, and SOX9. CXCL6 and CXCL8 were found in cartilage extracellular matrix in healthy tissue in distinct localisation patterns, which were disrupted in osteoarthritic tissue and following heparitinase digestion. In vivo analysis of 15 knockout and 15 wild type knees revealed that CXCR2-/- mice have significantly thinner epiphyseal growth plates and medial tibial plateaus, with a reduced sulphated proteoglycan content found in medial condyle articular cartilage. Conclusions Our findings indicate that CXCR1/2 signaling is in fact required for maintenance of phenotypic stability in articular chondrocytes. Interactions with heparan sulphate proteoglycans and distribution patterns of ligands within the ECM, and their disruption during pathology, indicate the presence of a homeostatic mechanism whereby CXC chemokines are retained within the articular cartilage matrix via interactions with heparan sulphate proteoglycans, where they maintain chondrocyte phenotypic stability via an autocrine/paracrine signaling mechanism. In vivo analysis suggests that CXCR1/2 signaling may be specifically required during periods of high chondrocyte turnover, including within the growth plate. Disclosure of Interest None Declared
Intramedullary Nailing is now accepted as the standard treatment for most femoral diaphyseal frac... more Intramedullary Nailing is now accepted as the standard treatment for most femoral diaphyseal fractures. Most intramedullary nails are designed for proximal and distal locking with screws. We describe our experience with the Brooker Wills femoral nail. This nail is unique as distal fixation is achieved with as transverse fixator deployed through slots in the nail, a concept first enunciated by deCamargo in 1952. The fins of the fixator pierce the distal cortex when deployed thereby conferring rotational stability. The entire nail (including the proximal and distal fixation devices) can be inserted through a single proximal incision in the skin. We treated 17 patients with femoral shaft fractures using this system. 93% of the patients were males. Motor vehicle accidents accounted for 80 % of the fractures. Most fractures involved the middle third of the femur (54%), followed by distal third (33%) and proximal third (13%). 67 % of the fractures showed Winquist and Hansen Grade 3 or 4 comminution. All the nailings were performed in the supine position. Static locking was done in 16 cases. Post operative weight bearing was individualized with 86% of the patients bearing full weight before the end of 16 weeks. The average time to full weight bearing was 14 weeks. The mean time to union was 17.1 weeks, with proximal, middle and distal third fractures showing average healing times of 19, 15.6 and 18.8 weeks respectively. All the fractures united. There was one case of delayed union. Intra-operative complications included–inability to deploy the distal fixator in one case and unwinding of the reamer in another case. There was one case of superficial infection where a patient developed a sinus over the metallic fin of the distal fixation device, which had penetrated the cortex. This healed after the distal fixation device was removed. There was one case of proximal nail migration, but the fracture went onto union with some limb shortening. Results were evaluated using the scoring system devised by Sanders etal (1991). The functional criteria in their scoring system include- knee flexion, presence of pain, femur deformity, walking distance, stair climbing and pre injury functional status. We achieved excellent results in 53% of patients, good- 27%, fair–13 % and poor-7%. We feel that the main advantage of the Brooker Wills Nail is the ease of distal locking. This saves time and also leads to lower level of radiation exposure, as the image intensifier is sparingly used for distal locking. In fact, this nail is an attractive option in centres which lack an image intensifier. We achieved good results with this nailing system and feel that it is an acceptable alternative to other nailing systems with conventional locking systems with screws.
The aim of our study was to assess the use of the Clavicular Hook Plate in treating acromio–clavi... more The aim of our study was to assess the use of the Clavicular Hook Plate in treating acromio–clavicular joint dislocations and fractures of the distal clavicle. The prospective study was carried out at two hospitals- a teaching hospital and a district general hospital. Between 2001 and 2004 a total of 37 patients with AC joint injuries and distal clavicle fractures were treated surgically with this device. Four of the patients had sustained a Neers Type 2 fracture of the distal clavicle, while 33 patients had acromio-clavicular joint dislocation (Rockwood Type 3 or higher). Mean age of the study group was 35.2 years. Post operatively, shoulder pendulum exercises were commenced on the second day and all patients discharged within 48 hours. During the first few weeks, we restricted shoulder abduction to 90 degrees. At the first postoperative follow up appointment at 2 weeks, average shoulder abduction was 30 degrees and forward elevation −40 degrees. This improved at 6 weeks to 85 degrees and 105 degrees respectively. The plates were removed at an average time interval of 11 weeks for the ACJ dislocations (range 8–12 weeks) and 15 weeks for the clavicle fractures (range 12–16 weeks). At three months after plate removal, we evaluated patients to measure the Visual Analogue Score(VAS) and Constant Score. The mean VAS was 1.4 (range 0–6) and the mean Constant score was 92 (range 72 to 98). Wound healing problems occurred in two patients, while two had a stress riser clavicle fracture. These had to be subsequently fixed with a Dynamic Compression Plate. One patient developed a superficial wound infection. Seven patients had problems due to impingement between the hook and the under surface of the acromion. A 45 year old female patient developed ACJ instability after plate removal. Radiographs revealed widening of the AC joint and some osteophyte formation. She went on to develop frozen shoulder which was treated with intensive physiotherapy. The AO hook plate represents an improvement over previous implants in treating injuries around the AC Joint. However, the need for a second operation to remove the plate remains a significant problem. Complications resulting from impingement were common in our patients and represent a major drawback of this implant.
Aims: To compare the cost of intra-medullary implants used stabilising paediatric diaphyseal frac... more Aims: To compare the cost of intra-medullary implants used stabilising paediatric diaphyseal fractures with the clinical outcome. Methods: Between March 1994 and August 2001, at two centres, The WomenOs and ChildrenOs Hospital, Adelaide, Australia and The Royal London Hospital, London UK 60 children were surgically treated for diaphyseal forearm fractures using Elastic Stable Intramedullary Nails (ESIN) or 2.5mm Kirschner wires. Having established no difference in the clinical outcome or subjective disability of either technique we compared the implant cost directly. Results: The two treatments both resulted in an excellent outcome with all fractures leading to union with no subjective disability. The Kirscner wires cost £3.00 per wire while the ESI Nails cost between £57.50 and £ 113.30 per wire, depending on the dimensions. Conclusions: We were not able to demonstrate any difference in outcome between ESIN and K-Wiring, although the nails do offer theoretical advantages. The cost ...
Journal of the American Academy of Orthopaedic Surgeons, 2006
The incidence of chronic renal disease is increasing, and the pattern of renal osteodystrophy see... more The incidence of chronic renal disease is increasing, and the pattern of renal osteodystrophy seems to be shifting from the classic hyperparathyroid presentation to one of low bone turnover. Patients with persistent disease also live longer than previously and are more physically active. Thus, patients may experience trauma as a direct result of increased physical activity in a setting of weakened pathologic bone. Patient quality of life is primarily limited by musculoskeletal problems, such as bone pain, muscle weakness, growth retardation, and skeletal deformity. Chronic renal disease also increases the risk of comorbidity, such as infection, bleeding, and anesthesia-related problems. Current treatment strategies include dietary changes, plate-and-screw fixation, and open reduction and internal fixation.
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