Regional five-year clinical outcomes of 289 consecutive cementless oxford uni-compartmental knee replacements at a non-inventor centre.

INTRODUCTION: Uncemented unicompartmental knee replacement offers a minimally invasive approach, faster rehabilitation and good levels of function, supported by evidence reporting low intra-operative fracture rate and mid-term stability with no implant migration at 5-years. Our aim was to examine the clinical outcomes in 289 consecutive Oxford unicompartmental knee arthroplasties (257 patients), five years post-operatively. METHODS: A retrospective study of patients treated between 2008 and 2014 in a non-inventor centre by a single surgeon was performed. Patients with anteromedial bone on bone uni-compartmental arthritis were included. Oxford Knee Scores (OKSs) at last follow-up were recorded, intra-operative complications reported with commentary on revision cases. RESULTS: Mean age of patients was 66 years (SD 9.6, 45-88 years). 122 (42%) patients were female and 135 (58%) were male. Patient in our study were ASA 1 (36%), ASA 2 (62%) and ASA 3 (01%). There were no intra-operative complications, particularly tibia fractures during impaction. The average oxford knee score was 40.1 (n = 232, Range 06 to 48, SD 8.46) at an average 6 years and 3 months from surgery, including revised patients. Six patients had their prosthesis revised within five-years of the index surgery. Five-year cumulative implant survival rate was 97.8% (95% CI 97.62 to 97.98, SE 0.09). Indications for revision were: lateral side wear (n = 1); dislocated spacer (n = 4); instability and spacer subluxation (n = 1). Thirteen patients died within five years of surgery Five-year cumulative survival rate was 94.9% (95% CI 94.87 to 94.925, SE 0.013). CONCLUSION: The proportion of patients requiring revision at five-years is lower than that generally reported for UKR. These findings add support for the use of the cementless oxford UKR outside the design centre.

Long-term outcomes after an initial experience of computer-navigated resection of primary pelvic and sacral bone tumours: soft-tissue margins must be adequate to reduce local recurrences.

AIMS: The aim of this study was to investigate the local recurrence rate at an extended follow-up in patients following navigated resection of primary pelvic and sacral tumours. PATIENTS AND METHODS: This prospective cohort study comprised 23 consecutive patients (nine female, 14 male) who underwent resection of a primary pelvic or sacral tumour, using computer navigation, between 2010 and 2012. The mean age of the patients at the time of presentation was 51 years (10 to 77). The rates of local recurrence and mortality were calculated using the Kaplan-Meier method. RESULTS: Bone resection margins were all clear and there were no bony recurrences. At a mean follow-up for all patients of 59 months (12 to 93), eight patients (34.8%) developed soft-tissue local recurrence, with a cumulative rate of local recurrence at six-years of 35.1% (95% confidence interval (CI) 19.3 to 58.1). The cumulative all-cause rate of mortality at six-years was 26.1% (95% CI 12.7 to 49.1). CONCLUSION: Despite the positive early experience with navigated-assisted resection, local recurrence rates remain high. With increasing knowledge of the size of soft-tissue margins required to reduce local recurrence and the close proximity of native structures in the pelvis, we advise against compromising resection to preserve function, and encourage surgeons to reduce local recurrence by prioritizing wide resection margins of the tumour. Cite this article: Bone Joint J 2019;101-B:484-490.

Risk factors for failure of the 36 mm metal-on-metal Pinnacle total hip arthroplasty system: a retrospective single-centre cohort study.

AIMS: To determine ten-year failure rates following 36 mm metal-on-metal (MoM) Pinnacle total hip arthroplasty (THA), and identify predictors of failure. PATIENTS AND METHODS: We retrospectively assessed a single-centre cohort of 569 primary 36 mm MoM Pinnacle THAs (all Corail stems) followed up since 2012 according to Medicines and Healthcare Products Regulation Agency recommendations. All-cause failure rates (all-cause revision, and non-revised cross-sectional imaging failures) were calculated, with predictors for failure identified using multivariable Cox regression. RESULTS: Failure occurred in 97 hips (17.0%). The ten-year cumulative failure rate was 27.1% (95% confidence interval (CI) 21.6 to 33.7). Primary implantation from 2006 onwards (hazard ratio (HR) 4.30; 95% CI 1.82 to 10.1; p = 0.001) and bilateral MoM hip arthroplasty (HR 1.59; 95% CI 1.03 to 2.46; p = 0.037) predicted failure. The effect of implantation year on failure varied over time. From four years onwards following surgery, hips implanted since 2006 had significantly higher failure rates (eight years 28.3%; 95% CI 23.1 to 34.5) compared with hips implanted before 2006 (eight years 6.3%; 95% CI 2.4 to 15.8) (HR 15.2; 95% CI 2.11 to 110.4; p = 0.007). CONCLUSION: We observed that 36 mm MoM Pinnacle THAs have an unacceptably high ten-year failure rate, especially if implanted from 2006 onwards or in bilateral MoM hip patients. Our findings regarding implantation year and failure support recent concerns about the device manufacturing process. We recommend all patients undergoing implantation since 2006 and those with bilateral MoM hips undergo regular investigation, regardless of symptoms. Cite this article: Bone Joint J 2017;99-B:592-600.

The management of open tibial fractures in children: a retrospective case series of eight years' experience of 61 cases at a paediatric specialist centre.

AIMS: Following the introduction of national standards in 2009, most major paediatric trauma is now triaged to specialist units offering combined orthopaedic and plastic surgical expertise. We investigated the management of open tibia fractures at a paediatric trauma centre, primarily reporting the risk of infection and rate of union. PATIENTS AND METHODS: A retrospective review was performed on 61 children who between 2007 and 2015 presented with an open tibia fracture. Their mean age was nine years (2 to 16) and the median follow-up was ten months (interquartile range 5 to 18). Management involved IV antibiotics, early debridement and combined treatment of the skeletal and soft-tissue injuries in line with standards proposed by the British Orthopaedic Association. RESULTS: There were 36 diaphyseal fractures and 25 distal tibial fractures. Of the distal fractures, eight involved the physis. Motor vehicle collisions accounted for two thirds of the injuries and 38 patients (62%) arrived outside of normal working hours. The initial method of stabilisation comprised: casting in nine cases (15%); elastic nailing in 19 (31%); Kirschner (K)-wiring in 13 (21%); intramedullary nailing in one (2%); open reduction and plate fixation in four (7%); and external fixation in 15 (25%). Wound management comprised: primary wound closure in 24 (39%), delayed primary closure in 11 (18%), split skin graft (SSG) in eight (13%), local flap with SSG in 17 (28%) and a free flap in one. A total of 43 fractures (70%) were Gustilo-Anderson grade III. There were four superficial (6.6%) and three (4.9%) deep infections. Two deep infections occurred following open reduction and plate fixation and the third after K-wire fixation of a distal fracture. No patient who underwent primary wound closure developed an infection. All the fractures united, although nine patients required revision of a mono-lateral to circular frame for delayed union (two) or for altered alignment or length (seven). The mean time to union was two weeks longer in diaphyseal fractures than in distal fractures (13 weeks versus 10.8 weeks, p = 0.016). Children aged > 12 years had a significantly longer time to union than those aged < 12 years (16.3 weeks versus 11.4 weeks, p = 0.045). The length of stay in hospital for patients with a Gustilo-Anderson grade IIIB fracture was twice as long as for less severe injuries. CONCLUSION: Fractures in children heal better than those in adults. Based on our experience of deep infection we discourage the use of internal fixation with a plate for open tibial fractures in children. We advocate aggressive initial wound debridement in theatre with early definitive combined orthopaedic and plastic surgery in order to obtain skeletal stabilisation and soft-tissue cover. Cite this article: Bone Joint J 2017;99-B:544-53.

A review of current surgical practice in the operative treatment of proximal humeral fractures: Does the PROFHER trial demonstrate a need for change?

OBJECTIVES: The PROximal Fracture of the Humerus: Evaluation by Randomisation (PROFHER) trial has recently demonstrated that surgery is non-superior to non-operative treatment in the management of displaced proximal humeral fractures. The objective of this study was to assess current surgical practice in the context of the PROFHER trial in terms of patient demographics, injury characteristics and the nature of the surgical treatment. METHODS: A total of ten consecutive patients undergoing surgery for the treatment of a proximal humeral fracture from each of 11 United Kingdom hospitals were retrospectively identified over a 15 month period between January 2014 and March 2015. Data gathered for the 110 patients included patient demographics, injury characteristics, mode of surgical fixation, the grade of operating surgeon and the cost of the surgical implants. RESULTS: A majority of the patients were female (66%, 73 of 110). The mean patient age was 62 years (range 18 to 89). A majority of patients met the inclusion criteria for the PROFHER trial (75%, 83 of 110). Plate fixation was the most common mode of surgery (68%, 75 patients), followed by intramedullary fixation (12%, 13 patients), reverse shoulder arthroplasty (10%, 11 patients) and hemiarthroplasty (7%, eight patients). The consultant was either the primary operating surgeon or supervising the operating surgeon in a large majority of cases (91%, 100 patients). Implant costs for plate fixation were significantly less than both hemiarthroplasty (p < 0.05) and reverse shoulder arthroplasty (p < 0.0001). Implant costs for intramedullary fixation were significantly less than plate fixation (p < 0.01), hemiarthroplasty (p < 0.0001) and reverse shoulder arthroplasty (p < 0.0001). CONCLUSIONS: Our study has shown that the majority of a representative sample of patients currently undergoing surgical treatment for a proximal humeral fracture in these United Kingdom centres met the inclusion criteria for the PROFHER trial and that a proportion of these patients may, therefore, have been effectively managed non-operatively.Cite this article: Mr B. J. F. Dean. A review of current surgical practice in the operative treatment of proximal humeral fractures: Does the PROFHER trial demonstrate a need for change? Bone Joint Res 2016;5:178-184. DOI: 10.1302/2046-3758.55.2000596.

One-year mortality in patients with bone and soft tissue sarcomas as an indicator of delay in presentation.

INTRODUCTION: For many cancers, one-year mortality following diagnosis is a reflection of either advanced stage at diagnosis, multiple co-morbidities and/or complications of treatment. One-year mortality has not been reported for soft tissue or bone sarcomas. This study reports 1-year sarcoma mortality data over a 25-year period, investigates prognostic factors and considers whether a delay in presentation affects 1-year mortality. METHODS: A total of 4,945 newly diagnosed bone sarcoma and soft tissue sarcoma patients were identified from a prospectively maintained, single institution oncology database. Of these, 595 (12%) died within 1 year of diagnosis. Both patient factors and tumour characteristics available at diagnosis were analysed for effect. RESULTS: There was significant variation in one-year mortality between different histological subtypes. There has been no significant change in mortality rate during the last 25 years (mean: 11.7%, standard deviation: 2.8 percentage points). Soft tissue sarcoma patients who survived over one year reported a longer duration of symptoms preceding diagnosis than those who died (median: 26 vs 20 weeks, p<0.001). Prognostic factors identified in both bone and soft tissue sarcomas mirrored those for mid to long-term survival, with high tumour stage, large tumour size, metastases at diagnosis and increasing age having the greatest predictive effect. CONCLUSIONS: One-year mortality in bone and soft tissue sarcoma patients is easy to measure, and could be a proxy for late presentation and therefore a potential performance indicator, similar to other cancers. It is possible to predict the risk of one-year mortality using factors available at diagnosis. Death within one year does not correlate with a long history but is associated with advanced disease at diagnosis.

If your lump is bigger than a golf ball and growing, think Sarcoma.

AIM: Only 1 in 100 of primary care consultations regarding new soft tissue lumps (STL) are malignant and are susceptible to a delay in diagnosis. We aimed to generate a Bayesian Belief Network to estimate the likelihood of malignancy in patients to facilitate the initial evaluation of a STL and improve timing and quality of referrals to specialist treatment centres. METHODS: We evaluated all patients referred with a new STL between 1996 and 2007. Variables investigated focused on patient factors, symptoms and STL characteristics. Relevant data was extracted and coded for statistical analysis. RESULTS: 3018 patients with a STL were assessed, of which 1563 (52%) were benign and 1455 (48%) malignant. The features most conditionally associated with the outcome of interest (Benign or Malignant) are referred to as first-degree associates, and are increasing size, age, size of the lump, and duration of symptoms, in that order. On cross validation, this model demonstrated an AUC of 0.77 (95%C.I. 0.75-0.79). CONCLUSIONS: For the first time, we have described the hierarchal relationship between factors and created an aide memoire, larger than a golf ball and growing, to trigger referral to tertiary tumor units. Importantly, we found pain to be a poor discriminatory factor. We hope our findings will lead to greater awareness and earlier diagnosis of STL.

Massive endoprosthetic replacement for bone metastases resulting from renal cell carcinoma: factors influencing patient survival.

BACKGROUND: Surgery remains the main treatment of bone metastases due to renal cell carcinoma (RCC). We reviewed 135 patients treated with resection and endoprosthetic replacement (EPR) and examined clinico-pathological factors predicting survival. METHODS: Surgical and oncological outcomes were examined using a prospectively maintained database between 1976 and 2012. Survival rates were calculated by Kaplan-Meier method. Multivariate analyses were performed to investigate factors predictive of increased survival. RESULTS: At diagnosis, 81 patients had synchronous RCC and bone metastases and the remaining developed metachronous metastases after primary treatment for RCC. The majority were solitary tumours (75%) and 77% had ≥ one concurrent visceral metastases. The median age at surgery was 61 years old (IQR 53-69). The median follow-up was 20 months (IQR 10-43) and the overall survival was 72% at one-year. This declined to 45% and 28% at three and five-years, respectively. After adjustments for prognostic factors, there was an increased risk of death in patients with multiple skeletal metastases (HR = 2), ≥one visceral metastases (HR = 3) and local recurrence (HR = 3) (all p ≤ 0.01). Ten patients required revision (7%) and the risk of revision was 4% at one-year and remained low at 8% from two years postoperatively. CONCLUSION: Patients with solitary bone lesions and no visceral metastases should be considered for bone resection and EPR. As survival beyond one-year can be expected in a majority of patients and the risk of further surgery after EPR is low, patients with multiple skeletal metastases and visceral metastases should also be considered.

Can computer navigation-assisted surgery reduce the risk of an intralesional margin and reduce the rate of local recurrence in patients with a tumour of the pelvis or sacrum?

We hypothesised that the use of computer navigation-assisted surgery for pelvic and sacral tumours would reduce the risk of an intralesional margin. We reviewed 31 patients (18 men and 13 women) with a mean age of 52.9 years (13.5 to 77.2) in whom computer navigation-assisted surgery had been carried out for a bone tumour of the pelvis or sacrum. There were 23 primary malignant bone tumours, four metastatic tumours and four locally advanced primary tumours of the rectum. The registration error when using computer navigation was < 1 mm in each case. There were no complications related to the navigation, which allowed the preservation of sacral nerve roots (n = 13), resection of otherwise inoperable disease (n = 4) and the avoidance of hindquarter amputation (n = 3). The intralesional resection rate for primary tumours of the pelvis and sacrum was 8.7% (n = 2): clear bone resection margins were achieved in all cases. At a mean follow-up of 13.1 months (3 to 34) three patients (13%) had developed a local recurrence. The mean time alive from diagnosis was 16.8 months (4 to 48). Computer navigation-assisted surgery is safe and has reduced our intralesional resection rate for primary tumours of the pelvis and sacrum. We recommend this technique as being worthy of further consideration for this group of patients.

Are all aciclovir cream formulations bioequivalent?

Topical aciclovir cream (ACV, Zovirax Cream) containing 40% propylene glycol (PG), the optimum found for skin penetration, is clinically effective in the treatment of recurrent herpes labialis. One hundred and thirty-nine ACV generic creams were analysed and 80% of these contained less than 20% PG. From this, we hypothesised that these generics might be bioinequivalent to the innovator cream. A pilot in vitro skin permeation study compared the innovator cream with two generics containing about 15% PG. Next, 10 generics containing 0-15% PG were tested in an independent laboratory. Finally, a PG dose-ranging study was conducted in Zovirax cream base. In all studies, human skin was used and ACV analysed by LC-MS-MS. In the pilot study, the innovator cream delivered 7.5-fold more ACV than the two generics. Superiority was confirmed in the second study against all 10 ACV generic creams. By grouping the creams according to PG content, a relationship to ACV skin permeation was suggested. The PG dose effect was confirmed in the third study. These studies suggest that not all marketed ACV creams are bioequivalent to the clinically proven innovator. Given the magnitude of the differences seen, there is concern over therapeutic inequivalence of generic ACV creams to the innovator cream.