European Orthopedic Product News

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European

Orthopaedic

Product News

April 2010

ISSN 1478 7393

www.opnews.com UK ÂŁ6.00

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April 2010 04 FROM THE EDITOR 04 OPN CONSULTANTS 06 NEWS 10 COMPANY NEWS 13 ANALYSIS DEBATE AT 2ND ‘SEM FOR 14 LIVELY LONDON 2012’ MEETING

Meet the Consultant Editors who contribute to OPN

Article by DJO Education

16 PRODUCT NEWS

IN HAITI AND THE 20 EARTHQUAKE SURGICAL RESPONSE Article by Miss Mekel Asad and Mr Asad Syed

24 FUTURE EVENTS RADIUS FRACTURES - THE ROLE 28 DISTAL OF VOLAR LOCKING PLATES A comprehensive guide to what’s on

Article by Sam Anand

30 BOOK REVIEW 32 JOURNAL REVIEWS 34 COFFEE BREAK

Step by Step Management of Lower Limbs Deformity

Current Fixation & Trauma and Hand Surgery Literature

Product News Section

Next Issue: May/June 2010 Knee Surgery and Knee Braces

Finsbury DeltaMotion® Finsbury, the world leader in large diameter bearing technology, has combined its knowledge with BIOLOX® delta, the world’s leading ceramic material, to bring you DeltaMotion®, the world’s first truly large diameter ceramicon-ceramic bearing.

Use of the latest advanced materials and technology permits optimisation of the head diameter to acetabular cup ratio allowing use of large heads in small diameter acetabulae. This dramatic increase in bearing size allows range of motion and stability of the replaced hip currently only possible using a large diameter metal-on-metal device, such as the ADEPT®.

Finsbury Orthopaedics 13 Mole Business Park, Randalls Road, Leatherhead, Surrey, KT22 7BA Tel: +44 (0)1372 360830 Fax: +44 (0)1372 360779 Web: www.finsbury.org

April In Focus Second Sport & Exercise Medicine Meeting Professor Nicola Maffulli, Centre Lead, QMUL Centre for Sports & Medicine, hosts the second programme of events in association with DJO Education. The sessions, held in March, focused on Preparticipation Screening and Low Back Pain Management.

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Surgical Response to the Earthquake in Haiti One of our consultants, Asad Syed, travelled to Haiti following the devasting earthquake in January this year.

He discusses the ongoing relief effort and the medical response to the trauma victims of the disaster.

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Open Reduction and Internal Fixation in Trauma Practice In our second article, consultant editor Sam Anand looks at distal radius fractures, one of the most common fractures encountered in any trauma practice. Here he focuses on the option of ORIF, with special emphasis on the role of locking plates, and the approach to applying the plates.

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From The Editor

Editorial

The OPN Team info@pelgr p.com

W

elcome to the April issue of European Orthopaedic Product News magazine, and with spring finally sprung we can now look forward to a bright summer and more new developments and research in the world of orthopaedics. As mentioned in the previous issue, with the Annual meeting of the American Academy of Orthopaedic Surgeons recently held in New Orleans, we have seen many exciting research articles, new products and news stories springing from the meeting. Three reports from the meeting look at the future of spine and back conditions, with future advances and treatment options for a slipped disc, spine injury in seniors and vertebral fractures. For more information on the studies see page 6.

With the incidence of osteoarthritis on the rise, experts expect that, by 2020, osteoarthritis could affect more than 40 million people and become the fourth-leading cause of disability. Nearly one in 10 people aged 65 and older have symptomatic knee osteoarthritis, and the number of seniors is expected to double in the next 25 years.

A new study from the Steadman Philippon Research Foundation presented at the 2010 AAOS Annual Meeting has proven the effectiveness of knee braces to reduce pain and improve physical function. The study, “Use of an Unloader Brace for Medial or Lateral Compartment Osteoarthritis of the Knee”, revealed that patients who used bracing reported significant improvement of their osteoarthritis symptoms, without resorting to surgery. Page 12 has more information on this study and it’s results.

One of our topics of interest in this issue is Fixation and Trauma and one of our contributors, Sam Anand, has submitted an article on page 28, looking at distal radial fractures and the role of volar locking plates in trauma practice, focusing on open reduction and internal fixation.

With news of the disaster in Haiti growing more distant, the help and desperation of the injured and helpless people out there is still evident.

Mehek Asad and Asad Syed have written an interesting article on page 20, as they explain details of their recent work in Haiti, helping trauma patients and survivors of the quake.

Finally, you can organise your diary for the year ahead in our Future Events section on pages 24-27 and take time out of your busy day with our Coffee Break feature at the rear of the magazine on page 34. I hope you enjoy this issue and if you have any feedback or would like to contribute something yourself, please email me at editor@pelgrp.com.

Group Editor: Leslie Charneca Assistant Editor: Kate Jackson Deputy Assistant Editor: Richard Redwin Deputy Assistant Editor: Matt Ng Group Sales & Marketing Manager: Debbie Hall Accounts: Gaye Wright Design: Neil Molyneaux Consultant Editors: Satish Kale Bob Chatterjee Issaq Ahmed Samena Chaudhry Ayaz Lakdawala Sam Anand Asad Syed Richard Bimmel New Media & E-commerce: Andy Hill Lead Developer: Jonathan Hill IT Support: Matt Wensley Proof Reading: Colin Taylor

Published in the UK by: Pelican Magazines Ltd Address: 2 Cheltenham Mount Harrogate HG1 1DL England Tel: +44 (0)1423 569676 Fax: +44 (0)1423 569677 Web Site: www.opnews.com Email: editor@opnews.com

Subscription Details OPN is available on subscription: £40 U.K. £50 Europe (Airmail) £65 Elsewhere (Airmail)

Every effort is made to ensure that information given in this magazine is accurate but no legal responsibility is accepted by the Editor or Publisher for errors or omissions in that information. Readers are recommended to contact manufacturers direct. Views expressed by contributors are not necessarily shared by OPN. Printed in the UK by Buxton Press.

Copyright © 2010 Pelican Magazines Ltd

Les Charneca Editor

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Consultant Editors Keeping OPN informative and relevant is no easy job - that’s why we get help from the eight people below! Our Consultant Editors are on hand to ensure that OPN is filled with the latest reviews as well as topical articles on the issue’s features. We are always looking to add to our Consultants, so feel free to contact us if you think you also have what it takes. If you have any questions for the Editors, email us at editor@pelgrp.com and we will pass them on.

Bob Chatterjee

Samena Chaudhry

SpR Trauma & Orthopaedics

SpR Trauma & Orthopaedics

Subhamoy Chatterjee, (better known as Bob) is an SpR on the Middlesex rotation in London.

Bob graduated from Guy’s & St Thomas’s Hospital in 1995, and completed his SHO training rotation in Swindon & Oxford. He then embarked on an MSc in Surgical Science in 2001 reading biomechanics and skeletal tissue. Bob’s research projects include external fixation, osseopromotive membranes and mobile bearing knees which he undertook at The Institute of Orthopaedics in Stanmore. His career interest is spine in which he intends to concentrate on degenerative spine surgery, particularly kyphoplasty and minimally invasive discectomy.

Samena qualified from Birmingham University before going on to complete her Basic Surgical Trainee in North Staffordshire hospitals. Samena works at the Royal Orthopaedic Hospital doing a spinal attachment, before embarking on a stint in Paediatrics. She has published work on hip fractures, imaging in scaphoid fractures and has researched into the cost effectiveness of cell salvage in pelic trauma surgery. In addition to this she is helping to set up an orthopaedic service at a hospital in Uganda near Kampala with an ambition to practise in the third world once fully qualified.

Satish Kale

Sam Anand

Consultant Orthopaedic Surgeon

Consultant Orthopaedic Surgeon

Satish Kale completed his basic Orthopaedic training in India and has been in the UK for more than 10 years finishing his FRCS from the Royal College of Surgeons of Edinburgh. Satish is a Surgical Tutor for the Royal College of Surgeons of Edinburgh and has authored several international presentations and publications. Satish has been Consultant Editor and contributor to OPN for more than three years now. He has reviewed several Orthopaedic and non-Orthopaedic books for the magazine, providing insights into their strengths and weaknesses. He has also provided technical articles on varying aspects of Orthopaedics.

Asad Syed FRCS, Trauma & Orthopaedics Asad is an Orthopaedic & Trauma Consultant at Wrexham Maelor Hospital, North Wales. He specialises in Foot & Ankle surgery and has been working in Orthopaedics for the last 12 years. Asad started his Orthopaedic training in Dublin & then continued on the Yorkshire rotation. Having worked in premier institutes in Dublin & in UK he then undertook a National Foot & Ankle fellowship in UK. Asad is a keen researcher with many papers to his name. One of his passions is humanitarian work. He has been involved in operating & salvaging limbs in many earthquake zones around the world, including the most recent mission in Haiti. He is also an advisor for a charity that provides free artificial limbs to the needy in a deprived third world country.

Richard Bimmel Consultant Orthopaedic Surgeon Richard trained in Belgium for his medical degree at the university of Antwerp and started training for orthopaedics and traumatology in 2002, finishing in 2008. The program took him to different hospitals in Belgium and also to UCH London for one year as a specialist registrar with Mr Fares Haddad. He specialises mainly in hip pathology, especially the hip problems in the young and active population. Resurfacing hip prosthesis and revision hip surgery take up a large amount of his practice. Richard now works in a nice hospital in the Northern part of the Netherlands with an enthusiastic young team of orthopaedic consultants with high interest in new developments in orthopaedics.

Sam Anand completed his basic Orthopaedic training in his native India and has been based in the United Kingdom for over ten years now. He has completed his FRCS (Trauma and Orthopaedics) from the Royal College of Surgeons in Edinburgh, Scotland and has also done an MSc in Orthopaedic Engineering from Cardiff University in Wales. Sam works as a Consultant Orthopaedic Surgeon at the Horton Hospital and the Horton NHS Treatment Centre in Banbury, England.

His special interests are the upper limb and trauma, especially sports related injuries and joint replacements. He has had several international presentations and is on the review panel of international journals.

Ayaz Lakdawala SpR Trauma & Orthopaedics Ayaz is an SpR (T&O) in the Birmingham Orthopaedic Training Programme and is currently based at The Royal Orthopaedic Hospital, Birmingham. His projects include ‘TKR in golfers’ and ‘Significance of surface changes on retrieved femoral components after TKR’. Ayaz is interested in Trauma and surgery of the knee. He has presented papers at various national and international orthopaedic meetings and have publications in various peer reviewed journals including The JBJS. Ayaz has designed a website for the Birmingham Orthopaedic Training Programme – www.brumorth.ninehub.com. This website is an educational resource aimed the trainees particularly preparing for the exams.

Issaq Ahmed SpR Trauma & Orthopaedics Issaq is a year 3 speciality registrar on the South East of Scotland rotation, and is currently working in Fife. His main interests include lower limb arthroplasty and tumour surgery. Prior to medicine he trained as an engineer for Jaguar Cars in Coventry. It was through his engineering degree that he became interested in Orthopaedics when he undertook a research project measuring bone strength and predicting fracture risk using spectral analysis of digitised x-ray images of the distal radius.

Other published work include autogenous bone grafting in total knee arthroplasty, soft tissue release in TKR.

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News NEWS IN BRIEF • Nurses in Teesside, England have played a leading role in slashing treatment times for patients with fractured neck of femur.

A revised patient pathway has seen the number of fractured neck of femur patients having their operation within 48 hours at South Tees Hospital Foundation increase from 62% to 72%, while the average length of hospital stay has been reduced from 18 to 14 days. It has saved the trust money and freed up bed space.

Senior trauma nurse Glynis Peat led the multi disciplinary group which redesigned the treatment pathway with input from patients and carers. As a result, the trust introduced a range of improvements including fast tracking through A&E for fractured neck of femur patients, a “fitness for surgery” checklist, better pain management and more patient information.

Ms Peat said: “We now have faster times to theatre, reduced length of stay and fewer readmissions. The improvements we made are now part of our normal business.”

The pathway is featured as a case study in a guide for clinicians on the Department of Health’s quality, innovation, productivity and prevention programme.

• New guidelines for frontline services have been published to help clinicians with health problems get prompt help without fear or stigma.

Invisible Patients sets out how organisations can ensure they support their workforce and build healthy workplaces for clinical professionals. Its recommendations are based on evidence reviewed for the full Health of Health Professionals report as well as best practice within healthcare organisations across the UK. Invisible Patients identifies the need for healthcare organisations and individual practitioners to prevent and manage ill health and for specialist services to be created to treat those small numbers of sick health professionals.

Welcoming the report, Professor Sir Liam Donaldson, Chief Medical Officer for England, said: “This report highlights the fact that those who provide essential healthcare services can themselves develop health problems. Most importantly, it provides a framework and recommendations to address these problems.

“I would encourage all healthcare organisations to use this report to aid them in developing systems that will help improve the health of health professionals and foster a healthy workplace where safe and high quality care can be delivered to patients.”

Source: Department of Health

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Breakthroughs in Treatment of Spine and Back Conditions Three new studies presented at the 2010 Annual Meeting of the American Academy of Orthopaedic Surgeons (AAOS) detail advances in back care and treatment options for specific back and spine conditions. Each of the following three studies consider and report on the patients’ best outcomes and options: • Does the duration of symptoms affect outcomes in the treatment of lumbar disc herniation?

• Treatment of Lumbar Spinal Stenosis: Who Decides to Have Surgery?

• Balloon Kyphoplasty vs Non-surgical Care: 2 Year Outcome of a Randomised Controlled Trial Slipped Disc - Lumbar disc herniation mainly affects adults aged 30 to 40 years and is commonly caused by degenerative changes in the spine. A new study just released analysed the effect of symptom duration when treating herniated discs in the lower back. A comparison was made between 927 patients who had intervertebral lumbar disc herniation symptoms for less than six months and 265 patients who had symptoms longer than six months. Patients with symptoms lasting longer than six months had worse outcomes after both operative and non-operative treatment than patients with shorter symptom duration.

“The bottom line is patients who seek treatment, whether it is surgical or non-surgical, during the first six months of symptoms will respond

better to treatment,” said Jeffrey A. Rihn, MD, study co-investigator and assistant professor, Department of Orthopaedic Surgery, Thomas Jefferson University and The Rothman Institute. “We also learned that surgery offers advantages over non-surgical treatment regardless of the duration of symptoms.”

Spine Injury in Seniors - Lumbar spinal stenosis is the leading cause of spine surgery in patients over age 65.

Previous studies have demonstrated the benefit of surgery over non-surgical management of this condition, however, in these studies it was unclear what were the indications for surgery and largely unknown which patients select surgery.

The study looked at 241 patients who underwent surgery and 115 who had non-operative care.

Researchers found that patients who chose surgery tended to be: • Younger; • With more pain and more disability • Felt their symptoms were progressing.

“These results help complete the evaluation and treatment algorithm for patients with spinal stenosis. The findings will enhance the shared decision-making process by aiding physicians in counseling patients to help them choose the right treatment option,” explained Mark F. Kurd, MD, lead author of the study and orthopaedic surgery resident, Thomas Jefferson University and The Rothman Institute.

Vertebral Fractures - Vertebral compression fractures are one of the most frequent consequences of osteoporosis. Current non-surgical treatment options involve pain medication, bed rest, physiotherapy and back bracing. However these options do not address the resulting vertebrae breakdown, height loss and other resulting problems.

Balloon kyphoplasty is a minimally invasive procedure for acute vertebral fractures. Results were presented from a study of 149 patients treated with balloon kyphoplasty and 151 patients treated with non-surgical treatment. Measurements for quality of life, back pain and function, and days of disability were assessed through 24 months of follow-up. Compared to non-surgical care, balloon kyphoplasty: • Improved quality of life; • Reduced back pain and disability • Did not increase adverse events including the risk of vertebral fracture over two years.

“I have been using balloon kyphoplasty to treat patients with painful vertebral compression fractures for years so the immediate and sustained pain relief we saw in the study did not surprise me,” concluded Jan Van Meirhaeghe, MD, study co-author. “But until now these decreased pain levels and significant quality of life improvement, as compared to nonsurgical treatment, had not been demonstrated in a clinical trial.”

Source: Science Daily

Screening May Reduce Osteoporotic Fracture Risk Screening middle-aged women for osteoporosis leads to increased use of hormone replacement therapy and other treatments, trial findings have indicated.

“This study strongly suggests that a population screening program to target treatment of those at risk of osteoporosis will reduce fractures,” say R Barr (University of Aberdeen, UK) and co-workers.

“It does however remain unclear which specific aspects of screening followed by therapy gives rise to this reduction in fracture risk,” they note.

The team reports on the findings from 4800 women, aged 45–54 years, who were randomly assigned to have a dual-energy Xray absorptiometry scan of the hip and spine, or no screening.

Overall, 1764 women accepted the screening offer and 1364

• April 2010

controls were recruited to the study.

Screened women in the lowest quartile for bone mineral density were then advised to consider taking HRT, while those in the higher quartiles were told they need not consider HRT for osteoporosis prevention unless taking drugs that increase their risk for the condition.

The women were questioned 9 years later to determine if screening had altered use of anti-osteoporotic therapies or risk for fracture.

At follow-up, screened women were significantly more likely to have used HRT than controls (52.4% vs 44.5%). Screening was also associated with an increased use of vitamin D, calcium supplements and anti-osteoporotic medications (36.6% vs 21.6%).

Furthermore, per protocol analysis of confirmed fractures indicated that women who

received screening had a 25.9% risk reduction for fracture at any site compared with unscreened controls, after adjusting for age, weight, and height.

“The significant reduction in fracture risk, associated with participation in this study, could not be explained by a reduction in falls, since the number of fallers and the number of falls in the screened and control groups were not significantly different, again implying that increased use of osteoporosis treatments was responsible,” write Barr et al.

They conclude in the journal Osteoporosis International: “Further work is required to determine the optimum age to undertake screening to ensure a cost-effective program.”

Source: Medwire News

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News NEWS IN BRIEF • One of OPN’s consultant editors, Issaq Ahmed is planning to undertake a period of voluntary work at a dedicated Orthopaedic hospital in the South Eastern Cape of South Africa. As this is a period of voluntary unpaid leave he is appealing for sponsorship and the possible donation of orthopaedic equipment, which would be of benefit to this hospital.

The Bedford Orthopaedic Hospital in Umtata is situated at the heart of the former homeland of Transkei. This hospital provides care for a mainly rural population of approximately 4 million people. It has around 200 beds within four wards and has a separate spinal and paediatric ward. The inspiration for this visit stems from the work of the late Dr Chris McConnachie, a Scottish surgeon who in 1984, with the help of charitable funds set up the orthopaedic service to provide healthcare to this impoverished region.

Issaq states, “This fellowship will allow exposure to several rare and untreated pathologies not seen in the United Kingdom.

Conditons commonly seen at this hospital include musculoskeletal tumours, severe chronic osteomyelitis, untreated club feet, tuberculosis, as well as a pandemic of injuries from road traffic accidents and gunshots.”

A significant part of his visit will also focus on teaching in conjunction with the Institute for Global Orthopaedics and Traumatology (IGOT). This is a non-profit academic organisation who aim to improve the musculoskeletal care in the developing world by focusing on training of local practitioners.

We at OPN are pleased to support Issaq, if your company or organisation are interested in sponsoring or donating equipment, please contact kate@pelgrp.com.

• The Trauma and Orthopaedic Department at Lancashire Teaching Hospitals NHS Foundation Trust, which runs the Royal Preston and Chorley and South Ribble hospitals, is celebrating double success.

The North West Orthopaedic Training Association voted orthopaedic consultant Danny Redfern as the best regional trainer of the year and orthopaedic consultant Aslam Mohammed won an award for the best research paper presented by Dr Taha Lilo, senior house officer in orthopaedics at the trust.

Mr Redfern said: “This is an honour and recognition of the strong track record at the trust in training the surgeons of the future and undertaking research.”

Mr Mohammed added: “We are delighted to have been recognised by our peers in this way.”

Source: Lancashire Evening Post

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The Royal National Orthopaedic Hospital in Stanmore to be Rebuilt A world-renowned hospital in Stanmore, London, has finally won its battle for funding from the government for its rebuilding project.

Health Secretary Andy Burnham announced £81m will be invested in rebuilding the Royal National Orthopaedic Hospital, bringing to an end a 46-year battle to keep the specialist facility open.

He said: “The NHS should be able to offer something better in this

day and age for patients.

“I think this will transform the patient experience here, giving them the space and privacy that is tremendously important.”

Patients, doctors, and health trust bosses have been lobbying the government for years, demanding the hospital, which is currently a network of ageing buildings, some predating the NHS itself, is rebuilt so facilities match the standard of care.

Professor Tim Briggs, medical director at the hospital, said: “We can now build world class facilities that complement the care that goes on in this organisation.”

Now funding has been confirmed, work on the new hospital should begin in 2012, and trust chiefs hope to open the new building in 2014.

Source: Harrow Times

Battling a Biceps Injury People who suffer from injuries to the distal biceps tendon may benefit from earlier surgical intervention and new surgical techniques, according to a review article published in the March 2010 issue of the Journal of the American Academy of Orthopaedic Surgeons (JAAOS).

The study reported individuals who undergo surgery soon after their injuries experience faster and more complete recoveries than patients who are treated nonsurgically, as well as those whose surgeries are delayed.

“Over the last 10 years there has been an increase in techniques to repair the distal biceps tendon,” said Karen Sutton, MD, assistant professor at Yale Medical School and attending orthopaedic surgeon at Yale New Haven Hospital. “Newer techniques allow for smaller incisions and often use one incision instead of two. Moreover, the use of hardware can often return the strength of the tendon to within 90% to 95% of its original strength.”

The study revealed surgical treatment offered a 30% greater improvement in elbow flexion and a 40% greater improvement in supination when compared to nonsurgical treatment. Upper extremity endurance was also improved in patients treated surgically.

The results of the study also indicate surgery is most effective, and simpler, when completed within two weeks of the initial injury.

“Early diagnosis and treatment of these injuries make surgical repair more straightforward,” Sutton added. “The ability to locate the end of the tendon in surgery is easier within the first two weeks, and if the tendon is repaired during this twoweek period, the patient should regain the majority of his or her elbow flexion and forearm supination strength. After two weeks, the tendon tends to scar, making it more difficult to bring the tendon back to

• April 2010

its original attachment.”

Injuries to the distal biceps tendon most often occur as the result of a single trauma involving lifting or moving heavy weights, and may occur more frequently in patients over the age of 30 years, as well as those who smoke and individuals who take anabolic steroids, Sutton noted.

Because other muscles initially may compensate for some of the loss of function following a trauma, these injuries occasionally can be difficult to detect initially, causing treatment to be delayed in some cases, she said. A detailed medical history is one of the primary components used to detect these injuries. Patients who injure their arm during exercise or other activity should be aware of the following warning signs which may point to an injury of the distal biceps tendon: • a “popping” sensation in the arm and bruising around the elbow at the time of injury; • a change in the contour or shape of the biceps muscle; and • pain and weakness in flexion and supination of the injured arm.

Sutton said people can help

prevent biceps injuries by: • avoiding smoking and anabolic steroid use, which decrease blood flow to the tendon, increasing the likelihood of injury; • avoiding lifting heavy weights using a biceps curl; and • exercising caution when moving heavy objects, especially in individuals who smoke, take steroids, or are older than 30.

When a biceps injury does occur, Sutton said no matter which surgical technique is used, one of the most important factors in successful treatment is ensuring the surgery is not delayed.

“There are multiple ways to repair the tendon surgically, and the specific technique used is based on the experience of the surgeon and the latest biomechanical studies on strength and stability of various repairs,” Sutton said. “For a healthy, active individual, it is best to seek medical attention quickly and to be evaluated by an orthopaedic surgeon if a tear is suspected, in order to ensure the best possible outcome.”

Source: American Academy of Orthopaedic Surgeons

An Apology In the January 2010 issue of Orthopaedic Product News, we published a SpR Diary article by Samena Chaudhry, entitled “It feels like we are waiting for a win on the stockmarket, as each consultant stares at the screens waiting for their figures”. We recently received a letter of complaint from The Surgeon citing that this editorial contained several similarities to one of their published articles, “Payment by Results and the Surgeon: Implications for Current and Future Practice” by SS Jameson and MR Reed, The Surgeon 2008, vol 6, issue 3, pages 133-5.

Following this, Orthopaedic

Product News launched an investigation into the matter. May we stress that OPN had no prior knowledge of the likenesses between the two articles until The Surgeon raised it to our recent attention, and the article that we commissioned was, to the best of our knowledge, an entirely original piece. The author of the article has now apologised to The Surgeon as well as to Mr Reed.

OPN treats allegations of plagiarism seriously. We would like to apologise to The Surgeon, Mr Reed and our readers, for the similarities in the January article, which we unknowingly published at the time.

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Company News SPONSORS OF OPN APPOINTMENTS SECTION SPECIALIST RECRUITERS WITHIN ORTHOPAEDICS APPOINTMENTS • Professor Alan Barrell, Executive Chairman of Health Enterprise East, has been appointed Chairman of the newly formed NHS Regional Innovation Council established by the Strategic Health Authority, NHS East of England.

The Council’s remit is to build new partnerships to stimulate and promote innovation across the NHS in the region, by supporting and sharing best practice in order to meet the emerging requirements of the new agenda around quality, innovation, productivity and prevention.

Members include key stakeholders from industry, academia, the NHS, voluntary and public sectors including the Academic Health Science Centre, East of England Development Agency and the Collaboration in Applied Health Research and Care.

Professor Alan Barrell said: “Innovation in the NHS has never been higher on the agenda and I am delighted to be chairing this new initiative to maximise its promotion within the East of England. This role is highly complementary to my position of Chairman at Health Enterprise East, the region’s NHS Innovation Hub which is now in its sixth year and going from strength to strength”.

The Innovation Council will also oversee and advise on the allocation of the Regional Innovation Funds of £1.6 million for 2009/10 with accountability to the East of England NHS Management Board.

Alan Barrell has spent almost 30 years in senior executive positions in technology-based industries. His roles include: Entrepreneur in Residence at the Judge Business School, University of Cambridge, Visiting Professor of Enterprise at the University of Bedfordshire School of Graduate Business Studies, Guest Professor at Xiamen University and Visiting Professor at Shanghai College of Science and Technology. Most recently he has been appointed Senior Research Fellow at Laurea University of Applied Sciences, Helsinki Finland.

• After almost five years as executive director of InMotion Orthopaedic Research Institute, Dick Tarr is retiring.

American company, InMotion has named Larry Foster as its new executive director.

Tarr has led InMotion since 2005, and under his guidance, InMotion has raised nearly $9 million and has grown to 13 employees, including five senior scientists. It is halfway to its fundraising goal of $6 million, which will create an endowment for the organization to cover research, operations and administrative costs.

With InMotion now a reliable source for orthopaedic research. Tarr says Foster was hired to take InMotion to a different level of research.

Source: Memphis Business Journal

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For further information, please call or visit our website

Tel: +44 (0)1636 642830 Web: www.cbasearch.com

Sandvik’s New Unified Quality Management System Saves Medical Device OEMs Time and Money In direct response to customer need, Sandvik has developed and introduced a unified quality management system (Unified QMS) for all its sites and products serving the medical technology sector. The Unified QMS unites the best practice from across Sandvik into a fully harmonized quality management system that is consistent across all sites.

Medical device OEMs can now treat Sandvik as one company, irrespective of the number of sites or products with which they deal.

This effectively rationalises the number of their suppliers, crucial for saving time and money as they secure the regulatory authorities’ quality accreditations for their products; particularly given the increased focus within the industry on supplier control.

The announcement of the Unified QMS represents the next phase in the company’s ongoing strategy of becoming a true strategic partner to medical device OEMs. The Unified QMS, which operates across all Sandvik’s sites in Europe and the US in the medical

sector, is fully compliant with the quality system requirements (QSR) set by the FDA in the US and is ISO 13485 certified.

Sandvik will also have secured multi-site ISO certification by mid-2010.

Jennie Gertun Olsson, Head of Business Assurance at Sandvik MedTech, explained: “The Unified QMS was initiated following consultation with customers and its development has been a long and detailed process, involving every part of the business. To date, customer feedback has been very positive.

“In particular, of real benefit to medical device OEMs is the focus and consequent improvement to contract review and change control processes. Changes to the manufacturing process may require the OEM to secure new approvals from the regulatory authorities so complete control is essential. This change control process has been

improved significantly.

“With regard to contract review the process has been enhanced using best practice.

Any deviances from earlier specifications are being picked up at the initial stages, greatly reducing the financial and time cost. A poorly controlled contract review process can easily let small deviances slip by.

“We are now working closely with our customers to make sure they realise the benefits the unified QMS can bring. We are determined they will gain the improvements in quality and productivity that are possible at the same time as they reduce their costs.”

To develop the Unified QMS, the Sandvik team has reviewed the business and audited and integrated a total of 30 process areas.

These include production management, sales management, purchasing and supplier management, crisis management, communication and project management. Via this approach Sandvik has been able to identify the best practice and use it to underpin the new processes.

Musculoskeletal Research to be Furthered with Introduction of New MRI Scientists at the Leeds Musculoskeletal Biomedical Research Unit (LMBRU), based at Chapel Allerton Hospital, have recently welcomed the installation of a MAGNETOM® Verio from Siemens Healthcare for musculoskeletal research. The system is the only large bore 3 Tesla MRI in the UK being used purely for this purpose.

The MAGNETOM Verio features a large 70cm bore to enable more flexibility and allow researchers to place patients off centre, providing better quality imaging results. The ability to place hands and wrists at the centre of the Verio provides the researchers with clearer and more in-depth images. The bore also accommodates a greater range of patients and can capture sharper

• April 2010

The MAGNETOM® Verio with from left to right Sue Smith, LMBRU Manager; Rob Evans, Senior MRI Research Radiographer; Peter Wright, MRI Medical Physicist; Dr. Richard Hodgson, Senior Lecturer in MRI; Neil Lincoln, Regional Sales Manager at Siemens Healthcare.

images due to less anxiety-related movement.

“Patients will undergo around three or four scans during the course of a research project so the scanner has to be comfortable,” said Dr. Philip O’Connor, Director of Imaging at LMBRU. “We also needed a large bore system for kinematic imaging.

Due to the size of the bore we can put patients off centre; this means we can place joints or extremities

in the middle of the scanner without the patient feeling claustrophobic.”

The LMBRU is part of the Biomedical Health Research Centre, a £13m investment by the Leeds Teaching Hospitals NHS Trust and University of Leeds.

The centre combines four scientific faculties of the university with clinical and scientific experts at the Leeds Teaching Hospitals NHS Trust.

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Company News Results Provide First Clinical Proof of Principle for Kuros’ Bioactive-Biomaterial Product Platform Kuros Biosurgery recently announced the results of a Phase IIb clinical trial assessing the potential of KUR-111 (Viz.I-0401) in the treatment of patients with tibial plateau fractures that require fixation and grafting. The study achieved its primary efficacy endpoint, which was the demonstration of statistical non-inferiority to autograft with respect to the proportion of patients who achieved radiological fracture union at 16 weeks after grafting. This is the first large scale clinical study to demonstrate the efficacy of a product based on Kuros’ proprietary bioactivebiomaterial technologies.

The repair of tibial plateau fractures often requires the replacement of bone lost by compaction with autologous bone taken from another site in the patient. Harvesting of autologous bone has implications for the patient in terms of risk of infection and additional morbidity, as well as requiring additional surgery. KUR-111 is designed to promote bone healing that is considered to be as good as autograft, which is the gold standard in many orthopaedic procedures.

KUR-111 is composed of a variant of parathyroid hormone (vPTH), fibrin sealant and hydroxyapatite/tri-calcium phosphate (HA/TCP) granules. The product is applied directly to the fracture site

as a mouldable putty able to form to the shape of the bone defect. KUR111 utilizes Kuros’ “TG-hook” technology for covalently binding vPTH into the fibrin sealant.

This Phase IIb trial is a randomised, controlled, open-label (dose-blinded), multi-center, dosefinding study. The study treated 183 patients at 30 centers across Europe and Australia. At 16 weeks, 84% of autograft treated patients and 84% of patients treated with the higher dose of KUR-111 had radiological fracture healing defined by an independent radiology panel using CT Scans at 16 weeks post surgery. In addition, a substantial difference was observed between the two doses of vPTH tested in this study, with the higher dose giving the higher efficacy (p value = 0.033).

Secondary endpoints related to efficacy were consistent with the primary endpoint. For example a composite endpoint of CT scan and clinical healing gave 72% for the higher dose of KUR-111 and 64% for autograft. There were no indications of any safety issues.

Virginia Jamieson, Chief Medical Officer of Kuros, commented: “We are extremely pleased with the outcome of this study. The product was well tolerated, with good bone healing. It demonstrated similar efficacy to autograft, and it showed a differ-

First Year Success for Orthopaedic Start-up Company Meeting NHS demand for cost effective services without compromising on quality has helped Newtech Ortho win the prestigious Best Start-Up Award at the West Midlands Medical and Healthcare Business Awards 2010.

Organised by MedilinkWM, the awards shine the spotlight on the success of companies within the Medical Technologies Cluster, supported by Advantage West Midlands, and Newtech Ortho will now go on to represent the region on the national stage at the Medilink UK Awards in March.

Less than 12 months old, Newtech Ortho beat off fierce competition to take the top prize for Best Start-Up, and has already enjoyed strong sales growth, supplying more than 170 NHS and privately owned hospitals in the UK with cost-effective, quality niche implant systems. As

well as choosing to enter a buoyant orthopaedics market, the firm recognised the increasing pressure within the NHS to provide better services with dwindling budgets, and has successfully targeted NHS buyers.

Newtech Ortho Chief Executive, Peter Dines, said: “We’re thrilled to win such a prestigious award so early in our development. It’s been a tough environment for a start-up company, but we feel we chose the right market and sustained the best strategy to meet our commercial targets.

We’ve brought competition into the orthopaedics market, providing NHS buyers with a real alternative to their traditional suppliers and in the next two years we’ll be expanding our range and streamlining our processes to further improve cost-effectiveness for customers.”

ence in the bone healing response between the two concentrations of vPTH tested”.

KUR-111 is the first of a family of product candidates based on Kuros’ “TG-Hook” technology that are designed to improve bone repair or to generate bone. These positive clinical results are not only supportive of this product candidate but also of others that are based on the same or similar technologies.

Didier Cowling, CEO of Kuros, stated: “These positive results further support the strength of Kuros’ product development activities based on bioactivebiomaterial combinations. We look forward to progressing this program, and others, with our partners and to bringing products to market that make a valuable contribution to patient treatment”.

McKenna Group Invests in New ERP Solution

McKenna Group have recently announced that they are now implementing the EFACS E/8 ERP solution from Exel Computer Systems. With a complete business solution in place, McKenna will benefit from a fully integrated system across the group and will be able to utilise toolset technology, automated workflow and processes, and touchscreen technology. EFACS will provide the company with complete visibility and instant access to all data which will better service its customers and provide enhanced performance in many areas such as leadtimes.

Because of their philosophy of continous improvement McKenna Group decided that Efacs is the most suitable solution because it allows them to integrate all aspects of their business onto one platform. The benefits of having a centralised system results in McKenna Group increasing their efficiency by more than 30%.

Efacs is expandable and can be integrated with other specialised software like CAD. This new solution will be launched in May 2010.

April 2010 •

NEWS IN BRIEF • Xanodyne Pharmaceuticals, Inc., an integrated specialty pharmaceutical company with both development and commercial capabilities focused on women’s healthcare and pain management, have recently announced that it has signed a co-promotion agreement for Zipsor™ (diclofenac potassium) Liquid Filled Capsules with Ferring Pharmaceuticals Inc., a global bio-pharmaceutical company, headquartered in Switzerland. Zipsor, a nonsteroidal anti-inflammatory drug (NSAID) indicated for the treatment of mild to moderate acute pain in adults received FDA approval in June 2009, and diclofenac, the active ingredient in Zipsor, is one of the most widely prescribed NSAIDs in the world.

Under the agreement, Ferring’s orthopaedic sales force will promote Zipsor to certain orthopaedic surgeons, rheumatologists, sports medicine physicians and physiatrists in the United States. Co-promotion efforts will begin on May 3, 2010.

“Zipsor represents an exciting addition to our current orthopaedic product portfolio,” said William N. Garbarini, Vice President, Orthopaedics / Urology Business Unit, Ferring Pharmaceuticals. “Ferring has successfully commercialised Euflexxa in the United States and welcomes the opportunity to expand our offering to the orthopaedic community by helping orthopaedic surgeons and rheumatologists treat patients with acute pain.”

Commenting on the agreement, Natasha Giordano, Xanodyne’s Chief Operating Officer said, “We are pleased to partner with a quality company such as Ferring to help us extend the reach of Zipsor in the United States beyond pain specialists and other selected physicians who are the primary focus of our current sales efforts. ” • Surgical Instrument Group Holdings Limited (SIGH) has acquired the business of ENDOSCOPIC MANUFACTURING AND SERVICE (EMS) of Park Royal, London. The business will be transferred immediately to SIGH’s headquarters in Croydon, Surrey.

Mr Brian Corry of EMS has agreed to join SIGH in order to enable a smooth transfer of the business and ensure it maintains its high standards of manufacturing and repair in the future.

Mr David Peddy, managing director of SIGH said “This acquisition represents an important improvement to our range of surgical instrument products and their associated services. At a time when hospital budgets are under pressure, we intend to provide a faster turnaround time for repairs to negate the need for purchasing unnecessary replacements”.

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Company News NEWS IN BRIEF • K2M, Inc. have announced that its Serengeti Minimally Invasive Retractor System received a 2010 Medical Design Excellence Award (MDEA).

Serengeti features a unique flexible polymer retractor which is captured under the head of a cannulated screw and placed with the screw for secure, spine-based retraction. The retractor provides simplified access to the hard to reach L5 - S1 levels, as well as rod introduction for multi-level complex posterior instrumentation procedures.

MDEA entries were evaluated on the basis of their design and engineering features, including innovative use of materials, userrelated functions that improve health care delivery and change traditional medical attitudes or practices, features that provide enhanced benefits to the patient, and the ability of the product development team to overcome design and engineering challenges so that the product meets its clinical objectives, according to the press release. A comprehensive review was performed by an impartial, multidisciplinary panel of third-party jurors with expertise in biomedical engineering, human factors, industrial design, medicine, and diagnostics.

“We are truly honoured to be recognised as a 2010 MDEA Winner,” K2M President and CEO Eric Major, stated. “This achievement reflects K2M’s continued commitment to innovation and our ongoing goal to provide surgeons with new technologies to enhance patient care. We strive to develop more efficient approaches to address spinal surgery through very small incisions.”

• Exactech have announced that the company has been granted approval to market its Novation® primary hip replacement system in Japan, a robust orthopaedics market where hip replacement surgeries outnumber knee replacement procedures.

“Expanding our hip implant sales in Japan is a significant opportunity and one for which we are well positioned,” said Exactech President David Petty. “We have been providing total knee replacement products in Japan for more than a decade. In January 2008 we established a direct distribution operation for the Japanese market, and the addition of our Novation hip line allows us to further leverage that investment.”

According to a report from Millennium Research Group in November 2009, Japan has the largest proportion of people over age 65 in the world, and will continue to be a source of steady revenues in the large-joint reconstructive implant market.

Japan’s Ministry of Health, Labour and Welfare granted Exactech the approval to market elements of the Novation comprehensive hip system, including the tapered femoral hip stem, femoral heads and bi-polar implants.

12 Orthopaedic Product News

New Research Reveals Benefits of Unloader Bracing to Treat Osteoarthritis

The incidence of osteoarthritis is on the rise, and experts expect that, by 2020, OA could affect more than 40 million people and become the fourth-leading cause of disability. Nearly one in 10 people aged 65 and older have symptomatic knee OA, and the number of seniors is expected to double in the next 25 years, which means the demand for medical care to treat OA will increase accordingly.

While knee surgery is available to alleviate pain and improve mobility, a new study from the Steadman Philippon Research Foundation has also proven the effectiveness of knee braces to reduce pain and improve physical function.

The study, “Use of an Unloader Brace for Medial or Lateral Compartment Osteoarthritis of the Knee” was presented in March at

the 2010 American Academy of Orthopaedic Surgeons Annual Meeting, and revealed that patients who used bracing reported significant improvement of their OA symptoms, without resorting to surgery.

The study measured patient expectations of treatment and outcomes following six months of using either a medial or lateral Össur Unloader One® knee brace.

Nearly a quarter (23%) of the patients in the study reported a decrease in the use of over-thecounter anti-inflammatory drugs, while 16% reported a decrease in the use of prescription antiinflammatory drugs.

The Össur Unloader One brace used in the study is designed to reduce pain caused by osteoarthritis by minimizing bone-on-bone contact within the knee joint. The brace’s thigh and calf shells, along with uniquely designed straps, create a leverage system that literally unloads the pressure from the affected area, creating more space between the bones.

Several other studies also support the conclusions of the Steadman Philippon research, including one titled “Patients with Moderate and Severe Knee OA Do Benefit from Using a Valgus Knee Brace,” an ongoing study being conducted by the Department of Orthopaedics at

the Akureyri Hospital, Akureyri, Iceland and also presented at the AAOS Annual Meeting. In the Icelandic study, the Unloader One knee brace was also shown to decrease pain, as it improved movement and function and helped to decrease stiffness.

These results were seen in the first weeks of bracing and these benefits were maintained throughout the six month study period.

Results of both studies indicate that bracing can be a real benefit for those who want, or need, to postpone knee surgery and that this is a proven non-surgical treatment option for knee pain sufferers.

The best way to manage or reduce the onset of OA is to maintain a healthy lifestyle, with exercise, stress reduction, weight management and diet. This new research shows that the Unloader One brace is a proven way to decrease pain and increase mobility, making all those activities potentially easier to accomplish.

To review the abstracts please visit: http://www3.aaos.org/education/anmeet/anmt2010/podium/podium.cfm?Pevent=638 And http://www3.aaos.org/education/anmeet/anmt2010/podium/podium.cfm?Pevent=637

Biospace Med to Accelerate Market Expansion of EOS in North America and Europe Biospace med has raised $18m to accelerate market expansion in North America and Europe of the company’s FDA-cleared EOS ultra-low-dose 2D/3D imaging system for bones.

Biospace med said that the EOS is a new medical imaging technique that allows full-body 2D and 3D imaging of patients using radiation doses up to 89% lower than those required for a standard CR X-ray. EOS will reduce irradiation linked to radiological investigations, which has risen by 600% over the past 20 years.

The benefits of EOS are particularly important in pediatrics, because children undergo X-rays throughout their development, when their organs are highly sus-

• April 2010

ceptible to ionizing radiation.

EOS is also beneficial in adults who do not wish to be exposed to ionizing radiation during standard X-rays or CT scans.

EOS targets particularly the diagnosis, follow-up, preoperative assessment and postoperative follow-up of degenerative diseases and bone and joint deformities.

Indeed, EOS allows full-body and 3-D images of the human skeleton with the help of the software that reconstructs and models a patient’s bones from just two simultaneous images.

The software also generates 3D measurements automatically, and can calculate a broad range of clinical parameters, some of which were hitherto inaccessible, but which are essential to diagno-

sis and surgical planning. The images and clinical parameters are obtained in standing or seated weight-bearing positions and thus reflect the bone and joint status of the patient’s posture.

Marie Meynadier, CEO of biospace med, said: “We are particularly pleased to welcome CDC Entreprises as a new shareholder in the company, and to acknowledge the renewed confidence of our current shareholders. This new fund raising will allow us to accelerate the market penetration of EOS in North America and Europe, so that this revolutionary musculoskeletal imaging modality can become a routine clinical tool.”

Source: Medical Devices Business Review

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Analysis Encouraging News in the UK Medical Equipment Industry – But not for Everyone...

In encouraging news for the UK Medical Equipment industry, 364 of the top 800 companies in the market are growing at more than 10% per annum and making healthy profits. However, according to industry analysts Plimsoll, while many of these companies are breaking new ground and leading a sustainable recovery in the market, there are 103 other companies whose headline grabbing sales growth masks something much more sinister.

David Pattison, senior analyst and author of the new Plimsoll Analysis explains, “Firstly, it makes a nice change to have some positive news to report. 364 growing, increasingly profitable companies have either tapped into a new, fast growing revenue streams or are just the best per-

formers in the old ones. Anyone struggling to make the most of the recovery should look at these companies and ask themselves ‘what do these guys sell, make or do differently to me?’”

However, Pattison warns that there are 103 companies achieving this eye catching sales growth but their profitability tells a very different story, “Essentially there are 2 types of growth in the market – Good v Bad. 103 companies have achieved over the 10% sales growth but in doing so have seen their profit margin collapse.

They are simply overtrading.

The accolades of growth are all well and good but the bills need paying too. More worrying, 19 of these companies have been loss making for 2 years – even with

Take the Risk or Miss the Opportunity? Growth, Innovation and Leadership? Europe 2010 Economic Keynote Announced Predicting the course of the global economy over the next twelve to eighteen months remains controversial. Although a number of respected analysts continue to be pessimistic, Frost & Sullivan is emphasising the positives.

While the financial crisis has been severe and unemployment continues to be a problem, for the past year Frost & Sullivan has emphasised that firms must seize opportunities in the changing global environment. In the words of one of the world’s most successful investors, Warren Buffet: “Be fearful when others are greedy, and be greedy when others are fearful.”

Holger Schmieding, Chief Economist, Bank of America Merrill Lynch will deliver this year’s Economic keynote address at Frost & Sullivan’s flagship client event, GIL 2010: Europe The Global Community of Growth, Innovation and Leadership. He will provide senior executives with key insight into today’s current economic climate and where companies need to stay focused in building their growth strategies to continue back to profitability in 2010.

Supporting Schmieding’s perspective of growth and profitability in 2010 is Frost & Sullivan’s

Chief Economist Vinnie Aggarwal and his analysis of today’s market.

“Unless firms are willing to take some calculated risks, they may miss key opportunities,” Aggarwal says. “In fact, some of today’s top corporations have started in the middle of a recession, with 16 of the 30 companies that make up the Dow industrial average claiming such an origin story.”

Aggarwal also notes that Asia’s growth will continue to be strong. Many analysts have expressed concern that China’s economy is developing a bubble with its rapid 10% growth rate driven by fiscal stimulus in part, but he believes that the continued efforts by the government in China to prevent this have been paying dividends.

Europe, by contrast, is showing slower signs of recovery, with a recent Reuter’s poll of analysts predicting growth of 1.2% this year and then 1.5% in 2011.

“These statistics are evidence that companies have no choice and must have a solid long-term growth strategy to recover,” says Aggarwal. “This includes looking at prospective acquisitions and investments that will position them for future growth.”

NEWS IN BRIEF

double digit sales growth I doubt they will make it to a third”.

On the subject of companies getting it wrong at both ends of the scale, Pattison offers this warning, “While the market continues to recover and the 364 top performers show the way, there are 149 companies facing a very bleak future indeed. Losing sales, profits and probably most of their remaining options, these companies have been rated as Danger in our report. Time is running out and only a takeover or a rapid turnaround is likely to redeem their situation”.

U.S. Market for Orthopaedic Large Joint Reconstructive Devices 2010 Report In 2009, the combined orthopaedic large joint replacement and bone cement market was valued at over $7 billion. Hip and knee arthroplasty has seen consistent doubledigit revenue growth since the early 2000s.

However, growth slowed during the recession that began in 2008, but nearly resumed its previous pace by the end of 2009.

Although large joint arthroplasty is not the fastest growing orthopaedic market, it has proven to be remarkably resilient due to the continued demand for hip and knee implants. The report by ReportsandReports covers these devices, as well as the total market for associated bone cement used for arthroplasty implantation.

The market includes: • The knee reconstruction market • The hip reconstruction market • The bone cement market Within the orthopaedic large joint replacement and bone cement market, companies such as Biomet, DePuy Orthopaedics, Smith & Nephew, Stryker Orthopaedics and Zimmer lead the market. The report provides a detailed analysis of market revenues by device type, market forecasts through 2016, unit sales, average selling prices, market drivers and limiters.

Source: www.reportsandreports.com

April 2010 •

• While the leading orthopaedic device manufacturers continue to be impacted by economic and regulatory challenges, factors such as increasing Research and Development (R&D) costs, a shortening product pipeline and increasing competition from small and medium-sized companies are putting additional pressure on these manufacturers to stay competitive and remain profitable.

Considering the everexpanding competitive landscape, it is important to have a thorough analysis and intelligent insight on the key orthopaedic pipeline devices expected to bring in dynamism in the market.

GlobalData’s new report, “Global Orthopaedic Devices Pipeline Landscape: Analysis of Key Upcoming Products and Technologies” provides key data, information and analysis on the key orthopaedic pipeline devices expected to hit the market in the next seven years.

The report also provides information on the market potential, market scope and expected market penetration of these products. It also identifies and reviews the existing competing technologies and the likely impact of the launch on the competitive landscape. This report is built using data and information sourced from proprietary databases, primary and secondary research and inhouse analysis by GlobalData’s team of industry experts.

• Santa Rosa medical technology startup Osseon Therapeutics is growing, with new funding and product launches outside the U.S. The four-year-old firm makes a next-generation system for repairing spinal fractures.

“We expect to triple our sales by the end of the year,” Osseon CEO John Stalcup said Thursday.

Osseon’s technology targets a $1.6 billion to $3 billion global market for treatments of vertebral compression fractures. They are mostly caused by osteoporosis, which affects about 10 million people in the U.S. The demand is growing as the population ages, Stalcup said.

Most compression fractures happen to women over 50.

The Obama Administration’s health care program also promises to drive sales by bringing millions of new patients into the health system, Stalcup said.

• Stryker reported a rise in their first quarter profit, helped by demand for its Orthopaedic Implants and MedSurg Equipments.

Both earnings and sales came in above Street estimates.

Domestic sales acted as the main thrust behind Stryker’s quarterly sales performance, though International sales also improved from the prior year, but were not as promising as Domestic sales.

Domestic sales rose 12.6% to $1.17 billion, while International sales rose 1.5% to $626.1 million.

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Article

Lively Debate at 2nd ‘SEM for London 2012’ Meeting A series of high level interdisciplinary education events for Senior SEM Practitioners A QMUL-CSEM and DJO Education Initiative

presentation on the Italian system of ‘Preparticipation Screening’ and ‘Low compulsory screening gave us some Back Pain Management’ were the excellent data but raised some intersubjects for the second quarterly esting questions about the usefulmeeting in the ‘Sport and Exercise ness of such mass screening.

Medicine for London 2012’ series of Unfortunately Dr Bryan English had educational events organised by pressing matters at Stamford Bridge Professor Nicola Maffulli, Centre and was unable to join us but Lead, QMUL Centre for Sports and Professor Maffulli eloquently spoke Exercise Medicine (CSEM). Held on about Achilles tendon rupture in the 19th March in association with DJO week that sadly saw David Beckham Education at the Royal Society of ruled out of the World Cup. Medicine, the meeting attracted an Our thanks to DJO Education for international group of 50 high level sponsoring an excellent event and I SEM practitioners with 10 speakers highly recommend the future meetfrom different SEM backgrounds. As Meeting organiser Professor Nicola Maffulli with Professor ings to my colleagues.” well as providing an educational platGiorgio Galanti form, the series of meetings offers a rare opportunity for SEM practitioners to share and debate current Lucie Hanaghan, County Gaelic Football Physiotherapist added: “This was the first meeting of the series I have attended and I thoroughissues and challenges in one room.

The morning’s session on Preparticipation Screening gave an ly enjoyed it. Not only were experts presenting current trends, research enlightening overview of the dilemmas faced by elite sports physi- data and practice in their fields, but the day also included comprehencians and sports bodies. The first speaker was Professor Giorgio sive and critical discussion amongst speakers and delegates at regular Galanti from Florence who candidly discussed the value of state intervals. The delegates included surgeons, physicians and physiotherintervention in preparticipation assessment in Italy. The next two apists working in a broad range of elite sports, which ensured lively speakers, Southern Medical lead for the EIS and CMO for Team debate and invited questions from all parties. As a private practitioner England at the Commonwealth Games, Dr Mike Loosemore and Dr seeing athletes from a spectrum of disciplines, this was exactly the mix Ian Beasley, Doctor for the Senior England Football Squad, further of expertise I was looking for. I now eagerly await the next event!” discussed screening in elite athletes as a tool for profiling and benchmarking to minimize risk of injuries and maximise perform- Professor Giorgio Galanti, Internal Medicine and Director of the ance. They were undecided as to the benefits of screening, prefer- School of Specialisation in Sports Medicine in Florence, added: “I ring the description of preparticipation ‘profiling’ which limits the totally enjoyed the day and being exposed to high level British Sports and Exercise Medicine. The fact that Professor Maffulli was able to implications of a ‘screen’ requiring an action based on findings.

The importance of a healthy heart, the role of Medical Passports cover for absent speakers in such a remarkable way was impressive.” and the success of cardiac screening for elite athletes was discussed by two of the country’s leading cardiologists, Dr Len Shapiro, and Professor Sanjay Sharma, the Medical Director for the Virgin London Marathon, who ended his presentation with a thought-provoking question: “At what cost should the life of one athlete be saved?”

The afternoon session focused on the complex nature of Low Back Pain Management with contributions from leaders in their field: Dr Craig Ranson, Senior Physiotherapist at UKA, Dr David Perry, Consultant Rheumatologist and Lead Clinician Emeritus at Barts and The London Centre for SEM, Mr Jonathan Betser, Consultant Sports Medicine Osteopath and Chairman of the Osteopathic Sports Care Association The speakers: (sitting) Craig Ranson, Giorgio Galanti, Mike (OSCA). The surgical speaker was substituted by the meeting’s chair, Loosemore (standing) Nicola Maffulli, Len Shapiro, Jonathan Professor Maffulli, who gave an insightful lecture on ‘Surgery after conBetser, Ian Beasley, Sanjay Sharma servative management of low back pain’.

Dr Simon Petrides, Clinic Director at the Blackberry Orthopaedic Clinic in Milton Keynes commented: “I would highly recommend this well organised and sponsored meeting for any specialist in elite sports, notwithstanding the networking opportunities and catching up with old friends which seems to get more important as we all get older!”

Dr Pippa Bennett, Chief Medical Officer England Women’s Football Teams & CMO, British Gymnastics added: “I had the pleasure of attending the morning session. Professor Giorgio Galanti’s

14 Orthopaedic Product News

• April 2010

The next meetings in 2010 are 18th June (Diabetes in the Elite Athlete and Injury Surveillance in Olympic Sports); 24th September (Tendinopathies & Compartment Syndrome/ CECS) and 10th December (Anti-doping and Knee Injuries). More information on CSEM-DJO Education events can be found at www.djoglobal.co.uk (news page).

Programmes and booking forms for future meetings are available from Barry Hill at barryghill@hotmail.com.

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Product News Finsbury DeltaMotion® Finsbury, the world leader in large diameter bearing technology, has combined its knowledge with BIOLOX® delta, the world’s leading ceramic material, to bring you DeltaMotion®, the world’s first truly large diameter ceramicon-ceramic bearing.

Use of the latest advanced materials and technology permits optimisation of the head diameter to acetabular cup ratio allowing use of large heads in small diameter acetabulae. This dramatic increase in bearing size allows range of motion and stability of the replaced hip currently only possible using a large diameter metal-on-metal device, such as the ADEPT®.

OrthoView Introduces SmartHip for Total Hip Planning in Less Than 60 Seconds OrthoView LLC, providers of digital planning solutions for orthopaedics, launched the latest version of their software at AAOS 2010. OrthoView Version 6 includes SmartHip automatic templating, an innovation that enables the user to plan a total hip procedure in less than 60 seconds.

SmartHip is one of the latest developments from OrthoView, available with the newest Version 6 release of the software.

“SmartHip enables the surgeon to template a total hip in less than 60 seconds by automatically placing the prosthesis stem template within the femur in the on-screen image.” Said William Peterson, Vice President of Sales for North America. “It also has a one-click reduction feature that provides the surgeon with an instant view of the post-operative position of the femur for a streamlined on-screen templating process.” SmartHip is an integrated feature of OrthoView 6.

OrthoView Tel: +1 800 318 0923 www.orthoview.com

Finsbury Orthopaedics Tel: +44 (0)1372 360830 www.finsbury.org

geneX®ds - Extending the Reach of Injectable Bone Grafts Biocomposites, the pioneers in synthetic bone graft materials have launched geneX ds, a dual syringe mixing and minimally invasive delivery system containing geneX, the unique resorbable bone graft material with a negative surface charge.

The powder and liquid components of geneX are provided pre-packed in separate syringes. The syringes connect together and allow a faster, simpler and cleaner way for mixing geneX. The resulting setting paste can then be delivered through an 8cm dispenser (included). geneX ds is ideal for difficult-to-reach surgical sites or minimally invasive procedures. geneX is a synthetic bone graft material with a unique bi-phasic composition manufactured through a proprietary process ZPC® (Zeta Potential Control) that confers the product with a reproducible negative surface charge. This property stimulates bone cell activity, accelerating bone formation and fusion by harnessing key proteins and directing osteoblast adhesion and proliferation for rapid osteogenesis. geneX is fully resorbable and is completely replaced by bone. geneX overcomes the surgeon’s reliance on donor tissue presenting both a cost saving and a reduction in the risks associated with its use. geneX ds is FDA cleared and CE marked. Available now in 2.5cc.

Biocomposites Ltd Tel: +44 (0)1782 338 580 www.biocomposites.com

16 Orthopaedic Product News

• April 2010

Uplifting Development for Patients with Lower Limb Injuries ‘Elevate’ Lower Limb is a ‘cushion support’ with a slightly pliant body which allows injured lower limbs to be lifted to a level around 12 inches above the heart to reduce, minimise or stem the swelling of the injured lower limb. It is now available to hospitals nationwide.

It has been invented and developed through a collaboration between a Consultant Orthopaedic & Trauma Surgeon at The Ipswich Hospital NHS Trust, Health Enterprise East (HEE), the regional NHS Innovation Hub and a technical textiles company, Precision Stitching Limited.

‘Elevate’ Lower Limb can be used for lower limb trauma, for example knee ligament injuries or ankle fractures, lower limb surgery including total knee replacement, lymphoedema, deep vein thrombosis, chronic venous insufficiency and peripheral oedema secondary to heart failure.

The covering fabric of the support is fluid-proof, latex free and easy to clean. It costs £87.50 + VAT + postage.

PSL Medical Tel: +44 (0)115 955 73 73 info@pslmedical.com www.pslmedical.com

To list your products within the Product News section simply send your product information to us at: editor@opnews.com

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Product News

Animations For Your Web Site Make the most of your Web site – educate your patients online with ViewMedica animations. The leader in multimedia patient education offers a library of more than 150 ViewMedica animations for your Web site.

ViewMedica animations explain common conditions and procedures for the spine, hip, knee, shoulder, hand, elbow, foot and ankle.

Visit www.opnews.com today to see the animations and learn how you can get a Web site that promotes your practice through patient education. ViewMedica animations are customised with your practice name. The animations have printable Web brochures, customised with your practice name and contact information. Print them in the office as a handout or let your patients print them from their home computer. Have your patients take an active role in their education – let them learn with ViewMedica animations.

Swarm Interactive Tel: +44 (0)1423 569 676 www.opnews.com/swarm

STORM used to Reduce Tibial Fractures The Staffordshire Orthopaedic Reduction Machine, STORM, provides an innovative approach to the treatment of unstable lower limb fractures. The basis for the product concept and design is to separate the reduction of the fracture from the fixation. STORM is used in the operating theatre and provides the surgeon with a simple but innovative approach to reducing difficult unstable tibial fractures prior to fixation. STORM provides precise and controllable axial traction, a simple lock wheel system allows large and fine adjustments to correct rotation and the unique translation arms correct angulation and translation.

In trials carried out in the University Hospital of North Staffordshire the use of STORM was shown to shorten operating times by almost 50%.

Firstly, by applying a simple but controlled method to reducing the fracture, the manipulation time to achieve an anatomical reduction averaged just 11 minutes and secondly because the reduction is firmly maintained during the application of the chosen method of fixation both internal and external.

STORM is used to reduce fractures throughout the tibia including the plateau and pilon as shown. As well as being used to reduce fresh fractures STORM can also used to successfully reduce fractures where treatment has been delayed.

Intelligent Orthopaedics Tel: +44 (0)844 800 4405

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April 2010 •

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Product News Pain-free Marathon Training with the Swiss DolorClast Runners with foot and ankle injuries can now use a revolutionary treatment device that is used by various Premier League football teams and was widely used by athletes at the Olympic Games in Beijing.

The Swiss DolorClast is a low-energy Extracorporeal Shockwave Therapy (ESWT) device that draws on the latest medical technology to treat Plantar Fasciitis and Achilles Tendonopathy.

Extracorporeal Shockwave Therapy is a relatively new technology and The National Institute of Health and Clinical Excellence (NICE) recently issued guidance that it is a safe treatment option for foot and ankle injuries. ESWT is a beneficial alternative to invasive surgery and the Swiss DolorClast can be used to treat and manage symptoms.

The Swiss DolorClast works by passing low-energy ‘radial’ shockwaves through the skin to the injured part of the body. Passing these shockwaves through the surface of the skin initiates an inflammation-like condition in the injured tissue that is being treated. This prompts the body to respond naturally by increasing blood circulation, the number of blood vessels and therefore metabolism in the injured tissue.

The UK now boasts an ever-expanding network of orthopaedic surgeons and physiotherapists that are using the Swiss DolorClast.

Spectrum Technology UK Tel: +44 (0)120 276 1198 www.spectrumtechnologyuk.com

18 Orthopaedic Product News

• April 2010

Intraoperative Excellence for Trauma Imaging In trauma and orthopaedic surgery, the precise identification and repositioning of fractures and the accurate placement of implants is of the highest importance. The ARCADIS® Orbic 3D from Siemens Healthcare generates CT-like slices and 3D volumes in real time, assisting with delicate placement tasks, reducing the rate of second interventions and smoothing workflow.

All processes and results can now be checked during intervention, enabling the clinician to react directly. At the same time, X-ray exposure for patient and staff is reduced.

The Orbic 3D has an optimally matched and fully digital 1k2 imaging chain from image acquisition to viewing and archiving. Furthermore, Enhanced Acquisition System (EASY) offers automatic image processing features such as dose, contrast and brightness control.

Its counterbalanced, isocentric C-arm design with intelligent colour coding enables fast and precise positioning. This helps save time and dose plus reduces readjustments by virtually unlimited projection possibilities with 190º orbital rotation.

Siemens Healthcare www.siemens.co.uk/healthcare

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Article

Earthquake in Haiti & the Surgical Response Authors: Miss Mehek Asad, Medical student, Manchester University Mr Asad Syed FRCS FRCS (Tr & Orth), Orthopaedic & Trauma Consultant with special interest in Foot & Ankle Surgery, Wrexham Maelor Hospital, Wrexham

MERLIN’s tented hospital in Port-Au-Prince

We arrived into Haiti three weeks from the devastating earthquake of January 12th that destroyed most of the Haitian capital of Port-AuPrince. Of the 4 million city residents nearly 3 million were affected with 300,000 injured & 400,000 living in open spaces.

The magnitude of this earthquake was 7.0 on the Richter scale.

However the devastation caused was immense compared to the subsequent massive earthquake in Chile which measured 8.8 on the Richter scale. Therefore the impact of a disaster is proportional to the vulnerability of those who are affected. The poor are always the most vulnerable due to over crowding & poor infrastructure. There is no consensus on the number of deaths but it is agreed that between 200,000 - 230,000 people lost their lives.

Who are we?

‘UK Med’ is a charity born out of such disasters. The charity is headed by Professor Tony Redmond Hospital Dean of Salford Royal & Professor of International Emergency Medicine. Its members are NHS consultants from varying fields who have worked in war zones & in natural disasters over the last 20 years. With this charity I have been to operate in earthquake hit regions of Kashmir 2005, China 2008 & Indonesia 2009.

Acute response for Haiti Once the extent of the disaster was appreciated a worldwide call for doctors, especially Orthopaedic surgeons, was issued by the UN & Red Cross. MERLIN one of the DEC (Disaster Emergency Committee) charities had approached ‘UK Med’ to send a team of surgical specialists to set up a hospital in Haiti. DEC is an umbrella organisation set up by the government to collect relief funds from the general public & then to spend the money among themselves on the basis of clinical need & priority. This system is also important from the point of view of preventing duplication of effort & working together to achieve the given aims.

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• April 2010

Our team included Consultant orthopaedics, a Consultant plastic surgeon, two specialist theatre nurses, a specialist burns nurse/manager, a consultant anaesthetist and a logistician. The 8 hour bus journey from Porto Domingo to Haiti was both fascinating and tiring. This road was the only ‘humanitarian corridor’ that connected the republic with Haiti.

All other means of transportation was disrupted. Communication was patchy and little information was coming through even at this stage. The contrast between Haiti and its neighbour the DR (Dominican Republic) could not be starker. Impressive colonial buildings, loud blaring music and smiling faces compared with sad eyes broken bodies & devastated homes. In some areas of the capital 90-95% of the homes were destroyed. Large banners erected around the makeshift camps begging for food & water showed the extent of their desperation.

We reached Port-Au-Prince in the dark and one strained their eyes to look for signs of the devastation caused. As you drew closer to Port Au Prince you regularly saw collapsed buildings. I was later told that most of the school buildings and hospitals had collapsed due to poor workmanship with a considerable loss of life. We arrived at our campsite late in the evening. For the last four weeks the whole city had been without running water, food, electricity and sanitation. The people had grown impatient waiting for the aid to arrive; emotions were high and tempers flaring. There was a sense of urgency as the security situation was precarious and the advice from UN was not to venture out after dark. The tents were erected and we all collapsed in our tents looking forward to starting work the next morning.

Tent Hospital in Port-Au-Prince Most of these disasters occur in hilly terrain and far flung area which are generally poorly accessible. Each disaster is different and understanding the needs of each is important in planning the humanitarian response. Our earlier experiences in Kashmir 2005, China 2008 and Indonesian earthquakes 2009 were entirely different. In all these places

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Article the Federal infrastructure was intact, providing the back bone for any emergency and subsequent rebuilding process. Here the government and the social infrastructure had collapsed due to the sheer scale of the disaster. Therefore all the essential equipment required to undertake such a mission had to be airlifted from outside, starting from the tents to X-ray machines, respirators and water purification plants.

In Haiti it was clear that most local hospitals had been badly damaged and a hospital was needed to treat the injured in this vast Metropolis. This is where working with a large organisation like MERLIN had its advantages as constructing a tent hospital would be a big undertaking requiring logistics, assessments and planning. Once constructed it would need expansion and constant replenishing of resources that only a big organisation could provide. The work in a disaster like this could be divided in acute and delayed response. Patients’ lives and limbs saved by emergency surgery will require many more months of painful reconstructive surgeries and rehabilitation. Teams of doctors and nurses are required to go on a short rotation to provide the continuity of care until the host infrastructure has recovered enough to undertake this work.

Our tent hospital was set up in a tennis court situated in Delmass 33, a poor area and heavily populated part of Port Au Prince. We were on the main road that snakes through this deprived area to end close to the sea front. Most other Non Governmental Organisations (NGO’s) like MSF (Medecins Sans Frontieres) had set up hospitals along this narrow corridor.

This hospital was an example of Anglo-American co-operation in managing the hospital. We worked closely with Irish charity called GOAL and an American NGO called IFM (International Faith Missions). The Irish team consisted of A&E consultants, an anaesthetist, a retired ophthalmologist and nurses. While the American group consisted mainly of nurses and young volunteers. The tent hospital consisted of three main areas. The entrance lead to the triage area where on one side medical emergencies were treated, while on the other side a minor surgery area looked after wound dressings and debridements. The second area was the Operating theatre suite with an adjacent recovery and three further tents housed pre and post op patients. Central to this was the tent that housed administration staff and logistics. The only surviving hut served as the store room of the medical supplies including medications and surgical instruments. The Irish and the Americans looked after the triage and managed the medical emergencies. Our team took on the responsibility of running the theatres and post operative care.

An important lesson learned early from other disasters is to involve the local workforce to give them a feeling of ownership and pride in the project. Therefore a number of locals were employed in the day-to-day running of the hospital. While a team of Haitian nurses were employed to run the hospital at night.

Every two weeks, up until three months, a surgical team consisting of two surgeons, anaesthetist and nurses arrived from UK at this hospital to provide continuity of care.

Type of injuries in an Earthquake Injuries sustained can be varied. The biggest number of injuries is simple fractures and soft tissue injuries which can be adequately treated with dressings and splinting. Most intrabdominal, chest or head injuries are usually fatal. Very few are diagnosed properly and lack of facilities or even training can be a cause of this high fatality rate. In China for example, multi-storey buildings housed most schools and accommodations facilities. As a result we saw a large number of thoraco-lumbar fracture dislocation and calcaneal fractures from jumping from a height. However the main orthopaedic injuries involve limbs including severe muscle-crush injury and open or neglected fractures.

Earthquake an Ortho-plastic Emergency Most fractures in natural disasters are open fractures. A number of these walking wounded are inadequately treated. The overlying soft tissue envelope is crushed and lost at the time of injury or excised during

debridement of devitalised tissue. While life threatening injuries take precedence, a number of simpler fracture configurations are inadequately treated, splinted and advised to seek help later. A number of these become infected; soft tissue envelope deteriorates further requiring skin graft, rotation flaps or free flaps after skeletal stabilisation. Published literature confirms that in order to minimise the rate of amputations or complications definitive plastic procedure has to be performed within 56 days of skeletal stabilisation.

During our stay our surgical team operated on between 30-35 patients. The plastic and Orthopaedic surgeon worked together on two tables simultaneously with two anaesthetists. There are clear advantages of this approach. Both can share from the experience of the other and valuable time can be saved with the orthopaedic surgeon performing debridement and skeletal stabilisation and then giving way to the plastic surgeon for soft tissue cover. This allows definitive surgery to take place in one go - a one stop shop. A number of operations were carried out over the 10 day period. These included open fractures requiring wound debridement, External fixator with skin flaps or grafts, open reduction internal fixation of neglected fracture dislocations, amputations, skin grafts and gastrocnemius & abdominal flaps for more difficult cases.

Asad Syed in the operating theatre

Difference between Earthquake & Blast injuries It is important to make a distinction between crushed limbs from falling masonry or subjected to a gun shot or blast injury. The treatment of both differs radically and treating these injuries on the same line as battlefield often causes confusion and leads to a higher rate of limb amputation that may be salvaged.

EQ Injuries are mainly low velocity injuries, mostly involving the limbs. Entrapment of limbs under rubble may cause extensive musclecrush injury leading to muscle-crush compartment syndrome. If untreated, crush syndrome characterised by hypovolemia, shock, hyperkalemia, acidosis & myoglobin related renal failure occurs. Muscle can resist vascular ischemia for up to four hours. However, adding critical ischemia to mechanical entrapment between two compressing surfaces above the diastolic blood pressure will accelerate this process and muscle death will occur within an hour. At cellular level myocytes lose their ability to maintain their intracellular hyperosmolarity due to cell membrane damage leading to fluid shift from extracellular to intracellular space and seepage of intracellular potassium in the opposite direction.

These events may cause hypovolaemic shock or cardiac arrest. This is further complicated by rhabdomyonecrosis leading to acute renal failure from the excess myoglobin leaked into the circulation. Death may occur within hours of extrication. It is therefore necessary to keep the patient well hydrated, reverse metabolic changes and ensure adequate diuresis.

Some of these patients will also develop compartment syndrome, however the muscle has already died as a result of the crush injury.

Traditional teaching is to perform urgent fasciotomy to release the

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Article compartment pressures. However, in these cases this can be counter productive. As a sterile dead environment invariably becomes infected, not only does the dead tissue bleed excessively, but all the infected dead muscle will now have to be removed. These muscles in a closed environment would have otherwise become fibrotic. It now agreed that performing fasciotomies can lead to severe sepsis and eventual amputation.

These cases of crush injury should be dealt with splintage, rehabilitation and delayed corrective surgery for contractures & clawing of toes.

Blast or gun shot injuries result from the interaction of shock wave with the body. Gas containing organs and viscera are affected.

Secondary blast injury is caused by blast wave or wind and bomb fragments while the tertiary blast injury results in the body being thrown through the air. There is additional damage to skin by thermal injury.

These are more serious multi organ injuries and require radical treatment like laparotomy and amputations immediately to save lives.

In natural disasters it is not necessary to perform amputations immediately. A more measured and cautious approach with initial wound debridement, even in more serious cases, and referring to centres with Orthoplastic cover can save many unnecessary amputations.

Case 3: A 15-yr-old male presented with a neglected open fracture dislocation of ankle at three weeks. The open wound debrided and a full thickness graft applied over the area of skin loss. Ankle was stabilised using an external fixator. (see images below).

Clinical Cases External fixation remains the main means of skeletal stabilisation.

Orthofix external fixators proved to be very versatile and easy to use. These were inserted using battery operated disposable drills. The major drawback of these battery operated drills was lack of power when using them on healthy young bone. The Mini C-arm bought at the cost of £50,000 proved to be invaluable in running of the A&E and performing surgery.

Case 1: A 30-yr-old female suffered a comminuted fracture of her femur and open fractures of her metatarsals of the left hand with loss of skin. She was extricated soon after the earthquake.

Her hand was operated multiple metatarsals were ‘K’ wired tendons reconstructed & one finger amputated. The femoral fracture was placed in a plaster until later. At three and a half weeks her lower limb was rotated, shortened & angulated. XSyed with Case 1 patient at ray revealed a fixed defor- Asad discharge mity. In a tent hospital internal fixation is to be discouraged. Here ORIF was undertaken as a last resort. She was fixed with a Large DCP plate with satisfactory results.

Case 2: A 24-yr-old sole earner of the family had a mutilating injury to her lower limb. She had lost most of her family and was terrified of surgery. She had lost a significant amount of soft tissue from the heel and foot with multiple fractures. The foot appeared insensate and the Plastic surgeon had deemed the foot unsalvageable (see below). A below knee amputation was successfully performed and the patient fitted with an artificial limb through Handicap International.

Orthofix fixator with full thickness skin graft

End of acute response After successfully working for three months following the EQ the MERLIN tent hospital is being dismantled and no further surgery planned. However, specialist nurses will continue to undertake dressings and provide outpatient care for the 200-300 patients attending this hospital daily. The orthopaedic and plastics patients will be provided monitoring and support in a newly established primary health care unit next to the tent hospital.

Advice to clinicians interested in working in disaster zones 1) Best time to salvage limbs is within the first week. Try and get in with the search and rescue teams.

2) Join a medical charity or organisation with the ability to mobiliseat short notice 3) Inform your hospital manager of your intention to do this kind of work. Taking leave and reorganising your commitment can be a tedious job.

4) Keep your vaccines up to date. It can take up to two weeks for them to start protecting you.

5) Undertake one of the Disaster Management courses to become aware of the issues surrounding a natural disaster.

6) Only travel as a part of team to be most effective. This ensures your personal safety and maximises your productivity.

7) Take all your essential gear with you. This may mean collecting instruments or materials over a period of time. There is no greater disappointment then to arrive at a disaster zone inadequately prepared.

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Future Events

May 2010

25 May Half Day Statistics Tutorial Venue: The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Trust, Oswestry, Shropshire, UK E-mail: alison.whitelaw@rjah.nhs.uk Tel: +44 (0)1691 404661

1-6 May 78th AANS Annual Meeting Venue: Philadelphia, PA, USA www.aans.org Contact: American Association of Neurological Surgeons E-mail: info@aans.org Tel: +1 847 378 0500

11th EFORT Congress When: 2-5 June 2010

7 May Legal Aspects of Surgical Practice Venue: London, UK www.rcseng.ac.uk Contact: The Royal College of Surgeons E-mail: generalsurgery@rcseng.ac.uk Tel: +44 (0) 20 7405 3474 10-15 May 13th ISPO World Congress Venue: Leipzig, Germany www.ispoint.org E-Mail: congress@ot-forum.de Tel: +49 231/557050-17

27-28 May Implants 2010 Venue: Lyon, France www.implants-2010.com E-mail: contact@implants-event.com Tel: +33 2 47 27 33 30

2-5 June 11th EFORT Congress Venue: Madrid, Spain www.efort.org Tel: +41 (44) 448 4400 Fax: +41 (44) 448 4411 Email: event@efort.org

14 May The South West Knee Surgeons Meeting Venue: Plymouth, England www.exac.co.uk/training Contact: Joanna Bartlett E-mail: Joanna.barrett@exac.co.uk Tel: +44(0)1527 591555 20 May Orthopaedic Anatomy Course for Junior Surgical Trainees Venue: The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Trust, Oswestry, Shropshire, UK E-mail: alison.whitelaw@rjah.nhs.uk Tel: +44 (0)1691 404661 Las Vegas

23-26 May Current Concepts in Joint Replacement Venue: Las Vegas, USA www.ccjr.com E-mail: info@ccjr.com Tel: +1 216 295 1900

• April 2010

Where: The Feria de Madrid, Madrid, Spain Madrid

27-30 May 83rd Annual Meeting of the Japanese Orthopaedic Association Venue: Tokyo, Japan www.joa2010.jp E-mail: joa2010@congre.co.jp

June 2010

12-13 May Advances in Knee Arthroplasty Venue: London, England E-mail: Joanna.barrett@exac.co.uk Tel: +44 (0)1527 591555

24 Orthopaedic Product News

Future Event In Focus

2 June Introductory Musculoskeletal Course Venue: Hitchin, England www.sonositeeducation.com E-mail: education@sonosite.com Tel: +44 (0)1462 444800 8-9 June Clinical Skills in Spinal Assessment and Management Venue: The Royal College of Surgeons of England, London www.rcseng.ac.uk E-mail: generalsurgery@rcseng.ac.uk 9-10 June 14th ESSKA Congress Venue: Oslo, Norway Contact: Congress Secretariat E-mail: esska@intercongress.de Tel: +49 0611 77160 9-11 June AO Injured Foot Course Venue: Bristol, England www.aouk.org E-mail: info.gb@ao-courses.com Tel: +44 (0)1707 395212 10-11 June Society for Back Pain Research Venue: Odense, Denmark www.sdu.dk

What the website says: The EFORT Congress 2010 is to be held in Madrid, Spain, in combination with the annual congress of the Spanish Orthopaedic and Traumatology Society.

The scientific programme includes symposia and instructional lectures delivered by distinguished speakers from across Europe. Free papers, e-posters, workshops, industrial symposia and technical exhibits will all feature. There will be simultaneous translation in the combined plenary sessions whereas the congress language remains English.

Controversial case discussions and pro and con debates invite you actively to contribute and share your knowledge with colleagues from all around Europe. Plus, in the half-day ExMEx sessions you will gain specialised expertise and share information with different opinion leaders on a specific topic in a group limited to 100 colleagues.

Along with the scientific exhibition, this congress format will cover the whole range of contemporary orthopaedics and traumatology issues in Europe.

There is also an attractive social programme that emphasises Madrid’s beauty and magnificence. (www.efort.org) Contact: Tel: +41 (44) 448 4400 Fax: +41 (44) 448 4411 Email: event@efort.org URL: www.efort.org

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Future Events

14-17 June National Neurotrauma Symposium Venue: Las Vegas, NV, USA www.neurotrauma.org Contact: Karen Gottlieb E-mail: NNS@neurotrauma.org Tel: +1 305 661 5581

29 June - 2 July AO Advances in Operative Fracture Management Course Venue: Leeds, England www.aouk.org E-mail: info.gb@ao-courses.com Tel: +44 (0)1707 395212

16-19 June 4th Advanced Resurfacing Course Venue: Ghent, Belgium www.resurfacing-congress.com E-mail: info@resurfacing-congress.com Tel: +32 (0)3 800 0654

30 June - 2 July Technical Advances to Skull Base Surgery Venue: The Royal College of Surgeons of England, London www.rcseng.ac.uk E-mail: generalsurgery@rcseng.ac.uk

18 June Basic and Advanced Course in Elastic Stable Intramedullary nailing in Children Venue: Sheffield, England E-mail: judith.shaw@sch.nhs.uk Tel: +44 (0)114 271 7568 Fax: +44 (0)114 226 7878 20-25 June 3rd International Conference on Osteoimmunology: Interactions of the Immune and Skeletal Systems Venue: Santorini, Greece Contact: Conference Secretariat E-mail: 3rdOsteoimmunology@aegeanconferences.org Tel: +1 610 527 7630

July 2010 5-8 July AO Principles in Operative Fracture Management Course Venue: Leeds, England www.aouk.org E-mail: info.gb@ao-courses.com Tel: +44 (0)1707 395212 12-16 July The Anatomy Lab Venue: Coventry, UK www.coringroup.com E-mail: events@coringroup.com Tel: +44 (0)1285 659866 14-15 July 3rd Oswestry Shoulder and Elbow course Venue: The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Trust, Oswestry, Shropshire, UK E-mail: alison.whitelaw@rjah.nhs.uk Tel: +44 (0)1691 404661

Geneva

26-30 July 7th Annual Meeting of the Society of Neurointerventional Surgery (SNIS) Venue: Carlsbad, CA, USA www.snisonline.org Contact: Meeting Organiser E-mail: info@snisonline.org Tel: +1 703 691 2272 27 July Half Day Statistics Tutorial Venue: The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Trust, Oswestry, Shropshire, UK E-mail: alison.whitelaw@rjah.nhs.uk Tel: +44 (0)1691 404661

August 2010 31 August - 3 Sep 7th SICOT/SIROT Annual International Conference Venue: Gothenburg, Sweden www.sicot.org E-mail: congress@sicot.org Tel: +32 2648 6823

September 2010 1-4 September BIOSPINE 3 - 3rd International Congress Biotechnologies for Spinal Surgery Venue: Amsterdam, The Netherlands www.biospine.org Contact: Congrex Deutschland GmbH E-mail: biospine@congrex.com Tel: +49 (0)30 25 89 46 2 Edinburgh

23-26 June CARS 2010 - Computer Assisted Radiology and Surgery - 24th International Congress and Exhibition Venue: Geneva, Switzerland www.cars-int.org E-mail: office@cars-int.org Tel: +49 7742 922 434 26-30 June 37th European Symposium on Calcified Tissues Venue: Glasgow, Scotland www.ectsoc.org E-mail: admin@ectsoc.org Tel: +44 (0)1454 610255 28 June -1 July AO Principles in Operative Fracture Management Course Venue: Leeds, England www.aouk.org E-mail: info.gb@ao-courses.com Tel: +44 (0)1707 395212

26 Orthopaedic Product News

โ ข April 2010

18-21 July 1st Society of Curacao Orthopaedic Surgeons, Radiologists and Trauma Surgeons (SOCORT) Bi-Annual Meeting Venue: Curaรงao, Netherlands Contact: J.L. Bloem E-mail: j.l.bloem@lumc.nl 21-24 July The 17th Scoliosis Research Society (SRS) International Meeting on Advanced Spine Techniques Venue: Toronto, Canada www.srs.org Contact: Meetings Department E-mail: meetings@srs.org Tel: +1 414 289 9107 24 July FRCS Orth Important Paper Course (Evidence Based) Venue: Reading, England www.frcsorth.co.uk E-mail: contact@medskills.co.uk Tel: +44 (0) 845 6439597

5-8 September 11th International Congress on Shoulder and Elbow Surgery (ICSES) Venue: Edinburgh International Conference Centre, Scotland. www.ICSES2010.com 8 September Introductory Musculoskeletal Course Venue: Hitchin, England www.sonositeeducation.com Contact: Jes Tiller E-mail: education@sonosite.com Tel: +44 (0)1462 444800 Fax: +44 (0)1462 444801

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Future Events 13 September - 15 October British Casting Certificate Course Venue: Royal National Orthopaedic Hospital, Stanmore, Middlesex www.dundee.ac.uk Contact: British Orthopaedic Association E-mail: casting@boa.ac.uk Tel: + 44 (0)20 7406 1750 13-17 September BOA Annual Congress - 12th Combined Associations Meeting Venue: Glasgow, Scotland www.boa.ac.uk E-mail: d.adams@boa.ac.uk Tel: +44 (0) 20 7405 6507 Fax: +44 (0) 20 7831 2676 15 September Introductory Shoulder Ultrasound Course Venue: Hitchin, England www.sonositeeducation.com Contact: Jes Tiller E-mail: education@sonosite.com Tel: +44 (0)1462 444800 Fax: +44 (0)1462 444801

21-24 September Scoliosis Research Society 45th Annual Meeting & Combined Course Venue: Kyoto, Japan www.srs.org Contact: Scoliosis Research Society Meetings Department E-mail: meetings@srs.org Tel: +1 414 289 9107 Fax: +1 414 276 3349 24-25 September 8th Interventional MRI Symposium Venue: Leipzig, Germany Contact: Department of Diagnostic and Interventional Radiol Tel: +493 419 717 400 Fax: +493 419 717 409

October 2010 3-7 October American College of Surgeons 96th Annual Meeting Venue: Washington, DC, USA www.facs.org Contact: American College of Surgeons E-mail: postmaster@facs.org Tel: +1 312 202 5000 Fax: +1 312 202 5001 5-9 October 25th Annual Meeting of the North American Spine Society (NASS) Venue: Orlando, FL, USA Contact: North American Spine Society E-mail: info@spine.org Tel: +1 (877) 774-6337

For more events in 2010, go to www.opnews.com If you would like to have your event listed in Future Events, please forward the details to: The Editor, Orthopaedic Product News, 2 Cheltenham Mount, Harrogate, HG1 1DL Tel: +44 (0)1423 569676 Fax: +44 (0)1423 569677 Email: editor@pelgrp.com To reproduce our list, please place an acknowledgement to OPN in your text.

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Article

Distal Radius Fractures – The Role of Volar Locking Plates Author: Sam Anand FRCS (Orth), Consultant Orthopaedic Surgeon, Horton Hospital and Horton NHS Treatment Centre, Banbury

Introduction Distal radius fractures are one of the most common fractures encountered in any trauma practice. Ever since Abraham Colles described the classical dinner fork deformity before the days of X-rays there has been a lot of interest and controversy over their management. The general principles in the management of these fractures are: 1. Anatomical reduction especially of any intra articular fragments 2. As rigid fixation as possible 3. Early mobilisation to prevent problems with stiffness Classification Although the term distal radial fractures includes a huge range of fracture patterns, they can be broadly classified into: 1. Extra articular 2. Intra articular Within these broad sub divisions the fractures are usually described according to the direction of displacement, being either volar or dorsal.

The most common cause of injury, i.e. fall on an outstretched hand, means dorsally displaced fractures were much more common then volar displaced fracture.

Treatment Options The traditional methods of treatment have been broadly along the following lines: 1. Manipulation alone 2. Manipulation with K wire fixation 3. Open reduction and internal fixation (ORIF) 4. External fixation Locking Plates In this article I will be focusing on the option of ORIF, with special emphasis on the role of locking plates, and the approach to applying the plates.

Before the age of locking plates internal fixation was used mainly as a buttressing device, depending on the direction of displacement, i.e. dorsal buttressing for the dorsally displaced fracture and vice versa. The plate which was usually a T plate was fixed to the proximal shaft and the distal T segment was used to buttress the distal fragment.

The advent of the locking plates changed the concept of plates from functioning, just as a buttress. These implants functioned as neutralisation devices where the distal locking screws provided direct stability by supporting the sub chondral bone. They did not rely on the purchase of the distal screws which was usually poor on osteoporotic comminuted bone.

Volar plating of the distal radius with double row of distal locking screws

forced rubbing of the extensor tendons against the implants.

3. Blood supply to the dorsal fragments is principally from the dorsal side and these can be damaged during the dissection.

4. The dorsal surface is usually comminuted which increases the difficulty of reduction 5. Dorsal scars are generally less well tolerated.

All of the above, especially the problems associated with extensor tendon attrition, dampened the enthusiasm for the application of the dorsal locking plates and an alternative was being sought.

Dorsal Plates Because most of the distal radius fractures were dorsally displaced and dorsal radius was more easily accessible due to the relative subcutaneous nature of the bone, this became the preferred approach of most surgeons. However there were problems associated with this:

Volar approach to the distal radius The volar aspect of the distal radius is better suited for implant positioning because: 1. More space is available from the skin to bone 2. The flexor tendons are separated from the implant by pronator quadratus 3. The concave surface of the distal radius facilitates better implant position 4. Blood supply is less likely to be disturbed 5. Volar cortex is usually less comminuted 6. Volar scars are better tolerated.

1. There is little space available between the skin and the dorsal surface of the radius and this is occupied by the extensor tendons 2. The dorsal surface of the radius is convex thus which induces

Watershed Line Careful examination of the volar aspect of the distal radius reveals the presence of what is called the watershed line. Distal to this line the

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Article radius slopes in a dorso-distal direction. This ridge is close, 2mm, to the joint line on the ulnar aspect and well proximal, 10-15mm, on the styloid side. It is important to place the implant distal to the watershed line to prevent impinging on the flexor tendons and causing injury.

Extended Volar approach and reduction of fracture The traditional volar approach through the bed of flexor carpi radialis (FCR) is sufficient for simple fractures and when the fractures are recent. But for complex dorsally displaced fractures, especially fractures which are a few days old where the fracture haematoma has organised, it does not give access to the fracture fragments and reduction is difficult. In these instances an extended FCR approach is used by releasing the radial septum and pronating the proximal fragment to gain access to the comminuted fracture fragments.

Biomechanical aspects By approaching distal radius fractures through the volar aspect we are converting a dorsally unstable fracture into one which is now unstable in both directions. Some fractures are inherently unstable in both directions. So the loads placed across the implant can be as high as 50lb for even activities of daily living. Because of the special geometry of the distal radius volar plates a volar plate is in a more favourable bio mechanical position than a corresponding distal radius plate. This is due to the fact that the whole articular surface is offset a few millimetres in a volar direction with respect to the shaft. The stability can also be increased by a second row of distal screws in an opposite inclination.

Together both rows form a scaffold that cradles the articular surface, maintaining reduction in spite of extreme instability.

Complications Complications encountered with volar locking plates are few and are usually related to poor surgical technique. These include inadequate reduction, insufficient exposure and improper implant positioning relating to flexor tendon problems. The other problems are implant failure, infection, non union and reflex sympathetic dystrophy.

Conclusion In conclusion locking volar plates have provided a new approach to the management of distal radius fractures regardless of the direction of displacement of the fracture. The obvious benefits are an early return to function, improved final motion, no extensor tendon problems and the abolition of routine plate removal. It is an easy to learn, simple procedure which has improved the outcome of this common injury.

References 1. J.Orbay. Volar Plate Fixation of Distal Radius Fractures Hand Clinic 21(2005)347-354 2. Ring et al, Prospective multi centre trial of a plate for dorsal fixation of distal radius fractures. J hand Surg Am 1997;22;777-84 3. Peine et al, Comparison of three different plating techniques for dorsum of the distal radius:a biomechanical study J Hand Surg Am 2000:25:29-33 4. Fernandez, Jupiter Fractures of the distal radius: a practical approach to management. New York :Spriinger-Verlag;1996 5. Putnam et al, Advances in fracture management in the hand and distal radius. Hand Clin 1989:5(3):455-70 6. Orbay, Fernandez, Volar fixed angle plate fixation for unstable distal radius fractures in the elderly patient. J Hand Surg 2004;29(1):96-102 7. Baratz et al Displaced intra articular fractures of the distal radius:effect of fracture displacement on contact stresses in a cadaver model. J hand Surg Am 1996:21:183-8

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Review

Book Review Step by Step Management of Lower Limbs Deformity Author: Rajendra Kumar Kanojia

Step by Step Management of Lower Limbs Deformity is another addition in the “Step by Step” series for Orthopaedic conditions. Authored by Rajendra Kumar Kanojia, this book has been published by Jaypee Brothers Medical Publishers Private Limited. It bears the ISBN 978-81-8448-631-5.

Step by Step Management of Lower Limbs Deformity is another addition in the “Step by Step” series for Orthopaedic conditions which aspire to The Pocket book for nutshell treatment of various disorders. This book, though not directed to any particular audience, may be suitable for medical students or orthopaedic residents in early years of training or residency. It is unlikely to be of any significant benefit to one seriously considering deformity correction as a career.

The book accelerates through various steps in deformity correction starting from understanding the deformity and planning deformity correction, then onto Ilizarov fixation and various facets in its execution. Case reports and complications are presented in conclusion, which may be useful for certain audiences.

Dr. Kanojia is Assistant Professor, Department of Orthopaedics at the famous Postgraduate Institute of Medical Education and Research in Chandigarh, India. Dr. Kanojia has been involved in various publications, predominantly dealing with back pain and its management, amongst other things. Dr. Kanojia has drawn his inspiration from Dror Paley, and also other leaders, in this exciting subspecialty, the notable ones in India being Mangal Parihar and G.S.Kulkarni.

The book, though apparently starting with various sections, appears to mix and sadly mash most of them together. Apart from cursory and personal references this book fails to excite the reader at all. Many illustrations are reproduced here and most seem to be neglected trauma or extreme cases of infections in open fractures which is still a large threat in the developing nations. These clinical scenarios are unlikely to be ever experienced in the developed world, except in parts of rural Africa or Asia.

Most clinical photographs accompanying the text are of extremely poor quality with negligible attempts at enhancement or editing. In many such photographs the anatomic location of the frame depicted is unclear and it is frankly difficult to estimate the proximal or the distal end of the limb. Some illustrations are frankly grotesque.

Most cases demonstrated deal with simple deformity correction or deformity correction that should not be attempted simply by factual and scientific recommendations against them. Of particular note in this category which finds mention here are the few cases of congenital pseudarthrosis of the tibia. In others many photographs indicate that the patient may have been better treated with amputa-

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tion in the first place rather than complex frames being used in management. Many photographs such as the one entitled, “a scene of roadside accident” end up wasting valuable space and convey nothing. Some interventions and recommendations are way too simplistic and are unlikely to be able to stand peer-review or statistical analysis. Deformity correction has focussed totally on external fixators and ring fixators and the title does not justify the contents which need to include more comprehensive coverage of various other modalities available to justify its title. The various framed depicted are basic and the book does not deal with current availability, advances or sophistications in the technique elsewhere in the world.

The colloquial style of writing and the rampant errors in spelling and grammar make poor reading eg. “Hybride” (sic). Anecdotal cases, personal opinions and reference to deities are appropriate for a patient education feature in a local neighbourhood weekly newspaper, but this does little to enhance its popularity amongst the physician community.

This book might be useful for the medical student who is planning to do his trauma elective in a developing country. It is common knowledge that in most such countries they have poorly funded state run hospitals where support and equipment is in too short a supply. It is amazing that physicians there actually do what they do with the limited resources available, compounded by abject poverty.

The cases illustrated do indeed reflect the massive workload at some of these institutions. And it is no doubt creditable that the author has dealt with such a significant volume of cases.

This book is only 170 pages long, is pocket sized and is easy to carry and leaf through in a matter of hours. Unfortunately I found the book uninteresting, uninspiring and entirely dispensable.

Book review by Mr. Satish Kale Consultant Orthopaedic Surgeon, FRCS.Ed, Diploma in Sports Medicine (UK), Trauma Fellow (NY, USA) Tutor, RCS.Ed and Consultant Orthopaedic Surgeon

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Review

Journal Review Current Fixation & Trauma Literature The Relationship Between Time to Surgical Debridement and Incidence of Infection After Open High-Energy Lower Extremity Trauma Andrew N. Pollak, MD, et al.

Journal of Bone and Joint Surgery. January 2010. Vol. 92-A. No. 1. Pp. 7-15.

When a person has a high-energy traumatic leg injury resulting in a bone fracture and an open wound, getting to a trauma center and getting treatment is a real emergency. Emergency doctors and staff need to know what the results are of delayed treatment for injuries of this type. With open fractures, the risk of deep infection is a big problem. Irrigation and debridement should be done within the first six hours after the injury.

Sometimes, soft tissue coverage is needed.

Getting treatment in the first six hours seems simple, but these patients often have multiple other life-threatening injuries that demand more immediate attention.

And they may live in a rural setting or need to be transported from one hospital to a trauma center. All of that takes time and attention away from the leg injury. It’s clear that urgent treatment is needed. But how soon?

What’s the optimum time for best results? These are the questions a study group tried to answer with this study.

They reviewed the charts of 315 patients who had high-energy leg injuries and who were treated at one of eight trauma centers. They collected a variety of data and information from the patients’ medical records.

Type of injury, time periods (in hours), and treatment administered were recorded. Patient characteristics such as age, gender, and other injuries were also noted. The patients were divided into two groups depending on whether they were admitted directly to the trauma center (direct group) or had to be transferred from another hospital (transfer group).

Patients ranged in ages from 16 to 69. Certain patients were not included in the study. Patients excluded were those who were in a coma or had a spinal cord injury, burn patients, or military personnel. Anyone who was admitted or transferred to the trauma center more than 24 hours after the injury was also left out of this study. The direct group was all admitted within the first eight hours after injury. Half of the transfer group made it to the trauma center within the first three hours. The remaining transfer patients arrived in equal numbers between four and 10 hours and 11 and 24 hours.

The number of patients in each group who developed infections was compared. Two types of infection were targeted: wound infection and osteomyelitis. Only infections involving the injury site that started during the first three months after the injury were counted. This information was analysed based on the time periods and other patient factors listed. They were trying to see if any particular factor or group of factors combined together might predict who was most likely to develop infection.

Of course, the eventual goal is to reduce and/or eliminate infections altogether. This might be possible if any of the predictive risk factors can be changed up front.

Their findings can be divided into two lists: those factors that made a significant difference on infection

rates and those that didn’t. First, the factors associated with an increased risk of major infection: • Severe tibial fractures (classified as Gustilo Type IIIC): more than two centimeters of bone loss present • Treatment with a metal plate instead of a nail inside the bone to hold it together while the fracture heals • Treatment with external fixation • Time from injury to trauma center (longer delays, greater risk of infection) • Patients who were delayed in getting to a trauma center by more than two hours had five times the risk of infection compared to those who arrived within two hours of their injuries. Once the patient made it to the trauma center, the timing of other events didn’t seem to reach significant levels according to statistical analysis.

Factors that did not seem to contribute to the risk of infection included: • Age, sex, or level of education and economic status • Smoking status • General health or number of other health problems (e.g., heart disease, diabetes, cancer) • Extent of all injuries: amount of muscle damage, skin defects, nerve damage • Type of treatment other than the use of fixation type described above Mostly useful for friends, family, and emergency medical personnel transporting patients, surgeons will find the conclusions useful, too. First, severe traumatic leg injuries should be treated at a trauma center whenever possible to avoid the risk of infection and other complications. Instead of going to a local hospital, it may be better to go directly to the trauma center even if it’s further away. Of course, it depends on the condition of the patient. If life saving measures are needed, hospital admission with delayed transfer to trauma center may be unavoidable. All things considered, admission to a trauma center within two hours of the injury significantly reduces the risk of infection later.

The treatment standard of operative debridement for these injuries within six hours of the traumatic event is still advised. But it appears that preventing infection is more dependent on getting the patient to the trauma center than on how soon the debridement is done.

The authors suggest a follow-up study looking at the timing of prophylactic antibiotics after severe leg injuries and the risk of infection. The information from such a study could help surgeons prioritise which aspects of treatment are most important: antibiotics, debridement, fracture stabilization, soft-tissue coverage, or limb-salvage procedures.

Provided courtesy of eOrthopod.com www.eorthopod.com

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Review Current Hand Surgery Literature Arthroscopically Assisted Percutaneous Fixation of Bennett Fractures Randall W. Culp, MD, and Jeff W. Johnson, MD. The Journal of Hand Surgery. January 2010. Vol. 35A. No. 1. Pp. 137-140.

Improved technology and smaller surgical instruments have changed the way hand surgeons repair Bennett fractures of the thumb. In this article, hand surgeons review those changes and describe how and when to use arthroscopy and fluoroscopy together to get the best results.

A Bennett fracture is a break along the bottom side of the thumb metacarpal closest to the wrist bone.

Because this is a pivotal joint that contributes to all the movements of the thumb, a close and careful fracture reduction is important.

The surgeon uses wires, pins, or screws to hold the bone in place while it heals. Until small-joint arthroscopy became available, surgeons used open incisions and fluoroscopy to guide the reduction and fixation.

But there have been problems just using traction and fluoroscopy because sometimes it looked like the bone is reduced and properly in place when it wasn’t.

Even a slight rotation of the bone can make a difference. Without an anatomic reduction, patients ended up with a painful, arthritic thumb. Combining

arthroscopy with the fluoroscopy has changed all that.

Now the hand surgeon can replace the bone fragments where they belong, apply the appropriate fixation, and make sure everything is lined up perfectly before putting the hand in a splint.

The surgeon faces many challenges coordinating these two tools. The arthroscope must be inserted into the joint without hitting nerves, blood vessels, or tendons. The broken fragment must be rotated and slipped back into place carefully with a tiny probe.

While holding the probe in place and keeping the bone in its perfect spot, the surgeon then fixes the bone in place. When using screws, the surgeon must be careful that the tip of the screw doesn’t go inside the joint.

Bennett fractures of the thumb can be surgically repaired in this fashion and provide patients with a much better long-term result. The authors caution that more complex fractures may still require an open surgery. If the shaft of the bone is broken and/or the soft tissues around the area have been torn, then a more extensive reconstructive procedure may be needed that requires a full incision.

Provided courtesy of eOrthopod.com www.eorthopod.com

Rate of Infection After Carpal Tunnel Release Surgery and Effect of Antibiotic Prophylaxis Neil G. Harness, MD, et al The Journal of Hand Surgery. February 2010. Vol. 35. No. 2. Pp. 189-196 Repetitive strain injuries are occurring more frequently with today’s lifestyles, but the most common one that affects the hand or arm is carpal tunnel syndrome.

Usually, surgery is not the first step approach to dealing with carpal tunnel syndrome. Nonsurgical management, such as taking anti-inflammatory drugs, using splints, and taking regular breaks are the usually first treatments. However, if these don’t work, then surgery may be necessary. The risk of infection is low with carpal tunnel surgery, however it is important to understand how it happens and to learn how to prevent it, if possible.

The authors of this article found that not much research had been done regarding how often infections occurred at the site of carpal tunnel surgery and if preventative antibiotics would help reduce the rate. To address this, the authors reviewed surgical cases involving carpal tunnel syndrome that took place over a 20-month period. They were looking at both superficial infections and those that occurred deep in the incision.

Researchers found 3,003 cases (2,067 women) to review, performed by 98 surgeons in 11 medical centers. This group was dubbed Group A. The patients ranged in age from 48 to 66 years and there were 546 patients who had diabetes. Using the files, the researchers looked for information on infections: if the patients received antibiotics before the surgery, how many patients developed infections, other health issues among the patients, and how the infections were treated. To clarify the infection types, superficial infections were defined as infections that occurred within a month of surgery and were restricted to the skin or superficial, subcutaneous, tissue. Deep incisional infections were infections that occurred within 30 days, but came from deeper within the wound, may have caused the wound

to open, or caused symptoms of infection, such as fever, pain, and/or tenderness at the site.

The first part of the study involved determining who had received prophylactic antibiotics and this rate varied considerably. In one hospital, only 12.3% of the patients received the prophylactic antibiotics, while in another, 89.9% did. The surgeons also varied as to whether they would prescribe them. One surgeon never prescribed the antibiotics (0%) while another did for all patients (100%). This resulted in 2,336 cases, which were put into Group B. In group A, 2,974 of the cases were done as outpatients, the remaining were in the hospital. Of all the 3003 patients, there were 11 surgical site infections: four were in an organ or the space below the tissue and seven were superficial or deep. Three of the 11 patients had diabetes.

One of these patients had extra surgery done at the same time as the carpal tunnel release, on the thumb, so the infection could have begun in that area. All the infections occurred in patients who were operated on as outpatients.

In group B, 1,419 (of 3,003) patients received prophylactic antibiotics, 917 did not and researchers could not be sure if 617 did or didn’t. Among the patients who did receive antibiotics, five developed infections. Six patients who didn’t take antibiotics developed infections too.

The researchers concluded that the overall infection rate after this type of surgery was low and more severe infections, in the organs, for example, was even lower than originally thought and reported. While using antibiotics before surgery is a good idea for some types of surgery, such as on the colon, it doesn’t seem to be necessary for carpal tunnel syndrome, because there were no significant differences in infection rates between patients who had received these antibiotics and those who didn’t.

Provided courtesy of eOrthopod.com www.eorthopod.com April 2010 •

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Coffee Break Coffee Break is a way to take a restful 15 minutes out of your busy day. Whether it’s to read up on a fellow surgeon’s quickfire Q+A, have a go at Sudoku (and win something in the process) or to see a different view on orthopaedics - it’s all here for you in bite-size chunks. If you would like to feature in Surgeon in Brief, please email kate@pelgrp.com.

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Simply fill in the puzzle and enter the three numbers in the blue squares (a, b & c) on www.opnews.com/sudoku to enter our competition. The winner will receive a one-off £50 voucher to spend on the specialist website orthopaedicbooks.com.

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A Different View Controlling Assistive Device (Powered Wheelchair) by Kathy Weaver A focus of Weaver’s art is on the human cost of war, including the impact of traumatic brain injuries and lost limbs on soldiers. She often contemplates how technology – especially robotics – may help them, if continued research investment is made. This chair is tailored to meet the needs of tetraplegic patients, who practice by using virtual reality as a step to creating the interface necessary to enable patients with limited mobility to steer precisely. “I found it fascinating that music is used with the patients to determine their dominant movements, so that body sensors may be more efficiently placed and programmed,” Weaver says.

This is part of the Wounded in Action: An Exhibition of Orthopaedic Advancements in Art. For more information, go to www.woundedinactionart.org

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Alternative News A recent investigation into King Tutankhamen’s life has revealed that the boy king of Egypt may have worn orthopaedic sandals specially designed to deal with several foot conditions he suffered from. When Howard Carter unearthed King Tut’s tomb in 1922, the treasure packed tomb included several pairs of footwear the king had been buried with. While the body of King Tut has undergone x-rays in the past it was only after a recent in-depth genetic investigation into his family that it was discovered the pharaoh suffered from foot conditions.

Researchers, publishing their work in the book “Tutankhamen’s Footwear: Studies of Ancient Egyptian Footwear,” found that King Tut wore special sandals to help him cope with various malformations in his feet. King Tut is believed to have suffered from Kohler disease II in addition to having very deformed feet, both of which would have left him hobbling around perhaps with the assistance of a cane. King Tut’s left foot was clubbed causing it to rotate internally at the ankle while the middle toe on his right foot was lacking a middle bone, making it shorter.

The recent investigations into the King’s footwear have shown that his sandals were specifically designed to aid his movement, including a tight strap on his sandals to help prevent him from dragging his feet.

Source: ecanadanow

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