NovoSorb® biodegradable temporising matrix (BTM) in the reconstruction of cutaneous malignancies in a major cancer centre: a case series.

BACKGROUND: Non-graftable or composite defect reconstruction represents a major challenge to the reconstructive surgeon, with many wounds requiring local flap or free microvascular tissue transfer approaches. The recent advent of synthetic skin substitutes such as Biodegradable Temporizing Matrix (BTM) have revolutionized the management of complex defects including those caused by burns, trauma and infection, with low-morbidity and low-complexity surgery. However, limited data exist supporting their use in cancer reconstruction in Australia. METHODS: We performed a prospective cohort study of patients undergoing cancer resection and reconstruction with BTM between February 2021 and February 2023 in our institution. Reported outcomes included matrix integration, infection, and return to theatre. RESULTS: Twelve patients underwent reconstruction of primary or secondary defects following cancer resection during this period. Eight patients were male, four female, mean age at surgery was 70 years. Pathology resected included squamous cell carcinoma (SCC) and melanoma of the head and neck, sarcoma resection of the lower limb, and osteoradionecrosis (ORN) of the scalp. T-stage of primary tumours ranged from T2 to T4 and one in-transit metastasis of melanoma. Four patients were treated with radiotherapy, two of whom received postoperative radiotherapy (PORT) and two who received neoadjuvant radiotherapy, three additional patients had an intervention to a previously irradiated wound bed for recurrence or ORN. Overall matrix integration was 83% (10/12), with a 50% integration rate (2/4) observed in the post-radiotherapy group, requiring return to theatre for alternative reconstructive approaches. CONCLUSION: We report our experience with a synthetic dermal matrix (BTM) in cancer reconstruction, the largest cohort of this type in the Australian literature. BTM represents an exciting reconstructive tool for the cancer reconstructive surgeon, with a high rate of success and low morbidity.

A comparison of internal fixation and hemiarthroplasty in the management of un- or minimally displaced hip fractures in patients over 60 years old.

BACKGROUND: The incidence of hip fractures in the elderly is increasing. Minimally displaced and undisplaced hip fractures can be treated with either internal fixation or hemiarthroplasty. OBJECTIVES: To identify the revision rate of internal fixation and hemiarthroplasty in patients 60 years or older with Garden I or II hip fractures and to identify risk factors associated with each method. METHOD: A retrospective analysis was conducted from 2 Major Trauma Centres and 9 Trauma Units between 01/01/2015 and 31/12/2020. Patients managed conservatively, treated with a total hip replacement and missing data were excluded from the study. RESULTS: 1273 patients were included of which 26.2% (n = 334) had cannulated hip fixation (CHF), 19.4% (n = 247) had a dynamic hip screw (DHS) and 54.7% (n = 692) had a hemiarthroplasty. 66 patients in total (5.2%) required revision surgery. The revision rates for CHF, DHS and hemiarthroplasty were 14.4%, 4%, 1.2% (p<0.001) respectively. Failed fixation was the most common reason for revision with the incidence increasing by 7-fold in the CHF group [45.8% (n = 23) vs. 33.3% (n = 3) in DHS; p<0.01]. The risk factors identified for CHF revision were age >80 (p<0.05), female gender (p<0.05) and smoking (p<0.05). The average length of hospital stay was decreased when using CHF compared to DHS and hemiarthroplasty (12.6 days vs 14.9 days vs 18.1 days respectively, p<0.001) and the 1 year mortality rate for CHF, DHS and hemiarthroplasty was 2.5%, 2% and 9% respectively. CONCLUSIONS: Fixation methods for Garden I and II hip fractures in elderly patients are associated with a higher revision rate than hemiarthroplasty. CHF has the highest revision rate at 14.4% followed by DHS and hemiarthroplasty. Female patients, patients over the age of 80 and patients with poor bone quality are considered high risk for fixation failure with CHF. Hemiarthroplasty is a suitable alternative with lowest revision rates. When considering an internal fixation method, DHS is more robust than a screw construct.

Results of hydroxyapatite ceramic coated primary femoral stem in revision total hip replacement.

PURPOSE: The purpose of this study was to assess survival rate, functional and radiological outcomes when using a hydroxyapatite-ceramic fully coated primary femoral stem in revision total hip arthroplasty. METHODS: Patients who underwent revision total hip arthroplasty using the Furlong hydroxyapatite-ceramic (HAC)-coated (Joint Replacement Instrumentation Ltd., Sheffield, UK) primary stem were retrospectively identified between 2013 and 2017. A total of 30 hips in 27 patients were identified and the mean follow-up duration was 44 months. Post-operative radiographs were scrutinized for signs of component loosening by two independent assessors. Patient's functional outcomes were assessed using the Oxford hip score and compared pre- and post-operatively. The prevalence of thigh pain was assessed at the latest follow-up. RESULTS: The most common cause of revision was adverse reactions to metal debris (ARMD) (46.6%). The overall complication rate was 13.3%. Results at final follow-up demonstrated 100% survival rate and no reported incidence of thigh pain. Using paired t test, all patients had a statistically significant (P < 0.05) improvement in post-operative mean Oxford hip score of 35 compared to a mean pre-operative score of 14. Radiographic analysis of the latest follow-up radiographs revealed no signs of component loosening or component subsidence. CONCLUSION: With a 100% survival rate and excellent reported functional outcomes, we believe that our experience and results support the use of primary cementless stems in selected revision cases.

Safety and Efficacy Concerns of Autologous Fat Grafting for Velopharyngeal Insufficiency.

OBJECTIVE: Autologous fat grafting of the velopharynx has been well described for the treatment of velopharyngeal insufficiency (VPI), with most studies purporting it as a technique with low morbidity useful in the treatment of mild VPI. Prompted by 3 cases of obstructive sleep apnea (OSA) following fat grafting of the velopharynx, we undertook a review of the outcomes of this procedure at our unit. DESIGN: Retrospective case series. PARTICIPANTS: All patients who underwent autologous fat grafting for VPI at the Royal Children's Hospital Melbourne. MAIN OUTCOME MEASURES: Preoperative nasendoscopy findings, perceptual speech assessment results, and rates of revisional surgery and complications. RESULTS: Twenty-eight patients were included in the study. Three patients (11%) developed severe OSA requiring removal of the grafted fat. In a subanalysis of cleft patients, there was a reported improvement in hypernasality in 63% though only 25% had complete resolution of their hypernasality. Patients who had an improvement in speech were more likely to have a velopharyngeal gap of less than 0.5 cm2 on preoperative nasendoscopy. All 3 patients who developed OSA had syndromes associated with hypotonia. CONCLUSIONS: This study raises serious concerns over the safety and efficacy of fat grafting for VPI. Overall, there was a relatively high complication rate with generally poor speech results in our series of patients. Stringent criteria should be used to select candidates for fat grafting, namely, a velopharyngeal gap less than 0.5 cm2 and the absence of a syndrome associated with hypotonia.

Stem Migration and Fretting Corrosion of the Antirotation Pin in the K2/Apex Hip System.

BACKGROUND: Many exchangeable neck hip systems have been withdrawn because of fretting corrosion at the neck/stem coupling. METHOD: Our prospective randomized study evaluating stem stability (Roentgen stereophotogrammetric analysis, dual-energy x-ray absorptiometry) and clinical outcomes between the K2/Apex hip systems was ceased early because of a withdrawal of the stems which had an unfavorably high early revision rate reported in the Australian Orthopaedic Association National Joint Registry (9.3% at 3 years). RESULTS: At 2 years, there are no clinical differences between the stems. Roentgen stereophotogrammetric analysis has identified a high proportion of potentially concerning subsidence and retroversion in both groups, more marked in the K2 stem, although mostly in asymptomatic patients. Dual-energy x-ray absorptiometry has shown similar bone density around the stems. Retrieval analysis of 3 study patients showed fretting corrosion of the antirotation pin and aseptic lymphocyte-dominated vasculitis-associated lesion, with no relationship to bearing type or size. Analysis of 7 further nonstudy K2/Apex stems confirmed similar corrosion. CONCLUSION: This study shows potentially concerning subsidence of both stems and is the first to describe corrosion at the neck-stem interface and a relationship to metal-related pathology.

The efficacy of tranexamic acid in hip hemiarthroplasty surgery: an observational cohort study.

Tranexamic acid (TXA) has been shown to reduce perioperative blood loss in elective lower limb arthroplasty surgery. There are potentially even greater physiological benefits in minimising blood loss in hip fracture surgery, however limited evidence exists for TXA use in hemiarthroplasty surgery. This study investigates the effect of TXA use on postoperative transfusion rates and haemoglobin (Hb) levels specifically following hemiarthroplasty surgery for hip fractures. A retrospective cohort study was conducted for consecutive hip hemiarthroplasties for fractures between June 2013 and October 2014 comparing patients with or without prophylactic TXA before incision. During the study, 305 hemiarthroplasties were performed with 271 cases eligible. TXA was given in 84 (31%) cases, and both patient groups were matched for known confounding factors. Patients given TXA had a lower transfusion rate (6% vs. 19%. p=0.005) and less blood loss (Hb drop>20g/L) on day 1 post surgery (26% vs. 42%; p=0.014). One transfusion was prevented with every 8 patients given prophylactic TXA. There were no differences in the 30 and 90-day mortality rates with TXA use. Tranexamic acid is safe, cost-effective and reduces the need for blood transfusion and should be considered in all patients undergoing hip hemiarthroplasty for fractures.

Prospective randomised clinical trial assessing subsidence and rotation, using radiostereometric analysis, of two modular cementless femoral stems (Global K2 and Apex).

AIMS: To accurately assess subsidence, rotation and clinical scores in two cementless femoral stems. METHODS: 260 patients received either K2 or Apex femoral stems and were studied over 2y, with RSA and clinical scores. RESULTS: Mean Oxford Hip score for both stems was excellent (45.78 and 46.76). Very little subsidence or rotation were noted on RSA in either stem. There were no statistically significant differences in clinical scores, or radiological motion between stems. Revision rate was 0.8% over the study period. CONCLUSION: Excellent clinical and RSA scores over the 2y study period predict good long term outcomes for these stems.

A retrospective medium- to long-term results of 1500 AGC total knee replacements - An independent centre functional follow up and survivorship.

BACKGROUND: The AGC knee is one of the most widely used knee replacements in the world with good survivorship in national joint registries, including the Swedish within which it remains the gold standard of risk. PURPOSE: However, there are few long term survivorship reviews from the centre other than those affiliated with the designer that also offer any insight into functional outcome. In this review, we present the results of one of the largest non-designer, medium- to long term follow-ups of the AGC knee replacement. METHODS: A total of 1538 AGC knees were performed during a 15 year period, of which 902 were followed up by postal or telephone questionnaire using Oxford Knee Scores, Visual Analogue Scores (VASs) of function and pain and survival analysis. RESULTS: 87.5% of patients reported excellent or good functional reports at final follow up and 90.3% reporting excellent or good pain scores. There is a mean survivorship of 95.88% at 15 years from the 1538 knees. 85.7% of patients had an Oxford score of between 12 and 40, with 71.2% scoring between 0 and 30. 65.6% of patients responded with a VAS of 0 or 1 at rest (minimum pain = 0) and 53.9% reported a VAS of 0 or 1 while walking. INTERPRETATION: Our study shows excellent mid to long term results in a large group of patients was achieved using the AGC TKR implanted by a variety of Consultants and trainee surgeons. This review and data from national registries suggest that in terms of both survivorship and function demonstrate the AGC knee replacement still remains the knee that newer designs must be measured against.

Oxford unicompartmental knee arthroplasty: medial pain and functional outcome in the medium term.

BACKGROUND: In our experience results of the Oxford unicompartmental knee replacement have not been as good as had been expected. A common post operative complaint is of persistent medial knee discomfort, it is not clear why this phenomenon occurs and we have attempted to address this in our study. METHODS: 48 patients were retrospectively identified at a mean of 4.5 years (range = 3 to 6 years) following consecutive Oxford medial Unicompartmental Knee arthroplasties for varus anteromedial osteoarthritis. The mean age at implantation was 67 years (range 57-86). Of these 48 patients, 4 had died, 4 had undergone revision of their unicompartmental knee replacements and 2 had been lost to follow up leaving 38 patients with 40 replaced knees available for analysis using the 'new Oxford Knee Score' questionnaire. During assessment patients were asked specifically whether or not they still experienced medial knee discomfort or pain. RESULTS: The mean 'Oxford score' was only 32.7 (range = 16 to 48) and 22 of the 40 knees were uncomfortable or painful medially.The accuracy of component positioning was recorded, using standard post operative xrays, by summing the angulation or displacement of each component in two planes from the ideal position (according to the 'Oxford knee system radiographic criteria'). No correlation was demonstrated between the radiographic scores and the 'Oxford scores', or with the presence or absence of medial knee discomfort or pain. CONCLUSION: In our hands the functional outcome following Oxford Unicompartmental knee replacement was variable, with a high incidence of medial knee discomfort which did not correlate with the postoperative radiographic scores, pre-op arthritis and positioning of the prosthesis.

Occupationally related bilateral calcific tendonitis of Flexor carpi ulnaris: case report.

We present a case of bilateral calcific tendonitis of the Flexor Carpi Ulnaris attributable to repetitive wrist action which was occupationally related. This was treated conservatively with avoidance of aggravating movement, resting splints and anti inflammatory medication when acute flare ups occurred. Since avoidance of repetitive strain on the wrists he has had no further flare ups in over 2 years. This is the only case of bilateral calcific tendonitis of Flexor Carpi Ulnaris that has been reported in the literature, further more it is the only one which has been attributed to occupation and settled following a change of career.

Long-term follow-up of the surgically corrected clubfoot.

We describe a 17-year follow-up of 44 surgically corrected clubfeet. They were classified preoperatively as mild, moderate or severe and grouped into those operated on before or after 3 months of age. Moderate and severe deformities underwent a posteromedial release after a trial of conservative management. The mean Ponseti score for both groups was 83.9 (good). Severely deformed feet achieved a more favourable result when operated upon before 3 months than those operated later. We conclude that early application of surgery yields better results with severely deformed feet and produces a good functional outcome in the majority of feet.