The outcome of bone graft surgery for nonunion of fractures of the scaphoid.

Data on 806 patients undergoing bone graft surgery for a scaphoid fracture nonunion were retrospectively collected at 19 centres in the United Kingdom. Each centre contributed at least 30 cases. Sufficient data were available in 462 cases to study factors that influenced the outcome of surgery. Overall union occurred in at least 69%, and nonunion in at least 22%, with 9% of cases having 'uncertain union status'. Union appeared to be adversely influenced by smoking and the time between acute scaphoid fracture and nonunion surgery, with adjusted odds ratios of 1.8 and 2.4, respectively, but neither achieved the pre-determined significance level of 0.003. The type of bone graft (vascular vs non-vascular; iliac crest vs distal radius) did not appear to influence outcome. Further large multicentre prospective studies with clear definitions of 'union' and other factors are needed to clarify whether modification of surgical technique can influence union. Level of evidence: IV.

Is the Best Plate a Nail? A Review of 3230 Unstable Intertrochanteric Fractures of the Proximal Femur.

OBJECTIVES: To evaluate the functional outcomes, revision, and mortality rates of 3 implants used for unstable intertrochanteric hip fractures; the sliding hip screw (SHS), with or without a trochanteric stabilization plate (TSP); and a cephalomedullary nail (CMN). DESIGN: Multicentre National Prospective Cohort Study. SETTING: Northern Ireland. PATIENT/PARTICIPANTS: Patients were identified from a prospective database. Fractures were classified according to OTA/AO A31A2.2, A2.3, and A3. All patients had a minimum of 12 months of follow-up. INTERVENTION: Patients received either an SHS, an SHS in combination with a TSP, or a CMN. Implant choice was at the discretion of the operating surgeon. OUTCOME MEASURE: Primary outcome was 12-month mortality analyzed by the Kaplan-Meier survival analysis. Secondary outcomes included 12-month functional status using a validated score and all time revision of implants for any reason. RESULTS: In total, 3230 patients met the inclusion criteria (2474 SHS, 158 SHS + TSP, and 598 CMN). CMN use increased over time, with concomitant reduction in SHS use. There was no significant difference in functional outcomes at 12 months (analysis of variance, P = 0.177). Although men were significantly younger, they were at a higher risk of 12-month mortality. CMNs had statistically significantly lower 12-month mortality rates (P = 0.0148). The highest revision rate (4.04%) was seen in patients treated with SHS alone (P = 0.041). CONCLUSIONS: The use of a CMN in unstable intertrochanteric hip fractures conveys the best results in functional outcomes, 12-month mortality, and has lower revision rates compared with an SHS ± TSP. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Improving efficiency of a regional stand alone bone bank.

The introduction of a stand-alone Bone Bank in our Regional Orthopaedic Hospital has improved the availability of femoral head allograft. Benninger et al. (Bone Joint J 96-B:1307-1311, 2014), demonstrated their institutions bank to be cost effective despite a 30 % discard rate for harvested allograft. We sought to audit our own discard rates and subsequent cost-effectiveness of our bone bank. Donor recruitment. Before approaching a potential donor, our establishment's nurse specialists review their clinical notes and biochemical laboratory results, available on a regional Electronic Care Records. They view femoral head architecture on radiographs against set criteria, Patient Archive and Communication system (SECTRA, Sweden). In total 1383 femoral heads were harvested, 247 were discarded giving an overall rate of 17.9 %. The most common reasons for discard of harvested graft was a positive microbiology/bacteriology result, n = 96 (38.9 %). After a rise in discard rates in 2007, we have steadily reduced our discard rates since 2006/2007 (28.2 %), 2008/2009 (17 %), 2010/2011 (14.8 %), and finally to 10.3 % in 2012/2013. In the current financial year, our cost to harvest, test, store and release a femoral head is £ 610. With a structured donor recruitment process and unique pre-operative radiographic analysis we have successfully reduced our discard rates bi-annually making our bone bank increasingly cost-effective.

Predictive factors for response to abiraterone in metastatic castration refractory prostate cancer.

BACKGROUND: Management of metastatic castration refractory prostate cancer (CRPC) is rapidly evolving. Rationalisation of treatment requires identification of those patients more likely to benefit from a particular therapy. We reviewed the outcome of patients treated with abiraterone at our Institution to describe factors predictive for response. PATIENTS AND METHODS: Patients with CRCP treated with abiraterone were identified. Baseline variables and potential prognostic factors were extracted from electronic records. Outcome measures included overall survival (OS), prostate-specific antigen (PSA) response and time to PSA progression (TTPP). The Kaplan-Meier method and Cox proportional hazards model were used to analyze survival data. RESULTS: A total of 61 patients met the inclusion criteria. In multivariate analysis, three independent predictors of OS were identified: Duration of response to androgen deprivation therapy (ADT) (hazard ratio(HR)=0.95, p=0.006), performance status (HR=7.4, p=0.013), and baseline haemoglobin (HR=0.47, p≤0.001). CONCLUSION: This study has identified three factors predictive for response to abiraterone in CRPC. Duration of response to ADT has not been previously shown to be a predictive factor for patients with CRCP. We suggest that a prospective validation is required.