European Orthopedic Product News

UK £6.00

April 2010

www.opnews.com

ProductNews Orthopaedic

European

ISSN 1478 7393

April 10 13/5/10 09:34 Page 1

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April 2010 • Orthopaedic Product News 3

04 FROM THE EDITOR

04 OPN CONSULTANTSMeet the Consultant Editors who contribute to OPN

06 NEWS

10 COMPANY NEWS

13 ANALYSIS

14 LIVELY DEBATE AT 2ND ‘SEM FOR LONDON 2012’ MEETINGArticle by DJO Education

16 PRODUCT NEWSProduct News Section

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

24 FUTURE EVENTSA comprehensive guide to what’s on

28 DISTAL RADIUS FRACTURES - THE ROLE OF VOLAR LOCKING PLATESArticle by Sam Anand

30 BOOK REVIEWStep by Step Management of Lower Limbs Deformity

32 JOURNAL REVIEWSCurrent Fixation & Trauma and Hand Surgery Literature

34 COFFEE BREAK

April 2010

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

Open Reduction and Internal Fixation inTrauma Practice

In our second article, consultant editor Sam Anand looks atdistal radius fractures, one of the most common fracturesencountered in any trauma practice. Here he focuses onthe option of ORIF, with special emphasis on the role oflocking plates, and the approach to applying the plates.

Page 28

Surgical Response to theEarthquake in Haiti

One of our consultants, Asad Syed, travelled to Haitifollowing the devasting earthquake in January this year.He discusses the ongoing relief effort and the medicalresponse to the trauma victims of the disaster.

Page 20

April In Focus

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Finsbury DeltaMotion®

Second Sport & Exercise MedicineMeeting

Professor Nicola Maffulli, Centre Lead, QMUL Centre forSports & Medicine, hosts the second programme of events inassociation with DJO Education. The sessions, held in March,focused on Preparticipation Screening and Low Back PainManagement.

Page 14

Finsbury, the world leader inlarge diameter bearingtechnology, has combined itsknowledge with BIOLOX®

delta, the world’s leadingceramic material, to bring youDeltaMotion®, the world’s firsttruly large diameter ceramic-on-ceramic bearing.

Use of the latest advancedmaterials and technologypermits optimisation of thehead diameter to acetabularcup ratio allowing use of largeheads in small diameteracetabulae. This dramaticincrease in bearing size allowsrange of motion and stability ofthe replaced hip currently onlypossible using a large diameter metal-on-metal device, such as theADEPT®.

April 10 13/5/10 09:34 Page 3

Group Editor: Leslie CharnecaAssistant Editor: Kate JacksonDeputy Assistant Editor: Richard RedwinDeputy Assistant Editor: Matt NgGroup Sales & Marketing Manager: Debbie HallAccounts: Gaye WrightDesign: Neil MolyneauxConsultant Editors: Satish Kale

Bob ChatterjeeIssaq AhmedSamena ChaudhryAyaz LakdawalaSam AnandAsad SyedRichard Bimmel

New Media & E-commerce: Andy HillLead Developer: Jonathan HillIT Support: Matt WensleyProof Reading: Colin Taylor

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Every effort is made to ensure that information given in this maga-zine is accurate but no legal responsibility is accepted by the Editoror Publisher for errors or omissions in that information. Readers arerecommended to contact manufacturers direct. Views expressed bycontributors are not necessarily shared by OPN. Printed in the UK byBuxton Press.

4 Orthopaedic Product News • April 2010

FFrroomm TThhee EEddiittoorr

EditorialWelcome to the April

issue of EuropeanOrthopaedic Product

News magazine, and withspring finally sprung we cannow look forward to a brightsummer and more new develop-ments and research in the worldof orthopaedics. As mentionedin the previous issue, with theAnnual meeting of theAmerican Academy ofOrthopaedic Surgeons recentlyheld in New Orleans, we haveseen many exciting researcharticles, new products and newsstories springing from themeeting. Three reports from themeeting look at the future ofspine and back conditions, withfuture advances and treatment options for a slipped disc, spine injury inseniors and vertebral fractures. For more information on the studies seepage 6.

With the incidence of osteoarthritis on the rise, experts expect that, by2020, osteoarthritis could affect more than 40 million people and becomethe fourth-leading cause of disability. Nearly one in 10 people aged 65 andolder have symptomatic knee osteoarthritis, and the number of seniors isexpected to double in the next 25 years.

A new study from the Steadman Philippon Research Foundationpresented at the 2010 AAOS Annual Meeting has proven the effectivenessof knee braces to reduce pain and improve physical function. The study,“Use of an Unloader Brace for Medial or Lateral CompartmentOsteoarthritis of the Knee”, revealed that patients who used bracingreported significant improvement of their osteoarthritis symptoms, withoutresorting to surgery. Page 12 has more information on this study and it’sresults.

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

With news of the disaster in Haiti growing more distant, the help anddesperation 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 traumapatients and survivors of the quake.

Finally, you can organise your diary for the year ahead in our FutureEvents section on pages 24-27 and take time out of your busy day with ourCoffee Break feature at the rear of the magazine on page 34. I hope youenjoy this issue and if you have any feedback or would like to contributesomething yourself, please email me [email protected].

Les CharnecaEditor

Copyright © 2010 Pelican Magazines Ltd

The OPN [email protected]

April 10 13/5/10 09:34 Page 4


Keeping OPN informative and relevant is no easy job - that’s why we get help from the eight people below! Our Consultant Editors are onhand 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 addto 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 usat [email protected] and we will pass them on.

Samena qualified from Birmingham Universitybefore going on to complete her Basic SurgicalTrainee in North Staffordshire hospitals. Samenaworks at the Royal Orthopaedic Hospital doing aspinal attachment, before embarking on a stint inPaediatrics. She has published work on hip frac-

tures, imaging in scaphoid fractures and has researched into the costeffectiveness of cell salvage in pelic trauma surgery. In addition to thisshe is helping to set up an orthopaedic service at a hospital in Ugandanear Kampala with an ambition to practise in the third world once fullyqualified.

Ayaz LakdawalaSpR Trauma & OrthopaedicsAyaz is an SpR (T&O) in the BirminghamOrthopaedic Training Programme and is currentlybased at The Royal Orthopaedic Hospital,Birmingham. His projects include ‘TKR in golfers’and ‘Significance of surface changes on retrievedfemoral components after TKR’. Ayaz is interest-

ed in Trauma and surgery of the knee. He has presented papers at var-ious national and international orthopaedic meetings and have publica-tions in various peer reviewed journals including The JBJS. Ayaz hasdesigned a website for the Birmingham Orthopaedic TrainingProgramme – www.brumorth.ninehub.com. This website is an educa-tional resource aimed the trainees particularly preparing for the exams.

Samena ChaudhrySpR Trauma & Orthopaedics

Bob ChatterjeeSpR Trauma & OrthopaedicsSubhamoy Chatterjee, (better known as Bob) isan SpR on the Middlesex rotation in London.Bob graduated from Guy’s & St Thomas’sHospital in 1995, and completed his SHO trainingrotation in Swindon & Oxford. He then embarkedon an MSc in Surgical Science in 2001 reading

biomechanics and skeletal tissue. Bob’s research projects includeexternal fixation, osseopromotive membranes and mobile bearingknees which he undertook at The Institute of Orthopaedics inStanmore. His career interest is spine in which he intends to concen-trate on degenerative spine surgery, particularly kyphoplasty and mini-mally invasive discectomy.

Issaq AhmedSpR Trauma & OrthopaedicsIssaq is a year 3 speciality registrar on the SouthEast of Scotland rotation, and is currently work-ing in Fife. His main interests include lower limbarthroplasty and tumour surgery. Prior to medi-cine he trained as an engineer for Jaguar Cars inCoventry. It was through his engineering degree

that he became interested in Orthopaedics when he undertook aresearch project measuring bone strength and predicting fracture riskusing spectral analysis of digitised x-ray images of the distal radius.Other published work include autogenous bone grafting in total kneearthroplasty, soft tissue release in TKR.

Satish KaleConsultant Orthopaedic Surgeon

Satish Kale completed his basic Orthopaedictraining in India and has been in the UK for morethan 10 years finishing his FRCS from the RoyalCollege of Surgeons of Edinburgh. Satish is aSurgical Tutor for the Royal College of Surgeonsof Edinburgh and has authored several interna-

tional presentations and publications. Satish has been ConsultantEditor and contributor to OPN for more than three years now. He hasreviewed several Orthopaedic and non-Orthopaedic books for themagazine, providing insights into their strengths and weaknesses. Hehas also provided technical articles on varying aspects ofOrthopaedics.

Sam AnandConsultant Orthopaedic SurgeonSam Anand completed his basic Orthopaedictraining in his native India and has been based inthe United Kingdom for over ten years now. Hehas completed his FRCS (Trauma andOrthopaedics) from the Royal College ofSurgeons in Edinburgh, Scotland and has also

done an MSc in Orthopaedic Engineering from Cardiff University inWales. Sam works as a Consultant Orthopaedic Surgeon at the HortonHospital and the Horton NHS Treatment Centre in Banbury, England.His special interests are the upper limb and trauma, especially sportsrelated injuries and joint replacements. He has had several internationalpresentations and is on the review panel of international journals.

Richard BimmelConsultant Orthopaedic Surgeon

Richard trained in Belgium for his medical degree atthe university of Antwerp and started training fororthopaedics and traumatology in 2002, finishing in2008. The program took him to different hospitals inBelgium and also to UCH London for one year as aspecialist registrar with Mr Fares Haddad. He spe-

cialises mainly in hip pathology, especially the hip problems in the youngand active population. Resurfacing hip prosthesis and revision hip surgerytake up a large amount of his practice. Richard now works in a nice hospi-tal in the Northern part of the Netherlands with an enthusiastic young teamof orthopaedic consultants with high interest in new developments inorthopaedics.

Asad SyedFRCS, Trauma & OrthopaedicsAsad is an Orthopaedic & Trauma Consultant atWrexham Maelor Hospital, North Wales. He specialises in Foot & Ankle surgery and has beenworking in Orthopaedics for the last 12 years. Asadstarted his Orthopaedic training in Dublin & thencontinued 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 hisname. One of his passions is humanitarian work. He has been involved inoperating & salvaging limbs in many earthquake zones around the world,including the most recent mission in Haiti. He is also an advisor for a charitythat provides free artificial limbs to the needy in a deprived third worldcountry.

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• Nurses in Teesside, Englandhave played a leading role inslashing treatment times forpatients with fractured neck offemur.

A revised patient pathway hasseen the number of fracturedneck of femur patients havingtheir operation within 48 hours atSouth Tees Hospital Foundationincrease from 62% to 72%, whilethe average length of hospitalstay has been reduced from 18 to14 days. It has saved the trustmoney and freed up bed space.

Senior trauma nurse GlynisPeat led the multi disciplinarygroup which redesigned the treat-ment pathway with input frompatients and carers. As a result,the trust introduced a range ofimprovements including fasttracking through A&E for frac-tured neck of femur patients, a“fitness for surgery” checklist,better pain management and morepatient information.

Ms Peat said: “We now havefaster times to theatre, reducedlength of stay and fewer readmis-sions. The improvements wemade are now part of our normalbusiness.”

The pathway is featured as acase study in a guide for clini-cians on the Department ofHealth’s quality, innovation,productivity and preventionprogramme.

• New guidelines for frontlineservices have been published tohelp clinicians with health prob-lems get prompt help without fearor stigma.

Invisible Patients sets out howorganisations can ensure theysupport their workforce and buildhealthy workplaces for clinicalprofessionals. Its recommenda-tions are based on evidencereviewed for the full Health ofHealth Professionals report aswell as best practice withinhealthcare organisations acrossthe UK.

Invisible Patients identifies theneed for healthcare organisationsand individual practitioners toprevent and manage ill health andfor specialist services to becreated to treat those smallnumbers of sick health profes-sionals.

Welcoming the report,Professor Sir Liam Donaldson,Chief Medical Officer for England,said: “This report highlights thefact that those who provideessential healthcare services canthemselves develop health prob-lems. Most importantly, itprovides a framework and recom-mendations to address theseproblems.

“I would encourage all health-care organisations to use thisreport to aid them in developingsystems that will help improve thehealth of health professionals andfoster a healthy workplace wheresafe and high quality care can bedelivered to patients.”

Source: Department of Health

Screening May Reduce Osteoporotic Fracture RiskScreening middle-aged womenfor osteoporosis leads to increaseduse of hormone replacementtherapy and other treatments, trialfindings have indicated.

“This study strongly suggeststhat a population screening programto target treatment of those at risk ofosteoporosis will reduce frac-tures,” say R Barr (University ofAberdeen, UK) and co-workers.

“It does however remainunclear which specific aspects ofscreening followed by therapygives rise to this reduction in frac-ture risk,” they note.

The team reports on the find-ings from 4800 women, aged45–54 years, who were randomlyassigned to have a dual-energy X-ray absorptiometry scan of the hipand spine, or no screening.

Overall, 1764 women acceptedthe screening offer and 1364

controls were recruited to the study.Screened women in the lowest

quartile for bone mineral densitywere then advised to considertaking HRT, while those in thehigher quartiles were told they neednot consider HRT for osteoporosisprevention unless taking drugs thatincrease their risk for the condition.

The women were questioned 9years later to determine if screeninghad altered use of anti-osteoporotictherapies or risk for fracture.

At follow-up, screened womenwere significantly more likely tohave used HRT than controls(52.4% vs 44.5%). Screening wasalso associated with an increaseduse of vitamin D, calcium supple-ments and anti-osteoporoticmedications (36.6% vs 21.6%).

Furthermore, per protocolanalysis of confirmed fracturesindicated that women who

received screening had a 25.9%risk reduction for fracture at anysite compared with unscreenedcontrols, after adjusting for age,weight, and height.

“The significant reduction infracture risk, associated withparticipation in this study, couldnot be explained by a reduction infalls, since the number of fallersand the number of falls in thescreened and control groups werenot significantly different, againimplying that increased use ofosteoporosis treatments wasresponsible,” write Barr et al.

They conclude in the journalOsteoporosis International:“Further work is required todetermine the optimum age toundertake screening to ensure acost-effective program.”

Source: Medwire News

better to treatment,” said Jeffrey A.Rihn, MD, study co-investigator andassistant professor, Department ofOrthopaedic Surgery, ThomasJefferson University and TheRothman Institute. “We also learnedthat surgery offers advantages overnon-surgical treatment regardless ofthe duration of symptoms.”

Spine Injury in Seniors - Lumbarspinal stenosis is the leading cause ofspine surgery in patients over age 65.Previous studies have demonstratedthe benefit of surgery over non-sur-gical management of this condition,however, in these studies it wasunclear what were the indications forsurgery and largely unknown whichpatients select surgery.

The study looked at 241 patientswho underwent surgery and 115who had non-operative care.Researchers found that patientswho chose surgery tended to be:

• Younger;• With more pain and moredisability• Felt their symptoms wereprogressing.

“These results help complete theevaluation and treatment algorithmfor patients with spinal stenosis. Thefindings will enhance the shareddecision-making process by aidingphysicians in counseling patients tohelp them choose the right treatmentoption,” explained Mark F. Kurd,MD, lead author of the study andorthopaedic surgery resident,Thomas Jefferson University andThe Rothman Institute.

Vertebral Fractures - Vertebralcompression fractures are one ofthe most frequent consequences ofosteoporosis. Current non-surgicaltreatment options involve painmedication, bed rest, physiotherapyand back bracing. However theseoptions do not address the resultingvertebrae breakdown, height lossand other resulting problems.

Balloon kyphoplasty is a mini-mally invasive procedure for acutevertebral fractures. Results were pre-sented from a study of 149 patientstreated with balloon kyphoplasty and151 patients treated with non-surgi-cal treatment. Measurements forquality of life, back pain and func-tion, and days of disability wereassessed through 24 months of fol-low-up. Compared to non-surgicalcare, balloon kyphoplasty:

• Improved quality of life;• Reduced back pain and disability• Did not increase adverseevents including the risk of ver-tebral fracture over two years.

“I have been using balloonkyphoplasty to treat patients withpainful vertebral compression frac-tures for years so the immediateand sustained pain relief we saw inthe study did not surprise me,”concluded Jan Van Meirhaeghe,MD, study co-author. “But untilnow these decreased pain levelsand significant quality of lifeimprovement, as compared to non-surgical treatment, had not beendemonstrated in a clinical trial.”

Source: Science Daily

Breakthroughs in Treatment of Spine and Back ConditionsThree new studies presented at the2010 Annual Meeting of theAmerican Academy of OrthopaedicSurgeons (AAOS) detail advancesin back care and treatment optionsfor specific back and spine condi-tions. Each of the following threestudies consider and report on thepatients’ best outcomes and options:

• Does the duration of symptomsaffect outcomes in the treatmentof lumbar disc herniation?• Treatment of Lumbar SpinalStenosis: Who Decides toHave Surgery?• Balloon Kyphoplasty vsNon-surgical Care: 2 YearOutcome of a RandomisedControlled Trial

Slipped Disc - Lumbar disc hernia-tion mainly affects adults aged 30 to40 years and is commonly caused bydegenerative changes in the spine. Anew study just released analysed theeffect of symptom duration whentreating herniated discs in the lowerback. A comparison was madebetween 927 patients who had inter-vertebral lumbar disc herniationsymptoms for less than six monthsand 265 patients who had symptomslonger than six months. Patientswith symptoms lasting longer thansix months had worse outcomesafter both operative and non-opera-tive treatment than patients withshorter symptom duration.

“The bottom line is patients whoseek treatment, whether it is surgicalor non-surgical, during the first sixmonths of symptoms will respond

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day and age for patients.“I think this will transform the

patient experience here, givingthem the space and privacy that istremendously important.”

Patients, doctors, and health trustbosses have been lobbying the gov-ernment for years, demanding thehospital, which is currently a net-work of ageing buildings, some pre-dating the NHS itself, is rebuilt sofacilities match the standard of care.

Professor Tim Briggs, medicaldirector at the hospital, said: “Wecan now build world class facili-ties that complement the care thatgoes on in this organisation.”

Now funding has been con-firmed, work on the new hospitalshould begin in 2012, and trustchiefs hope to open the new build-ing in 2014.

Source: Harrow Times

The Royal National Orthopaedic Hospital in Stanmoreto be Rebuilt

Battling a Biceps Injury

An Apology

People who suffer from injuries tothe distal biceps tendon may benefitfrom earlier surgical interventionand new surgical techniques,according to a review article pub-lished in the March 2010 issue of theJournal of the American Academy ofOrthopaedic Surgeons (JAAOS).

The study reported individualswho undergo surgery soon after theirinjuries experience faster and morecomplete recoveries than patientswho are treated nonsurgically, as wellas those whose surgeries are delayed.

“Over the last 10 years there hasbeen an increase in techniques torepair the distal biceps tendon,” saidKaren Sutton, MD, assistant profes-sor at Yale Medical School andattending orthopaedic surgeon atYale New Haven Hospital. “Newertechniques allow for smaller inci-sions and often use one incisioninstead of two. Moreover, the use ofhardware can often return thestrength of the tendon to within 90%to 95% of its original strength.”

The study revealed surgicaltreatment offered a 30% greaterimprovement in elbow flexion anda 40% greater improvement insupination when compared to non-surgical treatment. Upper extremi-ty endurance was also improved inpatients treated surgically.

The results of the study alsoindicate surgery is most effective,and simpler, when completed with-in two weeks of the initial injury.

“Early diagnosis and treatmentof these injuries make surgical repairmore straightforward,” Suttonadded. “The ability to locate the endof the tendon in surgery is easierwithin the first two weeks, and if thetendon is repaired during this two-week period, the patient shouldregain the majority of his or herelbow flexion and forearm supina-tion strength. After two weeks, thetendon tends to scar, making it moredifficult to bring the tendon back to

• One of OPN’s consultant editors,Issaq Ahmed is planning toundertake a period of voluntarywork at a dedicated Orthopaedichospital in the South EasternCape of South Africa. As this is aperiod of voluntary unpaid leavehe is appealing for sponsorshipand the possible donation oforthopaedic equipment, whichwould be of benefit to thishospital.

The Bedford OrthopaedicHospital in Umtata is situated atthe heart of the former homelandof Transkei. This hospitalprovides care for a mainly ruralpopulation of approximately 4million people. It has around 200beds within four wards and has aseparate spinal and paediatricward. The inspiration for this visitstems from the work of the late DrChris McConnachie, a Scottishsurgeon who in 1984, with thehelp of charitable funds set up theorthopaedic service to providehealthcare to this impoverishedregion.

Issaq states, “This fellowshipwill allow exposure to several rareand untreated pathologies notseen in the United Kingdom.Conditons commonly seen at thishospital include musculoskeletaltumours, severe chronicosteomyelitis, untreated club feet,tuberculosis, as well as apandemic of injuries from roadtraffic accidents and gunshots.”

A significant part of his visitwill also focus on teaching inconjunction with the Institute forGlobal Orthopaedics andTraumatology (IGOT). This is anon-profit academic organisationwho aim to improve the muscu-loskeletal care in the developingworld by focusing on training oflocal practitioners.

We at OPN are pleased tosupport Issaq, if your company ororganisation are interested insponsoring or donating equip-ment, please [email protected].

• The Trauma and OrthopaedicDepartment at LancashireTeaching Hospitals NHSFoundation Trust, which runs theRoyal Preston and Chorley andSouth Ribble hospitals, is cele-brating double success.

The North West OrthopaedicTraining Association votedorthopaedic consultant DannyRedfern as the best regionaltrainer of the year andorthopaedic consultant AslamMohammed won an award for thebest research paper presented byDr Taha Lilo, senior house officerin orthopaedics at the trust.

Mr Redfern said: “This is anhonour and recognition of thestrong track record at the trust intraining the surgeons of the futureand undertaking research.”

Mr Mohammed added: “We aredelighted to have been recog-nised by our peers in this way.”

Source: Lancashire Evening Post

A world-renowned hospital inStanmore, London, has finally wonits battle for funding from the gov-ernment for its rebuilding project.

Health Secretary AndyBurnham announced £81m will beinvested in rebuilding the RoyalNational Orthopaedic Hospital,bringing to an end a 46-year battleto keep the specialist facility open.He said: “The NHS should be ableto offer something better in this

its original attachment.”Injuries to the distal biceps ten-

don most often occur as the resultof a single trauma involving lift-ing or moving heavy weights, andmay occur more frequently inpatients over the age of 30 years,as well as those who smoke andindividuals who take anabolicsteroids, Sutton noted.

Because other muscles initiallymay compensate for some of theloss of function following a trauma,these injuries occasionally can bedifficult to detect initially, causingtreatment to be delayed in somecases, she said. A detailed medicalhistory is one of the primary com-ponents used to detect theseinjuries. Patients who injure theirarm during exercise or other activi-ty should be aware of the followingwarning signs which may point toan injury of the distal biceps tendon:

• a “popping” sensation in thearm and bruising around theelbow at the time of injury;• a change in the contour orshape of the biceps muscle; and• pain and weakness in flexionand supination of the injured arm.

Sutton said people can help

prevent biceps injuries by:• avoiding smoking and anabolicsteroid use, which decrease bloodflow to the tendon, increasingthe likelihood of injury;• avoiding lifting heavy weightsusing a biceps curl; and• exercising caution when mov-ing heavy objects, especially inindividuals who smoke, takesteroids, or are older than 30.

When a biceps injury doesoccur, Sutton said no matterwhich surgical technique is used,one of the most important factorsin successful treatment is ensuringthe surgery is not delayed.

“There are multiple ways torepair the tendon surgically, and thespecific technique used is based onthe experience of the surgeon andthe latest biomechanical studies onstrength and stability of variousrepairs,” Sutton said. “For a healthy,active individual, it is best to seekmedical attention quickly and to beevaluated by an orthopaedic surgeonif a tear is suspected, in order toensure the best possible outcome.”

Source: American Academy ofOrthopaedic Surgeons

In the January 2010 issue ofOrthopaedic Product News, wepublished a SpR Diary article bySamena Chaudhry, entitled “Itfeels like we are waiting for a winon the stockmarket, as each con-sultant stares at the screens waitingfor their figures”. We recentlyreceived a letter of complaintfrom The Surgeon citing that thiseditorial contained several simi-larities to one of their published arti-cles, “Payment by Results and theSurgeon: Implications for Currentand Future Practice” by SS Jamesonand MR Reed, The Surgeon 2008,vol 6, issue 3, pages 133-5.

Following this, Orthopaedic

Product News launched an inves-tigation into the matter. May westress that OPN had no priorknowledge of the likenessesbetween the two articles until TheSurgeon raised it to our recentattention, and the article that wecommissioned was, to the best ofour knowledge, an entirely origi-nal piece. The author of the articlehas now apologised to TheSurgeon as well as to Mr Reed.

OPN treats allegations of pla-giarism seriously. We would like toapologise to The Surgeon, Mr Reedand our readers, for the similari-ties in the January article, which weunknowingly published at the time.

April 10 13/5/10 09:34 Page 8

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CCoommppaannyy NNeewwss

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SPONSORS OF OPN APPOINTMENTS SECTION

• Professor Alan Barrell, ExecutiveChairman of Health Enterprise East,has been appointed Chairman of thenewly formed NHS RegionalInnovation Council established bythe Strategic Health Authority, NHSEast of England.

The Council’s remit is to buildnew partnerships to stimulate andpromote innovation across the NHSin the region, by supporting andsharing best practice in order to meetthe emerging requirements of thenew agenda around quality, innova-tion, productivity and prevention.

Members include key stakeholdersfrom industry, academia, the NHS,voluntary and public sectors includingthe Academic Health Science Centre,East of England Development Agencyand the Collaboration in AppliedHealth Research and Care.

Professor Alan Barrell said:“Innovation in the NHS has neverbeen higher on the agenda and I amdelighted to be chairing this newinitiative to maximise its promotionwithin the East of England. This roleis highly complementary to my posi-tion of Chairman at Health EnterpriseEast, the region’s NHS InnovationHub which is now in its sixth year andgoing from strength to strength”.

The Innovation Council will alsooversee and advise on the allocationof the Regional Innovation Funds of£1.6 million for 2009/10 withaccountability to the East of EnglandNHS Management Board.

Alan Barrell has spent almost 30years in senior executive positions intechnology-based industries. His rolesinclude: Entrepreneur in Residence atthe Judge Business School, Universityof Cambridge, Visiting Professor ofEnterprise at the University ofBedfordshire School of GraduateBusiness Studies, Guest Professor atXiamen University and VisitingProfessor at Shanghai College ofScience and Technology. Mostrecently he has been appointed SeniorResearch Fellow at Laurea Universityof Applied Sciences, Helsinki Finland.

• After almost five years as executivedirector of InMotion OrthopaedicResearch Institute, Dick Tarr is retiring.

American company, InMotionhas named Larry Foster as its newexecutive director.

Tarr has led InMotion since 2005,and under his guidance, InMotionhas raised nearly $9 million and hasgrown to 13 employees, includingfive senior scientists. It is halfway toits fundraising goal of $6 million,which will create an endowment forthe organization to cover research,operations and administrative costs.

With InMotion now a reliablesource for orthopaedic research. Tarrsays Foster was hired to take InMotionto a different level of research.

Source: Memphis Business Journal

Sandvik’s New Unified Quality Management SystemSaves Medical Device OEMs Time and MoneyIn direct response to customerneed, Sandvik has developed andintroduced a unified qualitymanagement system (UnifiedQMS) for all its sites and productsserving the medical technologysector. The Unified QMS unitesthe best practice from acrossSandvik into a fully harmonizedquality management system that isconsistent across all sites.

Medical device OEMs can nowtreat Sandvik as one company,irrespective of the number of sitesor products with which they deal.This effectively rationalises thenumber of their suppliers, crucialfor saving time and money as theysecure the regulatory authorities’quality accreditations for theirproducts; particularly given theincreased focus within the industryon supplier control.

The announcement of theUnified QMS represents the nextphase in the company’s ongoingstrategy of becoming a truestrategic partner to medical deviceOEMs.

The Unified QMS, which oper-ates across all Sandvik’s sites inEurope and the US in the medical

sector, is fully compliant with thequality system requirements(QSR) set by the FDA in the USand is ISO 13485 certified.Sandvik will also have securedmulti-site ISO certification bymid-2010.

Jennie Gertun Olsson, Head ofBusiness Assurance at SandvikMedTech, explained: “The UnifiedQMS was initiated followingconsultation with customers and itsdevelopment has been a long anddetailed process, involving everypart of the business. To date,customer feedback has been verypositive.

“In particular, of real benefit tomedical device OEMs is the focusand consequent improvement tocontract review and change controlprocesses. Changes to the manu-facturing process may require theOEM to secure new approvalsfrom the regulatory authorities socomplete control is essential. Thischange control process has been

improved significantly.“With regard to contract

review the process has beenenhanced using best practice.Any deviances from earlier speci-fications are being picked up atthe initial stages, greatly reducingthe financial and time cost. Apoorly controlled contract reviewprocess can easily let smalldeviances slip by.

“We are now working closelywith our customers to make surethey realise the benefits the unifiedQMS can bring. We are deter-mined they will gain the improve-ments in quality and productivitythat are possible at the same timeas they reduce their costs.”

To develop the Unified QMS,the Sandvik team has reviewedthe business and audited and inte-grated a total of 30 process areas.These include productionmanagement, sales management,purchasing and supplier manage-ment, crisis management,communication and projectmanagement. Via this approachSandvik has been able to identifythe best practice and use it tounderpin the new processes.

Musculoskeletal Research to be Furthered withIntroduction of New MRIScientists at the LeedsMusculoskeletal BiomedicalResearch Unit (LMBRU), basedat Chapel Allerton Hospital, haverecently welcomed the installationof a MAGNETOM® Verio fromSiemens Healthcare for muscu-loskeletal research. The system isthe only large bore 3 Tesla MRI inthe UK being used purely for thispurpose.

The MAGNETOM Veriofeatures a large 70cm bore toenable more flexibility and allowresearchers to place patients offcentre, providing better qualityimaging results. The ability toplace hands and wrists at thecentre of the Verio provides theresearchers with clearer and morein-depth images. The bore alsoaccommodates a greater range ofpatients and can capture sharper

images due to less anxiety-relatedmovement.

“Patients will undergo aroundthree or four scans during thecourse of a research project so thescanner has to be comfortable,”said Dr. Philip O’Connor,Director of Imaging at LMBRU.

“We also needed a large boresystem for kinematic imaging.Due to the size of the bore we canput patients off centre; this meanswe can place joints or extremities

in the middle of the scannerwithout the patient feeling claus-trophobic.”

The LMBRU is part of theBiomedical Health ResearchCentre, a £13m investment by theLeeds Teaching Hospitals NHSTrust and University of Leeds.The centre combines four scien-tific faculties of the universitywith clinical and scientific expertsat the Leeds Teaching HospitalsNHS Trust.

The MAGNETOM® Veriowith from left to right SueSmith, LMBRU Manager;Rob Evans, Senior MRIResearch Radiographer;Peter Wright, MRI MedicalPhysicist; Dr. RichardHodgson, Senior Lecturerin MRI; Neil Lincoln,Regional Sales Managerat Siemens Healthcare.

April 10 13/5/10 09:34 Page 10



NEWS IN BRIEF

• Xanodyne Pharmaceuticals, Inc.,an integrated specialty pharma-ceutical company with bothdevelopment and commercialcapabilities focused on women’shealthcare and pain management,have recently announced that ithas signed a co-promotion agree-ment for Zipsor™ (diclofenacpotassium) Liquid Filled Capsuleswith Ferring Pharmaceuticals Inc.,a global bio-pharmaceuticalcompany, headquartered inSwitzerland. Zipsor, a non-steroidal anti-inflammatory drug(NSAID) indicated for the treat-ment of mild to moderate acutepain in adults received FDAapproval in June 2009, anddiclofenac, the active ingredientin Zipsor, is one of the mostwidely prescribed NSAIDs in theworld.

Under the agreement,Ferring’s orthopaedic sales forcewill promote Zipsor to certainorthopaedic surgeons, rheumatol-ogists, sports medicine physi-cians and physiatrists in theUnited States. Co-promotionefforts will begin on May 3, 2010.“Zipsor represents an excitingaddition to our currentorthopaedic product portfolio,”said William N. Garbarini, VicePresident, Orthopaedics / UrologyBusiness Unit, FerringPharmaceuticals. “Ferring hassuccessfully commercialisedEuflexxa in the United States andwelcomes the opportunity toexpand our offering to theorthopaedic community byhelping orthopaedic surgeonsand rheumatologists treatpatients with acute pain.”

Commenting on the agree-ment, Natasha Giordano,Xanodyne’s Chief OperatingOfficer said, “We are pleased topartner with a quality companysuch as Ferring to help us extendthe reach of Zipsor in the UnitedStates beyond pain specialistsand other selected physicianswho are the primary focus of ourcurrent sales efforts. ”

• Surgical Instrument GroupHoldings Limited (SIGH) hasacquired the business of ENDO-SCOPIC MANUFACTURING ANDSERVICE (EMS) of Park Royal,London. The business will betransferred immediately toSIGH’s headquarters in Croydon,Surrey.

Mr Brian Corry of EMS hasagreed to join SIGH in order toenable a smooth transfer of thebusiness and ensure it maintainsits high standards of manufac-turing and repair in the future.

Mr David Peddy, managingdirector of SIGH said “This acqui-sition represents an importantimprovement to our range ofsurgical instrument products andtheir associated services. At atime when hospital budgets areunder pressure, we intend toprovide a faster turnaround timefor repairs to negate the need forpurchasing unnecessary replace-ments”.

Results Provide First Clinical Proof of Principle for Kuros’Bioactive-Biomaterial Product PlatformKuros Biosurgery recentlyannounced the results of a Phase IIbclinical trial assessing the potentialof KUR-111 (Viz.I-0401) in thetreatment of patients with tibialplateau fractures that require fixa-tion and grafting. The studyachieved its primary efficacyendpoint, which was the demonstra-tion of statistical non-inferiority toautograft with respect to the propor-tion of patients who achieved radio-logical fracture union at 16 weeksafter grafting. This is the first largescale clinical study to demonstratethe efficacy of a product based onKuros’ proprietary bioactive-biomaterial technologies.

The repair of tibial plateau frac-tures often requires the replacementof bone lost by compaction withautologous bone taken from anothersite in the patient. Harvesting ofautologous bone has implicationsfor the patient in terms of risk ofinfection and additional morbidity,as well as requiring additionalsurgery. KUR-111 is designed topromote bone healing that isconsidered to be as good as auto-graft, which is the gold standard inmany orthopaedic procedures.

KUR-111 is composed of avariant of parathyroid hormone(vPTH), fibrin sealant and hydrox-yapatite/tri-calcium phosphate(HA/TCP) granules. The product isapplied directly to the fracture site

as a mouldable putty able to form tothe shape of the bone defect. KUR-111 utilizes Kuros’ “TG-hook”technology for covalently bindingvPTH into the fibrin sealant.

This Phase IIb trial is arandomised, controlled, open-label(dose-blinded), multi-center, dose-finding study. The study treated 183patients at 30 centers across Europeand Australia. At 16 weeks, 84% ofautograft treated patients and 84%of patients treated with the higherdose of KUR-111 had radiologicalfracture healing defined by an inde-pendent radiology panel using CTScans at 16 weeks post surgery. Inaddition, a substantial differencewas observed between the twodoses of vPTH tested in this study,with the higher dose giving thehigher efficacy (p value = 0.033).Secondary endpoints related to effi-cacy were consistent with theprimary endpoint. For example acomposite endpoint of CT scan andclinical healing gave 72% for thehigher dose of KUR-111 and 64%for autograft. There were no indica-tions of any safety issues.

Virginia Jamieson, ChiefMedical Officer of Kuros,commented: “We are extremelypleased with the outcome of thisstudy. The product was well toler-ated, with good bone healing. Itdemonstrated similar efficacy toautograft, and it showed a differ-

First Year Success for OrthopaedicStart-up CompanyMeeting NHS demand for costeffective services without compro-mising on quality has helpedNewtech Ortho win the prestigiousBest Start-Up Award at the WestMidlands Medical and HealthcareBusiness Awards 2010.

Organised by MedilinkWM,the awards shine the spotlight onthe success of companies withinthe Medical Technologies Cluster,supported by Advantage WestMidlands, and Newtech Orthowill now go on to represent theregion on the national stage at theMedilink UK Awards in March.

Less than 12 months old,Newtech Ortho beat off fiercecompetition to take the top prizefor Best Start-Up, and has alreadyenjoyed strong sales growth,supplying more than 170 NHSand privately owned hospitals inthe UK with cost-effective,quality niche implant systems. As

well as choosing to enter abuoyant orthopaedics market, thefirm recognised the increasingpressure within the NHS toprovide better services with dwin-dling budgets, and has success-fully targeted NHS buyers.

Newtech Ortho ChiefExecutive, Peter Dines, said:“We’re thrilled to win such a pres-tigious award so early in our devel-opment. It’s been a tough environ-ment for a start-up company, butwe feel we chose the right marketand sustained the best strategy tomeet our commercial targets.We’ve brought competition intothe orthopaedics market, providingNHS buyers with a real alternativeto their traditional suppliers and inthe next two years we’ll beexpanding our range and stream-lining our processes to furtherimprove cost-effectiveness forcustomers.”

McKenna GroupInvests in NewERP Solution

McKenna Group have recentlyannounced that they are nowimplementing the EFACS E/8ERP solution from Exel ComputerSystems. With a complete busi-ness solution in place, McKennawill benefit from a fully integratedsystem across the group and willbe able to utilise toolset tech-nology, automated workflow andprocesses, and touchscreen tech-nology. EFACS will provide thecompany with complete visibilityand instant access to all data whichwill better service its customers andprovide enhanced performance inmany areas such as leadtimes.

Because of their philosophy ofcontinous improvement McKennaGroup decided that Efacs is themost suitable solution because itallows them to integrate all aspectsof their business onto one plat-form. The benefits of having acentralised system results inMcKenna Group increasing theirefficiency by more than 30%.Efacs is expandable and can beintegrated with other specialisedsoftware like CAD. This new solu-tion will be launched in May 2010.

ence in the bone healing responsebetween the two concentrations ofvPTH tested”.

KUR-111 is the first of afamily of product candidates basedon Kuros’ “TG-Hook” technologythat are designed to improve bonerepair or to generate bone. Thesepositive clinical results are notonly supportive of this productcandidate but also of others thatare based on the same or similartechnologies.

Didier Cowling, CEO ofKuros, stated: “These positiveresults further support the strengthof Kuros’ product developmentactivities based on bioactive-biomaterial combinations. Welook forward to progressing thisprogram, and others, with our part-ners and to bringing products tomarket that make a valuablecontribution to patient treatment”.

April 10 13/5/10 09:34 Page 11



NEWS IN BRIEF

• K2M, Inc. have announced thatits Serengeti Minimally InvasiveRetractor System received a 2010Medical Design Excellence Award(MDEA).

Serengeti features a uniqueflexible polymer retractor which iscaptured under the head of acannulated screw and placed withthe screw for secure, spine-basedretraction. The retractor providessimplified access to the hard toreach L5 - S1 levels, as well asrod introduction for multi-levelcomplex posterior instrumenta-tion procedures.

MDEA entries were evaluatedon the basis of their design andengineering features, includinginnovative use of materials, user-related functions that improvehealth care delivery and changetraditional medical attitudes orpractices, features that provideenhanced benefits to the patient,and the ability of the productdevelopment team to overcomedesign and engineering chal-lenges so that the product meetsits clinical objectives, according tothe press release. A comprehen-sive review was performed by animpartial, multidisciplinary panelof third-party jurors with expertisein biomedical engineering, humanfactors, industrial design, medi-cine, and diagnostics.

“We are truly honoured to berecognised as a 2010 MDEAWinner,” K2M President and CEOEric Major, stated. “This achieve-ment reflects K2M’s continuedcommitment to innovation and ourongoing goal to provide surgeonswith new technologies to enhancepatient care. We strive to developmore efficient approaches toaddress spinal surgery throughvery small incisions.”

• Exactech have announced thatthe company has been grantedapproval to market its Novation®

primary hip replacement systemin Japan, a robust orthopaedicsmarket where hip replacementsurgeries outnumber kneereplacement procedures.

“Expanding our hip implantsales in Japan is a significantopportunity and one for which weare well positioned,” said ExactechPresident David Petty. “We havebeen providing total knee replace-ment products in Japan for morethan a decade. In January 2008 weestablished a direct distributionoperation for the Japanese market,and the addition of our Novationhip line allows us to furtherleverage that investment.”

According to a report fromMillennium Research Group inNovember 2009, Japan has thelargest proportion of people overage 65 in the world, and willcontinue to be a source of steadyrevenues in the large-joint recon-structive implant market.

Japan’s Ministry of Health,Labour and Welfare grantedExactech the approval to marketelements of the Novation compre-hensive hip system, including thetapered femoral hip stem, femoralheads and bi-polar implants.

The incidence of osteoarthritis ison the rise, and experts expectthat, by 2020, OA could affectmore than 40 million people andbecome the fourth-leading causeof disability. Nearly one in 10people aged 65 and older havesymptomatic knee OA, and thenumber of seniors is expected todouble in the next 25 years,which means the demand formedical care to treat OA willincrease accordingly.

While knee surgery is avail-able to alleviate pain andimprove mobility, a new studyfrom the Steadman PhilipponResearch Foundation has alsoproven the effectiveness of kneebraces to reduce pain andimprove physical function.

The study, “Use of an UnloaderBrace for Medial or LateralCompartment Osteoarthritis of theKnee” was presented in March at

New Research Reveals Benefits of Unloader Bracing to Treat Osteoarthritis

Biospace med has raised $18m toaccelerate market expansion inNorth America and Europe of thecompany’s FDA-cleared EOSultra-low-dose 2D/3D imagingsystem for bones.

Biospace med said that theEOS is a new medical imagingtechnique that allows full-body2D and 3D imaging of patientsusing radiation doses up to 89%lower than those required for astandard CR X-ray. EOS willreduce irradiation linked to radio-logical investigations, which hasrisen by 600% over the past 20years.

The benefits of EOS are partic-ularly important in pediatrics,because children undergo X-raysthroughout their development,when their organs are highly sus-

Biospace Med to Accelerate Market Expansion of EOSin North America and Europe

ceptible to ionizing radiation.EOS is also beneficial in adultswho do not wish to be exposed toionizing radiation during standardX-rays or CT scans.

EOS targets particularly thediagnosis, follow-up, preoperativeassessment and postoperative fol-low-up of degenerative diseasesand bone and joint deformities.Indeed, EOS allows full-body and3-D images of the human skeletonwith the help of the software thatreconstructs and models apatient’s bones from just twosimultaneous images.

The software also generates3D measurements automatically,and can calculate a broad range ofclinical parameters, some ofwhich were hitherto inaccessible,but which are essential to diagno-

the 2010 American Academy ofOrthopaedic Surgeons AnnualMeeting, and revealed thatpatients who used bracing report-ed significant improvement oftheir OA symptoms, withoutresorting to surgery.

The study measured patientexpectations of treatment and out-comes following six months ofusing either a medial or lateralÖssur Unloader One® knee brace.Nearly a quarter (23%) of thepatients in the study reported adecrease in the use of over-the-counter anti-inflammatory drugs,while 16% reported a decrease inthe use of prescription anti-inflammatory drugs.

The Össur Unloader Onebrace used in the study isdesigned to reduce pain causedby osteoarthritis by minimizingbone-on-bone contact within theknee joint. The brace’s thigh andcalf shells, along with uniquelydesigned straps, create a leveragesystem that literally unloads thepressure from the affected area,creating more space between thebones.

Several other studies also sup-port the conclusions of theSteadman Philippon research,including one titled “Patients withModerate and Severe Knee OADo Benefit from Using a ValgusKnee Brace,” an ongoing studybeing conducted by theDepartment of Orthopaedics at

the Akureyri Hospital, Akureyri,Iceland and also presented at theAAOS Annual Meeting. In theIcelandic study, the Unloader Oneknee brace was also shown todecrease pain, as it improvedmovement and function andhelped to decrease stiffness.These results were seen in thefirst weeks of bracing and thesebenefits were maintainedthroughout the six month studyperiod.

Results of both studies indi-cate that bracing can be a realbenefit for those who want, orneed, to postpone knee surgeryand that this is a proven non-sur-gical treatment option for kneepain sufferers.

The best way to manage orreduce the onset of OA is tomaintain a healthy lifestyle, withexercise, stress reduction, weightmanagement and diet. This newresearch shows that the UnloaderOne brace is a proven way todecrease pain and increasemobility, making all those activi-ties potentially easier to accom-plish.

To review the abstracts pleasevisit: http://www3.aaos.org/edu-cation/anmeet/anmt2010/podi-um/podium.cfm?Pevent=638

And http://www3.aaos.org/edu-cation/anmeet/anmt2010/podi-um/podium.cfm?Pevent=637

sis and surgical planning. Theimages and clinical parameters areobtained in standing or seatedweight-bearing positions and thusreflect the bone and joint status ofthe patient’s posture.

Marie Meynadier, CEO of bio-space med, said: “We are particu-larly pleased to welcome CDCEntreprises as a new shareholder inthe company, and to acknowledgethe renewed confidence of our cur-rent shareholders. This new fundraising will allow us to acceleratethe market penetration of EOS inNorth America and Europe, so thatthis revolutionary musculoskeletalimaging modality can become aroutine clinical tool.”

Source: Medical Devices BusinessReview

April 10 13/5/10 09:34 Page 12


AAnnaallyyssiiss

In encouraging news for the UKMedical Equipment industry, 364of the top 800 companies in themarket are growing at more than10% per annum and makinghealthy profits. However, accord-ing to industry analysts Plimsoll,while many of these companiesare breaking new ground andleading a sustainable recovery inthe market, there are 103 othercompanies whose headline grab-bing sales growth masks some-thing much more sinister.

David Pattison, senior analystand author of the new PlimsollAnalysis explains, “Firstly, itmakes a nice change to have somepositive news to report. 364 grow-ing, increasingly profitable com-panies have either tapped into anew, fast growing revenuestreams or are just the best per-

Encouraging News in the UK Medical EquipmentIndustry – But not for Everyone...

Predicting the course of the globaleconomy over the next twelve toeighteen months remains contro-versial. Although a number ofrespected analysts continue to bepessimistic, Frost & Sullivan isemphasising the positives.

While the financial crisis hasbeen severe and unemploymentcontinues to be a problem, for thepast year Frost & Sullivan hasemphasised that firms must seizeopportunities in the changingglobal environment. In the wordsof one of the world’s most suc-cessful investors, Warren Buffet:“Be fearful when others aregreedy, and be greedy when oth-ers are fearful.”

Holger Schmieding, ChiefEconomist, Bank of America -Merrill Lynch will deliver thisyear’s Economic keynote addressat Frost & Sullivan’s flagshipclient event, GIL 2010: Europe -The Global Community ofGrowth, Innovation andLeadership. He will provide sen-ior executives with key insightinto today’s current economic cli-mate and where companies needto stay focused in building theirgrowth strategies to continue backto profitability in 2010.

Supporting Schmieding’s per-spective of growth and profitabili-ty in 2010 is Frost & Sullivan’s

Take the Risk or Miss theOpportunity? Growth, Innovationand Leadership? Europe 2010Economic Keynote Announced

formers in the old ones. Anyonestruggling to make the most of therecovery should look at thesecompanies and ask themselves‘what do these guys sell, make ordo differently to me?’”

However, Pattison warns thatthere are 103 companies achiev-ing this eye catching salesgrowth but their profitabilitytells a very different story,“Essentially there are 2 types ofgrowth in the market – Good vBad. 103 companies haveachieved over the 10% salesgrowth but in doing so have seentheir profit margin collapse.They are simply overtrading.The accolades of growth are allwell and good but the bills needpaying too. More worrying, 19 ofthese companies have been lossmaking for 2 years – even with

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

On the subject of companiesgetting it wrong at both ends ofthe scale, Pattison offers thiswarning, “While the market con-tinues to recover and the 364 topperformers show the way, thereare 149 companies facing a verybleak future indeed. Losing sales,profits and probably most of theirremaining options, these compa-nies have been rated as Danger inour report. Time is running outand only a takeover or a rapidturnaround is likely to redeemtheir situation”.

NEWS IN BRIEF

• While the leading orthopaedicdevice manufacturers continue tobe impacted by economic andregulatory challenges, factorssuch as increasing Research andDevelopment (R&D) costs, a short-ening product pipeline andincreasing competition from smalland medium-sized companies areputting additional pressure onthese manufacturers to staycompetitive and remain profitable.

Considering the ever-expanding competitive landscape,it is important to have a thoroughanalysis and intelligent insight onthe key orthopaedic pipelinedevices expected to bring indynamism in the market.GlobalData’s new report, “GlobalOrthopaedic Devices PipelineLandscape: Analysis of KeyUpcoming Products andTechnologies” provides key data,information and analysis on thekey orthopaedic pipeline devicesexpected to hit the market in thenext seven years.

The report also provides infor-mation on the market potential,market scope and expectedmarket penetration of these prod-ucts. It also identifies and reviewsthe existing competing technolo-gies and the likely impact of thelaunch on the competitive land-scape. This report is built usingdata and information sourced fromproprietary databases, primaryand secondary research and in-house analysis by GlobalData’steam of industry experts.

• Santa Rosa medical technologystartup Osseon Therapeutics isgrowing, with new funding andproduct launches outside the U.S.

The four-year-old firm makes anext-generation system forrepairing spinal fractures.

“We expect to triple our salesby the end of the year,” OsseonCEO John Stalcup said Thursday.

Osseon’s technology targets a$1.6 billion to $3 billion globalmarket for treatments of vertebralcompression fractures. They aremostly caused by osteoporosis,which affects about 10 millionpeople in the U.S.

The demand is growing as thepopulation ages, Stalcup said.Most compression fractureshappen to women over 50.

The Obama Administration’shealth care program also prom-ises to drive sales by bringingmillions of new patients into thehealth system, Stalcup said.

• Stryker reported a rise in theirfirst quarter profit, helped bydemand for its OrthopaedicImplants and MedSurg Equipments.Both earnings and sales came inabove Street estimates.

Domestic sales acted as themain thrust behind Stryker’s quar-terly sales performance, thoughInternational sales also improvedfrom the prior year, but were notas promising as Domestic sales.Domestic sales rose 12.6% to$1.17 billion, while Internationalsales rose 1.5% to $626.1 million.

In 2009, the combined orthopaediclarge joint replacement and bonecement market was valued at over$7 billion. Hip and knee arthro-plasty has seen consistent double-digit revenue growth since theearly 2000s.

However, growth slowed dur-ing the recession that began in2008, but nearly resumed its pre-vious pace by the end of 2009.Although large joint arthroplastyis not the fastest growingorthopaedic market, it has provento be remarkably resilient due tothe continued demand for hip andknee implants. The report byReportsandReports covers thesedevices, as well as the total marketfor associated bone cement usedfor arthroplasty implantation.

The market includes: • The knee reconstruction market • The hip reconstruction market • The bone cement market

Within the orthopaedic largejoint replacement and bonecement market, companies suchas Biomet, DePuy Orthopaedics,Smith & Nephew, StrykerOrthopaedics and Zimmer leadthe market. The report provides adetailed analysis of market rev-enues by device type, market fore-casts through 2016, unit sales,average selling prices, marketdrivers and limiters.

Source: www.reportsandreports.com

U.S. Market forOrthopaedicLarge JointReconstructiveDevices 2010Report

Chief Economist VinnieAggarwal and his analysis oftoday’s market.

“Unless firms are willing totake some calculated risks, theymay miss key opportunities,”Aggarwal says. “In fact, some oftoday’s top corporations havestarted in the middle of a reces-sion, with 16 of the 30 companiesthat make up the Dow industrialaverage claiming such an originstory.”

Aggarwal also notes thatAsia’s growth will continue to bestrong. Many analysts haveexpressed concern that China’seconomy is developing a bubblewith its rapid 10% growth ratedriven by fiscal stimulus in part,but he believes that the continuedefforts by the government inChina to prevent this have beenpaying dividends.

Europe, by contrast, is show-ing slower signs of recovery, witha recent Reuter’s poll of analystspredicting growth of 1.2% thisyear and then 1.5% in 2011.

“These statistics are evidencethat companies have no choiceand must have a solid long-termgrowth strategy to recover,” saysAggarwal. “This includes lookingat prospective acquisitions andinvestments that will positionthem for future growth.”

April 10 13/5/10 09:34 Page 13


AArrttiiccllee

‘Preparticipation Screening’ and ‘LowBack Pain Management’ were thesubjects for the second quarterlymeeting in the ‘Sport and ExerciseMedicine for London 2012’ series ofeducational events organised byProfessor Nicola Maffulli, CentreLead, QMUL Centre for Sports andExercise Medicine (CSEM). Held on19th March in association with DJOEducation at the Royal Society ofMedicine, the meeting attracted aninternational group of 50 high levelSEM practitioners with 10 speakersfrom different SEM backgrounds. Aswell as providing an educational plat-form, the series of meetings offers arare opportunity for SEM practitioners to share and debate currentissues and challenges in one room.

The morning’s session on Preparticipation Screening gave anenlightening overview of the dilemmas faced by elite sports physi-cians and sports bodies. The first speaker was Professor GiorgioGalanti from Florence who candidly discussed the value of stateintervention in preparticipation assessment in Italy. The next twospeakers, Southern Medical lead for the EIS and CMO for TeamEngland at the Commonwealth Games, Dr Mike Loosemore and DrIan Beasley, Doctor for the Senior England Football Squad, furtherdiscussed screening in elite athletes as a tool for profiling andbenchmarking to minimize risk of injuries and maximise perform-ance. They were undecided as to the benefits of screening, prefer-ring the description of preparticipation ‘profiling’ which limits theimplications of a ‘screen’ requiring an action based on findings.

The importance of a healthy heart, the role of Medical Passportsand the success of cardiac screening for elite athletes was discussedby two of the country’s leading cardiologists, Dr Len Shapiro, andProfessor Sanjay Sharma, the Medical Director for the Virgin LondonMarathon, who ended his presentation with a thought-provoking ques-tion: “At what cost should the life of one athlete be saved?”

The afternoon session focused on the complex nature of Low BackPain Management with contributions from leaders in their field: Dr CraigRanson, Senior Physiotherapist at UKA, Dr David Perry, ConsultantRheumatologist and Lead Clinician Emeritus at Barts and The LondonCentre for SEM, Mr Jonathan Betser, Consultant Sports MedicineOsteopath and Chairman of the Osteopathic Sports Care Association(OSCA). The surgical speaker was substituted by the meeting’s chair,Professor Maffulli, who gave an insightful lecture on ‘Surgery after con-servative management of low back pain’.

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

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

presentation on the Italian system ofcompulsory screening gave us someexcellent data but raised some inter-esting questions about the useful-ness of such mass screening.Unfortunately Dr Bryan English hadpressing matters at Stamford Bridgeand was unable to join us butProfessor Maffulli eloquently spokeabout Achilles tendon rupture in theweek that sadly saw David Beckhamruled out of the World Cup.

Our thanks to DJO Education forsponsoring an excellent event and Ihighly recommend the future meet-ings to my colleagues.”

Lucie Hanaghan, County Gaelic Football Physiotherapist added:“This was the first meeting of the series I have attended and I thorough-ly enjoyed it. Not only were experts presenting current trends, researchdata and practice in their fields, but the day also included comprehen-sive and critical discussion amongst speakers and delegates at regularintervals. The delegates included surgeons, physicians and physiother-apists working in a broad range of elite sports, which ensured livelydebate and invited questions from all parties. As a private practitionerseeing athletes from a spectrum of disciplines, this was exactly the mixof expertise I was looking for. I now eagerly await the next event!”

Professor Giorgio Galanti, Internal Medicine and Director of theSchool of Specialisation in Sports Medicine in Florence, added: “Itotally enjoyed the day and being exposed to high level British Sportsand Exercise Medicine. The fact that Professor Maffulli was able tocover for absent speakers in such a remarkable way was impressive.”

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

Programmes and booking forms for future meetings are availablefrom Barry Hill at [email protected].

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

Meeting organiser Professor Nicola Maffulli with ProfessorGiorgio Galanti

The speakers: (sitting) Craig Ranson, Giorgio Galanti, MikeLoosemore (standing) Nicola Maffulli, Len Shapiro, JonathanBetser, Ian Beasley, Sanjay Sharma

April 10 13/5/10 09:34 Page 14

April 10 13/5/10 09:34 Page 15

PPrroodduucctt NNeewwss


geneX®ds - Extending the Reachof Injectable Bone Grafts

Biocomposites, the pioneers in synthetic bone graftmaterials have launched geneX ds, a dual syringemixing and minimally invasive delivery systemcontaining geneX, the unique resorbable bone graftmaterial with a negative surface charge.

The powder and liquid components ofgeneX are provided pre-packed in separatesyringes. The syringes connect togetherand allow a faster, simpler and cleanerway for mixing geneX. The resultingsetting paste can then bedelivered through an 8cmdispenser (included).geneX ds is ideal fordifficult-to-reach surgicalsites or minimallyinvasive procedures.

geneX is asynthetic bone graftmaterial with aunique bi-phasic composition manufactured through a proprietary processZPC® (Zeta Potential Control) that confers the product with areproducible negative surface charge. This property stimulates bonecell activity, accelerating bone formation and fusion by harnessing keyproteins and directing osteoblast adhesion and proliferation for rapidosteogenesis. geneX is fully resorbable and is completely replaced bybone. geneX overcomes the surgeon’s reliance on donor tissuepresenting both a cost saving and a reduction in the risks associatedwith its use.

geneX ds is FDA cleared and CE marked. Available now in 2.5cc.

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

Finsbury DeltaMotion®

Finsbury, the world leader inlarge diameter bearingtechnology, has combined itsknowledge with BIOLOX®

delta, the world’s leadingceramic material, to bring youDeltaMotion®, the world’s firsttruly large diameter ceramic-on-ceramic bearing.

Use of the latest advancedmaterials and technologypermits optimisation of thehead diameter to acetabularcup ratio allowing use of largeheads in small diameteracetabulae. This dramaticincrease in bearing size allowsrange of motion and stabilityof the replaced hip currentlyonly possible using a largediameter metal-on-metaldevice, such as the ADEPT®.

Finsbury OrthopaedicsTel: +44 (0)1372 360830

www.finsbury.org

Uplifting Development forPatients with Lower LimbInjuries

‘Elevate’ Lower Limb is a ‘cushion support’ with a slightly pliantbody which allows injured lower limbs to be lifted to a levelaround 12 inches above the heart to reduce, minimise or stemthe swelling of the injured lower limb. It is now available tohospitals nationwide.

It has been invented and developed through a collaborationbetween a Consultant Orthopaedic & Trauma Surgeon at TheIpswich Hospital NHS Trust, Health Enterprise East (HEE), theregional NHS Innovation Hub and a technical textiles company,Precision Stitching Limited.

‘Elevate’ Lower Limb can be used for lower limb trauma, forexample knee ligament injuries or ankle fractures, lower limbsurgery including total knee replacement, lymphoedema, deepvein thrombosis, chronic venous insufficiency and peripheraloedema secondary to heart failure.

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

PSL MedicalTel: +44 (0)115 955 73 73

[email protected]

To list your productswithin the Product

News sectionsimply send your product information to us at:

[email protected]

OrthoView IntroducesSmartHip for Total HipPlanning in Less Than 60Seconds

OrthoView LLC, providers of digital planning solutions fororthopaedics, launched the latest version of their software at AAOS2010. OrthoView Version 6 includes SmartHip automatic templating,an innovation that enables the user to plan a total hip procedure inless 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 lessthan 60 seconds by automatically placing the prosthesis stemtemplate within the femur in the on-screen image.” Said WilliamPeterson, Vice President of Sales for North America. “It also has aone-click reduction feature that provides the surgeon with an instantview of the post-operative position of the femur for a streamlinedon-screen templating process.” SmartHip is an integrated feature ofOrthoView 6.

OrthoViewTel: +1 800 318 0923

www.orthoview.com

April 10 13/5/10 09:34 Page 16



PostScript Picture

(MckennaAdammended3.pdf)

Animations For Your Web Site

Make the most of your Website – educate your patientsonline with ViewMedica ani-mations. The leader inmultimedia patient educationoffers a library of more than150 ViewMedica animationsfor your Web site.ViewMedica animationsexplain common conditionsand procedures for thespine, hip, knee, shoulder,hand, elbow, foot and ankle.

Visit www.opnews.comtoday to see the animations and learn how you can get a Web sitethat promotes your practice through patient education. ViewMedicaanimations are customised with your practice name. The animationshave printable Web brochures, customised with your practice nameand contact information. Print them in the office as a handout or letyour patients print them from their home computer. Have yourpatients take an active role in their education – let them learn withViewMedica animations.

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

STORM used to Reduce TibialFractures

The Staffordshire OrthopaedicReduction Machine, STORM,provides an innovative approach tothe treatment of unstable lower limbfractures. The basis for the productconcept and design is to separatethe reduction of the fracture from thefixation. STORM is used in theoperating theatre and provides thesurgeon with a simple but innovativeapproach to reducing difficultunstable tibial fractures prior tofixation. STORM provides preciseand controllable axial traction, asimple lock wheel system allowslarge and fine adjustments to correct rotation and the unique translationarms correct angulation and translation.

In trials carried out in the University Hospital of North Staffordshire theuse 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 11minutes and secondly because the reduction is firmly maintained duringthe application of the chosen method of fixation both internal and external.

STORM is used to reduce fractures throughout the tibia including theplateau and pilon as shown. As well as being used to reduce freshfractures STORM can also used to successfully reduce fractures wheretreatment has been delayed.

Intelligent OrthopaedicsTel: +44 (0)844 800 4405

April 10 13/5/10 09:34 Page 17



Intraoperative Excellencefor Trauma Imaging

In trauma and orthopaedic surgery, the precise identificationand repositioning of fractures and the accurate placement ofimplants is of the highest importance. The ARCADIS® Orbic3D from Siemens Healthcare generates CT-like slices and3D volumes in real time, assisting with delicate placementtasks, reducing the rate of second interventions andsmoothing workflow.

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

The Orbic 3D has an optimally matched and fully digital1k2 imaging chain from image acquisition to viewing andarchiving. Furthermore, Enhanced Acquisition System(EASY) offers automatic image processing features such asdose, contrast and brightness control.

Its counterbalanced, isocentric C-arm design with intelli-gent colour coding enables fast and precise positioning. Thishelps save time and dose plus reduces readjustments byvirtually unlimited projection possibilities with 190º orbitalrotation.

Siemens Healthcare www.siemens.co.uk/healthcare

Pain-free Marathon Training withthe Swiss DolorClast

Runners with foot and ankleinjuries can now use a revolu-tionary treatment device thatis used by various PremierLeague football teams andwas widely used by athletesat the Olympic Games inBeijing.

The Swiss DolorClast isa low-energy ExtracorporealShockwave Therapy(ESWT) device that drawson the latest medical technology to treat Plantar Fasciitis and AchillesTendonopathy.

Extracorporeal Shockwave Therapy is a relatively new technologyand The National Institute of Health and Clinical Excellence (NICE)recently issued guidance that it is a safe treatment option for foot andankle injuries. ESWT is a beneficial alternative to invasive surgery andthe 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. Passingthese shockwaves through the surface of the skin initiates an inflamma-tion-like condition in the injured tissue that is being treated. This promptsthe body to respond naturally by increasing blood circulation, the numberof blood vessels and therefore metabolism in the injured tissue.

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

Spectrum Technology UKTel: +44 (0)120 276 1198

www.spectrumtechnologyuk.com

April 10 13/5/10 09:34 Page 18

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AArrttiiccllee

We arrived into Haiti three weeks from the devastating earthquake ofJanuary 12th that destroyed most of the Haitian capital of Port-Au-Prince. Of the 4 million city residents nearly 3 million were affectedwith 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 subse-quent massive earthquake in Chile which measured 8.8 on the Richterscale. Therefore the impact of a disaster is proportional to the vulnera-bility of those who are affected. The poor are always the most vulnera-ble due to over crowding & poor infrastructure. There is no consensuson the number of deaths but it is agreed that between 200,000 - 230,000people lost their lives.

Who are we?‘UK Med’ is a charity born out of such disasters. The charity is head-

ed by Professor Tony Redmond Hospital Dean of Salford Royal &Professor of International Emergency Medicine. Its members are NHSconsultants from varying fields who have worked in war zones & in nat-ural disasters over the last 20 years. With this charity I have been tooperate in earthquake hit regions of Kashmir 2005, China 2008 &Indonesia 2009.

Acute response for HaitiOnce the extent of the disaster was appreciated a worldwide call for

doctors, especially Orthopaedic surgeons, was issued by the UN & RedCross. MERLIN one of the DEC (Disaster Emergency Committee) char-ities had approached ‘UK Med’ to send a team of surgical specialists toset up a hospital in Haiti. DEC is an umbrella organisation set up by thegovernment to collect relief funds from the general public & then tospend the money among themselves on the basis of clinical need & pri-ority. This system is also important from the point of view of preventingduplication of effort & working together to achieve the given aims.

Our team included Consultant orthopaedics, a Consultant plastic sur-geon, two specialist theatre nurses, a specialist burns nurse/manager, aconsultant anaesthetist and a logistician. The 8 hour bus journey fromPorto Domingo to Haiti was both fascinating and tiring. This road wasthe only ‘humanitarian corridor’ that connected the republic with Haiti.All other means of transportation was disrupted. Communication waspatchy and little information was coming through even at this stage. Thecontrast between Haiti and its neighbour the DR (Dominican Republic)could not be starker. Impressive colonial buildings, loud blaring musicand smiling faces compared with sad eyes broken bodies & devastatedhomes. In some areas of the capital 90-95% of the homes weredestroyed. Large banners erected around the makeshift camps beggingfor food & water showed the extent of their desperation.

We reached Port-Au-Prince in the dark and one strained their eyes tolook for signs of the devastation caused. As you drew closer to Port AuPrince you regularly saw collapsed buildings. I was later told that mostof the school buildings and hospitals had collapsed due to poor work-manship with a considerable loss of life. We arrived at our campsite latein the evening. For the last four weeks the whole city had been withoutrunning water, food, electricity and sanitation. The people had grownimpatient waiting for the aid to arrive; emotions were high and tempersflaring. There was a sense of urgency as the security situation was pre-carious and the advice from UN was not to venture out after dark. Thetents were erected and we all collapsed in our tents looking forward tostarting work the next morning.

Tent Hospital in Port-Au-PrinceMost of these disasters occur in hilly terrain and far flung area which

are generally poorly accessible. Each disaster is different and under-standing the needs of each is important in planning the humanitarianresponse. Our earlier experiences in Kashmir 2005, China 2008 andIndonesian earthquakes 2009 were entirely different. In all these places

Earthquake in Haiti & the SurgicalResponse

Authors: Miss Mehek Asad, Medical student, Manchester UniversityMr 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

April 10 13/5/10 09:34 Page 20


AArrttiiccllee

the Federal infrastructure was intact, providing the back bone for anyemergency and subsequent rebuilding process. Here the governmentand the social infrastructure had collapsed due to the sheer scale of thedisaster. Therefore all the essential equipment required to undertakesuch a mission had to be airlifted from outside, starting from the tentsto X-ray machines, respirators and water purification plants.

In Haiti it was clear that most local hospitals had been badly dam-aged and a hospital was needed to treat the injured in this vastMetropolis. This is where working with a large organisation like MER-LIN had its advantages as constructing a tent hospital would be a bigundertaking requiring logistics, assessments and planning. Once con-structed it would need expansion and constant replenishing of resourcesthat only a big organisation could provide. The work in a disaster likethis could be divided in acute and delayed response. Patients’ lives andlimbs saved by emergency surgery will require many more months ofpainful reconstructive surgeries and rehabilitation. Teams of doctorsand nurses are required to go on a short rotation to provide the continu-ity of care until the host infrastructure has recovered enough to under-take 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 onthe main road that snakes through this deprived area to end close to thesea front. Most other Non Governmental Organisations (NGO’s) likeMSF (Medecins Sans Frontieres) had set up hospitals along this narrowcorridor.

This hospital was an example of Anglo-American co-operation inmanaging the hospital. We worked closely with Irish charity calledGOAL and an American NGO called IFM (International FaithMissions). The Irish team consisted of A&E consultants, an anaes-thetist, a retired ophthalmologist and nurses. While the American groupconsisted mainly of nurses and young volunteers. The tent hospital con-sisted of three main areas. The entrance lead to the triage area where onone side medical emergencies were treated, while on the other side aminor surgery area looked after wound dressings and debridements. Thesecond area was the Operating theatre suite with an adjacent recoveryand three further tents housed pre and post op patients. Central to thiswas the tent that housed administration staff and logistics. The only sur-viving hut served as the store room of the medical supplies includingmedications and surgical instruments. The Irish and the Americanslooked after the triage and managed the medical emergencies. Our teamtook on the responsibility of running the theatres and post operativecare.

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

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

Type of injuries in an EarthquakeInjuries sustained can be varied. The biggest number of injuries is

simple fractures and soft tissue injuries which can be adequately treat-ed with dressings and splinting. Most intrabdominal, chest or headinjuries are usually fatal. Very few are diagnosed properly and lack offacilities or even training can be a cause of this high fatality rate. InChina for example, multi-storey buildings housed most schools andaccommodations facilities. As a result we saw a large number of thora-co-lumbar fracture dislocation and calcaneal fractures from jumpingfrom a height. However the main orthopaedic injuries involve limbsincluding severe muscle-crush injury and open or neglected fractures.

Earthquake an Ortho-plastic EmergencyMost fractures in natural disasters are open fractures. A number of

these walking wounded are inadequately treated. The overlying soft tis-sue envelope is crushed and lost at the time of injury or excised during

debridement of devitalised tissue. While life threatening injuries takeprecedence, a number of simpler fracture configurations are inadequate-ly treated, splinted and advised to seek help later. A number of thesebecome infected; soft tissue envelope deteriorates further requiring skingraft, rotation flaps or free flaps after skeletal stabilisation. Publishedliterature confirms that in order to minimise the rate of amputations orcomplications definitive plastic procedure has to be performed within 5-6 days of skeletal stabilisation.

During our stay our surgical team operated on between 30-35patients. The plastic and Orthopaedic surgeon worked together on twotables simultaneously with two anaesthetists. There are clear advantagesof this approach. Both can share from the experience of the other andvaluable time can be saved with the orthopaedic surgeon performingdebridement and skeletal stabilisation and then giving way to the plas-tic surgeon for soft tissue cover. This allows definitive surgery to takeplace in one go - a one stop shop. A number of operations were carriedout over the 10 day period. These included open fractures requiringwound debridement, External fixator with skin flaps or grafts, openreduction internal fixation of neglected fracture dislocations, amputa-tions, skin grafts and gastrocnemius & abdominal flaps for more diffi-cult cases.

Difference between Earthquake & Blast injuriesIt is important to make a distinction between crushed limbs from

falling masonry or subjected to a gun shot or blast injury. The treatmentof both differs radically and treating these injuries on the same line asbattlefield often causes confusion and leads to a higher rate of limbamputation that may be salvaged.

EQ Injuries are mainly low velocity injuries, mostly involving thelimbs. Entrapment of limbs under rubble may cause extensive muscle-crush injury leading to muscle-crush compartment syndrome. If untreat-ed, crush syndrome characterised by hypovolemia, shock, hyper-kalemia, acidosis & myoglobin related renal failure occurs. Muscle canresist vascular ischemia for up to four hours. However, adding criticalischemia to mechanical entrapment between two compressing surfacesabove the diastolic blood pressure will accelerate this process and mus-cle death will occur within an hour. At cellular level myocytes lose theirability to maintain their intracellular hyperosmolarity due to cell mem-brane damage leading to fluid shift from extracellular to intracellularspace and seepage of intracellular potassium in the opposite direction.These events may cause hypovolaemic shock or cardiac arrest. This isfurther complicated by rhabdomyonecrosis leading to acute renal failurefrom the excess myoglobin leaked into the circulation. Death may occurwithin hours of extrication. It is therefore necessary to keep the patientwell hydrated, reverse metabolic changes and ensure adequate diuresis.Some of these patients will also develop compartment syndrome, how-ever the muscle has already died as a result of the crush injury.Traditional teaching is to perform urgent fasciotomy to release the

Asad Syed in the operating theatre

April 10 13/5/10 09:34 Page 21


AArrttiicclleecompartment pressures. However, in these cases this can be counterproductive. As a sterile dead environment invariably becomes infected,not only does the dead tissue bleed excessively, but all the infected deadmuscle will now have to be removed. These muscles in a closed envi-ronment would have otherwise become fibrotic. It now agreed that per-forming fasciotomies can lead to severe sepsis and eventual amputation.These cases of crush injury should be dealt with splintage, rehabilitationand delayed corrective surgery for contractures & clawing of toes.

Blast or gun shot injuries result from the interaction of shock wavewith the body. Gas containing organs and viscera are affected.Secondary blast injury is caused by blast wave or wind and bomb frag-ments while the tertiary blast injury results in the body being thrownthrough the air. There is additional damage to skin by thermal injury.These are more serious multi organ injuries and require radical treat-ment like laparotomy and amputations immediately to save lives.

In natural disasters it is not necessary to perform amputations imme-diately. A more measured and cautious approach with initial wounddebridement, even in more serious cases, and referring to centres withOrthoplastic cover can save many unnecessary amputations.

Clinical CasesExternal fixation remains the main means of skeletal stabilisation.

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

Case 1: A 30-yr-old femalesuffered a comminuted frac-ture of her femur and openfractures of her metatarsalsof the left hand with loss ofskin. She was extricatedsoon after the earthquake.Her hand was operated mul-tiple metatarsals were ‘K’wired tendons reconstructed& one finger amputated. Thefemoral fracture was placedin a plaster until later. Atthree and a half weeks herlower limb was rotated,shortened & angulated. X-ray revealed a fixed defor-mity. In a tent hospital inter-nal fixation is to be discouraged. Here ORIF was undertaken as a lastresort. 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 toher lower limb. She had lost most of her family and was terrified of sur-gery. She had lost a significant amount of soft tissue from the heel andfoot with multiple fractures. The foot appeared insensate and the Plasticsurgeon had deemed the foot unsalvageable (see below). A below kneeamputation was successfully performed and the patient fitted with anartificial limb through Handicap International.

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

End of acute responseAfter successfully working for three months following the EQ the

MERLIN tent hospital is being dismantled and no further surgeryplanned. However, specialist nurses will continue to undertake dress-ings and provide outpatient care for the 200-300 patients attending thishospital daily. The orthopaedic and plastics patients will be providedmonitoring and support in a newly established primary health care unitnext to the tent hospital.

Advice to clinicians interested in working in disaster zones1) Best time to salvage limbs is within the first week. Try and getin with the search and rescue teams.

2) Join a medical charity or organisation with the ability tomobiliseat short notice

3) Inform your hospital manager of your intention to do this kindof work. Taking leave and reorganising your commitment can bea tedious job.

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

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

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

7) Take all your essential gear with you. This may mean collect-ing instruments or materials over a period of time. There is nogreater disappointment then to arrive at a disaster zone inade-quately prepared.

Asad Syed with Case 1 patient at discharge

Orthofix fixator with full thickness skin graft

April 10 13/5/10 09:34 Page 22

April 10 13/5/10 09:34 Page 23


FFuuttuurree EEvveennttss

May 2010

1-6 May78th AANS Annual MeetingVenue: Philadelphia, PA, USAwww.aans.orgContact: American Association ofNeurological SurgeonsE-mail: [email protected]: +1 847 378 0500

7 MayLegal Aspects of Surgical PracticeVenue: London, UKwww.rcseng.ac.ukContact: The Royal College of SurgeonsE-mail: [email protected]: +44 (0) 20 7405 3474

10-15 May13th ISPO World CongressVenue: Leipzig, Germanywww.ispoint.orgE-Mail: [email protected]: +49 231/557050-17

12-13 MayAdvances in Knee ArthroplastyVenue: London, EnglandE-mail: [email protected]: +44 (0)1527 591555

14 MayThe South West Knee Surgeons MeetingVenue: Plymouth, Englandwww.exac.co.uk/trainingContact: Joanna BartlettE-mail: [email protected]: +44(0)1527 591555

20 MayOrthopaedic Anatomy Course for JuniorSurgical TraineesVenue: The Robert Jones and Agnes HuntOrthopaedic Hospital NHS Trust, Oswestry,Shropshire, UKE-mail: [email protected]: +44 (0)1691 404661

23-26 MayCurrent Concepts in Joint ReplacementVenue: Las Vegas, USAwww.ccjr.comE-mail: [email protected]: +1 216 295 1900

25 MayHalf Day Statistics TutorialVenue: The Robert Jones and Agnes HuntOrthopaedic Hospital NHS Trust, Oswestry,Shropshire, UKE-mail: [email protected]: +44 (0)1691 404661

27-28 MayImplants 2010Venue: Lyon, Francewww.implants-2010.comE-mail: [email protected]: +33 2 47 27 33 30

27-30 May83rd Annual Meeting of the JapaneseOrthopaedic AssociationVenue: Tokyo, Japanwww.joa2010.jpE-mail: [email protected]

June 20102-5 June11th EFORT CongressVenue: Madrid, Spainwww.efort.orgTel: +41 (44) 448 4400Fax: +41 (44) 448 4411Email: [email protected]

2 JuneIntroductory Musculoskeletal CourseVenue: Hitchin, Englandwww.sonositeeducation.comE-mail: [email protected]: +44 (0)1462 444800

8-9 JuneClinical Skills in Spinal Assessment andManagementVenue: The Royal College of Surgeons ofEngland, Londonwww.rcseng.ac.ukE-mail: [email protected]

9-10 June14th ESSKA CongressVenue: Oslo, NorwayContact: Congress SecretariatE-mail: [email protected]: +49 0611 77160

9-11 JuneAO Injured Foot CourseVenue: Bristol, Englandwww.aouk.orgE-mail: [email protected]: +44 (0)1707 395212

10-11 JuneSociety for Back Pain ResearchVenue: Odense, Denmarkwww.sdu.dk

Future EventIn Focus

When: 2-5 June 2010

Where: The Feria de Madrid, Madrid,Spain

What the website says: The EFORT Congress 2010 is to be heldin Madrid, Spain, in combination with theannual congress of the SpanishOrthopaedic and Traumatology Society.

The scientific programme includessymposia and instructional lectures deliv-ered by distinguished speakers from acrossEurope. Free papers, e-posters, workshops,industrial symposia and technical exhibitswill all feature. There will be simultaneoustranslation in the combined plenary ses-sions whereas the congress languageremains English.

Controversial case discussions and proand con debates invite you actively to con-tribute and share your knowledge with col-leagues from all around Europe. Plus, inthe half-day ExMEx sessions you will gainspecialised expertise and share informationwith different opinion leaders on a specifictopic in a group limited to 100 colleagues.

Along with the scientific exhibition,this congress format will cover the wholerange of contemporary orthopaedics andtraumatology issues in Europe.

There is also an attractive social pro-gramme that emphasises Madrid’s beautyand magnificence.

(www.efort.org)

Contact: Tel: +41 (44) 448 4400Fax: +41 (44) 448 4411Email: [email protected]: www.efort.org

11th EFORT Congress

Madrid

Las Vegas

April 10 13/5/10 09:34 Page 24

April 10 13/5/10 09:34 Page 25



14-17 JuneNational Neurotrauma SymposiumVenue: Las Vegas, NV, USAwww.neurotrauma.orgContact: Karen GottliebE-mail: [email protected]: +1 305 661 5581

16-19 June4th Advanced Resurfacing CourseVenue: Ghent, Belgiumwww.resurfacing-congress.comE-mail: [email protected]: +32 (0)3 800 0654

18 JuneBasic and Advanced Course in ElasticStable Intramedullary nailing in ChildrenVenue: Sheffield, EnglandE-mail: [email protected] Tel: +44 (0)114 271 7568Fax: +44 (0)114 226 7878

20-25 June3rd International Conference onOsteoimmunology: Interactions of theImmune and Skeletal SystemsVenue: Santorini, GreeceContact: Conference SecretariatE-mail: [email protected]: +1 610 527 7630

23-26 JuneCARS 2010 - Computer Assisted Radiologyand Surgery - 24th International Congressand ExhibitionVenue: Geneva, Switzerlandwww.cars-int.orgE-mail: [email protected]: +49 7742 922 434

26-30 June37th European Symposium on Calcified TissuesVenue: Glasgow, Scotlandwww.ectsoc.orgE-mail: [email protected]: +44 (0)1454 610255

28 June -1 JulyAO Principles in Operative FractureManagement CourseVenue: Leeds, Englandwww.aouk.orgE-mail: [email protected]: +44 (0)1707 395212

29 June - 2 JulyAO Advances in Operative FractureManagement CourseVenue: Leeds, Englandwww.aouk.orgE-mail: [email protected]: +44 (0)1707 395212

30 June - 2 JulyTechnical Advances to Skull Base SurgeryVenue: The Royal College of Surgeons ofEngland, Londonwww.rcseng.ac.ukE-mail: [email protected]

July 2010

5-8 JulyAO Principles in Operative FractureManagement CourseVenue: Leeds, Englandwww.aouk.orgE-mail: [email protected]: +44 (0)1707 395212

12-16 JulyThe Anatomy LabVenue: Coventry, UKwww.coringroup.comE-mail: [email protected]: +44 (0)1285 659866

14-15 July3rd Oswestry Shoulder and Elbow courseVenue: The Robert Jones and Agnes HuntOrthopaedic Hospital NHS Trust, Oswestry,Shropshire, UKE-mail: [email protected]: +44 (0)1691 404661

18-21 July1st Society of Curacao OrthopaedicSurgeons, Radiologists and TraumaSurgeons (SOCORT) Bi-Annual MeetingVenue: Curaçao, NetherlandsContact: J.L. BloemE-mail: [email protected]

21-24 JulyThe 17th Scoliosis Research Society (SRS)International Meeting on Advanced SpineTechniquesVenue: Toronto, Canadawww.srs.orgContact: Meetings DepartmentE-mail: [email protected]: +1 414 289 9107

24 July FRCS Orth Important Paper Course(Evidence Based)Venue: Reading, Englandwww.frcsorth.co.ukE-mail: [email protected]: +44 (0) 845 6439597

26-30 July7th Annual Meeting of the Society ofNeurointerventional Surgery (SNIS)Venue: Carlsbad, CA, USAwww.snisonline.orgContact: Meeting OrganiserE-mail: [email protected]: +1 703 691 2272

27 JulyHalf Day Statistics TutorialVenue: The Robert Jones and Agnes HuntOrthopaedic Hospital NHS Trust, Oswestry,Shropshire, UKE-mail: [email protected]: +44 (0)1691 404661

August 2010

31 August - 3 Sep7th SICOT/SIROT Annual InternationalConferenceVenue: Gothenburg, Swedenwww.sicot.orgE-mail: [email protected]: +32 2648 6823

September 2010

1-4 SeptemberBIOSPINE 3 - 3rd International CongressBiotechnologies for Spinal SurgeryVenue: Amsterdam, The Netherlandswww.biospine.orgContact: Congrex Deutschland GmbHE-mail: [email protected]: +49 (0)30 25 89 46 2

5-8 September11th International Congress on Shoulder and Elbow Surgery (ICSES)Venue: Edinburgh International ConferenceCentre, Scotland.www.ICSES2010.com

8 SeptemberIntroductory Musculoskeletal CourseVenue: Hitchin, Englandwww.sonositeeducation.comContact: Jes TillerE-mail: [email protected]: +44 (0)1462 444800Fax: +44 (0)1462 444801

Edinburgh

Geneva

April 10 13/5/10 09:34 Page 26



21-24 SeptemberScoliosis Research Society 45th AnnualMeeting & Combined CourseVenue: Kyoto, Japanwww.srs.orgContact: Scoliosis Research Society MeetingsDepartmentE-mail: [email protected]: +1 414 289 9107Fax: +1 414 276 3349

24-25 September8th Interventional MRI SymposiumVenue: Leipzig, GermanyContact: Department of Diagnostic andInterventional RadiolTel: +493 419 717 400Fax: +493 419 717 409

October 2010

3-7 OctoberAmerican College of Surgeons 96th AnnualMeetingVenue: Washington, DC, USAwww.facs.orgContact: American College of SurgeonsE-mail: [email protected]: +1 312 202 5000Fax: +1 312 202 5001

5-9 October25th Annual Meeting of the North AmericanSpine Society (NASS)Venue: Orlando, FL, USAContact: North American Spine SocietyE-mail: [email protected]: +1 (877) 774-6337

13 September - 15 OctoberBritish Casting Certificate CourseVenue: Royal National Orthopaedic Hospital,Stanmore, Middlesexwww.dundee.ac.ukContact: British Orthopaedic AssociationE-mail: [email protected] Tel: + 44 (0)20 7406 1750

13-17 SeptemberBOA Annual Congress - 12th CombinedAssociations MeetingVenue: Glasgow, Scotlandwww.boa.ac.ukE-mail: [email protected]: +44 (0) 20 7405 6507Fax: +44 (0) 20 7831 2676

15 SeptemberIntroductory Shoulder Ultrasound CourseVenue: Hitchin, Englandwww.sonositeeducation.comContact: Jes TillerE-mail: [email protected]: +44 (0)1462 444800Fax: +44 (0)1462 444801

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: [email protected]

To reproduce our list, please place an acknowledgement to OPN in your text.

April 10 13/5/10 09:34 Page 27


AArrttiiccllee

IntroductionDistal radius fractures are one of the most common fractures encoun-

tered in any trauma practice. Ever since Abraham Colles described theclassical dinner fork deformity before the days of X-rays there has beena lot of interest and controversy over their management. The generalprinciples in the management of these fractures are:

1. Anatomical reduction especially of any intra articular fragments2. As rigid fixation as possible3. Early mobilisation to prevent problems with stiffness

ClassificationAlthough the term distal radial fractures includes a huge range of

fracture patterns, they can be broadly classified into:1. Extra articular2. Intra articular

Within these broad sub divisions the fractures are usually describedaccording 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 volardisplaced fracture.

Treatment OptionsThe traditional methods of treatment have been broadly along the

following lines:1. Manipulation alone 2. Manipulation with K wire fixation3. Open reduction and internal fixation (ORIF)4. External fixation

Locking PlatesIn 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 theplates.

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

The advent of the locking plates changed the concept of plates fromfunctioning, just as a buttress. These implants functioned as neutralisa-tion devices where the distal locking screws provided direct stability bysupporting the sub chondral bone. They did not rely on the purchase ofthe distal screws which was usually poor on osteoporotic comminutedbone.

Dorsal PlatesBecause most of the distal radius fractures were dorsally displaced

and dorsal radius was more easily accessible due to the relative subcu-taneous nature of the bone, this became the preferred approach of mostsurgeons. However there were problems associated with this:

1. There is little space available between the skin and the dorsalsurface of the radius and this is occupied by the extensor tendons2. The dorsal surface of the radius is convex thus which induces

forced rubbing of the extensor tendons against the implants.3. Blood supply to the dorsal fragments is principally from the dor-sal side and these can be damaged during the dissection.4. The dorsal surface is usually comminuted which increases thedifficulty of reduction5. Dorsal scars are generally less well tolerated.

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

Volar approach to the distal radiusThe volar aspect of the distal radius is better suited for implant posi-

tioning because:1. More space is available from the skin to bone2. The flexor tendons are separated from the implant by pronatorquadratus3. The concave surface of the distal radius facilitates better implantposition4. Blood supply is less likely to be disturbed5. Volar cortex is usually less comminuted6. Volar scars are better tolerated.

Watershed LineCareful examination of the volar aspect of the distal radius reveals

the presence of what is called the watershed line. Distal to this line the

Distal Radius Fractures – The Role of VolarLocking Plates

Author: Sam Anand FRCS (Orth), Consultant Orthopaedic Surgeon, Horton Hospital and Horton NHS Treatment Centre, Banbury

Volar plating ofthe distal radiuswith doublerow of distal locking screws

April 10 13/5/10 09:34 Page 28


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

Extended Volar approach and reduction of fractureThe traditional volar approach through the bed of flexor carpi radi-

alis (FCR) is sufficient for simple fractures and when the fractures arerecent. But for complex dorsally displaced fractures, especially frac-tures which are a few days old where the fracture haematoma has organ-ised, it does not give access to the fracture fragments and reduction isdifficult. In these instances an extended FCR approach is used byreleasing the radial septum and pronating the proximal fragment to gainaccess to the comminuted fracture fragments.

Biomechanical aspectsBy approaching distal radius fractures through the volar aspect we

are converting a dorsally unstable fracture into one which is now unsta-ble in both directions. Some fractures are inherently unstable in bothdirections. So the loads placed across the implant can be as high as 50lbfor even activities of daily living. Because of the special geometry of thedistal radius volar plates a volar plate is in a more favourable biomechanical position than a corresponding distal radius plate. This is dueto the fact that the whole articular surface is offset a few millimetres ina volar direction with respect to the shaft. The stability can also beincreased 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.

ComplicationsComplications encountered with volar locking plates are few and are

usually related to poor surgical technique. These include inadequatereduction, insufficient exposure and improper implant positioning relat-ing to flexor tendon problems. The other problems are implant failure,infection, non union and reflex sympathetic dystrophy.

ConclusionIn conclusion locking volar plates have provided a new approach to

the management of distal radius fractures regardless of the direction ofdisplacement of the fracture. The obvious benefits are an early return tofunction, improved final motion, no extensor tendon problems and theabolition of routine plate removal. It is an easy to learn, simple proce-dure which has improved the outcome of this common injury.

References1. J.Orbay. Volar Plate Fixation of Distal Radius Fractures Hand Clinic21(2005)347-3542. Ring et al, Prospective multi centre trial of a plate for dorsal fixation of dis-tal radius fractures. J hand Surg Am 1997;22;777-843. Peine et al, Comparison of three different plating techniques for dorsum ofthe distal radius:a biomechanical study J Hand Surg Am 2000:25:29-334. Fernandez, Jupiter Fractures of the distal radius: a practical approach tomanagement. New York :Spriinger-Verlag;19965. Putnam et al, Advances in fracture management in the hand and distalradius. Hand Clin 1989:5(3):455-706. Orbay, Fernandez, Volar fixed angle plate fixation for unstable distalradius fractures in the elderly patient. J Hand Surg 2004;29(1):96-1027. Baratz et al Displaced intra articular fractures of the distal radius:effect offracture displacement on contact stresses in a cadaver model. J hand Surg Am1996:21:183-8

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Step by Step Management of Lower Limbs Deformity

Author: Rajendra Kumar Kanojia

Step by Step Management of Lower Limbs Deformity is anotheraddition in the “Step by Step” series for Orthopaedic conditionswhich aspire to The Pocket book for nutshell treatment of variousdisorders. This book, though not directed to any particular audience,may be suitable for medical students or orthopaedic residents inearly years of training or residency. It is unlikely to be of any signifi-cant benefit to one seriously considering deformity correction as acareer.

The book accelerates through various steps in deformity correc-tion starting from understanding the deformity and planningdeformity correction, then onto Ilizarov fixation and various facets inits execution. Case reports and complications are presented inconclusion, which may be useful for certain audiences.

Dr. Kanojia is Assistant Professor, Department of Orthopaedics atthe famous Postgraduate Institute of Medical Education andResearch in Chandigarh, India. Dr. Kanojia has been involved invarious publications, predominantly dealing with back pain and itsmanagement, amongst other things. Dr. Kanojia has drawn hisinspiration from Dror Paley, and also other leaders, in this excitingsubspecialty, the notable ones in India being Mangal Parihar andG.S.Kulkarni.

The book, though apparently starting with various sections,appears to mix and sadly mash most of them together. Apart fromcursory and personal references this book fails to excite the readerat all. Many illustrations are reproduced here and most seem to beneglected trauma or extreme cases of infections in open fractureswhich is still a large threat in the developing nations. These clinicalscenarios are unlikely to be ever experienced in the developedworld, except in parts of rural Africa or Asia.

Most clinical photographs accompanying the text are ofextremely poor quality with negligible attempts at enhancement orediting. In many such photographs the anatomic location of theframe depicted is unclear and it is frankly difficult to estimate theproximal or the distal end of the limb. Some illustrations are franklygrotesque.

Most cases demonstrated deal with simple deformity correctionor deformity correction that should not be attempted simply byfactual and scientific recommendations against them. Of particularnote in this category which finds mention here are the few cases ofcongenital pseudarthrosis of the tibia. In others many photographsindicate that the patient may have been better treated with amputa-

tion in the first place ratherthan complex frames beingused in management. Manyphotographs such as the oneentitled, “a scene of roadsideaccident” end up wastingvaluable space and conveynothing. Some interventionsand recommendations are waytoo simplistic and are unlikely to be able to stand peer-review orstatistical analysis. Deformity correction has focussed totally onexternal fixators and ring fixators and the title does not justify thecontents which need to include more comprehensive coverage ofvarious other modalities available to justify its title. The variousframed depicted are basic and the book does not deal with currentavailability, advances or sophistications in the technique elsewherein the world.

The colloquial style of writing and the rampant errors in spellingand grammar make poor reading eg. “Hybride” (sic). Anecdotalcases, personal opinions and reference to deities are appropriate fora patient education feature in a local neighbourhood weeklynewspaper, but this does little to enhance its popularity amongst thephysician community.

This book might be useful for the medical student who is planningto do his trauma elective in a developing country. It is commonknowledge that in most such countries they have poorly fundedstate run hospitals where support and equipment is in too short asupply. It is amazing that physicians there actually do what they dowith the limited resources available, compounded by abject poverty.The cases illustrated do indeed reflect the massive workload atsome of these institutions. And it is no doubt creditable that theauthor has dealt with such a significant volume of cases.

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

Book review by Mr. Satish KaleConsultant Orthopaedic Surgeon,

FRCS.Ed, Diploma in Sports Medicine (UK), Trauma Fellow (NY, USA)Tutor, RCS.Ed and Consultant Orthopaedic Surgeon

Step by Step Management of Lower Limbs Deformity isanother addition in the “Step by Step” series for Orthopaedicconditions. Authored by Rajendra Kumar Kanojia, this bookhas been published by Jaypee Brothers Medical PublishersPrivate Limited. It bears the ISBN 978-81-8448-631-5.

Book Review

April 10 13/5/10 09:34 Page 30

April 10 13/5/10 09:34 Page 31


Journal ReviewCurrent Fixation & Trauma Literature

When a person has a high-energy traumatic leg injuryresulting in a bone fracture and an open wound, gettingto a trauma center and getting treatment is a real emer-gency. Emergency doctors and staff need to knowwhat the results are of delayed treatment for injuries ofthis type. With open fractures, the risk of deep infectionis a big problem. Irrigation and debridement should bedone 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-threat-ening injuries that demand more immediate attention.And they may live in a rural setting or need to be trans-ported from one hospital to a trauma center. All of thattakes time and attention away from the leg injury. It’sclear that urgent treatment is needed. But how soon?What’s the optimum time for best results? These are thequestions a study group tried to answer with this study.

They reviewed the charts of 315 patients who hadhigh-energy leg injuries and who were treated at one ofeight trauma centers. They collected a variety of dataand information from the patients’ medical records.Type of injury, time periods (in hours), and treatmentadministered were recorded. Patient characteristicssuch as age, gender, and other injuries were alsonoted. The patients were divided into two groupsdepending on whether they were admitted directly tothe trauma center (direct group) or had to be trans-ferred from another hospital (transfer group).

Patients ranged in ages from 16 to 69. Certainpatients were not included in the study. Patients exclud-ed were those who were in a coma or had a spinal cordinjury, burn patients, or military personnel. Anyone whowas admitted or transferred to the trauma center morethan 24 hours after the injury was also left out of thisstudy. The direct group was all admitted within the firsteight hours after injury. Half of the transfer group madeit to the trauma center within the first three hours. Theremaining transfer patients arrived in equal numbersbetween four and 10 hours and 11 and 24 hours.

The number of patients in each group who developedinfections was compared. Two types of infection weretargeted: wound infection and osteomyelitis. Only infec-tions involving the injury site that started during the firstthree months after the injury were counted. This informa-tion was analysed based on the time periods and otherpatient factors listed. They were trying to see if any par-ticular factor or group of factors combined togethermight predict who was most likely to develop infection.Of course, the eventual goal is to reduce and/or elimi-nate infections altogether. This might be possible if anyof the predictive risk factors can be changed up front.

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

rates and those that didn’t. First, the factors associat-ed with an increased risk of major infection:

• Severe tibial fractures (classified as Gustilo TypeIIIC): more than two centimeters of bone losspresent

• Treatment with a metal plate instead of a nail insidethe 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 therisk of infection compared to those who arrivedwithin two hours of their injuries. Once the patientmade it to the trauma center, the timing of otherevents didn’t seem to reach significant levelsaccording to statistical analysis.

Factors that did not seem to contribute to the risk ofinfection included:

• Age, sex, or level of education and economic status• Smoking status• General health or number of other health prob-

lems (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 emergencymedical personnel transporting patients, surgeons willfind the conclusions useful, too. First, severe traumaticleg injuries should be treated at a trauma center when-ever possible to avoid the risk of infection and othercomplications. Instead of going to a local hospital, itmay be better to go directly to the trauma center evenif it’s further away. Of course, it depends on the condi-tion of the patient. If life saving measures are needed,hospital admission with delayed transfer to traumacenter may be unavoidable. All things considered,admission to a trauma center within two hours of theinjury significantly reduces the risk of infection later.

The treatment standard of operative debridementfor these injuries within six hours of the traumatic eventis still advised. But it appears that preventing infectionis more dependent on getting the patient to the traumacenter than on how soon the debridement is done.

The authors suggest a follow-up study looking atthe timing of prophylactic antibiotics after severe leginjuries and the risk of infection. The information fromsuch a study could help surgeons prioritise whichaspects of treatment are most important: antibiotics,debridement, fracture stabilization, soft-tissue cover-age, or limb-salvage procedures.

The Relationship Between Time to Surgical Debridement and Incidence ofInfection 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.

Provided courtesy of eOrthopod.comwww.eorthopod.com

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Current Hand Surgery Literature

Improved technology and smaller surgical instrumentshave changed the way hand surgeons repair Bennettfractures of the thumb. In this article, hand surgeonsreview those changes and describe how and when touse arthroscopy and fluoroscopy together to get thebest results.

A Bennett fracture is a break along the bottom sideof the thumb metacarpal closest to the wrist bone.Because this is a pivotal joint that contributes to all themovements of the thumb, a close and careful fracturereduction is important.

The surgeon uses wires, pins, or screws to hold thebone in place while it heals. Until small-jointarthroscopy became available, surgeons used openincisions and fluoroscopy to guide the reduction andfixation.

But there have been problems just using tractionand fluoroscopy because sometimes it looked like thebone is reduced and properly in place when it wasn’t.Even a slight rotation of the bone can make a differ-ence. Without an anatomic reduction, patients endedup with a painful, arthritic thumb. Combining

arthroscopy with the fluoroscopy has changed all that.Now the hand surgeon can replace the bone fragmentswhere they belong, apply the appropriate fixation, andmake sure everything is lined up perfectly before put-ting the hand in a splint.

The surgeon faces many challenges coordinatingthese two tools. The arthroscope must be inserted intothe joint without hitting nerves, blood vessels, or ten-dons. The broken fragment must be rotated andslipped back into place carefully with a tiny probe.While holding the probe in place and keeping the bonein its perfect spot, the surgeon then fixes the bone inplace. When using screws, the surgeon must be care-ful that the tip of the screw doesn’t go inside the joint.

Bennett fractures of the thumb can be surgicallyrepaired in this fashion and provide patients with amuch better long-term result. The authors caution thatmore complex fractures may still require an open sur-gery. If the shaft of the bone is broken and/or the softtissues around the area have been torn, then a moreextensive reconstructive procedure may be neededthat requires a full incision.

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

Repetitive strain injuries are occurring more frequentlywith today’s lifestyles, but the most common one thataffects the hand or arm is carpal tunnel syndrome.

Usually, surgery is not the first step approach to deal-ing with carpal tunnel syndrome. Nonsurgical manage-ment, such as taking anti-inflammatory drugs, usingsplints, and taking regular breaks are the usually firsttreatments. However, if these don’t work, then surgerymay be necessary. The risk of infection is low with carpaltunnel surgery, however it is important to understandhow it happens and to learn how to prevent it, if possible.

The authors of this article found that not muchresearch had been done regarding how often infectionsoccurred at the site of carpal tunnel surgery and if pre-ventative antibiotics would help reduce the rate. Toaddress this, the authors reviewed surgical casesinvolving carpal tunnel syndrome that took place over a20-month period. They were looking at both superficialinfections and those that occurred deep in the incision.

Researchers found 3,003 cases (2,067 women) toreview, performed by 98 surgeons in 11 medical cen-ters. This group was dubbed Group A. The patientsranged in age from 48 to 66 years and there were 546patients who had diabetes. Using the files, theresearchers looked for information on infections: if thepatients received antibiotics before the surgery, howmany patients developed infections, other health issuesamong the patients, and how the infections were treat-ed. To clarify the infection types, superficial infectionswere defined as infections that occurred within a monthof surgery and were restricted to the skin or superficial,subcutaneous, tissue. Deep incisional infections wereinfections that occurred within 30 days, but came fromdeeper within the wound, may have caused the wound

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

The first part of the study involved determining whohad received prophylactic antibiotics and this rate var-ied considerably. In one hospital, only 12.3% of thepatients received the prophylactic antibiotics, while inanother, 89.9% did. The surgeons also varied as towhether they would prescribe them. One surgeonnever prescribed the antibiotics (0%) while another didfor 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 outpa-tients, the remaining were in the hospital. Of all the 3003patients, there were 11 surgical site infections: four were inan organ or the space below the tissue and seven weresuperficial or deep. Three of the 11 patients had diabetes.One of these patients had extra surgery done at the sametime as the carpal tunnel release, on the thumb, so theinfection could have begun in that area. All the infectionsoccurred in patients who were operated on as outpatients.

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

The researchers concluded that the overall infectionrate after this type of surgery was low and more severeinfections, in the organs, for example, was even lowerthan originally thought and reported. While using antibi-otics before surgery is a good idea for some types of sur-gery, such as on the colon, it doesn’t seem to be neces-sary for carpal tunnel syndrome, because there were nosignificant differences in infection rates between patientswho had received these antibiotics and those who didn’t.

Rate of Infection After Carpal Tunnel Release Surgery and Effect of Antibiotic ProphylaxisNeil G. Harness, MD, et alThe Journal of Hand Surgery. February 2010. Vol. 35. No. 2. Pp. 189-196



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April 10 13/5/10 09:34 Page 33


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

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

SudokuWWiinn ££5500VVoouucchheerr

3 6 5 1 9

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A Different ViewControlling Assistive Device (Powered Wheelchair) by Kathy WeaverA focus of Weaver’s art is on the human cost of war, including theimpact of traumatic brain injuries and lost limbs on soldiers. She oftencontemplates how technology – especially robotics – may help them,if continued research investment is made. This chair is tailored to

This is part of the Wounded in Action: An Exhibition of Orthopaedic Advancements in Art.

For more information, go to www.woundedinactionart.org

meet the needs oftetraplegic patients,who practice by usingvirtual reality as a stepto creating theinterface necessary toenable patients withlimited mobility to steerprecisely. “I found itfascinating that musicis used with thepatients to determinetheir dominantmovements, so thatbody sensors may bemore efficiently placedand programmed,”Weaver says.

A recent investigation into King Tutankhamen’s life has revealedthat the boy king of Egypt may have worn orthopaedic sandalsspecially designed to deal with several foot conditions he sufferedfrom. When Howard Carter unearthed King Tut’s tomb in 1922, thetreasure packed tomb included several pairs of footwear the kinghad 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 investi-gation into his family that it was discovered the pharaoh sufferedfrom foot conditions.

Researchers, publishing their work in the book “Tutankhamen’sFootwear: Studies of Ancient Egyptian Footwear,” found that KingTut wore special sandals to help him cope with various malforma-tions in his feet. King Tut is believed to have suffered from Kohlerdisease II in addition to having very deformed feet, both of whichwould have left him hobbling around perhaps with the assistance ofa cane. King Tut’s left foot was clubbed causing it to rotateinternally at the ankle while the middle toe on his right foot waslacking a middle bone, making it shorter.

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

Source: ecanadanow

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