Background: Hip fracture is the most common serious injury in older people. It is also the most common reason for older people to need emergency anaesthesia and surgery, and the commonest cause of death following an accident. A FICB is the injection of anaesthetic agents into the fascia- iliaca compartment with the effect of blocking the lumbar plexus via an anterior approach. FICB is clinically safe and efficient and provides consistent analgesic effects irrespective of the performing doctor's experience of frailty fractures of the proximal femur.
Methods: Data from the National Hip Fracture Database (NHFD) for all patients admitted with a neck of femur fracture between October 2018 and May 2019 was interrogated and audited. Results of this audit were discussed in the department of Trauma & Orthopaedics' and the Trust's mortality review meetings. Teaching sessions were held for doctors and filling out of the neck of femur fracture proforma to detail administration or not of FICB and a valid reason when the later occurred was encouraged. A re-audit was carried out in May 2020.
Results: We noted a statistically significant increase in the number of patients who got a fascia iliaca block on presentation with a fractured neck of the femur from after our second audit (p<0.00001). There were no complications associated with the administration of FICB to patients with neck of femur fractures. This study showed that clinical processes could be improved through audits, staff education and by employing the use of proformas to ensure compliance.

The relationship between sonographic entropy and the degree of damage to ischemic skeletal muscle was investigated. In the experiment, rabbits (Chinchilla, 4.2-4.5kg) were subjected to an elastic tourniquet width 5.5 cm on the hind limb for 6 hours. After removal the tourniquet, autologous concentrates of platelet plasma, bone marrow aspirate and adipose tissue cells were injected into the calf muscle. The dynamics of changes in calf muscle were studied at 5, 15 and 30 days by histological and ultrasound examination. Morphometrically estimated the percentage of altered tissue (total reflecting necrosis, atrophy and fibrotic changes) to the total area of the micropreparation. There was a significant increase in the density of lesions at 30 days after ischemia and administration of adipose tissue cells, and after introduction of platelet plasma and bone marrow cell aspirate was significantly lower (ischemia: 69.9±0.85%, PRP: 38.4±2.99%, bone marrow aspirate 39.0±1.03%, adipose tissue cells: 66.1 ± 4.28%). There is a replacement of muscle tissue with fibrous connective tissue. Sonographic examination showed reduced vertical δ-entropy on day 5 in the group with bone marrow aspirate, on 15 and 30 day the level of entropy returned to control values. High correlation was between vertical δ-entropy and the degree of muscle damage. Correlation with horizontal δ-entropy was only in the group with bone marrow cell aspirate. The conclusion was that a significant indicator in muscle sonography is vertical δ-entropy, which can be used to assess, predict the severity of compartment syndrome and muscle condition in reactive recovery period.

Purpose: Pro-inflammatory mediators released after trauma and the subsequent inflammatory response are important factors in the development of complications in polytraumatized patients. New methods for the investigation of specific circulating and organ bound lipids have found rapidly increasing usage investigating metabolic and cardiovascular disease. Several lipid subgroups have been shown to mediate inflammatory response. In the current study, we employed a well-established porcine polytrauma model and investigated the posttraumatic intravasation of 233 specific lipids. Methods: 54 male Pigs were split in polytrauma (PT), monotrauma (MT) and sham group. PT received a combined injury of lung contusion, liver laceration, controlled hemorrhagic shock, and femoral shaft fracture. MT received an isolated femoral shaft fracture. After 60 minutes animals were resuscitated and fractures received intramedullary nailing. Venous blood was taken regularly from baseline to 6hours post trauma. Lipid concentrations and lipid composition were investigated using mass spectrometry. Results: Total lipid concentration decreased significantly (p<0.05) in PT . Acylcarnitines, phosphatidylcholine and fatty acyls showed a significant (p<0.05) increase directly after polytrauma. Five subgroups (ceramides, Diacylglyceroles, lysophosphatidylcholine, Phosphatidylethanolamine and triacylglycerols) increased significantly in MT group after trauma and in in both groups after treatment (p<0.05).
Conclusion: Our results clearly suggests that intravasal lipid composition was significantly changed after trauma and treatment with intramedullary reaming and nailing. Corresponding factors might be the posttraumatic intravasation of lipids from bone marrow, a response to posttraumatic cytokine storm or the onset of a hypermetabolic state. Individual pathways have yet to be investigated and collation with clinical data is needed.

Background: Recruitment of patients in Randomised control trials (RCTs) is a challenging task. In trauma RCTs, the identification & recruitment are time-critical. Multiple strategies have been tried to improve the participation of doctors and recruitment of patients.

Aim: Study the efficacy of recruiting patients to a multicentre hip fracture RCT before and after having a trainee principal investigator (TPI), at a major trauma centre in the UK.

Methods: Retrospective review of efficacy of recruiting eligible patients and number of junior doctors participating in recruitment before and after the introduction of TPI, who was assigned in Sept’19.

Results: Seven junior doctors were recruiting in the pre-TPI period (Oct'18-July'19) versus 11 in post-TPI period (Sept'19-Feb'20). TPI had a direct influence on 9 of the 11 trainees to participate by guidance. There was a statistically significant improvement in recruitment after introducing TPI. Of the 164 eligible patients, 100 were recruited (61% of eligible, 110% of target) in the pre-TPI period, versus 102 recruited (76% of eligible, 189% of target) out of the 135 eligible patients in the post-TPI period. There was also a statistically significant increase in recruitment by junior doctors after introducing TPI. The proportion of recruitment done by the trainees was 36% versus research team in the pre-TPI period improving to 70% in the post-TPI period.

Conclusion: TPI can work alongside the principal investigator and research team to be a valuable link person coordinating and engaging local trainees to take part in trials, thus significantly improving recruitment in trauma RCTs.

Introduction: Alterations in the collagen (COL) composition have been co-related to degenerative disc disease (DDD). The current study aimed to analyze the entire COL composition of human IVD across fetal (developmental phenotype), normal (healthy phenotype), scoliotic (early degeneration), herniated (degenerate phenotype), and degenerated (degenerate phenotype) IVDs using high-end proteomic technology.

Methods: Nucleus pulposus (NP) tissues were segregated from IVDs harvested from five different disc phenotypes and washed with phosphate buffer solution (PBS) and snap-frozen in liquid nitrogen ((LN2) -196⁰C) immediately before subjecting to proteomic analysis.

Results: Tandem mass spectrometric analysis revealed a total of 1050 proteins in fetal discs (FD); 1809 in ND; 1487 in SD; 1859 in DH and 1538 in the DD group. Fetal discs (FD) expressed 14 different major types of Collagen, compared to 10 (ND), 11 (SD), 15(DH), and 19 in DD groups. Collagens types - 1,2,6,11 and 14 were found in all the groups along with their sub-types. Collagen type -22 was found only in the FD group whereas type -15,25,26 and 27 were found only in DD group. Amongst the fibril-forming collagens, the abundance of COL-1 and 11 was highest amongst fetal discs representing their role in the development of NP. In addition, COL-24 was highly abundant in normal discs indicating their role in homeostasis. Of notable importance was the higher expression of COL-7 (anchoring-fibril forming), COL-10 (network forming) and Col-15 (Multiplexin) in normal discs.

Conclusion: The selective proteomic analysis of collagen composition in this study has revealed novel molecular targets for regenerative potential.

We have previously shown that intraosseous pressure (IOP) varies because it is governed by local perfusion at the needle tip and extraosseous systemic pressures. During loading in vivo there is a proportional rise in IOP. With repetitive loading the IOP falls implying that there is a one-way valve within the subchondral circulation. Very high surface and subchondral pressures of up to 18MPa may arise. Adipocytes are frail and their contents are semi-liquid at body temperature. We previously described radiating subchondral vascular marks on upper tibial water-bright MRI scans. They are reduced in number in early osteoarthritis (p<0.002) SICOT, Vienna 2017. In this study of normal upper tibial bone, we sought histological confirmation that the radiating marks were vascular. We looked for other structures that support load transfer by hydraulic pressure. We found radiating subchondral vessels as seen in the MRI scans. They were absent in osteoarthritic bone. As the vessels approach the cortical margin there were complex distortions which would act as choke valves when the surrounding IOP is raised during loading. These were absent in osteoarthritic bone. Load is transmitted through the slightly flexible subchondral tissues and adipocytes, partly by hydraulic pressure acting to transfer force onto the trabeculae and down the cortical shaft. Subcortical choke valves exist which close as the surrounding pressure rises, thereby preventing destructive turbulent flow. We confirm that there is a specialised subchondral circulation which allows the transfer of load through relatively delicate tissues partly by hydraulic pressure.

Introduction: The necessary basic science questions regarding the rib construct(RC) are 1) what is the strength of the RC compared with pedicle screw fixation for resistance to pullout forces? 2) How does the immature spine with a fixed kyphotic deformity respond to corrective rib fixation? Methods: 12 porcine spines(6 with pedicle screw fixation, and 6 with rib fixation) from 20Kk pigs were potted distally custom mounts to the base of the mechanical testing system (858 Mini Bionix II, MTS, Minneapolis, MN). A pure bending mode, which simulated hyperkyphosis, was applied to 12 porcine spines, 6 with pedicle screw fixation, 6 with RC fixation. All spines were loaded from 0 - 90°. A kyphotic immature animal model was created by partial vertebrectomy of T10, screw placement at T9 and T11, and interspinous ligament release in 10 Kg pigs. After the deformity was established, RC fixation was inserted proximal and distal to the kyphotic deformity Results: The pedicle screw group withstood 64.6 ± 7.3° of bending and 118.6 ± 25.7 N of maximal force, at which point all proximal fixations failed. RC fixation withstood 97.9 ± 10.0° of bending (p<0.001) and 119.7 ± 13.9 N of maximal force with no failure. In response to corrective RC fixation of an immature kyphotic spine, growth modulation was documented by gross and histologic studies. . Conclusion: The Rib construct provides more secure proximal fixation than pedicle screw, and induces favorable remodeling in immature spines with a fixed kyphotic deformity

Introduction. Bone grafts are frequently used as a delivery vehicle for antibiotics. However, there is concern that high-antibiotic concentrations in the surrounding area can substantially reduce osteoblast replication and even cause cell death.

Objectives. To evaluate bone tissue formation after filling bone defect with antibiotic-impregnated bone allograft and bone allograft without antibiotic.

Materials and method. Bone defects (3-mm diameter, 10-mm depth) were created in the femur of 48 rabbits (24 rabbits in each group). In the control group the defects were filled with bone allografts, in the experimental group with Gentamycin-impregnated bone allografts. The animals were killed after 14, 30 and 60 days. The qualitative and quantitative histological examining were carried out to assess new bone formation.

Results. No statistically significant differences (p<0,05) in levels bone tissue formation between control and experimental groups after 14, 30 and 60 days were observed. However, the resorption and mineralization of the allograft in the intramedullary space was significantly higher in the experimental groups than in the control group (p<0,05).

Conclusion. Femur defects in regeneration of Gentamycin-impregnated bone allografts were found to be as effective as bone allografts without antibiotic. The use of gentamycin-impregnated bone allografts may be of value in the treatment of bone infection without disturbing bone regeneration.

Introduction: Degeneration of the intervertebral disc is associated with a decrease in Extra-cellular matrix(ECM) content due to an imbalance in anabolic and catabolic signaling. This study aims to explore ECM regulators, associated proteins, and secreted factors of the fetal NP.

Methods: Proteomic data of 9 fetal and 7 healthy adults (age 22-79) nucleus pulposus (NP) was analyzed to understand the expression pattern of ECM regulators.

Results: Based on the selection criteria, a total of 45 proteins were identified, of which 15 were uniquely expressed in fetal NP’s, 2 showed a significantly higher expression as compared to healthy adult NP’s, and 1 protein was >2 fold higher expressed in fetal NP’s. Pathway analysis with the 18 abovementioned proteins revealed a significant upregulation of 1 pathway and 3 biological processes, in which 13 proteins were involved. Prolyl 4 hydroxylase (P4HA) 1 and 2, Procollagen-lysine, 2-oxoglutarate 5-dioxygenase (PLOD) 1, 2 and 3, and Heat shock protein 47 (SERPINH1) were involved in ‘collagen biosynthesis’ pathway. In addition, PLOD 1-3, SERPINH1, Annexin A1 and A4, CD109 and Tetranectin (CLEC3B) were all involved in biological process of ‘tissue development’. Furthermore, the second biological process ‘regulation of proteolysis’ contained CD109, CLEC3B, SERPINH1 and SERPINF1. At last, Annexin A1, A4 and A5, Galectin-3 (LGALS-3) and SERPINF1 featured ‘negative regulation of cell death’. When integrating the interaction analysis, ANXA 4 and SERPINH1 interacted directly or indirectly as initiators of all abovementioned processes.

Conclusion: This study reveals fetal ECM regulators and ECM-affiliated proteins of interest to study for regenerative therapies.

Introduction: Steroids are thought to raise intraosseous pressure (IOP) and cause osteonecrosis by fat cell swelling. We explored the effects of vascular occlusion on IOP in a steroid treated animal model. Methods: IOP was measured in 41 sites among 15 control and 6 steroid treated rabbits through upper tibial intraosseous needles connected to pressure transducers, with and without proximal vascular occlusion. After angiography the femora were removed, photographed and x-rayed. Results: Resting basal IOP (IOPb) varied widely (24.8 mmHg, SD 11.6) but had a proportionate pulse pressure (PP) (R2=0.64). Proximal arterial occlusion (IOPa) lowered (p<0.0001) and proximal venous occlusion (IOPv) increased IOP (p<0.0001). Subtracting IOPv-IOPa gave a delta pressure with a better measure of perfusion pressure range achievable at the needle tip than IOPb alone. Six steroid treated subjects showed a raised IOPb (p<0.002) but without a significant change in delta pressure range IOPv-IOPa (p=0.59). Steroids caused cachexia and weight loss (p<0.003). The raised IOP was secondary to increased intraosseous vascular space and better perfusion confirmed on photographs and x-ray micro angiography. Conclusions: We show that basal IOP varies but has a proportionate PP as a needle variably accesses the vascular tree. We describe a subtraction technique (IOPv-IOPa) which gives a delta perfusion pressure at the needle tip. In this model, corticosteroids reduced fat cell volume thereby improving perfusion at the needle tip rather than raising IOP by fat cell swelling. Our work offers a new insight into bone perfusion physiology.