Orthopaedics and Trauma Queensland Annual Report 2011

Orthopaedics and Trauma Queensland, a Centre for Research and Education in Musculoskeletal Disorders, is an internationally recognised research group that is developing into an international leader in research and education. It provides a stimulus for research, education and clinical application within the international orthopaedic and trauma communities. Orthopaedics and Trauma Queensland develops and promotes the innovative use of engineering and technology, in collaboration with surgeons, to provide new techniques, materials, procedures and medical devices. Its integration with clinical practice and strong links with hospitals ensure that the research will be translated into practical outcomes for patients. The group undertakes clinical practice in orthopaedics and trauma and applies core engineering skills to challenges in medicine. The research is built on a strong foundation of knowledge in biomedical engineering, and incorporates expertise in cell biology, mathematical modelling, human anatomy and physiology and clinical medicine in orthopaedics and trauma. New knowledge is being developed and applied to the full range of orthopaedic diseases and injuries, such as knee and hip replacements, fractures and spinal deformities.

Recruitment and results of a pilot trial of vitamin D supplementation in the general population of Australia

Context: The benefits of high serum levels of 25-hydroxyvitamin D [25(OH)D] are unclear. Trials are needed to establish an appropriate evidence base. Objective: We plan to conduct a large-scale trial of vitamin D supplementation for the reduction of cancer incidence and overall mortality and report here the methods and results of a pilot trial established to inform its design. Design: Pilot D-Health was a randomized trial carried out in a general community setting with 12 months intervention and follow-up. Participants: Participants were 60- to 84-yr-old residents of one of the four eastern Australian states who did not have any vitamin D-related disorders and who were not taking more than 400 IU supplementary vitamin D per day. A total of 644 participants were randomized, and 615 completed the study (two persons withdrew because of nonserious adverse events). Interventions: The interventions were monthly doses of placebo or 30,000 or 60,000 IU vitamin D3. Main Outcomes: The main outcomes were the recruitment rate and changes in serum 25(OH)D. Results: Ten percent of those approached were recruited. At baseline, the mean 25(OH)D was 42 nmol/liter in all three study arms. The mean change in 25(OH)D in the placebo group was 0.12 nmol/liter, compared with changes of 22 and 36 nmol/liter in the 30,000- and 60,000-IU groups, respectively. Conclusions: The D-Health pilot has shown that a large trial is feasible in Australia and that a dose of 2000 IU/d will be needed to ensure that a large proportion of the population reaches the target serum 25(OH)D level. Copyright © 2012 by The Endocrine Society.

Were intercalated komatiites and dacites at the Black Swan nickel sulphide mine, Yilgarn Craton, Western Australia, emplaced as extrusive lavas or intrusive bodies? The significance of breccia textures and contact relationships

Intercalated Archean komatiites and dacites sit above a thick footwall dacite unit in the host rock succession at the Black Swan Nickel Mine, north of Kalgoorlie in the Yilgarn Craton, Western Australia. Both lithofacies occur in units that vary in scale from laterally extensive at the scale of the mine lease to localized, thin, irregular bodies, from > 100 m thick to only centimetres thick. Some dacites are only slightly altered and deformed, and are interpreted to post-date major deformation and alteration (late porphyries). However, the majority of the dacites display evidence of deformation, especially at contacts, and metamorphism, varying from silicification and chlorite alteration at contacts to pervasive low grade regional metamorphic alteration represented by common assemblages of chlorite, sericite and albite. Texturally, the dacites vary from entirely massive and coherent to partially brecciated to totally brecciated. Strangely, some dacites are coherent at the margins and brecciated internally. Breccia textures vary from cryptically defined, to blocky, closely packed, in situ jig-saw fit textures with secondary minerals in fractures between clasts, to more apparent matrix rich textures with round clast forms, giving apparent conglomerate textures. Some clast zones have multi-coloured clasts, giving the impression of varied provenance. Strangely however, all these textural variants have gradational relationships with each other, and no bedding or depositional structures are present. This indicates that all textures have an in situ origin. The komatiites are generally altered and pervasively carbonate veined. Preservation of original textures is patchy and local, but includes coarse adcumulate, mesocumulate, orthocumulate, crescumulate-harrisite and occasionally spinifex textures. Where original contacts between komatiites and dacites are preserved intact (i.e. not sheared or overprinted by alteration), the komatiites have chilled margins, whereas the dacites do not. The margins of the dacites are commonly silicified, and inclusions of dacite occur in komatiite, even at the top contacts of komatiite units, but komatiite clasts do not occur in the dacites. The komatiites therefore were emplaced as sills into the dacites, and the intercalated relationships are interpreted as intrusive. The brecciation and alteration in the dacites are interpreted as being largely due to hydraulic fracturing and alteration induced by contact metamorphic effects and hydrothermal alteration deriving from the intrusion of komatiites into the felsic pile. The absence of autobreccia and hyaloclastite textures in the dacites suggest that they were emplaced as an earlier intrusive (sill?) complex at a high level in the crust.

A new model to study healing of a complex femur fracture with concurrent soft tissue injury in sheep

High energy bone fractures resulting from impact trauma are often accompanied by subcutaneous soft tissue injuries, even if the skin remains intact. There is evidence that such closed soft tissue injuries affect the healing of bone fractures, and vice versa. Despite this knowledge, most impact trauma studies in animals have focussed on bone fractures or soft tissue trauma in isolation. However, given the simultaneous impact on both tissues a better understanding of the interaction between these two injuries is necessary to optimise clinical treatment. The aim of this study was therefore to develop a new experimental model and characterise, for the first time, the healing of a complex fracture with concurrent closed soft tissue trauma in sheep. A pendulum impact device was designed to deliver a defined and standardised impact to the distal thigh of sheep, causing a reproducible contusion injury to the subcutaneous soft tissues. In a subsequent procedure, a reproducible femoral butterfly fracture (AO C3-type) was created at the sheep’s femur, which was initially stabilised for 5 days by an external fixator construct to allow for soft tissue swelling to recede, and ultimately in a bridging construct using locking plates. The combined injuries were applied to twelve sheep and the healing observed for four or eight weeks (six animals per group) until sacrifice. The pendulum impact led to a moderate to severe circumferential soft tissue injury with significant bruising, haematomas and partial muscle disruptions. Posttraumatic measurements showed elevated intra-compartmental pressure and circulatory tissue breakdown markers, with recovery to normal, pre-injury values within four days. Clinically, no neurovascular deficiencies were observed. Bi-weekly radiological analysis of the healing fractures showed progressive callus healing over time, with the average number of callus bridges increasing from 0.4 at two weeks to 4.2 at eight weeks. Biomechanical testing after sacrifice showed increasing torsional stiffness between four and eight weeks healing time from 10% to 100%, and increasing ultimate torsional strength from 10% to 64% (relative to the contralateral control limb). Our results demonstrate the robust healing of a complex femur fracture in the presence of a severe soft tissue contusion injury in sheep and demonstrate the establishment of a clinically relevant experimental model, for research aimed at improving the treatment of bone fractures accompanied by closed soft tissue injuries.

First steps towards modeling a multi-scale Earth system

Recent advances in computational geodynamics are applied to explore the link between Earth’s heat, its chemistry and its mechanical behavior. Computational thermal-mechanical solutions are now allowing us to understand Earth patterns by solving the basic physics of heat transfer. This approach is currently used to solve basic convection patterns of terrestrial planets. Applying the same methodology to smaller scales delivers promising similarities between observed and predicted structures which are often the site of mineral deposits. The new approach involves a fully coupled solution to the energy, momentum and continuity equations of the system at all scales, allowing the prediction of fractures, shear zones and other typical geological patterns out of a randomly perturbed initial state. The results of this approach are linking a global geodynamic mechanical framework over regional-scale mineral deposits down to the underlying micro-scale processes. Ongoing work includes the challenge of incorporating chemistry into the formulation.

Organized crime in Oceania

Oceania has a relatively low level of crime prevalence yet in the smaller and under-developed PICs we have shown that transnational crime has become increasingly common. A risk contained but potentially dangerous if state failure or fragility undermines law enforcement capacities. We predict that as the pace of globalization quickens and the demand for raw materials and resources grows some parts of the Pacific will be prone to criminal enterprises run by both indigenous and foreign crime groups. Australia and New Zealand will remain attractors of illicit goods notably ATS but will in turn be source countries for diminishing fish stock such as beche de mere and abalone as well forest timber. Finally the role of states such as Australia and New Zealand in helping to maintain law enforcement capacities throughout the region will be crucial if organized crime in Oceania is to be kept in check while demand for illicit resources grow.

Transnational organized crime in Oceania

Oceania has a relatively low level of crime prevalence yet in the smaller and under-developed PICs we have shown that transnational crime has become increasingly common. A risk contained but potentially dangerous if state failure or fragility undermines law enforcement capacities. We predict that as the pace of globalization quickens and the demand for raw materials and resources grows some parts of the Pacific will be prone to criminal enterprises run by both indigenous and foreign crime groups. Australia and New Zealand will remain attractors of illicit goods notably ATS but will in turn be source countries for diminishing fish stock such as beche de mere and abalone as well forest timber. Finally the role of states such as Australia and New Zealand in helping to maintain law enforcement capacities throughout the region will be crucial if organized crime in Oceania is to be kept in check while demand for illicit resources grow.

Polyalanine repeat polymorphism in RUNX2 is associated with site-specific fracture in post-menopausal females

Runt related transcription factor 2 (RUNX2) is a key regulator of osteoblast differentiation. Several variations within RUNX2 have been found to be associated with significant changes in BMD, which is a major risk factor for fracture. In this study we report that an 18bp deletion within the polyalanine tract (17A>11A) of RUNX2 is significantly associated with fracture. Carriers of the 11A allele were found to be nearly twice as likely to have sustained fracture. Within the fracture category, there was a significant tendency of 11A carriers to present with fractures of bones of intramembranous origin compared to bones of endochondral origin (p=0.005). In a population of random subjects, the 11A allele was associated with decreased levels of serum collagen cross links (CTx, p=0.01), suggesting decreased bone turnover. The transactivation function of the 11A allele was quantitatively decreased. Interestingly, we found no effect of the 11A allele on BMD at multiple skeletal sites, although these were not the sites where a relationship with fracture was most evident. These findings suggest that the 11A allele is a biologically relevant polymorphism that influences serum CTx and confers enhanced fracture risk in a site-selective manner related to intramembranous bone ossification.

Orthopaedics and trauma Queensland annual report 2012

Orthopaedics and Trauma Queensland, the Centre for Research and Education in Musculoskeletal Disorders, is an internationally recognised research group that continues to develop its reputation as an international leader in research and education. It provides a stimulus for research, education and clinical application within the international orthopaedic and trauma communities. Orthopaedics and Trauma Queensland develops and promotes the innovative use of engineering and technology, in collaboration with surgeons, to provide new techniques, materials, procedures and medical devices. Its integration with clinical practice and strong links with hospitals ensure that the research will be translated into practical outcomes for patients. The group undertakes clinical practice in orthopaedics and trauma and applies core engineering skills to challenges in medicine. The research is built on a strong foundation of knowledge in biomedical engineering, and incorporates expertise in cell biology, mathematical modelling, human anatomy and physiology and clinical medicine in orthopaedics and trauma. New knowledge is being developed and applied to the full range of orthopaedic diseases and injuries, such as knee and hip replacements, fractures and spinal deformities.

Improving in vivo models of fracture fixation associated osteomyelitis

This project’s aim was to create new experimental models in small animals for the investigation of infections related to bone fracture fixation implants. Animal models are essential in orthopaedic trauma research and this study evaluated new implants and surgical techniques designed to improve standardisation in these experiments, and ultimately to minimise the number of animals needed in future work. This study developed and assessed procedures using plates and inter-locked nails to stabilise fractures in rabbit thigh bones. Fracture healing was examined with mechanical testing and histology. The results of this work contribute to improvements in future small animal infection experiments.

Characterisation of microvasulature changes after closed soft tissue trauma by contrast enhanced micro-CT imaging

INTRODUCTION It is known that the vascular morphology and functionality are changed following closed soft tissue trauma (CSTT) [1], and bone fractures [2]. The disruption of blood vessels may lead to hypoxia and necrosis. Currently, most clinical methods for the diagnosis and monitoring of CSTT with or without bone fractures are primarily based on qualitative measures or practical experience, making the diagnosis subjective and inaccurate. There is evidence that CSTT and early vascular changes following the injury delay the soft tissue tissue and bone healing [3]. However, a precise qualitative and quantitative morphological assessment of vasculature changes after trauma is currently missing. In this research, we aim to establish a diagnostic framework to assess the 3D vascular morphological changes after standardized CSTT in a rat model qualitatively and quantitatively using contrast-enhanced micro-CT imaging. METHODS An impact device was used for the application of a controlled reproducible CSTT to the left thigh (Biceps Femoris) of anaesthetized male Wistar rats. After euthanizing the animals at 6 hours, 24 hours, 3 days, 7 days, or 14 days after trauma, CSTT was qualitatively evaluated by macroscopic visual observation of the skin and muscles. For visualization of the vasculature, the blood vessels of sacrificed rats were flushed with heparinised saline and then perfused with a radio-opaque contrast agent (Microfil, MV 122, Flowtech, USA) using an infusion pump. After allowing the contrast agent to polymerize overnight, both hind-limbs were dissected, and then the whole injured and contra-lateral control limbs were imaged using a micro-CT scanner (µCT 40, Scanco Medical, Switzerland) to evaluate the vascular morphological changes. Correlated biopsy samples were also taken from the CSTT region of both injured and control legs. The morphological parameters such as the vessel volume ratio (VV/TV), vessel diameter (V.D), spacing (V.Sp), number (V.N), connectivity (V.Conn) and the degree of anisotropy (DA) were then quantified by evaluating the scans of biopsy samples using the micro-CT imaging system. RESULTS AND DISCUSSION A qualitative evaluation of the CSTT has shown that the developed impact protocols were capable of producing a defined and reproducible injury within the region of interest (ROI), resulting in a large hematoma and moderate swelling in both lateral and medial sides of the injured legs. Also, the visualization of the vascular network using 3D images confirmed the ability to perfuse the large vessels and a majority of the microvasculature consistently (Figure 1). Quantification of the vascular morphology obtained from correlated biopsy samples has demonstrated that V.D and V.N and V.Sp were significantly higher in the injured legs 24 hours after impact in comparison with the control legs (p<0.05). The evaluation of the other time points is currently progressing. CONCLUSIONS The findings of this research will contribute to a better understanding of the changes to the vascular network architecture following traumatic injuries and during healing process. When interpreted in context of functional changes, such as tissue oxygenation, this will allow for objective diagnosis and monitoring of CSTT and serve as validation for future non-invasive clinical assessment modalities.

Using GPS and accelerometry to assess older adults' driving behaviours and performance : challenges and future directions

With the projected increase in older adults, the older driver population is estimated to be the fastest growing cohort of drivers among many developed countries. The increased physical fragility associated with the aging process make older adults who drive private automobiles a vulnerable road user group. Much of the current research on older drivers’ behaviours and practices rely on self-report data. This paper explores the utility of in-vehicle devices (Global Positioning Systems and recording accelerometers) in assessing older drivers’ habitual driving behaviours. Seventy-eight older drivers (above 65 years of age), from the Australian Capital Territory, Australia, participated in the current study. The driving behaviours and practices of these participants were prospectively assessed over a two-week period. The use of combined GPS and recording accelerometers to improve understanding of older drivers’ driving behaviours show promise within the current study. The challenges of using multiple in-vehicle devices in assessing driving beahaviours and performances within this cohort will be discussed. Based on the current findings, recommendations for future research regarding the use of in-vehicle devices among the older driver cohort are proposed.

Predicting the fatigue life of internal fracture fixation plates

Failures of fracture fixation plates, often related to fatigue fractures of the implants, have been reported (Banovetz et al, 1996). While metallurgical defects can usually be excluded, many of these fractures can be explained with the biomechanical situation. This study investigated the biomechanics of two clinical cases, both of which used a 14-hole locking compression plate. In the first case, a titanium plate was used in a rigid configuration with 12 screws resulting in plate breakage after 7 weeks (Sommer et al, 2003). In the second case, a stainless steel plate, which endured the entire healing process, was used in a flexible application with only 6 screws.

Prevention of Alcohol-Related Crime and Trauma (PACT) : brief interventions in routine care pathway – a study protocol

Background Globally, alcohol-related injuries cause millions of deaths and huge economic loss each year . The incidence of facial (jawbone) fractures in the Northern Territory of Australia is second only to Greenland, due to a strong involvement of alcohol in its aetiology, and high levels of alcohol consumption. The highest incidences of alcohol-related trauma in the Territory are observed amongst patients in the Maxillofacial Surgery Unit of the Royal Darwin Hospital. Accordingly, this project aims to introduce screening and brief interventions into this unit, with the aims of changing health service provider practice, improving access to care, and improving patient outcomes. Methods Establishment of Project Governance: The project governance team includes a project manager, project leader, an Indigenous Reference Group (IRG) and an Expert Reference Group (ERG). Development of a best practice pathway: PACT project researchers collaborate with clinical staff to develop a best practice pathway suited to the setting of the surgical unit. The pathway provides clear guidelines for screening, assessment, intervention and referral. Implementation: The developed pathway is introduced to the unit through staff training workshops and associate resources and adapted in response to staff feedback. Evaluation: File audits, post workshop questionnaires and semi-structured interviews are administered. Discussion This project allows direct transfer of research findings into clinical practice and can inform future hospital-based injury prevention strategies.

Older driver safety and mobility : where to from here?

The older adult population (65 years and over) represents a rapid growing segment of the population in many developed countries. Unlike earlier cohorts of older drivers that included many who were familiar with public transportation, the present cohort of older drivers historically has a greater reliance on the private automobile as their main form of transportation. Recent studies of older adults’ travel patterns reported automobile to be responsible for over 80% of the total number of hours spent on all trips. While older drivers, as a group, does not demonstrate a particular road risk, the evident demographic change and the increased physical fragility and severity of crash-related injuries makes older driver safety a prevalent public health issue. This study systematically reviewed the safety and mobility outcomes of existing strategies used internationally to manage older driver safety, with a specific focus on age-based testing (ABT), license restriction and self-regulation (i.e. voluntary limiting driving in potentially hazardous situations). ABT remains the most commonly adopted strategy by licensing authorities both within Australia and internationally. Heterogeneity in the development of functional declines, and in driving behaviours within the older driver population, makes age an unreliable index of driving capacity. Given the counter-productive safety and mobility outcomes of ABT strategies, their continued popularity within both the legislative and public domains remains problematic. Self-regulation may provide greater potential for reducing older drivers’ crash risk while maintaining their mobility and independence. The current body of literature on older drivers’ self-regulation is systematically reviewed. Despite being promoted by researchers and licensing authorities as a strategy to maintain older driver safety and mobility, the proportion of older drivers who self-regulate, and exactly how they do so, remains unclear. Future research on older drivers’ adoption of self-regulation, particularly the underlying psychological factors that underlies this process, is needed in order to promote its use within the older driver community.