Background. Involving research users in setting priorities for research is essential to ensure research outcomes are patient-centred and to maximise research value and impact. The Musculoskeletal (MSK) Disorders Research Advisory Group Versus Arthritis led a research priority setting exercise across MSK disorders. Methods. The Child Health and Nutrition Research Initiative (CHRNI) method of setting research priorities with a range of stakeholders were utilised. The MSKD RAG identified, through consensus, four research Domains: Mechanisms of Disease; Diagnosis and Impact; Living Well with MSK disorders and Successful Translation. Following ethical approval, the research priority exercise involved four stages and two surveys, to: 1) gather research uncertainties; 2) consolidate these; 3) score uncertainties using agreed criteria of importance and impact on a score of 1–10; and 4) analyse scoring, for prioritisation. Results. The first survey had 209 respondents, who described 1290 research uncertainties, which were refined into 68 research questions. 285 people responded to the second survey. The largest group of respondents represented patients and carers, followed by researchers and healthcare professionals. A ranked list was produced, with scores ranging between 12 and 18. Key priorities included developing and testing new treatments, better targeting of treatments, early diagnosis, prevention and better understanding and management of pain, with an emphasis on understanding underpinning mechanisms. Conclusions. For the first time, we have summarised priorities for research across MSKD, from discovery science to applied clinical and health research, including translation. We present a call to action to researchers and funders to target these priorities. Conflict of Interest: None. Sources of funding: We thank the funder, Versus Arthritis for their support of the research advisory groups and this activity

Purposes of the study and background. The care and cure of patients with low back disorders is of a multidisciplinary nature. Cooperation and communication between the disciplines would improve standardized care delivery to the patient. We engaged to establish a national group of multidisciplinary spine specialists to promote research and education in the field of spinal disorders. Summary of the methods used and results. A multidisciplinary group of spine professionals, opinion leaders and research leaders in spinal disorders in the Netherlands were invited to participate in a national network (“Netwerk Wervelkolomaandoeningen”). The group consists of physiotherapists, family physicians, neurosurgeons, orthopedic surgeons, anesthesiologists, as well as clinical researchers and epidemiologists. Group meetings were organized in various locations in the country. Priorities were set and divided in research and education. Communication lines were established with a resource website and a linked-in page. The first educational series of symposia for primary care professionals on multidisciplinary approaches for disc herniation and spinal stenosis is being organized in different regions in the Netherlands. The first meetings on research initiatives are being held on an idea-driven basis. Conclusion. The Dutch Network for Spinal Disorders is a promising initiative that has the potential to align care and cure for spinal disorders across disciplines

The purpose of this study was to investigate the association of endocrine disease with calcific tendinitis and the effects that such disease has on its natural history. A retrospective observational cohort study of 102 consecutive patients (125 shoulders) with calcific tendinitis is presented. Seventy-three (71.6 %) female, 29 (28.4 %) male. Compared with population prevalences, significant levels of endocrine disorders were found in our study cohort. Sixty-six patients (81 shoulders, 62 female (93.9 %), 4 male (6.1 %), mean age 50.3 years) with associated endocrine disease were compared with 36 patients (44 shoulders, 11 female (30.6 %), 25 male (69.4 %), mean age 52.4 years) without endocrine disease. The endocrine cohort were significantly younger than the non-endocrine cohort when symptoms started (mean 40.9 years and 46.9 years respectively, p=0.0026), had significantly longer natural histories (mean 79.7 months compared with 47.1 months, p=0.0015) and a significantly higher proportion underwent operative treatment (46.9 % compared with 22.7 %, p=0.0014). Disorders of thyroid and oestrogen metabolism may contribute to calcific tendinitis aetiology. Classifying calcific tendinitis into Type I idiopathic and Type II secondary or endocrine-related aids prognosis and management

Genetic skeletal disorders constitute a rare and heterogeneous bone diseases often leading to poor quality of life. Several surgical options are available. The surgeon must deal with specific features (bone deformity, previous procedures, abnormal bone quality, stiffness or instability, muscle weakness). The questions concern the feasibility of the procedures and the surgical strategy.

55 patients (26 W, 29 M) were reviewed between 2016 and 2022. The mean age of the patients was 35 years (17–71). The diagnosis included 9 hereditary multiple exostoses, 8 osteogenesis imperfecta, 6 multiple epiphyseal dysplasia congenita, 6 achondroplasia, 4 osteopetrosis, 3 pycnodysostosis, 3 hypophosphatemic rickets, 3 fibrous dysplasia, 2 mucopolysaccharidosis, and 10 miscellaneous. 25 patients were referred for hip problems (40 hips). 4 patients (7 hips) requiring a THA have not been operated (4 planned). 4 patients (6 hips) had a proximal femoral fixation (2 osteotomies, 4 fracture fixations). 17 patients (27 hips) sustained a THA (25 primary, 2 revisions). All of them were operated by one operator, using a posterolateral approach and standard implants (including 7 dysplastic and 2 short stems). No customized implant has been used.

As regard the 27 THAs, the mean follow up was 4.2 years (1–12). The early complications included 2 femoral cracks and 1 femur fracture. There were 2 revisions (1 cup loosening at 2 years, 1 stem loosening at 4 years). No infection nor dislocation occurred. All the patients were satisfied with their treatment and regain some autonomy. 3 THA were considered as unfeasible.

Constitutional bone diseases need a multidisciplinary program of care. The indication for surgery is based on a mutual trust patient/surgeon, a careful evaluation of benefits/risks, and an accurate imaging to anticipate the difficulties. The expected results are a better function and quality of life, and a stability over time.

Summary. Metastatic spinal disease is a common entity of much debate in terms of ideal surgical treatment. The introduction of MIS can be a game-changer in the treatment of MSD due to less peri-operative morbidity and allowing earlier radiotherapy and/or chemotherapy. Introduction. Less invasive techniques have always been welcome for management of patients with ‘Metastatic Spinal Disorders’. This is because these patients can be poor candidates for extensive / major invasive surgery even though radiologically, there may be an indication for one. The aim of the treatment with Minimal Invasive Fixation (MIS) systems is mainly for ‘pain relief’ than to radically decrease tumour burden or to achieve near total spinal cord decompression, which could be major presentations in these patients. These procedures address the ‘spinal instability’ very well and they can address pain associated with compression fractures resulting from metastatic disease from a solid organ as well as multiple myeloma with minimal complications. These procedures can be combined with radiology and chemotherapy without much concern for wound problems in the way of infection or dehiscence. They also have a great advantage of timing of adjunct therapy closer to the index procedure. The disadvantage, however, are they do not allow thorough decompression of the spinal cord. There could also be problem in addressing patients who have severe vertebral height loss or loss of integrity of the anterior column where anterior column reconstruction may be required. There is a risk of inadequate fixation or implant loosening or failure. We aim to examine the results of MIS surgery in our department and support the rationale for its use. Patients and Methods. We prospectively collected data of patients who underwent MIS posterior instrumentation for MSD. Between June 2011 and December 2012, 10 patients presented with acute motor deficit, instability and/or threatening radiological features. Effectiveness of MIS was assessed in terms of operative parameters and clinical outcomes. Results. No patient suffered intra-operative complications. The median surgical time was 198 minutes (range: 149 – 403), median blood loss was 100 ml (range: 60 – 400). All patients maintained full neurological function and reported effective pain reduction. All patients were discharged with a median hospital stay was 13 days (range: 4 – 45) post-surgery. 9 patients started oncological treatment as planned. The median time in 7 patients who had radiotherapy post-surgery was 23 days (range: 20 – 40). Chemotherapy was initiated in 4 patients at a median of 9 days post-surgery (range: 6 – 23). No patient as yet has required open procedure due to progression of the disease. Discussion/Conclusion. We have shown that satisfactory outcomes are achievable with MIS in a selected group of patients with MSD. While our results are limited by small study size, we have been able to improve patient quality of living through minimally invasive intervention. By reducing surgical morbidity and enabling early implementation of oncological treatment, MIS has the potential to re-evaluate multi-disciplinary decision making for early surgery in MSD

The application of immune regenerative strategies to deal with unsolved pathologies, such as tendinopathies, is getting attention in the field of tissue engineering exploiting the innate immunomodulatory potential of stem cells [1]. In this context, Amniotic Epithelial Cells (AECs) represent an innovative immune regenerative strategy due to their teno-inductive and immunomodulatory properties [2], and because of their high paracrine activity, become a potential stem cell source for a cell-free treatment to overcome the limitations of traditional cell-based therapies. Nevertheless, these immunomodulatory mechanisms on AECs are still not fully known to date. In these studies, we explored standardized protocols [3] to better comprehend the different phenotypic behavior between epithelial AECs (eAECs) and mesenchymal AECs (mAECs), and to further produce an enhanced immunomodulatory AECs-derived secretome by exposing cells to different stimuli. Hence, in order to fulfill these aims, eAECs and mAECs at third passage were silenced for CIITA and Nrf2, respectively, to understand the role of these molecules in an inflammatory response. Furthermore, AECs at first passage were seeded under normal or GO-coated coverslips to study the effect of GO on AECs, and further exposed to LPS and/or IL17 priming to increase the anti-inflammatory paracrine activity. The obtained results demonstrated how CIITA and Nrf2 control the immune response of eAECs and mAECs, respectively, under standard or immune-activated conditions (LPS priming). Additionally, GO exposition led to a faster activation of the Epithelial-Mesenchymal transition (EMT) through the TGFβ/SMAD signaling pathway with a change in the anti-inflammatory properties. Finally, the combinatory inflammatory stimuli of LPS+IL17 enhanced the paracrine activity and immunomodulatory properties of AECs. Therefore, AECs-derived secretome has emerged as a potential treatment option for inflammatory disorders such as tendinopathies.

Acknowledgement: This research is part of the P4FIT project ESR1, funded under the H2020-ITN-EJD-Marie-Skłodowska-Curie grant agreement 955685.

In the context of regenerative medicine for the treatment of musculoskeletal pathologies mesenchymal stromal cells (MSCs) have shown good results thanks to secretion of therapeutic factors, both free and conveyed within the extracellular vesicles (EV), which in their totality constitute the “secretome”. The portfolio and biological activity of these molecules can be modulated by both in vitro and in vivo conditions, thus making the analysis of these activities very complex. A deep knowledge of the targets regulated by the secretome has become a matter of fundamental importance and a homogeneous and complete molecular characterization is still lacking in the field of applications for the musculoskeletal system. Therefore, the aim of this work was to characterize the secretome obtained from adipose-derived MSCs (ASCs), and its modulation after pre-conditioning of the ASCs. Pre-conditioning was done by culturing cells in the presence of i) high levels of IFNγ, as proposed for the production of clinical grade secretome with enhanced regenerative potential, ii) low levels of inflammatory stimuli, mimicking conditions found in the osteoarthritis (OA) synovial fluid. Furthermore, EVs ability to migrate within cartilage, chondrocyte and synoviocytes obtained from OA patients was evaluated.

The data showed that more than 50 cytokines / chemokines and more than 200 EV-microRNAs are detectable at various intensity levels in ASCs secretomes. The majority of the most abundantly present molecules are involved in the remodelling of the extracellular matrix and in the homeostasis and chemotaxis of inflammatory cells including macrophages, which in OA are often characterized by an M1 inflammatory polarization, promoting their transition to an M2 anti-inflammatory phenotype. Inflammatory priming with IFNγ and synovial fluid-like conditions were able to further increase the ability of the secretome to interact with inflammatory cells and modulate their migration. Finally, the penetration of the EVs in the cartilage explants resulted a rapid process, which begins a few minutes after administration of the EVs that are able to reach a depth of 30-40 μm in 5 hours. The same capacity for interaction was also verified in chondrocytes and synoviocytes isolated from the cartilage and synovial membrane of OA patients.

Thanks to the soluble factors and EV-microRNAs, the ASCs secretome has shown a strong propensity to modulate the inflammatory and degenerative processes that characterize OA. The inflammatory pre-conditioning through high concentrations of inflammatory molecules or in conditions similar to the synovial fluid of OA patients was able to increase this capacity by increasing their chemotactic power. The microscopy data also support the hypothesis of the ability of MSC-EVs to influence the chondrocytes residing in the ECM of the cartilage and the synovial cells of the synovial membrane through active interaction and the release of their therapeutic content.

Purpose and background

Nearly 70% of UK physiotherapists experience work-related musculoskeletal disorders (WRMSDs) during their career, with a significant proportion occurring in the back and being attributed to patient handling tasks. Evidence suggests that manual handling training alone is ineffective and interventions among nurses indicate that a tailored approach, including targeted exercise (TE), can reduce WRMSD rates. This study aimed to explore physiotherapists’ perspectives of WRMSDs, patient handling, and the role of TE in reducing WRMSDs among physiotherapists.

Introduction and Objective

Dislocation of a hip hemiarthroplasty is a significant complication with a high mortality rate in elderly patients. Previous studies have shown a higher risk of dislocation in patients with neuromuscular conditions. In this study, we reviewed our larger cohort of patients to identify if there is a link between neuromuscular disorders and dislocation of hip hemiarthroplasty in patients with neuromuscular conditions.

Abstract

Introduction and Objective

The use of microfragmented adipose tissue (mFAT) for the treatment of musculoskeletal disorders, especially osteoarthritis, is gaining popularity following the positive results reported in recent case series and clinical trials. The purpose of this study is to characterize mFAT in terms of structure, cell content and secretome (i.e. protein and microvescicles released as paracrine mediators), and to compare it with unprocessed lipoaspirate tissue, in order to understand the possible mechanisms of action and the benefit derived from tissue processing.

Abstract

The future of work brings several challenges and opportunities for occupational health and safety on three major drivers: the rapid progress of technological innovation; demographic changes, in particular ageing of the workforce and migration; and changes in the labour market, especially owing to new ways of per-forming jobs. Innovation technologies are leading to an overall transformation of industrial processes that offer huge developmental perspectives in the world of work and opportunities for society. In the field of prevention of musculoskeletal disorders, relevant progresses have been made in the clinical setting and in the context of care, also in relation to the ageing society. In the near future, the adaptation of workstations and the implementation of sensors and enabling technologies (collaborative robots and exoskeletons) will offer, together with the innovations in the clinic and orthopaedic surgery, a significant contribution to the reduction of risks from biomechanical overload, as well as support interventions to increase work ability and reduce the impact of disability. However, the potential risk scenarios for health and safety in the workplace, along with the progress in occupational health research, lead to the need for creating an inte-grated system of skills and approaches to adopt a Prevention through Design perspective. This requires designing and conceiving processes taking into consideration occupational risk prevention and guarantee-ing the return to work in a multidisciplinary and integrated perspective.

The objective of this study was to quantify the burden of musculoskeletal disorders (MSDs) on the Ontario health care system. Specifically, we examined the magnitude and costs of MSD-associated ambulatory physician care and hospital service use, considering different physician types (e.g. primary care, rheumatologists, orthopaedic surgeons) and hospital settings (e.g. emergency department (ED), day surgery, inpatient hospitalizations).

Administrative health data were analyzed for fiscal year 2013/14 for adults aged 18+ years (N=10,841,302). Data sources included: Ontario Health Insurance Plan Claims History Database, which captures data on in- and out-patient physician services, Canadian Institute for Health Information (CIHI) Discharge Abstract Database, which records diagnoses and procedures associated with all inpatient hospitalizations, and CIHI National Ambulatory Care Reporting System, which captures data on all emergency department (ED) and day surgery encounters. Services associated with MSDs were identified using the single three digit International Classification of Diseases (ICD) version 9 diagnosis code provided on each physician service claim for outpatient physician visits and the “most responsible” ICD-10 diagnosis code recorded for hospitalizations, ED visits and day surgeries. Patient visit rates and numbers of patients and visits were tabulated according to care setting, patient age and sex, and physician specialty. Direct medical costs were estimated by care setting. Data were examined for all MSDs combined as well as specific diagnostic groupings, including a comprehensive list of both trauma and non-trauma related conditions.

Overall, 3.1 million adult Ontarians (28.5%) made 8 million outpatient physician visits associated with MSDs in 2013/14. These included 5.6 million primary care visits, nearly 15% of all adult primary care visits in the province. MSDs accounted for 560,000, 12.3%, of all adult ED visits. Patient visit rates to the ED for non-trauma spinal conditions were the highest of all MSDs at 1032 per 100,000 population, accounting for 23% of all MSD-related ED visits. Osteoarthritis had the highest rate of inpatient hospitalization of all MSDs at 340 per 100,000 population, accounting for 42% of all MSD-related admissions. Total costs for MSD-related care were $1.6 billion, with 12.6% of costs attributed to primary care, 9.2% to specialist care, 8.6% to ED care, and 61.2% of total costs associated with inpatient hospitalizations. Costs due to ‘arthritis and related conditions’ as a group accounted for 40.1% of total MSD costs ($966 million). Costs due to non-trauma related spinal conditions accounted for 10.5% ($168 million) of total MSD costs. All trauma-related conditions (spine and non-spine combined) were responsible for 39.4% ($627 million) of total MSD costs. MSD-related imaging costs for patients who made physician visits for MSDs were $169 million. Including these costs yields a total of $1.8 billion.

MSDs place a significant and costly burden on the health care system. As the population ages, it will be essential that health system planning takes into account the large and escalating demand for MSD care, both in terms of health human resources planning and the implementation of more clinically and cost effective models of care, to reduce both the individual and population burden.

A recent French report suggested that cobalt metal ions released from total hip replacements (THRs) were associated with an increased risk of dilated cardiomyopathy and heart failure. If the association is causal the consequences would be significant given the millions of Orthopaedic procedures in which cobalt-chrome is used annually. We examined whether cobalt-chrome containing THRs were associated with an increased risk of all-cause mortality, heart failure, cancer, and neurodegenerative disorders.

Data from the National Joint Registry was linked to NHS English hospital inpatient episodes for 375,067 primary THRs with up to 14·5 years follow-up. Implants were grouped as either containing cobalt-chrome or not containing cobalt-chrome. The association between implant construct and the risk of all-cause mortality and incident heart failure, cancer, and neurodegenerative disorders was examined.

There were 132,119 individuals (35·2%) with an implant containing cobalt-chrome. There were 48,106 deaths, 27,406 heart outcomes, 35,823 cancers, and 22,097 neurodegenerative disorders. There was no evidence of an association that patients with cobalt-chrome implants had higher rates of any of the outcomes. For all-cause mortality there was a very small survival advantage for patients having a cobalt-chrome implant (restricted mean survival time 13·8=days, 95% CI=6·8-20·9).

Cobalt-chrome containing THRs did not have an increased risk of all-cause mortality, heart failure, cancer, and neurodegenerative disorders into the second decade post-implantation. Our findings will reassure clinicians and patients that primary THR is not associated with systemic implant effects.

The transtrochanteric anterior rotational osteotomy (TRO) was developed by Sugioka as a joint-preserving procedure which prevents further deformity by transposing the necrotic area from a site of primary weight-bearing to a secondary area. We performed this procedure for children and young adults with various hip disorders.

Between 1994 and 2015 we performed TROs on 12 joints in 12 patients with SCFE (4), pigmented villonodular synovitis (2), septic arthritis (1), FAI (1), hip dysplasia (1), femoral neck fracture (2) and postoperative RAO (1). The mean age at the time of surgery was 21 years (10–43) and the mean follow-up period was 8 years (1–22). The rotational directions of the femoral head were anterior (5) and posterior (7). Clinical assessment was undertaken using the system of Merle d'Aubigné and Postel, grading pain, mobility and walking ability with scores from 0 to 6. Radiographically bone regeneration and OA progression were estimated.

The mean clinical score improved from 9.0 to 14.4 at final follow-up. Spur formation of femoral head was observed in 7 patients (58%). OA progression was in two patients (17%) and one patient was converted to THA 22 years after surgery. All cases with osteonecrosis in SCFE and femoral neck fracture showed remarkable bone regeneration.

The TRO is a reliable joint-preserving procedure for various hip disorders in children and young adults.

Material and Methods: This prospective study included 15 patients, 9 males and 6 females, who have been scoped for peroneal tendon disorder between 1999 and 2004. All patients were diagnosed clinically to have chronic peroneal tendon dysfunction and all had conventional x-ray films, ultrasonographic assessment and magnetic resonance imaging. The mean age was 44 (range 23 to 65). The mean duration of symptoms were 16 (range from 2 to 65). All patient had a trial of conservative treatment before being referred to us.

Results: 7 patients was found to have tenosynovitis, which could be resected endoscopically in all cases. In 2 patients a low lying muscle belly (LLMB) of peroneus brevis was present; this could be resected with a shaver very easily. 1 patient had a peroneal tendon instability. This was surgical treated in an open technique with reconstruction of the retinaculum. In 5 patients we could document partial lesions of the peroneal tendons (fig.6,7). This were posttraumtic after a supination trauma in 2 patients and degenerative in the remaining 3 patients. In 4 patients this could be treated minimal invasive with debridement. In one patient a traumatic longitudinal splitting tear was reconstructed with open surgery.

At time of follow up (average 2.8 years; range: 78– 18 months) all patients where without symptom on average 3 months (range: 4 – 17 weeks) after surgery. They where able to perform all activities of daily living as well as moderate athletic activities such as jogging and biking. These clinical results where stable until the time of follow-up.

Clincal relevance: Tendoscopy of the peroneal tendons is an effective and minimal invasive management tool, that can be indicated in many of peroneal disorders. Further studied are needed at that respect to improve results and promote minimal invasive surgical techniques.

Purpose and background

Lumbar spinal fusion (LSF) is frequently and increasingly used in lumbar degenerative disorders despite conflicting results and recommendations. Further understanding of patient outcomes after LSF is required to inform decisions regarding surgery and to improve post-surgery management. The objective was to evaluate the course of pain and disability in patients with degenerative disorders of the lumbar spine (spinal stenosis, spondylolisthesis, disc herniation, discogenic low back pain) after first-time LSF.

Background

Patient-rated measures are the gold standard for assessing spine surgery outcomes, but there is no consensus on the appropriate timing of follow-up. Journals often demand a minimum 2-year follow-up, but the indiscriminate application of this principle may not be warranted. We examined the course of change in patient outcomes up to 5 years postoperatively.

Introduction: Now that evidence base medicine gains importance scientifically good evaluation of the results of treatment is fundamental. There exist however a large number of evaluation tools for dorsolumbar disorders. These tools measure different aspects of outcome, like pain, impairment, handicap, disability, satisfaction and health perception. These tools are not always well validated either. These problems make it difficult to select the appropriate test for different purposes.

Aim of the study: To compose and evaluate a system of outcome measuring tools that covers most aspects of outcome and that is relevant to spine surgeons.

Materials and Methods: The tests were selected from literature, based on their scientific validity, their relevance, the frequency of their use by others and the ease of their use. The visual analogue scale for pain (VAS-pain), the low back outcome score (LBOS), the handicap subsection of the LBOS, the finger-tip to floor test (FTFT), The Oswestry disability index (ODI) and patient satisfaction were tested in a group of “pure-dorsolumbar-disorder-patients” (selected from a trauma group) and in a group of patients with degenerative disorders, as encountered in a spine surgery practice. The prospectively gathered pre- vs. postop. differences obtained with the different tests were compared with those obtained with the Oswestry disability index, which was chosen as “golden standard”. The obtained correlations (Kendall’s rank correlation coefficients and point-biserial coefficient) are a measure for the construct-validity and responsiveness of the different tests.

Results: The correlation with the ODI was: weak and not significant for VAS-pain in the degenerative group, for FTFT-distance in both groups, for FTFT-pain in the trauma group and for satisfaction in both groups. The same correlation was weak but significant for the VAS-pain in the trauma group and for the LBOS-handicap part in the trauma group. It was moderate for LBOS and the LBOS-disability part in both groups, for the LBOS-handicap part in the degenerative group and for FTFT-pain in the degenerative group. There was no correlation of satisfaction with the other tests. Correlation of FTF- pain with VAS-pain was not significant in the degenerative group and moderate and in the trauma group.