The primary aim of this study was to compare the clinical outcomes of osteoid osteoma (OO) between the group of patients with the presence of nidus on biopsy samples from radiofrequency ablation (RFA) with those without nidus. Secondly, we aimed to examine other factors that may affect the outcomes of OO reflecting our experience as a tertiary orthopaedic oncology centre. We retrospectively reviewed 88 consecutive patients diagnosed with OO treated with RFA between November 2005 and March 2015, consisting of 63 males (72%) and 25 females (28%). Sixty-six patients (75%) had nidus present in their biopsy samples. Patients’ mean age was 17.6 years (4-53). Median duration of follow-up was 12.5 months (6-20.8). Lesions were located in the appendicular skeleton in seventy-nine patients (90%) while nine patients (10%) had an OO in the axial skeleton. Outcomes assessed were based on patients’ pain alleviation (partial, complete, or no pain improvement) and the need for further interventions. Pain improvement in the patient group with nidus in histology sample was significantly better than the group without nidus (OR 7.4, CI 1.35-41.4, p=0.021). The patient group with nidus on biopsy demonstrated less likelihood of having a repeat procedure compared to the group without nidus (OR 0.092, CI 0.016-0.542, p=0.008). Our study showed significantly better outcomes in pain improvement in appendicular lesions compared to the axially located lesions (p = 0.005). Patients with spinal lesions tend to have relatively poor pain relief than those with appendicular or pelvic lesions (p=0.007). Patients with nidus on histology had better pain alleviation compared to patients without nidus. The histological presence of nidus significantly reduces the chance of repeat interventions. The pain alleviation of OO following RFA is better in patients with appendicular lesions than spinal or axially located lesions

Background. There is growing evidence for an important role of central sensitization (CS) in the development and maintenance of chronic pain. Consequently, alleviation of CS might be helpful, as was demonstrated for pregabalin. For tapentadol this is unknown. Tapentadol is a drug with a dual mechanism: 1) it acts on the mu-opioid receptor (µ-OR) and 2) it inhibits the reuptake of noradrenalin in the central nervous system3. The noradrenergic effect might involve a modulation of descending pain pathways and thereby reduce or alleviate CS. Aim. The aim of the present study is to determine the alterations in CS parameters by tapentadol in patients with chronic visceral (endometriosis) pain and deep somatic (low back) pain, using pregabalin as comparator. Hypothesis. In both visceral and deep somatic pain when using tapentadol or pregabalin a decrease in pain (NRS) correlates to a decrease in CS. Method/design. Prospective, open label 2×2 randomized cross-over study in 30 patients with proven endometriosis and 30 patients with chronic (>3 months) low back pain radiating to the leg (CLBPr). Each group of patients will start with either pregabalin of tapentadol for 8 weeks, followed by a wash out period of one week, after which the second drug is used for 8 weeks. Discussion. The rationale for this study is to provide more insights about the affect tapentadol has on CS parameters in comparison to pregabalin in patients suffering from chronic pain that has a visceral or deep somatic origin. No conflict of interest. Sources of funding: Grünenthal

Introduction: To date, herniated nucleus pulposus (NP) with radiculopathy and central or lateral recess stenosis are considered as contraindications for lumbar disc arthroplasty. In the present study we used data from a unique mandatory spine register, SWISSspine to investigate associations between preoperative status of NP herniated/non herniated with presence/absence of sciatica and clinical outcome. Methods: Between 3/2005 and 8/2008, 358 mono-segmental lumbar total disc arthroplasties were documented in a prospective observational multicenter mode. The data collection included peri-operative data and clinical outcomes based on NASS, EuroQol and VAS. The patients were divided into 4 groups: group I-128 patients with herniated NP with sciatica, group II-48 patients with herniated NP without sciatica, group III-74 patients without herniated NP but with sciatica and group IV-108 patients without herniated NP and no sciatica (classic indication). The groups were pair wise compared regarding 1-year postoperative VAS, EuroQol and NASS scores using ANOVA-test with Boferroni-Holm adjustment (α=0.05). Results: The 4 groups had similar demographic characteristics. Statistical analyses showed no significant outcome differences between the classic and the other indications. For example a outcomes for group IV: NASS back pain pre-post: 72.0/31.7 EQ-5D pre-post: 0.32/0.69. Discussion and Conclusion: Our analysis revealed no differences between patients with herniated NP combined with neural compression and patients with stenosis of recesses regarding pain alleviation and QoL improvement. The findings suggest that these diagnoses may not have to be considered as absolute contraindications for TDR anymore. The results of this multicenter observational study however, need to be verified in a controlled or experimental study design

Purpose: Metal-on-metal articulations in total hip arthroplasty (THA) have been recently re-introduced for the treatment of osteoarthritis. There have been excellent short-term clinical outcomes reported. The long-term clinical results of these implants are still unknown. In this study, we examined the four to ten -year results of metal-on-metal total hip arthroplasty at our institution. Method: All patients receiving a metal-on-metal prosthesis were prospectively registered in a computerized database. The period July 1997 – May 2003 was selected for analysis. This group contained 251 cases (207 patients) and had an average follow-up of 6.8 years. Of the 251 implants the femoral head components were either Metasul. ™. (203) or Ultamet. ™. (48) and the acetubular component Fitek. ™. (12), Interop. ™. (191) or Pinnacle. ™. (48). All patients were assessed with the Harris hip and UCLA activity scores at routinely scheduled follow-up visits. The mean age of patients at surgery was 52 years (18 to 70 years old). The average follow-up was of 6.8 years (4.2–10 years). No patients were lost to follow-up. Results: The mean UCLA and Harris hip score pre-operatively were 3.6 (1–8) and 42 (15–81), respectively. Values of the UCLA and the Harris hip scores on the most recent follow-up visit were 7.0 (60% of patients had a score equal to or greater than 7) and 85 (70% of patients had a score equal to or greater than 85), respectively. Thirteen hips (5.1%) were revised in total: 1 (0.4%) for early deep infection, 1 (0.4%) for revision of undersized stem and 11 (4.3%) for acetabular revisions due to manufacturing defects. Radiological results showed no osteolysis and 9 non-progressive radiolucency. Conclusion: At four to ten year follow-up, metal-on-metal total hip replacement provides consistently good clinical and radiographic results with a low revision rate. They provide longstanding pain alleviation and improved function and activity levels in patients suffering from osteoarthritis

Summary Statement. Prophylactic vertebroplasty treatment of ‘at-risk’ vertebrae may reduce fracture risk, however which areas weaken, thus providing surgical targets? Direct spatial 3D mapping of ReTm overcomes the constraints of 2D histology, and by application may provide insight into specific regional atrophy. Introduction. Insidious bone loss with age makes the skeleton fracture-prone in the rapidly expanding elderly population. Diagnosis of osteoporosis is often made after irreversible damage has occurred. There are over 300,000 new fragility fractures annually in the UK, more than 120,000 of these being vertebral compression fractures (VCF). Some VCFs cause life-altering pain, requiring surgical intervention. Vertebroplasty is a minimally invasive procedure whereby bone cement is injected into the damaged vertebral body with the aim of stabilisation and pain alleviation. However, vertebroplasty can alter the biomechanics of the spine, apparently leaving adjacent vertebrae with an increased VCF risk. Prophylactic augmentation of intact, though ‘at-risk’, vertebrae may reduce the risk of adverse effects. The question therefore arises as to which areas of a non-fractured vertebral body, structurally weakened with age, and thus should be targeted. Frequent reports of an overlap in BMD (bone mineral density) between fracture and non-fracture subjects suggest the combination of bone quantity and its ‘quality’ (microarchitectural strength) may be a more reliable fracture predictor than BMD alone. Providing a reliable method of cancellous connectivity measurement (a highly significant bone strength factor) is challenging. Traditional histological methods for microarchitectural interconnection are limited as they usually indirectly extrapolate 3D structure from thin (8 µm) 2D undecalcified sections. To address this difficulty, Aaron et al (2000) developed a novel, thick (300 µm) slicing and superficial staining procedure, whereby unstained real (not stained planar artifactual) trabecular termini (ReTm) are identified directly within their 3D context. The aim of this study was to automate a method of identifying trabecular regions of weakness in vertebral bodies from ageing spines. Patients and methods. 27 Embalmed cadaveric vertebral bodies (T10-L3) from 5 women (93.2±8.6 years) and 3 men (90±4.4 years) were scanned by µCT (micro-computerised tomography; µCT80, Scanco Medical, Switzerland, 74 µm voxel size), before plastic-embedding, slicing (300µm thick), and surface-staining with the von Kossa (2% silver nitrate) stain. The ReTm were mapped using light microscopy, recording their coordinates using the integrated stage, mapping them within nine defined sectors to demonstrate any apparent loci of structural disconnectivity that may cause weakness disproportionate to the bone loss. A transparent 3D envelope corresponding to the cortex, was constructed using code developed in-house (Matlab 7.3, Mathworks, USA), and was modulated and validated by overlay of the previous µCT scan and the coordinate data. Results. The ReTm distribution was found to be remarkably heterogeneous (p<0.05) and independent of the bone volume (p<0.05). For example, there was preliminary evidence of central endplate disconnection predominantly in the selected preparations. Discussion/Conclusion. Such automated spatial mapping of the ReTm within a 3D framework overcomes the constraints of 2D histology. By application of this new automated method, patterns of trabecular disconnection in the spine may now provide insight into specific regional atrophy, perhaps explaining why some vertebrae fracture while others with the same BMD do not, and indicating better targets for prophylactic vertebroplasty

Introduction: Metastatic bone disease of the humerus may be associated with disabling pain and loss of function. Surgery must provide good local tumor control, immediate mechanical stability, and a short rehabilitation period. Between 1980 and 2000, the authors operated 59 patients with metastatic disease of the humerus. The current study summarizes the principles of the surgical technique and functional and oncological outcomes. Materials and Methods: There were 33 females and 26 males. Indications for surgery included pathological fracture (40), impending fracture (11), and intractable pain (6). Anatomic locations of humeral metastases included: around the proximal humeral metaphysic and head (Type I) – 18, humeral diaphysis (Type II) – 39, and humeral condyles (Type III) – 2. Types I and III metastases were treated with resection and endoprosthetic reconstruction. Type II metastases were treated with intralesional tumor removal and cemented nailing. Postoperatively, 31 patients were treated with radiation therapy, 35 with chemotherapy, and 14 with immunotherapy. Follow-up of the study patients included physical examination, radiological evaluation and functional evaluation according to the American Musculoskeletal Tumor Society system. Results: Patients who had cemented nailing had better overall function, emotional acceptance, hand positioning, and lifting ability than patients who underwent endoprosthetic reconstruction. Pain alleviation and dexterity were comparable in both groups. All patients had a stable extremity and overall function of 56 patients (95%) was > 68% of normal upper extremity function. Only two patients (3%) had a local tumor recurrence. Conclusions: An aggressive surgical approach in patients who have humeral metastases and meet the criteria for surgical intervention is beneficial; it provides durable reconstruction and is associated with good function and local tumor control in most patients

Aims. The increase in prescription opioid misuse and dependence is now a public health crisis in the UK. It is recognized as a whole-person problem that involves both the medical and the psychosocial needs of patients. Analyzing aspects of pathophysiology, emotional health, and social wellbeing associated with persistent opioid use after injury may inform safe and effective alleviation of pain while minimizing risk of misuse or dependence. Our objectives were to investigate patient factors associated with opioid use two to four weeks and six to nine months after an upper limb fracture. Methods. A total of 734 patients recovering from an isolated upper limb fracture were recruited in this study. Opioid prescription was documented retrospectively for the period preceding the injury, and prospectively at the two- to four-week post-injury visit and six- to nine-month post-injury visit. Bivariate and multivariate analysis sought factors associated with opioid prescription from demographics, injury-specific data, Patient Reported Outcome Measurement Instrumentation System (PROMIS), Depression computer adaptive test (CAT), PROMIS Anxiety CAT, PROMIS Instrumental Support CAT, the Pain Catastrophizing Scale (PCS), the Pain Self-efficacy Questionnaire (PSEQ-2), Tampa Scale for Kinesiophobia (TSK-11), and measures that investigate levels of social support. Results. A new prescription of opioids two to four weeks after injury was independently associated with less social support (odds ratio (OR) 0.26, p < 0.001), less instrumental support (OR 0.91, p < 0.001), and greater symptoms of anxiety (OR 1.1, p < 0.001). A new prescription of opioids six to nine months after injury was independently associated with less instrumental support (OR 0.9, p < 0.001) and greater symptoms of anxiety (OR 1.1, p < 0.001). Conclusion. This study demonstrates that potentially modifiable psychosocial factors are associated with increased acute and chronic opioid prescriptions following upper limb fracture. Surgeons prescribing opioids for upper limb fractures should be made aware of the screening and management of emotional and social health. Cite this article: Bone Jt Open 2021;2(2):119–124

Objectives

Although vertebroplasty is very effective for relieving acute pain from an osteoporotic vertebral compression fracture, not all patients who undergo vertebroplasty receive the same degree of benefit from the procedure. In order to identify the ideal candidate for vertebroplasty, pre-operative prognostic demographic or clinico-radiological factors need to be identified. The objective of this study was to identify the pre-operative prognostic factors related to the effect of vertebroplasty on acute pain control using a cohort of surgically and non-surgically managed patients.

Objectives

The aim of this study was to determine whether there is any significant difference in temporal measurements of pain, function and rates of re-tear for arthroscopic rotator cuff repair (RCR) patients compared with those patients undergoing open RCR.