Aims

Studies of infant hip development to date have been limited by considering only the changes in appearance of a single ultrasound slice (Graf’s standard plane). We used 3D ultrasound (3DUS) to establish maturation curves of normal infant hip development, quantifying variation by age, sex, side, and anteroposterior location in the hip.

Aims. The aim of this study was to develop and evaluate machine-learning-based computerized adaptive tests (CATs) for the Oxford Hip Score (OHS), Oxford Knee Score (OKS), Oxford Shoulder Score (OSS), and the Oxford Elbow Score (OES) and its subscales. Methods. We developed CAT algorithms for the OHS, OKS, OSS, overall OES, and each of the OES subscales, using responses to the full-length questionnaires and a machine-learning technique called regression tree learning. The algorithms were evaluated through a series of simulation studies, in which they aimed to predict respondents’ full-length questionnaire scores from only a selection of their item responses. In each case, the total number of items used by the CAT algorithm was recorded and CAT scores were compared to full-length questionnaire scores by mean, SD, score distribution plots, Pearson’s correlation coefficient, intraclass correlation (ICC), and the Bland-Altman method. Differences between CAT scores and full-length questionnaire scores were contextualized through comparison to the instruments’ minimal clinically important difference (MCID). Results. The CAT algorithms accurately estimated 12-item questionnaire scores from between four and nine items. Scores followed a very similar distribution between CAT and full-length assessments, with the mean score difference ranging from 0.03 to 0.26 out of 48 points. Pearson’s correlation coefficient and ICC were 0.98 for each 12-item scale and 0.95 or higher for the OES subscales. In over 95% of cases, a patient’s CAT score was within five points of the full-length questionnaire score for each 12-item questionnaire. Conclusion. Oxford Hip Score, Oxford Knee Score, Oxford Shoulder Score, and Oxford Elbow Score (including separate subscale scores) CATs all markedly reduce the burden of items to be completed without sacrificing score accuracy. Cite this article: Bone Jt Open 2022;3(10):786–794

Aims. Reimers migration percentage (MP) is a key measure to inform decision-making around the management of hip displacement in cerebral palsy (CP). The aim of this study is to assess validity and inter- and intra-rater reliability of a novel method of measuring MP using a smart phone app (HipScreen (HS) app). Methods. A total of 20 pelvis radiographs (40 hips) were used to measure MP by using the HS app. Measurements were performed by five different members of the multidisciplinary team, with varying levels of expertise in MP measurement. The same measurements were repeated two weeks later. A senior orthopaedic surgeon measured the MP on picture archiving and communication system (PACS) as the gold standard and repeated the measurements using HS app. Pearson’s correlation coefficient (r) was used to compare PACS measurements and all HS app measurements and assess validity. Intraclass correlation coefficient (ICC) was used to assess intra- and inter-rater reliability. Results. All HS app measurements (from 5 raters at week 0 and week 2 and PACS rater) showed highly significant correlation with the PACS measurements (p < 0.001). Pearson’s correlation coefficient (r) was constantly over 0.9, suggesting high validity. Correlation of all HS app measures from different raters to each other was significant with r > 0.874 and p < 0.001, which also confirms high validity. Both inter- and intra-rater reliability were excellent with ICC > 0.9. In a 95% confidence interval for repeated measurements, the deviation of each specific measurement was less than 4% MP for single measurer and 5% for different measurers. Conclusion. The HS app provides a valid method to measure hip MP in CP, with excellent inter- and intra-rater reliability across different medical and allied health specialties. This can be used in hip surveillance programmes by interdisciplinary measurers. Cite this article: Bone Jt Open 2023;4(5):363–369

Abstract. Background. Meniscal tears affect 222 per 100,000 of the population and can be managed non-operatively or operatively with an arthroscopic partial meniscectomy (APM), meniscal repair or meniscal transplantation. The purpose of this review is to summarise the outcomes following treatment with a meniscal tear and explore correlations between outcomes. Methodology. A systematic review was performed of MEDLINE, EMBASE, AMED and the Cochrane Central Register of Controlled Trials to identify prospective studies describing the outcomes of patients with a meniscal tear. Comparisons were made of outcomes between APM and non-operative groups. Outcomes were graphically presented over time for all treatment interventions. Pearson's correlations were calculated between outcome timepoints. Results. 35 studies were included, 28 reported outcomes following APM; four following meniscal repair and three following meniscal transplant. Graphical plots demonstrated a sustained improvement for all treatment interventions. A moderate to very strong correlation was reported between baseline and three-month outcomes. In the medium term, there was small significant difference in outcome between APM and non-operative measures (SMD 0.17; 95 % CI 0.04, 0.29), however, this was not clinically significant. Conclusions. Patients with a meniscal tear demonstrated a sustained initial improvement in function scores, which was true of all treatments examined. APM may have little benefit in older people, however, previous trials did not include patients who meet the current indications for surgery as a result the findings should not be generalised to all patients with a meniscal tear. Further trials are required in patients who meet current operative indications

This study aimed to examine the effect of high tibial osteotomy (HTO) on the ankle and subtalar joints via analysis of static radiographic alignment. We hypothesised that surgical alteration of the alignment of the proximal tibia would result in compensatory distal changes. 35 patients recruited as part of the wider Biomechanics and Bioengineering Centre Versus Arthritis HTO study between 2011 and 2018 had pre- and postoperative full-length weightbearing radiographs taken of their lower limbs. In addition to standard alignment measures of the limb and knee (mechanical tibiofemoral angle, Mikulicz point, medial proximal tibial angle), additional measures were taken of the ankle/subtalar joints (lateral distal tibial angle, ground-talus angle, joint line convergence angle of the ankle) as well as a novel measure of stance width. Results were compared using a paired T-test and Pearson's correlation coefficient. Following HTO, there was a significant (5.4°) change in subtalar alignment. Ground-talus angle appeared related both to the level of malalignment preoperatively and the magnitude of the alignment change caused by the HTO surgery; suggesting subtalar positioning as a key adaptive mechanism. In addition to compensatory changes within the subtalar joints, the patients on average had a 31% wider stance following HTO. These two mechanisms do not appear to be correlated but the morphology of the tibial plafond may influence which compensatory mechanisms are employed by different subgroups of HTO patients. These findings are of vital importance in clinical practice both to anticipate potential changes to the ankle and subtalar joints following HTO but it could also open up wider indications for HTO in the treatment of ankle malalignment and osteoarthritis

Accurate measurement of pelvic tilt (PT) is critical in diagnosing hip and spine pathologies. Yet a sagittal pelvic radiograph with good quality is not always available. Studies explored the correlation between PT and sacro-femoral-pubic (SFP) angle from anteroposterior (AP) radiographs yet demonstrated conflicting conclusions about its feasibilities. This study aims to perform a cohort-controlled meta-analysis to examine the correlation between the SFP angle and PT and proposes an application range of the method. This study searched PubMed, Embase, Cochrane, and Web of Science databases for studies that evaluated the correlation between SFP angle and PT. The Pearson's correlation coefficient r from studies were tabulated and compared. Pooled r for overall and gender/age (teenage or adult) controlled subgroup were reported using Fisher's Z transformation. Heterogeneity and publication bias were evaluated using Egger's regression test for the funnel plot asymmetry. Eleven studies were recruited, with nine reported r (totalling 1,247 patients). The overall pooled r was 0.61 with high inter-study heterogeneity (I2 = 75.95%). Subgroup analysis showed that the adult group had a higher r than the teenage group (0.70 versus 0.56, p < 0.001). Although statistically insignificant (p = 0.062), the female group showed a higher r than the male group (0.72 versus 0.65). The SFP method must be used with caution and should not be used in the male teenage group. The current studies did not demonstrate that the SFP method was superior to other AP landmarks correlating to PT. Identical heterogeneity was observed among studies, indicating that more ethnicity-segregated and gender-specific subgroup studies might be necessary. More data input analysing the errors will be useful

Background. The PATH-2 trial found no evidence of a benefit of Platelet Rich Plasma (PRP) injection versus a placebo after Achilles tendon rupture (ATR) at six-months. ATR often leave longer-term functional deficiencies beyond six-months. This study aim is to determine if PRP affect tendon functional outcomes at two-years after rupture. Study design. Randomised multi-centre two-arm parallel-group, participant- and assessor-blinded, superiority trial. Methods. Adults with acute ATR managed non-surgically were recruited in 19 UK hospitals from 2015 to 2019. Exclusions were insertion or musculotendinous injuries, leg injury or deformity, diabetes, haematological disorder, corticosteroids and anticoagulation therapy. Participants were randomised via an online system 1:1 to PRP or placebo. Primary outcome was Achilles Tendon Rupture Score (ATRS) at two-years. Secondary outcomes were pain, Patient-Specific Functional Scale (PSFS), SF-12 and re-rupture. Assessors were blinded. Intention-to-treat and Compliance Average Causal effects (CACE) analyses were carried out. Consistency of effects across subgroups age, BMI, smoking and gender were assessed using Forest plots. Pearson's correlation was used to explore ATRS correlation with blood and growth factors. Results. 216/230 (94%) participants completed the 6-months follow-up were contacted. 182/216 (84%) completed the two-year follow-up. Participants were aged mean 46 (SD 13.0), 57 female/159 male. 96% received the allocated intervention. Two-years ATRS scores were 82.2 (SD 18.3) in the PRP group (n=85) and 83.8 (SD 16.0) in the placebo group (n=92). There was no evidence of a difference in the two-years ATRS (adjusted-mean difference −0.752 95%CI −5.523 to 4.020, p=0.757), or in any secondary outcome, and no re-rupture between at two-years. Neither PRP cellular or growth factors correlated with the two-year ATRS. Conclusion. PRP did not improve patient-reported function or quality of life two-years after acute Achilles tendon rupture, compared with placebo, indicating that PRP offers no patient benefit in the longer term

This study examined pre-operative measures to predict post-operative biomechanical outcomes in total knee arthroplasty (TKA) patients. Twenty-eight patients (female=12/male=16, age=63.6±6.9, BMI=29.9±7.4 kg/m2) with knee osteoarthritis scheduled to undergo TKA were included. All surgeries were performed by the same surgeon (GD) with a subvastus approach. Patients visited the gait lab within one-month prior to surgery and 12 months following surgery. At the gait lab, patients completed the knee injury and osteoarthritis outcome score (KOOS), a timed up and go (TUG), maximum knee flexion and extension strength evaluation, and a walking task. Variables of interest included the five KOOS sub-scores, TUG time, maximum knee flexion and extension strength normalized to body weight, walking speed, and peak knee biomechanics variables (flexion angle, abduction moment, power absorption). A Pearson's correlation was used to identify significantly correlated variables which were then inputted into a multiple regression. No assumption violations for the multiple regression existed for any variables. Pre-operative knee flexion and extension strength, TUG time, and age were used in the multiple regression. The multiple regression model statistically significantly predicted peak knee abduction moment, post-operative walking speed, and post-operative knee flexion strength. All four variables added statistically significantly to the prediction p<.05. Pre-operative KOOS values did not correlate with any biomechanical indicators of post-operative success. Age, pre-operative knee flexion and extension strength, and TUG times predicted peak knee abduction moment, which is associated with medial knee joint loading. These findings stress the importance of pre-surgery condition, as stronger individuals achieved better post-operative biomechanical outcomes. Additionally, younger patients had better outcomes, suggesting that surgeons should not delay surgery in younger patients. This delay in surgery may prevent patients from achieving optimal outcomes. Future studies should utilize a hierarchical multiple regression to identify which variables are most predictive

Aim. The analysis of synovial fluid has proved to be of crucial importance in the diagnostic process of prosthetic joint infections (PJI), suggesting the presence of an infection before the microbiological culture results. In this context, several studies illustrated the efficacy of synovial calprotectin in supporting the diagnosis of PJI [1, 2]. However, several testing methods have been explored to detect synovial calprotectin levels, emphasizing the need to use a standardized, rapid and rapid test. In this study, synovial calprotectin was analyzed by means of a commercial stool test [3] to explore whether the detected levels might predict PJIs and, therefore, being a promising tool for the fast and reliable diagnosis of this complication. Method. The synovial fluid of 55 patients underwent to revision of the prosthetic implant were analyzed. The measurement of calprotectin was carried out by of commercial stool test, following the protocol for liquid samples. Calprotectin levels were then compared to other synovial biomarkers of PJI such as leucocyte esterase and count and percentage of polymorphonuclear cells. Data analysis were performed using R software v4.1.1 (R Core Team) and package “pROC” [4]. Receiver operator characteristics curves were designed using culture test as gold standard to evaluate the area under curve (AUC) of each method (with DeLong method for confidence-interval calculation). Thresholds were calculated to maximize Youden's index; sensitivity and specificity were reported. One-to-one Pearson's correlations coefficient were calculated for each pair of methods. P value <0.05 were considered statistically significant. Results. Of the 55 synovial fluids analyzed, 13 patients were diagnosed with PJI and 42 with an aseptic failure of the implant. The specificity, sensitivity, and AUC of calprotectin resulted 0.90, 0.85, and 0.86 (95%CI: 0.72–0.99), respectively with a set threshold of 226.5 µg/g. The values of calprotectin had a moderate and statistically relevant correlation with the synovial leucocyte counts (r. s. = 0.54, p = 0.0003) and the percentage of polymorphonuclear cells (r. s. = 0.68, p = 0.0000). Conclusions. From this analysis, it can be concluded that synovial calprotectin is a valuable biomarker that correlates with other established indicator of local infection, delivering a rapid and reliable results and supporting the diagnostic process of PJI

To investigate if the countermovement jump height differs between ACL injured and uninjured female adolescents and to explore kinematic differences between limbs. Additionally, the association between isometric knee extension strength and jump height was investigated. Thirty-one ACL injured female adolescents (ACLi, 15.3 ± 1.4yrs, 163.9 ± 6.6cm, 63.0 ± 9.3kg) and thirty-eight uninjured (CON, 13.2±1.7yrs, 161.7 ± 8.1cm, 50.6 ± 11.1kg) participated in this study. All participants performed a countermovement jump task, with 3D kinematics collected using a motion analysis system (Vicon, Nexus, Oxford, UK) at 200Hz, and a maximum isometric knee extension task on an isokinetic dynamometer (Biodex Medical Systems, New York, USA) for three trials. The peak torque was extracted from the isometric trials. Independent samples t-test compared the maximum jump height normalised by the dominant leg length between groups, paired samples t-test compared the maximum hip and knee extension and ankle plantar flexion velocities before take-off between limbs in both groups, and a Pearson's correlation test investigated the association between the isometric knee extension strength and jump height. The ACLi jumped 13% lower compared to the CON (p=0.022). In the ACLi, the maximum hip and knee extension and ankle plantar flexion velocities were greater in the non-injured limb, compared to the injured limb; however, no differences between limbs were found in the CON. The isometric knee extension strength of both limbs was positively correlated with jump height (limb 1: r=0.329; p=0.006, and limb 2: r=0.386; p=0.001; whereas limb 1 corresponds to the ACLi injured limb and CON non-dominant limb, and limb 2 to the ACLi non-injured limb and CON dominant limb). ACL injured female adolescents present lower jump height than controls and greater contribution of their non-injured limb, compared to their injured limb, during a countermovement jump task. Also, current results indicate that jump height is positively related to isometric knee extension strength measure

There is a need for non-radiographic, objective outcome measures for children with Adolescent Idiopathic Scoliosis (AIS). Standing balance and stability is altered in children with AIS. The Margin of Stability (MoS) has been used to compare gait stability in clinical populations. Our objective was to compare the MoS in anterior-posterior (MoS. AP. ) and mediolateral (MoS. ML. ) directions in girls with AIS to Controls. Girls with AIS and healthy girls walked at three speeds on an instrumented treadmill wearing retroreflective markers, surrounded by motion capture cameras. The MoS. AP/ML. was calculated at left and right heel strike. Data was processed in Visual 3D. A two-way ANOVA was used to compare MoS. AP/ML. between group, speed and the interaction between group and speed. Pearson's correlation coefficient was used to compare the MoS to Cobb angle. Statistical significance was accepted when p > 0.05. A priori power analysis suggested 12 participants per group. Three Cases and four Controls were recruited. Girls with AIS all had right-sided main thoracic curves (Lenke type 1a, 61.3° ± 10.0°). MoS. AP. was significantly bigger for Cases compared to Controls on the left (p=0.038) and right foot (p=0.041). There was no significant difference between Cases and Controls for MoS. ML. , but there was a visual trend for a smaller MoS. ML. in Cases. There was no significant difference for speed or the interaction between group and speed for MoS. AP. or MoS. ML. In Cases, MoS. AP. increased with increasing Cobb angle on the left (r. 2. =0.687, p=0.054) and right (r. 2. =0.634, p=0.067) and MoS. ML. decreased with increasing Cobb angle on the left (r. 2. =-0.912, p=0.002). Further subjects are being recruited. Girls with Lenke type 1a AIS are more stable in the AP direction and less stable in the ML direction than Controls during treadmill walking. AP stability increases and ML stability decreases with increasing Cobb angle. This research suggests that the MoS could be used as an outcome measure for children with AIS. Continued work is required to increase the power of this study. Further work could consider these changes during walking overground, measuring an MoS or MoS-like measure using a wearable device, and in different curve types

The Banff Patellofemoral Instability Instrument 2.0 (BPII 2.0) is a patient-reported disease-specific quality of life (QOL) outcome measure used to assess patients with recurrent lateral patellofemoral instability (LPI) both pre- and post-operatively. The purpose of this study was to compare the BPII 2.0 to four other relevant patient reported outcome measures (PROMs): the Tampa Scale-11 for kinesiophobia (TSK-11), the pain catastrophizing scale (PCS), a general QOL (EQ-5D-5L), and a return to sport index (ACL-RSI). This concurrent validation sought to compare and correlate the BPII 2.0 with these other measures of physical, psychological, and emotional health. The psychological and emotional status of patients can impact recovery and rehabilitation, and therefore a disease-specific PROM may be unable to consistently identify patients who would benefit from interventions encompassing a holistic and person-focused approach in addition to disease-specific treatment. One hundred and ten patients with recurrent lateral patellofemoral instability (LPI) were assessed at a tertiary orthopaedic practice between January and October 2021. Patients were consented into the study and asked to complete five questionnaires: the BPII 2.0, TSK-11, PCS, EQ-5D-5L, and the ACL-RSI at their initial orthopaedic consultation. Descriptive demographic statistics were collected for all patients. A Pearson's r correlation coefficient was employed to examine the relationships between the five PROMs. These analyses were computed using SPSS 28.0 © (IBM Corporation, 2021). One hundred and ten patients with a mean age of 25.7 (SD = 9.8) completed the five PROMs. There were 29 males (26.3%) and 81 females (73.6%) involving 50% symptomatic left knees and 50% symptomatic right knees. The mean age of the first dislocation was 15.4 years (SD = 7.3; 1-6) and the mean BMI was 26.5 (SD = 7.3; range = 12.5-52.6) The results of the Pearson's r correlation coefficient demonstrated that the BPII 2.0 was statistically significantly related to all of the assessed PROM's (p. There was significant correlation evident between the BPII 2.0 and the four other PROMs assessed in this study. The BPII 2.0 does not explicitly measure kinesiophobia or pain catastrophizing, however, the significant statistical relationship of the TSK-11 and PCS to the BPII 2.0 suggests that this information is being captured and reflected. The preliminary results of this concurrent validation suggest that the pre-operative data may offer predictive validity. Future research will explore the ability of the BPII 2.0 to predict patient quality of life following surgery

A hip fracture represents the extreme end of osteoporosis, placing a significant burden on secondary care, society, and the individual patient. The National Hip Fracture Database (NHFD) reports each hospital's attainment of the BPT with other measures, along with reporting outcomes. There is clearly wide variability in provision of orthogerriatrician (OG) services across the dataset. Unfortunately, despite overwhelming evidence that provision of an OG service is of benefit, it is presently challenging to recruit to this important specialty within the UK. Publicly available reports from the NHFD were obtained for each of the 177 participating hospitals for 2017. This was matched with information held within the annual NHFD Facilities Audit for the same period, which include hours of OG support for each hospital. This information was combined with a Freedom of Information request made by email to each hospital for further details concerning OG support. The outcome measures used were Length of Stay (LoS), mortality, and return to usual residence. Comparison was made with provision of OG services by use of Pearson's correlation coefficient. In addition, differences in services were compared between the 25% (44) hospitals delivering outcomes at the extremes for each measure. Attainment of BPT correlated fairly with LoS (−0.48) and to less of a degree with mortality (−0.1) and return home (0.05). Perioperative medical assessment contributed very strongly with BPT attainment (0.75). In turn perioperative medical assessment correlated fairly with LoS (−0.40) and mortality (−0.23) but not return home (0.02). Provision of perioperative medical assessment attainment was correlated fairly with total OG minutes available per new patient (0.22), total OG minutes available per patient per day (0.29) and number of days per week of OG cover (0.34); with no link for number of patients per orthogeriatrician (0.01). Mortality for the best units were associated with 30% more consultant OG time available per patient per day, and 51% more OG time available per patient. Units returning the most patients to their usual residence had little association with OG time, although had 59% fewer patients per OG, the best units had a 19% longer LoS. For all three measures results for the best had on average 0.5 days per week better routine OG access. There is no doubt that good quality care gives better results for this challenging group of patients. However, the interaction of BPT, other care metrics, level of OG support and patient factors with outcomes is complex. We have found OG time available per patient per day appears to influence particularly LoS and mortality. Options to increase OG time per patient include reducing patient numbers (ensuring community osteoporosis/falls prevention in place, including reducing in-patient falls); increasing OG time across the week (employing greater numbers/spreading availability over 7 days per week); and reducing LoS. A reduction in LoS has the largest effect of increasing OG time, and although it is dependent on OG support, it is only fairly correlated with this and many other factors play a part, which could be addressed in units under pressure

Abstract. OBJECTIVE. Knee varus malalignment increases medial knee compartment loading and is associated with knee osteoarthritis (OA) progression and severity. 1. Altered biomechanical loading and dysregulation of joint tissue biology drive OA progression, but mechanistic links between these factors are lacking. Subchondral bone structural changes are biomechanically driven, involve bone resorption, immune cell influx, angiogenesis, and sensory nerve invasion, and contribute to joint destruction and pain. 2. We have investigated mechanisms underlying this involving RANKL and alkaline phosphatase (ALP), which reflect bone resorption and mineralisation respectively. 3. and the axonal guidance factor Sema3A. Sema3A is osteotropic, expressed by mechanically sensitive osteocytes, and an inhibitor of sensory nerve, blood vessel and immune cell invasion. 4. Sema3A is also differentially expressed in human OA bone. 5. HYPOTHESIS: Medial knee compartment overloading in varus knee malalignment patients causes dysregulation of bone derived Sema3A signalling directly linking joint biomechanics to pathology and pain. METHODS. Synovial fluid obtained from 30 subjects with medial knee OA (KL grade II-IV) undergoing high tibial osteotomy surgery (HTO) was analysed by mesoscale discovery and ELISA analysis for inflammatory, neural and bone turnover markers. 11 of these patients had been previously analysed in a published patient-specific musculoskeletal model. 6. of gait estimating joint contact location, pressure, forces, and medial-lateral condyle load distribution in a published data set included in analyses. Data analysis was performed using Pearson's correlation matrices and principal component analyses. Principal Components (PCs) with eigenvalues greater than 1 were analysed. RESULTS. PC1 (32.94% of variation) and PC2 (25.79% of variation) from PCA analysis and correlation matrices separated patients according to correlated clusters of established inflammatory markers of OA pain and progression (IL6/IL8, r=0.754, p<0.001) and anti-inflammatory mediators (IL4/IL10, r=0.469, p=0.005). Bone turnover marker ALP was positively associated with KL grade (r=0.815, p=0.002) and negatively associated with IL10 (r=−0.402, p=0.018) and first peak knee loading pressures (r=−0.688, p=0.019). RANKL was positively associated with IL4 (r=0.489, p=0.003). Synovial fluid Sema3A concentrations showed separate clustering from all OA progression markers and was inversely correlated with TNF-α (r=−0.423, p=0.022) in HTO patients. Sema3A was significantly inversely correlated with total predicted force in the medial joint compartment (r=−0.621, p=0.041), mean (r=−0.63, p=0.038) and maximum (r=−0.613, p=0.045) calculated medial compartment joint pressures during the first phase and mean (r=−0.618, p=0.043) and maximum (r=−0.641, p=0.034) medial compartment joint pressures during midstance outputs of patient-specific musculoskeletal model. CONCLUSIONS. This study shows joint inflammatory status and mechanical overloading influence subchondral bone-remodelling. Synovial Sema3A concentrations are inversely correlated to patient-specific musculoskeletal model estimations of pathological medial overloading. This study reveals Sema3A as a biological mediator with capacity to induce OA pain and disease progression that is directly regulated by gait mechanical loading. Declaration of Interest. (b) declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported:I declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research project

Abstract. Objectives. Neonatal motor development transitions from initially spontaneous to later increasingly complex voluntary movements. A delay in transitioning may indicate cerebral palsy (CP). The general movement optimality score (GMOS) evaluates infant movement variety and is used to diagnose CP, but depends on specialized physiotherapists, is time-consuming, and is subject to inter-observer differences. We hypothesised that an objective means of quantifying movements in young infants using motion tracking data may provide a more consistent early diagnosis of CP and reduce the burden on healthcare systems. This study assessed lower limb kinematic and muscle force variances during neonatal infant kicking movements, and determined that movement variances were associated with GMOS scores, and therefore CP. Methods. Electromagnetic motion tracking data (Polhemus) was collected from neonatal infants performing kicking movements (min 50° knee extension-flexion, <2 seconds) in the supine position over 7 minutes. Tracking data from lower limb anatomical landmarks (midfoot inferior, lateral malleolus, lateral knee epicondyle, ASIS, sacrum) were applied to subject-scaled musculoskeletal models (Gait2354_simbody, OpenSim). Inverse kinematics and static optimisation were applied to estimate lower limb kinematics (knee flexion, hip flexion, hip adduction) and muscle forces (quadriceps femoris, biceps femoris) for isolated kicks. Functional principal component analysis (fPCA) was carried out to reduce kicking kinematic and muscle force waveforms to PC scores capturing ‘modes’ of variance. GMOS scores (lower scores = reduced variety of movement) were collected in parallel with motion capture by a trained operator and specialised physiotherapist. Pearson's correlations were performed to assess if the standard deviation (SD) of kinematic and muscle force waveform PC scores, representing the intra-subject variance of movement or muscle activation, were associated with the GMOS scores. Results. The study compared GMOS scores, kinematics, and muscle force variances from a total of 26 infants with a mean corrected gestational age of 39.7 (±3.34) weeks and GMOS scores between 21 and 40. There was a significant association between the SD of the PC scores for knee flexion and the GMOS scores (PC1: R = 0.59, p = 0.002; PC2: R = 0.49, p = 0.011; PC3: R = 0.56, p = 0.003). The three PCs captured variances of the overall flexion magnitude (66% variance explained), early-to-late kick knee extension (20%), and continual to biphasic kicking (6%). For hip flexion, only the SD of PC1 correlated with GMOS scores (PC1: R = 0.52, p = 0.0068), which captured the variance of the overall flexion magnitude (81%). For the biceps femoris, the SD of PC1 and PC3 associated with GMOS scores (PC1: R = 0.50, p = 0.002; PC3: R = 0.45, p = 0.03), which captured the variance of the overall bicep force magnitude (79%) and early-to-late kick bicep activation (8%). Conclusions. Infants with reduced motor development as scored in the GMOS displayed reduced variances of knee and hip flexion and biceps femoris activation across kicking cycles. These findings suggest that combining objectively measured movement variances with existing classification methods could facilitate the development of more consistent and accurate diagnostic tools for early detection of CP. Declaration of Interest. (b) declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported:I declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research project

Bone turnover and the accumulation of microdamage are impacted by the presence of skeletal metastases which can contribute to increased fracture risk. Treatments for metastatic disease may further impact bone quality. The present study aims to establish a preliminary understanding of microdamage accumulation and load to failure in osteolytic vertebrae following stereotactic body radiotherapy (SBRT), zoledronic acid (ZA), or docetaxel (DTX) treatment. Twenty-two six-week old athymic female rats (Hsd:RH-Foxn1rnu, Envigo, USA) were inoculated with HeLa cervical cancer cells through intracardiac injection (day 0). Institutional approval was obtained for this work and the ARRIVE guidelines were followed. Animals were randomly assigned to four groups: untreated (n=6), spine stereotactic body radiotherapy (SBRT) administered on day 14 (n=6), zoledronic acid (ZA) administered on day 7 (n=5), and docetaxel (DTX) administered on day 14 (n=5). Animals were euthanized on day 21. T13-L3 vertebral segments were collected immediately after sacrifice and stored in −20°C wrapped in saline soaked gauze until testing. µCT scans (µCT100, Scanco, Switzerland) of the T13-L3 segment confirmed tumour burden in all T13 and L2 vertebrae prior to testing. T13 was stained with BaSO. 4. to label microdamage. High resolution µCT scans were obtained (90kVp, 44uA, 4W, 4.9µm voxel size) to visualize stain location and volume. Segmentations of bone and BaSO. 4. were created using intensity thresholding at 3000HU (~736mgHA/cm. 3. ) and 10000HU (~2420mgHA/cm. 3. ), respectively. Non-specific BaSO. 4. was removed from the outer edge of the cortical shell by shrinking the segmentation by 105mm in 3D. Stain volume fraction was calculated as the ratio of BaSO. 4. volume to the sum of BaSO. 4. and bone volume. The L1-L3 motion segments were loaded under axial compression to failure using a µCT compatible loading device (Scanco) and force-displacement data was recorded. µCT scans were acquired unloaded, at 1500µm displacement and post-failure. Stereological analysis was performed on the L2 vertebrae in the unloaded µCT scans. Differences in mean stain volume fraction, mean load to failure, and mean bone volume/total volume (BV/TV) were compared between treatment groups using one-way ANOVAs. Pearson's correlation between stain volume fraction and load to failure by treatment was calculated using an adjusted load to failure divided by BV/TV. Stained damage fraction was significantly different between treatment groups (p=0.0029). Tukey post-hoc analysis showed untreated samples to have higher stain volume fraction (16.25±2.54%) than all treatment groups (p<0.05). The ZA group had the highest mean load to failure (195.60±84.49N), followed by untreated (142.33±53.08N), DTX (126.60±48.75N), and SBRT (95.50±44.96N), but differences did not reach significance (p=0.075). BV/TV was significantly higher in the ZA group (49.28±3.56%) compared to all others. The SBRT group had significantly lower BV/TV than the untreated group (p=0.018). Load divided by BV/TV was not significantly different between groups (p=0.24), but relative load to failure results were consistent (ZA>Untreated>DTX>SBRT). No correlations were found between stain volume fraction and load to failure. Focal and systemic cancer treatments effect microdamage accumulation and load to failure in osteolytic vertebrae. Current testing of healthy controls will help to further separate the effects of the tumour and cancer treatments on bone quality

Bone turnover and the accumulation of microdamage are impacted by the presence of skeletal metastases which can contribute to increased fracture risk. Treatments for metastatic disease may further impact bone quality. The present study aims to establish a preliminary understanding of microdamage accumulation and load to failure in osteolytic vertebrae following stereotactic body radiotherapy (SBRT), zoledronic acid (ZA), or docetaxel (DTX) treatment. Twenty-two six-week old athymic female rats (Hsd:RH-Foxn1rnu, Envigo, USA) were inoculated with HeLa cervical cancer cells through intracardiac injection (day 0). Institutional approval was obtained for this work and the ARRIVE guidelines were followed. Animals were randomly assigned to four groups: untreated (n=6), spine stereotactic body radiotherapy (SBRT) administered on day 14 (n=6), zoledronic acid (ZA) administered on day 7 (n=5), and docetaxel (DTX) administered on day 14 (n=5). Animals were euthanized on day 21. T13-L3 vertebral segments were collected immediately after sacrifice and stored in −20°C wrapped in saline soaked gauze until testing. µCT scans (µCT100, Scanco, Switzerland) of the T13-L3 segment confirmed tumour burden in all T13 and L2 vertebrae prior to testing. T13 was stained with BaSO. 4. to label microdamage. High resolution µCT scans were obtained (90kVp, 44uA, 4W, 4.9µm voxel size) to visualize stain location and volume. Segmentations of bone and BaSO. 4. were created using intensity thresholding at 3000HU (~736mgHA/cm. 3. ) and 10000HU (~2420mgHA/cm. 3. ), respectively. Non-specific BaSO. 4. was removed from the outer edge of the cortical shell by shrinking the segmentation by 105mm in 3D. Stain volume fraction was calculated as the ratio of BaSO. 4. volume to the sum of BaSO. 4. and bone volume. The L1-L3 motion segments were loaded under axial compression to failure using a µCT compatible loading device (Scanco) and force-displacement data was recorded. µCT scans were acquired unloaded, at 1500µm displacement and post-failure. Stereological analysis was performed on the L2 vertebrae in the unloaded µCT scans. Differences in mean stain volume fraction, mean load to failure, and mean bone volume/total volume (BV/TV) were compared between treatment groups using one-way ANOVAs. Pearson's correlation between stain volume fraction and load to failure by treatment was calculated using an adjusted load to failure divided by BV/TV. Stained damage fraction was significantly different between treatment groups (p=0.0029). Tukey post-hoc analysis showed untreated samples to have higher stain volume fraction (16.25±2.54%) than all treatment groups (p<0.05). The ZA group had the highest mean load to failure (195.60±84.49N), followed by untreated (142.33±53.08N), DTX (126.60±48.75N), and SBRT (95.50±44.96N), but differences did not reach significance (p=0.075). BV/TV was significantly higher in the ZA group (49.28±3.56%) compared to all others. The SBRT group had significantly lower BV/TV than the untreated group (p=0.018). Load divided by BV/TV was not significantly different between groups (p=0.24), but relative load to failure results were consistent (ZA>Untreated>DTX>SBRT). No correlations were found between stain volume fraction and load to failure. Focal and systemic cancer treatments effect microdamage accumulation and load to failure in osteolytic vertebrae. Current testing of healthy controls will help to further separate the effects of the tumour and cancer treatments on bone quality

Inter- and intra-observer variation has been noted in the analysis of radiographic examinations with regard to experience of surgeons, and the monitors used for conducting the evaluations. The aim of this study is to evaluate inter/intra observer variation in the measurement of mechanical alignment from long-leg radiographs. 40 patients from the elective waiting list for TKA underwent long leg radiographs pre-operatively and 6 months post-operatively (total of 80 radiographs). The x-rays were analysed by 5 observers ranging in experience from medical student to head orthopaedic surgeon. Two observers re-analysed their results 6 months later to determine intraobserver correlation, and one observer re-measured the alignment on a different monitor. These measurements were all conducted blindly and none of the observers had access to the others’ results. 80 radiographs were analysed in total, 40 pre-op and 40 post-op. The mechanical alignment was analysed using Pearson's correlation (r = 0 no agreement, r = 1 perfect agreement) and revealed that experience as an orthopaedic surgeon has little effect on the measurement of mechanical alignment from long leg radiograph. The results for the different monitor analysis were also analysed using Pearson's correlation of long leg alignment. Monitor quality does seem to affect the correlation between alignment measurements when reviewing both intra and inter observer correlation on different computer monitors. Surgical experience has little impact on the measurement of alignment on long leg radiographs. Of greater concern is that monitors of different resolution can affect measurement of mechanical alignment. As there might be a range of monitors in use in different institutions, and also in outpatient clinics to surgical theatres, close attention should be paid to the implications of these results

Introduction and Objective. An important subset of patients is dissatisfied after total joint arthroplasty (TJA) due to residual functional impairment. This study investigated the assessment of objectively measured step-up performance following TJA, to identify patients with poor functional improvement after surgery, and to predict residual functional impairment during early postoperative rehabilitation. Secondary, longitudinal changes of block step-up (BS) transfers were compared with functional changes of subjective patient reported outcome measures (PROMs) following TJA. Materials and Methods. Patients with end stage hip or knee osteoarthritis (n = 76, m/f = 44/32; mean age = 64.4 standard deviation 9.4 years) were measured preoperatively and 3 and 12 months postoperatively. PROMs were assessed using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) function subscore. BS transfers were assessed by wearable-derived measures of time. In our cohort, subgroups were formed based on either 1) WOMAC function score or 2) BS performance, isolating the worst performing quartile (impaired) of each measure from the better performing others (non-impaired). Subgroup comparisons were performed with the Man-Whitney-U test and Wilcoxon Signed rank test resp. Responsiveness was calculated by the effect size, correlations with Pearson's correlation coefficient. A regression analysis was conducted to investigate predictors of poor functional outcome. Results. WOMAC function scores were strongly correlated to WOMAC pain scores (Pearson's r=0.67–0.84) and moderately correlated to BS performance (Pearson's r = 0.31–0.54). Prior to surgery, no significant differences for WOMAC function scores and BS performance were found between the impaired and non-impaired subgroups. One year after TJA, our cohort performed significantly better at WOMAC and BS with largest effect size for the non-impaired subgroups (0.62 and 0.43 resp.) At 12 months postop, 56% of patients allocated to the impaired subgroup defined by WOMAC, represented the impaired subgroup defined by BS. Allocation to the impaired subgroup at 3 months postop, raised the odds for belonging to the impaired subgroup at 12 months for WOMAC with an odds ratio=19.14 (67%) and for BS with an odds ratio=4.41 (42%). Conclusions. Assessment of BS performance following TJA reveals residual functional impairment that is not captured by pain-dominated PROMs. Its additional use may help to early identify those patients at risk for a poor outcome

Abstract. Objectives. Identifying risk factors for inferior outcomes after anterior cruciate ligament reconstruction (ACLR) is important for prognosis and patient information. This study aimed to ascertain if BMI, pre-operative scores, demographic data and concomitant injuries in patients undergoing ACLR affected patient-reported functional outcomes. Methods. A prospective review collected data from a single surgeon series of 278 patients who underwent arthroscopic ACLR. BMI, age, gender, graft choice, pre-op Lysholm score, meniscal and chondral injuries were recorded. The Lysholm score, hop test and KT1000 were used to measure post-op functional outcome at one year. Multiple regression analysis was used to determine factors that predicted Lysholm scores at one year. Results. The mean age was 29 years, with 58 female and 220 male patients. The mean pre-op Lysholm score was 53.8. One hunded and seventy-nine patients had meniscal injuries, of which 81 were medial, 60 lateral, and 38 bilateral. Eighteen patients also had chondral injury and 106 patients had no other associated injury. Age, gender, graft type and presence of meniscal or chondral injuries did not affect one-year post-operative Lysholm scores. A BMI greater than 30, physio compliance and preoperative Lysholm scores helped predict one-year post-operative Lysholm scores (p=0.02). Pearson's correlation found a direct link between BMI and post-operative Lysholm (p=0.03). Conclusions. BMI, physio compliance and pre-operative Lysholm scores are the most significant determinants of short-term functional outcome after ACLR. However, the effects of associated injuries may be apparent in the long-term as degenerative changes set in or the continued detriment resulting from the concomitant injury affect outcome. Declaration of Interest. (b) declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported:I declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research project