Introduction

The management of open or unstable ankle and distal tibial fractures pose many challenges. In certain situations, hindfoot nailing (HFN) is indicated, however this depends on surgeon preference and regional variations exist. This study sought to establish the current management and outcomes of complex ankle fractures in the UK.

Introduction

Spinal aBMD only explains 50–80% of vertebral strength, and the application of aBMD measurements in isolation cannot accurately identify individuals who are likely to eventually experience bone fracture, due to the low sensitivity of the test. For appropriate treatment intervention, a more sensitive test of bone strength is needed. Such a test should include not only bone mineral density, but also bone quality. Quantitative computed tomography-based finite element methods (QCT/FEM) may allow structural analyses taking these factors into consideration to accurately predict bone strength (PBS). To date, however, basic data have not been reported regarding the prediction of bone strength by QCT/FEM with reference to age in a normal population. The purpose of this study was thus to create a database on PBS in a normal population as a preliminary trial. With these data, parameters that affect PBS were also analyzed.

Introduction: There is a clear need for the development of more sensitive risk assessment tools for clinical predictors of fractures. Bone densitometries are limited in the ability to account for complex geometry, architecture, and heterogeneity of bone. Quantitative computed tomography (QCT)-based finite element (FE) Methods: (QCT/FEM) are able to perform structural analyses taking these factors into consideration to accurately predict bone strength. However, no basic data have been available regarding predicted strength (PS) of the proximal femur by QCT/FEM with reference to age in a normal population. The purpose of this study was thus to create a database on PS in a normal population as a preliminary trial. With these data, parameters that affect PS were also analyzed.

Methods: Participants in this study comprised individuals who participated in a health checkup program with computed tomography (CT) at our hospital in 2008. Participants included 487 men and 237 women (age range, 40–87 years). Exclusion criteria were provided. Scan data of the proximal femur were isolated and taken from overall data from CT of each participant with simultaneous scans of a calibration phantom containing hydroxyapatite rods. A FE model was constructed from the isolated data using Mechanical Finder software. For each of the FE models, loading and boundary conditions as well as the definition of PS were exactly the same as described by Bessho et al. (Bone 2009). For each participant, height, weight, and abdominal circumference (AC) were measured. The analyses included linear regression analysis relating age and PS, one-way analysis of variance to compare average PS among the groups of participants who were divided into 5-year age brackets, and multiple regression analysis to determine how PS was affected by age, height, weight, and AC. Differences were considered significant for values of p< 0.05.

Result: The following results were obtained. First, average PS was lower in women than in men for all age ranges. Second, PS in men under stance configuration, and those in women under stance and fall configurations significantly decreased with age. Third, weight positively affected PS in both men and women.

Discussion: This was the first study to investigate changes in PS with age in a normal population. Whether PS by QCT/FEM correlates more closely with fracture risk for osteoporotic patients in comparison to other bone densitometries remains unclear, but the our results did not contradict any existing concept of risk factors for fragility fracture. More baseline data for PS in normal populations need to be accumulated by increasing the number of participants in studies like this.

Aims

The risk factors for abnormal spinopelvic mobility (SPM), defined as an anterior rotation of the spinopelvic tilt (∆SPT) ≥ 20° in a flexed-seated position, have been described. The implication of pelvic incidence (PI) is unclear, and the concept of lumbar lordosis (LL) based on anatomical limits may be erroneous. The distribution of LL, including a unusual shape in patients with a high lordosis, a low pelvic incidence, and an anteverted pelvis seems more relevant.

Aims

Young adults undergoing total hip arthroplasty (THA) largely have different indications for surgery, preoperative function, and postoperative goals compared to a standard patient group. The aim of our study was to describe young adult THA preoperative function and quality of life, and to assess postoperative satisfaction and compare this with functional outcome measures.

Aims

This study aimed to determine whether lateral femoral wall thickness (LWT) < 20.5 mm was associated with increased revision risk of intertrochanteric fracture (ITF) of the hip following sliding hip screw (SHS) fixation when the medial calcar was intact. Additionally, the study assessed the association between LWT and patient mortality.

Aims

Ankle fractures are common, mainly affecting adults aged 50 years and over. To aid recovery, some patients are referred to physiotherapy, but referral patterns vary, likely due to uncertainty about the effectiveness of this supervised rehabilitation approach. To inform clinical practice, this study will evaluate the effectiveness of supervised versus self-directed rehabilitation in improving ankle function for older adults with ankle fractures.

Summary. Our statistical shape analysis showed that size is the primary geometrical variation factor in the medial meniscus. Shape variations are primarily focused in the posterior horn, suggesting that these variations could influence cartilage contact pressures. Introduction. Variations in meniscal geometry are known to influence stresses and strains inside the meniscus and the articulating cartilage surfaces. This geometry-dependent functioning emphasizes that understanding the natural variation in meniscus geometry is essential for a correct selection of allograft menisci and even more crucial for the definition of different sizes for synthetic meniscal implants. Moreover, the design of such implants requires a description of 3D meniscus geometry. Therefore, the aim of this study was to quantify 3D meniscus geometry and to determine whether variation in medial meniscus geometry is size or shape driven. Patients & Methods. Sagittal knee MR images (n=35; 15 males, 20 females, aged 33±12) were acquired at 3 Tesla using a 3D SPACE sequence with isotropic resolution of 0.5×0.5×0.5mm. 3D models were generated by manual segmentation of the medial menisci from the MR scans. The surface of a reference meniscus was then described by 250 landmarks. Using an affine iterative closest point transformation, these landmarks were registered onto the full set of 3D models. Based on the set of corresponding landmarks, a point distribution model was created using the Shapeworks software (NITRC, University of Utah), an open source algorithm for constructing correspondence-based statistical models of sets of similar shapes. Several modules from Shapeworks and the Arthron software (UCD, Dublin) were used to perform principal component analysis (PCA) upon the set of landmarks. The results of the PCA enabled quantification and visualisation of the primary modes of variation in meniscal geometry. Results. The majority (77%) of variation in medial meniscus geometry was found to be due to sizing (principal component (PC) 1). Including the shape-related PC's 2 to 4, increased the cumulative percentage of represented geometry variation to over 90%. The independent shape variations described by PCs 2–4 all display larger variations in geometry of the posterior meniscal horn than the anterior section. Discussion. From this study, we can conclude that geometry variation of the medial meniscus is mainly determined by differences in size. However, since the posterior aspect of the medial meniscus experiences higher loads during daily activities than the anterior part, the shape variations described by PCs 2–4 may have a significant influence on cartilage contact pressures. Therefore, PCA alone does not provide sufficient information to define the number of implant sizes to cover a majority of the population. Analysis of the sensitivity of cartilage contact pressures to the shape variations identified in this analysis could provide the additional information needed

Introduction. Antibiotic-impregnated bone cement (AIBC) has been used for decades to treat and prevent post-operative infections in joint arthroplasty. Local delivery of antibiotics may theoretically have a bactericidal effect, however evidence supporting this is controversial and literature suggests its prophylactic use in primary total knee arthroplasty (TKA) is seldom justified. With evolving standards of care, historical data is no longer relevant in addressing the efficacy of AIBC in the contemporary TKA. The purpose of this study was to evaluate outcomes following primary TKA using AIBC and regular non-AIBC by comparing rates of surgical site infection (SSI) and prosthetic joint infection (PJI). Methods. A retrospective review was conducted of all cemented primary TKA procedures from a large institutional database between January 1, 2015 and December 31st, 2016. This identified 6,073 cases, n=2,613 in which AIBC was used and n=3,460 cases using bone cement without antibiotics. Patients were stratified into low risk and high-risk groups based on age (>65 years), BMI (>40), and Charlson Comorbidity Index (CCI; >3). Medical records were reviewed for diagnoses of SSI (skin and superficial wound infections) and PJI (deep joint infections requiring surgery) over a 2-year postoperative period. Univariate analysis and multivariate regression models were used to ascertain the effects of cement type, patient factors (age, gender, BMI, CCI), operative time, and length of stay on infection rates. Additionally, mixed models (adjusted for gender, age, race, BMI, and CCI) were built to account for surgeon variability. Results. The use of AIBC and risk group distributions were equal across the study period and no collinearity was found between the study variables. The SSI rate was 3.0% and the PJI rate was 0.8% in the total study population. Univariate analysis showed there was no significant difference in SSI rates with AIBC compared to non-AIBC (3.3% vs. 2.8%, p=0.278) or in PJI rates (1.0% vs. 0.7%, p=0.203). Multivariate logistic regression analysis adjusted for patient factors, operative time, and length of stay showed no significant difference in SSI rates with a procedure using AIBC compared to non-AIBC (OR=0.90; 95% CI, 0.66–1.23; p=0.515) and no significant difference in PJI rates (OR=1.01; 95% CI, 0.55–1.84; p=0.984). Mixed models also showed no difference in PJI rates with AIBC use after adjusting for surgeon variability as well as patient factors (gender, race, age, BMI, and CCI). Discussion. Prophylactic use of AIBC in primary TKA is not without consequence when considering the significant increase in cost and its potential side effects, namely organism specific antibiotic resistance and mechanical loosening. This study shows that even when adjusted for patient factors, procedure-related factors, and length of stay, there is no clinically significant decrease in infection rates with the use of AIBC in primary TKAs

With the increasing use of 3D medical imaging, it is possible to analyze 3D patient anatomy to extract features, trends and population specific shape information. This is applied to the development of ‘standard implants’ targeted to specific population groups. INTRODUCTION. Human beings are diverse in their physical makeup while implants are often designed based on some key measurements taken from the literature or a limited sampling of patient data. The different implant sizes are often scaled versions of the ‘average’ implant, although in reality, the shape of anatomy changes as a function of the size of patient. The implant designs are often developed based on a certain demographic and ethnicity and then, simply applied to others, which can result in poor design fitment [1]. Today, with the increasing use of 3D medical imaging (e.g. CT or MRI), it is possible to analyze 3D patient anatomy to extract features, trends and population specific shape information. This can be applied to the development of new ‘standard implants’ targeted to a specific population group [2]. PATIENTS & METHODS. Our population analysis was performed by creating a Statistical Shape Model (SSM) [3] of the dataset. In this study, 40 full Chinese cadaver femurs and 100 full Caucasian cadaver femurs were segmented from CT scans using Mimics®. Two different SSMs, specific to each population, were built using in-house software tools. These SSMs were validated using leave-one-out experiments, and then analyzed and compared in order to enhance the two population shape differences. RESULTS. An SSM is typically represented by an average model and a few independent modes of variation that capture most of the inherent variations in the data. Based on these main modes of variations, the shape features, e.g. length, thickness, curvature neck angle and femoral version, presenting largest variations were determined, and correlations between these features were calculated. Figure 1 represents the Caucasian and Chinese average models, and shows that while the length of these two models was significantly different, the AP and ML dimensions were similar, indicating a difference of morphology (other than a scaling) between the two populations. Figure 2 represents the first mode of variation that illustrates the variation of Chinese femur shape with size. As an example, the neck angle increases of 26° with an increase of 139 mm in femur length, indicative of the effect of changes in loading conditions on geometry as a function of size. CONCLUSION. The advantage of using more advanced statistical analyses is that the 3D data are probed in an unbiased fashion, allowing the most important parameters of variation to be determined. These analyses are thus particularly effective to compare different populations, to evaluate how well existing implant designs fit specific populations, and to highlight the design parameters that need to be adapted for good fitment of specific populations

Summary Statement. Progenitor cells from the periosteal niche are of great clinical interest due to their remarkable regenerative capacity. Here we report on progenitor cells from arthritic patients whose femoral neck periosteum was resected over the course of hip replacement. Introduction. This study aims to determine whether periosteum derived cells (PDCs) can be isolated from tissue resected in the normal course of hip arthroplasty. Further, it aims to determine how different isolation protocols affect PDC behavior (surface marker expression, proliferation, and differentiation). In addition, the study aims to characterise the populations of PDCs, isolated through either enzymatic digestion or migration, and their relative capacity to differentiate down multiple capacities; direct comparison with commercially available human marrow-derived stromal cells cultured under identical conditions will enable the placement of the PDC data in context of the current state of the field. Methods. Proximal femoral head/neck explants (n=4) were acquired from patients within 8 h of hip replacement surgery (IRB 12–335, Cleveland Clinic), after examination and diagnosis by pathology. To isolate digested PDCs (dPDCS), the minced tissue is suspended in 3 mg/ml collagenase II (Gibco) solution in alpha-MEM with Glutamax (Invitrogen) with 1% antibioticantimycotic (Invitrogen) overnight in a 37°C incubator. Any undigested tissue is filtered from the cells using a 100 μm filter, and isolated cells are cultured in standard culture media. To isolate migrated PDCs (mPDCs), the minced tissue is directly plated into tissue culture flasks in alpha-MEM with Glutamax supplemented with 10% FBS (Invitrogen), 1% antibioticantimycotic overnight, and cultured in standard culture media. The cells are left to egress from the tissue for one week. Finally, validated bone marrow derived hMSCs (BMSCs) are purchased from four independent vendors (Lonza, PromoCell, ScienCell, Cell Applications) as standards for comparison. Cell cohorts are compared using proliferation assays, cell population analysis using flow cytometry, and quantitative adipogenesis, osteogenesis and chondrogenesis assays. Results. PDCs and BMSCs exhibit similar proliferation rate, morphology, and surface receptor expression. PDCs showed no significant differences to BMSCs with regard to osteo- and adipogenic differentiation capacity. Chondrogenic assay of PDCs showed increased pellet size with pellets exhibiting staining indicative of hyaline cartilage for BMSC, and immature fibrocartilage for dPDCs and mPDCs. This study demonstrates, for the first time to our knowledge, the feasibility of isolating PDCs from the femoral neck of patients undergoing joint replacement surgery. PDCs and BMSCs exhibit similar surface marker expression and equivalent adipogenic and osteogenic capacity. Interestingly, cell cohorts from the same tissue albeit different isolation protocols show intrinsic differences in their differentiation capacities. Additionally, all cell types display marked intraindividual differences in their capacity to differentiate down different lineages, with no significant correlation to age. Discussion/Conclusion. The femoral neck periosteum offers a feasible source for isolation and a possible source for banking of autologous multipotent cells with similar potential as BMSCs. Further in vivo studies will determine the regenerative capacity of these cells in a more physiological context

To identify if disease severity and cancer-risk might depend on genotype in Hereditary Multiple Exostoses (HME). The discovery that the EXT family of tumour suppressor genes is responsible for Hereditary Multiple Exostoses (HME) now enables correlation of clinical features with genetic defects. Genetic epidemiological studies, such as this, may provide additional data of use to the clinician. In most population-based HME cohorts, the incidence of sarcomatous degeneration has been estimated as 1–5%. This is not high, but occurs at a younger age (on average 2–3 decades younger) than chondrosarcoma in the general population. Genetic stratification might allow a very high-risk subgroup to be identified, within which surveillance for neoplastic change in osteochondromas could be concentrated. In a pilot study, 29 affected individuals from 17 families with HME were screened for EXT mutation, with mutations identified in 12 families. Pedigrees were obtained and a complete assessment of disease severity made. We have since expanded this cohort; a further 71 affected individuals from 34 families with HME have provided detailed pedigree data and undergone a simple clinical examination to assess number of palpable osteo-chondromas. EXT mutation was assessed by means of fluorescent single-strand conformational polymorphism (f-SSCP) screening, followed by sequencing analysis. Validation of clinical examination : In those who underwent radiographic examination for clinical purposes, number of palpable osteochondromas correlated strongly with number seen on radiographs at 146 anatomical sites (r= 0.814, p< 0.001), validating the usefulness of clinical examination in a population analysis, and negating the need for a radiographic skeletal survey in individuals at risk from malignant change. EXT mutation : EXT mutation detection rates for f-SSCP were calculated to be 93%. As suggested in the pilot study, most (84%) were loss-of-function mutations. 60% had not previously been reported in the literature. There were 42 individuals with EXT1 and 29 with EXT2 mutations. Disease severity and EXT mutation: In the pilot study, median number of palpable osteochondromas were about twice as frequent in the 7 families with EXT1 mutation than in the 5 families with EXT2 mutation (p< 0.05). This was also reflected in overall disease severity scores. In the larger follow-up study, individuals with EXT1 mutation had a median number of 32 osteochondromas, compared with 16 osteochondromas in those with EXT2 mutation (Wilcoxon rank sum test p< 0.0005). Cancer risk: Six chondrosarcomas occurred, and were only found in individuals with EXT1 mutation. The observation that osteochondromas are more frequent in patients with EXT1 than EXT2 mutations is an important message in genetic counselling. If disease severity and cancer risk is greater in individuals with EXT1 mutation, screening for neoplastic change might be targeted on this group, in which lifetime risk of malignant change in osteochondromas could be increased to between 5% and 10%

Some military personnel are having Femoral Acetabular Impingement (FAI) surgery. The use of the alpha angle (AA) to help assess the diagnosis is common. Currently there are no standardised values available across a asymptomatic pre-arthritic population. Retrospective analysis of 200 consecutive individuals (400 hip joints) with ages 20 to 50, who had a CT performed between 1 Apr 2011 and 29 Nov 2011 due to abdominal pathology. The AA of Notzli was measured on the axial view. The mean AA value was 53.5 (95%CI 1.30) for Right hips and 53.4 (95% CI 1.31) for the left. In age 20–30 Right 52.6 (95%CI 3.5) the Left 52.0 (95%CI 2.9), 31–40 Right 53.9 (95%CI 2.5) Left 53.4 (95%CI 3.1), 41–50 Right 53.8 (95% CI 1.9) Left 53.2 (95% CI 1.8). Mean male Right 52.9 (95% CI 1.5) Left 53.2 (95%CI 1.9) Female Right 52.5 (95% CI 1.5) Left 49.9 (95% CI 1.6). 144/400 (37%) of patients had angle >55 degrees. Previous literature suggests an AA >55 degrees is diagnostic of FAI, we suggest that the AA is highly variable across age and sex and that >1/3rd of asymptomatic patients will have an AA that was previously regarded as abnormal

Open fractures are uncommon in the UK sporting population, however because of their morbidity then are a significant patient group. Currently there is very little in the literature describing the epidemiology of open fracture in sport. We describe the epidemiology of sport related open fractures from one centre's adult patient population. Retrospective analysis of a prospectively collected database recording all sport related open fracture s over a 15 year period in a standard population. Over the 15 year period, there were 85 fractures in 84 patients. The mean age was 29.2 years (range 15–67). 70 (83%) were male and fourteen female (17%). The six most common sports were football (n=19, 22%), rugby (n=9, 11%), cycling (n=8, 9%), hockey (n=8, 9%); horse riding (n=6, 7%) and skiing (n=6, 7%). The top five anatomical locations were fingers phalanges, 35%; tibia-fibula 23%; foreman 14%; ankle 11% and metacarpals 5%. The mean injury severity score was 7.02. Forty five patients were grade 1; 28 patients were grade 2; 8 patients were grade 3a; and 4 were grade 3b according to the Gustilo-Anderson classification system. Seven patients (8%) required plastic surgical intervention for the treatment of these fractures. The types of flaps used were split skin graft (n=4), fasciocutaneous flaps (n=2); and adipofascial flap (n=1). We looked at the epidemiology open fractures secondary to sport in one centre over a 15 year period. Football was the most common sport (22%) and within football, the most common site was the tibia and fibula. In contrast, within the cohort a whole the majority of fractures were upper limb, with the hand being the most common site. Whilst not common in sport, when they are sustained they are frequently occur on muddy sport fields or forest tracks and must be treated appropriately. A good understanding of the range and variety of injuries commonly sustained in different sports is important for clinicians and sports therapists

Aims

The EuroQol five-dimension (EQ-5D) questionnaire is a widely used multiattribute general health questionnaire where an EQ-5D < 0 defines a state ‘worse than death’ (WTD). The aim of this study was to determine the proportion of patients awaiting total hip arthroplasty (THA) or total knee arthroplasty (TKA) in a health state WTD and to identify associations with this state. Secondary aims were to examine the effect of WTD status on one-year outcomes.

Objectives

Wound complications are reported in up to 10% hip and knee arthroplasties and there is a proven association between wound complications and deep prosthetic infections. In this randomised controlled trial (RCT) we explore the potential benefits of a portable, single use, incisional negative pressure wound therapy dressing (iNPWTd) on wound exudate, length of stay (LOS), wound complications, dressing changes and cost-effectiveness following total hip and knee arthroplasties.

The June 2015 Knee Roundup360 looks at: Cruciate substituting versus retaining knee replacement; What’s behind the psychology of anterior cruciate ligament (ACL) reconstruction?; Is there a difference in total knee arthroplasty risk of revision in highly crosslinked versus conventional polyethylene?; Unicompartmental knee arthroplasty: is age the missing variable?; Satisfaction rates following total knee arthroplasty; Is knee alignment dynamic?; Unicompartmental knee arthroplasty: cemented or cementless?; Can revision knee services pay?