Obesity is associated with worse outcomes following total knee/hip arthroplasty (TKA/TKA). This study aimed to determine the feasibility of a dietitian-led low-inflammatory weight-loss program for people with obesity awaiting arthroplasty.

Quasi-experimental pilot study enrolled people with obesity waitlisted for primary TKA/THA into ‘usual care’ (UC) or weight-loss (low-inflammatory diet) program (Diet). Recruitment occurred between July 2019 and February 2020 at Fairfield and Campbelltown Hospitals. Assessments at baseline, pre-surgery, time of surgery and 90-days following surgery included anthropometric measurements, patient-reported outcomes, serum biomarkers and 90-day postoperative complication rate.

97 people consented to the study (UC, n=47, mean age 67, BMI 37, TKA 79%; Diet, n=50, mean age 66, BMI 36, TKA 72%). Baseline characteristics indicated gross joint impairments and poor compliance with a low-inflammatory diet. Study feasibility criteria included recruitment rate (52%), proportion of diet patients that improved compliance to low-inflammatory diet by ≥10% (57%) and had ≥60% attendance of dietitian consultations (72%), proportion of patients who undertook serum biomarkers (55%).

By presurgery assessments, the diet group had more patients who cancelled their surgery due to symptom improvement (4 vs 0), reduced waist-circumference measurements, increased compliance with the Low-Inflammatory diet and preservation of physical activity parameters. More usual care participants experienced at least one postoperative complication to 90-days (59% vs 47%) and were discharged to inpatient rehabilitation (21% vs 11%). There was no difference in weight change, physical function, and patient-reported outcome measures from pre-surgery to 90-days post-surgery, and length of hospital stay.

Using pre-determined feasibility criteria, conducting a definitive trial is not feasible. However, intervention audit demonstrated high intervention fidelity.

Pilot data suggest our program may promote weight loss but the clinical effects for most are modest. Further research utilising a stronger intervention may be required to assess the effectiveness of a pre-arthroplasty weight-loss intervention.

Weight loss is commonly recommended as a treatment for back pain. However, there is little literature to support this. A recent systematic review has identified only studies relating to bariatric surgery. There are no other studies that address whether weight loss improves back pain. Forty-five consecutive consenting patients were recruited following enrolment in a tertiary multidisciplinary weight management program. These patients were referred primarily for treatment of obesity. The program consisted of consultation and on-going supervision by a sub-specialty weight management physician, and group and individual sessions addressing diet, exercise and behaviour modification. Patients were assessed by independent observers prior to start of program and at twelve weeks into the program with standardised and validated outcomes tools measuring baseline factors, back pain and related functional disability at twelve weeks follow-up. Prior to starting the program, forty-two patients (93%) reported some degree of low back pain of which 40% rated their pain as moderate (n = 12) or severe (n = 6). Using the Oswestry Low Back Pain Disability Index, 73% patients reported moderate (n = 18) or severe disability (n = 15). At twelve weeks, thirty-seven (82%) patients were available for assessment. There were significant improvement in VAS pain scores (mean change = 1.5, 95% CI: 0.7 to 2.4) and in Oswestry Low Back Disability Index (mean change= 8.6, 95% CI: 3.9 to 13.2). There were significant reductions in the prevalence of moderate or severe back pain (p = 0.04) and moderate or severe disability (p = 0.007) in the entire group. This is the first study to provide empirical evidence on the positive effects of a weight loss program on back pain. These results lay the groundwork for longer follow-up and comparative studies

Aims

The aim of this study was to produce clinical consensus recommendations about the non-surgical treatment of children with Perthes’ disease. The recommendations are intended to support clinical practice in a condition for which there is no robust evidence to guide optimal care.

Aims

People with severe, persistent low back pain (LBP) may be offered lumbar spine fusion surgery if they have had insufficient benefit from recommended non-surgical treatments. However, National Institute for Health and Care Excellence (NICE) 2016 guidelines recommended not offering spinal fusion surgery for adults with LBP, except as part of a randomized clinical trial. This survey aims to describe UK clinicians’ views about the suitability of patients for such a future trial, along with their views regarding equipoise for randomizing patients in a future clinical trial comparing lumbar spine fusion surgery to best conservative care (BCC; the FORENSIC-UK trial).

Obesity is a growing worldwide health issue! In my home country, the percentage of obese Canadians grew from 13.8% in 1979 to 23.1% in 2004. Interestingly, TKA rates have grown substantially during this time frame and obesity seems to have been a major contributor. In a large study, we found that increasing obesity had an exponential effect on TKA rates (i.e. patients with a body mass index >40 having a 33X greater relative risk of receiving a TKA compared to a normal weight patients). This is an important issue, as obese TKA patients have been shown to have greater pre-operative disability, have longer waits for surgery, be associated with greater technical difficulties (i.e. wound healing, infection, ligamentous injury, deep vein thrombosis and medical issues) and have more peri-operative complications. As a result, some countries have advocated deferring TKAs in obese patients until they have lost a substantial amount of weight despite the fact that many studies have demonstrated that the required weight reduction is seldom achieved. In an effort to understand this issue, we have conducted several studies. In a multicentre study, we could find no link between patient obesity and the level of patient satisfaction following a primary TKA. In another mid-term study, we found that obese patients had equal implant survivorship, but did note that obese patients had lower pre-operative and post-operative health-related quality of life outcome scores. However, in this manuscript we advocated determining the ‘improvement or delta score’ (i.e. difference between the pre-operative and post-operative scores) and found that when this was done, obese TKA patients actually demonstrated more improvement than normal and overweight patients!. Based on our research, we would make the following recommendations: (1) the public should be educated on the effect of obesity on TKA rates, (2) weight management should be an important part of non-operative knee arthritis management and (3) TKA should ‘not’ be withheld from obese patients with end-stage knee arthritis

Treatment of acute Achilles tendon rupture is based on obtaining and maintaining apposition of the ruptured tendon ends. Surgical treatment utilises direct suture repair to produce this objective, while conservative or non-surgical management achieves the same effect of closing the tendon gap by immobilisation of the ankle joint in a plantar flexed position within a plaster cast or POP. There is still variability in the conservative treatment practices and protocols of acute Achilles tendon ruptures. The purpose of this study is to examine the current practice trends in the treatment of Achilles tendon ruptures amongst orthopaedic surgeons in the UK. A postal questionnaire was sent to 221 orthopaedic consultants in 25 NHS hospitals in the Greater London area in June 2010. Type and duration of immobilisation were considered along with the specifics of the regime used. Ninety questionnaires were returned giving a 41% response rate. Conservative treatment methods were used by 72% of respondents. A below knee plaster was the top choice of immobilisation (83%) within this group. The mean period of immobilisation was 9.2 weeks (Range 4-36). Weight bearing was allowed at a mean of 5.3 weeks (range 0-12). The specific regime used by consultants was quite heterogeneous across the group, however the most used immobilisation regimen was a below knee plaster in equinus with 3 weekly serial plaster changes to a neutral position, for a total of nine weeks. A heel raise after plaster removal was favoured by 73% of respondents used for a mean period of 6.4 weeks (Range 2-36). In response to ultrasound use as a diagnostic tool, 42.4% of respondents would never use it, 7.6% would use it routinely, while 50% would use it only according to the clinical situation. Comparison of foot and ankle specialists with non-specialists did not reveal a significant difference in practice in duration of immobilisation or time to bearing weight. Conservative management remains a widely practice option in the treatment of Achilles tendon ruptures. Although there are available a number of modern walking aids, the concept of functional brace immobilisation is not as widely used as below knee plaster cast immobilisation, which remains a popular choice amongst orthopaedic surgeons today. There is still no consensus on the ideal immobilisation regimen although a below knee plaster in equinus with serial changes for a total of nine weeks is the most frequently used choice. Further randomised controlled trials are required to establish the optimal treatment strategy for conservative management of Achilles tendon rupture

It is well appreciated that thigh pain following recent arthroplasty surgery is likely to be due to prosthetic loosening or infection. Both these sequelae can lead to periprosthetic fracture presenting complex challenges to even experienced surgeons. Revision arthroplasty patients are prone to both fatigue and insufficiency fractures as they may have reduced bone stock after previous surgery and reduced bone density secondary to medical and immobility reasons. The post operative painfree condition will frequently permit early load bearing leading to a relatively rapid increase in activity and load bearing. Fatigue fractures occur in bone of normal quality subject to abnormal cyclical overloading, leading to resorption and eventual failure, before adequate time has passed to permit adaptive remodelling. Insufficiency fractures occur when normal physiological loads are applied to bone of abnormal quality. Surprisingly few periprosthetic stress fractures are reported in the literature but a series notes lateral tensile stress fractures associated with varus prosthetic alignment. These all occurred near the tip of the prosthesis. The case of an unusual Gruen Zone 2, Vancouver B1 stress fracture, 9 months following revision arthroplasty is reported. Initially loosening was suspected due to the development of load bearing thigh pain. Plain radiography revealed the development of a dreaded black line, consistent with a stress fracture. Bone scintigraphy revealed the typical appearance of a stress fracture in the absence of loosening or infection. The unusual location of this stress fracture allowed consideration of conservative non weight bearing management which lead to the alleviation of symptoms rather than further revision surgery. This report illustrates this unusual stress fracture and highlights the importance of careful loading practises to permit adequate remodelling following complex revision surgery

Objectives

To investigate psychosocial and biomedical outcomes following total hip replacement (THR) and to identify predictors of recovery from THR.

Objectives

The goals of this study were: 1) to determine if high-fat diet (HFD) feeding in female mice would negatively impact biomechanical and histologic consequences on the Achilles tendon and quadriceps muscle; and 2) to investigate whether exercise and branched-chain amino acid (BCAA) supplementation would affect these parameters or attenuate any negative consequences resulting from HFD consumption.