Energy storing tendons such as the human Achilles and equine superficial digital flexor tendon (SDFT) are prone to age-related injury. Tendons have poor healing capacity and a lack of effective treatments can lead to ongoing pain, reduced function and re-injury. It is therefore important to identify the mechanisms underpinning age-related tendinous changes in order to develop more effective treatments. Our recent single cell sequencing data has shown that tendon cell populations have extensive heterogeneity and cells housed in the tendon interfascicular matrix (IFM) are preferentially affected by ageing. There is, however, a lack of established surface markers for cell populations in tendon, limiting the capacity to isolate distinct cell populations and study their contribution to age-related tendon degeneration. Here, we investigate the presence of the cell surface proteins MET proto-oncogene (MET), integrin subunit alpha 10 (ITGA10), fibroblast activation protein alpha (FAP) and platelet derived growth factor receptor alpha (PDGFRA) in the equine SDFT cell populations and their co-localisation with known markers.

Using Western blot we validated the specificity of selected antibodies in equine tissue before performing immunohistochemistry to establish the location of the respective proteins in the SDFT. We subsequently used double labelling immunofluorescence with the established mural cell marker desmin (DES) to distinguish between tenocyte and mural cell populations.

In situ, MET, ITGA10, and FAP presence was found in cells throughout the tendon whereas PDGFRA was present in cells within the IFM. Double labelling immunofluorescence with the mural cell marker DES showed lack of co-localisation between PDGFRA and DES suggesting PDGFRA is labelling an IFM cell population distinct from those associated with blood vessels.

PDGFRA is a promising target for the specific cell sorting of IFM-localised tenocytes, enabling their isolation and subsequent characterisation.

Acknowledgments: The authors acknowledge the Biotechnology and Biological Sciences Research Council (BB/W007282/1) for funding this work.

Introduction

Patellofemoral instability is one of the most common presentations to a children's orthopaedic clinic. Recurrent patellar dislocations and instability episodes are painful, disabling and increase the risk of irreversible chondral damage. The medial patellofemoral ligament is the primary static stabiliser to prevent lateral dislocation of the patella and is almost always torn or attenuated in these cases. Reconstruction of this ligament is commonly performed using autologous hamstring tendon however there has been some interest recently in use of quadriceps tendon as a graft. Children with patellar instability also present unique challenges due to the small size of the patella and the presence of open growth plates which may require adaptations to the common techniques.

Objectives

Congenital cruciate ligament deficiency is a rare condition that may occur in isolation or in association with longitudinal limb deficiencies such as fibular hemimelia or proximal femoral focal deficiency. Often anomalies of the menisci and their attachments can be very abnormal and impact on surgical management by standard techniques. Arthroscopic surgical knee reconstruction is undertaken to improve symptomatic instability and/or to stabilise and protect the knee for future planned limb lengthening surgery.

The aim of this study is to evaluate the arthroscopic findings of patients undergoing surgery for congenital cruciate ligament deficiency, and specifically to determine the frequency and types of meniscal anatomical variations seen in these cases.

Abstract

Introduction

This study reviews the orthopaedic care of the thirteen patients who were admitted and treated at Royal Manchester Children's' Hospital following the Manchester Arena Bomb blast

To analyse the management of open paediatric tibial fractures treated at a children's Major Trauma Centre (MTC), comparing fixation methods, union and complications.

We retrospectively identified all patients admitted to RMCH with an open tibia fracture between 2008 – 2016. Demographics, mechanism, inpatient stay and follow-up management were reviewed. There were a total of 44 patients, with an average age = 10 years (3–15). 93% of cases were caused by road traffic accidents, commonly pedestrian versus car. Older children were more likely to sustain higher grade injuries, requiring increased length of stay. 35 patients had primary / delayed wound closure, 1 patient required fasciotomies and 4/44 needed skin grafts and/or flap. 7 patients were treated in plaster, 9 by elastic nailing, 15 had mono-lateral fixators and 12 with circular frame. The average number of surgeries = 3 (1–7) with older children having increased risk of revision surgery. Monolateral fixators were the most common primary fixation method (n=15), however 60% required revision to ring fixator due to displacement or delayed union. The main risk factor for displacement was inadequate fracture reduction in theatre, as well as those fracture patterns involving butterfly fragments. Union (defined as RUST score = 3 on >3 cortices) was achieved in all patients (ave 6 months). Delayed union was associated with higher grade injuries, those treated with elastic nails demonstrated the longest union time (ave 7.3 months). 21/44 (47.7%) patients had complications, with pin site infection being the most commonly seen. 18% patients suffered a major complications needing further surgery.

Various fixation methods can be successfully used to treat these fractures. They demonstrate a high complication rate and often require multiple surgeries, with union taking an average of 6 months. Mono-lateral fixators demonstrate a high revision rate, particularly if the fracture is not well reduced.

Background:

Acute deformity correction with the help of osteotomies and stabilisation with intramedullary (IM) nail is a recognised technique. We present our case series of long bong deformity correction using an innovative technique that aids accurate correction after osteotomy and insertion of IM nail.

The accurate and detailed documentation of surgical procedures is essential, forming part of good clinical practice set out by the General Medical Council (GMC). In the case of knee arthroscopy, it is vital for planning further management when referring to a soft tissue knee specialist. This study assesses the quality of documentation of knee arthroscopy and evaluates the implementation of a novel operative template.

A retrospective study of 50 operative-notes of patients undergoing knee arthroscopy was completed. A 41-point assessment was made based on guidelines from the GMC, Royal College of Surgeons of England (RCSE), British Orthopaedic Association (BOA) and British Association for Surgery of the Knee (BASK).

An operative-note template was devised to address the criteria important for further interventions and then assessed for its efficacy in providing appropriately detailed findings.

Detailed documentation deemed essential by current guidelines were lacking the minimum standards expected. Criteria that were considered necessary for an arthroscopic procedure were as low as 4%. After instigating the new operative template, there was a statistically significant increase (p < 0.001) in documentation accuracy throughout the necessary criteria set out by the GMC, RCSE, BOA and BASK.

We have devised an operative template for knee arthroscopy that improves the quality of documentation and allows for optimal further surgical planning. Clear documentation is important for patient safety, adequate referral to a specialist, research and coding purposes. This will ideally reduce the number of repeat knee arthroscopies performed and optimise patient care from the outset.

The aim of this retrospective study is to compare the different anaesthetic techniques in children undergoing circular frame application for lengthening and deformity correction. Data was collected from 68 cases on severe pain episodes, postoperative duration of analgesia, requirement for top-up analgesia, complications and side-effects and number of osteotomies. The three analgesic methods used were morphine infusion (M), epidural analgesia (E) and continuous peripheral nerve blocks (CPNB). There was a significant difference between the number of episodes of severe pain experienced by the patients receiving a morphine infusion when compared to the epidural and CPNB groups (M vs. E p<0.0001, M vs. CPNB p=0.018). CPNB were associated with the lowest incidence of severe pain episodes and top-up analgesia requirements. The difference in the incidence of nausea and vomiting between the methods was approaching significance (p=0.06). A significant difference was found when comparing epidural and morphine infusions (p=0.05). Epidural analgesia was associated with significantly more nausea and vomiting (p=0.023), and motor blockade (p<0.01) than CPNB. The results show the most effective method of post-operative analgesia for our paediatric patients, in light of pain episodes and associated side-effects, is sciatic nerve catheterisation with continuous infusion.

Aim

To demonstrate the effect of location of the split of the plaster on the raised intercompartmental pressure in the volar and dorsal compartments.

Introduction: Arthrodesis of 1st metatarsophalangeal joint is a reliable procedure for the treatment of symptomatic arthritis. Various techniques are in use to facilitate arthrodesis. We evaluated our results using a new and simple construct of two staples applied perpendicular to one another.

Material and Methods: Prospective observational study. A total of 29 patients (26 females, 3 males), Mean age 59yrs. 34 Hallux MTP joint fusions, 5 of them bilateral. Pre-operative diagnosis was Osteoarthritis in 27 and Rheumatoid arthritis in 2.

Technique: Medial incision, planar cuts using saw. Staples placed dorsoventrally and mediolaterally.

Patients: were mobilised in heel weight bearing post op shoe for 4–6 weeks. All patients had regular clinical and radiological assessment. Mean followup was 24 months.

Results: Pre-op mean AOFAS score was 31 (Modified AOFAS score, total value 90 Portion of MTP joint motion was not included). Post-op mean AOFAS (modified) score was 81. 26 patients were very satisfied with the outcome of surgery, 2 were satisfied with reservation and one patient was not satisfied. 28 out of 29 patients would recommend this procedure to others. Ability to wear shoes improved in 26, same in 2 and worse in one patient. There were two mal-unions, one superficial wound infection treated with antibiotics and 6 patients had prominent staples requiring removal. There was no radiological non-union

Conclusion: Our technique of 1st MTP joint arthrodesis using 2 staples applied perpendicular to each other provides a reliable and stable construct that does not require use of plaster post-operatively. This has resulted in painfree post-op period without any need for plaster thus saving time and avoiding complications of plaster i.e stiffness and DVT. We strongly recommend the use of this type of fixation.

Aim: Inability to lose weight is often attributed to restriction of mobility due to painful arthritic joints. We hypothesise that removing the pain by total hip replacement or knee replacement will improve patients exercise tolerance thereby helping them lose weight.

Method: A prospective study of obese patients (BMI > 30) undergoing consecutive primary total hip or knee replacement. BMI was measured pre operatively and 1 year post operatively. Patients with medical conditions or complications of surgery that would limit mobility were excluded. A questionnaire detailing pre and postoperative activity levels, walking distance/aids and diet was completed.

Results: 37 patients were included in the study. All patients had symptomatic osteoarthritis. There were 21 female and 16 male patients with an average age of 70 (range 51 – 85). 23 patients had total knee replacements and 14 had total hip replacement. The average follow up was 11.4 months (range 8 – 12 months).

The International classification of adult weight according to BMI was used to categorise patients. Obesity is defined as a BMI greater than 30 and is graded in severity. Class I is a BMI of 30.0 – 34.9, Class II is 35.0 – 39.9 and Class III is greater than 40.0

There were 14 patients in obese class I. 5 patients increased their BMI, 4 patients remained the same and 5 patients decreased their BMI. There was an average increase in BMI of 0.36. 13 patients had an improvement in walking distance and in 1 patient it remained unchanged.

There were 16 patients in obese class II. 6 patients increased their BMI, 5 patients remained the same and 5 patients decreased their BMI. There was an average increase in BMI of 0.62. 14 patients had an improvement in walking distance and in 2 patients it remained unchanged.

There were 7 patients in obese class III. 1 patient increased their BMI, 1 patient remained the same and 5 patients decreased their BMI. There was an average decrease in BMI of 1.3. 5 patients had an improvement in walking distance and in 2 patients it remained unchanged.

There was an average increase of BMI of 0.19 in all patients. All patients reported an improvement in activity levels and a reduction in the use of walking aids.

Conclusion: Overall there was an increase in the BMI of obese patients undergoing total knee or hip replacement. This study suggests that total knee or hip replacement in obese patients for osteoarthritis despite improved activity levels does not result in a reduction in BMI. This is either as the improvement in mobility is not sufficient to confer a significant loss of weight or that pre-operative obesity is unrelated to inactivity due to osteoarthritis. Interestingly, the weight loss in obese class III patients (BMI > 40) who undergo total hip or knee replacement suggests that they benefit more from surgery than other classes of obesity.

We present the early results of 36 primary total elbow arthroplasties using the Acclaim prosthesis. The Acclaim prosthesis was used in 46 primary total elbow arthroplasties between July 2000 and August 2002. All operations were performed or directly supervised by the two senior authors (IAT and JKS). There were 32 females and 14 males. The mean age at surgery was 64 years (range, 34–93). The underlying pathology was rheumatoid arthritis in 39, osteoarthritis in five and post-traumatic arthritis in two. The early results of 36 cases are presented at a minimum follow-up of two years. Patients were assessed using the American Shoulder and Elbow Surgeons patient self assessment form and the range of movement of the elbow measured. The Wrightington method was used for radiographic analysis of lucencies. There was good relief of pain and range of movement improved. The mean preoperative pain score was 8.1 and decreased to 2.1 at latest follow up. The mean disability score increased from 34.2 to 66.1. The mean overall satisfaction rating following surgery was 9.3 on a visual analogue scale from zero to ten. The mean range of flexion increased from 83^oto105^o. The mean flexion gain was just over 10^o and the mean extension gain was just over 12^o. There were 11 cases of intraoperative fracture of the humeral condyle. One of these fractures failed to unite and required revision to a linked prosthesis because of persistent instability. There was one case of deep infection. There were three cases of ulnar neuropathy, one of which resolved. There was no evidence of loosening. The Acclaim total elbow arthroplasty gives good symptomatic relief and improvement in function according to the American Shoulder and Elbow Surgeons patient self assessment form. These early results are encouraging but the frequency of intra-operative fractures is of some concern.

Arthroscopic procedures may be associated with considerable pain in the first 24 hours. Intra-articular bupi-vacaine provides good analgesia but is short lasting. Intra-articular morphine has been shown to prolong postoperative analgesia in knee and ankle arthroscopy. The aim of this study is to assess the safety and analgesic effect of intra-articular morphine following day case wrist arthroscopy.

Ethical approval was firstly obtained. 31 patients were randomly assigned to one of 2 groups in a double blind clinical study. Group 1 received 5ml of 0.5% bupi-vacaine intra-articularly with 5mg of morphine subcutaneously. Group 2 received 5ml of 0.5% bupivacaine and 5mg of morphine intra-articularly. There were 15 patients (mean age 41.2 years) in group 1, and 16 patients (mean age 38.9 years) in group 2. Postoperatively pain was assessed using a 100mm visual analogue pain scale (VAPS) at 1, 2, 6 and 24 hours. Analgesia requirements were recorded at these times post operatively. The presence of nausea, vomiting, other complications and patient satisfaction were recorded.

Visual analogue pain scores did not show any significant difference between the groups at 1, 2, 6 and 24 hours. Supplementary analgesic consumption over the 24 hour period was slightly greater in group 1 than in group 2. None of the patients who had intra-articular Morphine had vomiting nor any other complications and did not require anti-emetics. Most patients in either group were satisfied with the level of postoperative analgesia.

Intra-articular bupivacaine with or with out morphine provides adequate postoperative pain relief following wrist arthroscopy. There seems to be little difference between the two methods studied.

Aim: Patients with advanced rheumatoid arthritis who were managed with ipsilateral shoulder and elbow arthroplasties were reviewed to determine appropriate sequence of surgery, operative technique and the functional outcome.

Methods: Between 1992 and 2002, twenty-two patients underwent ipsilateral elbow and shoulder arthroplasties. Nineteen patients were available for final review. Clinical and radiological assessments were done on these patients.

Results: Twenty-four upper limbs in nineteen patients were reviewed. Mean age at final follow-up was 61.1 years (49.9 to 73.3yrs; SD 8.2). Mean duration of follow-up from the last operation was 55.5 months (12 to 129.3m; SD 33.5). The average interval between the operations was 40.1 months; it was 41.2 months when elbow operated first and 38.7 months when shoulder was operated first. This difference was not significant (p=0.82). All movements showed significant improvement after respective joint replacements. There was a significantly greater improvement in external rotation of the shoulder when it was operated first (p=0.48). The average improvement in Constant-Murley scores was 28.8 points; with no statistically significant difference between either sequence of operations (p=0.49). However, there was statistically significant improvement in the average Mayo elbow performance score after the elbow arthroplasty when it was operated first (p=0.03).

Two patients needed conversion of shoulder hemi-arthroplasty to total shoulder replacement due to subsequent erosion of the glenoid. One elbow replacement was revised because of recurrent dislocations. There were four patients who developed ulnar neuropathy, of which two were permanent. There were no peri-prosthetic fractures in this series. One patient needed custom-made short-stemmed shoulder prosthesis due to the presence of a long-stemmed humeral component of total elbow prosthesis in situ.

Conclusion: Ipsilateral shoulder and elbow replacements significantly improve pain and function of the limb, when there is advanced arthritis. The joint that appears clinically and radiologically worse should be replaced first. However if both the joints are equally involved we feel that elbow should be replaced first as the functional improvement seems to be better. Careful preoperative planning is required in choosing the type and size of prosthesis, to avoid potential complications.

The treatment of acetabular dysplasia in adolescents (age> 12) is difþcult and various complex pelvic osteotomies have been described. The aim of surgery being improvement in pain and to delay the onset of secondary osteoarthrosis. Methods: We present our experience of using the Tonnis triple pelvic osteotomy for treatment of acetabular dysplasia in the adolescent and adult age groups (range 13–27 years). This retrospective analysis includes 25 patients operated on over a nine year period (1991–2000) with an average followup of four years (range 2–8 years). More than 50% of the patients had had a previous open reduction or femoral osteotomy for CDH. Results: Radiographic analysis (pre & post op) included CE angle of Wiberg, Sharp-Ullmann index and the acetabular angle of the weight bearing zone. All parameters showed an improvement in the post operative analysis with an improvement in pain and range of movement in all patients. Discussion: The Tonnis triple pelvic osteotomy has the advantage of allowing the operator a direct þeld of view at all times and achieving a great deal of lateral rotation and medial displacement of the acetabulum due to the proximity of the osteotomy to the acetabulum. The ischial ramus and its ligaments to the sacrum are left intact, leading to greater stability of the pelvis and spine. Conclusion: Though technically difþcult and needing a long learning curve, it does improve acetabular alignment and symptoms in the early postoperative years. However long term studies are required to document its effect on the rate of secondary osteoarthrosis.

Aim: The purpose of this prospective study was to assess the outcome of scarfe osteotomy for hallux valgus. Method: 26 patients were reviewed but only the results of 24 patients (33 osteotomies) were available for analysis. The assessment involved the American Academy Foot and Ankle Society Score, pedobarographic & radiographic examination.

There were 3 male and 21 female patients with a mean age of 46 years. The mean follow up was 17 months. Statistical analysis was carried out. Results: The AAFAS score improved from a mean preoperative value of 52 to 89 postoperatively. The mean improvement was 34 (range 12–46). The inter-metatarsal and hallux valgus angles improved from a mean preoperative value of 15 and 31 degrees respectively to a mean postoperative value of 8 and 14 degrees. 22 patients (91.6%) were satisþed with the outcome of surgery. The pedobarographic results will be illustrated. In one patient a fracture occurred intra-operatively and two patients had wound infection which settled with antibiotics. Conclusion: The early results of the scarfe osteotomy for hallux valgus in our hands are encouraging.

Purpose: The role of hip aspiration as a preoperative investigation for the painful hip remains controversial. Since 1999, we have performed hip aspiration under local anaesthetics in the X-ray department. This paper reviews our experience with this technique.

Results: Hip aspirations were carried out subsequently on 182 patients from November 1999 to November 2002. Out of 68 patients that underwent revision hip surgery, 63 were included in the study. Three of the five patients excluded had received antibiotics at induction prior to obtaining the operative samples and two did not have any operative samples taken at the time of surgery. Fifteen (23.8%) of the 63 hips were found to be infected based on operative tissue cultures. The sensitivity and specificity of the test were 80% and 87.5%, respectively. Positive and negative predictive values were 66.6% and 93.3% respectively and the accuracy was 85.7%.

Conclusion: Hip aspiration in the Radiology department is a simple, cost effective and reliable preoperative test when used selectively. When used in combination with other laboratory and radiological investigation it can act as an important preoperative investigation in the diagnosis of sepsis. There is an added advantage of identifying the microorganism along with its antibiotic sensitivities. This can guide clinicians in choosing the correct antibiotic for the cement and also for the postoperative antibiotic therapy.

Children with osteogenesis imperfecta(OI) have multiple long bone fractures with subsequent deformities. The mainstay of treatment is correction with multiple osteotomies and intramedullary fixation. The Shefffield intramedullary telescoping rod system has been successful in the treament of long bone fractures and deformities (Wilkinson et al ,JBJS-B,1998) Bisphosphonates (Pamidronate -1- 1.5mg/kg/day)have been used as adjuvant therapy in the treatment of OI since the last five years. The perceived benefits include reduction in fracture frequency, improvement in bone density and a general feeling of well being.

We present our experience of five cases of OI who developed infections around thier Sheffield telescoping rods while on Pamidronate therapy. There was only one case of sepsis over a ten year period(over eighty patients)in a previously reported series from our centre.

The time interval between the start of Pamidronate therapy and the diagnosis of infection varied between 12–36 months ie. between 4–12 cycles of Pamidronate (parenteral administration over a three day period at three month intervals). All patients had their intramedullary rods in situ from anywhere between 2–7 years. The infections were low grade with a 2–3 month period of dull ache prior to actual presentation. Intrestigly though all patients had multiple rods in situ, only one of their femoral rods was affected and they did not have any other infective focus at the time of diagnosis. Three patients presented with thigh abcesses while the other two presented with ipsilateral knee pain and effusion. All had raised inflammatory markers, radiological signs of sepsis with Staph Aureus the commonest infecting organism.

Those cases presenting with abcesses were treated by drainage and rod removal, however only antibiotics were sufficient in the rest. The relationship between Pamidronate therapy and these infections is not absolutely clear and has not been reported previously. The possible links are discussed and a high degree of suspicion is recommended for those cases of OI on bisphosphonate