Aims

The burden of revision total hip arthroplasty (rTHA) continues to grow. The surgery is complex and associated with significant costs. Regional rTHA networks have been proposed to improve outcomes and to reduce re-revisions, and therefore costs. The aim of this study was to accurately quantify the cost and reimbursement for a rTHA service, and to assess the financial impact of case complexity at a tertiary referral centre within the NHS.

Prolonged bedrest in hospitalized patients is a major risk factor for venous thromboembolism (VTE), especially in high risk patients with hip fracture. Thrombelastography (TEG) is a whole blood viscoelastic hemostatic assay with evidence that an elevated maximal amplitude (MA), a measure of clot strength, is predictive of VTE in orthopaedic trauma patients. The objective of this study was to compare the TEG MA parameter between patients with hip fracture who were more mobile post-operatively and discharged from hospital early to patients with hip fracture with reduced mobility and prolonged hospitalizations post-operatively.

In this prospective cohort study, TEG analysis was performed in patients with hip fracture every 24-hours from admission until post-operative day (POD) 5, then at 2- and 6-weeks post-operatively. Hypercoagulability was defined by MA > 65. Patients were divided into an early (within 5-day) and late (after 5-day) discharge group, inpatient at 2-weeks group, and discharge to MSK rehabilitation (MSK rehab), and long term care (LTC) groups. Two-sample t-test was used to analyze differences in MA between the early discharge and less mobile groups. All statistical tests were two-sided, and p-values < 0.05 were considered statistically significant.

In total, 121 patients with a median age of 81.0 were included. Patients in the early discharge group (n=15) were younger (median age 64.0) and more likely to ambulate without gait aids pre-injury (86.7%) compared to patients in the late discharge group (n=105), inpatients at 2-weeks (n=48), discharged to MSK rehab (n=30), and LTC (n=20). At two weeks post-operative, the early discharge group was significantly less hypercoagulable (MA=68.9, SD 3.0) compared to patients in the other four groups. At 6-weeks post-operative, the early discharge group was the only group to demonstrate a trend towards mean MA below the MA > 65 hypercoagulable threshold (MA=64.4, p=0.45). Symptomatic VTE events were detected in three patients (2.5%) post-operatively. All three patients had hospitalizations longer than five days after surgery.

In conclusion, our analysis of hypercoagulability secondary to reduced post-operative mobility demonstrates that patients with hip fracture who were able to mobilize independently sooner after hip fracture surgery, have a reduced peak hypercoagulable state. In addition, there is a trend towards earlier return to normal coagulation status as determined by the TEG MA parameter. Post-operative mobility status may play a role in determining individualized duration of thromboprophylaxis following hip fracture surgery. Future studies comparing TEG to clinically validated mobility tools may more closely evaluate the contribution of venous stasis due to reduced mobility on hypercoagulation following hip fracture surgery.

Prolonged bedrest in hospitalized patients is a major risk factor for venous thromboembolism (VTE), especially in high risk patients with hip fracture. Thrombelastography (TEG) is a whole blood viscoelastic hemostatic assay with evidence that an elevated maximal amplitude (MA), a measure of clot strength, is predictive of VTE in orthopaedic trauma patients. The objective of this study was to compare the TEG MA parameter between patients with hip fracture who were more mobile post-operatively and discharged from hospital early to patients with hip fracture with reduced mobility and prolonged hospitalizations post-operatively.

In this prospective cohort study, TEG analysis was performed in patients with hip fracture every 24-hours from admission until post-operative day (POD) 5, then at 2- and 6-weeks post-operatively. Hypercoagulability was defined by MA > 65. Patients were divided into an early (within 5-day) and late (after 5-day) discharge group, inpatient at 2-weeks group, and discharge to MSK rehabilitation (MSK rehab), and long term care (LTC) groups. Two-sample t-test was used to analyze differences in MA between the early discharge and less mobile groups. All statistical tests were two-sided, and p-values < 0.05 were considered statistically significant.

In total, 121 patients with a median age of 81.0 were included. Patients in the early discharge group (n=15) were younger (median age 64.0) and more likely to ambulate without gait aids pre-injury (86.7%) compared to patients in the late discharge group (n=105), inpatients at 2-weeks (n=48), discharged to MSK rehab (n=30), and LTC (n=20). At two weeks post-operative, the early discharge group was significantly less hypercoagulable (MA=68.9, SD 3.0) compared to patients in the other four groups. At 6-weeks post-operative, the early discharge group was the only group to demonstrate a trend towards mean MA below the MA > 65 hypercoagulable threshold (MA=64.4, p=0.45). Symptomatic VTE events were detected in three patients (2.5%) post-operatively. All three patients had hospitalizations longer than five days after surgery.

In conclusion, our analysis of hypercoagulability secondary to reduced post-operative mobility demonstrates that patients with hip fracture who were able to mobilize independently sooner after hip fracture surgery, have a reduced peak hypercoagulable state. In addition, there is a trend towards earlier return to normal coagulation status as determined by the TEG MA parameter. Post-operative mobility status may play a role in determining individualized duration of thromboprophylaxis following hip fracture surgery. Future studies comparing TEG to clinically validated mobility tools may more closely evaluate the contribution of venous stasis due to reduced mobility on hypercoagulation following hip fracture surgery.

Revision total hip arthroplasty (rTHA) can be complex and associated with significant cost, with an increasing burden within the UK and globally. Regional rTHA networks have been proposed aiming to improve outcomes, reduce re-revisions and therefore costs. The aim of this study was to accurately quantify the cost and reimbursement for the rTHA service and to assess the financial impact of case complexity at a tertiary referral centre within the NHS.

A retrospective analysis of all revision hip procedures was performed over two consecutive financial years (2018–2020). Cases were classified according to the Revision Hip Complexity Classification (RHCC) and by mode of failure; infected or non-infected. Patients of ASA grade of 3 or greater or BMI over 40 are considered “high-risk” by the RHCC. Costs were calculated using PLICS and remuneration based on the HRG data. The primary outcome was the financial difference between tariff and cost per episode per patient. Comparisons between groups were analysed using analysis of variance and two-tailed unpaired t-test.

199 revision episodes were identified in 168 patients: 25 (13%) least complex revisions (H1), 110 (55%) complex revisions (H2) and 64 (32%) most complex revisions (H3). 76 (38%) cases were due to infection. 78 (39%) of patients were in the “high-risk” group. Median length of stay increased with case complexity from 4, to 6 to 8 days (p=0.17) and significantly for revisions performed for infection (9 vs 5 days; p=0.01). Cost per episode increased significantly between complexity groups (p=0.0002) and for infected revisions (p=0.003). All groups demonstrated a mean deficit, but this significantly increased with revision complexity (£301, £1,820 and £4,757 per case; p=0.02) and for infected failure (£4,023 vs £1,679; p=0.02). The total deficit to the trust for the two-years was £512,202.

Current NHS reimbursement for rTHA is inadequate and should be more closely aligned to complexity. An increase in the most complex rTHA at major revision centres (MRC) will likely place a greater financial burden on these units.

Abstract

Nearly one quarter of ankle fractures have a recognized syndesmosis injury. An intact syndesmosis ligament complex stabilizes the distal tibio-fibular joint while allowing small, physiologic amounts of relative motion. When injured, malreduction of the syndesmosis has been found to be the most important independent factor that contributes to inferior functional outcomes. Despite this, significant variability in surgical treatment remains. This may be due to a poor understanding of normal dynamic syndesmosis motion and the resultant impact of static and dynamic fixation on post-injury syndesmosis kinematics. As the syndesmosis is a dynamic structure, conventional CT static images do not provide a complete picture of syndesmosis position, giving potentially misleading results. Dynamic CT technology has the ability to image joints in real time, as they are moved through a range-of-motion (ROM). The aim of this study was to determine if syndesmosis position changes significantly throughout ankle range of motion, thus warranting further investigation with dynamic CT.

This is an a priori planned subgroup analysis of a larger multicentre randomized clinical trial, in which patients with AO-OTA 44-C injuries were randomized to either Tightrope or screw fixation. Bilateral ankle CT scans were performed at 1 year post-injury, while patients moved from maximal dorsiflexion (DF) to maximal plantar flexion (PF). In the uninjured ankles, three measurements were taken at one cm proximal to the ankle joint line in maximal DF and maximal PF: Anterior (ASD), middle (MSD), and posterior (PSD) syndesmosis distance, in order to determine normal syndesmosis position. Paired samples t-tests compared measurements taken at maximal DF and maximal PF.

Twelve patients (eight male, six female) were included, with a mean age of 44 years (±13years). The mean maximal DF achieved was 1-degree (± 7-degrees), whereas the mean maximal PF was 47-degrees (± 8-degrees). The ASD in DF was 3.0mm (± 1.1mm) versus 1.9mm (± 0.8mm) in PF (p<0.01). The MSD in DF was 3.3mm (±1.1mm) versus 2.3mm (±0.9mm) in PF (p<0.01). The PSD in DF was 5.3mm (±1.5mm) versus 4.6mm (±1.9mm) in PF (p<0.01). These values are consistent with the range of normal parameters previously reported in the literature, however this is the first study to report the ankle position at which these measurements are acquired and that there is a significant change in syndesmosis measurements based on ankle position.

Normal syndesmosis position changes in uninjured ankles significantly throughout range of motion. This motion may contribute to the variation in normal anatomy previously reported and controversies surrounding quantifying anatomic reduction after injury, as the ankle position is not routinely standardized, but rather static measurements are taken at patient-selected ankle positions. Dynamic CT is a promising modality to quantify normal ankle kinematics, in order to better understand normal syndesmosis motion. This information will help optimize assessment of reduction methods and potentially improve patient outcomes. Future directions include side-to-side comparison using dynamic CT analysis in healthy volunteers.

Venous thromboembolism (VTE) is the second most common complication and pulmonary embolism (PE) is the fourth most common cause of death after a hip fracture. Despite thromboprophylaxis, deep vein thrombosis (DVT) is detected in up to 45% of hip fracture patients. Thrombelastography (TEG) is a whole-blood, point of care test capable of providing clinicians with a global assessment of the clotting process, from fibrin formation to clot lysis. Maximal amplitude (mA) from TEG analysis is a measure of clot strength. Elevated admission mA values of >65mm and >72mm have been determined to be independent predictors of in-hospital PE. The coagulation index (CI) is calculated based on TEG parameters and defines hypercoagulable state as CI >3. This study aimed to use serial TEG analysis to determine the duration of hypercoagulable state after hip fracture.

A prospective cohort of hip fracture patients >50 years of age amenable to surgical treatment (AO 31A1–A3 & 31B1–B3) were enrolled at a Level I trauma centre. Serial TEG analysis (TEG 6S) was performed every 24-hours from admission until 5-days post-operatively and at 2- and 6-week follow-up visits. All patients received a minimum of 28 days of thromboprophylaxis. Descriptive statistics and single sample t-tests were used for comparison of mA to the 65mm threshold.

Thirty-five patients (26 female) with a median age of 83 (range = 71–86) years were included. On admission, 31.4% and 82.9% of patients were hypercoagulable based on mA >65mm and CI, respectively. At 2 weeks, all patients remained hypercoagulable, however, mA >72mm showed that 16 patients (47.1%) were at even higher risk for VTE. At 6-weeks, 65.7% and 97.1% of patients were hypercoagulable based on mA >65mm and CI, respectively. When compared with the mA >65mm threshold, patients were hypocoagulable at the time of admission (mA = 62.2 (±6.3), p = 0.011), but became significantly more hypercoagulable at 2-weeks (mA = 71.6 (±2.6), p < 0 .001), followed by continued hypercoagulability at 6-weeks, however not significantly elevated above the 65mm threshold (mA = 66.2 (±3.8), p = 0.058). One patient developed a symptomatic DVT at 2-weeks and had a mA = 72.9 and a CI of 5.9.

This is the first study to demonstrate that >50% of hip fracture patients remain hypercoagulable 6 weeks post fracture despite thromboprophylaxis, and there are individual hypercoagulable responses. This is critical, as guidelines only recommend 28 to 35 days of thromboprophylaxis in this high-risk population. Previously determined mA thresholds may be a more sensitive test for risk-stratifying patients' VTE risk than the CI threshold. Additionally, assessing ΔmA using serial TEG may better predict VTE risk.

Introduction

Prosthetic joint infection (PJI) is the leading cause of failure of primary and revision hip and knee arthroplasty. It is challenging condition which represents a growing burden on hospital resources. In-patient hospital stay for antibiotic therapy post-operatively is costly and access to out-patient IV therapy (OPAT) varies between regions. In a tertiary referral centre for revision and infection, the suitability and cost-effectiveness of Dalbavancin was reviewed as a “single-shot” therapy following DAIR or revision lower limb arthroplasty for PJI.

The syndesmosis ligament complex stabilizes the distal tibiofibular joint, while allowing for the subtle fibular motion that is essential for ankle congruity. Flexible fixation with anatomic syndesmosis reduction results in substantial improvements in functional outcomes. New dynamic CT technology allows real-time imaging, as the ankle moves through a range of motion. The aim of this study was to determine if dynamic CT analysis is a feasible method for evaluating syndesmosis reduction and motion following static and flexible syndesmosis fixation.

This is a subgroup analysis of a larger multicenter randomized clinical trial, in which patients with AO 44-C injuries were randomized to either Tightrope (one knotless Tightrope, Group T) or screw fixation (two 3.5-mm cortical screws, Group S). Surgical techniques and rehabilitation were standardized. Bilateral ankle CT scans were performed at one year post-injury, while patients moved from maximal dorsiflexion (DF) to maximal plantar flexion (PF). Three measurements were taken at one cm proximal to the ankle joint line in maximal DF and maximal PF: anterior, midpoint, and posterior tibiofibular distances. T-tests compared Group T and Group S, and injured and uninjured ankles in each group.

Fifteen patients (six Group T [three male], nine Group S [eight male]) were included. There was no difference for mean age (T = 42.8 ± 14.1 years, S = 37 ± 12.6, P = 0.4) or time between injury and CT scan (T = 13 ± 1.8 months, S = 13.2 ± 1.8, P = 0.8). Of note in Group S, seven of nine patients had at least one broken screw and one additional patient had screws removed by the time of their dynamic CT. There was no significant difference between treatment groups for tibiofibular distance measurements in maximal PF or DF. Group T showed no significant difference between the injured and uninjured side for tibiofibular measurements in maximal PF and DF, suggesting anatomic reduction. For Group S, however, there was a significantly larger distance for all three measurements at maximal PF compared to the uninjured ankle (all P < 0 .05).

In all but one Group S patient, screws were broken or removed prior to their dynamic CT, allowing possible increased syndesmotic motion, similar to Group T. Despite this, dynamic CT analysis detected increased tibiofibular distance in Group S as ankles moved into maximal PF when compared with the uninjured ankle. Given the importance of anatomic syndesmosis reduction, dynamic ankle CT technology may provide valuable physiologic information warranting further investigation.

Introduction

We aim to evaluate the outcome of debridement and implant retention (DAIR) procedures performed for primary total hip prosthetic joint infections (PJI) and to identify factors correlating with a successful outcome.

Intervertebral disc (IVD) degeneration presents a harsh microenvironment characterised by low glucose, low oxygen and matrix acidity posing a significant challenge for cell-based therapies. The objective of this work was to assess the effect of primed bone marrow derived stem cells (BMSC) and articular chondrocytes (AC) in different pH (7.1, 6.8 and 6.5) conditions and assess metabolic activity in terms of oxygen (O₂) and glucose consumption as well as lactate production. Secondly, we investigated pH effects on cell viability and matrix accumulation capacity. Primary cells were encapsulated in alginate beads and cultured in disc-like conditions (5% O₂, 5mM glucose, pH 7.1, 6.8 and 6.5). For growth factor priming, cells were cultured with 10ng/ml TGF-β3 at a pH of 7.4 for 14 days prior to being subjected to acidic pH conditions. AC exhibited superior cell viability and sGAG deposition compared to BMSC at all pH levels which was further enhanced after priming. Priming also reduced O₂ consumption of AC for all pH conditions while lactate production profiles of both cell types were altered with decreasing extracellular pH. This work demonstrates the importance of cell type selection to sustain disc-like microenvironmental conditions. Results show that BMSCs that have not been primed may need additional factors to sustain the harsh acidic microenvironment. In contrast, AC were capable of sustaining the low pH conditions better than BMSC and accumulated more similar disc-like matrix in all conditions. Overall this study highlights that AC may be advantageous for disc regeneration and warrant further investigation for disc repair.

High tibial osteotomy (HTO) is a common procedure for treating medial compartment knee arthritis. The main goal is to reduce knee pain by transferring weight-bearing loads to the relatively unaffected lateral compartment and thus delaying the need of total knee replacement (TKR) by slowing or stopping destruction of medial compartment.

Between 2002 and 2010, 34 HTO's were carried out in 32 patients (Mean age 44.2). Results were reviewed in 23 patients with an average follow-up of 10.2 years (range 6–14 years). Oxford knee score (OKS) assessment was carried out on those patients. Of the remaining 11 patients, one was excluded, 2 were lost to follow-up, and 2 had died. Five cases had TKR at an average 8.8 years since having HTO.

OKS results revealed nine cases (39.1percnt;) scored (40–48) which indicate satisfactory joint function and don't require treatment. Three cases (13percnt;) scored (30–39) indicating mild to moderate arthritis. Six cases (26.1percnt;), scored (20–29) indicating moderate to severe arthritis. Five cases (21.8percnt;) scored (0–19) indicating severe arthritis.

Only five patients (14.7percnt;) had TKR (6–14) years after there HTO. The majority of cases had an OKS suggesting satisfactory joint function. Even those with scores suggesting moderate to severe arthritis were able to function normally for more than 6 years.

The successful outcome of HTO can be maintained for more than 6–16 years. We conclude that HTO should be recommended for the treatment of medial compartment arthritis of the knee in young and active patients for symptomatic improvement and maintenance of activity levels.

Tibial plateau fractures are common injuries. Displaced fractures are treated with open reduction and internal fixation (ORIF). Goals of treatment include restoration of extremity axial alignment, joint stability and congruity, allowing for early motion and prevention of osteoarthritis. Short term results of surgical fixation of tibial plateau fractures are good, however, longer term outcomes have demonstrated a higher risk of end-stage arthritis and total knee arthroplasty. Despite the vast literature around tibial plateau fractures, to our knowledge there are no series examining post-operative reductions using axial imaging. It is our goal to define the incidence of articular malreductions following surgical fixation of tibial plateau fractures, to identify patient or surgeon factors associated with malreductions, and to define any regional patterns of malreduction location.

De-identified post operative computed tomography (CT) scans were reviewed to identify tibial plateau malreductions with a step or gap greater than 2 mm, or condylar width greater than 5 mm. Three independent assessors reviewed the scans meeting criteria using Osirix DICOM software. Steps and gaps were mapped onto the axial sequence at the level of the joint line. Images were then matched to side and overlaid as best fit in Photoshop software to create a map of malreductions. A grid was created to divide the medial and lateral plateaus into quadrants to identify the density of malreductions by location. A multi-variate regression model was used to assess risk factors for malreduction.

Sixty five post-operative CT scans were reviewed. Twenty one reductions had a step or gap more than 2 mm for a malreduction incidence of 32.3%. The incidence in patients undergoing submeniscal arthrotomy or fluoroscopic assisted reduction was 16.6% and 41.4%, respectively (p <0.001). Side of injury, age, BMI, AO fracture type, and use of locking plates were not predictive of malreduction. Malreductions were heavily weighted to the posterior lateral tibial plateau.

The incidence of articular malreductions was high at 32.3%. Fluoroscopic reduction alone was a predictor for articular malreduction with most malreductions located in the posterior lateral quadrants of the plateau.

Orthopaedic surgeons frequently assess fragility fractures (FF), however osteoporosis (OP) is often managed by primary care physicians (PCP). Up to 48% of FF patients have had a previous fracture (Kanis et al., 2004). Discontinuity between fracture care and OP management is a missed opportunity to reduce repeat fractures. This studied aimed to evaluate current OP management in FF patients presenting to cast clinic.

A single centre, prospective observational study where seven traumatologists screened for FF in cast clinic. FF was defined as a hip, distal radius (DR), proximal humerus (PH), or ankle fracture due to a ground level fall. Patients completed a self-administered questionnaire for demographics, fracture type and treatment, medical and fracture history, and previous OP care. The primary outcome was number of FF patients who received OP investigation and/or treatment. Secondary outcomes included Fracture Risk Assessment Tool (FRAX), repeat fracture rate, and anti-resorptive related fractures. Descriptive statistics were used for analysis.

Between November 17, 2014 and October 13, 2015, a total of 1,677 patients attended cast clinic for an initial assessment. FF were identified in 120 patients (7.2%). The FF cohort had a mean age of 65.3 (± 14.3) years, mean BMI of 26.1 (± 5.3), and was comprised of 83.3% females. Fracture distribution was 69 (57.5%) DR, 23 (19%) ankle, 20 (16.5%) PH, and seven (5.8%) hip fractures, with 24 of the FF (19.8%) treated operatively. Thirteen (10.8%) were current smokers and 40 (33.3%) formerly smoked. A history of steroid use was present in 13 patients (10.8%). Ninety (n = 117; 76.9%) of patients ambulated independently. Twenty-two patients (18.3%) reported prior diagnosis of OP, most often by a PCP (n = 19; 73.7%) over 5 years previously. Calcium (n = 59; 49.2%) and Vitamin D (n = 70; 58.3%) were common and 26 patients (21.5%) had a prior anti-resorptive therapy, with Alendronate (n = 9) being most common. One patient had an anti-resorptive-related fracture. Raloxifene was used in ten patients. Forty-seven patients (39.2%) had a prior fracture at a mean age of 61.3 (± 11.9) years, with DR and PH fractures being most common. Eleven patients had two or more prior fractures. A family history of OP was found in 34 patients (28.1%). Mean FRAX score was 20.8% (± 10.8%) 10-year major fracture risk and 5.9% (± 6.6%) 10-year hip fracture risk (n = 30 bone densiometry within one-year). Of the 26 patients with a Moderate (10–20%) or High (> 20%) 10-year major fracture risk, only eight (30.8%) reported a diagnosis of OP and only three (11.5%) had seen an OP specialist.

Cast clinics provide an opportunity for OP screening, initiation of treatment, and patient education. This cohort demonstrated a high rate of repeat fractures and poor patient reporting of prior OP diagnosis. This study likely underestimated FF and calls for resource allocation for quantifying true burden of disease and outpatient fracture liaison service.

Development of more effective diagnostic and therapeutic solutions is vital to tackling the growing challenge of bone diseases and disorders in aging societies. Spatially offset Raman spectroscopy (SORS) enables the chemical specificity of conventional Raman spectroscopy to be combined with sub-surface probing. SORS has successfully been applied to transcutaneous investigations of underlying bone and shows great potential to become an in vivo tool for non-invasive diagnosis of various bone conditions.

The volume within the complex hierarchical bone tissue probed by SORS depends on the specimen's optical properties. Understanding the actual sampling depth is important to correctly assign detected chemical changes to specific areas in the bone. This study explores the hypothesis that the effective Raman signal recovery from certain depths requires different spatial offsets depending on the bone mineralisation.

SORS depth investigations were conducted on three bones with significantly different mineralisation levels. Thin slices (0.6 – 1.0 mm thickness) were cut from deer antler, horse metacarpal and whale tympanic bulla and stacked together (4 – 7 layers; 4.1 – 4.7 mm total thickness). A 0.38 mm thin slice of polytetrafluoroethylene (PTFE) served as reference sample and was inserted in between the layers of stacked bone slices. Raman spectra were acquired at 30 s using 830 nm excitation.

A quantitative relation between the SORS offset and the primarily interrogated depth inside the bone was established. Maximum accessible depths at small offset strongly depend on the mineralisation level. Using large spatial offsets of 7 – 9 mm PTFE signal recovery depths of 4.4 – 4.6 mm through cortical bone can be realized with only minor dependence on the bone mineralisation.

These findings highlight the potential of SORS for medical diagnostics by enabling the non-invasive detection of bone conditions characterised by chemical alterations several millimetres inside compact bone tissue (e.g. infections, tumours, etc.).

Introduction

Data on the outcome of THA in patients under the age of 30 years is sparse. There is a perceived reluctance to offer surgery to young patients on the basis of potential early failure of the implant. We aim to review our experience with THA in this group of patients to establish outcomes in a high volume specialist arthroplasty unit.

Background

An extended trochanteric osteotomy (ETO) is a widely used approach for revision hip arthroplasty. Following an ETO it is common practice to use a long stemmed femoral prosthesis at the second stage to bypass the osteotomy. We propose that at the second stage, if the osteotomy has united, it is appropriate to use a standard length prosthesis, which preserves bone stock for any future revisions.

Objectives

T-cells are considered to play an important role in the inflammatory response causing arthroplasty failure. The study objectives were to investigate the composition and distribution of CD4+ T-cell phenotypes in the peripheral blood (PB) and synovial fluid (SF) of patients undergoing revision surgery for failed metal-on-metal (MoM) and metal-on-polyethylene (MoP) hip arthroplasties, and in patients awaiting total hip arthroplasty.

Osteoarthritis (OA) is a common, debilitating joint disease involving degeneration of cartilage and bone. It has been suggested that subtle changes in the molecular structure of subchondral bone may precede cartilaginous changes in the osteoarthritic joint. To explore these changes Raman spectroscopy was employed as a diagnostic tool. Raman spectroscopy measures inelastic scattered laser light produced when photons interact with chemical materials. Resultant changes in wavelength form spectra relative to the chemical composition of the given sample: with bone this includes the mineral and matrix components, unlike conventional X-rays. The aim of our study is to explore the hypothesis: Changes in matrix composition of osteoarthritic subchondral bone can be detected with Raman spectroscopy. pQCT and Raman spectroscopy were employed to determine the bone mineral density (BMD) and bone quality, respectively. Ten medial compartment OA and five control (non-OA) tibial plateaus were interrogated and analysis performed to compare OA to control, and medial to lateral compartments. The subchondral bone of the medial OA compartments had higher BMD (p=0.05) and thickness compared to lateral and control samples. Spectral analysis revealed there is no difference between the medial and lateral compartments within either cohort. However, there is a statistically significant (p=0.02) spectral difference between the OA and control specimens. The detection of bone matrix changes in osteoarthritis using Raman spectroscopy contributes to the understanding of the biochemical signature of subchondral bone across diseased and control tibial plateaus. This technique has potential to shed light on the role of bone in osteoarthritis.

Introduction

MSCs have long promised benefits of synthesising bone/cartilage, treating non-unions and potentially accelerating fracture repair. This potential has been tempered by MSC scarcity in the ‘gold-standard’ iliac crest bone marrow aspirate (ICBMA) and the resulting need to expand numbers via cell-culture. Culture of MSCs is time-consuming, expensive and results in cells with a reduced differentiation capacity.

The reamer-irrigator-aspirator (RIA) is an innovation designed to reduce intra-medullary (IM) pressures during reaming of long-bones via continuous irrigation and suction. Aspirated contents are passed via a coarse filter, which traps bony-fragments before moving into a ‘waste’ bag - from which MSCs have been previously isolated. We examined liquid and solid phases found in this ‘waste’, performed a novel digestion of the solid phase and made a comparative assessment in terms of number, phenotype and differentiation capacity with matched ICBMA.