Introduction and Objective

Osteoarthritis (OA) is the most common inflammatory and degenerative joint disease. Mesenchymal Stromal Cells (MSCs), with their chondro-protective and immune-regulatory properties, have been considered as a new approach to treat OA. Considering the risk of cell leakage outside the articular space and the poor survival rate after intra-articular (IA) injection, we hypothesized that cell encapsulation in cytoprotective hydrogels could overcome these limitations and provide cells with a suitable 3D microenvironment supporting their biological activity. We previously generated micromolded alginate particles (diameter 150 μm) and demonstrated the long-term viability of microencapsulated MSCs isolated from human adipose tissue (hASCs). Encapsulated cells maintained their in vitro ability to sense and respond to a pro-inflammatory environment (IFN-γ/TNF-α or synovial fluids from OA patients) by secreting PGE₂, IDO, HGF and TGF-β. In this study, we evaluated the anti-OA efficacy of these microencapsulated hASCs in a post-traumatic OA model in rabbits.

Virtual Fracture Clinic (VFC) is a consultant-led orthopaedic trauma outpatient triage and management service. The use of VFC has recently become commonplace in the United Kingdom. It allows multiple referral sources to the orthopaedic team, with clinical information and imaging reviewed by a consultant in VFC who formulates an appropriate management plan with the patient contacted; either to attend clinic for consultation or discharged with advice over the phone. The VFC is more efficient than a traditionally delivered outpatient fracture clinic service. We have utilized VFC for 1 year at our hospital, East Kent University Hospital Foundation Trust (EKHUFT), and undertook a closed loop audit to evaluate the service and highlight potential areas of improvement. The Objective of the study was to identify whether the implementation of new re-designed VFC referral guidelines together with teaching set across one of the hospitals in EKHUFT improved the effectiveness and standards of VFC referrals.

An initial audit was performed of all referrals made to VFC over a 2 weeks period in December 2018. Changes to the VFC referral pathway were implemented, and teaching sessions performed by the orthopaedic team to all referring units, including minor injury units (MIU) and the emergency department (ED). After implementation, re-audit of VFC referrals was performed in February 2019 over a similar 2 weeks period. Patient demographics, diagnosis and outcomes were collected from the online patient record with images reviewed using PACS software.

Following intervention, referral rates dropped by 27.7% (136 vs 188 patients) over the 2 weeks periods. Patient demographics, injury type and severity remained the same between the 2 groups. 51.5% (70/136) did not meet VFC pathway criteria after the intervention and were considered inappropriate, compared to 70% in the original group. 15.4% (21/136) referrals could have been managed in the emergency department using the new guidelines and leaflet discharge. 5.1% (7/136) of the referrals should have been referred to orthopaedic on-call acutely and 22% (30/136) of the referrals had a soft tissue injury or no injury identified. This did not change between the 2 groups despite intervention.

Referring MIU and ED units require continued support and teaching over a prolonged time period to hopefully see further improvements. Immediate hot reporting of radiographs may further benefit the service, but staffing and funding issues particularly out of hours, means this remains an aspiration.

Aims

Robotic-assisted total knee arthroplasty (RA-TKA) has been introduced to provide accurate bone cuts and help achieve the target knee alignment, along with symmetric gap balancing. The purpose of this study was to determine if any early clinical benefits could be realized following TKA using robotic-assisted technology.

Summary Statement

Using a weight-bearing force control task, age-related changes in muscle action were observed in osteoarthritic subjects, however, greater activation of rectus femoris and medial hamstring muscles in the OA group compared to control indicates greater cocontraction and varied stabilisation strategies.

We have investigated whether a system of four inertial measurement units (IMUs) attached to the segments of the lower limbs could provide useful information about the kinematics of limb segment movement in gait in a healthy population. Four IMUs were attached to participants over their clothes. Participants then walked at their self-selected speed for 10 metres along a corridor and back. IMUs were removed, data downloaded on to a computer and ranges of motion were calculated for thigh, calf and knee, in addition to stride duration. 128 participants were recruited aged 18–97. There was little variation in most angle parameters up to age of 80. The relationships between angle and age are non-linear. There was a slight increase in stride duration with age of about 0.1% per year. The study concentrated on active subjects, with no specific co-morbidities that might affect gait. Results obtained may represent what is achievable for any given age, and approximate to changes that occur due to primary ageing. We propose that, after the age 80, peak muscle power declines below a threshold, such that muscular activity required to move a limb approaches the peak power available, and that it is the decline in peak muscle power that ultimately limits gait in active older people. Walking ability is important in maintaining independence as people age. It would be more effective to encourage exercises to maintain normal gait at a much earlier age. Deviations from the normal range could be identified early, and appropriate intervention given.

Introduction

The management of chronic wrist pain is a challenging clinical problem. Wrist denervation aims to achieve an improvement in pain through selective neurotomy, irrespective of cause. Numerous authors have reported their experience and demonstrated a range of clinical outcomes. No studies to date have reliably identified patient populations in whom denervation surgery is most likely to succeed. We aimed to establish and investigate a new approach, combining local anaesthetic injections with a uniquely tailored functional assessment by a hand therapist, to act as a tool to identify individuals in whom surgical denervation is more likely to yield benefit.

Introduction

“No routine post-operative follow up appointments” policy has been implemented in NHS hospitals in different specialties for uncomplicated surgical procedures. In trauma and orthopaedics few studies to date reviewed this practice and reflected on the patients' opinions.

Purpose This was an observational study to determine the prevalence of 25-hydroxyvitamin D (25[OH]D deficiency in our paediatric orthopaedic patient population.

Methods We have measured serum 25(OH)D levels in 44 paediatric patients who presented with bone pain. None of these patients had a pre-existing diagnosis of 25(OH)D deficiency. The age of patients ranged from 11 months to 16.5 years. There were 23 female and 21 male patients. The range of diagnoses included hip pain/irritable hip (4), Blount's disease (4), developmental hip dysplasia (7), genu valgum (3), Legg Calve Perthes’ disease (6), slipped capital femoral epiphysis (11), knee pain (3), other (6).

Those found to be 25(OH)D deficient underwent further biochemical investigation and were referred for paediatric endocrinology review with a view to vitamin D supplementation.

Results We found 9 patients (20%) with serum 25(OH)D levels of <20ng/mL indicating 25(OH)D deficiency. 17 patients (39%) had serum 25(OH)D levels in the range 20-30ng/mL indicating possible deficiency. The remaining 18 patients (41%) had a normal level of 25(OH)D. There was no association between low serum 25(OH)D level and any specific diagnosis, nor with gender or age of patient. There was, however, a statistically significant difference between the serum 25(OH)D level in those patients with unexplained joint pain (mean 22.5ng/mL) and those with other diagnoses (mean 30.7ng/ml) (P<0.05).

Conclusion Our results are consistent with other recent prevalence studies showing a concerning level of 25(OH)D deficiency among the paediatric population, and may suggest an increasing burden of disease in the coming years arising from the problem.

Introduction

There are no specific and clear guidelines regarding management of trauma patients who are on Warfarin. The objective of this study was to compare two methods of anticoagulation management in the pre-operative period for this group.

Introduction: The International Knee Documentation Committee (IKDC) recommends use of the IKDC score to document subjective, objective and functional ACL outcome. To further improve knowledge concerning patient QOL after ACL reconstruction, an additional specific QOL questionnaire was developed. Using a combination of univariate and multivariate analysis the patient factors and surgical factors that influenced QOL 5- years after ACL reconstruction were determined.

Materials: 500 patients operated on for arthroscopic ACL reconstruction at our institution between 1997 and 2001 were prospectively enrolled. Patient psychosocial profile, sport expectations, knee exam, type of graft, associated lesion, type of anesthesia, complications, IKDC, KT 2000 at 6 moths, 1 year and 2 years were recorded. At five years, patients were asked to complete a 5-subscale validated QOL questionnaire for ACL deficiency. A multivariate analysis was performed to identify the factors influencing 5-year QOL.

Results: 203 patients completed the 5-years QOL questionnaire. Responders did not statistically differ from non responders. Patient subjective factors such as: patient expectations, pre-operative symptoms, work-school concerns, recreations concerns, social and psycho-social concerns were significantly (p< 0.05) and independently associated with the five-year QOL results. Objective factors such as meniscus tears and results of the KT 2000 (p< 0.05) were the two surgical factors correlated with 5-year QOL.

Discussion: In this large prospective study, most of the factors influencing the 5-year QOL results after ACL reconstruction were related to patient expectations, psycho-social, symptoms and work-sport concerns. The presence of a meniscus tear and greater KT 2000 laxity also contributed to poorer 5-year QOL results.

We aimed to collate guidelines for preoperative marking in orthopaedic surgery, identify areas of convergence and difference and relate them to previous work on guideline effectiveness.

We performed a systematic search of Medline and Google using ‘correct site’, ‘wrong site’, ‘marking’, ‘surgery’, ‘orthopaedics’ and ‘guidelines’. Orthopaedic societies and bodies, personal knowledge and unindexed conference abstracts were also used.

We found nine guidelines from ten institutions in seven different countries; UK National Patient Safety Agency/Royal College of Surgeons of England, Australian College of Surgeons, JCAHO (USA), Canadian Orthopaedic Association, Veterans Health Association (USA), Copenhagen Hospital Corporation, German Coalition for Patient Safety, American Academy of Orthopaedic Surgeons and the New Zealand Orthopaedic Association.

We identified four ‘core-steps’ common to the majority of guidelines. Firstly, using indelible pen. Secondly, the operating surgeon should mark the patient. Thirdly, the patient should be involved in confirming side/site. Finally, a ‘time-out’ before starting the procedure. Only one of the ‘core steps’ is carried out in theatre. The others are carried out before theatre emphasising the importance of accurately identifying and marking early in the patient’s journey.

Common sense suggests guidelines should be simple, user friendly and quick to complete. Making guidelines compatible with existing values and not deviating from existing routines are recognised to increase their use. Guidelines issued by practitioners’ own professional bodies are likely to have more impact than those from outside the profession. However increasing the number of items a guideline contains does not necessarily make it better or safer.

The four core steps we identified are the basis for any marking guideline. It is reasonable to assume that incorporating the guidance into clinical orthopaedic practice will further improve safety. Future work should focus on establishing the relative impact of each guideline aspect.

We report the outcome of 135 knees with medial compartment osteoarthritis treated by Oxford meniscal-bearing unicompartmental arthroplasty. They have been performed in a Distict General hospital by a single surgeon. All the knees had an intact anterior cruciate ligament, a correctable varus deformity and the lateral compartment was uninvolved or had minor osteoarthritic changes. At review 29 knees were in patients who had died and 106 were in those who were still living. The mean elapsed time since operation was 5.82 years (range 2–12 yrs).

Using revision as the end point the outcome for every knee was established. Five knees have been revised, giving a cumulative prosthetic survival rate at ten years of 94.04% (95% confidence interval 84.0 to 97.8). The causes for revision were aseptic loosening in three, progressive valgus deformity in one and dislocation of the bearing in one. Knee rating and patient function were assessed using the modified Knee Society Scoring system. The mean Knee score was 92.2 (51–100), and mean Functional score was 76.2 (51–100). 90% of the patients did not require blood transfusion. Two patients had deep vein thrombosis and three knees had superficial wound infection that responded to antibiotics. Intraoperatively, one patient had fracture of the proximal tibia which was fixed with two partially threaded cancellous screws.

92% of patients were fully satisfied with the procedure and 91% of them said that they would undergo a similar procedure in the opposite knee.

The implant survival is comparable to that reported by the designers of the prosthesis and not significantly different from those for total knee replacement. Uni-compartmental knee replacement with all its advantages offers a viable alternative in patients with medial gonarthrosis. Appropriate patient selection and good surgical technique are the key factors.

Introduction and Aims: It is probable that the success of total knee arthroplasty without patellar resurfacing is influenced by the design of the femoral trochlea. The aim of this study was to compare measures of clinical outcome including gait analysis between total knee arthroplasty with and without patellar resurfacing using a prosthesis compatible with the native patella.

Method: A prospective trial of 78 patients was performed, with 43 total knee arthroplasty randomised to receive patellar resurfacing and 48 to receive patellar retention. The mean duration of follow-up was 3.2 years (range 2.0–4.7 years). Patients were assessed pre- and post-surgery using the Knee Society Clinical Rating System, the Knee Pain Scale, and a Patellar Function Score. A subset of 34 patients also underwent pre- and post-surgery analysis of knee kinematics and kinetics during walking.

Results: At a minimum two-year follow-up, total knee arthroplasty with patellar resurfacing had significantly lower Knee Society knee scores (Mann Whitney U test; p = 0.036). Total knee arthroplasty with patellar resurfacing exhibited a greater degree of knee flexion contracture (Mann-Whitney U test; p = 0.020) and significantly less knee extension at heelstrike during walking in those subjects undergoing gait analysis (Independent t-test; p = 0.013). The presence of a knee flexion contracture was a significant predictor of post-surgery anterior knee pain (Exp β = 4.1, CI: 1.1 to 14.9, p = 0.033). Post-surgery Knee Society function scores and Patellar Function Scores were significantly better in those patients with total knee arthroplasty without patellar resurfacing (Mann-Whitney test; p = 0.031 and 0.017 respectively).

Conclusion: In this study using an anatomically designed femoral component with a domed patellar prosthesis, total knee arthroplasty with patellar resurfacing exhibited inferior clinical results as compared to total knee arthroplasty with patellar retention. Total knee arthroplasty with patellar resurfacing exhibited significant limitation of knee extension, which was significantly associated with the presence of post-surgery anterior knee pain (p = 0.033).

Aims: To determine the optimum hydroxyapatite-coating pattern of the femoral component in cement-less hip arthroplasty. Methods: Between January 1996 and May 1997, the þrst 65 patients (73 hips) of a single center prospective trial were randomised to receive a proximally coated Osteonics or a fully coated JRI Furlong stem. 30 Osteonics and 43 JRI stems were implanted. Clinical assessment was carried out using the modiþed Merle DñAubigne and Postel (MDP) system and the visual analogue scale (VAS). Radiological evaluation included measurement of subsidence, bone resorbtion, pedestal formation and implant-bone interface assessment. All live patients were reviewed. The average follow up was 50.3 months in the JRI group and 51.8 months in the Osteonics group. Results: There was one cup revision in both groups for aseptic loosening and one excision arthroplasty in the JRI group for sepsis. Clinical evaluation revealed an MDP of 16.3 (8–18) and a VAS of 0.55 (0–7) for the JRI group. The MDP for the Osteonics group was 16.31 (8–18) and the VAS 0.62 (0–4). Radiological evaluation revealed resorbtion in zone 7A in 16 of the JRI hips and 5 of the Osteonics. There was a reactive line around the distal part of the Osteonics stem in 17 patients, which was not correlated with symptoms. Conclusion: Both hips performed well. There was no difference in revision rate for loosening (p> 0.84). Clinical evaluation showed no signiþcant difference in outcome (p> 0.83). Radiology revealed different patterns, which did not represent a clinical importance at this stage.

Aims: To evaluate the outcome of 135 Oxford Unicompartmental Knee replacements with regards to knee function and implant survival. Methods: 135 Oxford unicompartmental knee replacements were performed by a single surgeon between 1989–2000. Indication was anteromedial knee osteoarthritis with a correctable varus deformity and intact anterior cruciate ligament. The patients were evaluated in clinic both clinically & radiologically. Modiþed Knee Society Score was used to evaluate knee function. X-rays were performed to look for implant loosening and progression of arthritis. Results: 29 patients died and 5 were too ill to attend clinic. A total of 5 revisions were carried out. There were 53 male and 43 females. 74% patients were betweem 60 Ð 80 yrs. Follow up ranged from 1–11 yrs with a mean follow up of 5.2 yrs. 88% patients had range of movement of more than 105 degrees. The mean Total Knee Score was 92 and the mean functional knee score was 76. Blood transfusion was not necessary in 90% of patients. Superþcial wound infection was noted in 2 cases and hematoma formation in 4 cases. Tibial component loosening was the cause for revision. Conclusions: 1. With appropriate patient selection Oxford unicompartmental knee is a reliable treatment option for anteromedial osteoarthritis of the knee. 2. It offers long term relief of symptoms and good knee function in a high percentage of cases. 3. Implant survival is comparable to total knee replacement and to the series reported by the designers.

Restoration of hand function following division of a flexor tendon remains a significant challenge.

We describe a new method of tendon repair. The first suture is placed in the standard fashion, the second suture is inserted with a round bodied needle to avoid damage to the first repair. This is placed at right angles to the first repair and enters the tendon at the furthest point from the cut tendon end. This suture is then tied with the knot on the surface of the tendon, using 4/0 Ti.cron. The repair is completed with a circumferential continuous epitenon suture, using 6/0 Prolene. This method produces a repair with a four-strand core suture and is referred to throughout this paper as the Evans repair.

Flexor digitorum profundus tendons harvested from pigs were used as the experimental model. They were divided at the mid-point and then repaired using either a ‘modified Kessler’ 4/0 Ethibond core suture, a ‘modified Kessler’ 4/0 Ti.cron core suture or the Evans double core suture. The specimens were then tested to failure on an Instron materials testing machine. This produced a figure for the ultimate tensile strength of each repair.

The average tensile strength for the Ethibond Kessler repair was 33 (range, 27–36) Newtons and that of the Ti.cron Kessler repair was 31 (range 21–43) Newtons. The average tensile strength for the Evans repair was 52 (range 43–60) Newtons, and it is significantly stronger than the two standard Kessler repairs (p< 0.001, Student’s t-test). Even the weakest of the Evans repairs was as strong as the strongest of the standard Kessler repairs.

Increasing emphasis is placed on outcomes research. In this community study knee outcomes scores were evaluated in a ‘normal’ elderly population

The American knee society (AKS), Oxford, and Bristol knee scores were recorded in 100 elderly people without a history of lower limb disorder. The mean age of subjects was 72 years. Mean normalised scores were 90%, 91% and 94% for AKS, Oxford and Bristol knee scores respectively. There were significant negative correlations between knee score and advanced age (p< 0.001) and knee score and co-existent major medical disorders (p< 0.001). The function component was the score component most senitive to these variables (p< 0.001)

Control studies are necessary if knee scores are to be taken as accurate measures of outcome. Comparison of outcome after knee replacement on the basis of knee scores should take account of demographic variables. Scores with a large ‘function’ component appear to be more susceptible to demographic variation.

Aim of the study: To determine the optimum hydroxy-apatite-coating pattern of the femoral component in cementless hip arthroplasty.

Methods: Between January 1996 and May 1997, the first 65 patients (73 hips) of a single center prospective trial were randomised to receive a proximally coated Osteonics or a fully coated JRI Furlong stem. 30 Osteonics and 43 JRI stems were implanted. Clinical assessment was carried out using the modified Merle D’Aubigne and Postel (MDP) scoring system and the visual analogue scale (VAS). Radiological evaluation included measurement of subsidence, bone resorbtion, pedestal formation and implant-bone interface assessment. All live patients were reviewed. The average follow up was 50.3 months in the JRI group and 51.8 months in the Osteonics group.

Results: There were eight intra-operative femoral and one medial acetabullar wall fractures in the JRI group. In the Osteonics group there was one intra operative femoral fracture. There was one cup revision in both groups for aseptic loosening and one excision arthroplasty in the JRI group for sepsis. Clinical evaluation revealed a mean MDP of 16.3 (8–18) and a mean VAS of 0.55 (0–7) for the JRI group. The mean MDP for the Osteonics group was 16.31 (8–18) and the mean VAS 0.62 (0–4). Radiological evaluation revealed resorbtion in zone 7A in 16 of the JRI hips and 5 of the Osteonics. There was a reactive line around the distal part of the Osteonics stem in 17 patients, which was not correlated with symptoms. Subsidence rates were limited and comparable.

Conclusion: Both hips performed well. There was no difference in revision rate for loosening (p> 0.84). Clinical evaluation showed no significant difference in outcome between the prostheses (p> 0.83 for MDP & VAS). Radiology revealed different patterns, which did not represent a clinical importance at this stage.

Aim: To accurately identify the meniscofemoral ligaments in cadaveric human specimens, and to determine anatomical variations in the posterior cruciate ligament that may lead to mis-identification of these structures.

Methods: A total of 79 fresh frozen knees were examined from 45 cadavers Combined anterior and posterior approaches were used to inspect the vicinity of the posterior cruciate ligament (PCL) for the presence of the anterior and posterior meniscofemoral ligaments. The anterior approach utilised a medial parapatellar incision followed by division of the anterior cruciate ligament, whilst a midline posterior arthrotomy was used for the posterior approach. Further dissection facilitated inspection of the meniscal and femoral attachments of the MFLs, and measurement of their lengths. Videos of MFL and PCL motion during passive flexion of the cadaveric were also performed.

Results: In total, 74 (94%) of the 79 specimens contained at least one meniscofemoral ligament. The posterior meniscofemoral ligament (pMFL) was present in 56 (71%) specimens, whilst the anterior meniscofemoral ligament (aMFL) was present in 58 specimens (73%). Both ligaments coexisted in 40 (51%) of knees. In 15 specimens the PCL was seen to have oblique fibres, which attached proximal to the tibial attachment of the main part of the PCL. We termed this “the false pMFL”, as it could be easily mis-identified as the posterior meniscofemoral ligament. Several other anatomical variations were also identified. The mean length of the aMFL was 20.7±3.9mm, whilst that of the pMFL was 23±4.2mm. Although the lengths of the MFLs were relatively constant, there was a wide variation in thickness.

Discussion: This study confirms the high incidence of at least one MFL in humans, which suggests a functional role for these structures. The oblique fibres of the PCL can be readily mis-identfied as the pMFL. These caveats should be borne in mind, during both arthroscopic examination and in the interpretation of magnetic resonance imaging (MRI) scans of the knee. Although some variations of the MFLs have been reported on MRI imaging2, there has been no note of the oblique fibres of the PCL reported in the present study. As this variation was present in almost one in five of our specimens, its appearance on MRI scanning requires investigation.

The function of the meniscofemoral ligaments is undetermined, although many hypotheses comment on a role in guiding the motion of the lateral meniscus during knee flexion. Other possibilities include a function as a secondary restraint supplementing the posterior cruciate ligament.

Purpose of study: Sixty four patellofemoral (PF) arthroplasties in 48 patients were evaluated to assess the effectiveness of this procedure in patients with a preoperative diagnosis of patellofemoral osteoarthritis.

Methods: All patients who underwent patellofemoral arthroplasty for patellofemoral osteoarthritis between 1992 and 1998 in two district general hospitals were studied. Three authors not directly involved in the patients care assessed the patients by:

both a modified Hungerford and Kenna knee rating system and Insall and Crosby grading system, and

Results: Preoperative diagnosis included 53 patients with primary PF arthritis, 1 with post-traumatic arthritis and 1 with PF osteoarthritis secondary to recurrent subluxation. The average patient age at surgery was 73 (range 42–89) and the average length of follow-up was 41 months (range 6–90 months).

Preoperatively 17 knees had undergone arthroscopy. 36 Lubinus, 17 Cartier and 2 PFV prostheses were used. 5 patients died with 8 PF arthroplasties in situ, 1 patient lost to follow up (these patients are not included further in the analysis). 48 Patellofemoral arthroplasty knees were reviewed. 38 knees were classed as good or excellent, 10 had unsatisfactory results, and 7 were revised. 5 implants were revised to TKR and 2 were revised to PF arthroplasty (for maltracking). Subjectively 41 patients felt they were better, 5 unchanged and 2 worse.

Overall we had 69% good or excellent results, 18% poor, and 12% revised. There were no infections, no revision for loosening, and no documented difficulty in revisions. The worst results were obtained in patients with evidence of tiblo-femoral OA preoperatively and in patients with tracking problems.

Conclusion: PF arthroplasty is technically demanding. Nevertheless, providing one adheres to strict patient selection criteria, and the surgery is performed by a dedicated specialist knee surgeon, PF arthroplasty may be used to treat proven isolated patellofemoral arthritis.