Aims

The management of fractures of the medial epicondyle is one of the greatest controversies in paediatric fracture care, with uncertainty concerning the need for surgery. The British Society of Children’s Orthopaedic Surgery prioritized this as their most important research question in paediatric trauma. This is the protocol for a randomized controlled, multicentre, prospective superiority trial of operative fixation versus nonoperative treatment for displaced medial epicondyle fractures: the Surgery or Cast of the EpicoNdyle in Children’s Elbows (SCIENCE) trial.

Abstract. Introduction. Secondary osteonecrosis of the knee affects young population and causes bilateral extensive lesions. Arthroplasty is the last resort in younger population and joint preserving options questionable in pathological bone. Conservative measures have shown failure in multiple studies and hence no gold standard treatment advocated. We aimed at identifying and analysing various treatment options for secondary osteonecrosis with respect to the outcomes and studying features of symptomatic secondary osteonecrosis with regards to demographic pattern, radiological features and causative factors. Methods. A systematic review of literature was performed in accordance with the Cochrane handbook for systematic reviews and reported according to the PRISMA guidelines. Results. Six studies which included a total of 192 patients with data on 240 knee joints were included in the final review. Follow up period ranged from 1 year to 16 years. The mean age of the patients was 34.7. 3 studies were on arthroplasty and 3 on joint preserving interventions. Majority of patients were in Stage 2 or Stage 4 of osteonecrosis. Steroid induced osteonecrosis was the majority followed by SLE and sickle cell disease. The pooled analysis showed an improvement of pre-operative knee score from 50.47 to 89.21 post-operatively. The pooled effect size for failure rate was 8.7% in joint preserving interventions and 9.2% in joint replacement group. Conclusion. Joint preserving techniques with bone marrow aspirate infiltration showed promising functional outcome and to a certain extent reversal of the pathological process. For advanced stages with subchondral collapse cemented arthroplasty showed satisfactory functional outcomes

Aims

Registry studies on modified acetabular polyethylene (PE) liner designs are limited. We investigated the influence of standard and modified PE acetabular liner designs on the revision rate for mechanical complications in primary cementless total hip arthroplasty (THA).

Symptomatic and non-symptomatic hip osteonecrosis related to sickle cell disease (SCD) has a high risk of progression to collapse and total hip arthroplasty (THA) in this disease has a high rate of complications. We asked question about the benefit of performing an IRM to detect and treat with cell therapy an early (stage I or II) contralateral osteonecrosis. 430 consecutive SCD adult (32 years, 18 to 51) patients (225 males) with bilateral osteonecrosis (diagnosed with MRI) were included in this study from 1990 to 2010. One side with collapse was treated with THA and the contralateral without collapse (stage I or II) treated with cell therapy. The volume of osteonecrosis was measured with MRI. For cell therapy, the average total number of mesenchymal stem cells (MSCs) counted as number of colony forming units-fibroblast injected in each hip was 160,000 ± 45,000 cells (range 75,000 to 210,000 cells). At the most recent FU (20 years, range 10 to 30), among the 430 hips treated with cell therapy, 45 hips (10.5%) had collapsed and had required THA at 10 years (range 5 to 14 years) and 380 hips (88%) were without collapse and asymptomatic (or with few symptoms) with a decrease percentage of necrosis on MRI from 45% to 11%. Among the 430 contralateral THA, 96 (22.3%) had required one revision, 28 had a re-revision, and 12 a third re-revision with aseptic loosening (85% of revisions) and/or infection (6% of revisions). Hips undergoing cell therapy were approximately three times less likely to undergo revision or re-revision surgery (p < 0.01) as compared with hips undergoing a primary THA. THA is the usual treatment of collapsed ON in patients with SCD. In this population, it is worth looking with MRI for an early stage on the contralateral hip and performing (when necessary) bone marrow cell implantation during the same anesthesia as for arthroplasty

Aims

To investigate whether idiopathic osteonecrosis of the femoral head (ONFH) is related to impaired osteoblast activities.

Aims

Displaced distal radius fractures were investigated at a level 1 major trauma centre during the COVID-19 2020 lockdown due to the implementation of temporary changes in practice. The primary aim was to establish if follow-up at one week in place of the 72-hour British Orthopaedic Association Standards for Trauma & Orthopaedics (BOAST) guidance was safe following manipulation under anaesthetic. A parallel adaptation during lockdown was the non-expectation of Bier’s block. The secondary aim was to compare clinical outcomes with respect to block type.

Hypoxic Inducible Factor and Hypoxic mimicking agents (HMA) trigger the initiation and promotion of angiogenic-osteogenic cascade events. However, there has been paucity of studies investigating how HIF could be over expressed under chronic hypoxic conditions akin to that seen in sickle cell disease patients to help form a template for tackling the matter of macrocellular avascular necrosis. Angiogenesis and osteogenesis are tightly coupled during bone development and regeneration, and the hypoxia-inducible factor-1 alpha (HIF-1) pathway has been identified as a key component in this process studies have shown. There are still no established experimental models showing how this knowledge can be used for the evaluation of bone implant integration and suggest ways of improving osseointegration in sickle cell disease patients with hip arthroplasty and thereby prevent increased implant loosening. The aim of this study is to help develop an in vitro experimental model which would mimic the in vivo pathologic state in the bone marrow of sickle cell disease patients. It also seeks to establish if the hypoxic inducible factor (HIF) could be over expressed in vitro and thus enhancing osseointegration. MG63 osteoblastic cells were cultured under normoxia and hypoxic conditions (20%; and 1% oxygen saturation) for 48 and 72 hours. Cobalt chloride was introduced to the samples in order to mimic true hypoxia. Cells cultured under normoxic conditions and without cobalt chloride was used as the control in this study. The expression of the hypoxic inducible factor was assessed using the reverse transcriptase qualitative polymerase chain reaction (RT-qPCR). There was increased expression of HIF1-alpha at 72hours as compared to 48hours under the various conditions. The level of expression of HIF increased from 48hrs (mean rank= 4.60) to 72hrs (mean rank =5.60) but this difference was not statistically significant, X2(1) = 0.24, p =0.625. The mean rank fold change of HIF in hypoxic samples decreased compared to the normoxic samples but this difference was not statistically significant, X2(1) = 0.54, p= 0.462. Therefore, the expression of HIF is only increased with prolonged hypoxia as seen in the 72hours samples. The expression of HIF increased in samples with CoCl2 (mean rank=5.17), compared with samples without CoCl2 (mean rank 4.67), however this was not statistically significant, X2(1) = 0.067, p=0.796, p value > 0.05. The over expression of HIF was achieved within a few days (72hours) with the introduction of Cobalt Chloride, which is a mimetic for hypoxia similar to the in vivo environment in sickle cell disease patients. This is an in vitro model which could help investigate osseointergation in such pathologic bone conditions

Aims

Recent improvements in surgical technique and perioperative blood management after total joint replacement (TJR) have decreased rates of transfusion. However, as many surgeons transition to outpatient TJR, obtaining routine postoperative blood tests becomes more challenging. Therefore, we sought to determine if a preoperative outpatient assessment tool that stratifies patients based on numerous medical comorbidities could predict who required postoperative haemoglobin (Hb) measurement.

Aims

Despite advances in the treatment of paediatric hip disease, adolescent and young adult patients can develop early onset end-stage osteoarthritis. The aims of this study were to address the indications and medium-term outcomes for total hip arthroplasty (THA) with ceramic bearings for teenage patients.

Osteoporosis (OP) is a chronic metabolic bone disease characterized by the decrease of bone tissue per unit volume under the combined action of genetic and environmental factors, which leads to the decrease of bone strength, makes the bone brittle, and raises the possibility of bone fracture. However, the exact mechanism that determines the progression of OP remains to be underlined. There are hundreds of trillions of symbiotic bacteria living in the human gut, which have a mutually beneficial symbiotic relationship with the human body that helps to maintain human health. With the development of modern high-throughput sequencing (HTS) platforms, there has been growing evidence that the gut microbiome may play an important role in the programming of bone metabolism. In the present review, we discuss the potential mechanisms of the gut microbiome in the development of OP, such as alterations of bone metabolism, bone mineral absorption, and immune regulation. The potential of gut microbiome-targeted strategies in the prevention and treatment of OP was also evaluated.

Cite this article: Bone Joint Res 2020;9(8):524–530.

Aims

As the peak of the COVID-19 pandemic passes, the challenge shifts to safe resumption of routine medical services, including elective orthopaedic surgery. Protocols including pre-operative self-isolation, COVID-19 testing, and surgery at a non-COVID-19 site have been developed to minimize risk of transmission. Despite this, it is likely that many patients will want to delay surgery for fear of contracting COVID-19. The aim of this study is to identify the number of patients who still want to proceed with planned elective orthopaedic surgery in this current environment.

Aims. Sickle cell disease (SCD) is an autosomal recessive inherited condition that presents with a number of clinical manifestations that include musculoskeletal manifestations (MM). MM may present differently in different individuals and settings and the predictors are not well known. Herein, we aimed at determining the predictors of MM in patients with SCD at the University Teaching Hospital, Lusaka, Zambia. Methods. An unmatched case-control study was conducted between January and May 2019 in children below the age of 16 years. In all, 57 cases and 114 controls were obtained by systematic sampling method. A structured questionnaire was used to collect data. The different MM were identified, staged, and classified according to the Standard Orthopaedic Classification Systems using radiological and laboratory investigations. The data was entered in Epidata version 3.1 and exported to STATA 15 for analysis. Multiple logistic regression was used to determine predictors and predictive margins were used to determine the probability of MM. Results. The cases were older median age 9.5 (interquartile range (IQR) 7 to 12) years compared to controls 7 (IQR 4 to 11) years; p = 0.003. After multivariate logistic regression, increase in age (adjusted odds ratio (AOR) = 1.2, 95% confidence interval (CI) 1.04 to 1.45; p = 0.043), increase in the frequency of vaso-occlusive crisis (VOC) (AOR = 1.3, 95% CI 1.09 to 1.52; p = 0.009) and increase in percentage of haemoglobin S (HbS) (AOR = 1.18, 95% CI 1.09 to 1.29; p < 0.001) were significant predictors of MM. Predictive margins showed that for a 16-year-old the average probability of having MM would be 51 percentage points higher than that of a two-year-old. Conclusion. Increase in age, frequency of VOC, and an increase in the percentage of HbS were significant predictors of MM. These predictors maybe useful to clinicians in determining children who are at risk. Cite this article: Bone Joint Open 2020;1-6:175–181

Aims

The Precice intramedullary limb-lengthening system has demonstrated significant benefits over external fixation lengthening methods, leading to a paradigm shift in limb lengthening. This study compares outcomes following antegrade and retrograde femoral lengthening in both adolescent and adult patients.

Aims

The purpose of this study was to examine whether leg-length discrepancy (LLD) following unilateral total hip arthroplasty (THA) affects the incidence of contralateral head collapse and subsequent THA in patients with bilateral osteonecrosis, and to determine factors associated with subsequent collapse.

It is well documented that implant loosening rate in sickle cell disease patients is higher than that seen in patients with hip arthroplasty from other indications. The Hypoxic inducible factor(HIF) - is activated in the microcellular hypoxic environment and this through a cascade of other enzymatic reactions promotes the activity of other factors and further help enhance angiogenesis and osteogenesis. The aim of this study was to investigate and propose a potential model for investigating osseointegration in a hypoxic microcellular environment using osteoblasts(MG63). Human MG63 osteoblastic cells were cultured under normoxia and hypoxic conditions (20%; and 1% oxygen saturation) for 72 hours under two different condition- with and without cobalt chloride. The samples cultured under normoxic condtions without cobalt chloride acted as control. Using qualitative polymerase chain reaction-(qPCR) - HIF expression was assessed under the above conditions in relation to the control. The results showed there was significant expression of the HIF 1 alpha protein under hypoxic condition with cobalt chloride in comparison with the control samples- all at 72hours incubation. Mann-Whitney U test was used to deduce level of significance of fold change.(p=0.002; <0.05). This was deemed as being a significant difference in the level of expression of HIF compared to the control. The results show that the hypoxic inducible factor can be expressed using the above tested. experimental invitro-model with significant results which can be a foundation for further research into improving hip implant prosthesis design to help enhance osseo-integration in sickle cell disease patient with AVN

We questioned about bearing surface and infection in two populations of patients who had bilateral THA with different bearings performed in the same hospital by the same surgical team from the year 1981 to the year 2010 (mean followup 15 years; 7 to 35). 1) first population (mean age 32 years): 325 patients (650 hips) with sickle cell disease (SCD) with two different bearing on each side. 116 patients had Metal on PE (MoP) on one side and Ceramic on PE (CoP) on the contralateral; 106 patients had (CoP) and Ceramic on Ceramic (CoC); 103 patients had MoP and CoC. 2) matched control population (same age, same period) of 820 patients without co-morbidities: 354 patients had MoP and CoP; 237 had CoP and CoC; 229 had MoP and CoC. Among the 2290 hips, 3 early (less than 12 months) unilateral infections (2 in the controls, 1 in the SCD), and 59 late unilateral infections: 23 (1.4%) in 1640 THAs control, versus 36 (5.5%) in the SCD 650 THAs (P < 0.0001) during the observation period of 35 years. In control group with the Kaplan-Meier analysis, increase infections over time but different (p=0.02) for each bearing surfaces, respectively from 0% at one year to 0.4% revision (2 cases) at most recent follow-up for 466 CoC hips, from 0% to 1.1% (7 cases) for 591 CoP hips, and from 0.3% to 2.4% (14 cases) for 583 MoP hips. In sickle cell disease group MoP hips had higher risk of infection (26 among 219) when compared with CoP (9 among 222; p=0.002), and CoC (1 among 209 hips; p=0.0004); with increase over time from 1% at one year to 4% with CoP, and from 1% to 11.8% with MoP. When contralateral hip of same patient is control, PE components are more prone to infection than those involving ceramic-on-ceramic

Successful nonarthroplasty solutions for the treatment of osteonecrosis of the femoral head continued to be sought. However, no definitive nonarthroplasty solutions have to date been found. Hence, even in the best of hands a large number of patients with osteonecrosis end up with debilitating end-stage osteoarthritis. In the inception of total hip arthroplasty (THA), the results of treatment of femoral head osteonecrosis by THA were inferior to total hip replacement performed for osteoarthritis. Reasons for this included the young age of many osteonecrosis patients, the high numbers of comorbidities in this population (SLE, sickle cell anemia, alcoholism), and the poor bone quality at the time of surgery. Arthroplasty considerations included bipolar replacement, hemiresurfacing, resurfacing (non metal-on-metal and later metal-on-metal), cemented total hip arthroplasty and cementless total hip arthroplasty. Previous to the use of cementless arthroplasty, all of these procedures had a relatively high 5 to 10 year failure rate of 10–50%. Even our own 10-year results using contemporary cementing techniques demonstrated 10% failure compared to 1–2% failure in our nonosteonecrosis patients. For this reason, it made sense to continue exploring nonarthroplasty solutions for osteonecrosis of the hip. The introduction of cementless fixation for total hip arthroplasty changed the entire thinking about hip osteonecrosis treatment for many of us. Although initially we were concerned about whether bone would grow into the prosthesis in the environment of relatively poor bone, the early results demonstrated that it can and does. Most recently, with the use of crosslinked polyethylene, the cementless construct gives many of us hope that with cementless fixation, the treatment of many patients including the young (especially if followed closely to exchange bearing surfaces if necessary) will last a lifetime with THA being the only and definitive procedure. Our most recent 10-year results demonstrated a femoral stem revision rate of 1.5% will all other stems (other than the stem revised) bone ingrown. Acetabular fixation was also 100% and although 6% required liner exchange, our own and others' results with crosslinked polyethylene would suggest that this problem should be markedly reduced