The progressive painful and disabling predicament of patients with severe osteoarthritis awaiting a total hip or knee arthroplasty (THA/TKA) results in a decline in muscle mass, strength and function also known as Sarcopenia.

We conducted a cross-sectional, prospective study of patients on the waiting-list for a THA/TKA in the South Australian public healthcare system and compared the findings to healthy participants and patients newly referred from their general practitioners. Participants with a history of joint replacements, pacemakers and cancers were excluded from this study. Outcomes of this study included (i) sarcopenia screening (SARC-F ≥4); (ii) sarcopenia, defined as low muscle strength (hand grip strength M<27kg; F<16kg), low muscle quality (skeletal muscle index M<27%, F<22.1%) and low physical performance (short physical performance battery ≤8). Additional outcomes include descriptions of the recruitment feasibility, randomisation and suitability of the assessment tools.

29 healthy controls were recruited; following screening, 83% (24/29) met the inclusion criteria and 75% (18/24) were assessed. 42 newly referred patients were recruited; following screening, 67% (30/45) met the inclusion criteria and 63% (19/30) were assessed. 68 waiting list patients were recruited; following recruitment, 24% (16/68) met the inclusion criteria and 75% (12/16) were assessed. Preliminary data shows increasing waiting time is associated with higher SARC-F scores, lower hand grip strength and lower muscle quality.

As a pilot study, preliminary data demonstrate that: (1) study subjects’ willingness to participate will enable a larger study to be conducted to establish the prevalence of sarcopenia and the diagnostic cut-off points for this patient group. (2) SARC-F is a suitable tool to screen for sarcopenia. (3) There is a positive correlation between waiting time for a THA/TKA and sarcopenia.

As Total Hip Replacement (THR) rates increase healthcare providers have sought to reduce costs, while at the same time improving patient safety and satisfaction. Up to 50% of patients may be appropriate for Day Case THR, and in appropriately selected patients’ studies show no increase in complication rate while affording a significant cost saving and maintaining a high rate of patient satisfaction.

Despite the potential benefits, levels of adoption of Day Case THR vary. A common cause for this is the perception that doing so would require the adoption of new surgical techniques, implants, or theatre equipment. We report on a Day-Case THR pathway in centres with an established and well-functioning Enhanced Recovery pathway, utilising the posterior approach and standard implants and positioning.

We prospectively collected the data on consecutive THRs performed by a single surgeon between June 2018 and July 2021. A standardised anaesthetic regimen using short acting spinal was used. Surgical data included approach, implants, operative time, and estimated blood loss. Outcome data included time of discharge from hospital, post operative complications, readmissions, and unscheduled health service attendance.

Data was gathered on 120 consecutive DCTHRs in 114 patients. 93% of patients were successfully discharged on the day of surgery. Four patients required re-admission: one infection treated with DAIR, one dislocation, one wound ooze admitted for a day of monitoring, one gastric ulcer. One patient had a short ED attendance for hypertension.

Our incidence of infection, dislocation and wound problems were similar to those seen in inpatient THR. Out data show that the widely used posterior approach using standard positioning and implants can be used effectively in a Day Case THR pathway, with no increase in failure of same-day discharge or re-admission to hospital.

Recently, several smartphone applications (apps) have been developed and validated for ankle ROM measurement tools like the universal goniometer. This is the first innovative study introduces a new smartphone application to measure ankle joint ROM as a remote solution. This study aimed to assess the correlation between smartphone ROM and universal goniometer measurements, and also report the evaluation of the DijiA app by users.

The study included 22 healthy university students (14F/8M; 20.68±1.72 years) admitted to Yeditepe University. Fourty four feet was measured by both the universal goniometer (UG) and DijiA app. The datas were analyzed through using the intraclass correlation coefficient (ICC). The DijiA app was evaluated by usability testing with representative users.

Pearson correlation coefficient test showed moderate correlation between the DijiA and UG for dorsiflexion (DF) and plantar flexion (PF) measurements (Pearson correlation coefficient: r=0.323, for DF; r=0.435 for PF 95% confidence interval). The application usability was found as high with 76.5 average score and users liked it.

The DijiA app may be a more convenient and easy way to measure ankle DF and PF-ROM than UG. It can be used to evaluate ROM in clinical practice or home using as a personal smartphone.

Abstract

Abstract

Abstract

C. Difficile infections in elderly patients with hip fractures is associated with high morbidity and mortality. Antibiotic regimens with penicillin and its derivatives is a leading cause. Antibiotic prophylactic preferences vary across different hospitals within NHS. We compared two antibiotic prophylactic regimens - Cefuroxime only prophylaxis and Teicoplanin with Gentamicin prophylaxis in fracture neck of femur surgery, and evaluated the incidence of C. Difficile diarrhea and Surgical Site Infection (SSI).

To assess the Surgical Site Infection and C. Difficile infection rate associated with different regimens of antibiotics prophylaxis in fracture neck of femur surgery.

Data was analyzed retrospectively. Neck of femur fracture patients treated surgically from 2009 in our unit were included. Age, gender, co morbidities, type of fracture, operation, ASA grade was collected. 1242 patients received Cefuroxime only prophylaxis between January 2009 and December 2012 (Group 1) and 486 patients received Teicoplanin with Gentamicin between October 2015 and March 2017 (Group 2). There were 353 males and 889 female patients in Group 1 and 138 males and 348 female patients in Group 2. The co morbidities in both groups were comparable. Incidence of C. Difficile diarrhea and Surgical Site Infection (SSI) was noted. Statistical analysis with chi square test was performed to determine the ‘p’ value.

C. Diff diarrhea rate in Group 2 was 0.41 % as compared to 1.29 % in Group 1. The Surgical Site Infection (SSI) rate in Group 2 was 0.41 % as compared to 3.06 % in Group 1. The comparative results were statistically significant (p = 0.0009).

Prophylactic antibiotic regimen of Teicoplanin with Gentamicin showed significant reduction in C. Difficile diarrhea & Surgical Site Infection in fracture neck of femur patients undergoing surgery.

Cannulated hip screws are frequently used in the management of hip fractures. There have been concerns over the failure rate of the technique and the outcomes of those that subsequently require conversion to total hip replacement (THR).

This study utilised a database of over 600 cannulated hip screw (CHS) fixations performed over a 14-year period and followed up for a minimum of one year (1-14). We identified 57 cases where a conversion to THR took place (40 females, 17 males, mean age: 71.2 years). Patient demographics, original mechanism of injury, fracture classification, reason for fixation failure, time until arthroplasty, implant type and post-arthroplasty complications were recorded. Clinical outcomes were measured using the Oxford Hip Score.

The failure rate of cannulated screw treatment was 9.4% and the mean time from initial fixation to arthroplasty was 15.4 (16.5) months. Thirty six fractures were initially undisplaced and 21 were displaced. As one might expect the displaced cases tended to be younger but this didn't reach statistical significance [66.5(14.3) vs 72.7(13.1), p=0.1]. The commonest causes of failure were non-union (25 cases, 44%) and avascular necrosis (17 cases, 30%). Complications after THR consisted of one leg length discrepancy and one peri-prosthetic fracture. The mean Oxford score pre-arthroplasty was 12.2 (8.4), improving to 38.4 (11.1) at one-year. Although the pre op Oxford scores tended to be lower in patients with undisplaced fractures and higher ASA scores, the improvement was the same whatever the pre-op situation. The one-year Oxford score and the improvement in score are comparable to those seen in the literature for THR in general.

In conclusion, CHS has a high success rate and where salvage arthroplasty is required it can provide good clinical outcomes with low complication rates.

Abstract

Total hip replacement (THR) is indicated for patients with osteoarthritis where conservative treatment has failed. Metal alloys used in THR implants such as cobalt-chromium (CoCr) have been known to cause pro-inflammatory reactions in patients, therefore leading to the need for costly revision surgery. This study therefore aimed to investigate the role of TLR4 in the activation of a human osteoblast model in response to CoCr particles in vitro.

Human osteoblasts (MG-63 cell line) were seeded at a density of 100,000 cells and treated with 0.5, 5, 50mm3 CoCr particles per cell for 24-hours. Trypan blue and the XTT Cell Proliferation Kit II were then used in conjunction with the cells to assess CoCr-induced cytotoxicity. Cells were pre-treated with a commercially available TLR4-specific small molecule inhibitor (CLI-095) for 6 hours. Untreated cells were used as a negative control and lipopolysaccharide (LPS) was used as a positive control. Following treatment the cell supernatant was collected and used for enzyme-linked immunosorbant assay (ELISA) to measure the secretion of interleukin-8 (IL-8), CXCL10, and interleukin-6 (IL-6).

Trypan blue and XTT analysis showed that there was no significant changes to cell viability or proliferation at any dose used of CoCr after 24 hours. There was a significant increase in protein secretion of IL-8 (p<0.001), CXCL10 (p<0.001), and IL-6 (p<0.001) in the cells which received the highest dosage of CoCr. This pro-inflammatory secretory response was ameliorated by TLR4 blockade (p<0.001).

CoCr particles are not cytotoxic to osteoblasts but they do induce pro-inflammatory changes as characterised by increased secretion of chemokines IL-8, CXCL10, and IL-6. These responses occur via a TLR4-mediated pathway and upon inhibition they can be effectively ameliorated. This is particularly important as TLR4 could be a potential target for pharmacological intervention used in patients experiencing immunological reactions to metal implant debris.

Plantar fasciitis (PF) is one of the widespread conditions causing hindfoot pain. The most common presenting symptoms are functional limitation and pain (first step and activity) on plantar surface of the foot. The non-operative treatments provide complete resolution of pain in 90% of patients, but functional limitation still remains as a risk factor for recurrency of PF. Although the number of non-operative treatment options showing efficacy on pain and functional limitation are excessive, the evidences are limited for functional limitation. Additionally, Mulligan mobilization with movement (MMWM) in Chronic Plantar Fasciitis has been poorly studied in the literature. According to these findings, the study was aimed to determine effectiveness of Mulligan mobilization with movement on Chronic Plantar Fasciitis.

A total of 25 patients (40 feet) with chronic PF were included in the study. The patients were randomly divided into Mulligan concept rehabilitation group (PF-M, n=20 feet) and Home Rehabilitation group (PF-H, n=20 feet). (MMWM), Foot and ankle exercises program were applied to PF-M, twice a week totally 8 week (16 sessions) and foot- ankle exercises as a home program were given for PF-H, 8 weeks. The range of motion (ROM) for dorsiflexion and plantar flexion was measured by using a manual goniometer. Pain, disability and activity restriction were assessed by Foot Function Index (FFI) . The first step morning pain was evaluated by Visual Analogue Scale (VAS) and Kinesiophobia was also reported by using Tampa Scale (TSK). Patients were evaluated at baseline and 8 weeks.

FFI, VAS, TSK, ROM values improved in all groups (intragroup variability) at 8th week (P < .05). The other result indicated that ROM values for DF and PF and TSK scores in PF-M had more significant improvement than PF-H (p<.05).

To the best of our knowledge this is the first randomised controlled trial for investigating Mulligan Concept efficiancy on chronic PF. Both Mulligan mobilization with movement (MMWM) and exercise protocols are effective for chronic PF. Furthermore, The Mulligan concept seems more effective treatment option in reducing kinesiophobia and improving functional capacity.

Background

Low back pain (LBP) is a major problem across the globe and is the leading cause worldwide of years lost to disability. Self-management is considered an important component the treatment of people with non-specific LBP. However, it seems that the self-management support for people with non-specific LBP provided by physiotherapists can be improved. Moreover, the way exercise therapists (ET) address self-management in practice is unknown.

Femoral stem design affects periprosthetic bone mineral density (BMD), which may impact long term survival of cementless implants in total hip arthroplasty (THA). The aim of this study was to examine proximal femoral BMD in three morphologically different uncemented femoral stems designs to investigate whether one particular design resulted in improved preservation of BMDMethods: 119 patients were randomised to receive either a proximally coated dual taper wedge stem, a proximally coated anatomic stem or a fully coated collarless triple tapered stem. All surgeries were performed via the posterior approach with mobilization on the day of surgery. Dual energy x-ray absorptiometry scans (Lunar iDXA, GE Healthcare, Madison, WI) assessed BMD across the seven Gruen zones pre-operatively, and post-operatively at 6-weeks, 1-year, and 2-years and compared to the unoperated contralateral femur as a control. Patient reported outcome measures of pain, function and health were also included at these corresponding follow-ups.

BMD increased in zones one (2.5%), two (17.1%), three (13.0%), five (10%) and six (17.9%) for all stems. Greater preservation of BMD was measured on the lateral cortex (zone 2) for both the dual taper wedge and anatomic stems (p = 0.019). The dual taper wedge stem also demonstrated preservation of BMD in the medial calcar (zone 7) whilst the anatomic and triple taper stem declined in this region, however this was not statistically significant (p = 0.059). BMD decreased on average by 2.1% inthe mid-diaphysis region, distal to the stem tip (zone 4) for all implants. All stems performed equivalently at final follow-up in all patient reported outcome measures.

This study demonstrated maintenance of femoral BMD in three different cementless femoral stem designs, with all achieving excellent improvements in patient reported outcomes. There was no significant stress shielding observed, however longer follow-up is required to elucidate the impact of this finding on implant survivorship.

Aim

To determine mortality and outcomes of patients diagnosed with fracture-related infections (FRIs).

The purpose of this study was to develop a quality appraisal tool for the assessment of laboratory basic science biomechanical studies.

Materials andScore development comprised of the following phases: item identification/development, item reduction, content/face/criterion validity, weighting, test-retest reliability and internal consistency. For item identification/development, the panel was asked to independently list criteria and factors they considered important for cadaver study and generate items that should be used to appraise cadaver study quality. For content validity, the content validity ratio (CVR) was calculated. The minimum accepted content validity index (CVI) was set to 0.85. For weighting, equal weight for each item was 6.7% [15 items]. Based on these figures the panel was asked to either upscale or downscale the weight for each item ensuring that the final sum for all items was 100%. Face validity was assessed by each panel member using a Likert scale from 1–7. Strong face validity was defined as a mean score of >5. Test-retest reliability was assessed using 10 randomly selected studies. Criterion validity was assessed using the QUACS scale as standard. Internal consistency was assessed using Cronbach's alpha.

Five items reached a CVI of 1 and 10 items a CVI of 0.875. For weighting five items reached a final weight of 10% and ten items 5%. The mean score for face validity was 5.6. Test-retest reliability ranged from 0.78–1.00 with 9 items reaching a perfect score. Criterion validity was 0.76 and considered to be strong. Cronbach's alpha was calculated to be 0.71 indicating acceptable internal consistency.

The new proposed quality score for basic science studies consists of 15 items and has been shown to be reliable, valid and of acceptable internal consistency. It is suggested that this score should be utilised when assessing basic science studies.

This study aimed to examine the changing trends in the reasons for total hip replacement (THR) revision surgery, in one country over a twenty-one year period, in order to assess whether changes in arthroplasty practices have impacted revision patterns and whether an awareness of these changes can be used to guide clinical practice and reduce future revision rates.

The reason for revision THR performed between January 1999 and December 2019 was extracted from the New Zealand Joint Registry (NZJR). The results were then grouped into seven 3-year periods to allow for clearer visualization of trends. The reasons were compared across the seven time periods and trends in prosthesis use, patient age, gender, BMI and ASA grade were also reviewed. We compared the reasons for early revision, within one year, with the overall revision rates.

There were 20,740 revision THR registered of which 7665 were revisions of hips with the index procedure registered during the 21 year period. There has been a statistically significant increase in both femoral fracture (4.1 – 14.9%, p<0.001) and pain (8.1 – 14.9%, p<0.001) as a reason for hip revision. While dislocation has significantly decreased from 57.6% to 17.1% (p<0.001). Deep infection decreased over the first 15 years but has subsequently seen further increases over the last 6 years. Conversely both femoral and acetabular loosening increased over the first 12 years but have subsequently decreased over the last 9 years. The rate of early revisions rose from 0.86% to 1.30% of all revision procedures, with a significant rise in revision for deep infection (13-33% of all causes, p<0.001) and femoral fracture (4-18%, p<0.001), whereas revision for dislocation decreased (59-30%, p<0.001). Adjusting for age and gender femoral fracture and deep infection rates remained significant for both (p<0.05). Adjusting for age, gender and ASA was only significant for infection.

The most troubling finding was the increased rate of deep infection in revision THR, with no obvious linked pattern, whereas, the reduction in revision for dislocation, aseptic femoral and acetabular loosening can be linked to the changing patterns of the use of larger femoral heads and improved bearing surfaces.

Abstract

Fractures of the ankle are common, and they mostly affect young adults. Wound complications are not uncommon following the fixation of these fractures. This study evaluated the impact of HIV on wound healing after plate osteosynthesis in patients with closed ankle fractures.

This is an observational retrospective study of patients operated on at a tertiary level hospital. We reviewed hospital records for patients above 18 years of age who presented with wound breakdown following ankle open reduction and internal fixation. The patients’ hospital records were retrieved to identify all the patients treated for closed ankle fractures and those who developed wound breakdown. Patients with Pilon fractures were excluded. The National Health Laboratory System (NHLS) database was accessed to retrieve the CD4 count, viral load, haematology study results, and biochemistry results of these patients at the time of surgery and subsequent follow-up. The x-rays were retrieved from the electronic picture archiving system (PACS) and were assessed for fracture union at a minimum of 3 months follow-up.

We reviewed the medical records of 172 patients with closed ankle fractures treated from 2018 to 2022. Thirty-one (18.0%) developed wound breakdown after surgery, and they were all tested for HIV. Most of the patients were male (58.0%), and the average age of the cohort was 43.7 years (range: 21 years to 84 years). Ten of these patients (32.2%) were confirmed HIV positive, with CD4 counts ranging from 155 to 781. Viral load levels were lower than detectable in 40% of these patients. All patients progressed to fracture union at a minimum of 3 months follow-up.

We observed no difference between HIV-positive and HIV-negative patients in terms of wound breakdown and bone healing post-plate osteosynthesis for closed ankle fractures.

To investigate whether anterior pelvic plane-pelvic tilt (APP-PT) is associated with distinct hip pathomorphologies, we asked: (1) Is there a difference in APP-PT between symptomatic young patients eligible for joint preservation surgery and an asymptomatic control group? (2) Does APP-PT vary between distinct acetabular and femoral pathomorphologies? (3) Does APP-PT differ in symptomatic hips based on demographic factors?

IRB-approved, single-center, retrospective, case-control, comparative study in 388 symptomatic hips (357) patients (mean age 26 ± 2 years [range 23 to 29], 50% females) that presented to our tertiary center for joint preservation over a five year-period. Patients were allocated to 12 different morphologic subgroups. The overall study group was compared to a control group of 20 asymptomatic hips (20 patients). APP-PT was assessed in all patients based on AP pelvis X-rays using the validated HipRecon software. Values between overall and control group were compared using an independent samples t-test. Multiple regression analysis was performed to examine the influences of diagnoses and demographic factors on APP-PT. Minimal clinically important difference (MCID) of APP-PT was defined as >1 standard deviation.

No significant differences in APP-PT between the control group and overall group (1.1 ± 3.0° [−4.9 to 5.9] vs 1.8 ± 3.4° [−6.9 to 13.2], p = 0.323) were observed. Acetabular retroversion and overcoverage groups showed higher APP-PT compared to the control group (both p < 0.05) and were the only diagnoses with significant influence on APP-PT in the stepwise multiple regression analysis. However, all observed differences were below the MCID. Demographic factors age, gender, height, weight and BMI showed no influence on APP-PT.

APP-PT across different hip pathomorphologies showed no clinically significant variation. It does not appear to be a relevant contributing factor in the evaluation of young patients eligible for hip preservation surgery.

To quantify the acetabular coverage of the femoral head, Lequesne's vertical-center-anterior edge (VCA) angle is used on the false profile view. Lateral coverage is determined by Wiberg's lateral-center-edge (LCE) angle on an ap pelvic view. The delimitation of the weightbearing area is defined by the end of the subchondral sclerosis line for both views. To our knowledge the exact anatomic location of the points used for measurement on the acetabular rim are not known.

Six hips from three cadaver pelvises (3 male and 3 female) were investigated. The anterior and lateral points of interested were identified radiographically using fluoroscopy and marked with 1mm ceramic bullets. Standard false profile views and ap pelvic views in neutral inclination and rotation were taken to check the correct location of the ceramic bullets. A CT of each pelvis was made to locate the ceramic bullets and to define the exact anatomic location of the measurement points on the o'clock position. 6 o‘clock was defined as the midpoint between anteroinferior and the posteroinferior rim edges. Values were normalized for a right hip.

The mean clockface location for the VCA was 1:33 (range, 1:15 to 1:40) and for the LCE 0:38 (range, 0:20 to 0:50).

The LCEA is slightly anterior to the 12 o'clock position and remains useful to quantify the lateral coverage. Surprisingly, the point used for measuring the VCA is only about 30° (1h) anterior of the point used for measuring the LCEA. Its value for determining anterior cover has to be questioned. The discrepancy to other studies in the literature is because this study identifies and measures the end of the weight bearing zone, and not the border of the bony acetabulum.