Introduction

Achilles tendinopathy (AT) is a highly prevalent injury in athletes and non-athletes with an unknown aetiology. Genetic risk factors have been a recent focus of investigation. The aim of this systematic review was to determine which loci have been linked with mid-portion AT and could potentially be used as biomarkers in tendinopathy risk models or as preventative or therapeutic targets.

Successful treatment of periprosthetic joint infection involves surgical intervention and identification of infecting organisms to enable targeted antibiotic therapy. Current guidelines recommend intra-operative culture sampling to include at least 4 tissue samples and for each sample to be taken with a separate instrument.

We aimed to review current revision arthroplasty practice for Greater Glasgow, specifically comparing intra-operative sampling technique for infected revision cases with these guidelines.

We reviewed the clinical notes of all patients undergoing lower limb revision arthroplasty procedures in Greater Glasgow Hospitals (WIG, GRI, SGH) from July 2013 to August 2014. Demographics of all cases were collected. For revision procedures performed for infection we recorded details of intraoperative samples taken (number, type and sampling technique) and time for samples to reach the laboratory. Results of microbiology cultures were reviewed.

Two hundred and fifty five revision arthroplasty procedures (152 hips, 103 knees) were performed in the 12 month study period. Of these 57 (22%) were infected cases (28 hips, 29 knees). These cases were treated by 14 arthroplasty surgeons with a median number of 3 infected cases managed per surgeon (range 1–11). 58% of cases had the recommended number of tissue samples taken. The median number of microbiology samples collected was 4 (range 1–14). Most procedures (91%) had no documentation of whether separate instruments were used for sampling. Number of tissue samples taken (≥4, p=0.01), time to lab (<24 hours, p=0.03) were significantly associated with positive culture results.

In Greater Glasgow, a large number of surgeons manage infected arthroplasty cases with variability in intra-operative sampling techniques. Sample collection adheres to guideline recommendations in 58% cases. Adhering to guideline standards increases the likelihood of positive tissue cultures. Implementation of a standardised approach to intra-operative sampling for infected cases may improve patient management.

Summary

This study shows a significant reduction in knee adduction moment in patients with medial compartment osteoarthritis, in both the symptomatic and asymptomatic knees. Long-term follow-up studies are required to confirm the effect of treating the asymptomatic side on disease progression.

Summary Statement

This study provides preliminary evidence that people with knee osteoarthritis have greater asymmetry in joint loading than healthy controls. Altered loading of the contralateral limb may signify increased risk of injury to other lower limb joints in knee osteoarthritis.

Summary

The dGEMRIC index correlates more strongly with the pattern of radiographic joint space narrowing in hip osteoarthritis at five year follow-up than morphological measurements of the proximal femur. It therefore offers potential to refine predictive models of hip osteoarthritis progression.

Summary

162 patient cohort with serial Metal Artefact Reduction Sequence MRI scans. Patients with normal initial scans can be followed up at 1 year. Those with abnormal scans should be followed up at a shorter interval of 6 months.

Summary Statement

We have shown that integrin mRNA expression is regulated by the application of mechanical load. This indicates that mechanical loading may modify cell sensitivity to perceive further load through increased interaction with the ECM.

The number of primary Total Knee Arthroplasty (TKA) and primary Total Hip Arthroplasty (THA) procedures carried out in England and Wales is increasing annually. The British Orthopaedic Association guidelines for follow up currently differ for patients with TKA and THA. In THA the BOA recommends that Orthopaedic Data Evaluation Panel (ODEP) 10A rated implants should be followed up in the first year, once at seven years and three yearly thereafter. The BOA guidelines for TKA minimum requirement is radiographs at 5 years and each five years thereafter. Few studies have investigated if early follow up affects patient management following total hip and knee arthroplasty

We carried out a retrospective review of all revision procedures carried out in our institution between April 2010 to April 2013. The medical notes and radiographs for each patient were examined to determine the operative indications and patients symptoms. 92 knee revisions and 143 hip revisions were identified. Additionally we retrospectively reviewed the outcome of 300 one year routine arthroplasty follow up appointments.

The mean time of hip revision was 8.5years (range 0 to 27years) and 5.6years (range 0 to 20years) for knee revisions. The commonest cause for revision was aseptic loosening associated with pain in 49 (53%) of knee revision patients and 89 (63%) of hip revisions. Infection accounted for 26 (28%) knee revisions and 16 (12%) hip revisions. Only 1% of hip and knee revisions was carried out in asymptomatic patients with aseptic loosening.

We did not identify any cases were a patients management was altered at the routine arthroplasty review clinic and none were referred on for further surgical treatment. The findings of our study suggest there is no evidence for a routine one year arthroplasty review and revisions were carried out in asymptomatic patients in 1% of patients.

Introduction:

When having to remove broken or embedded metal implants using high speed burrs, the consequence is often a significant amount of metal debris which becomes embedded in the soft tissues. This may then act as a source for a foreign body inflammatory reaction or as a third body wear in the situation of joint arthroplasty. We describe a simple, cheap and effective method of reducing this debris using only a sterile water-based lubricating gel.

Decreased oxygenation and delayed wound healing may negate the advantages of using a medial parapatellar incision in Total Knee Replacement. Tissue biochemical and blood flow data are not currently available in the literature.

20 patients were included in the study and randomised to midline or medial parapatellar skin incision groups, being supervised by one of 3 Consultant surgeons. Cutaneous blood flow was measured using a Speckle Contrast Blood Perfusion Imager at pre-operative and Days 1 & 3 post-operative intervals. Interstitial fluid measurements for lactate, pyruvate, lactate/pyruvate ratio and glucose were obtained from subcutaneous catheters with a dialysis membrane. Pre-operative samples were obtained from a catheter inserted into the prospective lateral wound edge. A catheter inserted after wound closure supplied dialysates at 0.5, 1, 2, 4, 6, 12 and 24-hour intervals. One catheter was corrupted on insertion; therefore the patients with biochemical data numbered 19.

Cutaneous blood flow improved over the 3 post-operative days in both types of incision and both sides, the medial retaining comparatively better flow. At Day 3, the parapatellar incision group displayed better flow on both sides of the wound. The concentration of lactate was highest in the parapatellar incision group of patients at all intervals. Pyruvate concentrations did not appear to differ across the incision types. Similarly, glucose concentrations did not appear to differ until after 4 hours, when higher concentrations were recorded in the midline group. Lactate/pyruvate ratio appeared to be notably greater in the parapatellar incision group. Plotting change in blood flow relative to change in lactate concentration demonstrated an increase in lactate as flow deteriorates.

The study findings suggest medial parapatellar incisions have increased anaerobic metabolites due to tissue hypoperfusion. Previous studies have demonstrated decreased oxygen tension in lateral based flaps and more recently the medial to lateral arterial anatomy has been demonstrated.

The link between squeaking and ceramic on ceramic (CoC) bearings has been widely reported in orthopaedic literature and is described as a hard bearing phenomenon. We aim to look at the incidence of noise in CoC bearings compared to Metal on Polyethylene (MoP) bearing, which have yet to be linked to squeaking.

We developed a noise characterizing hip questionnaire and sent that along with the Oxford Hip Score (OHS) to 1000 patients; 3:2 ratio of CoC to MoP. 282 CoC patients and 227 MoP patients returned the questions: 509 patients in total. Our patient database provided details on femoral head size and the acetabular inclination angle, for each respondent

47 (17%) of the CoC hip patients reported noise compared to 19 (8%) of the MoP hip patients (P=0.054). 9 CoC patients and 4 MoP patients reported squeaking, while clicking was the most frequent answer in both groups. 27% patients with noise reported avoiding recreational activities because of it. Patient's with noisy hips scored on average, 5 points worse in the OHS (CoC: P = 0.04 and MoP: P = 0.007) and were on average 5 years younger (CoC: P<0.001 and MoP: P=0.007). No correlation was found between noisy hips and femoral head size or inclination angle.

The squeaking hip phenomenon is not exclusive to hard bearing THA. Noise from patient's hips may have social implications and this should be highlighted when consenting a patient for either of these hip procedures. In both implants, we showed there to be a correlation between noise production and a lower OHS. However, longer follow up studies are needed to link noise to a poorly functioning implant

Many orthopaedic procedures require implants to be trialled before definitive implantation. Where this is required, the trials are provided in a set with the instrumentation. The most common scenario this is seen in during elective joint replacements. In Scotland (2007) the Scottish Executive (http://www.sehd.scot.nhs.uk/cmo/CMO(2006)13.pdf) recommended and implemented individually packed orthopaedic implants for all orthopaedic sets. The premise for this was to reduce the risk of CJD contamination and fatigue of implants due to constant reprocessing from corrosion. During many trauma procedures determining the correct length of plate or size of implant can be challenging. Trials of trauma implants is no longer common place. Many implants are stored in closed and sealed boxes, preventing the surgeon looking at the implant prior to opening and contaminating the device. As a result many implants are incorrectly opened and either need reprocessed or destroyed due to infection control policy, thus implicating a cost to the NHS. With even the simplest implants costing several hundreds of pounds, this cost is a very significant waste in resources that could be deployed else where. My project was to develop a method to produce in department accurate, cheap and disposable trials for implants often used in trauma, where the original manufacturer do not offer the option of a trial off the shelf. The process had to not involve contaminating or destroying the original implant in the production of a trial.

Several implants which are commonly used within Glasgow Royal Infirmary and do not have trials were identified. These implants were then CT scanned within their sealed and sterile packaging without contamination. Digital 3D surface renders of the models were created using free open source software (OsiriX, MeshLab, NetFabb). These models were then processed in to a suitable format for 3D printing using laser sintering via a cloud 3D printing bureau (Shapeways.com). The implants were produced in polyamide PA220 material or in 316L stainless steel. These materials could be serialized using gamma irradiation or ethylene oxide gas. The steel models were suitable for autoclaving in the local CSSU.

The implants produced were accurate facsimiles of the original implant with dimensions within 0.7mm. The implants were cost effective, an example being a rim mesh was reproduced in polyamide PA220 plastic for £3.50 and in 316L stainless steel for £15. The models were produced within 10 days of scanning. The stainless steel trials were durable and suitable for reprocessing and resterilisation.

The production of durable, low cost and functional implant trials all completed in department was successful. The cost of production of each implant is so low that it would be offset if just one incorrect implant was opened during a single procedure. With some of the implants tested, the trials would have paid for themselves 100 times. This is a simple and cost saving technique that would help reduce department funding and aid patient care.

Arthritis of the glenohumeral joint accompanied by an irreparable tear of the rotator cuff can cause severe pain, disability and loss of function, particularly in the elderly population. Anatomical shoulder arthroplasty requires a functioning rotator cuff, however, reverse shoulder arthroplasty is capable of addressing both rotator cuff disorders and glenohumeral deficiencies. The Aequalis Reversed Shoulder Prosthesis design is based on two bio-mechanical principles by Grammont; a medialized center of rotation located inside the glenoid bone surface and second, a 155 degree angle of inclination. Combined, they increase the deltoid lever arm by distalizing the humerus and make the prosthesis inherently stable.

24 consecutive primary reverse total shoulder arthroplasties were performed by a single surgeon for arthritis with rotator cuff compromise and 1 as a revision for a failed primary total shoulder replacement between December 2009 and October 2012. Patients were assessed postoperatively with the use of the DASH score, Oxford shoulder score, range of shoulder motion and plain radiography with Sirveaux score for scapular notching.

Mean age at the time of surgery was 72.5 years (range 59 to 86). Average follow up time was 19.4 months (range 4 to 38). Functional outcome scores from our series were comparable with patients from other follow up studies of similar prosthesis design. All patients showed improvement in range of shoulder movement postoperatively. Complications included one dislocation, one acromion fracture and one humeral shaft fracture. No cases of deep infection were recorded. Overall, the short-term clinical results were promising for this series of patients and indicate reverse shoulder arthroplasty as an appropriate treatment for this group of patients.

The purpose of this study was to evaluate the effect of body mass index (BMI) on patients undergoing primary total knee arthroplasty for osteoarthritis. Data was collected on 664 patients at 4 centres all of whom received a Depuy PFC Sigma prosthesis. Data collected included patient demographics, Oxford Knee Score (OKS), American Knee Society Score, SF-12, complications of surgery and the need for revision.

14% of patients had a BMI<25, 35% were overweight (BMI-25–30), 32% suffered from Grade 1 obesity (BMI-30–35) and 19% had grade 2 obesity (BMI>35). Obese patients were more likely to be female, have a higher ASA grade, present at a younger age and do sedentary work or no work at all. Pre-operative Oxford knee score was significantly worse in the BMI>35 group (p<0.001).

After surgery there was a significant improvement in functional outcome measures at 5 years post-operatively with all BMI groups improved by an average of 18 or 19 points in the OKS. However because those patients with high BMI have poorer pre-operative Oxford scores their post-operative scores were lower compared to patients with a normal BMI. Similar findings were noted with range of motion of the knee joint.

Overall complication rates were found to be significantly higher in obese patients and both revision surgery and deep infection rates increased stepwise with increasing BMI levels.

Deep Infection rates were as follows: BMI<25 0%, BMI-25–30 1.3%, BMI-30–35 1.4%, BMI-35–40 3.2% and BMI>40 6.1%.

Revision rates were as follows: BMI<25 0%, BMI-25–30 0.9%, BMI-30–35 0.9%, BMI-35–40 3.2% and BMI>40 6.1%.

Although obese patients with knee osteoarthritis do benefit from joint arthroplasty, they suffer from an increased rate of complications and need for revision surgery.

We compared the postoperative wound discharge rates and 3 months clinical results of three types of wound closure and dressing – 2-octylcyanoacrylate with Opstie (G+O), 2-octylcyanoacrylate with Tegaderm (G+T), and Opsite without 2-octylcyanoacrylate (O) in patients having primary total hip arthroplasty.

We randomised 141 patients scheduled for primary total hip arthroplasty into 3 arms of this study- G+O, G+T, or O. The extent of wound discharge was recorded on a diagrammatic representation of the dressing in situ on paper and graded each day. Dressings were left in-situ provided the extent of wound discharge allowed for this. The patient was clinically reviewed at 3 months to assess their scar length, cosmesis, scar discomfort, and evidence of superficial or deep wound sepsis.

A greater number of patients dressings remained dry on day 1 postoperatively in the two groups with 2-octylcyanoacrylate compared to the no glue group p=0.001. G+T group had a significantly lower proportion of patients with increased leakage of wounds on 2^nd postoperative day p=0.044. At 3 months review, there was no statistical difference in the Hollander score or scar discomfort.

In patients who have had primary total hip arthroplasty, usage of 2-octylcyanoacrylate for wound closure along with Tegaderm dressing reduces wound discharge. The same effect is not noted in glue with Opsite group. Whilst dressing changes required in the non-glue group compared from the two glue groups did not reach statistical significance, this may have clinical relevance for patients and nursing staff. No effect on postoperative length of stay, or wound complications was noted.

In 2012 collagenase Clostridium histolyticum (Xiapex) was approved by the SMC for restricted use for the treatment of Dupuytren's contracture. Xiapex was approved on a case by case basis for patients with a palpable pretendinous cord, giving rise to MCPJ contracture of greater than 30 degrees. As of September 2012 we began to offer Xiapex injections to patients in Ayrshire who enquired about the injection, and met the SMC criteria.

To date injections have been performed on 3 patients, in a total of 7 digits. Patients were assessed prior to injection and manipulation, with the degree of contracture recorded and DASH scores noted. Each patient then underwent a standard injection of 0.58 mg of Xiapex. 48 hours post injection each patient underwent manipulation under local anaesthetic, with contractures remeasured, pain scored using a visual analogue scale and complications noted. Each patient was then reviewed at 4 weeks post injection where the residual degree of contracture was recorded and a further DASH score completed.

Mean contracture at the MCPJ prior to injection was 57° (range 34–80), and mean DASH score of 20.8 (range 16.7–24.2). Following manipulation mean residual contracture at the MCPJ measured 21° (range 18–28). The average pain score following was manipulation was rated at 1.1. Mild bruising and swelling were reported in all cases following injection, and manipulation resulted in 2 minor skin tears. At the 4 week review prolonged improvement of contracture was achieved with a mean residual contracture of 14° (range −2–40); with a significant improvement in DASH scores – mean 0.6 (range 0–1.8)

Despite small numbers, we have found Xiapex injections to be a successful and well tolerated treatment for moderate Dupuytren's disease. Further follow up is required to assess the longevity of the correction and ensure the cost effectiveness of Xiapex.

The aim of this study was to characterise noise associated with ceramic-on-ceramic total hip arthroplasty (THA).

A questionnaire was constructed to assess noise associated with THA. 116 patients responded. All had ceramic-on-ceramic hybrid THA at Glasgow Royal Infirmary between 2005 and 2007 using a Trident prosthesis and Exeter stem. Oxford Hip Questionnaires (OHS) were also completed by the patients.

16.4% of respondents reported noise associated with their ceramic hip. The vast majority reported onset at least 1 year after implantation. The most common noise types were ‘clicking’ (47%) or ‘grinding’ (42%), while ‘squeaking’ was least frequently reported (11%). Noise was most commonly brought on by bending and during sit to stand movements.

No correlation was identified between the incidence of noise and any patient specific factor or demographic variable. The mean OHS at questionnaire follow-up was 39 and there was no significant difference in OHS when comparing noisy and silent hips (p=0.65). Only 1 patient limited social or recreational activities and overall patients felt the noise had minimal effect on their quality of life.

Acetabular component inclination angles were compared on post-operative x-rays. There was no significant difference (p=0.51) in inclination angles of the noisy (47.1°±6.3°, range 30–57°) and silent hips (47.8°±6.1°, range 35–68°). The groups were further analysed for deviation out with the desirable inclination range of 40–45°. Of the noisy hips, a total of 73% were out with this range compared to 63% in the silent hip group.

The incidence of noise within this ceramic-on-ceramic THA group did not appear to be related to patient specific factors, patient reported outcome (OHS) or acetabular inclination angles. Subjective appraisal of the noise revealed that ‘squeaking’ was not common but patients tended to report ‘clicking’ and ‘grinding’ more. The precipitation of noise with bending activities reinforces a possible mechanical cause.

To validate the Modified Forgotten Joint Score (MFJS) as a new patient-reported outcome measure (PROM) in hip and knee arthroplasty against the UK's gold standard Oxford Hip and Knee Scores (OHS/OKS).

The original Forgotten Joint Score was created by Behrend et al to assess post-op hip/knee arthroplasty patients. It is a new assessment tool devised to provide a greater discriminatory power, particularly in the well performing patients. It measures an appealing concept; the ability of a patient to forget about their artificial joint in everyday life. The original FJS was a 12-item questionnaire, which we have modified to 10-items to improve reliability and missing data.

Postal questionnaires were sent out to 400 total hip/knee replacement (THR/TKR) patients who were 1–2 years post-op, along with the OHS/OKS and a visual pain analog score. The data collected from the 212 returned questionnaires (53% return rate) was analysed in relation to construct and content validity. A sub-cohort of 77 patients took part in a test-retest repeatability study to assess reliability of the MFJS.

The MFJS proved to have an increased discriminatory power in high-performing patients in comparison to the OHS and OKS, highlighted by its more normal frequency of distribution and reduced ceiling effects in the MFJS. 30.8% of patients (n=131) scored 42–48 (equivalent to 87.5–100 in the MFJS) or more in the OKS compared to just 7.69% in the MFJS TKR patients. The MFJS proved to have an increased test-retest repeatability based upon its intra-class correlation coefficient of 0.968 compared to the Oxford's 0.845.

The MFJS provides a more sensitive tool in the assessment of well performing hip and knee arthroplasties in comparison to the OHS/OKS. The MFJS tests the concept of awareness of a prosthetic joint, rather than pain and function and therefore should be used as adjunct to the OKS/OHS.

Femoroacetabular impingement (FAI) is a significant cause of osteoarthritis in young active individuals but the pathophysiology remains unclear. Increasing mechanistic studies point toward an inflammatory component in OA. This study aimed to characterise inflammatory cell subtypes in FAI by exploring the phenotype and quantification of inflammatory cells in FAI versus OA samples.

Ten samples of labrum were obtained from patients with FAI (confirmed pathology) during open osteochondroplasty or hip arthroscopy. Control samples of labrum were collected from five patients with osteoarthritis undergoing total hip arthroplasty. Labral biopsies were evaluated immunohistochemically by quantifying the presence of macrophages (CD68 and CD202), T cells (CD3), mast cells (mast cell tryptase) and vascular endothelium (CD34).

Labral biopsies obtained from patients with FAI exhibited significantly greater macrophage, mast cell and vascular endothelium expression compared to control samples. The most significant difference was noted in macrophage expression (p<0.01). Further sub typing of macrophages in FAI using CD202 tissue marker revealed and M2 phenotype suggesting that these cells are involved in a regenerate versus a degenerate process. There was a modest but significant correlation between mast cells and CD34 expression (r=0.4, p<0.05) in FAI samples.

We provide evidence for an inflammatory cell infiltrate in femoroacetabular impingement. In particular, we demonstrate significant infiltration of mast cells and macrophages suggesting a role for innate immune pathways in the events that mediate hip impingement. Further mechanistic studies to evaluate the net contribution and hence therapeutic utility of these cellular lineages and their downstream processes may reveal novel therapeutic approaches to the management of early hip impingement.

A retrospective analysis was carried out to determine the influence of pre-existing spinal pathology on the outcome of Total Knee Replacement surgery. Data was collected from 345 patients who had undergone Total Knee Replacement, at four centres in the UK, between 2000 and 2007. Oxford Knee Scores (OKS), American Knee Society Scores (AKSS) and SF-12 questionnaires were recorded prospectively. Data was collected pre-operatively and then post-operatively at 3 months, 1 year and 2 years. Patients were divided into those with (n=40) and without a history of low back pain (n=305). In addition to determining the influence of low back pain on outcome after Total Knee Replacement we also examined the influence of concomitant hip and ankle pathology in the same cohort of patients.

OKS scores were significantly worse for patients with symptomatic low back pain at 3 (p=0.05), 12 (p=0.009) and 24 months (p=0.039) following surgery. SF-12 physical scores followed a comparable pattern with significance demonstrated at 3 (p=0.038), 12 (p=0.0002) and 24 months (p=0.016). AKSS followed a similar pattern, but significance was only reached at 1 year (p=0.013). The mental component of the SF-12 measure demonstrated a significant improvement in patients' mental health post-operatively for patients with no history of low back pain. In contrast patients with low back pain showed no improvement in mental health scores post-operatively.

In contrast to low back pain, hip and ankle pathology had no statistically significant detrimental effect on the outcome of Total Knee Replacement surgery.

This study demonstrates that low back pain significantly affects the functional outcome after Total Knee Replacement surgery and that patients with low back pain show no improvement in mental health post-operatively.