self complete proforma video recording.
ii) A check-list of treatment modalities was constructed from this proforma. Twelve sessions were recorded on video (one new and one review patient for each therapist). The recordings were rated by 3 blinded, independent observers using the checklist. These were compared with the self-report audit forms relating to the same physiotherapy session.
In shallow or deficient sockets, we describe a simple technique by 180° rotation of the Cormet 2000 metal-on-metal resurfacing pegged acetabular prosthesis. This works by utilising ischio-pubic splines for superolateral socket engagement. We have used this technique in three patients with successful outcome avoiding the need of structural graft augmentation. In one patient, this technique was supplemented with cadaveric allograft.
The intended early contact (within first week) of workers absent with musculoskeletal disorders only occurred at one experimental site; the control sites had no procedure for early contact. Absence rates improved over the four years at the intervention sites compared with the control sites: a decrease of 2.0 v an increase of 0.9 days/1000 working hours. The median return-to-work time for early intervention compared with controls was 4 days v 5 days (P=NS). Considering return-to-work time irrespective of whether the intervention was delivered early or late, the median durations were also 4 days v 5 days (P<
0.05). When looking at work retention over 12 months, the median duration of subsequent absence for early intervention was 5 days compared with 11 days for controls (P=NS). For the larger number of workers receiving a late intervention, the median duration of subsequent absence was median 4 days v 11 days for controls (P<
0.05).
Previously defined cut-off scores were used to categorise hypothesised risk; scores beyond the cut-off point were considered detrimental, and the ‘flag’ was considered to be ‘flying’. Odds ratios (OR) were calculated to explore the association between the flags and taking sick leave; a statistically significant association was found with ORs between 1.5 and 2.9. The cut-off scores were then used to compare the length of absence between workers who had zero flags flying and those who had one or more flags flying. Absence over the ensuing 15 months was significantly longer for those people who had one or more flags flying (mean 10.6 days compared with 6.1 days, P<
0.05). There was a trend for longer absence with more flags flying.
Recently there has been considerable interest in the role of inflammatory mediator production by herniated degenerate discs. Modic has described MR endplate changes which have an inflammatory appearance and have been linked with discogenic back pain. To date there has been no biomechanical investigation of discs with associated Modic changes. The aim of this study is to determine if degenerate discs with associated Modic changes have higher levels of pro-inflammatory mediator production than those without Modic changes. Intervertebral disc tissue was obtained from 52 patients undergoing spinal surgery for sciatica [40] and discogram proven discogenic low back pain [12]. The tissue was cultured and the medium analysed for interleukin-6, interleukin-8 and prostaglandin E2 using an enzyme linked immunoabsorbetn assay method. Preoperative MR images of the patients were examined by a double blinded radiologist to determine the Modic status of the cultured disc level. Forty percent of patients undergoing surgery for discogenic low back pain had a Modic 1 change compared to only 12.5% of patients undergoing surgery for sciatica [p<
.05] There was a statistically significant difference between levels of IL-6, IL-8 and PGE2 production by both the Modic1 [M1] and Modic2 [M2] groups compared to the Modic negative [NEG] group. IL-6:NEGvM1 p<
.001, NEG v M2 p<
.05, IL-8: NEG v M1 p<
.01, NEG v M2 p>
.05, PGE2: NEG v M1 p<
01, NEG v M2 p<
.05. Modic changes have been associated with positive provocative discography by a number of authors. Pain generation requires the presence of nerves and hyperalgsia inducing mediators. Both IL-8 and PGE2 are known to induce hyperalgesia. The fact that Modic changes are associated with high levels of production of these mediators supports their role as an objective marker of discogenic low back pain.
Data = mean ± standard deviation. Statistical analysis was by students t test. A significant result between control and stimulated groups is indicated by: * p=0.024m, † p=0.0007 or ‡ p=0.012. Methylprednisolone (2mg/ml) caused a significant (p=0.044) 30-fold reduction in IL-6 production and a significant (p=0.00004) 500-fold reduction in IL-8 levels as compared with nucleus pulposus cultured with 5 μg/ml LPS alone for 24 hours. Addition of 500 μM indomethacin significantly (p=0.04) decreased IL-6 production by a factor of 120 and IL-8 levels by a factor of 50 (p=0.00004). Necrotic cell death, as measured by lactate dehydrogenase (LDH) concentration, was not significant in any of the experiments.
Degenerate disc disease is a major cause of low back pain, yet its aetiology is still poorly understood. The intervertebral disc is the largest avascular structure in the body. Cells of the nucleus pulposus, therefore, rely on diffusion of oxygen &
nutrients down concentration gradients from peripheral vessels in the cartilage end-plates. Thus, there is a low oxygen tension and cellular respiration is largely anaerobic. The purpose of this study was to examine the effects of inflammation, hypoxia and acidosis on degeneration and pro-inflammatory mediator production in virgin porcine nucleus pulposus cultures. Intervertebral discs were harvested from normal 6-month old agricultural pigs slaughtered for other purposes. Nucleus pulposus was contained within the annulus until further dissection under sterile conditions in the laboratory was performed. Nucleus pulposus was harvested, diced and divided into 200mg samples. Samples were incubated under optimal conditions. Discs were cultured in 5μg/ml E. coli lipopolysaccharide, in a hypoxic environment or at low pH. IL-6, IL-8 and LDH assays were performed by ELISA, in accordance with manufacturer’s instructions. Time and dose-response curves were generated for each experiment (results not shown). Results at 72 hours incubation are tabulated below: These results confirm that nucleus pulposus is a biochemically active tissue capable of producing pro-inflammatory mediators in response to environmental stresses. IL-6 and IL-8 are both involved in the inflammatory cascade, causing chemotaxis of neutrophils and macrophages to the area. IL-8 itself causes hyperalgesia. Acidotic and inflammatory conditions, but not hypoxia, stimulated cytokine release. This may indicate a protective reduction in cellular activity in reduced oxygen environments. Necrosis, as measured by LDH production, was negligible.
This basic science study attempts to explain why patients with spinal cord injuries have been seen to display increased healing of attendant fractures. For the main part, this has been a clinical observation with laboratory work confined to rats. While the benefits in relation to quicker fracture healing are obvious, this excessive bone growth (heterotopic ossification) also causes unwanted side effects, such as decreased movement around joints, joint fusion and renal tract calculi. However, the cause for this phenomenon remains unclear. This paper evaluates two group with spinal column fractures – those with neurological compromise (n=10) and those without (n=11), and compares them with a control group with isolated long bone fractures (n=10). Serum was taken from these patients at five specific time intervals post injury (24hrs, 120hrs, 10 days, 6 weeks and 12 weeks). The time period most closely related to the end of the acute inflammatory reaction and the laying down of callus was the 10-day post injury time period. Serum samples taken at this time period were analysed for IGF-1 and TGF-ß levels, both known to initiate osteoblastic activity, using ELISA kits. They were also exposed to an osteoblast cell culture line and cell proliferation was measured. Results show that the group with neurology has increased levels of IGF-1 compared to the other groups (p<
0.14, p<
0.18 respectively, Student’s t-test) but had lower TGF-ß (p<
0.05, p<
0.006) and osteoblast proliferation levels (p<
0.002, p<
0.0001). When the neurology group is subdivided into complete (n=5) and incomplete (n=5), it was shown that the complete group had higher levels of both IGF-1 and TGF-ß. This trend is reversed in the osteoblast proliferation assay. This work, for the first time in human subjects, identifies a factor which may be regulating this complication of acute spinal cord injuries, namely IGF-1. Furthermore, the observed trend in the two cytokines seen in the complete neurology group may suggest a role for TGF-ß. However, the results do show that a direct mediation of this unwanted side effect of spinal cord injuries is unlikely as seen in the proliferation assay. Further work remains to be done to fully understand the complexities of the excessive bone growth recognised in this patient group.
The role of nucleus pulposus (NP) biology in the genesis of sciatica is being increasingly investigated. The aim of this study was to examine the ability of control and degenerate human nucleus pulposus to respond to an exogenous pro-inflammatory stimulus. Control disc material was obtained from surgical procedures for scoliosis and degenerate disc tissue from surgical procedures for sciatica and low back pain. Disc specimens were cultured using a serumless technique under basal and lipopolysaccharride (LPS) stimulated conditions and the media harvested, aliquoted and stored at –80°C for subsequent analysis. Levels of IL-1β,TNFα, LTB4, GM-CSF, IL-6, IL-8, MCP-1, PGE2, bFGF and TGFβ-1 in the media were estimated using commercially available enzyme linked immunoabsorbent assay kits. Neither basal nor LPS stimulated control or degenerate NP produced detectable levels of IL-1β, TNFα, LTB4 or GM-CSF. Control disc IL-8 secretion increased significantly with LPS stimulation, p<
.018. Degenerate disc IL-6, IL-8 and PGE2 production increased significantly with LPS stimulation, p<
.01, p<
.001 and p<
.005 respectively. LPS stimulated degenerate NP secreted significantly more IL-6, IL-8 and PGE2 than LPS stimulated control NP, p <
0.05, 0.02 and 0.003 respectively. LPS induces an increase in both control and degenerate NP mediator production demonstrating the ability of human NP to react to a noxious stimulus by producing pro-inflammatory mediators. The difference in levels of basal and LPS stimulated mediator production between control and degenerate discs show that as a disc degenerates it increases both its level of inflammatory mediator production and its ability to react to a pro-inflammatory stimulus. The increased sensitivity of degenerating human NP to noxious stimuli and increased ability to respond with inflammatory mediator production support the role of NP as an active participant in the genesis of lumbar radiculopathy and discogenic back pain.
Total knee arthroplasty has evolved considerably over the last thirty years. Early implant design achieved the short-term goals of pain relief and mobility, however loosening and polyethylene wear associated with over constraint was problematic. The Low Contact Stress total knee arthroplasty was developed in an attempt to address the problems of loosening and polyethylene wear. The highly congruent interface between the femoral component and the mobile insert minimises stress within the polyethylene and reduces the potential of wear and damage. Furthermore, the mobile bearing phenomenon minimises both torsional and shear stresses at the component bone interface. In our unit the impact of choice is the LCS rotating platform prosthesis, which is inserted with cruciate-sacrifice. We reviewed 219 patients (272 knees) with an average follow-up of 6 years (5–8 years). In almost all cases the components were inserted with cement fixation. The patella was primarily resurfaced in 20 patients (21 knees). All operations were performed or supervised by the senior author. Female to male ratio was 2:1. Average age at surgery was 68 years (40–86) with osteoarthritis being the commonest primary diagnosis (89%). Postoperative range of motion ranges from 30–130° (average 103°). Average Oxford Knee, American Knee Society Score and Patellar Score was 19 (12–53), 160 (42–199) and 25 (4–30) respectively. Six patients (1.7%) required MUA at six weeks. Two patients (0.6%) required secondary patellar resurfacing. Three patients (0.8%) had revision of their components for persistent pain. At operation all components were noted to be well fixed. Spinout of the rotating platform occurred in one patient (0.3%). This was treated by exchange of the insert. In conclusion, our early results of the LCS rotating platform prosthesis are encouraging with no cases of component loosening to date. This supports the continued use of the implant.
Dupuytren’s contracture is characterised by abnormal fibroblast proliferation and extracellular matrix deposition in the palmar fascia. Fibroblast proliferation and matrix deposition in connective tissues are regulated by cytokines. A number of cytokines including transforming growth factor beta (TGFβ), basic fibroblast growth factor (bFGF), platelet derived growth factor (PDGF) and epidermal growth factor (EGF) are known to have potent anabolic effects on connective tissue. The aim of this study was to investigate the role played by anabolic cytokines in the pathogenesis of Dupuytren’s disease. Twelve specimens of Dupuytren’s contracture and six control specimens of palmar fascia obtained from patients undergoing carpal tunnel release were cultured using a serumless method under standard conditions for 72 h. Levels of TGFβ-1, bFGF, PDGF and EGF in the medium were estimated using an enzyme linked immunoabsorbent assay technique. Neither Dupuytren’s tissue nor control palmar fascia produced any EGF. The mean (±S.D.)levels of bFGF, PDGF and TGFβ-1 produced by cultured palmar fascia were: 1270 ± 832, 74 ± 24, <
7, and for Dupuytren’s tissue were 722 ± 237, 139 ± 76.6, 645 ± 332, respectively. The levels of PDGF and TGFβ-1 were significantly higher in Dupuytren’s tissue. PDGF is produced in increased amounts by Dupuytren’s tissue. This may contribute to the fibroblast proliferation and increased ECM deposition observed in this condition. TGFβ-1 is not produced by normal palmar fascia but is produced in large amounts by Dupuytren’s tissue. The major physiologic role of TGFβ-1 is to stimulate formation of fibrous tissue. It plays a major role in wound healing and also in pathological conditions where fibrosis is a prominent feature. Inappropriate production of TGFβ-1 in the palmar fascia in Dupuytren’s disease may play a central role in initiating and stimulating the abnormal fibroblast proliferation and collagen synthesis seen in this condition.
The pathophysiology of discogenic low back pain is poorly understood. The morphological changes occurring in disc degeneration are well documented but unhelpful in determining if a particular degenerate disc will be painful or not. Herniated intervertebral disc tisssue has been shown to produce a number of pro-inflammatory mediators and cytokines. No similar studies have to date been done utilising disc material from patients with discogenic low back pain. The aim of this study was to compare levels of production of interleukin-6 (IL-6), interleukin-8 (IL-8) and Prostaglandin E2 (PGE2) in disc tissue from patients undergoing discectomy for sciatica with that from patients undergoing fusion for discogenic low back pain. Tissue from 50 patients undergoing discectomy for sciatica and 20 patients undergoing fusion for discogenic low back pain was cultured and the medium harvested for subsequent analysis using an enzyme linked immunoabsorbent assay method. Statistical analysis of the results was performed using the Mann-Whitney test. Disc specimens from both experimental groups produced measurable levels of all three mediators. Mean production of IL-6, IL-8 and PGE2 in the sciatica group was 26.2±75.7, 247±573 and 2255±3974 respectively. Mean production of IL-6, IL-8 and PGE2 in the low back pain group was 92±154, 776±987 and 3221±3350 respectively (data = mean production pg/ml ± 1 standard deviation). There was a statistically significant difference between the levels of IL-6 and IL-8 production in the sciatica and low back pain groups (p<
0.006 and p<
0.003 respectively). The high levels of pro-inflammatory mediator production found in disc tissue from patients undergoing fusion for discogenic LBP may indicate that nucleus pulposis pro-inflammatory mediator production is a major factor in the genesis of a painful lumbar disc. This could explain why some degenerate discs cause LBP while other morphologically similar discs do not.
Rapidly progressive cases of primary idiopathic hip osteoarthrosis are well known and recognised. The prevalence reported in the literature varies from 4–18%. Three types have been identified- type 1 (rapid), type 2 (moderate) and type 3 (delayed) depending on the duration of chondrolysis and the subsequent rate of bone loss per year. We reviewed the charts of all patients deemed to be RPO type 1 who had underwent hip arthroplasty under the care of the senior author (DEB) over a two-year period in an attempt to identify risk factors, which may have contributed to the rapid progression of their disease. All patients were treated using a custom femoral stem and a spiked Duraloc cementless socket following careful preparation of the acetabulum. We identified 34 patients (40 hips) with type 1 rapidly progressive osteoarthrosis. Over the same time period 991 patients had underwent primary total hip arthroplasty, giving a prevalence of 4%. Of the 34 patients, 29 were female of average age 70.6 years (range, 51–83 years). All of the bilateral cases (6 patients) were female. Body mass index (BMI) for the female group ranged from 20.6 to 41.1Kg/m2 (average, 28.2kg/m2) whilst that for the males was on average 25.8Kg/m2 (range, 23.4–29.7Kg/m2). Preoperative erythrocyte sedimentation rate (ESR) was 18mm/hr on average for the female group (range, 2–65mm/hr) and ranged from 3–52mm/hr (average, 20mm/hr) for the male patients. The preoperative Oxford Hip Score averaged 51 points for the female group and 48 points for the male group. A detailed review of occupational history did not reveal any common occupational hazard. The majority of patients were non-smokers and denied any regular alcohol intake. Twenty-two patients (65%) had a history of hypertension. Twenty-seven patients (79%) had a history of non-steroidal anti-inflammatory use (most common preparation-diclofenac). Twenty-four patients (71%) resided in a rural area. When compared to a cohort of patients undergoing primary total hip arthroplasty over the same time period, the only statistically significant risk factor identified was female gender. We conclude, that patients who develop rapidly progressive osteoarthrosis of the hip are difficult to identify due to the absence of specific clinical features. We also outline our experience in the management of these technically challenging cases.