Aims

Acetabular fractures are associated with long-term morbidity. Our prospective cohort study sought to understand the recovery trajectory of this injury over five years.

Aims. Understanding of open fracture management is skewed due to reliance on small-number lower limb, specialist unit reports and large, unfocused registry data collections. To address this, we carried out the Open Fracture Patient Evaluation Nationwide (OPEN) study, and report the demographic details and the initial steps of care for patients admitted with open fractures in the UK. Methods. Any patient admitted to hospital with an open fracture between 1 June 2021 and 30 September 2021 was included, excluding phalanges and isolated hand injuries. Institutional information governance approval was obtained at the lead site and all data entered using Research Electronic Data Capture. Demographic details, injury, fracture classification, and patient dispersal were detailed. Results. In total, 1,175 patients (median age 47 years (interquartile range (IQR) 29 to 65), 61.0% male (n = 717)) were admitted across 51 sites. A total of 546 patients (47.1%) were employed, 5.4% (n = 63) were diabetic, and 28.8% (n = 335) were smokers. In total, 29.0% of patients (n = 341) had more than one injury and 4.8% (n = 56) had two or more open fractures, while 51.3% of fractures (n = 637) occurred in the lower leg. Fractures sustained in vehicle incidents and collisions are common (38.8%; n = 455) and typically seen in younger patients. A simple fall (35.0%; n = 410) is common in older people. Overall, 69.8% (n = 786) of patients were admitted directly to an orthoplastic centre, 23.0% (n = 259) were transferred to an orthoplastic centre after initial management elsewhere, and 7.2% were managed outwith specialist units (n = 81). Conclusion. This study describes the epidemiology of open fractures in the UK. For a decade, orthopaedic surgeons have been practicing in a guideline-driven, network system without understanding the patient features, injury characteristics, or dispersal processes of the wider population. This work will inform care pathways as the UK looks to the future of trauma networks and guidelines, and how to optimize care for patients with open fractures. Cite this article: Bone Jt Open 2022;3(10):746–752

Aims. The Open-Fracture Patient Evaluation Nationwide (OPEN) study was performed to provide clarity in open fracture management previously skewed by small, specialist centre studies and large, unfocused registry investigations. We report the current management metrics of open fractures across the UK. Method. Patients admitted to hospital with an open fracture (excluding phalanges or isolated hand injuries) between 1 June 2021 and 30 September 2021 were included. Institutional information governance approval was obtained at the lead site and all data entered using Research Electronic Data Capture software. All domains of the British Orthopaedic Association Standard for Open Fracture Management were recorded. Results. Across 51 centres, 1,175 patients were analyzed. Antibiotics were given to 754 (69.0%) in the emergency department, 240 (22.0%) pre-hospital, and 99 (9.1%) as inpatients. Wounds were photographed in 848 (72.7%) cases. Median time to first surgery was 16 hrs 14 mins (interquartile range (IQR) 8 hrs 29 mins to 23 hrs 19 mins). Complex injuries were operated on sooner (median 12 hrs 51 mins (IQR 4 hrs 36 mins to 21 hrs 14 mins)). Of initial procedures, 1,053 (90.3%) occurred between 8am and 8pm. A consultant orthopaedic surgeon was present at 1,039 (89.2%) first procedures. In orthoplastic centres, a consultant plastic surgeon was present at 465 (45.1%) first procedures. Overall, 706 (60.8%) patients required a single operation. At primary debridement, 798 (65.0%) fractures were definitively fixed, while 734 (59.8%) fractures had fixation and coverage in one operation through direct closure or soft-tissue coverage. Negative pressure wound therapy was used in 235 (67.7%) staged procedures. Following wound closure or soft-tissue cover, 509 (47.0%) patients received antibiotics for a median of three days (IQR 1 to 7). Conclusion. OPEN provides an insight into care across the UK and different levels of hospital for open fractures. Patients are predominantly operated on promptly, in working hours, and at specialist centres. Areas for improvement include combined patient review and follow-up, scheduled operating, earlier definitive soft-tissue cover, and more robust antibiotic husbandry. Cite this article: Bone Joint J 2022;104-B(9):1073–1080

Introduction and Objective. Forced external rotation is hypothesized as the key mechanism of syndesmotic ankle injuries. This complex trauma pattern ruptures the syndesmotic ligaments and induces a three-dimensional deviation from the normal distal tibiofibular joint configuration. However, current diagnostic imaging modalities are impeded by a two-dimensional assessment, without taking into account ligamentous stabilizers. Therefore, our aim is two-fold: (1) to construct an articulated statistical shape model of the normal ankle with inclusion of ligamentous morphometry and (2) to apply this model in the assessment of a clinical cohort of patients with syndesmotic ankle injuries. Materials and Methods. Three-dimensional models of the distal tibiofibular joint were analyzed in asymptomatic controls (N= 76; Mean age 63 +/− 19 years), patients with syndesmotic ankle injury (N = 13; Mean age 35 +/− 15 years), and their healthy contralateral equivalent (N = 13). Subsequently, the statistical shape model was generated after aligning all ankles based on the distal tibia. The position of the syndesmotic ligaments was predicted based on previously validated iterative shortest path calculation methodology. Evaluation of the model was described by means of accuracy, compactness and generalization. Canonical Correlation Analysis was performed to assess the influence of syndesmotic lesions on the distal tibiofibular joint congruency. Results. Our presented model contained an accuracy of 0.23 +/− 0.028 mm. Mean prediction accuracy of ligament insertions was 0.53 +/− 12 mm. A statistically significant difference in anterior syndesmotic distance was found between ankles with syndesmotic lesions and healthy controls (95% CI [0.32, 3.29], p = 0.017). There was a significant correlation between presence of syndesmotic injury and the morphological distal tibiofibular configuration (r = 0.873, p <0,001). Conclusions. In this study, we constructed a bony and ligamentous statistical model representing the distal tibiofibular joint Furthermore, the presented model was able to detect an elongation injury of the anterior inferior tibiofibular ligament after traumatic syndesmotic lesions in a clinical patient cohort

Aims. The aim of this study was to compare patient-reported outcome measures (PROMs) and the Single Assessment Numerical Evaluation (SANE) score in patients treated with a volar locking plate for a distal radial fracture. Methods. This study was a retrospective review of a prospective database of 155 patients who underwent internal fixation with a volar locking plate for a distal radial fracture between August 2014 and April 2017. Data which were collected included postoperative PROMs (Disabilities of the Arm, Shoulder, and Hand questionnaire (DASH) and Patient-Rated Wrist Evaluation (PRWE)), and SANE scores at one month (n = 153), two months (n = 155), three months (n = 144), six months (n = 128), and one year (n = 73) after operation. Patients with incomplete data were excluded from this study. Correlation and agreement between PROMs and SANE scores were evaluated. Subgroup analyses were carried out to identify correlations according to variables such as age, the length of follow-up, and subcategories of the PRWE score. Results. The Pearson correlation coefficient (r) between PROMs and SANE scores was -0.76 (p < 0.001) for DASH and -0.72 (p < 0.001) for PRWE, respectively. Limits of agreement between PROMs and ‘100-SANE’ scores were met for at least 93% of the data points. In subgroup analysis, there were significant negative correlations between PROMs and SANE scores for all age groups and for follow-up of more than six months. The correlation coefficient between PRWE subcategories and SANE score was -0.67 (p < 0.001) for PRWE pain score and -0.69 (p < 0.001) for PRWE function score, respectively. Conclusion. We found a significant correlation between postoperative SANE and PROMs in patients treated with a volar locking plate for a distal radial fracture. The SANE score is thus a reliable indicator of outcome for patients who undergo surgical treatment for a radial fracture. Cite this article: Bone Joint J 2020;102-B(6):744–748

Bone infections due to fractures or implants are a big medical problem. In experimental medicine, many experimental models have been created on different animal species to simulate the disease condition and to do experience treatments. The aim of this paper was to present an antibacterial efficacy of using a bone allograft developed according to the Marburg system of bone bank on a model of chronic osteomyelitis induced in rabbits. In research was used 54 rabbits. Osteomyelitis was induced in rabbits by a human strain of St. aureus ATCC 43300, in the rabbit femur. There have been created 3 groups of animals. In 1. st. group used antibiotic impregnated biodegradable material “PerOssal”. In 2. nd. group used antibiotic impregnated whole bone allograft. In 3. rd. group used antibiotic impregnated perforated bone allograft. Evaluation of installation and evolution of the disease was done by microbiological. A separate study of microbiological data is presented here. This study showed, in the 1. st. and 3. rd. groups there is a persistent decrease in CFU by 14 knocks to 120.4 in the 1. st. group and to 3.5 in the 3. rd. group, and in the 2. nd. group, on the contrary, there is an increase in CFU to 237.33. This shows the lack of effectiveness of using a whole bone allograft. The results showed, after 7 days there was no statistically significant difference between the groups. After 14 days the perforated bone allograft impregnated with antibiotic was better than the biodegradable material “PerOssal”

Background. Approximately half of all hip fractures are displaced intracapsular fractures. The standard treatment for these fractures is either hemiarthroplasty or total hip arthroplasty. The recent National Institute for Health and Care Excellence (NICE) guidance on hip fracture management recommends the use of ‘proven’ cemented stem arthroplasty with an Orthopaedic Device Evaluation Panel (ODEP) rating of at least 3B (97% survival at three years). The Thompsons prosthesis is currently lacking an ODEP rating despite over 50 years of clinical use, likely due to the paucity of implant survival data. Nationally, adherence to these guidelines is varied as there is debate as to which prosthesis optimises patient outcomes. Design. This study design is a multi-centre, multi-surgeon, parallel, two arm, standard-of-care pragmatic randomised controlled trial. It will be embedded within the WHiTE Comprehensive Cohort Study (ISRCTN63982700). The main analysis is a two-way equivalence comparison between Hemi-Thompson and Hemi-Exeter polished taper with Unitrax head. Secondary outcomes will include radiological leg length discrepancy measured as per Bidwai and Willett, mortality, re-operation rate and indication for re-operation, length of index hospital stay and revision at four months. This study will be supplemented by the NHFD (National Hip Fracture Database) dataset. Discussion. Evidence on the optimum choice of prosthesis for hemiarthroplasty of the hip is lacking. National guidance is currently based on expert opinion rather than empirical evidence. The incidence of hip fracture is likely to continue to increase and providing high quality evidence on the optimum treatment will improve patient outcomes and have important health economic implications. Cite this article: A. L. Sims. The World Hip Trauma Evaluation Study 3: Hemiarthroplasty Evaluation by Multicentre Investigation – WH. I. TE 3: HEMI – An Abridged Protocol. Bone Joint Res 2016;5:18–25. doi: 10.1302/2046-3758.51.2000473

Aims. To validate the Sydney Hamstring Origin Rupture Evaluation (SHORE), a hamstring-specific clinical assessment tool to evaluate patient outcomes following surgical treatment. Methods. A prospective study of 70 unilateral hamstring surgical repairs, with a mean age of 47.3 years (15 to 73). Patients completed the SHORE preoperatively and at six months post-surgery, and then completed both the SHORE and Perth Hamstring Assessment Tool (PHAT) at three years post-surgery. The SHORE questionnaire was validated through the evaluation of its psychometric properties, including; internal consistency, reproducibility, reliability, sensitivity to change, and ceiling effect. Construct validity was assessed using Pearson’s correlation analysis to examine the strength of association between the SHORE and the PHAT. Results. The SHORE demonstrated an excellent completion rate (100%), high internal consistency (Cronbach’s alpha 0.78), and good reproducibility (intraclass correlation coefficient (ICC) 0.82). The SHORE had a high correlation with the validated PHAT score. It was more sensitive in detecting clinical change compared to the PHAT. A ceiling effect was not present in the SHORE at six months; however, a ceiling effect was identified in both scores at three years post-surgery. Conclusion. This study has validated the SHORE patient reported outcome measure (PROM) as a short, practical, reliable, valid, and responsive tool that can be used to assess symptom and function following hamstring injury and surgical repair. Cite this article: Bone Joint J 2020;102-B(3):388–393

Valid and reliable techniques for assessing performance are essential to surgical education, especially with the emergence of competency-based frameworks. Despite this, there is a paucity of adequate tools for the evaluation of skills required during joint replacement surgery. In this scoping review, we examine current methods for assessing surgeons’ competency in joint replacement procedures in both simulated and clinical environments. The ability of many of the tools currently in use to make valid, reliable and comprehensive assessments of performance is unclear. Furthermore, many simulation-based assessments have been criticised for a lack of transferability to the clinical setting. It is imperative that more effective methods of assessment are developed and implemented in order to improve our ability to evaluate the performance of skills relating to total joint replacement. This will enable educators to provide formative feedback to learners throughout the training process to ensure that they have attained core competencies upon completion of their training. This should help ensure positive patient outcomes as the surgical trainees enter independent practice.

Cite this article: Bone Joint J 2013;95-B:1445–9.

Introduction. Vancomycin is a prophylactic antibiotic used to protect against methicillin resistant staph aureus. Recent literature has suggested that using intraosseus (IO) infusions are capable of providing improved local tissue concentrations compared to intravenous (IV) access. The purpose of this study is to evaluate clinical outcomes of patients who received pre-operative IO vancomycin for total knee arthroplasty (TKA). Methods. Patients who received IO vancomycin (500mg vancomycin in 200ml NS) as standard of care from September 1, 2018 to March 1, 2019 were retrospectively evaluated. This data was compared to primary and revision TKAs performed immediately prior to the initiation of IO administration. Evaluation included pre and post-op creatinine values, tourniquet time (TT), and knee-related 30 and 90-day complications. Data for primary and revision TKA cases were analyzed independently. Results. Final analysis had 100 primaries and 29 revisions in the control (IV) and 100 primaries and 19 revisions in the intervention (IO) arm. 30 and 90-day complications were not significantly different in primaries, while decreased 30–day complications for revisions approached significance (control=17.2%, intervention=10.5%). 90-day complications were decreased in the revision group receiving IO (Control=27.6%, Intervention = 0%; p=0.015). No cases of Redman Syndrome were identified. No increase in post-operative creatinine values occurred. TT was increased by 1.87min in the PI, which was not statistically significant (p=0.10). Discussion / Conclusion. We've demonstrated IO vancomycin is a safe and effective alternative to using pre-operative IV vancomycin. This is one of the largest series to date evaluating the clinical outcomes while using IO antibiotics pre-operatively in TKA. Patients who receive IO vancomycin have equivalent or improved 30 and 90-day complication rates, significantly so in revision TKAs. In addition, this study evaluated longer-term outcomes of revision TKAs that are provided IO vancomycin, proving it may be appropriate to extend indications. For figures, tables, or references, please contact authors directly

Purpose: In order to improve our understanding of club-foot, an international rating system of evaluation is proposed which is supported by the International Club Foot Study Group (ICFSG). Method: All the parameters of the assessment shall be objective. They are clinical and radiographic. On the clinical side, the morphology of foot is assessed for the hindfoot, midfoot and the forefoot. Then, the global morphology of the foot and lower limb is assessed. But the function of the foot is the major criteria which enhances the value of the outcome. It is assessed on the passive motion of the different parts of the foot. Then, the active motion is evaluated. Arc added a clinical gait analysis and the occurrence of eventual pain. On the radiographic side, the various angles of bones axes are calculated on AP and lateral views. Results: The score of Outcome Evaluation ranges from 0 up to 60 points, the latter expressing the worst result. Four groups of results are mentioned so as excellent, good, fair and poor. The Outcome Evaluation should be performed at 6 years old and at the end of the growth. Conclusion: The Outcome Evaluation will allow us to be able to compare truly the forthcoming series of club-foot

Radiological assessment of total and unicompartmental knee replacement remains an essential part of routine care and follow-up. Appreciation of the various measurements that can be identified radiologically is important. It is likely that routine plain radiographs will continue to be used, although there has been a trend towards using newer technologies such as CT, especially in a failing knee, where it provides more detailed information, albeit with a higher radiation exposure.

The purpose of this paper is to outline the radiological parameters used to evaluate knee replacements, describe how these are measured or classified, and review the current literature to determine their efficacy where possible.

Introduction: Prostheses radiolucent lines are currently used to evaluate the components fixation. The objective of this study is to determine concordance and reproducibility of humeral stem radiolucent lines evaluation. Material and method: Five observers evaluated 64 x-ray belonging to 32 pairs (1 antero-posterior view and 1 outlet view) obtained from 16 shoulder prostheses. 16 x-ray pairs were obtained immediately after surgery and 16 one year after surgery. Evaluation in four degrees of radiolucent width for each of the 7 zones that the humeral component was divided for. Evaluation of the component-cement interface and the cement-bone interface. Each observer made two evaluations of the 64 x-ray separated in 6 weeks. Statistics : index kappa with quadratic weighting. Results: Intra-observer results: mean kappa index for component-cement interface: 0,3274. mean kappa index for cement-bone interface: 0,5269. Inter-observer results: mean kappa index for component-cement interface: 0,1242. mean kappa index for cement-bone interface: 0,2478. Evaluation of 2 pairs of x-ray of the each prostheses taken in a period of 1 year: component-cement interface: mean of 91,67% of plausible results, cement-bone interface: mean of 80,2% of plausible Results:. Conclusions:. - low kappa index of reproducibility (0,3274–0,5269) of humeral component radiolucent lines evaluation for component-cement interface as well as for cement-bone interface. - low kappa index of concordance (0,1242–0,2478) of humeral component radiolucent lines evaluation for component-cement interface as well as for cement-bone interface. - High number of plausible observations when the same prostheses was evaluated immediately after surgery and at 1 year follow-up

Aims

The primary aim of this study is to assess the survival of the uncemented hydroxyapatite (HA) coated Trident II acetabular component as part of a hybrid total hip arthroplasty (THA) using a cemented Exeter stem. The secondary aims are to assess the complications, joint-specific function, health-related quality of life, and radiological signs of loosening of the acetabular component.

Aims

An objective technological solution for tracking adherence to at-home shoulder physiotherapy is important for improving patient engagement and rehabilitation outcomes, but remains a significant challenge. The aim of this research was to evaluate performance of machine-learning (ML) methodologies for detecting and classifying inertial data collected during in-clinic and at-home shoulder physiotherapy exercise.

Aims. Torus fractures of the distal radius are the most common fractures in children. The NICE non-complex fracture guidelines recently concluded that bandaging was probably the optimal treatment for these injuries. However, across the UK current treatment varies widely due to a lack of evidence underpinning the guidelines. The Forearm Fracture Recovery in Children Evaluation (FORCE) trial evaluates the effect of a soft bandage and immediate discharge compared with rigid immobilization. Methods. FORCE is a multicentre, parallel group randomized controlled equivalence trial. The primary outcome is the Wong-Baker FACES pain score at three days after randomization and the primary analysis of this outcome will use a multivariate linear regression model to compare the two groups. Secondary outcomes are measured at one and seven days, and three and six-weeks post-randomization and include the Patient Reported Outcome Measurement Information System (PROMIS) upper extremity limb score, EuroQoL EQ-5D-Y, analgesia use, school absence, complications, and healthcare resource use. The planned statistical and health economic analyses for this trial are described here. The FORCE trial protocol has been published separately. Conclusion. This paper provides details of the planned analyses for this trial, and will reduce the risks of outcome reporting bias and data driven results. Cite this article: Bone Joint Open 2020;1-6:205–213

Evaluation of transtibial aiming of the femoral tunnel at its anatomical position in arthroscopical ACL reconstruction. 43 ACL reconstructions with hamstrings’ graft were studied. First, the femoral tunnel was drilled through the anteromedial portal at 09.30–10.00 (14.00–14.30 resp.) and then the tibial tunnel (av. anteroposterior angle: 63,5°, sagittal: 64,2°) at the same diameter with simoultaneous radiological documentation. Then, with a femoral aiming device, we tried to put a K-wire at the center of the drilled femoral tunnel. Fotographic documentation took place. In 20 cases the diameter of the tunnels was 7mm, in 11, 7,5mm, in 7, 8mm, in 3, 8,5mm and in 1, 9mm. Evaluation of all radiological and photographic material from 2 observers followed, according to the deviation of the transtibial K-wire from the center of the femoral tunnel. 38 ACL reconstructions were evaluated. It was shown that in 11 cases the transtibial K-wire was in the femoral tunnel (28,9%) (in 7 with a diameter of 7mm., in 2 with 7,5mm. and in 2 with 8mm.). The K-wire was in 23 cases (60,5%) at the perimeter or out of the femoral tunnel (in 11, with a diameter of 7mm., in 8 with 7,5mm., in 4 with 8mm., in 3 with 8,5mm. and in 1 with 9mm.). There was no correlation with the angles of the tibial tunnel or the age of the patients. Transtibial aiming of the femoral tunnel at its anatomical position is very difficult and there is no correlation of the transtibial deviation with the diameter of the tibial tunnel

A reliable and valid measurement tool, The Western Ontario Meniscal Evaluation Tool (WOMET) was developed to assess the benefit of conservative and surgical interventions for meniscal pathology. A methodologic protocol designed by Guyatt was used for the development. This measurement tool can be used as the primary outcome tool in clinical trials evaluating the outcome of patients in this population. It can also be used to monitor a patients’ progress in private practice. The purpose of this study was to develop a measure of quality of life, which is reliable and valid, to assess the benefit of conservative and surgical interventions for meniscal pathology. Health-related quality-of-life measurement tool development. A modified methodologic protocol designed by Guyatt was used to develop the Western Ontario Meniscal Evaluation Tool (WOMET) a disease-specific quality of life measurement tool for patients with meniscal pathology. The stages were: 1) item generation, 3) item selection, 4) pretesting. Evaluation of the WOMET included testing reliability, responsiveness and validity. The final instrument, the Western Ontario Meniscal Evaluation Tool has sixteen items representing the domains of physical symptoms (nine items), sports, recreation/work/lifestyle (four items), and emotions (three items). The instrument proved to be valid by demonstrating predicted correlations with previously published knee measurement tools. Reliability at two weeks was high with an intraclass correlation coefficient of 0.833. The new instrument was also more responsive than other knee measurement tools. Since the patients own perception of changes in their health status is the most important indicator for success of a treatment, this measurement tool can be used as the primary outcome tool in clinical trials evaluating the outcome of patients in this population. It can also be used to monitor a patients’ progress in private practice

Meniscal tears are the most common knee injuries, occurring in acute ruptures or in chronic degenerative conditions. Meniscectomy and meniscal repair are two surgical treatment options. Meniscectomy is easier, faster, and the patient can return to their normal activities earlier. However, this procedure has long-term consequences in the development of degenerative changes in the knee, potentially leading to knee replacement. On the other hand, meniscal repair can offer prolonged benefits to the patients, but it is difficult to perform and requires longer rehabilitation.

Sutures are used for meniscal repairs, but they have limitations. They induce tissue damage when passing through the meniscus. Furthermore, under dynamic loading of the knee, they can cause tissue shearing and potentially lead to meniscal repair failure.

Our team has developed a new technology of resistant adhesive hydrogels to coat the suture used to repair meniscal tissue.

The objective of this study is to biomechanically compare two suture types on bovine menisci specimens: 1) pristine sutures and 2) gel adhesive puncture sealing (GAPS) sutures, on a repaired radial tear under cyclic tensile testing.

Five bovine knees were dissected to retrieve the menisci. On the 10 menisci, a complete radial tear was performed. They were separated in two groups and repaired using either pristine (2-0 Vicryl) or GAPS (2-0 Vicryl coated with adhesive hydrogels) with a single stitch and five knots.

The repaired menisci were clamped on an Instron machine. The specimens were cyclically preconditioned between one and 10 newtons for 10 cycles and then cyclically loaded for 500 cycles between five and 25 newtons at a frequency of 0.16 Hz. The gap formed between the edges of the tear after 500 cycles was then measured using an electronic measurement device. The suture loop before and after testing was also measured to ensure that there was no suture elongation or loosening of the knot.

The groups were compared statistically using Mann-Whitney tests for nonparametric data. The level of significance was set to 0.05.

The mean gap formation of the pristine sutures was 5.61 mm (SD = 2.097) after 500 cycles of tensile testing and 2.38 mm (SD = 0.176) for the GAPS sutures. Comparing both groups, the gap formed with the coated sutures was significantly smaller (p = 0.009) than with pristine sutures. The length of the loop was equal before and after loading. Further investigation of tissue damage indicated that the gap was formed by suture filament cutting into the meniscal tissue.

The long-term objective of this research is to design a meniscal repair toolbox from which the surgeon can adapt his procedure for each meniscal tear. This preliminary experimentation on bovine menisci is promising because the new GAPS sutures seem to keep the edges of the meniscal tear together better than pristine sutures, with hopes of a clinical correlation with enhanced meniscal healing.

Meniscal tears are the most common knee injuries, occurring in acute ruptures or in chronic degenerative conditions. Meniscectomy and meniscal repair are two surgical treatment options. Meniscectomy is easier, faster, and the patient can return to their normal activities earlier. However, this procedure has long-term consequences in the development of degenerative changes in the knee, potentially leading to knee replacement. On the other hand, meniscal repair can offer prolonged benefits to the patients, but it is difficult to perform and requires longer rehabilitation.

Sutures are used for meniscal repairs, but they have limitations. They induce tissue damage when passing through the meniscus. Furthermore, under dynamic loading of the knee, they can cause tissue shearing and potentially lead to meniscal repair failure.

Our team has developed a new technology of resistant adhesive hydrogels to coat the suture used to repair meniscal tissue.

The objective of this study is to biomechanically compare two suture types on bovine menisci specimens: 1) pristine sutures and 2) gel adhesive puncture sealing (GAPS) sutures, on a repaired radial tear under cyclic tensile testing.

Five bovine knees were dissected to retrieve the menisci. On the 10 menisci, a complete radial tear was performed. They were separated in two groups and repaired using either pristine (2-0 Vicryl) or GAPS (2-0 Vicryl coated with adhesive hydrogels) with a single stitch and five knots.

The repaired menisci were clamped on an Instron machine. The specimens were cyclically preconditioned between one and 10 newtons for 10 cycles and then cyclically loaded for 500 cycles between five and 25 newtons at a frequency of 0.16 Hz. The gap formed between the edges of the tear after 500 cycles was then measured using an electronic measurement device. The suture loop before and after testing was also measured to ensure that there was no suture elongation or loosening of the knot.

The groups were compared statistically using Mann-Whitney tests for nonparametric data. The level of significance was set to 0.05.

The mean gap formation of the pristine sutures was 5.61 mm (SD = 2.097) after 500 cycles of tensile testing and 2.38 mm (SD = 0.176) for the GAPS sutures. Comparing both groups, the gap formed with the coated sutures was significantly smaller (p = 0.009) than with pristine sutures. The length of the loop was equal before and after loading. Further investigation of tissue damage indicated that the gap was formed by suture filament cutting into the meniscal tissue.

The long-term objective of this research is to design a meniscal repair toolbox from which the surgeon can adapt his procedure for each meniscal tear. This preliminary experimentation on bovine menisci is promising because the new GAPS sutures seem to keep the edges of the meniscal tear together better than pristine sutures, with hopes of a clinical correlation with enhanced meniscal healing.

Glenoid and humeral head bone defects have long been recognized as major determinants in recurrent shoulder instability as well as main predictors of outcomes after surgical stabilization. However, a universally accepted method to quantify them is not available yet. The purpose of the present study is to describe a new CT method to quantify bipolar bone defects volume on a virtually generated 3D model and to evaluate its reproducibility.

A cross-sectional observational study has been conducted. Forty CT scans of both shoulders were randomly selected from a series of exams previously acquired on patients affected by anterior shoulder instability. Inclusion criterion was unilateral anterior shoulder instability with at least one episode of dislocation. Exclusion criteria were: bilateral shoulder instability; posterior or multidirectional instability, previous fractures and/or surgery to both shoulders; congenital or acquired inflammatory, neurological, or degenerative diseases. For all patients, CT exams of both shoulders were acquired at the same time following a standardized imaging protocol. The CT data sets were analysed on a standard desktop PC using the software 3D Slicer. Computer-based reconstruction of the Hill-Sachs and glenoid bone defect were performed through Boolean subtraction of the affected side from the contralateral one, resulting in a virtually generated bone fragment accurately fitting the defect. The volume of the bone fragments was then calculated. All measurements were conducted by two fellowship-trained orthopaedic shoulder surgeons. Each measurement was performed twice by one observer to assess intra-observer reliability. Inter and intra-observer reliability were calculated. Intraclass Correlation Coefficients (ICC) were calculated using a two-way random effect model and evaluation of absolute agreement. Confidence intervals (CI) were calculated at 95% confidence level for reliability coefficients. Reliability values range from 0 (no agreement) to 1 (maximum agreement).

The study included 34 males and 6 females. Mean age (+ SD) of patients was 36.7 + 10.10 years (range: 25 – 73 years). A bipolar bone defect was observed in all cases. Reliability of humeral head bone fragment measurements showed excellent intra-observer agreement (ICC: 0.92, CI 95%: 0.85 – 0.96) and very good interobserver agreement (ICC: 0.89, CI 95%: 0.80 – 0.94). Similarly, glenoid bone loss measurement resulted in excellent intra-observer reliability (ICC: 0.92, CI 95%: 0.85 – 0.96) and very good inter-observer agreement (ICC: 0.84, CI 95%:0.72 – 0.91).

In conclusion, matching affected and intact contralateral humeral head and glenoid by reconstruction on a computer-based virtual model allows identification of bipolar bone defects and enables quantitative determination of bone loss.

Objectives. Regenerative medicine is an emerging field aimed at the repair and regeneration of various tissues. To this end, cytokines (CKs), growth factors (GFs), and stem/progenitor cells have been applied in this field. However, obtaining and preparing these candidates requires invasive, costly, and time-consuming procedures. We hypothesised that skeletal muscle could be a favorable candidate tissue for the concept of a point-of-care approach. The purpose of this study was to characterize and confirm the biological potential of skeletal muscle supernatant for use in regenerative medicine. Methods. Semitendinosus muscle was used after harvesting tendon from patients who underwent anterior cruciate ligament reconstructions. A total of 500 milligrams of stripped muscle was minced and mixed with 1 mL of saline. The collected supernatant was analysed by enzyme-linked immunosorbent assay (ELISA) and flow cytometry. The biological effects of the supernatant on cell proliferation, osteogenesis, and angiogenesis in vitro were evaluated using human mesenchymal stem cells (hMSCs) and human umbilical cord vein endothelial cells (HUVECs). Results. The supernatant contained several GFs/CKs, with especially high levels of basic fibroblast growth factor, and CD34+ cells as the stem/progenitor cell fraction. With regard to biological potential, we confirmed that cell proliferation, osteoinduction, and angiogenesis in hMSCs and HUVECs were enhanced by the supernatant. Conclusions. The current study demonstrates the potential of a new point-of-care strategy for regenerative medicine using skeletal muscle supernatant. This attractive approach and readily-available material could be a promising option for tissue repair/regeneration in the clinical setting. Cite this article: M. Yoshikawa, T. Nakasa, M. Ishikawa, N. Adachi, M. Ochi. Evaluation of autologous skeletal muscle-derived factors for regenerative medicine applications. Bone Joint Res 2017;6:277–283. DOI: 10.1302/2046-3758.65.BJR-2016-0187.R1

Duchenne muscular dystrophy (DMD) is a prevalent childhood neuromuscular disease characterized by progressive skeletal and cardiac muscle degeneration due to dystrophin protein deficiency. Despite ongoing drug development efforts, no cure exists, with limited success in preclinical studies. To expedite DMD drug development, we introduce an innovative organ-on-a-chip (OOC) platform. This microfluidic device sustains up to six 3D patient-derived skeletal muscle tissues, enabling real-time evaluation of anti-DMD treatments. Our in vitro model recreates myotube integrity loss, a hallmark of DMD, by encapsulating myogenic precursors in a fibrin-composite matrix using a PDMS casting mold. Continuous contractile regimes mimic sarcolemmal instability, monitored through tissue contractibility and Creatine Kinase (CK) levels—an established marker of muscle damage. We further enhance our platform with a nanoplasmonic CK biosensor, enabling rapid, label-free, and real-time sarcolemmal damage assessment. Combining these elements, our work demonstrates the potential of OOCs in accelerating drug development for DMD and similar neuromuscular disorders.

Despite the growing success of OCA transplantation in treating large articular cartilage lesions in multiple joints, revisions and failures still occur. While preimplantation subchondral drilling is intended to directly decrease allograft bioburden and has been associated with significant improvements in outcomes after OCA transplantation, the effects of size, number, and spacing of subchondral bone drill sites have not been fully evaluated. This study aimed to investigate the effects of drill size with or without pulse-lavage of OCA subchondral bone by quantifying remnant marrow elements using histomorphometry.

With IRB and ACUC approvals, human and canine OCAs were acquired for research purposes. Portions of human tibial plateau OCAs acquired from AATB-certified tissue banks that would otherwise be discarded were recovered and sectioned into lateral and medial hemiplateaus (n=2 each) with a thickness of 7 mm. Canine femoral condyles and tibial plateaus were split into lateral and medial components with a thickness of 7 mm (n=8). Using our clinical preimplantation preparation protocol, holes were drilled into the subchondral bone of each condyle and hemiplateau OCA using either 1.6 mm OD or 3.2 mm OD drill bits from the cut surface to the cortical subchondral bone plate. One femoral condyle and one hemiplateau per drill bit size were pulse-lavaged while the corresponding OCAs were not. The mean total %-fill remaining marrow elements for each treatment group was calculated.

Little to no quantifiable bone marrow element retention was noted to remain within the subchondral bone of human or canine OCA specimens after subchondral drilling of allograft bone with either drill bit size evaluated and with or without pulse-lavage. The %-fill was consistent across zones, ranging from 1-5%.

This project was designed to provide a preliminary histologic evaluation of the effects of drill size on OCA preimplantation preparation efficacy based on amount of remaining bone marrow elements in human and canine femoral condyle and tibial plateau specimens. Based on these initial findings, choice of drill bit size for OCA subchondral drilling may need to be based on the associated biomechanical effects rather than effects on donor bone marrow element removal.

Aim

While 16S rRNA PCR - Sanger sequencing has paved the way for the diagnosis of culture-negative bacterial infections, it does not provide the composition of polymicrobial infections. We aimed to evaluate the performance of the Nanopore-based 16S rRNA metagenomic approach using partial-length amplification of the gene, and to explore its feasibility and suitability as a routine diagnostic tool for bone and joint infections (BJI) in a clinical laboratory.

In severe cases of total knee arthroplasty which cannot be treated with off-the-shelf implants anymore custom-made knee implants may serve as one of the few remaining options to restore joint function or to prevent limb amputation. Custom-made implants are specifically designed and manufactured for one individual patient in a single-unit production, in which the surgeon is responsible for the implant design characteristics in consultation with the corresponding engineer.

The mechanical performance of these custom-made implants is challenging to evaluate due to the unique design characteristics and the limited time until which the implant is needed. Nevertheless, the custom-made implant must comply with clinical and regulatory requirements. The design of custom-made implants is often based on a underlying reference implant with available biomechanical test results and well-known clinical performance. To support surgeons and engineers in their decision whether a specific implant design is suitable, a method is proposed to evaluate its mechanical performance.

The method uses finite element analysis (FEA) and comprises six steps: (1) Identification of the main potential failure mechanism and its corresponding FEA quantity of interest. (2) Reproduction of the biomechanical test of the reference implant via FEA. (3) Identification of the maximum value of the corresponding FEA quantity of interest at the required load level. (4) Definition of this value as the acceptance criteria for the FEA of the custom-made implant. (5) Reproduction of the biomechanical test with the custom-made implant via FEA. (6) Conclusion whether the acceptance criteria is fulfilled or not.

The method was applied to two exemplary cases of custom-made knee implants. The FEA acceptance criteria derived from the reference implants were fulfilled in both custom-made implants. Subsequent biomechanical tests verified the FEA results.

This study suggests and applies a non-destructive and efficient method for pre-clinical testing of a single-unit custom-made knee implant to evaluate whether the design is mechanically suitable.

Patient reported outcome measures (PROMs) after total knee arthroplasty (TKA) are typically used to assess longitudinal change in pain and function after total knee arthroplasty (TKA). The Patient's Knee Implant Performance (PKIP) score was developed to evaluate outcomes more broadly including function, stability, confidence, and satisfaction. Although validated in patients having a primary TKA, the PKIP has not been evaluated as an outcome measure for patients having revision TKA. This study examined patient outcomes at one year following primary and revision TKA measured using the PKIP, compared to Oxford Knee Scores.

A retrospective analysis of pre-operative and one-year post-operative outcomes was completed for 39 patients (21 female) who had primary (n=27) or revision (n=12) TKA with a single surgeon between 2017 and 2020. The mean age was 69.2±7.4 years, and mean weight 87.4± 5.1kg. The change over time and correlation between the self-reported outcome measures was evaluated.

There was a significant improvement in the PKIP overall score at the 12-month follow-up (32± 13 v 69± 15, p= <0.001), with no significant difference between groups (3.3 points, p=0.50). Among the PKIP sub-scores, there was a significant improvement in knee confidence (3.5±2 vs 7.7±2; p<0.001), stability (3.4±2 vs 7.4±3; p<0.001) and satisfaction (2.5±1.7 vs 6.6±3, p<0.001). Between group differences in PKIP sub-scores one year after surgery were small and non-significant. For all patients, the OKS and PKIP scores were moderately correlated before surgery (r=0.64, p=<0.05), and at 1 year after surgery (r=0.61, p= <0.001).

Significant improvements in knee confidence, stability, and satisfaction one year after TKA were identified from the PKIP responses, with no significant difference between primary and revision surgery. The moderate correlation with the OKS suggests these questionnaires measure difference constructs and may provide complementary outcome information in this patient cohort.

Dual plate constructs have become an increasingly common fixation technique for midshaft clavicle fractures and typically involve the use of mini-fragment plates. The goal of this technique is to reduce plate prominence and implant irritation, as these are common reasons for revision surgery. However, limited biomechanical data exist for these lower-profile constructs. The study aim was to compare dual mini-fragment orthogonal plating to traditional small-fragment clavicle plates for biomechanical non-inferiority and to determine if an optimal plate configuration could be identified, using a cadaveric model.

Twenty-four cadaveric clavicles were randomized to one of six groups (n=4 per group), stratified by CT-based bone mineral content (BMC). The six different plating configurations compared were: pre-contoured superior or anterior fixation using a single 3.5-mm LC-DC plate, and four different dual-plating constructs utilizing 2.4-mm and 2.7-mm reconstruction or LC-DC plates. The clavicles were plated and then osteotomized to create an inferior butterfly fracture, which was then fixed with a single interfragmentary screw (OTA 15.2B). Axial, torsional, and bending (anterior and superior surface loading) stiffness were determined for each construct through non-destructive cyclic testing, using an MTS 858 Bionix materials testing system. This was followed by a load-to-failure test in three-point superior-surface bending. Kruskal-Wallace H and Mann-Whitney U were used to test for statistical significance.

There were no significant differences in BMC (median 7.9 g, range 4.2-13.8 g) for the six groups (p=1.000). For axial stiffness, the two dual-plate constructs with a superior 2.4-mm and anterior 2.7-mm plate (either reconstruction or LC-DC) were significantly stiffer than the other four constructs (p=0.021). For both superior and anterior bending, the superior 2.4-mm and anterior 2.7-mm plate constructs were significantly stiffer when compared to the 3.5-mm superior plate (p=0.043). In addition, a 3.5-mm plate placed anterior was a stiffer construct than a superior 3.5-mm plate (p=0.043). No significant differences were found in torsional stiffness or load-to-failure between the different constructs.

Dual plating using mini-fragment plates is biomechanically superior for fixation of midshaft clavicle fractures when compared to a single superior 3.5-mm plate and has similar biomechanical properties to a 3.5-mm plate placed anteriorly. With the exception of axial stiffness, no significant differences were found when different dual plating constructs were compared to each other. However, placing a 2.4-mm plate superiorly in combination with a 2.7-mm plate anteriorly might be the optimal construct, given the biomechanical superiority over the 3.5-mm plate placed superior.

Aim

The analysis of synovial fluid has proved to be of crucial importance in the diagnostic process of prosthetic joint infections (PJI), suggesting the presence of an infection before the microbiological culture results. In this context, several studies illustrated the efficacy of synovial calprotectin in supporting the diagnosis of PJI [1, 2]. However, several testing methods have been explored to detect synovial calprotectin levels, emphasizing the need to use a standardized, rapid and rapid test.

In this study, synovial calprotectin was analyzed by means of a commercial stool test [3] to explore whether the detected levels might predict PJIs and, therefore, being a promising tool for the fast and reliable diagnosis of this complication.

Mechanical failure of spine posterior fixation in the lumbar region Is suspected to occur more frequently when the sagittal balance is not properly restored. While failures at the proximal extremity have been studied in the literature, the lumbar distal junctional pathology has received less attention. The aim of this work was to investigate if the spinopelvic parameters, which characterize the sagittal balance, could predict the mechanical failure of the posterior fixation in the distal lumbar region.

All the spine surgeries performed in 2017-2019 at Rizzoli Institute were retrospectively analysed to extract all cases of lumbar distal junctional pathology. All the revision surgeries performed due to the pedicle screws pull-out, or the breakage of rods or screws, or the vertebral fracture, or the degenerative disc disease, in the distal extremity, were included in the junctional (JUNCT) group. A total of 83 cases were identified as JUNCT group. All the 241 fixation surgeries which to date have not failed were included in the control (CONTROL) group. Clinical data were extracted from both groups, and the main spinopelvic parameters were assessed from sagittal standing preoperative (pre-op) and postoperative (post-op) radiographs with the software Surgimap (Nemaris). In particular, pelvic incidence (PI), sagittal vertical axis (SVA), pelvic tilt (PT), T1 pelvic angle (TPA), sacral slope (SS) and lumbar lordosis (LL) have been measured.

In JUNCT, the main failure cause was the screws pull-out (45%). Spine fixation with 7 or more levels were the most common in JUNCT (52%) in contrast to CONTROL (14%). In CONTROL, PT, TPA, SS and PI-LL were inside the recommended ranges of good sagittal balance. For these parameters, statistically significant differences were observed between pre-op and post-op (p<0.0001, p=0.01, p<0.0001, p=0.004, respectively, Wilcoxon test). In JUNCT, the spinopelvic parameters were out of the ranges of the good sagittal balance and the worsening of the balance was confirmed by the increase in PT, TPA, SVA, PI-LL and by the decrease of LL (p=0.002, p=0.003, p<0.0001, p=0.001, p=0.001, respectively, paired t-test) before the revision surgery. TPA (p=0.003, Kolmogorov-Smirnov test) and SS (p=0.03, unpaired t-test) differed significantly in pre-op between JUNCT and CONTROL. In post-op, PI-LL was significantly different between JUNCT and CONTROL (p=0.04, unpaired t-test). The regression model of PT vs PI was significantly different between JUNCT and CONTROL in pre-op (p=0.01, Z-test).

These results showed that failure is most common in long fused segments, likely due to long lever arms leading to implant failure. If the sagittal balance is not properly restored, after the surgery the balance is expected to worsen, eventually leading to failure: this effect was confirmed by the worsening of all the spinopelvic parameters before the revision surgery in JUNCT. Conversely, a good sagittal balance seems to avoid a revision surgery, as it is visible is CONTROL. The mismatch PI-LL after the fixation seems to confirm a good sagittal balance and predict a good correction. The linear regression of PT vs PI suggests that the spine deformity and pelvic conformation could be a predictor for the failure after a fixation.

Screw fixation is an established method for anterior cruciate ligament (ACL) reconstruction, although with a high rate of implant-related complications. An allograft system for implant fixation in ACL reconstruction, the Shark Screw ACL (surgebright GmbH) could overcome some of the shortcomings of bioabsorbable screws, such as foreign body reaction, need for implant removal and imaging artefacts. However, it needs to provide sufficient mechanical stability. Therefore, the aim of this study was to investigate the biomechanical stability, especially graft slippage, of the novel allograft system versus a conventional bioabsorbable interference screw (BioComposite Interference Screw; Arthrex Inc.) for tibial implant fixation in ACL reconstruction.

Twenty-four paired human proximal tibiae (3 female, 9 male, 72.7 ± 5.6 years) underwent ACL reconstruction. The quadrupled semitendinosus and gracilis tendon graft were fixed in one specimen of each pair using the allograft fixation system Shak Screw ACL and the contralateral one using an interference screw. All specimens were cyclically loaded at 1 Hz with peak load levels monotonically increased from 50 N at a rate of 0.1 N/cycle until catastrophic failure. Relative movements of the graft versus the tibia were captured with a stereographic optical motion tracking system (Aramis SRX; GOM GmbH).

The two fixation methods did not demonstrate any statistical difference in ultimate load at graft slippage (p = 0.24) or estimated survival at slippage (p = 0.06). Both, the ultimate load and estimated survival until failure were higher in the interference screw (p = 0.04, and p = 0.018, respectively). Graft displacement at ultimate load reached values of up to 7.2 mm (interference screw) and 11.3 mm (Shark Screw ACL).

The allograft screw for implant fixation in ACL reconstruction showed similar behavior in terms of graft slippage compared to the conventional metal interference screw but underperformed in terms of ultimate load. However, the ultimate load may not be considered a direct indicator of clinical failure.

Rotational acetabular osteotomy (RAO), one of periacetabular osteotomies, is an effective joint-preserving surgical treatment for developmental dysplasia of the hip. Since 2013, we have been using a CT-based navigation for RAO to perform safe and accurate osteotomy. CT-based navigation allows precise osteotomy during surgery but cannot track the bony fragment after osteotomy. Thus, it is an issue to achieve successful reorientation in accordance with preoperative planning. In this presentation, we introduce a new method to achieve reorientation and evaluate its accuracy.

Thirty joints in which CT-based navigated RAO was performed were included in this study. For the first 20 joints, reorientation was confirmed by tracing the lateral aspect of rotated fragment with navigation and checked if it matched with the preoperative planning. For the latter 10 joints, a new method was adopted. Four fiducial points were made on lateral side of the acetabulum in the preoperative 3-dimensional model and intraoperatively, rotation of the osteotomized bone was performed so that the 4 fiducial points match the preoperative plan.

To assess the accuracy of position of rotated fragment in each group, preoperative planning and postoperative CT were compared. A total of 24 radial reformat images of postoperative CT were obtained at a half-hour interval following the clockface system around the acetabulum. In every radial image, femoral head coverage of actual postop- and planned were measured to evaluate the accuracy of acetabular fragment repositioning.

The 4-fiducial method significantly reduced the reorientation error. Especially in the 12:00 to 1:00 position of the acetabulum, there were significantly fewer errors (p<0.01) and fewer cases with under-correction of the lateral acetabular coverage.

With the new method with 4 reference fiducials, reorientation of the acetabulum could be obtained as planned with lesser errors.

Background

Scoliosis is described as a lateral spinal curvature exceeding ten degrees on radiograph with vertebral rotation. Approximately 80% of scoliosis presentations are adolescent idiopathic scoliosis (AIS). Current management for AIS in the UK occurs in Surgeon or Paediatrician-led clinics and can be conservative or surgical. The musculoskeletal assessment and triage of AIS appears well-suited to an advanced physiotherapist practitioner (APP) skill set. The aim of this service evaluation was to scope, develop, implement and evaluate a four-month pilot of an APP-led AIS triage pathway.

Evaluation of patients with painful total knee replacement requires a thorough clinical examination and relevant investigations in order to reach a diagnosis. Awareness of the common and uncommon problems leading to painful total knee replacement is useful in the diagnostic approach. This review article aims to act as a guide to the evaluation of patients with painful total knee replacement

Introduction. Stiffness after total knee arthroplasty (TKA) has been reported to occur due to component malpositioning and/or oversizing, improper femoral component (FC) flexion and tibial component (TC) slope, tight extension gap, inaccurate joint line placement, deficient posterior osteophyte resection, heterotopic ossification (HO), poor patellofemoral joint reconstruction, poor posterior condylar offset restoration, and/or posterior cruciate ligament (PCL) under-resection or retraction. However, the importance of these potential factors for stiffness are not well documented in the medical literature. The aim of this study was therefore to evaluate specific radiographic parameters in patients who had stiffness after primary TKA. Material and Methods. An IRB-approved retrospective chart review was performed to identify patients that were revised due to stiffness after TKA. We defined stiffness as 15º or more of flexion contraction, less than 75º of flexion or a range of motion (ROM) of 90º with the chief complaint of limited ROM and pain. Patients with history of previous revisions and/or ORIF, infection, or isolated polyethylene exchange were excluded. Patients with a minimum of 1 year radiographic follow-up were included. Radiographic measurements were performed as described by the Knee Society TKA Roentgenographic Evaluation System (KSRES). Two blinded observers performed all measurements. Descriptive data is reported as mean (range). Inter-observer correlations were reported using Intraclass correlations coefficient (ICC). Results. A total of 44 patients met the inclusion criteria. Of those, 13 (30%) were male and 31 (70%) were female. Mean BMI was 33.9 kg/m2 (19.5–58). ICCs ranged from good to excellent (>0.8) for all measurements performed. Coronal FC and TC alignments were 95.29º (82.4º–100.6º) and 89.16º (84.4º–94.2º) respectively. HO ranged from 0 to 3 (0:43%, 1:36%, 2:11%, 3:10%). FC-Flexion and TC-slope were 10.17 (3.5–19.8) and 86.7 (61.2–99.2) respectively. Insall-Salvati ratio was 1.01 (0.58–2.04). Posterior condylar offset (CO) ratio was 0.51 (0.34–1.11). Anterior CO ratio was 0.2 (0–0.34). Anterior femoral cortex notching ranged from 0 to 3 (0:39%, 1:43%, 2:14%, 3:4%). Femoral posterior osteophytes were observed in 32% of patients. A gap between the anterior flange and the femoral cortex was observed in 45% of patients. The patella was resurfaced in 93% of patients with a mean patellar tilt and patellar displacement of 5.34º (−8.9º to 5.34º) and 9.88% (−5 to 41%) respectively. Conclusion. To our knowledge this is the first study reporting specific radiographic data on postoperative stiffness following primary TKA. From the observed radiographic measurements, the increased mean femoral component flexion, the high amount of postoperative HO and posterior osteophytes, and the anterior cortical and component gap suggest possible risk factors influencing the occurrence of postoperative stiffness. Future focus will include a matched control population of patients in order to establish statistical significance of all observed values

Abstract

Abstract

Objectives. Implant-related infection is one of the most devastating complications in orthopaedic surgery. Many surface and/or material modifications have been developed in order to minimise this problem; however, most of the in vitro studies did not evaluate bacterial adhesion in the presence of eukaryotic cells, as stated by the ‘race for the surface’ theory. Moreover, the adherence of numerous clinical strains with different initial concentrations has not been studied. Methods. We describe a method for the study of bacterial adherence in the presence of preosteoblastic cells. For this purpose we mixed different concentrations of bacterial cells from collection and clinical strains of staphylococci isolated from implant-related infections with preosteoblastic cells, and analysed the minimal concentration of bacteria able to colonise the surface of the material with image analysis. Results. Our results show that clinical strains adhere to the material surface at lower concentrations than collection strains. A destructive effect of bacteria on preosteoblastic cells was also detected, especially with higher concentrations of bacteria. Conclusions. The method described herein can be used to evaluate the effect of surface modifications on bacterial adherence more accurately than conventional monoculture studies. Clinical strains behave differently than collection strains with respect to bacterial adherence. Cite this article: M. Martinez-Perez, C. Perez-Jorge, D. Lozano, S. Portal-Nuñez, R. Perez-Tanoira, A. Conde, M. A. Arenas, J. M. Hernandez-Lopez, J. J. de Damborenea, E. Gomez-Barrena, P. Esbrit, J. Esteban. Evaluation of bacterial adherence of clinical isolates of Staphylococcus sp. using a competitive model: An in vitro approach to the “race for the surface” theory. Bone Joint Res 2017;6:315–322. DOI: 10.1302/2046-3758.65.BJR-2016-0226.R2

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.

Background

Mobile apps have shown promise in helping people to self-manage conditions like chronic low back pain (CLBP). However, it is unclear who benefits most, why, and under what circumstances. This limits our understanding of how to maximize the potential of mobile app technology.

Large cartilage lesions in younger patients can be treated by fresh osteochondral allograft transplantation, a surgical technique that relies on stable initial fixation and a minimum chondrocyte viability of 70% in the donor tissue to be successful. The Missouri Osteochondral Allograft Preservation System (MOPS) may extend the time when stored osteochondral tissues remain viable. This study aimed to provide an independent evaluation of MOPS storage by evaluating chondrocyte viability, chondrocyte metabolism, and the cartilage extracellular matrix using an ovine model.

Femoral condyles from twelve female Arcott sheep (6 years, 70 ± 15 kg) were assigned to storage times of 0 (control), 14, 28, or 56 days. Sheep were assigned to standard of care [SOC, Lactated Ringer's solution, cefazolin (1 g/L), bacitracin (50,000 U/L), 4°C storage] or MOPS [proprietary media, 22-25°C storage]. Samples underwent weekly media changes. Chondrocyte viability was assessed using Calcein AM/Ethidium Homodimer and reported as percent live cells and viable cell density (VCD). Metabolism was evaluated with the Alamar blue assay and reported as Relative Fluorescent Units (RFU)/mg. Electromechanical properties were measured with the Arthro-BST, a device used to non-destructively compress cartilage and calculate a quantitative parameter (QP) that is inversely proportional to stiffness. Proteoglycan content was quantified using the dimethylmethylene blue assay of digested cartilage and distribution visualized by Safranin-O/Fast Green staining of histological sections. A two-way ANOVA and Tukey's post hoc were performed.

Compared to controls, MOPS samples had fewer live cells (p=0.0002) and lower VCD (p=0.0004) after 56 days of storage, while SOC samples had fewer live cells (p=0.0004, 28 days; p=0.0002, 56 days) and lower VCD (p=0.0002, 28 days; p=0.0001, 56 days) after both 28 and 56 days (Table 1). At 14 days, the percentage of viable cells in SOC samples were statistically the same as controls but VCD was lower (p=0.0197). Cell metabolism in MOPS samples remained the same over the study duration but SOC had lower RFU/mg after 28 (p=0.0005) and 56 (p=0.0001) days in storage compared to controls. These data show that MOPS maintained viability up to 28 days yet metabolism was sustained for 56 days, suggesting that the conditions provided by MOPS storage allowed fewer cells to achieve the same metabolic levels as fresh cartilage. Electromechanical QP measurements revealed no differences between storage methods at any individual time point. QP data could not be used to interpret changes over time because a mix of medial and lateral condyles were used and they have intrinsically different properties. Proteoglycan content in MOPS samples remained the same over time but SOC was significantly lower after 56 days (p=0.0086) compared to controls. Safranin-O/Fast Green showed proteoglycan diminished gradually beginning at the articular surface and progressing towards bone in SOC samples, while MOPS maintained proteoglycan over the study duration (Figure 1).

MOPS exhibited superior viability, metabolic activity and proteoglycan retention compared to SOC, but did not maintain viability for 56 days. Elucidating the effects of prolonged MOPS storage on cartilage properties supports efforts to increase the supply of fresh osteochondral allografts for clinical use.

For any figures or tables, please contact the authors directly.

Background. Patient specific instrumentation (PSI) for total knee replacement (TKR) has demonstrated mixed success in simplifying the operation, reducing its costs, and improving limb alignment. Evaluation of PSI with tools such as radiostereometric analysis (RSA) has been limited, especially for cut-through style guides providing mechanical alignment. The primary goal of the present study was to compare implant migration following TKR using conventional and PSI surgical techniques, with secondary goals to examine whether the use of PSI reduces operative time, instrumentation, and surgical waste. Methods. The study was designed as a prospective, randomized controlled trial of 50 patients, with 25 patients each in the PSI and conventional groups, powered for the RSA analysis. Patients in the PSI group received an MRI and standing 3-foot x-rays to construct patient-specific cut-through surgical guides for the femur and tibia with a mechanical alignment. All patients received the same posterior-stabilized implant, with marker beads inserted in the bone around the implants to enable RSA imaging. Intraoperative variables such as time, number of instrumentation trays used, and mass of surgical waste were recorded. Patients underwent supine RSA exams at multiple time points (2&6 weeks, 3&6 months and yearly) with 6 months data currently available. Migration of the tibial and femoral components was calculated using model-based RSA software. WOMAC, SF-12, EQ5D, and UCLA outcome measures were recorded pre-operatively and post-operatively. Results. There were no demographic differences between groups. One patient in the PSI group was revised for infection, and three patients required manipulation, with no revisions or manipulations in the conventional group. There was no difference in maximum total point motion between groups for the tibia (mean 0.50 vs. 0.50 mm, p = 0.98) or femur (mean 0.46 vs. 0.48 mm, p = 0.87). The PSI group displayed greater tibial posterior tilt (p = 0.048, Fig. 1) and greater femoral anterior tilt (p = 0.01) and valgus rotation (p = 0.04, Fig. 2) than the conventional group, but there were no other differences in migrations. The PSI group required less instrument trays than the conventional group (mean 4.8 vs. 8.1 trays, p < 0.0001), but procedure time was equivalent (mean 79 vs. 74 min, p = 0.06). The PSI group produced less recyclable waste (mean 0.3 vs. 1.4 kg, p < 0.001), but total waste (Fig. 3) was equivalent between groups (mean 10.1 vs. 10.6 kg, p = 0.32). At 6 months there was no difference between groups for SF-12, WOMAC, EQ5D, or UCLA scores. Discussion. At early RSA follow-up, the two groups were broadly similar in implant fixation except for small rotational changes in the tibial and femoral components. The PSI group provided minimal or no advantage over the conventional group for operative time, instrumentation used, or surgical waste produced. The observed increase in manipulations in the PSI group is concerning, and requires additional investigation. Further radiographic and economic analysis is underway to determine if there is any benefit to the use of PSI for TKR during the perioperative and early follow-up period. For any figures or tables, please contact authors directly (see Info & Metrics tab above).

Patient-reported outcome measures (PROMs) have failed to highlight differences in function or outcome when comparing knee replacement designs and implantation techniques. Ankle-worn inertial measurement units (IMUs) can be used to remotely measure and monitor the bi-lateral impact load of patients, augmenting traditional PROMs with objective data. The aim of this study was to compare IMU-based impact loads with PROMs in patients who had undergone conventional total knee arthroplasty (TKA), unicompartmental knee arthroplasty (UKA), and robotic-assisted TKA (RA-TKA).

77 patients undergoing primary knee arthroplasty (29 RA-TKA, 37 TKA, and 11 UKA) for osteoarthritis were prospectively enrolled. Remote patient monitoring was performed pre-operatively, then weekly from post-operative weeks two to six using ankle-worn IMUs and PROMs. IMU-based outcomes included: cumulative impact load, bone stimulus, and impact load asymmetry. PROMs scores included: Oxford Knee Score (OKS), EuroQol Five-dimension with EuroQol visual analogue scale, and the Forgotten Joint Score.

On average, patients showed improved impact load asymmetry by 67% (p=0.001), bone stimulus by 41% (p<0.001), and cumulative impact load by 121% (p=0.035) between post-operative week two and six. Differences in IMU-based outcomes were observed in the initial six weeks post-operatively between surgical procedures. The mean change scores for OKS were 7.5 (RA-TKA), 11.4 (TKA), and 11.2 (UKA) over the early post-operative period (p=0.144). Improvements in OKS were consistent with IMU outcomes in the RA-TKA group, however, conventional TKA and UKA groups did not reflect the same trend in improvement as OKS, demonstrating a functional decline.

Our data illustrate that PROMs do not necessarily align with patient function, with some patients reporting good PROMs, yet show a decline in cumulative impact load or load asymmetry. These data also provide evidence for a difference in the functional outcome of TKA and UKA patients that might be overlooked by using PROMs alone.

Abstract

Introduction

Tibial Pilon fractures are potentially limb threatening, yet standards of care are lacking from BOFAS and the BOA. The mantra of “span, scan, plan” describes staged management with external fixation to allow soft tissue resuscitation, followed by a planning CT-scan. Our aim was to evaluate how Tibial Pilon fractures are acutely managed.

Background

Advanced spinal practitioner physiotherapists (ASPPs) assess and manage spinal referrals, as advocated by the National Low Back Pain Pathway in the United Kingdom. The ASPP pathway relies on multi-disciplinary team (MDT) meetings where potential surgically appropriate or complex cases can be discussed. Meetings were held with two different Consultant Spinal Neurosurgeons (total 2 meetings per month). The aim of this service evaluation was to assess MDT meeting outcomes and surgical listing.

Introduction

By utilising the inherent variability achievable with circular frames, surgeons can manage a wide spectrum of complex injuries, and can deal with deformity at multiple levels, in multiple planes. The aim of this study was to assess functional outcomes utilising patients reported outcome measures (PROMs) of patients being treated with circular (Ilizarov) frame fixation for complex lower limb injuries and assess these results in conjunction with the observed postoperative alignment of the patients’ limbs.

Currently implemented accuracy metrics in open-source libraries for segmentation by supervised machine learning are typically one-dimensional scores [1]. While extremely relevant to evaluate applicability in clinics, anatomical location of segmentation errors is often neglected.

This study aims to include the three-dimensional (3D) spatial information in the development of a novel framework for segmentation accuracy evaluation and comparison between different methods.

Predicted and ground truth (manually segmented) segmentation masks are meshed into 3D surfaces. A template mesh of the same anatomical structure is then registered to all ground truth 3D surfaces. This ensures all surface points on the ground truth meshes to be in the same anatomically homologous order. Next, point-wise surface deviations between the registered ground truth mesh and the meshed segmentation prediction are calculated and allow for color plotting of point-wise descriptive statistics. Statistical parametric mapping includes point-wise false discovery rate (FDR) adjusted p-values (also referred to as q-values).

The framework reads volumetric image data containing the segmentation masks of both ground truth and segmentation prediction. 3D color plots containing descriptive statistics (mean absolute value, maximal value,…) on point-wise segmentation errors are rendered. As an example, we compared segmentation results of nnUNet [2], UNet++ [3] and UNETR [4] by visualizing the mean absolute error (surface deviation from ground truth) as a color plot on the 3D model of bone and cartilage of the mean distal femur.

A novel framework to evaluate segmentation accuracy is presented. Output includes anatomical information on the segmentation errors, as well as point-wise comparative statistics on different segmentation algorithms. Clearly, this allows for a better informed decision-making process when selecting the best algorithm for a specific clinical application.

Aims

The International Consensus Meeting on Musculoskeletal Infection (ICM, Philadelphia 2018) recommended histology as one of the diagnostic tests although this is not routinely used in a number of UK hospitals. This study aims to explore the role of histology in the diagnosis of infection and whether it is of practical use in those cases where the microbiology samples are either diagnostically unclear or do not correspond to the pre-operative diagnosis or the clinical picture.

Introduction and Objective

Lower limb fractures are amongst the most common surgically managed orthopaedic injuries, with open reduction and internal fixation (ORIF) as the conventional method of treatment of the fibula. In recent years, dedicated intramedullary implants have emerged for fibula fixation in tandem with the move towards minimally invasive surgery in high-risk patients. This is the largest multicentre review to date with the aim of establishing the clinical outcomes following intramedullary nail (IMN) fixation of the fibula and to identify the absolute indication for fibula IMN fixation.

Summary Statement. In young, active patients cementless THR demonstrates excellent prosthetic stability by RSA and outstanding clinical outcomes at 5 years using a tapered titanium femoral stem, crosslinked polyethylene liners and either titanium or tantalum shells. Introduction. Early femoral implant stability is essential to long-term success in total hip replacement. Radiostereometric analysis (RSA) provides precise measurements of micromotion of the stem relative to the femur that are otherwise not detectable by routine radiographs. This study characterised micromotion of a tapered, cementless femoral stem and tantalum porous-coated vs. titanium acetabular shells in combination with highly cross-linked UHMWPE or conventional polyethylene liners using radiostereometric analysis (RSA) for 5 years following THR. Patients and Methods. This IRB-approved, prospective, double randomised, blinded study, involved 46 patients receiving a primary THR by a single surgeon. Each patient was randomised to receive a titanium (23) (Trilogy, Zimmer) or tantalum (23) (Modular Tantalum shell, Zimmer) uncemented hemispheric shell and either a highly-crosslinked or conventional polyethylene liner. Tantalum RSA markers were implanted in each patient. All patients had a Dorr A or B femoral canal and received a cementless, porous-coated titanium tapered stem (M/L Taper, Zimmer). All final femoral broaches were stable to rotational and longitudinal stress. RSA examinations, Harris Hip, UCLA, WOMAC, SF-12 scores were obtained at 10 days, 6 months, and annually through 5 years. Results. All patients demonstrated statistically significant improvement in Harris Hip, WOMAC, and SF-12 PCS scores post-operatively. Evaluation of polyethylene wear demonstrated that median penetration measurements were significantly greater in the conventional compared to the HXPLE liner cohorts at 1 year through 5 years follow-up (p<0.003). At 5 years, conventional liners showed 0.38 ± 0.05mm vertical wear whereas HXLPE liners showed 0.08 ± 0.02mm (p<0.003). Evaluation of the femoral stems demonstrated that the rate of subsidence was highest in the first 6 months (0.09mm/yr), with no other detectable motion through 5 years. Two outlying patients had significantly higher stem subsidence values at 6 months (0.7 mm and 1.0mm). One stem stabilised without further subsidence after 6 months (0.7mm), and the other stem stabilised at 1 year (1.5mm). Neither patient has clinical evidence of loosening. Evaluation of acetabular shells demonstrated less median vertical translation in tantalum than titanium shells at each time-point except at 3-years follow-up, however due to large standard errors, there was no significant difference between the two designs (p>0.05). These large standard errors were predominantly caused by two outliers, neither of which had clinical evidence of loosening. Discussion/Conclusion. In this RSA study of young THR patients, cementless tapered femoral stems, highly crosslinked polyethylene liners, and tantalum or titanium acetabular shells all demonstrated excellent performance through 5 years follow-up. Highly crosslinked polyethylene liners demonstrated significantly less wear than conventional liners. The femoral stem showed excellent stability through 5 years, with no clinical or radiologic episodes of failure. The small amount of micromotion seen is less than that previously reported for similar tapered, cementless stems and approaches the accuracy of RSA (0.05mm). Both acetabular shells demonstrated excellent stability with minimal micromotion at 5 years without significant differences in migration. All patients demonstrated significant clinical improvement in pain and function and additional RSA evaluation of these patients is planned

µCT images are commonly analysed to assess changes in bone density and architecture in preclinical murine models. Several platforms provide automated analysis of bone architecture parameters from volumetric regions of interest (ROI). However, segmentation of the regions of subchondral bone to create the volumetric ROIs remains a manual and time-consuming task. This study aimed to develop and evaluate automated pipelines for trabecular bone architecture analysis of mouse proximal tibia subchondral bone.

A segmented dataset involving 62 knees (healthy and arthritic) from 10-week male C57BL/6 mice were used to train a U-Net type architecture, with µCT scans (downsampled) input that output segmentation and bone volume density (BV/TV) of the subchondral trabecular bone. Segmentations were upsampled and used in tandem with the original scans (10µ) as input for architecture analysis along with the thresholded trabecular bone. The analysis considered the manually and U-Net segmented ROIs using two available pipelines: the ITKBoneMorphometry library and CTan (SKYSCAN). The analyses included: bone volume (BV), total volume (TV), BV/TV, trabecular number (TbN), trabecular thickness (TbTh), trabecular separation (TbSp), and bone surface density (BSBV).

There was good agreement for bone measures between the manual and U-Net pipelines utilizing ITK (R=0.88-0.98) and CTan (R=0.91-0.98). ITK and CTan showed good agreement for BV, TV, BV/TV, TbTh and BSBV (R=0.9-0.98). However, a limited agreement was seen between TbN (R=0.73) and TbSb (R=0.59) due to methodological differences in how spacing is evaluated.

This U-Net/ITK pipeline seamlessly automated both segmentation and quantification of the proximal tibia subchondral bone. This automated pipeline allows the analysis of large volumes of data, and its open-source nature may enable the standardization of stereologic analysis of trabecular bone across different research groups.

Little information exists when using cell viability assays to evaluate cells within whole tissue, particularly specific types such as the intervertebral disc (IVD). When comparing the reported methodologies and the protocols issued by manufacturers, the processing, working times, and dye concentrations vary significantly, making the assay's reproducibility a costly and time-consuming trial and error process. This study aims to develop a detailed step-by-step cell viability assay protocol for evaluating IVD tissue.

IVDs were harvested from bovine tails (n=8) and processed at day 0 and after 7 days of culture. Nucleus pulposus (NP) and the annulus fibrosus (AF) 3 mm cuts were incubated at room temperature (26˚C) with a Viability/Cytotoxicity Kit containing Calcein AM and Ethidium Ethidium homodimer-1 for 2 hr, followed by flash freezing in liquid nitrogen. Thirty µm sections were placed in glass slides and sealed with nail varnish or Antifade Mounting Medium. The IVD tissue was imaged within the next 4h after freezing using an inverted confocal laser-scanning microscope equipped with 488 and 543 nm laser lines.

Cell viability at day 0 (NP: 92±9.6 % and AF:80±14.0%) and day 7 (NP: 91±7.9% and AF:76±20%) was successfully maintained and evaluated. The incubation time required is dependent on the working temperatures and tissue thickness. The calcein-AM dye will not be retained in the cells for more than four hours.

The specimen preparation and culturing protocol have demonstrated good cell viability at day 0 and after seven days of culture. Processing times and sample preparation play an essential role as the cell viability components in most kits hydrolyse or photobleach quickly. A step-by-step replicable protocol for evaluating the cell viability in IVD will facilitate the evaluation of cell and toxicity-related outcomes of biomechanical testing protocols and IVD regenerative therapies.

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 BMD.

119 patients were randomized to receive either a proximally coated dual taper wedge stem, a proximally coated anatomic stem or a fully coated collarless triple tapered stem. 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 comparing the unoperated contralateral femur as a control.

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% in the 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.

Implant design was shown to impact BMD changes. All stems preserved bone at the metaphyseal level in early follow-up, which theoretically indicates favorable implant fixation. There was no significant stress shielding observed, however longer follow-up is required to elucidate the impact of this finding on implant survivorship.

Aim of this study was the development of a dynamic FE-framework to identify worst-case size combinations and kinematics in a virtual wear simulator setup covering five daily activities and high, dynamic loads.

Two cruciate sacrificing knee designs (D1 & D2) were tested physically on a wear-testing machine prior the model development using a high demanding, daily activity protocol (HDA) [1]. A simplified FE-setup was generated, reduced to the 3D geometries of the assembly whereas the representation of the mechanical wear simulator conditions and the load transmission was achieved by joint elements. Inertial and other time-related effects of the physical situation were compensated by a system of spring- and damper elements.

Using a time-series signal optimization approach on the anterior-posterior translation and the internal-external rotation results for each activity, 38 variable parameters were varied in between pre-defined limits in a semiautomatic workflow. For each design, two consecutive cycles of a single activity were analysed and the results of the second cycle were used for the optimization. Based on the determined values, a single set of averaged parameter settings was identified that covers all activity cycles sufficiently.

A total of 1010 dynamic analyses were carried out in order to find a sharable set of parameter values.

In this study, an efficient simulation workflow for design evaluation was developed. Therefore, a HDA wear-testing machine was simplified to boundary conditions and stabilizing elements, using a single set of parameters for all activities. The calculated kinematics were in a comparable range to the machine output. Further applications of the method were found in systematic analyses of entire implant systems to achieve consistent kinematics over the size compatibility range in the design process of new implant systems.

Aims

Knee arthroplasty surgery is a highly effective treatment for arthritis and disorders of the knee. There are a wide variety of implant brands and types of knee arthroplasty available to surgeons. As a result of a number of highly publicized failures, arthroplasty surgery is highly regulated in the UK and many other countries through national registries, introduced to monitor implant performance, surgeons, and hospitals. With time, the options available within many brand portfolios have grown, with alternative tibial or femoral components, tibial insert materials, or shapes and patella resurfacings. In this study we have investigated the effect of the expansion of implant brand portfolios and where there may be a lack of transparency around a brand name. We also aimed to establish the potential numbers of compatible implant construct combinations.

INTRODUCTION. Several papers have reported the efficacy of an imageless navigation system in acetabular cup orientation during total hip arthroplasty (THA). Also, an imageless navigation system is useful for recovering leg length discrepancy. However, no study has evaluated the accuracy of the stem antetorsion angle (SAA) with an imageless navigation system in THA. The purpose of this study was to evaluate the accuracy of the stem antetorsion angles, which were measured by CT with the CT-free navigation system. Also, we evaluate the factors that affect the inaccuracy. MATERIALS AND METHODS. CT evaluation was performed in 60 patients (60 joints) who underwent primary THA from December 2011 to March 2014. Fifty-nine patients were female. The mean age at surgery was 67 years. The mean BMI at surgery was 24.0 kg/m2. Fifty-four patients had osteoarthrosis, 5 patients had osteonecrosis, and 1 patient had femoral neck fracture. All surgeries were performed in the supine position with the direct anterior approach. The OrthoPilot imageless navigation system was used during surgery. An Excia stem was used in 47 patients and a Bicontact stem was used in the other 13. Evaluation of SAA was carried out. Instead of SAA, the navigation indicates the rasp antetorsion angle based on the hip-knee-ankle plane during surgery. SAA based on the posterior condylar plane was measured with CT by using 3D THA plannning software. The accuracy of the imageless navigation system was evaluated by comparison of the navigation values obtained during surgery with the CT measured values. Correlations were analyzed with Pearson correlation analysis. RESULTS. The rasp antetorsion angle was 28.1±9.6 degrees [range 7.7–49.2 degrees]. The mean SAA was 29.9±8.9 degrees [10.7–49.7 degrees] in CT. Strong correlation was found between the rasp antetorsion angle and SAA (p<0.001, r=0.858, Figure). The difference between SAA and the rasp antetorsion angle (SAA – rasp antetorsion angle) was 1.8±4.7 degrees [-6.7–11.9 degrees]. The mean absolute difference between the rasp antetorsion angle and SAA was 4.0±3.1 degrees [0.2–11.9 degrees]. Forty-five cases (75%) showed less than 5 degrees of difference between SAA and the rasp antetorsion angle. Five cases (8.3%) showed more than 10 degrees of difference. In these five cases, SAAs were greater than the rasp antetorsion angles. Patients’ age, height, weight, and BMI did not affect the difference. Deformity of the femoral head, osteoarthrosis of the hip with subluxation, and osteoarthrosis of the knee were found in the patients who showed more than 5 degrees of difference between SAA and the rasp antetorsion angle. DISCUSSION. This study demonstrated that imageless navigation showed good accuracy for determining SAA during operation. This helps surgeons to recognize combined anteversion during surgery, and to avoid impingement after THA. This navigation system determines rasp antetorsion angle based on the hip-knee-ankle plane. The hip center is defined by setting the trial cup on the acetabulum. The knee center and the ankle center are defined by pointing over the skin. Therefore, deformity of the acetabulum or femoral head may affect the accuracy of the rasp antetorsion angle

Background. In the literature are different data about the allogenic blood transfusion rate after total knee replacement. The common intention in orthopedic surgery is to reduce the requirement for allogenic blood transfusions by optimizing the blood management. The aim of this study is to determine the efficacy of the mechanical autotransfusion system OrthoPAT® to reduce the postoperative allogenic blood transfusion (ABT) rate. Method. According to the preliminary performed power analysis we did a prospective controlled study including 151 patients which were randomized in a group A (OrthoPAT® for intra- and postoperative blood salvage and retransfusion, n=76 patients) and a control group B (no retransfusion system was used, n=75 patients). All patients had a primary osteoarthritis of the knee and were operated on without use of a tourniquet. We implanted in all patients a cemented posterior stabilized total knee prosthesis design. In group A the autotransfusion system was used for 6 hours (intra- and postoperatively) and the collected blood was retransfused. The retransfused blood was anticoagulated, filtered and centrifuged to separate waste products. Red cells were washed with saline and reconcentrated to a high hematocrit. The preoperative data for cardiopathy, angiopathy, preoperative anemia or anticoagulant treatment showed no significant differences for group A and B. Because of missing data we finally were able to use the results of 140 patients: 70 group A and 70 in group B. The indications for a blood transfusion were influenced by the clinical symptoms of anemia, the hemoglobin value (hemoglobin < 8.0 g/dl) and the anamnesis of cardiovascular diseases. Evaluation was done with the medical history and the pre-/postoperative hemoglobin values and postoperative need of allogenic blood transfusion. Results. The two groups showed no significant differences relating to the demographic data or the medical history. 23 patients (33 %) of the retransfusion group who in mean received 281 ml of salvaged blood needed allogenic blood transfusion compared with 23 patients (33 %) of the control group B (p=0,999). The hemoglobin values of group A versus the control group showed after the donation of the salvaged blood a tendency to a higher hemoglobin value (p=0,062) but no longer at the third and fifth day postoperative. Conclusions. In this clinical observation the use of the autotransfusion system does not reduce the postoperative allogenic blood transfusion rate. At the third and fifth day postoperatively no significant differences of the hemoglobin values could be stated comparing group A with group B

Objectives. This study aimed to evaluate the histological and mechanical features of tendon healing in a rabbit model with second-harmonic-generation (SHG) imaging and tensile testing. Materials and Methods. A total of eight male Japanese white rabbits were used for this study. The flexor digitorum tendons in their right leg were sharply transected, and then were repaired by intratendinous stitching. At four weeks post-operatively, the rabbits were killed and the flexor digitorum tendons in both right and left legs were excised and used as specimens for tendon healing (n = 8) and control (n = 8), respectively. Each specimen was examined by SHG imaging, followed by tensile testing, and the results of the two testing modalities were assessed for correlation. Results. While the SHG light intensity of the healing tendon samples was significantly lower than that of the uninjured tendon samples, 2D Fourier transform SHG images showed a clear difference in collagen fibre structure between the uninjured and the healing samples, and among the healing samples. The mean intensity of the SHG image showed a moderate correlation (R. 2. = 0.37) with Young’s modulus obtained from the tensile testing. Conclusion. Our results indicate that SHG microscopy may be a potential indicator of tendon healing. Cite this article: E. Hase, K. Sato, D. Yonekura, T. Minamikawa, M. Takahashi, T. Yasui. Evaluation of the histological and mechanical features of tendon healing in a rabbit model with the use of second-harmonic-generation imaging and tensile testing. Bone Joint Res 2016;5:577–585. DOI: 10.1302/2046-3758.511.BJR-2016-0162.R1

Purpose of the study

The purpose of this project was to evaluate whether OHEIs could facilitate student physiotherapy placement training in their educational outpatient clinics.

Abstract

The use of intraoperative navigation and robotic surgery for minimally invasive lumbar fusion has been increasing over the past decade. The aim of this study is to evaluate postoperative clinical outcomes, intraoperative parameters, and accuracy of pedicle screw insertion guided by intraoperative navigation in patients undergoing lumbar interbody fusion for spondylolisthesis. Patients who underwent posterior lumbar fusion interbody using intraoperative 3D navigation since December 2021 were included. Visual Analogue Scale (VAS), Oswestry Disability Index (ODI), and Short Form Health Survey-36 (SF-36) were assessed preoperatively and postoperatively at 1, 3, and 6 months. Screw placement accuracy, measured by Gertzbein and Robbins classification, and facet joint infringement, measured by Yson classification, were assessed by intraoperative Cone Beam CT scans performed at the end of instrumentation. Finally, operation time, intraoperative blood loss, hospital stay, and screw insertion time were evaluated. This study involved 50 patients with a mean age of 63.7 years. VAS decreased from 65.8±23 to 20±22 (p<.01). ODI decreased from 35.4%±15 to 11.8%±14 (p<.01). An increase of SF-36 from 51.5±14 to 76±13 (p<.01) was demonstrated. The accuracy of “perfect” and “clinically acceptable” pedicle screw fixation was 89.5% and 98.4%, respectively. Regarding facet violation, 96.8% of the screws were at grade 0. Finally, the average screw insertion time was 4.3±2 min, hospital stay was 4.2±0.8 days, operation time was 205±53 min, and blood loss was 169±107 ml. Finally, a statistically significant correlation of operation time with hospital stay, blood loss and placement time per screw was found. We demonstrated excellent results for accuracy of pedicle screw fixation and violation of facet joints. VAS, ODI and SF-36 showed statistically significant improvements from the control at one month after surgery.

Navigation with intraoperative 3D images represents an effective system to improve operative performance in the surgical treatment of spondylolisthesis.

Aim

Staphylococcus aureus (SA) can cause various infections and is associated with high morbidity and mortality rates of up to 40%. Antibiotic treatment often fails to eradicate SA infections even if the causative strain has been tested susceptible in vitro. The mechanisms leading to this persistence is still largely unknown. In our work, we to reveal SA interactions with host cells that allow SA to persist at the site of infection.

The external fixator is an invaluable device when treating acute complex trauma and in limb reconstruction. It is therefore important to ensure its efficient and safe application to avoid complications. A lot of research has been done to evaluate the factors around external fixator stability, pin site infections and more is still being done to understand pin loosening. The purpose of this study was to evaluate other factors that may contribute in external fixator pin loosening. The aim was to evaluate if the different Schanz pin insertion techniques contribute to pin loosening.

Two tibia diaphyses from two cadavers were each divided into three sections. Three different drilling techniques were repeated in each of the sections. A total of 36 Schanz pins were inserted and a section cut out of the bone in front of the pins was done allowing visual inspection of the pin hole for features of thread stripping. These features were predefined as thread pattern disruption, smoothening and shallow imprint on the cortex.

Evidence of pin thread stripping was seen in all of the pin insertion techniques. The first method where the hole was pre-drilled and pin inserted with the drill showed 100% thread stripping. The second method of pre-drilling and hand insertion showed the least amount with 16.7% of pin stripping noted and 66.7% pin thread stripping was observed when inserting the pin with power without pre-drilling the pilot hole using the third method.

Different pin insertion techniques result in varying amounts of pin thread stripping. The most amount of thread stripping occurs when a Schanz pin is inserted with power after pre-drilling. This finding, although not measured scientifically, supports the current recommendation of pre-drilling and manual insertion of the pin. In future, more scientific measurement are necessary to quantify these findings and assess their clinical significance.

Aim

Bone and joint infections (BJIs) are serious infections requiring early optimized antimicrobial therapy. BJIs can be polymicrobial or caused by fastidious bacteria, and the patient may have received antibiotics prior to sampling, which may decrease the sensitivity of culture-based diagnosis. Furthermore, culture-based diagnosis can take up to 14 days. Molecular approaches can be useful to overcome these concerns. The BioFire® system performs syndromic multiplex PCR in 1 hour, with only a few minutes of sample preparation. The BioFire® Joint Infection (JI) panel (BF-JI), recently FDA-cleared, detects both Gram-positive (n=15) and Gram-negative bacteria (n=14), Candida, and eight antibiotic resistance genes directly from synovial fluids. The aim of this study was to evaluate its performance in acute JIs in real-life conditions.

Introduction

Lower limb immobilisation with full casts is commonly used to manage fractures. There may be the need to split casts in an emergency, such as compartment syndrome, with no current consensus as to which technique is most effective in reducing pressure quickly. Our study aims to compare the reduction in pressure across lower leg compartments using three different cast splitting techniques.

Aim

Synovial calprotectin point-of-care test (POC) has shown promising clinical value in diagnosing periprosthetic joint infections (PJIs). However, limited data are available in unclear cases. Moreover, cut-off values for calprotectin lateral flow assay (LFA) and enzyme-linked immunosorbent assay (ELISA) need to be adapted. The aim of this study was to evaluate the performance of an upgraded and more sensitive version of a synovial calprotectin LFA along with ELISA immunoassay in patients with septic, aseptic, and unclear cases.

Thirty- seven patients were enrolled in a single-blind prospective randomized clinical trial comparing the use of the Endopearl in femoral fixation in otherwise similar anterior cruciate ligament (ACL) reconstructions. Evaluation pre-operatively, three months, six months and eighteen months post-operatively suggested significant difference in the side to side KT-1000 values suggesting improved graft fixation with the EndoPearl by eighteen months post surgery with no differences in the Mohtadi ACL QOL questionnaire. Thus, when bioabsorbable interference screws are used for ACL reconstruction, the use of the EndoPearl improves anterior-posterior stability up to eighteen months post-operatively. The EndoPearl is an adjunct to bioabsorbable interference screw fixation in the femoral tunnel in ACL reconstruction. The purpose of the study was to assess the clinical effectiveness of the EndoPearl using the KT-1000 Knee Arthrometer and the Mohtadi ACL Quality of Life (ACL-QOL) Questionnaire. The application of the EndoPearl in hamstring ACL reconstruction has no significant benefit when compared to conventional treatment in KT-1000 and ACL-QOL Questionnaire outcomes. Prospective Single-blind Randomized Clinical Trial. ACL reconstruction with autogenous semitendino-sus and gracilis tendons was performed on thirty-seven patients. Pre-operatively, three months, six months and a eighteen months post-operatively, patients’ knees were evaluated using the KT-1000 Knee Arthrometer and the ACL-QOL questionnaire. Statistically significant differences were achieved in terms of KT-1000 side-to-side differences between the study group and the control group at six months and eighteen months post-operatively; the mean-side-to-side differences are significantly less in the study group when compared to the control group. Statistically significant differences could not be detected when comparing the ACL-QOL questionnaire between the two groups. The application of the EndoPearl in conjunction with a bioscrew in the femoral tunnel in autogenous ACL reconstruction using semitendinosus and gracilis tendon grafts provides a significantly decreased laxity up to eighteen months post-operatively in terms of KT-1000 side-to-side differences. In an accelerated post-operative rehabilitation program, patients and doctors have increased confidence in terms of graft stability with the application of the Endo-Pearl in hamstring ACL reconstruction. Please contact author for pictures and/or diagrams

Background: In the literature are different data about the allogenic blood transfusion rate after total knee replacement. The common intention in orthopedic surgery is to reduce the requirement for allogenic blood transfusions by optimizing the blood management. The aim of this study is to determine the efficacy of the mechanical autotransfusion system OrthoPAT (Haemonetics Corp., MA, USA) to reduce the postoperative allogenic blood transfusion rate. Method: According to the preliminary performed power analysis we did a prospective controlled study including 104 patients which were randomized in a group A (OrthoPAT for intra- and postoperative blood salvage and retransfusion, n = 52 patients) and a control group B (no retransfusion system was used, n = 52 patients) All patients had a primary osteoarthritis of the knee and were operated on without use of a tourniquet. We implanted in all patients a cemented posterior stabilized total knee prosthesis design (LPS-Flex Mobile, Zimmer, IN, USA). In group A the autotransfusion system was used for 6 hours (intra- and postoperatively) and the collected blood was retransfused. The retransfused blood is anticoagulanted, filtered and centrifuged to separate waste products. Red cells are washed with saline and reconcentrated to a high haematocrit. The preoperative data for cardiopathy, angiopathy, preoperative anemia or anticoagulant treatment showed no significant differences for group A and B. Because of missing data we finally were able to use the results of 98 patients: 48 group A and 50 in group B. The indications for a blood transfusion were influenced by the clinical symptoms of anemia, the hemoglobin value (hemoglobin < 8.0 g/dl) and the anamnesis of cardiovascular diseases. Evaluation was done with the medical history and the pre-/postoperative hemoglobin values, postoperative blood loss and postoperative need of allogenic blood transfusion. Results: The two groups showed no significant differences relating to the demographic data or the medical history. 16 patients (33 %) of the retransfusion group who in mean received 281 ml of salvaged blood needed allogenic blood transfusion compared with 22 patients (44 %) of the control group B (p = 0,306). The hemoglobin values of group A versus the control group showed after the donation of the salvaged blood a significant difference (p = 0,027) but no longer at the 3rd and 5th day postoperative. Conclusions: The use of the autotransfusion system seems to reduce the postoperative allogenic blood transfusion rate but not statistical significant. At the 3rd and 5th day postoperatively no significant differences of the hemoglobin values could be stated comparing group A with group B. For us this was a clue showing that the quality of the erythrocytes after the reclamation was reduced

Introduction. A variety of patient reported outcome (PRO) surveys have been established and validated to evaluate the effectiveness of surgical interventions. The Hip Disability and Osteoarthritis Outcome Score (HOOS) has been validated as one method to evaluate the effectiveness of total hip arthroplasty patients. This PRO facilitates the assessment of factors that alter patient outcomes in hip arthroplasty. This retrospective study assesses the effect of psychological post-operative expectations on HOOS in total hip arthroplasty patients. In this pilot study, patient data was collected for 499 patients using the AAOS established Musculoskeletal Outcomes Data Evaluation and Management System (MODEMS) [1] and HOOS surveys. Method. Patient data was matched using similar preoperative HOOS scores to allow for comparable room for improvement in HOOS score postoperatively. These patients were placed into groups of high performers and low performers. HOOS is based on a 0 to 100 scale, 100 as the best. High performers were defined as those with a ratio of change in HOOS score between preoperative and postoperative over the highest difference in score possible (reaching a postoperative HOOS of 100) of 1. Low performers were defined as those with the aforementioned ratio, but under the value of 0.3. Using these defined groups we were able to compare the summation of patient specific MODEMS scores using a univariate regression. The HOOS growth ratio is calculated based on the following. HOOS growth ratio = (HOOS postop – HOOS preop)/(100-HOOS preop). A principal component analysis (PCA) was conducted to identify the significant group of factors that could identify changes in the outcome of 41 patients (20 low performers and 21 high performers). Results and analysis. PCA was conducted on 5 items with orthogonal rotation (varimax). The Kaiser–Meyer–Olkin measure verified the sampling adequacy for the analysis, KMO = .0.688, which is well above the acceptable limit of 0.5. Two components had eigenvalues over Kaiser's criterion of 1 and in combination explained 74.487% of the variance. The scree plot demonstrate the two components that were retained in the final analysis. Component 1 represents expected outcome measured on Household activity, sleep comfort, and expected relief; the second component was made of expected outcome based on recreation activity and expected time to return to job. The outcome of the logistic regression model indicated that the factors in the first component group could significantly identify the performance of the patients after surgery. Conclusions. In this study we used MODEMS questionnaire to find the postoperative performance outcome of the patients with THA. MODEMS has shown potential in identifying these individuals however the major component in this questionnaire were expected outcome measured on Household activity, sleep comfort, and expected relief. THis questionnaire can be used for future studies

7% of adolescent idiopathic scoliosis (AIS) patients also present with a pars defect. To date, there are no available data on the results of fusion ending proximal to a spondylolysis in the setting of AIS. The aim of this study was to analyze the outcomes of posterior spinal fusion (PSF) in this patient cohort, to investigate if maintaining the lytic segment unfused represents a safe option.

Retrospective review of all patients who received PSF for AIS, presented with a spondylolysis or spondylolisthesis and had a min. 2-years follow-up. Demographic data, instrumented levels and preoperative radiographic data were collected. Mechanical complications, coronal or sagittal parameters, amount of slippage and pain levels were evaluated.

Data from 22 patients were available (age 14.4 ± 2.5 years), 18 Lenke 1–2 and four Lenke 3–6. Five patients (24%) had an isthmic spondylolisthesis, all Meyerding I. The mean preoperative Cobb angle of the instrumented curves was 58 ± 13°. For 18 patients the lowest instrumented vertebra (LIV) was the last touched vertebra (LTV); for two LIV was distal to the LTV; for two, LIV was one level proximal to the LTV. The number of segments between the LIV and the lytic vertebra ranged from 1 to 6. At the last follow-up, no complications were observed. The residual curve below the instrumentation measured 8.5 ± 6.4°, the lordosis below the instrumented levels was 51.4 ± 13°. The magnitude of the isthmic spondylolisthesis remained constant for all included patients. Three patients reported minimal occasional low back pain.

The LTV can be safely used as LIV when performing PSF for the management of AIS in patients with L5 spondylolysis

Abstract

The lack of a universal, consistent protocol for the subjective, objective and radiographic evaluation of these injuries has hampered the comparison of results. Methods. 45 patients with complex fractures of the calcaneus were included in this prospective study, which was undertaken from July 2003 to December 2005. The fracture classification of Essex-Lopresti was used. We also observed the extent of secondary fracture lines extending from the primary shear line (on axial and external oblique plain radiographs) to establish comminution. The external oblique view for subtalar joint was performed with the patient supine, the knee at about 60 degree of flexion and the limb rotated externally 45 degree with a vertical X ray beam. All of these patients were managed by an external fixator using the principle of ligamentotaxis. Patients were evaluated by AOFAS. Results. We identified two broad patterns of secondary lines on plain X-rays:. with anterior secondary fracture lines and. with posterior secondary fracture lines. There were 20 cases of tongue type and 25 of joint depression type fracture pattern by the Essex-Lopresti classification. Forty two (93.4%) patients had fractures with posterior secondary fracture line and 3 (6.7%) patients had anterior secondary lines. The calcaneo-cuboid type of anterior secondary line pattern was present in 2 (4.5%) cases, and the plantar type in only 1 (2.5%) case. We observed posterior secondary line Type A pattern in 2 (4.5%) cases, depression / central depression type B in 20 (44.5%) cases, tongue shaped Type C pattern in 16 (36.5%) cases and Type D severely comminuted fracture line pattern in 4 (8.7%) cases. Conclusion. Comminution was significantly associated with prognosis and final outcome. Evaluation of secondary fracture lines corresponds with comminution of fractures of the calcaneus and the final outcome of these fractures. NO DISCLOSURES

Noise induced hearing loss (NIHL) is a common cause of preventable deafness in adults and exposure to loud noise at work is a significant risk factor for its development. In order to protect the hearing of workers in the U.K., the Health and Safety Executive (HSE), on behalf of the Department for Work and Pensions, established the Control of Noise at Work Regulations (2005). The objectives of this study were to define the levels of noise exposure for the surgeon, assistant, scrub nurse and anaesthetist during total hip and knee arthroplasty surgery. In addition, we sought to determine whether the noise exposure during these procedures reaches or exceeds the action values set out by the U.K. Noise at Work Regulations (2005). To our knowledge no real-time assessment of personal noise exposure has been performed simultaneously on multiple members of the theatre team during arthroplasty surgery.

Individual noise exposure during arthroplasty hip and knee surgery was recorded using a personal noise dosemeter system model 22 (DM22) (Pulsar instruments, Filey, U.K.). Recordings were taken real-time during five separate theatre sessions. Each theatre session included two arthroplasty procedures and lasted approximately 4hrs. Personal noise exposure was expressed in terms of peak sound pressure and an average noise exposure over an 8-hour time-period to reflect the noise experienced by the ear over a working day.

In all three sessions involving total hip replacement surgery the peak sound pressure, for the operating surgeon, exceeded the exposure action values set out by the U.K. Noise at Work Regulations. Theatre sessions involving total knee replacement surgery did not exceed any exposure action values.

The peak sound pressures experienced during total hip replacement surgery are too high and mandate that the surgeon should be provided with appropriate hearing protection. In addition, if the upper exposure action value is routinely exceeded then the theatre should be designated a hearing protection zone.

Acute spinal cord injury (SCI) is most often secondary to trauma, and frequently presents with associated injuries. A neurological examination is routinely performed during trauma assessment, including through Advanced Trauma Life Support (ATLS). However, there is no standard neurological assessment tool specifically used for trauma patients to detect and characterize SCI during the initial evaluation. The International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) is the most comprehensive and popular tool for assessing SCI, but it is not adapted to the acute trauma patients such that it is not routinely used in that setting. Therefore, the objective is to develop a new tool that can be used routinely in the initial evaluation of trauma patients to detect and characterize acute SCI, while preserving basic principles of the ISNCSCI.

The completion rate of the ISCNSCI during the initial evaluation after an acute traumatic SCI was first estimated. Using a modified Delphi technique, we designed the Montreal Acute Classification of Spinal Cord Injuries (MAC-SCI), a new tool to detect and characterize the completeness (grade) and level of SCI in the polytrauma patient. The ability of the MAC-SCI to detect and characterize SCI was validated in a cohort of 35 individuals who have sustained an acute traumatic SCI. The completeness and neurological level of injury (NLI) were assessed by two independent assessors using the MAC-SCI, and compared to those obtained with the ISNCSCI.

Only 33% of patients admitted after an acute traumatic SCI had a complete ISNCSCI performed at initial presentation. The MAC-SCI includes 53 of the 134 original elements of the ISNCSCI which is 60% less. There was a 100% concordance between the severity grade derived from the MAC-SCI and from the ISNCSCI. Concordance of the NLI within two levels of that obtained from the ISNCSCI was observed in 100% of patients with the MAC-SCI and within one level in 91% of patients. The ability of the MAC-SCI to discriminate between cervical (C0 to C7) vs. thoracic (T1 to T9) vs. thoraco-lumbar (T10 to L2) vs. lumbosacral (L3 to S5) injuries was 100% with respect to the ISNCSCI.

The rate of completion of the ISNCSCI is low at initial presentation after an acute traumatic SCI. The MAC-SCI is a streamlined tool proposed to detect and characterize acute SCI in polytrauma patients, that is specifically adapted to the acute trauma setting. It is accurate for determining the completeness of the SCI and localize the NLI (cervical vs. thoracic vs. lumbar). It could be implemented in the initial trauma assessment protocol to guide the acute management of SCI patients.

To analyse bone stresses in humerus-megaprosthesis construct in response to axial loading under varying implant lengths in proximal humeral replacement following tumour excision.

CT scans of 10 cadaveric humeri were processed in 3D Slicer to obtain three-dimensional (3D) models of the cortical and cancellous bone. Megaprostheses of varying body lengths (L) were modelled in FreeCAD to obtain the 3D geometry. Four FE models: group A consisting of intact bone; groups B (L=40mm), C (L=100mm) and D (L=120mm) comprising of humerus-megaprosthesis constructs were created. Isotropic linear elastic behaviour was assigned for all materials. A tensile load of 200N was applied to the elbow joint surface with the glenohumeral joint fixed with fully bonded contact interfaces. Static analysis was performed in Abaqus. The bone was divided at every 5% bone length beginning distally. Statistical analysis was performed on maximum von Mises stresses in cortical and cancellous bone across each slice using one-way ANOVA (0-45% bone length) and paired t-tests (45-70% bone length). To quantify extent of stress shielding, average percentage change in stress from intact bone was also computed.

Maximum stress was seen to occur distally and anteriorly above the coronoid fossa. Results indicated statistically significant differences between intact state and shorter megaprostheses relative to longer megaprostheses and proximally between intact and implanted bones. Varying levels of stress shielding were recorded across multiple slices for all megaprosthesis lengths. The degree of stress shielding increased with implant lengthening being 2-4 times in C and D compared to B.

Axial loading of the humerus can occur with direct loading on outstretched upper limbs or indirectly through the elbow. Resultant stress shielding effect predicted in longer megaprosthesis models may become clinically relevant in repetitive axial loading during activities of daily living. It is recommended to use shorter megaprosthesis to prevent failure.

Acute spinal cord injury (SCI) is most often secondary to trauma, and frequently presents with associated injuries. A neurological examination is routinely performed during trauma assessment, including through Advanced Trauma Life Support (ATLS). However, there is no standard neurological assessment tool specifically used for trauma patients to detect and characterize SCI during the initial evaluation. The International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) is the most comprehensive and popular tool for assessing SCI, but it is not adapted to the acute trauma patients such that it is not routinely used in that setting. Therefore, the objective is to develop a new tool that can be used routinely in the initial evaluation of trauma patients to detect and characterize acute SCI, while preserving basic principles of the ISNCSCI.

The completion rate of the ISCNSCI during the initial evaluation after an acute traumatic SCI was first estimated. Using a modified Delphi technique, we designed the Montreal Acute Classification of Spinal Cord Injuries (MAC-SCI), a new tool to detect and characterize the completeness (grade) and level of SCI in the polytrauma patient. The ability of the MAC-SCI to detect and characterize SCI was validated in a cohort of 35 individuals who have sustained an acute traumatic SCI. The completeness and neurological level of injury (NLI) were assessed by two independent assessors using the MAC-SCI, and compared to those obtained with the ISNCSCI.

Only 33% of patients admitted after an acute traumatic SCI had a complete ISNCSCI performed at initial presentation. The MAC-SCI includes 53 of the 134 original elements of the ISNCSCI which is 60% less. There was a 100% concordance between the severity grade derived from the MAC-SCI and from the ISNCSCI. Concordance of the NLI within two levels of that obtained from the ISNCSCI was observed in 100% of patients with the MAC-SCI and within one level in 91% of patients. The ability of the MAC-SCI to discriminate between cervical (C0 to C7) vs. thoracic (T1 to T9) vs. thoraco-lumbar (T10 to L2) vs. lumbosacral (L3 to S5) injuries was 100% with respect to the ISNCSCI.

The rate of completion of the ISNCSCI is low at initial presentation after an acute traumatic SCI. The MAC-SCI is a streamlined tool proposed to detect and characterize acute SCI in polytrauma patients, that is specifically adapted to the acute trauma setting. It is accurate for determining the completeness of the SCI and localize the NLI (cervical vs. thoracic vs. lumbar). It could be implemented in the initial trauma assessment protocol to guide the acute management of SCI patients.

Acute spinal cord injury (SCI) is most often secondary to trauma, and frequently presents with associated injuries. A neurological examination is routinely performed during trauma assessment, including through Advanced Trauma Life Support (ATLS). However, there is no standard neurological assessment tool specifically used for trauma patients to detect and characterize SCI during the initial evaluation. The International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) is the most comprehensive and popular tool for assessing SCI, but it is not adapted to the acute trauma patients such that it is not routinely used in that setting. Therefore, the objective is to develop a new tool that can be used routinely in the initial evaluation of trauma patients to detect and characterize acute SCI, while preserving basic principles of the ISNCSCI.

The completion rate of the ISCNSCI during the initial evaluation after an acute traumatic SCI was first estimated. Using a modified Delphi technique, we designed the Montreal Acute Classification of Spinal Cord Injuries (MAC-SCI), a new tool to detect and characterize the completeness (grade) and level of SCI in the polytrauma patient. The ability of the MAC-SCI to detect and characterize SCI was validated in a cohort of 35 individuals who have sustained an acute traumatic SCI. The completeness and neurological level of injury (NLI) were assessed by two independent assessors using the MAC-SCI, and compared to those obtained with the ISNCSCI.

Only 33% of patients admitted after an acute traumatic SCI had a complete ISNCSCI performed at initial presentation. The MAC-SCI includes 53 of the 134 original elements of the ISNCSCI which is 60% less. There was a 100% concordance between the severity grade derived from the MAC-SCI and from the ISNCSCI. Concordance of the NLI within two levels of that obtained from the ISNCSCI was observed in 100% of patients with the MAC-SCI and within one level in 91% of patients. The ability of the MAC-SCI to discriminate between cervical (C0 to C7) vs. thoracic (T1 to T9) vs. thoraco-lumbar (T10 to L2) vs. lumbosacral (L3 to S5) injuries was 100% with respect to the ISNCSCI.

The rate of completion of the ISNCSCI is low at initial presentation after an acute traumatic SCI. The MAC-SCI is a streamlined tool proposed to detect and characterize acute SCI in polytrauma patients, that is specifically adapted to the acute trauma setting. It is accurate for determining the completeness of the SCI and localize the NLI (cervical vs. thoracic vs. lumbar). It could be implemented in the initial trauma assessment protocol to guide the acute management of SCI patients.

Biphasic calcium phosphate (BCP) with a characteristic needle-shaped submicron surface topography (MagnetOs) has attracted much attention due to its unique bone-forming ability which is essential for repairing critical-size bone defects such as those found in the posterolateral spine. Previous in vitro and ex-vivo data performed by van Dijk LA and Yuan H demonstrated that these specific surface characteristics drive a favorable response from the innate immune system.

This study aimed to evaluate and compare the in vivo performance of three commercially-available synthetic bone grafts, (1) i-FACTOR Putty^®, (2) OssDsign^® Catalyst Putty and (3) FIBERGRAFT^® BG Matrix, with that of a novel synthetic bone graft in a clinically-relevant instrumented sheep posterolateral lumbar spine fusion (PLF) model. The novel synthetic bone graft comprised of BCP granules with a needle-shaped submicron surface topography (MagnetOs) embedded in a highly porous and fibrillar collagen matrix (MagnetOs Flex Matrix).

Four synthetic bone grafts were implanted as standalone in an instrumented sheep PLF model for 12 weeks (n=3 bilateral levels per group; levels L2/3 & L4/5), after which spinal fusion was determined by manual palpation, radiograph and µCT imaging (based on the Lenke scale), range-of-motion mechanical testing, and histological and histomorphological evaluation.

Radiographic fusion assessment determined bilateral robust bone bridging (Lenke scale A) in 3/3 levels for MagnetOs Flex Matrix compared to 1/3 for all other groups. For µCT, bilateral fusion (Lenke scale A) was found in 2/3 levels for MagnetOs Flex Matrix, compared to 0/3 for i-FACTOR Putty^®, 1/3 for OssDsign^® Catalyst Putty and 0/3 for FIBERGRAFT^® BG Matrix. Fusion assessment for MagnetOs Flex Matrix was further substantiated by histology which revealed significant graft resorption complemented by abundant bone tissue and continuous bony bridging between vertebral transverse processes resulting in bilateral spinal fusion in 3/3 implants.

These results show that MagnetOs Flex Matrix achieved better fusion rates compared to three commercially-available synthetic bone grafts when used as a standalone in a clinically-relevant instrumented sheep PLF model.

Introduction

Traditionally, limb reconstruction physiotherapy consisted of face to face group rehabilitation. During the COVID-19 pandemic OP physiotherapy service provision was significantly reduced and delivery methods limited due to staff redeployment, service prioritisation and restriction of footfall within the hospital. A virtual exercise group for acute limb reconstruction patients was set up to maintain contact and clinical support.

Barriers to successful return to previous level of activity following Anterior Cruciate Ligament Recon-struction (ACLR) are multifactorial and recent research suggests that athletic performance deficits persist after completion of the rehabilitation course in a large percentage of patients. Thirty soccer athletes (26.9 ± 5.7 years old, male) with ACL injury were surgically treated with all-inside technique and semitendi-nosus tendon autograft. At 2 years from surgery, they were called back for clinical examination, self-reported psychological scores, and biomechanical outcomes (balance, strength, agility and velocity, and symmetry).

Nonparametric statistical tests have been adopted for group comparisons in terms of age, concomitant presence of meniscus tear, injury on dominant leg, presence of knee laxity, presence of varus/valgus, body sides, and return to different levels of sports. Athletes with lower psychological scores showed lesser values in terms of power, resistance and neuromuscular activity as compared to the ones with good psychological scores that showed, instead, better self-reported outcomes (TLKS, CRSQ) and low fear of reinjury (TSK). In the athletes who had a functional deficit in at least one subtest, a safe return to sports could not have been recommended. Our findings confirmed that demographics, physical function, and psychological factors were related to playing the preinjury level sport at mean 2 years after surgery, sup-porting the notion that returning to sport after surgery is multifactorial. A strict qualitative and quantitative assessment of athletes’ status should be performed at different follow-ups after surgery to guarantee a safe and controlled RTP.

We designed a study to evaluate whether (1) there were differences in PROMs between different reasons for revision THA at baseline, (2) there was a different interaction effect for revision THA for all PROMs, and (3) complication and re-revision rates differ between reason for revision THA.

Prospective cohort of 647 patients undergoing rTHA, with a minimum of 2 years FU. The reason for revision were classified as infection, aseptic loosening, dislocation, structural failure and painful THA with uncommon causes. PROMs (EQ-5D score, Oxford hip score (OHS), VAS pain, complication and failure rates were compared between different groups.

Patients with different reason for revision had improvement of PROMs’ over time. Preoperatively, patients revised due to infection and aseptic loosening had poorer OHS and EQ-5D than patients with other reason for revision. Pain scores at baseline were highest in patients revised due to dislocation. Infection and aseptic loosening groups also showed a significant interaction effect over time in both OHS and EQ-5D. No PROMs significant differences between groups were observed 2 years postoperatively. Overall complications, and re-revision rates were 35.4 and 9.7% respectively.

The reason for revision THA did not associate with clinical outcomes. Good outcomes were reached regardless of the reason for revision, as patients with the poorest pre-operative scores had the best improvement in PROMs over time. Complication and re-operation rates were relatively high, in line with previous reports, but did not differ between different reasons for revision THA.

Introduction and Objective

Hyaluronic acid (HA) is an effective option for the treatment of osteoarthritis (OA) patients due to several properties such as normalization of the mechanical and rheological properties of the synovial fluid and amelioration of OA symptoms and joints function by promoting cartilage nutrition. Since OA progression is also significantly related to oxidative stress and reactive oxygen species (ROS), sodium succinate (SS) is envisioned as a promising compound for cartilage treatment by providing antioxidant defense able to normalize intracellular metabolism and tissue respiration via mitochondrial mechanism of action. The scope of this study was to investigate on an in vitro inflammatory model the efficacy of Diart^® product, a combination of HA and SS.

Introduction: Articular cartilage defects within the knee joint have poor capacity for repair. The purpose of this study is to analyse the short-term clinical and histological results of the treatment of deep chondral defects with autologous chondrocyte transplantation. Methods: This is a prospective study involving twenty-two consecutive patients receiving autologous chondrocyte transplantation. Chondrocytes from a non weight bearing area of the knee are harvested, then isolated and cultured in vitro. Re-implantation involves injection of the chondrocytes into the defect which is then sealed with a porcine I/III collagen membrane. Evaluation consists of clinical assessment, arthroscopy and histological examination. Histological evaluation consists of examination of a biopsy of the transplanted area one-year post-op. Staining techniques include the use of Erlich’s H & E, Safranin O and S100. Using polarised light, the absence of the fibrillar nature of fibrocartilage confirms the presence of hyaline cartilage. Further confirmation can be gained by the examination of messenger RNA content, confirming the presence of type II collagen. Results: The patients were treated between July 1998 and December 2000. The age range of the patients was 15–51 years (mean age 31 years). Of the 22 patients treated, 13 had right-sided lesions, 11 had left-sided lesions with two patients receiving bilateral procedures. Solitary lesions were treated in 23 knees with two defects being treated in one knee (25 defects in total). The defects were located on the medial femoral condyle in 17 cases, the lateral femoral condyle in five, the trochlea in two and the patella in one case. The defect size ranged from 1–5.4cm2 (mean area 2.65cm2). The follow-up of the patients ranges from 3-30 months (mean 16 months). Thirteen patients have at least one-year follow-up. Of these patients, using the Brittberg Rating, two patients have excellent results, with six good, four fair and one poor. The mean Lysholm and Gillquist scores improved from 50 pre-op to 72 one-year post-op and the mean Verbal Numerical Pain Scores improved from 7.2 to 2.6. Arthroscopy revealed that the transplants were level with the surrounding surface in most cases. Biopsy at one year confirmed the presence of hyaline cartilage in 10 out of 13 cases. Conclusion: Although the results are short-term, autologous chondrocyte transplantation can provide, with careful patient selection and meticulous surgical technique, an effective treatment for cartilage defects of the knee. The histological results are extremely encouraging and chondrocyte transplantation may be the only procedure to allow regeneration of hyaline cartilage

Abstract

The Patient Evaluation Measure (PEM) was designed at the Derby consensus meeting in 1995. It was validated for Carpal Tunnel Syndrome (CTS) in 2005 (Hobby et al) and was preferable to the DASH score for CTS assessment. We aimed to audit CTS treated by surgical decompression in our unit using the PEM, and to compare our results with the published literature. Thirty consecutive patients undergoing carpal tunnel decompression were questioned about one hand. Patients completed a preoperative PEM and a postoperative PEM at 3 months. Mean PEM scores improved from 41.3 to 23.9 (P< 0.001). Individual questions showed statistically significant improvements in mean scores: Feeling in the hand, Cold intolerance, Pain, Dexterity, Movement and Hand in general (all P< 0.001): Work (P< 0.005): ADL (P< 0.01): Movements, Grip and Appearance (P< 0.05). Our results are similar to previously published series, both overall, and for individual questions in the PEM. Results for Carpal Tunnel Decompression in our unit match those of other units. We found the PEM was easy to use; and effective, both in the assessment of patients with CTS, and for outcome measurement following surgical decompression. Our study supports the idea that the PEM could be used widely as an audit tool, to assist Hand Surgeon and/or Hand Surgery Unit Appraisal

Aims: Consideration of gravity of talar neck fractures and evaluation of their treatment results. Methods: From 1992 to 2001 were admitted to our department 26 patients, suffering from talar neck fractures. We were able to reexam 22 patients (17 males and 5 females), with mean age 34,14y. (16 to 64y.). Fourteen pt. (63,6%) were car accident victims. In the rest of them fracture occurred after fall from height more than 3m. There were 8 (36.3%) multi-injured patients. Preoperative diagnostic approach included simple x-rays and CT scan and Hawkins classiþcation was used. All patients underwent surgical treatment. Operative technique included open reduction and internal þxation using screws and/or K-Ws. Postoperatively patients were evaluated with radiological and clinical criteria according to Iowa Ankle Evaluation score. Results: Mean follow up was 58 months (from 12 months to 9 years). Results were excellent in 10 (45,4%), good in 6 (27.2%), fair in 4 (18.1%) and poor in 2 (11%) patients. Two cases developed avascular necrosis (1 type D and 1 type C) followed by body collapse and treated with ankle arthrodesis. Furthermore 1 patient underwent ankle and 6 patients subtalar arthrodesis because of arthritis caused from concomitant fractures. Conclusions: Treatment of talar neck fractures is a challenge because of high rate of complications, because of talusñ shape and vascular anatomy. Anatomic reduction and rigid internal þxation, in combination with immobilization and no weight bearing until restoration of talusñ architecture is achieved, are essential requirements for good result

Background: During total hip or knee replacement there is blood loss, wich often requires allogenic blood transfusions. The risks associated with this practice are well documented in the literature, and numerous strategies have been employed to conserve blood following total joint arthroplasty. The aim of this study is to determine the efficacy of an autologous retransfusion drain system to reduce the postoperative allogenic blood transfusion rate and the lack of adverse effects when using it. Method: We did a retrospective study of patients operated on hip and knee primary replacements during the first six months of 2008, which had a postoperative blood salvage and retransfusion (Bellovac ABT autotransfusion system-Astra Tech, Mölndal, Swedenn-), Group A, n=220 patients, and a control group, Group B, with patients operated on hip or knee replacements during the first six months of the year before, which had standard drainage system, n=177. In first group the drain was opened inmediatly after tourniquet release and the shed blood was returned to the patient after collecting up to 500 ml and no later than six hours after surgery. The pre-operative data for cardiopathy, angiopathy, preoperative anemia or anticoagulant treatment showed no significant differences for group A and B. We standardised the transfusion criteria in order to allow an accurate comparison between the two groups. Evaluation was done with the medical history and the pre-/postoperative hemoglobin values, postoperative blood loss and postoperative need of allogenic blood transfusion. Results: The two groups showed no significant differences relating to the demographic data or the medical history. 17 patients (7.7 %) of the retransfusion group needed allogenic blood transfusion compared with 16 patients (9 %) of the control group B (p > 0.05). The hemoglobin values of group A versus the control group showed after the donation of the salvaged blood a significant difference (p = 0,0007) but only in the subgroup of total knee replacement. Only three adverse events were observed when using the recuperator, which were not a risk for patients life and were solved with the cessation of postoperative reinfusion. Conclusions: The use of the autotransfusion system seems to reduce the postoperative allogenic blood transfusion rate but not statistical significant. Our study therefore confirms the safety of retransfusion drains

Aims

Iliosacral sarcoma resections have been shown to have high rates of local recurrence (LR) and poor overall survival. There is also no universal classification for the resection of pelvic sarcomas invading the sacrum. This study proposes a novel classification system and analyzes the survival and risk of recurrence, when using this system.

Background. Skeletal stem cells (SSCs) have been used for the treatment of osteonecrosis of the femoral head to prevent subsequent collapse. In isolation SSCs do not provide structural support but an innovative case series in Southampton, UK, has used SSCs in combination with impaction bone grafting (IBG) to improve both the biological and mechanical environment and to regenerate new bone at the necrotic site. Aims. Analysis of retrieved tissue-engineered bone as part of ongoing follow-up of this translational case series. Methods. With Proof-of-Concept established in vitro and in vivo, the use of a living bone composite of SSCs and allograft has been translated to four patients (five hips) for treatment of osteonecrosis of their femoral heads. Parallel in vitro culture of the implanted cell-graft construct was performed. Patient follow-up was by serial clinical and radiological examination. In one patient collapse occurred in both hips due to more advanced disease than was originally appreciated. This necessitated bilateral hip arthroplasty, but allowed retrieval of the femoral heads. These were analyzed for Type 1 Collagen production, bone morphology, bone density and mechanical strength by micro computed tomography (CT), histology (A/S stain, Collagen Type 1 immunostain, biorefringence) and mechanical testing. Representative sections of cortical, trabecular and tissue engineered bone were excised from the femoral heads using a diamond-tipped saw-blade and tested to failure by axial compression. Results. Parallel in vitro analysis demonstrated sustained cell growth and viability on the allograft. Three patients currently remain asymptomatic at up to three year follow-up. Histological analysis of the two retrieved femoral heads demonstrated, critically, Type 1 collagen production in the regenerated tissue as well as mature trabecular architecture, indicative of de novo tissue engineered bone. The trabecular morphology of regenerated bone was evident on CT, and this had a bone density of 1400 Grey scale units, (compared to 1200 for natural trabecular bone and 1800 for cortical bone). On axial compressive testing the regenerated bone on the left showed a 24.8% increase in compressive strength compared to ipsilateral normal trabecular bone, and a 22.9% increase on the left. Conclusions. Retrieval analysis data has demonstrated the translational potential of a living bone composite, while ongoing clinical follow-up shows this to be an effective new treatment for osteonecrosis of the femoral head. Regeneration of the necrotic bone may prevent subsequent collapse, thereby delaying, or possibly avoiding, the need for hip arthroplasty in early stage osteonecrosis. Evaluation of this tissue engineering construct has confirmed the potential for clinical treatment of bone defects using SSC based strategies

Aims: Clinical and radiographic evaluation of retinacular lateral releases using an arthroscopic approach, for anterior knee pain in cases with slight patelar axial malposition Methods: Prospective study in 34 patients. Evaluation according to the Insall clinical score, patient opinion, and change in radiographic angles and index from pre-operative to post-operative. Results: Postoperative clinical score (Insall 1983): 82% excellent; 6% good; 6% poor; 6% bad. Angular values: patelar index (Cross 1976) of 7,1 and sulcus angle (Brattstrom 1964) of 139,6∞. Radiographic correction: from 15,7 to 17,9 in patello-femoral angle (Laurin 1978); from −5,6 to −5,3∞ in congruency angle (Merchant 1974); and from 1,37 to 1,12 in patello-femoral index (Laurin 1978). Conclusions: Clinical results, patient satisfaction, and radiographic correction of congruency angle, patello-femoral angle and patello-femoral index make justifiable the use of arthroscopic lateral releases in the treatment of selected cases of patello-femoral pain

INTRODUCTION. Metal-on-metal hip resurfacing (MoMHRA) requires a new standardized radiographic evaluation protocol. Evaluation of the acetabular component is similar to total hip arthroplasty but the femoral component requires different criteria since there is no component in the femoral canal and the metallic femoral implant overlies the junctions between bone-cement and cement-prosthesis. Lucencies around the metaphyseal HRA femoral stem can be described with the femoral zonal system into 3 peg-zones (Amstutz' et al) but this doesn't account for bony changes of the femoral neck away from the stem. This study proposes a new femoral zonal system for radiographic HRA assessment. We tested the efficacy of radiographs in identifying a problem by reviewing 711 radiographs of resurfaced hips and correlating radiographic features to outcome. METHODS. 611 in-situ HRA (one surgeon) with minimum two radiographs at >12 months postoperatively and 100 revised HRA (55 referred) were assessed for component positioning, reactive lines±cortical thickening±cancellous condensation (borderline) and lucent lines±osteolysis±bone resorption (sinister). Findings around the acetabular implant were classified in six zones: Zones I-III equally distributed acetabular zones (DeLee-Charnley); Zone IV, V and VI situated in the iliac, pubic and ischial bone respectively. Findings around the proximal femur are defined with a new zonal system, dividing the implant-cement-bone interfaces and the femoral neck into 7 areas. Zones 1,7 at the superior and inferior part of the femoral neck-head, zones 2,3 at the proximal and distal halves of the superior aspect of the stem, zone 4 at the tip, zones 5,6 at the distal and proximal inferior aspects of the stem). Radiological findings and zones were correlated with gender, size, survival, Harris Hip Scores (HHS), metal ions, and adverse soft tissue reactions (ALTR). RESULTS. Radiological changes were found in 260 cases (36.7%), 151 sinister (21.2%) and 110 borderline (15.5%). 82% of revisions had sinister findings versus 11.3% of in-situ HRA (p<0.001). Of the 52 revised cases with ALTR, 2 had normal Xrays, 3 borderline and 47 sinister (90.4%). Females had a higher incidence of sinister findings (28.9%) compared to males (16.6%)(p<0.001). Sinister radiographs were significantly associated with lower HHS (mean 85 versus 98)(p<0.001), smaller sizes (median 48 versus 50)(p<0.001) and ASR design (58.8%). Metal ions were significantly higher with sinister (mean Cr:17.6μg/l-Co:17.8μg/l)(p<0.001) and borderline findings (mean Cr:3.34μg/l-Co:3.01μg/l)(p<0.01) compared to normal radiographs (mean Cr:2.61μg/l-Co:2.26μg/l). A higher number of pathological zones was correlated with risk of revision(p=0.006), ALTR(p<0.001), female gender(p<0.001), smaller size(p<0.001), and lower HHS(p<0.001). Pathological findings in . 3. 4 zones had a sensitivity of 50% and specificity of 94.2% (AUC=0.898) in detecting hips with ALTR (risk ratio=19.6). DISCUSSION. Radiographic assessment of HRA provides valuable information: 82% of problematic hips had sinister changes and 90.4% of cases with proven ALTR. In order to accurately evaluate progressive radiographic changes in HRA, specific zones have been established around the HRA femoral component. There was a high correlation between radiographic findings, clinical outcome and metal in levels. However, the absence of sinister radiologic findings does not eliminate a problematic HRA and further investigations (ion levels, imaging) would be indicated in symptomatic patients

The poor prognosis of patients with advanced bone and soft-tissue sarcoma has highlighted the necessity for new therapeutic approaches. T-cell based immunotherapies are a promising alternative to traditional cancer treatments due to their ability to target only malignant cells, leaving benign cells unharmed. The development of successful immunotherapy requires the identification of targetable immunogenic tumor antigens. Cancer-testis antigens (CTA) are a group of highly immunogenic tumor-associated proteins that have emerged as potential targets for CD8+ T-cell recognition. The goal of this study is to screen for CTA expression, HLA expression, and tumor T-cell infiltration in human dedifferentiated liposarcoma (DDLPS) and osteosarcoma (OS) to establish their immune profile and to identify targetable immunogenic antigens for T-cell based immunotherapy.

Human tissue micro-arrays composed of 78 cores of OS and 50 cores of DDLPS were obtained, along with matched control tissues from the same patients. IHC for the cancer testis antigens NY-ESO-1, MAGE-A3, and SSX2, was performed, and the staining results were scored by two authors based on maximal staining intensity on a scale of zero to three (absent=0, weak=1, moderate=2, or strong=3) and the percentage of tumor cells that stained. IHC for CD8 and CD3 was also performed, and T-cell tumor infiltration was defined as either brisk, nonbrisk, or absent, as described in melanoma literature. Concurrently, evaluation of 38 human DDLPS specimens and 10 healthy human fat specimens by the Nanostring nCounter platform is underway for identification of novel antigen targets and to establish the immune profile of DDLPS.

Immunohistochemical analysis of CTA expression showed considerable inter- and intra-tumoral heterogeneity. DDLPS showed relatively low expression of all CTAs tested, with only 22% of samples exhibiting MAGE-A3 and one sample each (3.1%) showing expression of SSX2 and NY-ESO-1 in low percentages of tumor cells. By contrast, in osteosarcoma, 74% of samples expressed MAGE-A3 and 68% expressed SSX, both with >80% of positive cases showing moderate to high expression. NY-ESO-1 was expressed in 41% of OS samples, predominantly at low levels. Brisk infiltration of CD8+ T cells was observed in over 70% of both sarcoma types tested. Furthermore, all sarcoma samples tested were positive for HLA expression.

To date, these results show promising expression of CTAs MAGE-A3 and SSX in OS, which may be used as targets in the future development of an immunotherapy for sarcoma. DDLPS shows relatively low expression, highlighting the need for more exploratory study with NanoString. The data generated throughout this project will provide insight into the immune profile of DDLPS.

Malpositioning of prosthetic components in TKA may cause clinical relevant complications. This study focuses on a variety of TKA problems that were related to femoral component internal malrotation. Inclusion criteria in this study were all TKA seen at one-year follow-up with a moderate or poor clinical outcome using the Knee Society Score. Reduced mobility, pain, and patella problems were most frequent in this group. Infection, trauma, or wound problems were exclusion criteria. Two different mobile bearing knee systems were utilised in one large centre; LCS (DePuy Int, Leeds, UK) and MBK (Zimmer, Warsaw, USA). From more than 200 LCS and 70 MBK prostheses 27 cases entered the study, all of which underwent spiral CT investigation for evaluation of femoral component rotational alignment. There was an increased incidence of femoral component internal rotation in this group with poor outcome. Mean internal rotation was 4.2 degrees (0 to 8) in relation to the transepicondylar axis. Evaluation of femoral component rotational alignment in TKA has recently gained increased attention. Particularly internal malrotation does often lead to flexion instability, poor biomechanics, and patellofemoral tracking problems with lateral subluxation. It is also associated with painful and stiff knees as recently reported (AAOS 2002, Dallas, USA). In this study early postoperative complications in TKA were also associated with femoral component internal malrotation. We, therefore, recommend CT evaluation of component alignment in clinically doubtful knees. Cases that present with internal malrotation should be considered for revision surgery with the view to revise the femoral and/or tibial component

Purpose. Evaluation of our experience on the treatment of comminuted, radial head fractures, and of the outcomes of pyrocarbon prosthetic replacement in such cases. Materials and Methods. We evaluated 47 cases of prosthetic replacement, performed from May 2003 to July 2008. There were 18 males and 29 females with an average follow-up of 48 months (12 to 60). The Hotchkiss classification was used to characterize the fractures. The indicators for the procedure were type III fractures in 27 cases, type IV fractures in 10 cases, comminuted radial head fractures (associated with disruption in medial collateral ligament) in 3 cases, Monteggia variant in 5 cases, and Essex Lopresti in 2 cases. Functional outcomes were assessed using the Mayo Elbow Performance Index and the Visual Analog Scales (VAS) of pain, joint motion, and stability. Results. The mean VAS score for elbow pain was 1 (0.5–2.1). Patients showed an average arch of motion from 6 degrees to 140, with 75 degrees of pronation, and 67 of supination. By the Mayo Elbow Performance Index, 42 patients had good to excellent results, 3 fair, and 2 poor. The complications that we have encountered were: implant dislocations (2 cases), elbow stiffness (1), implant dissociation (1), stem rupture (1), and transient PIN palsy (2 cases with complete recovery of nervous function at 5 and 8 weeks). There was no persistent instability, infection, synosthosis, severe degenerative changes, or impingement. Conclusion. The pyrocarbon implants are a good treatment option in complicated, radial head fractures, but the outcome depends on the severity of the initial fracture and the associated lesions. We have also encountered a tendency towards overestimating the prosthesis size, causing restriction of motion, impingement, overstuffing, or dislocation. For these results we are now using the non-modular prosthesis in our center, but further studies are required

Objective:. Evaluation of the early results of the implementation of reverse shoulder arthroplasty prosthesis “Comprehensive Reverse” in primary and revision shoulder arthroplasties. Material and Methods:. September 2010–December 2012, 48 patients (32 women, 16 men) underwent reverse shoulder arthroplasty using Comprehensive Reverse system. Average age of 69.88. A total of 46 patients were followed. In 22 patients the operation was performed for revision. Patients were pre-and postoperatively evaluated using Oxford, Constant, SF-12 scores, radiographs, pain and range of motion. Mean follow-up 13 months. Results:. In both groups there was an improvement in pain level from 7.9 to 3.2 in the primary replacement group and 7.8 to 5.3 in the revision group. Forward flexion has improved from 60 ° to 107 ° and from 53 ° to 95 ° respectively. Abduction has improved from 52 ° to 90 ° and 42 ° to 77 °, respectively. Significant improvement of Oxford Score from 13.77 to 33.30 in the first group and 12.27 to 21.20 in the second group. Constant score improved from 19.17 to 45.43 and 17.36 to 34.50 in both groups respectively. Furthermore, significant correlations were observed between the key variables. Post operative Complications includes separation of baseplate–glenosphere (one patient) required revision, large post operative hematoma in one patient and periprosthetic fracture type C in one case after a fall required revision using Mosaic Modular System. There was one case of superficial infection treated surgically and with antimicrobial treatment. Discussion:. The results of this study show a satisfactory short and acceptable result for the use of reverse shoulder prosthesis “Comprehensive” against primary disease of the shoulder and for revision with better results in the first group. Long-term monitoring is required to better and more complete clinical assessment of the reverse arthroplasty

Aims: Evaluation of the clinical and radiological results after primary surgical treatment of CDH in children with late discovered CDH. Methods: We have studied 64 hips of 58 patients (51 female and 7 male), who were between 18 months-8 years old with late discovered CDH. The study was made between 1991–2000. Teratological and neuromuscular cases were excluded. None of the patients have had previous treatment before admission in hospital. Preoperative radiographic evaluation of the cases was made based on the Tšnnis classiþcation system (12-gr.I, 26-gr.II, 19-gr.III, 7-gr.IV). Preliminary traction was used in 5 hips (4 patients). 8 of them were treated by open reduction, 18 by open reduction and pericapsular osteotomy of the ilium described by Pemberton, 38 by combined pelvic osteotomy (29 Pem-berton osteotomy, 9 Chiari osteotomy) and femoral derotation and/or varus osteotomy (with femoral shortening in 8 cases). Postoperatively, a plaster cast was applied for 6 weeks. Average follow-up period was 6.8 years. Results: The radiological results are based on Severin Classiþcation. We obtained in 77.5% of the cases excellent, good and satisfactory results. Using the clinical rating system of Fergusson and Howard, the results were good and satisfactory in 78.8 of the cases. Avascular necrosis occurred in 6 cases, being rated as group II and III according to the Kalamchi and Mac Ewen classiþcation system. Conclusions: In case of late discovered CDH, the results of conservative treatment are not satisfactory, the surgical treatment being recommended. Four years old or elder children can be treated safely with one stage operation consisting of open reduction, pelvic osteotomy with or without femoral derotation and varus osteotomy (with shortening if it is necessary)

Patients with advanced cancer can develop bone metastases in the femur which are often painful and increase the risk of pathological fracture. Accurate segmentation of bone metastases is, amongst others, important to improve patient-specific computer models which calculate fracture risk, and for radiotherapy planning to determine exact radiation fields. Deep learning algorithms have shown to be promising to improve segmentation accuracy for metastatic lesions, but require reliable segmentations as training input. The aim of this study was to investigate the inter- and intra-operator reliability of manual segmentation of femoral metastatic lesions and to define a set of lesions which can serve as a training dataset for deep learning algorithms. F

CT-scans of 60 advanced cancer patients with a femur affected with bone metastases (20 osteolytic, 20 osteoblastic and 20 mixed) were used in this study. Two operators were trained by an experienced radiologist and then segmented the metastatic lesions in all femurs twice with a four-week time interval. 3D and 2D Dice coefficients (DCs) were calculated to quantify the inter- and intra-operator reliability of the segmentations. We defined a DC>0.7 as good reliability, in line with a statistical image segmentation study.

Mean first and second inter-operator 3D-DCs were 0.54 (±0.28) and 0.50 (±0.32), respectively. Mean intra-operator I and II 3D-DCs were 0.56 (±0.28) and 0.71 (±0.23), respectively. Larger lesions (>60 cm³) scored higher DCs in comparison with smaller lesions.

This study reveals that manual segmentation of metastatic lesions is challenging and that the current manual segmentation approach resulted in dissatisfying outcomes, particularly for lesions with small volumes. However, segmentation of larger lesions resulted in a good inter- and intra-operator reliability. In addition, we were able to select 521 slices with good segmentation reliability that can be used to create a training dataset for deep learning algorithms. By using deep learning algorithms, we aim for more accurate automated lesion segmentations which might be used in computer modelling and radiotherapy planning.

Background: The number of total ankle replacements has been raising in the last years. Most publications present short- and medium-term results. Comparison of outcomes is difficult because of inconsistent terminology and different parameters used. Moreover, poorly performing implants cannot be identified quickly because of low numbers, delayed reporting or publication bias. Methods: Therefore, we have developed a module for total ankle prostheses in the framework of the International Documentation and Evaluation System (IDES) for standardized and centralized documentation of TAA outcomes. Content validation was conducted with a single surgeon series of 74 HINTEGRA_ ankle replacements. Results: Between March 2004 and February 2008 74 patients were treated. The preoperative diagnosis was 18.9% osteoarthritis, 32.4% rheumatoid arthritis, 43.3% posttraumatic, 1.4% osteonecrosis and 4% others. There were intraoperative complications in 4%, local postoperative complications in 17.6% and revision surgeries in 16.2% of patients. The AOFAS hind-foot score improved from 23.8 points preoperative to 75.3 points after a mean followup time of 8.4 months. No significant differences in outcome were revealed between the various diagnostic groups. Conclusion: The IDES-forms facilitate a structured and standardized data collection that is feasible in a research orientated but also purely clinical setting; this because of the different extents to which data can be recorded. The consistent use of the system assures a stringent internal quality assurance, and more interesting, an external quality assurance by means of comparisons and benchmarking with other users feeding the data pool with the exact same variables and outcomes. The Hintegra ankle appeared as a safe device with low complication rates in the hands of a foot and ankle specialist. A surgical learning curve was seen in the first two years

Porous surfaces on orthopaedic implants have been shown to promote tissue ingrowth. This study evaluated biological fixation of novel additively manufactured porous implants with and without hydroxyapatite coatings in a canine transcortical model.

Laser rapid manufacturing (LRM) Ti6Al4V cylindrical implants were built with a random interconnected architecture mimicking cancellous bone (5.2 mm diameter, 10mm length, 50–60% porous, mean pore size 450μm). Three groups were investigated in this study: as-built with no coating (LRM), as-built coated with solution precipitated hydroxyapatite (LRM-PA), and as-built coated with a plasma sprayed hydroxyapatite (LRM-PSHA). Implants were press-fit into a 5mm unicortical, perpendicular drill hole in the femoral diaphysis of the left and right femurs in 12 canines. Right femora were harvested for histology (SEM, bone ingrowth into implant within cortical region) and left femora for mechanical push-out testing (shear strength of bone-implant interface) at 4 and 12 weeks (N=6, un-paired Student's t-test, p=0.05).

For mean bone ingrowth, there was no significant difference between groups at 4 weeks (LRM, LRM-PA, LRM-PSHA: 41.5+8.6%, 51+5.5% and 53.2+11%, respectively) or 12 weeks (LRM, LRM-PA, LRM-PSHA: 64.4+2.8%, 59.9+7.6%, 64.9+6.4%, respectively). LRM and LRM-PA implants had more bone ingrowth at 12 weeks than 4 weeks (p < 0 .05). Mean shear strength of all implants at 12 weeks (LRM, LRM-PA, LRM-PSHA: 39.9+3.6MPa, 33.7+4.6MPa, 36+4.1MPa respectively) were greater than at 4 weeks (LRM, LRM-PA, LRM-PSHA: 21.6+2.8MPa, 20.7+1.1MPa, 20.2+2.5MPa respectively) (p < 0 .05). No significant difference was observed between all groups at 4 or 12 weeks.

Overall, this canine study confirmed the suitability of this novel additive manufacturing porous material for biological fixation by bone ingrowth. All implants exhibited high bone ingrowth and mechanical shear strength in this canine model. No difference was observed between uncoated and hydroxyapatite coated implants.