Aims. This study, using a surgeon-maintained database, aimed to explore the risk factors for surgery-related complications in patients undergoing primary cervical spine surgery for degenerative diseases. Methods. We studied 5,015 patients with degenerative cervical diseases who underwent primary cervical spine surgery from 2012 to 2018. We investigated the effects of diseases, surgical procedures, and patient demographics on surgery-related complications. As subcategories, the presence of cervical kyphosis ≥ 10°, the presence of ossification of the posterior longitudinal ligament (OPLL) with a canal-occupying ratio ≥ 50%, and foraminotomy were selected. The surgery-related complications examined were postoperative upper limb palsy (ULP) with a manual muscle test (MMT) grade of 0 to 2 or a reduction of two grade or more in the MMT, neurological deficit except ULP, dural tear, dural leakage, surgical-site infection (SSI), and postoperative haematoma. Multivariate logistic regression analysis was performed. Results. The significant risk factors (p < 0.050) for ULP were OPLL (odds ratio (OR) 1.88, 95% confidence interval (CI) 1.29 to 2.75), foraminotomy (OR 5.38, 95% CI 3.28 to 8.82), old age (per ten years, OR 1.18, 95% CI 1.03 to 1.36), anterior spinal fusion (OR 2.85, 95% CI 1.53 to 5.34), and the number of operated levels (OR 1.25, 95% CI 1.11 to 1.40). OPLL was also a risk factor for neurological deficit except ULP (OR 5.84, 95% CI 2.80 to 12.8), dural tear (OR 1.94, 95% CI 1.11 to 3.39), and dural leakage (OR 3.15, 95% CI 1.48 to 6.68). Among OPLL patients, dural tear and dural leakage were frequently observed in those with a canal-occupying ratio ≥ 50%. Cervical rheumatoid arthritis (RA) was a risk factor for SSI (OR 10.1, 95% CI 2.66 to 38.4). Conclusion. The high risk of ULP, neurological deficit except ULP, dural tear, and dural leak should be acknowledged by clinicians and OPLL patients, especially in those patients with a canal-occupying ratio ≥ 50%. Foraminotomy and RA were dominant risk factors for ULP and SSI, respectively. An awareness of these risks may help surgeons to avoid surgery-related complications in these conditions. Cite this article: Bone Joint J 2021;103-B(1):157–163

There has been debate about the role of unicompartmental knee replacement in the presence of radiologically identifiable degenerative changes of the patellofemoral joint. We studied 195 knees in 163 patients in whom an Oxford unicompartmental knee replacement had been performed for medial osteoarthritis between January 2004 and July 2007. The mean age of the patients was 66 years (51 to 93). The degree of degenerative change of the patellofemoral joint was assessed using Jones’ criteria. Functional outcome was assessed at a mean of 3.4 years (2 to 7) post-operatively, using the Oxford knee score and the Short-form 12 score. Degenerative changes of the patellofemoral joint were seen pre-operatively in 125 knees (64%) on the skyline radiographs. There was no statistically significant difference in the Oxford knee or Short-form 12 scores between those patients who had patellofemoral osteoarthritis pre-operatively and those who did not (p = 0.22 and 0.54, respectively). These results support the opinion expressed at the designer’s hospital that degenerative changes of the patellofemoral joint in isolation should not be considered to be a contraindication to medial Oxford unicompartmental knee replacement

We reviewed 87 patients who underwent revision anterior cruciate ligament (ACL) reconstruction. The incidence of meniscal tears and degenerative change was assessed and related to the timing from primary ACL graft failure to revision ACL reconstruction. Patients were divided into either an early group (revision surgery within 6 months of graft failure) or a delayed group. Degenerative change was scored using the French Society of Arthroscopy system. There was a significantly higher incidence of articular cartilage degeneration in the delayed group compared to the early group (53.2% vs 24%, p < 0.01, Mann- Whitney U test). No patients in the early group had advanced degenerative change (SFA grades 3 or 4), compared with 12.9% of patients in the delayed group. There was no significant difference in the incidence of meniscal tears between the two groups. In conclusion, the findings of the study support the view that patients with a failed ACL reconstruction and symptomatic instability should have an early revision reconstruction procedure carried out to minimise the risk of articular degenerative change

Aims. Patients with osteoarthritis of the knee commonly have degenerative meniscal tears. Arthroscopic meniscectomy is frequently performed, although the benefits are debatable. Recent studies have concluded that there is no role for arthroscopic washout in osteoarthritis of the knee. Our aim was to perform a systematic review to assess the evidence for the efficacy of arthroscopic meniscectomy in patients with meniscal tears and degenerative changes in the knee. Patients and Methods. A literature search was performed, using the PubMed/MEDLINE database, for relevant articles published between 1975 and 2015. A total of six studies, including five randomised controlled trials and one cross-sectional study of a prospective cohort, met the inclusion criteria. Relevant information including study design, operations, the characteristics of the patients, outcomes, adverse events and further operations were extracted. Results. The degree of osteoarthritis in the patients who were included and the rate of cross over from one form of treatment to another varied in the studies. Two randomised controlled trials showed a benefit of arthroscopic surgery in patients with limited degenerative joint disease, compared with conservative treatment. One cross-sectional study showed that patients with less severe degenerative changes had better outcomes. Conclusion. Patients with symptomatic meniscal tears and degenerative changes in the knee can benefit from arthroscopic meniscectomy, particularly if the osteoarthritis is mild. A trial of conservative management may be effective and should be considered, especially in patients with moderate osteoarthritis. Cite this article: Bone Joint J 2016;98-B:934–8

A distinctive and consistent pattern of degenerative change was seen in 560 acromioclavicular joints from dry bone skeletons of subjects over 40 years of age. An appreciation of this characteristic configuration is helpful at operation or when introducing a needle into the joint

Aims. Degenerative cervical spondylosis (DCS) is a common musculoskeletal disease that encompasses a wide range of progressive degenerative changes and affects all components of the cervical spine. DCS imposes very large social and economic burdens. However, its genetic basis remains elusive. Methods. Predicted whole-blood and skeletal muscle gene expression and genome-wide association study (GWAS) data from a DCS database were integrated, and functional summary-based imputation (FUSION) software was used on the integrated data. A transcriptome-wide association study (TWAS) was conducted using FUSION software to assess the association between predicted gene expression and DCS risk. The TWAS-identified genes were verified via comparison with differentially expressed genes (DEGs) in DCS RNA expression profiles in the Gene Expression Omnibus (GEO) (Accession Number: GSE153761). The Functional Mapping and Annotation (FUMA) tool for genome-wide association studies and Meta tools were used for gene functional enrichment and annotation analysis. Results. The TWAS detected 420 DCS genes with p < 0.05 in skeletal muscle, such as ribosomal protein S15A (RPS15A) (PTWAS = 0.001), and 110 genes in whole blood, such as selectin L (SELL) (PTWAS = 0.001). Comparison with the DCS RNA expression profile identified 12 common genes, including Apelin Receptor (APLNR) (PTWAS = 0.001, PDEG = 0.025). In total, 148 DCS-enriched Gene Ontology (GO) terms were identified, such as mast cell degranulation (GO:0043303); 15 DCS-enriched Kyoto Encyclopedia of Genes and Genomes (KEGG) pathways were identified, such as the sphingolipid signalling pathway (ko04071). Nine terms, such as degradation of the extracellular matrix (R-HSA-1474228), were common to the TWAS enrichment results and the RNA expression profile. Conclusion. Our results identify putative susceptibility genes; these findings provide new ideas for exploration of the genetic mechanism of DCS development and new targets for preclinical intervention and clinical treatment. Cite this article: Bone Joint Res 2023;12(1):80–90

Examination was made of 486 skeletons of subjects over the age of 60 years to study patterns of degenerative change in the glenohumeral joint. Three distinct types were found. Useful clinical implications are drawn from these distinctions

Osteoarthritis (OA) is a degenerative disease resulting from progressive joint destruction caused by many factors. Its pathogenesis is complex and has not been elucidated to date. Advanced glycation end products (AGEs) are a series of irreversible and stable macromolecular complexes formed by reducing sugar with protein, lipid, and nucleic acid through a non-enzymatic glycosylation reaction (Maillard reaction). They are an important indicator of the degree of ageing. Currently, it is considered that AGEs accumulation in vivo is a molecular basis of age-induced OA, and AGEs production and accumulation in vivo is one of the important reasons for the induction and acceleration of the pathological changes of OA. In recent years, it has been found that AGEs are involved in a variety of pathological processes of OA, including extracellular matrix degradation, chondrocyte apoptosis, and autophagy. Clearly, AGEs play an important role in regulating the expression of OA-related genes and maintaining the chondrocyte phenotype and the stability of the intra-articular environment. This article reviews the latest research results of AGEs in a variety of pathological processes of OA, to provide a new direction for the study of OA pathogenesis and a new target for prevention and treatment. Cite this article: Bone Joint Res 2022;11(5):292–300

Over 5 years we gave 84 patients epidural cortisone (80 mg depomedrol and local anaesthesia) for back and/or leg pain due to degenerative disease of the spine. The mean age of the 35 men and 49 women was 65.2 years (37 to 86). All patients had back pain and 77% had neurogenic leg pain. Spinal radiographs demonstrated degenerative changes, including intervertebral disc space narrowing and/or facet joint arthritis, in 84%. MRI, performed in 80 patients (95%), confirmed degenerative disease of the lumbar spine and demonstrated neural compression in 78 of the 80 (97%). Five patients received a second epidural injection and one a third. Complete resolution of back and/or leg pain occurred in 32 patients (38%), and 34 (40%) had relief for between 1 and 12 months. There was no change in the symptoms of 18 patients (21%). Surgery was undertaken in 17 patients (20%), with seven undergoing spinal decompression alone and 10 decompression and a fusion. After surgery, four of the seven patients who did not have a fusion still had back pain. All 10 of the patients who underwent decompression and fusion had a good outcome. One patient developed an epidural haematoma following the epidural injection. Epidural steroid injection had a favourable outcome in 78% of our patients, with a low incidence of complications. Patients who failed to respond to the epidural injection did poorly with spinal decompression alone

Purpose of the study: Glenohumeral dysplasia is an uncommon cause of degenerative disease of the shoulder joint. In this context, arthroplasty is a therapeutic challenge due to the bony deformations. Material and methods: Between 1998 and 2004, simple humeral prostheses were implanted in eight shoulders (seven patients, two men and five women, mean age 49.5 years). There was no procedure on the glenoid cavity. A Neer II was used for four shoulders (two dysplasic cases with short 63 mm stems) and a Neer III for four shoulders. Results: At mean follow-up of 4.5 years (maximum 7 yers) the Neer outcome was satisfactory for five patients and non-satisfactory for two. Five of the seven patients were satisfied with their operation. The Constant scores improved: from 3.5 to 11.8 for pain, 9.8 to 16.6 for activity, and 13.8 to 24.4 for active mobility. Active anterior elevation was 114° on average, external rotation 25°, and internal rotation at level L3. The overall constant score was 52.8 points with a weighted score of 43%. Radiographically, there were no lucent lines around the humeral implant. Anterior dislocation occurred in one shoulder six months after the initial operation. Capsuloligament revision was performed but the implant was left in place. For one other shoulder, secondary rotator cuff tears limited the function outcome, but the prosthesis was not revised. Discussion and conclusion: The results were average, but did allow our patients to resume nearly normal activity without pain. Looking at the failures in this small series suggests that the status of the rotator cuff is the main prognostic factor. Neither glenoid deformation nor the lack of replacement appeared to have an effect on the final outcome. Deformation of the proximal end of the humerus may require use of a shorter stem which should be available at the time of the operation

Late degenerative changes are known to follow meniscectomy, but there is little agreement on their incidence or on which patients are most at risk. A total of 210 patients have been reviewed 10 to 22 years after meniscectomy, and long leg radiographs taken of both knees. Radiological degeneration was seen in 18%, while 7% had significant symptoms and signs. Statistical analysis showed increased changes in older patients, in those with abnormal leg alignment, and in those who had undergone lateral as against medial meniscectomy. Our findings emphasise the important mechanical function of the meniscus and support the current cautious approach to meniscectomy, especially for patients in high risk groups. They also indicate the value of early high tibial osteotomy for symptomatic varus deformity after medial meniscectomy

To assess adverse events related to XLIF approach in lumbar degenerative disease. Recently novel minimally disruptive spine procedure eXtreme lateral Interbody Fusion i.e XLIF has been developed. It is 90 (off the midline true lateral approach, which allows large graft placement, excellent disc height restoration and indirect decompression at the stenotic motion segment. We describe our experience in 28 patients. Retrospective review of records of patients undergoing surgery between July 2008- Jan 2010. Presenting complaints, number of levels performed and complications (medical, approach, or implant related) were audited. Results: 28 patients (17 female: 11 male) with median age of 47 yrs, range (38-75) formed the study group. Average stay was 4 days. All patients had MRI of lumbar spine. 2/3 rd patients had low back pain as their presenting complaint. All patients had nerve monitoring through out the procedure. There were 12 single, 15 two level and 1 three level cases (total 45 levels). 14/28 patients underwent plating at the same time. EBL was 100ml. There were 11/45 adverse events (24.4%). 6 events were approach, 4 were implant bone interface and 1 medical related. Major complication occurred in 1 patient (3.6%). 2/3 rd of patients, were better after the surgery. Almost negligible blood loss, low infection rate and short average stay seemed to work in favour of this approach. Complications are there as (with any new procedure) our results indicate, but these are manageable and less common with this technique. This did not require Ethics approval and there was no grant or industry support for the above

Introduction: Energy storing tendons, such as the human Achilles tendon, suffer a much higher incidence of rupture than non- energy storing positional tendons, such as the anterior tibialis tendon. Similarly, in the horse partial rupture of the energy storing superficial digital flexor tendon (SDFT) and suspensory ligament (SL) occurs much more frequently than to the deep digital flexor tendon (DDFT) and common digital extensor tendon (CDET) which are not involved in energy storage. In order to function effectively, energy storing tendons experience strains during high speed locomotion which are much closer to failure strain than non-energy storing tendons. Therefore, these tendons are likely to sustain high levels of microdamage, hence cell metabolism may also be higher in order to repair damage and maintain matrix integrity. Maintenance of the matrix requires not only synthesis of new matrix components but also degradation of matrix macromolecules which is achieved, in part, by a family of matrix metalloproteinase enzymes (MMPs). In this study we test the hypothesis that the energy storing equine SDFT and SL which are prone to degenerative changes have higher levels of MMP2 and MMP9 than the positional DDFT and CDET that are rarely injured. Methods: Tendons (SDFT, DDFT, SL, CDET) were harvested from the distal part of the forelimbs of 18 month old Thoroughbred horses (n = 12). Tissue from the mid-metacarpal region of each tendon was snap frozen, lyophilised, powdered and MMPs extracted. Gelatin zymography was used to determine levels of the pro and active forms of the gelatinase enzymes, MMP2 and MMP 9. Proteolytic activity (units per mg dry weight tissue) was quantified based on densitometry measurements and standardised between gels using an equine neutrophil MMP extract. Statistical significance was evaluated using a general linear model (SPSS software). Results: The main activity observed in all tendon samples was that of proMMP2. Quantification showed that the energy storing SDFT (23.4 ± 10.95) and SL (18.9 ± 5.3) had significantly higher levels than the non-energy storing DDFT (2.90 ± 0.99) and CDET (4.06 ± 2.06). Active MMP2 levels were lower than the pro form and were not sufficient to quantify. However, there appeared to be more in the energy storing structures compared with the non energy storing structures. MMP9 activity was detected in some samples. A higher number of the CDET extracts contained MMP9 activity compared to extracts from the other structures. Discussion: The results of this study show higher levels of MMPs in energy storing structures than in non-energy storing structures. This suggests that there may be an increased demand for repair of micro-damage in these tendons and hence an increased capacity for matrix degradation. Previous studies on energy storing structures in the horse have shown that they do not undergo adaptive hypertrophy or a change in structural architecture in response to mechanical demand, unlike non-energy storing structures. The results of this study indicate that this lack of adaptation in energy storing structures is not due to a general deficiency in cell activity but may be a means of preventing increase in tendon stiffness and a subsequent decrease in efficiency. In order to maintain tendon integrity MMP activity must be matched by mechanisms to inhibit activity and/or to synthesize new matrix components. Degeneration may therefore occur when there is an imbalance between these processes

Aims

The escalating demand for medical resources to address spinal diseases as society ages is an issue that requires careful evaluation. However, few studies have examined trends in spinal surgery, especially unscheduled hospitalizations or surgeries performed after hours, through large databases. Our study aimed to determine national trends in the number of spine surgeries in Japan. We also aimed to identify trends in after-hours surgeries and unscheduled hospitalizations and their impact on complications and costs.

Introduction

Degeneration of the cervical spine can lead to neurological symptoms that require surgical intervention. Often, an anterior cervical discectomy (ACD) with fusion is performed with interposition of a cage. However, a cage substantially increases health care costs. The polymer polymethylmethacrylate (PMMA) is an alternative to cages, associated with lower costs. The reported high-occurrence of non-fusion with PMMA is often seen as a drawback, but evidence for a correlation between radiological fusion and clinical outcome is absent. To investigate if the lower rate of fusion with PMMA has negative effects on long-term clinical outcome, we assessed the clinical results of ACD with PMMA as a intervertebral spacer with a 5–10 year follow-up.

Anterior cruciate ligament (ACL) of four major knee ligaments is most crucial ligament to maintain normal knee kinematics. It is well know that ACL dysfunction causes secondary osteoarthritis of the knee. The influence of age on the biomechanical properties of the ACL was examined. The structural properties of 27 pairs of human cadaver knees without OA were evaluated. Specimens were equally divided into three groups of nine pairs each based on age: younger (22 to 35 years), middle (40 to 50 years), and older (60 to 97 years). Tensile tests of the femur-ACL-tibia complex were performed at 30 degrees of knee flexion with the ACL aligned vertically along the direction of applied tensile load. Structural properties of the femur-ACL-tibia complex, as represented by the linear stiffness, ultimate load, and energy absorbed, were found to decrease significantly with specimen age.

On the other hand, little has been written about the arthritic ACL. This study was designed to evaluate the relationship among ROM, cross sections of the intercondylar notch and the macroscopic condition of ACL degeneration. Fifty osteoarthritic patients who underwent TKA as a result of severe osteoarthritis were randomly selected. Occupation rate of the osteophytes to the notch width were measured at the anterior 1/3, middle 1/3, and posterior 1/3 notche images obtained from preoperative tunnel view. ROM was measured preoperatively and under anesthesia. Macroscopic conditions of the ACL and PCL were classified into four types of Normal, Frayed, Partial rupture, and Absent.

The macroscopic ACL conditions were Normal: 12 cases, Frayed: 15 cases, Partial rupture: 14 cases, and Absent: 9 cases. The macroscopic PCL conditions were Normal: 34 cases, Frayed: 9 cases, Partial rupture: 7 cases, and Absent: 0 case. Occupation rate of the osteophytes to the notch correlated to the preoperative varus deformity (p < 0.05). In terms of ACL, the occupation rate of the osteophytes to the notch were 22.9%, 28.8%, 46.0%, and 81.8% in Normal, Frayed, partial ruptured, and Absent, respectively. The patients with more than 40% occupation rate and less than 110 degree of knee flexion angle showed either partial rupture or absent of the ACL during the surgery. Those results correlated with the degree of OA deterioration. We conclude that occupation rate of the osteophytes to the notch poor preoperative ROM is a good predictor of evaluating the ACL degeneration in osteoarthritic knee. We also conclude that ACL dysfunction due to joint space narrowing accelerates the advancement of the knee OA.

Patellofemoral joint degeneration is often considered a contraindication to medial unicompartmental knee replacement. We examined the validity of this preconception using information gathered prospectively on the intra-operative status of the patellofemoral joint in 824 knees in 793 consecutive patients who underwent Oxford unicondylar knee replacement for anteromedial osteoarthritis. All operations were performed between January 1998 and September 2005. A five-point grading system classified degeneration of the patellofemoral joint from none to full-thickness cartilage loss. A subclassification of the presence or absence of any full-thickness cartilage loss was subsequently performed to test selected hypotheses. Outcome was evaluated independently by physiotherapists using the Oxford and the American Knee Society Scores with a minimum follow-up of one year.

Full-thickness cartilage loss on the trochlear surface was observed in 100 of 785 knees (13%), on the medial facet of the patella in 69 of 782 knees (9%) and on the lateral facet in 29 of 784 knees (4%). Full-thickness cartilage loss at any location was seen in 128 knees (16%) and did not produce a significantly worse outcome than those with a normal or near-normal joint surface. The severity of the degeneration at any of the intra-articular locations also had no influence on outcome.

We concluded that, provided there is not bone loss and grooving of the lateral facet, damage to the articular cartilage of the patellofemoral joint to the extent of full-thickness cartilage loss is not a contraindication to the Oxford mobile-bearing unicompartmental knee replacement.

Purpose

Posterior lumbar fusion using minimally invasive surgical (MIS) techniques are reported to minimise postoperative pain, soft tissue damage and length of hospital stay when compared to the traditional open procedure.

Introduction: Disc Replacement has been described as 21st Century revolution in spinal surgery that preserves mobility and prevents adjacent segment degeneration. Numerous short-term studies are available on clinical outcome but to date there are no published long term clinical, radiological and survival data on disc replacement.

Aim: To analyse clinical, radiological & survival results of Charite III Disc Replacement.

Study Design: Ethical committee approved retrospective study.

Methodology: 160 patients (Av. Age 46yrs; Std.Dev 8.06; 62 Males & 98 Females) underwent disc replacement surgery between Jan1990 and Dec2000. An independent observer reviewed case notes, radiographs and administered a questionnaire that included Oswestry Disability Index, and Pain Score.

Results: Clinical: At an average follow up of 79 (range 31 to 161) months, mean improvement in ODI and pain score were 18.01(p< 0.001) and 1.69(p< 0.001) respectively.

Radiological: average movement at replaced disc, defined as greater than 4 degrees on flexion-extension lateral view was 1.5 degrees for L3L4, 4.01 degrees for L4L5 and 4.8 degrees for L5S1 disc replacement.

Survival: A mean survival time of 147(95% C.I. 140 to 154) months was observed with cumulative survival of 55% with implant removal as an endpoint. A mean survival time of 124(95% C.I. 116 to 133) months with cumulative survival of 35% was observed with all radiological failures as an endpoint.

Complications: were post-operative incisional hernia seen in 17(10.6%), wound infection 9(5.6%) and retrograde ejaculation in 5(3.1%) patients.

Conclusion: Charite III Disc Replacement results in clinically significant (> 15, p< 0.001) improvement in ODI, but does not result in clinical significant (> 2 points) improvement in back pain. Motion is preserved at L4L5 and L5S1 level. It has low survival rate and does not seem to prevent onset of facet arthritis. This study does not support the use of this device for management of back pain.

The value of arthroscopic partial meniscectomy in the severely arthritic knee has been questioned. Some authors suggest that it may result in progression of osteoarthritis precipitating the need for joint replacement and that symptomatic improvement may occur from lavage alone.

126 patients with a torn meniscus and Outerbridge grade IV changes in the same compartment underwent arthroscopic partial meniscectomy and limited debridement of unstable articular cartilage. The indication for surgery was a symptomatic meniscal tear not osteoarthritis. A control group consisted of 13 patients with grade IV changes and intact but frayed menisci who underwent washout alone. Mean age and follow up were similar in the two groups.

Initially meniscectomy improved symptoms in 82 cases (65%). Symptoms were unchanged in 26 cases (21%) and were made worse in 18 cases (14%). At a mean follow up of 55 months, 50 patients (40%) felt their knees were better than they were preoperatively. Their mean Lysholm score was 75. 5. 35 knees (28%) were not improved (mean Lysholm socre 59). 41 patients (32%) had undergone further surgery: 39 total knee replacements, 1 unicompartmental knee replacement and 1 tibial osteotomy. Older patients, those with varus/ valgus malalignment, and those with exposed bone on both articular surfaces fared worse.

Outcome following meniscectomy was better than outcome following washout alone: more patients reported an improvement after meniscectomy and fewer had undergone further surgery on their knees (p=0. 04). The median time between arthroscopy and the decisions for joint replacement was the same in both groups (8 months in the meniscectomy group and 7. 5 months in the washout group) indicating meniscectomy did not precipitate joint replacement.

These results suggest that arthroscopic partial men-iscectomy in the presence of Outerbridge grade IV changes can result in satisfactory long term outcomes for many patients, is more effective than washout alone and does not precipitate the need for joint replacement.

A clinical retrospective study was conducted. Results of isolated decompression for degenerative lumbar stenosis was compared with the outcome in patients who underwent decompression-stabilisation.

From January 1992 to December 2002, 127 patients (average age 65.5) with lumbar degenerative stenosis surgically treated were studied. In all patients the Roy-Camille technique was used for decompression; in 41 patients decompression and posterior stabilisation procedures were carried out. Average follow-up was 6 years (range 2–11 years).

The outcomes, evaluated according to Lassale classification, were satisfactory in 81% of the decompressed group while improved to 88% in the stabilised–decompressed group. Three patients of the first group required stabilisation for intractable low back pain (one patient) and lumboradicular symptoms (two patients), while problems related to the device (one hardware failure) and two instances of adjacent segmental instability were seen in the second group.

Decompression alone is associated with an increased rate of residual low back pain (one patient in this cohort required fusion). The decompression–stabilisation procedure reduces the incidence of low back pain but is associated with other complications such as significant blood loss, possible wound infections, urinary tract infections (due to increased surgical time), device failures, root impingement and late adjacent segmental pathologies.

The Roy Camille technique is effective for achieving adequate decompression. The surgeon should always be aware of patients who might require fusion. The instrumented stabilisation should be reserved for patients with chronic low back pain and evident instability, degenerative spondylolisthesis and spine deformities such as scoliosis or kyphosis.

Radiographs of the shoulders of 84 asymptomatic individuals aged between 40 and 83 years were evaluated to determine changes in 23 specific areas. Two fellowship-trained orthopaedic radiologists graded each area on a scale of 0 to II (normal 0, mild changes I, advanced changes II). Logistic regression analysis indicated age to be a significant predictor of change (p < 0.05) for sclerosis of the medial acromion and lateral clavicle, the presence of subchondral cysts in the acromion, formation of osteophytes at the inferior acromion and clavicle, and narrowing and degeneration of the acromioclavicular joint. Gender was not a significant predictor (p > 0.05) for radiological changes. Student’s t-test determined significance (p < 0.05) between age and the presence of medial acromial and lateral clavicular sclerosis, subchondral acromial cysts, inferior acromial and clavicular osteophytes, and degeneration of the acromioclavicular joint.

Radiological analysis in conditions such as subacromial impingement, pathology of the rotator cuff, and acromioclavicular degeneration should be interpreted in the context of the symptoms and normal age-related changes.

Purpose of the study: TKA on genu valgum raises serious problems for the ligament balance. Excessive release of the lateral retracted ligaments exposes the knee to potential instability in the frontal plane. To resolve this problem and avoid implantation of a constrained TKA, we opted for osteotomy of the lateral condyle removing the insertion of the lateral collateral ligament and the popliteal muscle after release of the fascia lata. The purpose of our study was to evaluate the functional and radiographic outcomes of these patients.

Material and methods: This was a retrospective study from 2002 to 2006. All patients with degenerative joint disease of the knee with severe and/or fixed genu valgum were included. These patients were implanted with a navigated posterostabilised Wallaby TKA (Navitrack) associated with osteotomy of the lateral condyle fixed with screws after acquisition of the ligament balance. The diagnosis and surgical history were noted. The preoperative alignement was determined on the full limb x-ray and from navigation data. The following variables were reviewed: polyethylene height, lowering of the lateral condyle, blood loss, operative time. The postoperative alignment was established at least one year after surgery. Intraoperative, postoperative and late complications were noted. The Knee Society function scores were used.

Results: Fifteen patients, mean age 70 years were reviewed at mean 35 months. The mean duration of the operative time was 136 min with mean blood loss of 620 ml. The mean PE height was 13 mm. All operated knees were corrected with mean alignment improving from 17.71 to 1.5 valgus postoperatively. The function score improved from 35 preoperatively to 79 at last follow-up. There were no cases of patellar instability or secondary laxity. Two patients developed late reflex dystrophy. The only case of revision concerned one non-union of the lateral condyle (screw removed at four months) but had a function score of 85 at last follow-up.

Discussion: Performing an osteotomy of the lateral condyle in complement with the navigated posterostabilised TKA for fixed genu valgum enabled good relaxation and satisfactory functional results so that totally constrained implants can be avoided.

The relationship of degeneration to symptoms has been questioned. MRI detects apparently similar disc degeneration and degenerative changes in subjects both with and without back pain. We aimed to overcome these problems by re-annotating MRIs from asymptomatic and symptomatic groups onto the same grading system. We analysed disc degeneration in pre-existing large MRI datasets. Their MRIs were all originally annotated on different scales. We re-annotated all MRIs independent of their initial grading system, using a verified, rapid automated MRI annotation system (SpineNet) which reported degeneration on the Pfirrmann (1-5) scale, and other degenerative features (herniation, endplate defects, marrow signs, spinal stenosis) as binary present/absent. We compared prevalence of degenerative features between symptomatics and asymptomatics. Pfirrmann degeneration grades in relation to age and spinal level were very similar for the two independent groups of symptomatics over all ages and spinal levels. Severe degenerative changes were significantly more prevalent in discs of symptomatics than asymptomatics in the caudal but not the rostral lumbar discs in subjects < 60 years. We found high co-existence of degenerative features in both populations. Degeneration was minimal in around 30% of symptomatics < 50 years. We confirmed age and disc level are significant in determining imaging differences between asymptomatic and symptomatic populations and should not be ignored. Automated analysis, by rapidly combining and comparing data from existing groups with MRIs and information on LBP, provides a way in which epidemiological and ‘big data’ analysis could be advanced without the expense of collecting new groups

Aims. It remains controversial whether patellofemoral joint pathology is a contraindication to lateral unicompartmental knee arthroplasty (UKA). This study aimed to evaluate the effect of preoperative radiological degenerative changes and alignment on patient-reported outcome scores (PROMs) after lateral UKA. Secondarily, the influence of lateral UKA on the alignment of the patellofemoral joint was studied. Methods. A consecutive series of patients who underwent robotic arm-assisted fixed-bearing lateral UKA with at least two-year follow-up were retrospectively reviewed. Radiological evaluation was conducted to obtain a Kellgren Lawrence (KL) grade, an Altman score, and alignment measurements for each knee. Postoperative PROMs were assessed using the Kujala (Anterior Knee Pain Scale) score, Knee Injury and Osteoarthritis Outcome Score Joint Replacement (KOOS JR), and satisfaction levels. Results. A total of 140 knees (130 patients) were identified for analysis. At mean 4.1 years (2.0 to 8.5) follow-up, good to excellent Kujala scores were reported. The presence of mild to moderate preoperative patellofemoral joint osteoarthritis had no impact on these scores (KL grade 0 vs 1 to 3, p = 0.203; grade 0 to 1 vs 2 to 3, p = 0.674). Comparable scores were reported by patients with osteoarthritis (Altman score of ≥ 2) evident on either the medial or lateral patellofemoral joint facet (medial, p = 0.600 and lateral, p = 0.950). Patients with abnormal patellar congruence and tilt angles (≥ 17° and ≥ 14°, respectively) reported good to excellent Kujala scores. Furthermore, lateral UKA resulted in improvements to patellofemoral alignment. Conclusion. This is the first study demonstrating that mild to moderate preoperative radiological degenerative changes and malalignment of the patellofemoral joint are not associated with poor patient-reported outcomes at mid-term follow-up after lateral fixed-bearing UKA. Our data suggest that this may be explained by realignment of the patella and thereby redistribution of loads across the patellofemoral joint. Cite this article: Bone Joint J 2020;102-B(6):727–735

In the unstable patellofemoral joint (PFJ), the patella will articulate in an abnormal manner, producing an uneven distribution of forces. It is hypothesised that incongruency of the PFJ, even without clinical instability, may lead to degenerative changes. The aim of this study was to record the change in joint contact area of the PFJ after stabilisation surgery using an established and validated MRI mapping technique. A prospective MRI imaging study of patients with a history of PFJ instability was performed. The patellofemoral joints were imaged with the use of an MRI scan during active movement from 0° through to 40° of flexion. The congruency through measurement of the contact surface area was mapped in 5-mm intervals on axial slices. Post-stabilisation surgery contact area was compared to the pre-surgery contact area. In all, 26 patients were studied. The cohort included 12 male and 14 female patients with a mean age of 26 (15–43). The greatest mean differences in congruency between pre- and post-stabilised PFJs were observed at 0–10 degrees of flexion (0.54 cm. 2. versus 1.18 cm. 2. , p = 0.04) and between 11° and 20° flexion (1.80 cm. 2. versus 3.45 cm. 2. ; p = 0.01). PFJ stabilisation procedures increase joint congruency. If a single axial series is to be obtained on MRI scan to compare the pre- and post-surgery joint congruity, the authors recommend 11° to 20° of tibiofemoral flexion as this was shown to have the greatest difference in contact surface area between pre- and post-operative congruency

Abstract. Introduction. A lipohaemarthrosis seen on Horizontal beam lateral X-ray in acute knee injury is often considered predictive of an intra-articular fracture requiring further urgent imaging. Methodology. We retrospectively searched a five-year X-ray database for the term “lipohaemarthrosis”. We excluded cases if the report concluded “no lipohaemarthrosis” or “lipohaemarthrosis” AND “fracture”. All remaining cases were reviewed by an Orthopaedic Consultant with a special interest in knee injuries (AD) blinded to the report. X-rays were excluded if a fracture was seen, established osteoarthritic change was present, a pre-existing arthroplasty present or no lipohaemarthrosis present. Remaining cases were then studied for any subsequent Radiological or Orthopaedic surgical procedures. Results. 136 cases were identified and reviewed by an Orthopaedic Consultant. 31 were excluded for no lipohaemarthrosis (n= 11), for degenerative change (n=9), for fracture (n=4), for existing arthroplasty (n=4) and for data errors (n=3). The remaining 105 patients had a mean age of 32, and range 5–90 years. 66 patients underwent further imaging in the form of MRI scan (n=47), CT Scan (n=9) repeat x-rays (n=9) and ultrasound (n=1). 27 fractures were identified. Surgery was performed in 12 cases (11%). Two (2%) urgently (One ACL reconstruction plus meniscus repair, one for ORIF of tibial plateau fracture). Ten (10%) had elective surgery (6 for ACL reconstruction, 2 for ACL reconstruction plus meniscus repair, 2 for loose body removal. Conclusion. The presence of a lipohaemarthrosis on x-ray following acute knee injury was a poor predictor of intra-articular fracture (26%) or need for urgent surgery (2%)

There is no agreement as to the superiority or specific indications for cast treatment, percutaneous pinning or open fracture fixation for Bennett's fractures of the thumb metacarpal. We undertook this study to compare the outcomes of treatment for patients treated for Bennett's fracture in the medium term. We reviewed 33 patients treated in our unit for a bennett's fracture to the thumb metacarpal with closed reduction and casting. Each patient was matched with a patient treated surgically. Patients were matched for sex, age, Gedda grade of injury and hand dominance. Patients were reviewed at a minimum of 5-years and 66-patients were reviewed in total. Patients were examined clinically and also asked to complete a DASH questionnaire score and the brief Michigan hand questionnaire. Follow up plain radiographs were taken of the thumb and these were reviewed and graded for degenerative change using the Eaton-Littler score. Sixty-six patients were included in the study, with 33 in the surgical and non-surgical cohorts respectively. The average age was 39 years old. In each cohort, 12/33 were female, 19/33 were right-handed with 25% of individuals injuring their dominant hand. In each coort there were 16 Grade 1 fractures, 4 Grade 2 and 13 Grade 3 fractures. There was no difference between the surgically treated and cast-treatment cohorts of patients when radiographic arthritis, pinch grip, the brief Michigan Hand Questionnaire and pain were assessed at final review. The surgical cohort had significantly lower DASH scores at final follow-up. There was no significant difference in the normalised bMHQ scores. Our study was unable to demonstrate superiority of either operative or non-operative fracture stabilization. Patients in the surgical cohort reported superior satisfaction and DASH scores but did not demonstrate any superiority in any other objectively measured domain

Aims. The aim of this study was to assess the accuracy of pedicle screw placement, as well as intraoperative factors, radiation exposure, and complication rates in adult patients with degenerative disorders of the thoracic and lumbar spines who have undergone robotic-navigated spinal surgery using a contemporary system. Methods. The authors reviewed the prospectively collected data on 196 adult patients who had pedicle screws implanted with robot-navigated assistance (RNA) using the Mazor X Stealth system between June 2019 and March 2022. Pedicle screws were implanted by one experienced spinal surgeon after completion of a learning period. The accuracy of pedicle screw placement was determined using intraoperative 3D fluoroscopy. Results. A total of 1,123 pedicle screws were implanted: 1,001 screws (89%) were placed robotically, 63 (6%) were converted from robotic placement to a freehand technique, and 59 (5%) were planned to be implanted freehand. Of the robotically placed screws, 942 screws (94%) were determined to be Gertzbein and Robbins grade A with median deviation of 0.8 mm (interquartile range 0.4 to 1.6). Skive events were noted with 20 pedicle screws (1.8%). No adverse clinical sequelae were noted in the 90-day follow-up. The mean fluoroscopic exposure per screw was 4.9 seconds (SD 3.8). Conclusion. RNA is highly accurate and reliable, with a low rate of abandonment once mastered. No adverse clinical sequelae occurred after implanting a large series of pedicle screws using the latest generation of RNA. Understanding of patient-specific anatomical features and the real-time intraoperative identification of risk factors for suboptimal screw placement have the potential to improve accuracy further. Cite this article: Bone Joint J 2023;105-B(5):543–550

Chronic low back pain (CLBP) is the most common cause of disability worldwide, and lumbar spine fusion (LSF) is often chosen to treat pain caused by advanced degenerative disease when clinical treatment failed certain cases, the post-surgical outcomes are not what was expected. Several studies highlight how important are. In psychological variables during the postoperative spine surgery period. The aim of this study is to assess the role of preoperative depression on postoperative clinical outcomes. We included patients who underwent LSF since December 2021. Preoperative depression was assessed administering Beck Depression Inventory questionnaire (BDI). And pain and disability were evaluated at 1, 3, and 6 months, administering respectively Visual Analogic Scale (VAS) and Oswestry Disability Index (ODI). As statistical analysis Mann-Whitney test was performed. We included 46 patients, 20 female (43,5%) and 26 male (56,5%) with an average age of 64,2. The population was divided in two groups, fixing the BDI cut-off point at 10. Patients with BDI < 10 points (N=28) had normal mental health status, instead patients with BDI > 10 points (N=16) had depressive disorders. At 3 months patients with healthy mental status reported statistically significant reduction of pain (U = 372,5, p = .006) and improvement of disability but without statistical significancy (U = 318, p = 0,137). At 6 months patients without psychological disease reported statistically significant reduction of pain (U = 342, p = 0,039) and disability (U = 372,5, p = 0,006). This study demonstrates the correlation between pre-existing depressive state and poorer clinical outcomes after spine surgery. These results are consistent with the literature. Therefore, during the surgical decision making it is crucial to take psychological variables into account in order to predict the results after surgery and inform patients on the potential influence of mental status

Background. Lateral ankle instability is a common problem, but the precise role of the lateral ankle structures has not been accurately investigated. This study aimed to accurately investigate lateral ankle complex stability for the first time using a novel robotic testing platform. Method. A six degrees of freedom robot manipulator and a universal force/torque sensor were used to test 10 foot and ankle specimens. The system automatically defined the path of unloaded plantar/dorsi flexion. At four flexion angles: 20° dorsiflexion, neutral flexion, 20° and 40° of plantarflexion; anterior-posterior (90N), internal-external (5Nm) and inversion-eversion (8Nm) laxity were tested. The motion of the intact ankle was recorded first and then replayed following transection of the lateral retinaculum, Anterior Talofibular Ligament (ATFL) and Calcaneofibular Ligament (CFL). The decrease in force/torque reflected the contribution of the structure to restraining laxity. Data were analysed using repeated measures of variance and paired t-tests. Results. The ATFL was the primary restraint to anterior drawer (P< 0.01) and the CFL the primary restraint to inversion throughout range (P< 0.04), but with increased plantarflexion the ATFL's contribution increased. The ATFL had a significant role in resisting tibial external rotation, particularly at higher levels of plantarflexion, contributing 63% at 40° (P< 0.01). The CFL provided the greatest resistance to external tibial rotation, 22% at 40° plantarflexion (P< 0.01). The extensor retinaculum and skin did not offer significant restraint in any direction tested. Conclusion. This study shows accurately for the first time the significant role the ATFL and CFL have in rotational ankle stability. This significant loss in rotational stability may have implications in the aetiology of osteophyte formation and early degenerative changes in patients with chronic ankle instability. This is the first time the role of the lateral ankle complex has been quantified using a robotic testing platform

Low back pain is the single most common cause for disability in individuals aged 45 years or younger, it carries tremendous weight in socioeconomic considerations. Degenerative aging of the structural components of the spine can be associated with genetic aspects, lifetime of tissue exposure to mechanical stress & loads and environmental factors. Mechanical consequences of the disc degenerative include loss of disc height, segment instability and increase the load on facets joints. All these can lead to degenerative changes and osteophytes that can narrow the spinal canal. Surgery is indicated in patients with spinal stenosis who have intractable pain, altered quality of life, substantially diminished functional capacity, failed non-surgical treatment and are not candidates for non-surgical treatment. The aim was to determine the reasons for refusal of surgery in patients with established degenerative lumber spine pathology eligible for surgery. All patients meeting the study criteria, patients older than 18 years, patients with both clinical and radiological established symptomatic degenerative lumbar spine pathology and patients eligible for surgery but refusing it were recruited. Questionnaire used to investigate reasons why they are refusing surgery. Results 59 were recruited, fifty-one (86.4 %) females and eight (13.6 %) males. Twenty (33.8 %) were between the age of 51 and 60 years, followed by nineteen (32.2 %) between 61 and 70 years, and fourteen (23.7 %) between 71 and 80 years. 43 (72 %) patients had lumber spondylosis complicated by lumber spine stenosis, followed by nine (15.2 %) with lumbar spine spondylolisthesis and four (6.7 %) had adjacent level disease. 28 (47.4 %) were scared of surgery, fifteen (25.4 %) claimed that they are too old for surgery and nine (15.2 %) were not ready. Findings from this study outlined that patients lack information about the spinal surgery. Patients education about spine surgery is needed

Osteoarthritis (OA) is the leading cause of pain and disability worldwide and is characterized by the degenerative changes of articular cartilage. Joint loading is required for cartilage maintenance; however, hyper-physiologic loading is a risk factor for OA. Mechanosensitive ion channels Piezo1 and Piezo2 synergistically transduce hyper-physiologic compression of chondrocytes, leading to chondrocyte death and onset of OA. This injury response is inhibited by Piezo channel loss of function, however the mechanistic role of Piezo channels in vivo is unknown. We examined the hypothesis that deletion of Piezo in chondrocytes will protect mice from joint damage and pain-related behaviors following a surgical destabilization of the medial meniscus (DMM), investigating a key mechanistic and mechanobiological role of these channels in the pathogenesis of OA. Aggrecan-Cre Piezo1 and Piezo1/2 knockout mice ((Agc)1-CRE. ERT2. ;Piezo1. fl/fl. Piezo2. fl/fl. ) were generated and given a 5-day Tamoxifen regimen at 12-weeks of age (n=6–12/group/sex). Cre-negative mice served as controls. At 16-weeks, mice received DMM surgery on the left knee. 12-weeks following DMM prior to sacrifice, activity and hyperalgesia were measured using spontaneous running wheels and a small animal algometer. Structural changes in bone, cartilage, and synovium were characterized using microCT, histology, and Modified Mankin Score criteria. Knockout of Piezo1/2 channels was chondroprotective in both sexes following DMM surgery as demonstrated by reduced Modified Mankin Score compared to control animals. Piezo1 KO was chondroprotective in only female mice, indicating a sexually dimorphic response. Piezo1 and Piezo1/2 KO was protective against pain in male mice, while females displayed no differences compared to controls. No changes were observed in bone morphology. Chondrocyte-specific Piezo1/2 knockout protects the knee joint from structural damage, hyperalgesia and functional deficits in a surgical model of PTOA in male and female mice, illustrating the importance of Piezo channels in response to injury in vivo. Future work aims to interrogate potential sexually dimorphic responses to cartilage damage and investigating Piezo2 KO mice

Invertebral disc degeneration (IDD) is a degenerative disease involving a variety of musculoskeletal and spinal disorders such as lower back pain (LBP). Secretome derived from mesenchymal stem cells (MSCs) have exerted beneficial effect on tissue regeneration. In this study, the goal was to investigate the paracrine and the anti-inflammatory effects of secretome from interleukin IL1β preconditioned Bone Marrow MSCs (BMSCs) on human nucleus pulposus cells (hNPCs) in a 3D in vitro model. Secretome was collected from BMSCs (BMSCs-sec) after preconditioning with 10 ng/mL IL1β. hNPCs were isolated from surgical specimens, culture expanded in vitro, encapsulated in alginate beads and treated with: growth medium; IL1β 10 ng/mL; IL1β 10 ng/mL for 24 hours and then BMSCs-sec. We examined: i) cell proliferation and viability (flow cytometry), ii) nitrite production (Griess assay) and ROS quantification (Immunofluorescence) iii) glycosaminoglycan (GAG) amount (DMBB) and iv) gene expression levels of extracellular matrix (ECM) components and inflammatory mediators (qPCR). One-way ANOVA analysis was used to compare the groups under exam and data were expressed as mean ± S.D. In vitro tests showed an enhancement of hNPCs proliferation after treatment with BMSCs-sec (p ≤ 0.05) compared to IL1β group. After 24 hours, the percentage of dead cells was higher in IL1β treated hNPCs compared to control group and decreased significantly in combined IL1β and BMSCs-sec sample group (p ≤ 0.01). Nitrite and ROS production were significantly mitigated and GAGs content was improved by preconditioned BMSCs-sec (p ≤ 0.05). Furthermore, gene expression levels were modulated by BMSCs-sec treatment compared to controls. Our results supported the potential use of BMSCs' secretome as a cell-free strategy for IDD, overcoming the side effects of cell-therapy. Moreover, secretome derived from IL1β preconditioned BMSCs was able to reduce hNPCs death, attenuate ECM degradation and oxidative stress counteracting IDD progression. Acknowledgements: Financial support was received from the “iPSpine” and “RESPINE” Horizon 2020 projects

To evaluate the therapeutic effect of Pulsed Electromagnetic Field (PEMF) in the treatment of meniscal tears in the avascular region. Seventy-two twelve-week-old male Sprague-Dawley rats with full-thickness longitudinal medial meniscal tears in the avascular region were divided into 3 groups: control group (G. con. ), treated with classic signal PEMF (G. classic. ), and high slew rate signal PEMF(G. HSR. ). The HSR signal has the same pulse and burst frequencies as the classic signal, but with a higher slew rate. Macroscopic observation and histological analysis of the meniscus and articular cartilage were performed to evaluate the meniscal healing and progressions of osteoarthritis. The synovium was harvested for histological and immunofluorescent analysis to assess the intra-articular inflammation. The meniscal healing, articular cartilage degeneration, and synovitis were quantitatively evaluated according to their respective scoring system. Dramatic degenerative changes of the meniscus and articular cartilage were noticed during gross observation and histological evaluation in the control group at 8 weeks. However, the menisci in the two treatment groups were restored to normal morphology with a smooth surface and shiny white color. Particularly, the HSR signal remarkably enhanced the fibrochondrogenesis and accelerated the remodeling process of the regenerated tissue. The meniscal healing scores of PEMF treatment groups were significantly higher than those in the control group at 8 weeks. Specifically, the HSR signal showed a significantly higher meniscal repair score than the classic signal at week 8 (P < .01). The degeneration score (G. con. versus G. classic. : P < .0001; Gcon versus G. HSR. : P < .0001) and synovitis score (G. con. versus Gclassic: P < .0001; G. con. versus G. HSR. : P = .0002) of the control groups were significantly higher than those in the two treatment groups. PEMF promoted the healing of meniscal tears in the avascular region and restored the injured meniscus to its structural integrity in a rat model. Compared to the classic signal, the HSR signal showed the increased capability to promote fibrocartilaginous tissue formation and modulate the inflammatory environment and therefore protected the knee joint from post-traumatic osteoarthritis development

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

The rotator cuff tendinopathy is one of the most common shoulder problems leading to full-thickness rotator cuff tendon tear and, eventually, to degenerative arthritis. Recent research on rotator cuff tendon degeneration has focused on its relationship to cell death. The types of cell death known to be associated with rotator cuff tendon degeneration are apoptosis, necrosis, and autophagic cell death. The increased incidence of cell death in degenerative tendon tissue may affect the rates of collagen synthesis and repair, possibly weakening tendon tissue and increasing the risk of tendon rupture. The biomolecular mechanisms of the degenerative changes leading to apoptotic cell death in rotator cuff tenofibroblasts have been identified as oxidative-stress-related cascade mechanisms. Furthermore, apoptosis, necrosis, and autophagic cell death are all known to be mediated by oxidative stress, a condition in which ROS (reactive oxygen species) are overproduced. Lower levels of oxidative stress trigger apoptosis; higher levels mediate necrosis. Although the signaltransduction pathway leading to autophagy has not yet been fully established, ROS are known to be essential to autophagy. A neuronal theory regarding rotator cuff degeneration has been developed from the findings that glutamate, a neural transmitter, is present in increased concentrations in tendon tissues with tendinopathy and that it induces rat supraspinatus tendon cell death. Recent studies have reported that hypoxia involved in rotator cuff tendon degeneration. Because antioxidants are known to scavenge for intracellular ROS, some studies have been conducted to determine whether antioxidants can reduce cell death in rotator cuff tendon-origin fibroblasts. The first study reported that an antioxidant has the ability to reduce apoptosis in oxidative-stressed rotator cuff tenofibroblasts. The second study reported that antioxidants have both antiapoptotic effects and antinecrotic effects on rotator cuff tendon-origin fibroblasts exposed to an oxidative stimulus. The third study reported that an antioxidant has antiautophagic-cell-death effects on rotator cuff tendon-origin fibroblasts exposed to an oxidative stimulus. The fourth study reported that glutamate markedly increases cell death in rotator cuff tendonorigin fibroblasts. The glutamate-induced cytotoxic effects were reduced by an antioxidant, demonstrating its cytoprotective effects against glutamate-induced tenofibroblast cell death. The fifth study reported that hypoxia significantly increases intracellular ROS and apoptosis. The hypoxia-induced cytotoxic effects were markedly attenuated by antioxidants, demonstrating their cytoprotective effects against hypoxia-induced tenofibroblast cell death. In conclusion, antioxidants have cytoprotective effects on tenofibroblasts exposed in vitro to an oxidative stressor, a neurotransmitter, or hypoxia. These cytoprotective effects result from antiapoptotic, antinecrotic, and antiautophagic actions involving the inhibition of ROS formation. These findings suggest that antioxidants may have therapeutic potential for rotator cuff tendinopathy. Further studies must be conducted in order to apply these in vitro findings to clinical situations

Osteoarthritis (OA) is a degenerative disease that lacks regenerative treatment options. Current research focuses on mesenchymal stem cells (MSCs) and Platelet-Rich Plasma (PRP) as regenerative therapies, but extracellular vesicles (EVs) have shown to be more advantageous. This study compares the regenerative potential of human umbilical cord MSC-derived EVs (cEVs) and platelet-derived EVs (pEVs) in ex vivo and in vivo OA models. In the ex vivo study, OA conditions were induced in human cartilage explants, which were then treated either with pEVs or cEVs. Results showed a higher content of DNA and collagen in the pEVs group compared to control and cEVs groups, suggesting that pEVs could be a potential alternative to cEVs. In the in vivo study, an OA model was established in the knee joints of rats through MIA (monoiodoacetate) injection and then treated either with pEVs or cEVs. Results showed that pEVs-treated knee joints had better subchondral bone integrity and greater OA reversion, particularly in female rats, indicating that pEVs are a viable regeneration treatment for OA and outperform cEVs in terms of efficacy. Overall, the study demonstrates the potential of EVs as a regenerative treatment for OA, with pEVs showing promising results in both ex vivo and in vivo models. The use of pEVs in clinical practice could provide a faster path to translation due to the established use of platelet concentrates in therapeutics. However, further studies are needed to fully evaluate the potential of pEVs for OA treatment and to elucidate the mechanisms behind their regenerative effects. Acknowledgments: The authors thank Dr Fernando Hierro (UIB) for their technical contribution with TEM, Mª Trinidad García (UIB) for the access to radioactivity facilities, Aina Arbós (IUNICS) for her contribution in the histology staining, María Tortosa (IdISBa) for her assistance with the animal care and ADEMA School of Dentistry for the access to the cone beam computed tomography (CBCT). Funding: This research was funded by Instituto de Salud Carlos III, Ministerio de Economía y Competitividad, co-funded by the ESF European Social Fund and the ERDF European Regional Development Fund (MS16/00124; CP16/00124), PROGRAMA JUNIOR del proyecto TALENT PLUS, construyendo SALUD, generando VALOR (JUNIOR01/18), financed by the sustainable tourism tax of the Balearic Islands; the Direcció General d'Investigació and Conselleria d'Investigació, Govern Balear (FPI/2046/2017); the Mecanisme de Recuperació i Resiliència, intended to execute research projects of «Noves polítiques públiques per a un mercat de treball dinàmic, resilient i inclusiu», collected in Pla de Recuperació, Transformació i Resiliència, financed by European Union-Next Generation EU and driven by SOIB and Conselleria de Fons Europeus, Universitat i Cultura i la Conselleria de Model Econòmic, Turisme i Treball (NG0421) and the grant SYN20/03 from IdISBa

Spinal surgery deals with the treatment of different pathological conditions of the spine such as tumors, deformities, degenerative disease, infections and traumas. Research in the field of vertebral surgery can be divided into two main areas: 1) research lines transversal to the different branches; 2) specific research lines for the different branches. The transversal lines of research are represented by strategies for the reduction of complications, by the development of minimally invasive surgical techniques, by the development of surgical navigation systems and by the development of increasingly reliable systems for the control of intra-operative monitoring. Instead, specific lines of research are developed within the different branches. In the field of oncological pathology, the current research concerns the development of in vitro models for the study of metastases and research for the study of targeted treatment methods such as electrochemotherapy and mesenchymal stem cells for the treatment of aneurysmal bone cysts. Research in the field of spinal deformities is focused on the development of increasingly minimally invasive methods and systems which, combined with appropriate pharmacological treatments, help reduce trauma, stress and post-operative pain. Scaffolds based on blood clots are also being developed to promote vertebral fusion, a fundamental requirement for improving the outcome of vertebral arthrodesis performed for the treatment of degenerative disc disease. To improve the management and the medical and surgical treatment of vertebral infections, research has focused on the definition of multidisciplinary strategies aimed at identifying the best possible treatment path. Thus, flow-charts have been created which allow to manage the patient suffering from vertebral infection. In addition, dedicated silver-coated surgical instrumentation and bone substitutes have been developed that simultaneously guarantee mechanical stability and reduce the risk of further local infection. In the field of vertebral traumatology, the most recent research studies have focused on the development of methods for the biostimulation of the bone growth in order to obtain, when possible, healing without surgery. Methods have also been developed that allow the minimally invasive percutaneous treatment of fractures by means of vertebral augmentation with PMMA, or more recently with the use of silicone which from a biomechanical point of view has an elastic modulus more similar to that of bone. It is clear that scientific research has changed clinical practice both in terms of medical and surgical management of patients with spinal pathologies. The results obtained stimulate the basic research to achieve even more. For this reason, new lines of research have been undertaken which, in the oncology field, aim at developing increasingly specific therapies against target receptors. Research efforts are also being multiplied to achieve regeneration of the degenerated intervertebral disc and to develop implants with characteristics increasingly similar to those of bone in order to improve mechanical stability and durability over time. Photodynamic therapies are being developed for the treatment of infections in order to reduce the use of antibiotic therapies. Finally, innovative lines of research are being launched to treat and regenerate damaged nerve structures with the goal, still far from today, of making patients with spinal cord injuries to walk

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

Adverse events (AEs) are still a major problem in spinal surgery, despite advances in surgical techniques, innovative technologies available and the introduction of checklist and predictive score systems aimed at reducing surgical complications. We previously analysed the results of the introduction of the WHO Safety Surgical Checklist (SSC) in our Institution, comparing the incidence of complications between two periods: from January to December 2010 (without checklist) and from January 2011 and December 2012 (with checklist), in order to assess the checklist effectiveness. The sample size was 917 patients with an average of 30 months of follow-up. Complications were observed in 107 patients (11.6%) among 917 spinal surgery procedures performed, with 159 (17.3%) complications in total. The overall incidence of complications for trauma, infectious pathology, oncology, and degenerative disease was 22.2%, 19.2%, 18.4%, and 15.3%, respectively. We observed a reduction of the overall incidence of complications following the introduction of the WHO Surgical Checklist: in 2010 without checklist, the incidence of complications was 24.2%, while in 2011 and 2012, following the checklist introduction, the incidence of complications was 16.7% and 11.7%, respectively (mean 14.2%) (p<0.0005). Thus, the SSC appeared to be an effective tool to reduce complications in spinal surgery and we proposed to extend the use of checklist system also to the pre-operative and post-operative phases in order to further reduce the incidence of complications. We also believe that a correct capture and classification of complications is fundamental to generate a clinical decision support system aimed at improving patients’ safety in spinal surgery. In the period between January 2017 and January 2018 we prospectively recorded the adverse events and complications of patients undergoing spinal surgery in our department, without using any collection system. Then we retrospectively recorded the intraoperative and postoperative adverse events of surgically treated patients during the same one-year period, using the SAVES v2 system introduced by Rampersaud and collaborators (Rampersaud YR et al. J Neurosurg Spine 2016 Aug; 25 (2): 256-63) to classify them. In the one-year period from January 2017 to January 2018 a total of 336 patients underwent spinal surgery: 223 for degenerative conditions and 113 for spinal tumors. Comorbidities were collected (Charlson Comorbidity Index [CCI]). Overall, a higher number of adverse events (AEs) was recorded using SAVES compared to the prospective recording without the use of any capture system and the increased number was statistically significant for early postoperative AEs (138/336 vs 44/336, p<0.001). 210 adverse events were retrospectively recorded using the SAVES system (30 intraoperative adverse events, 138 early postoperative and 42 late postoperative adverse events). 99 patients (29.5%) on the cohort had at least one complication. Furthermore, the correlation between some risk factors and the onset of complications or the prolonged length of stay was statistically analyzed. The risk factors taken into account were: age, presence of comorbidities (CCI), ASA score, previous surgery at the same level, type of intervention, location of the disease, duration of the surgery. In particular, the duration of the surgery (more than 3 hours) and the presence of previous surgeries resulted to be risk factors for complications in multivariate analyses

Stem cells represent an exciting biological therapy for the management of many musculoskeletal tissues that suffer degenerative disease and/or where the reparative process results in non-functional tissue (‘failed healing’). The original hypothesis was that implanted cells would differentiate into the target tissue cell type and synthesise new matrix. However, this has been little evidence that this happens in live animals compared to the laboratory, and more recent theories have focussed on the immunomodulatory effects via the release of paracrine factors that can still improve the outcome, especially since inflammation is now considered one of the central processes that drive poor tendon healing. Because of the initial ‘soft’ regulatory environment for the use of stem cells in domestic mammals, bone and fat-derived stem cells quickly established themselves as a useful treatment for naturally occurring musculoskeletal diseases in the horse more than 20 years ago (Smith, Korda et al. 2003). Since the tendinopathy in the horse has many similarities to human tendinopathy, we propose that the following challenges and, the lessons learnt, in this journey are highly relevant to the development of stem cells therapies for human tendinopathy:. Source – while MSCs can be recovered from many tissues, the predominant sources for autologous MSCs have been bone and fat. Other sources, including blood, amnion, synovium, and dental pulp have also been commercialised for allogenic treatments. Preparation – ex vivo culture requires transport from a licensed laboratory while ‘minimally manipulated’ preparations can be prepared patient-side. Cells also need a vehicle for transport and implantation. Delivery – transport of cells from the laboratory to the clinic for autologous ex vivo culture techniques; implantation technique (usually by ultrasound-guided injection to minimise damage to the cells (or, more rarely, incorporated into a scaffold). They can also be delivered by regional perfusion via venous or arterial routes. Retention – relatively poor although small numbers of cells do survive for at least 5 months. Immediate loss to the lungs if the cells are administered via vascular routes. Synovially administered cells do not engraft into tendon. Adverse effects – very safe although needle tracts often visible (but do not seen to adversely affect the outcome). Allogenic cells require careful characterisation for MHC Class II antigens to avoid anaphylaxis or reduced efficacy. Appropriate injuries to treat – requires a contained lesion when administered via intra-lesional injection. Intrasynovial tendon lesions are more often associated with surface defects and are therefore less appropriate for treatment. Earlier treatment appears to be more effective than delayed, when implantation by injection is more challenging. Efficacy - beneficial effects shown at both tissue and whole animal (clinical outcome) level in naturally-occurring equine tendinopathy using bone marrow-derived autologous MSCs Recent (licenced) allogenic MSC treatment has shown equivalent efficacy while intra-synovial administration of MSCs is ineffective for open intra-synovial tendon lesions. Regulatory hurdles – these have been lighter for veterinary treatments which has facilitated their development. There has been greater regulation of commercial allogenic MSC preparations which have required EMA marketing authorisation

Introduction. Distal femoral and proximal tibial osteotomies are effective procedures to treat degenerative disease of the knee joint. Previously described techniques advocate the use of bone graft to promote healing at the osteotomy site. In this present study a novel technique which utilises the osteogenic potential of the cambial periosteal layer to promote healing “from the outside in” is described. Materials and Methods. A retrospective analysis of a consecutive single-surgeon series of 23 open wedge osteotomies around the knee was performed. The median age of the patients was 37 years (range 17–51 years). The aetiology of the deformities included primary genu valgum (8/23), fracture malunion (4/23), multiple epiphyseal dysplasia (4/23), genu varum (2/23), hypophosphataemic rickets (1/23), primary osteoarthritis (1/23), inflammatory arthropathy (1/23), post-polio syndrome (1/23), and pseudoachondroplasia (1/23). Results. There were two cases lost to follow-up with a median follow-up period 17 months (range 1–32 months). Union was achieved in all cases, with 1/23 requiring revision for early fixation failure for technical reasons. The median time to radiographic union 3.2 months (95% Confidence Interval (CI) 2.5–3.8 95% CI). CT scans demonstrated early periosteal callus, beneath the osteoperiosteal flap, bridging the opening wedge cortex. Clinical union occurred at 4.1 months (95% CI 3.9–4.2 months). Complications included superficial surgical site infection (1/23), deep vein thrombosis (1/23), and symptomatic metalwork requiring removal (7/23). Conclusions. The osteoperiosteal flap technique was a safe and effective technique for opening wedge osteotomies around the knee with a reliable rate of union

Introduction. To face the problem of surgical complications, which is generally relevant in surgical fields, an intraoperative checklist (Safety Surgical Checklist, SSC) was elaborated and released by the World Health Organization in 2008, and its use has been described in 2009. In our Institution, the WHO SSC was introduced in 2011. In spinal surgery, many preventive measures were investigated to reduce complications, but there is no report on the effectiveness of the WHO checklist in reducing complications. Aim. The aim of this study was to compare the incidence of complications between the two periods, from January to December 2010 (without checklist) and from January 2011 to December 2012 (with checklist), in order to assess the checklist effectiveness. Materials and Methods. A retrospective and single center study was carried out on patients who underwent spinal surgery during the three-year period from January 2010 to December 2012. Patients were classified according to the spine pathology and the different presentation of the complication. We registered the complications arising in patients treated from 2010 to 2012 during a 3 years follow up period for each patient, assessing the possible differences before and after the checklist's introduction. Results. The sample size was 917 patients, the mean age was 52.88 years. The majority of procedures were performed for oncological diseases (54.4%) and degenerative diseases (39.8%). 159 complications in total were detected (17.3%). The overall incidence of complications for trauma, infectious pathology, oncology, and degenerative disease was 22.2%, 19.2%, 18.4%, and 15.3%, respectively. No correlation was observed between the type of pathology and the complication incidence. We observed a reduction of the overall incidence of complications following the introduction of the SSC: in 2010 without checklist, the incidence of complications was 24.2%, while in 2011 and 2012, following the checklist introduction, the incidence of complications was 16.7% and 11.7%, respectively (mean 14.2%). Conclusion. Despite the limitations of the study, in particular the impossibility to carry out a randomized study, SSC seems to be an effective tool to reduce complications in spinal surgery. We propose to extend the use of checklist system also to the pre-operative and post-operative phases in order to further reduce the incidence of complications

Abstract. Osteoarthritis (OA) is a degenerative disorder associated with cartilage loss and is a leading cause of disability around the world. In old age, the capacity of cartilage to regenerate is diminished. With an aging population, the burden of OA is set to rise. Currently, there is no definitive treatment for OA. However, cell-based therapies derived from adipose tissue are promising. A PRISMA systematic review was conducted employing four databases (MEDLINE, EMBASE, Cochrane, Web of Science) to identify all clinical studies that utilized adipose tissue derived mesenchymal stem cells (AMSCs) or stromal vascular fraction (SVF) for the treatment of knee OA. Eighteen studies were included, which met the inclusion criteria. Meta-analyses were conducted on fourteen of these studies, which all documented WOMAC scores after the administration of AMSCs. Pooled analysis revealed that cell-based treatments definitively improve WOMAC scores, post treatment. These improvements increased with time. The studies in this meta-analysis have established the safety and efficacy of both AMSC therapy and SVF therapy for knee OA in old adults and show that they reduce pain and improve knee function in symptomatic knee OA suggesting that they may be effective therapies to improve mobility in an aging population

No animal model currently exists for hip abductor tendon tears. We aimed to 1. Develop a large animal model of delayed abductor tendon repair and 2. To compare the results of acute and delayed tendon repair using this model. Fourteen adult Romney ewes underwent detachment of gluteus medius tendon using diathermy. The detached tendons were protected using silicone tubing. Relook was performed at six and 16 weeks following detachment, histological analysis of the muscle and tendon were performed. We then attempted repair of the tendon in six animals in the six weeks group and compared the results to four acute repairs (tendon detachment and repair performed at the same time). At 12 weeks, all animals were culled and the tendon–bone block taken for histological and mechanical analysis. Histology grading using the modified Movin score confirmed similar tendon degenerative changes at both six and 16 weeks following detachment. Biomechanical testing demonstrated inferior mechanical properties in both the 6 and 16 weeks groups compared to healthy controls. At 12 weeks post repair, the acute repair group had a lower Movin's score (6.9 vs 9.4, p=0.064), and better muscle coverage (79.4% of normal vs 59.8%). On mechanical testing, the acute group had a significantly improved Young's Modulus compared to the delayed repair model (57.5MPa vs 39.4MPa, p=0.032). A six week delay between detachment and repair is sufficient to produce significant degenerative changes in the gluteus medius tendon. There are significant histological and mechanical differences in the acute and delayed repair groups at 12 weeks post op, suggesting that a delayed repair model should be used to study the clinical problem

Abstract. Focal articular cartilage defects do not heal and, left untreated, progress to more widespread degenerative changes. A promising new approach for the repair of articular cartilage defects is the application of cell-based regenerative therapies using mesenchymal stromal cells (MSCs). MSCs are however present in a number of tissues and studies suggest that they vary in their proliferation, cell surface characterisation and differentiation. As the phenotypic properties of MSCs vary depending on tissue source, a systematic comparison of the transcriptomic signature would allow a better understanding of these differences between tissues, and allow the identification of markers specific to a MSC source that is best suited for clinical application. Tissue was used from patients undergoing total knee replacement surgery for osteoarthritis following ethical approval and informed consent. MSCs were isolated from bone, cartilage, synovium and infrapatellar fat pad. MSC number and expansion were quantified. Following expansion in culture, MSCs were characterised using flow cytometry with several cell surface markers; the cells from all sources were positive for CD44, CD90 and CD105. Their differentiation potential was assessed through tri-lineage differentiation assays. In addition, bulk mRNA-sequencing was used to determine the transcriptomic signatures. Differentially expressed (DE) genes were predicted. An enrichment analysis focused on the DE genes, against GO and pathway databases (KEGG and Reactome) was performed; protein-protein interaction networks were also inferred (Metascape, Reactome, Cytoscape). Optimal sourcing of MSCs will amplify their cartilage regeneration potential. This is imperative for assessing future therapeutic transplantation to maximise the chance of successful cartilage repair. A better understanding of differences in MSCs from various sources has implications beyond cartilage repair

AO Spine Guideline for Using Osteobiologics in Spine Degeneration project is an international collaborative initiative to identify and evaluate evidence on existing use of osteobiologics in spine degenerative diseases. It aims to formulate clinically relevant and internationally applicable guidelines ensuring evidence-based, safe and effective use of osteobiologics. The current focus is the use of osteobiologics in anterior cervical discectomy and fusion surgeries. The guideline development is planned in three phases. Phase 1- Evidence synthesis and Recommendation; Phase 2- Guideline with osteobiologics grading and Validation; Phase 3- Guideline dissemination and Development of a clinical decision support tool. The key questions formulating the guidelines for the use of osteobiologics will be addressed in a series of systematic reviews in Phase 1. The evidence synthesized by the systematic reviews will be assessed by Grading of Recommendations, Assessment, Development and Evaluations (GRADE) methodology, including expert panel discussions to formulate a recommendation. In Phase 2, osteobiologics will be graded based on evidence and the grading will be integrated with the recommendation from Phase 1, and thus formulate a guideline. The guideline will be further validated by prospective clinical studies. In the third phase, dissemination of the proposed guideline and development of a decision support tool is planned. AO-GO aims to bridge an important gap between quality of evidence and use of osteobiologics in spine fusion surgeries. With a holistic approach the guideline aims to facilitate evidence-based, patient-oriented decision-making process in clinical practice, thus stimulating further evidence-based studies regarding osteobiologics usage in spine surgeries

Aims. The aetiologies of common degenerative spine, hip, and knee pathologies are still not completely understood. Mechanical theories have suggested that those diseases are related to sagittal pelvic morphology and spinopelvic-femoral dynamics. The link between the most widely used parameter for sagittal pelvic morphology, pelvic incidence (PI), and the onset of degenerative lumbar, hip, and knee pathologies has not been studied in a large-scale setting. Methods. A total of 421 patients from the Cohort Hip and Cohort Knee (CHECK) database, a population-based observational cohort, with hip and knee complaints < 6 months, aged between 45 and 65 years old, and with lateral lumbar, hip, and knee radiographs available, were included. Sagittal spinopelvic parameters and pathologies (spondylolisthesis and degenerative disc disease (DDD)) were measured at eight-year follow-up and characteristics of hip and knee osteoarthritis (OA) at baseline and eight-year follow-up. Epidemiology of the degenerative disorders and clinical outcome scores (hip and knee pain and Western Ontario and McMaster Universities Osteoarthritis Index) were compared between low PI (< 50°), normal PI (50° to 60°), and high PI (> 60°) using generalized estimating equations. Results. Demographic details were not different between the different PI groups. L4 to L5 and L5 to S1 spondylolisthesis were more frequently present in subjects with high PI compared to low PI (L4 to L5, OR 3.717; p = 0.024 vs L5 to S1 OR 7.751; p = 0.001). L5 to S1 DDD occurred more in patients with low PI compared to high PI (OR 1.889; p = 0.010), whereas there were no differences in L4 to L5 DDD among individuals with a different PI. The incidence of hip OA was higher in participants with low PI compared to normal (OR 1.262; p = 0.414) or high PI (OR 1.337; p = 0.274), but not statistically different. The incidence of knee OA was higher in individuals with a high PI compared to low PI (OR 1.620; p = 0.034). Conclusion. High PI is a risk factor for development of spondylolisthesis and knee OA. Low pelvic incidence is related to DDD, and may be linked to OA of the hip. Level of Evidence: 1b. Cite this article: Bone Joint J 2020;102-B(9):1261–1267

Osteoarthritis (OA), one of the most common motor system disorders, is a degenerative disease involving progressive joint destruction caused by a variety of factors. At present, OA has become the fourth most common cause of disability in the world. However, the pathogenesis of OA is complex and has not yet been clarified. Long non-coding RNA (lncRNA) refers to a group of RNAs more than 200 nucleotides in length with limited protein-coding potential, which have a wide range of biological functions including regulating transcriptional patterns and protein activity, as well as binding to form endogenous small interference RNAs (siRNAs) and natural microRNA (miRNA) molecular sponges. In recent years, a large number of lncRNAs have been found to be differentially expressed in a variety of pathological processes of OA, including extracellular matrix (ECM) degradation, synovial inflammation, chondrocyte apoptosis, and angiogenesis. Obviously, lncRNAs play important roles in regulating gene expression, maintaining the phenotype of cartilage and synovial cells, and the stability of the intra-articular environment. This article reviews the results of the latest research into the role of lncRNAs in a variety of pathological processes of OA, in order to provide a new direction for the study of OA pathogenesis and a new target for prevention and treatment. Cite this article: Bone Joint Res 2021;10(2):122–133

Aims. Patients may present with concurrent symptomatic osteoarthritis (OA) of the hip and degenerative disorders of the lumbar spine, with surgical treatment being indicated for both. Whether arthroplasty of the hip or spinal surgery should be performed first remains uncertain. Materials and Methods. Clinical scenarios were devised for a survey asking the preferred order of surgery and the rationale for this decision for five fictional patients with both OA of the hip and degenerative lumbar disorders. These were symptomatic OA of the hip and: 1) lumbar spinal stenosis with neurological claudication; 2) lumbar degenerative spondylolisthesis with leg pain; 3) lumbar disc herniation with leg weakness; 4) lumbar scoliosis with back pain; and 5) thoracolumbar disc herniation with myelopathy. This survey was sent to 110 members of The Hip Society and 101 members of the Scoliosis Research Society. The choices of the surgeons were compared among scenarios and between surgical specialties using the chi-squared test. The free-text comments were analyzed using text-mining. Results. Responses were received from 51 hip surgeons (46%) and 37 spine surgeons (37%). The percentages of hip surgeons recommending ‘hip first’ differed significantly among scenarios: 59% for scenario 1; 73% for scenario 2; 47% for scenario 3; 47% for scenario 4; and 10% for scenario 5 (p < 0.001). The percentages of spine surgeons recommending ‘hip first’ were 49% for scenario 1; 70% for scenario 2; 19% for scenario 3; 78% for scenario 4; and 0% for scenario 5. There were significant differences between the groups for scenarios 3 (more hip surgeons recommended ‘hip first’; p = 0.012) and 4 (more hip surgeons recommended ‘spine first’; p = 0.006). Conclusion. In patients with coexistent OA of the hip and degenerative disorders of the spine, the question of ‘hip or spinal surgery first’ elicits relatively consistent answers in some clinical scenarios, but remains controversial in others, even for experienced surgeons. The nature of neurological symptoms can influence surgeons’ decision-making. Cite this article: Bone Joint J 2019;101-B(6 Supple B):37–44

We reviewed 183 patients who had undergone reconstruction of the anterior cruciate ligament. The incidence of meniscal tears and degenerative change was assessed and related to the timing from injury to surgery. Degenerative change was scored using the French Society of Arthroscopy system. The patients were divided into an early (surgery within 12 months of injury) and a late group (surgery more than 12 months from injury). The late group was also subdivided into four groups of 12-month periods ranging from one year to more than four years after injury. There was a significantly higher incidence of meniscal tears in patients undergoing reconstruction after 12 months compared with those in the early group (71.2% vs 41.7%; p < 0.001). This was due to a large increase in medial meniscal tears in the late group. An increased incidence of degenerative change was also found in the late group (31.3% vs 10.7%; p < 0.001). Analysis of the subgroups showed that the incidence of meniscal tears and degenerative change did not differ significantly when surgery was performed after 12 months from injury. We conclude that reconstruction of the anterior cruciate ligament should be carried out within 12 months of injury to minimise the risk of meniscal tears and degenerative change

Purpose and background. Lumbar spinal fusion (LSF) is frequently and increasingly used in lumbar degenerative disorders despite conflicting results and recommendations. Further understanding of patient outcomes after LSF is required to inform decisions regarding surgery and to improve post-surgery management. The objective was to evaluate the course of pain and disability in patients with degenerative disorders of the lumbar spine (spinal stenosis, spondylolisthesis, disc herniation, discogenic low back pain) after first-time LSF. Methods and results. A systematic review and meta-analysis of pain and disability outcomes in prospective cohort studies after first time LSF for degenerative disorders. Two independent researchers searched key databases, determined study eligibility, extracted data and assessed risk of bias (modified Quality in Prognostic Studies tool). A third reviewer mediated at each stage. N weighted pooled estimates were calculated. Twenty-five articles (n=1,777 participants) were included. 17 studies were at unclear risk of bias and 8 at high risk. Back pain (12 studies) decreased modestly and irregularly at follow-up intervals. The n weighted mean VAS back pain decreased from 65.4 (±3.3) pre-surgery to 22.2 (±3.1) at 23 months, but then 45.0 (±not reported; 2 studies at risk of bias) at 42 months. In contrast, leg pain (12 studies) improved substantially short and long-term. Disability (20 studies) improved steadily over time with the exception of the 42-months and 48-months intervals. Conclusion. The overall improvement of leg pain and disability after first-time LSF in degenerative disorders is promising in contrast to back pain outcomes. Further research is needed to analyse outcomes in patients of different diagnostic subgroups. Conflicts of interest. None. Sources of funding. None

Tendinopathy is one of the most common orthopaedic pathological conditions characterized by tendon degenerative changes. Excessive mechanical loading is considered as a major causative factor in the development of tendinopathy, but the mechanisms of pathogenesis remain unclear. High mobility group box-1 (HMGB1), a potent inflammatory mediator when released into the matrix, has been identified in the early stage tendinopathy patients. Since the release and contribution of HMGB1 in tendinopathy development due to mechanical overloading is unknown, we investigated the role of HMGB1 in tendinopathy using a mouse intensive treadmill running (ITR) model and injection of glycyrrhizin (GL), a specific inhibitor of HMGB1. A total of 48 mice were divided into four groups, Cage Control group: The animals were allowed to move freely in their cage, GL group: The animals were received daily IP injection of GL (50 mg/kg body weight) for 24 weeks, ITR group: The animals ran on treadmill at 15 meters/min for three h/ day, five days a week for 12 or 24 weeks, GL+ITR group: The animals ran the same protocol as that of ITR group plus daily IP injection of GL for 12 or 24 weeks. Six mice/group were sacrificed at 12 or 24 weeks and the Achilles and patellar tendon tissues were harvested and used for histochemical staining and immunostaining. Mechanical overloading induced HMGB1 released from the cell nuclei to the matrix (Fig. 1a, b) caused tendon inflammation (Fig. 1c, d) and led to tendon degenerative changes (Fig. 1e-j). After 12 weeks of ITR, the tendon tissue near the bone insertion site showed typical tendinopathic changes in cell shape, accumulation of glycosaminoglycans (GAG) (Fig. 1e, f), and increase in SOX-9 staining (Fig. 1g-j). After 24 weeks ITR, the distal site of Achilles tendon showed considerable changes in cell shape (Fig. 2A, g, arrows), which is round compared to more elongated in the control and GL groups (Fig. 2A, e, f). However, daily treatment with GL prior to ITR blocked the cell shape change (Fig. 2A, h) and, ITR induced extensive GAG accumulation in ITR group (Fig. 2B, bottom panel). Furthermore, GL inhibited ITR-induced expression of chondrogenic markers (SOX-9 and collagen II) in the tendons (Fig. 3). Our results showed that mechanical overloading-induced HMGB1 plays a critical role in the development of tendinopathy by initiating tendon inflammation and eventual degeneration characterized by the presence of chondrocyte-like cells, accumulation of proteoglycans, high levels of collagen type II production, and chondrogenic marker SOX-9 expression. These results provide the first evidence for the role of HMGB1 as a therapeutic target to prevent tendinopathy before its onset and block further development at its early inflammation stages. The inhibition of tendinopathy development by GL administration in this study also suggests the putative therapeutic potential of this natural triterpene that is already in clinical use to treat other inflammation-related diseases. For any figures or tables, please contact authors directly

Osteoarthritis (OA) is one of the most prevalent joint diseases involving progressive and degenerative changes to cartilage resulting from a variety of etiologies including post-traumatic incident or aging. OA lesions can be treated at its early stages through cell-based tissue engineering therapies using Mesenchymal Stem Cells (MSCs). In vivo models for evaluating these strategies, have described both chondral (impaction) and osteochondral (biopsy punch) defects. The aim of the investigation was to develop a compact and reproducible defect inducing post-traumatic degenerative changes mimicking early OA. Additionally, a pilot study to evaluate the efficacy of MSC-hydrogel treatment was also assessed. Surgery was performed on New Zealand white rabbits (male, 5–8 months old) with defects created on medial femoral condyle. For developing an appropriate defect, three approaches were used for evaluation: a biopsy punch (n = three at six and twelve weeks), an impaction device1 (n = three at six and twelve weeks) and a dental drill model (n = six at six and twelve weeks). At stated time points, condyles were harvested and decalcified in 10% EDTA, then embedded in Tissue-Tek and sectioned using a cryostat. Upon identification of region of interest, sections were stained with Safranin-O/Fast green and scored using OARSI scoring system by two blinded observers2. For the pilot study, autologous bone marrow was harvested from rabbits and used to isolate and expand MSCs. The Dental drill model was applied to both knee condyles, left untreated for six weeks at which stage, PKH26 fluorescently labelled MSCs were seeded into a hyaluronic acid hydrogel (TETEC). Repair tissue was removed from both condyles and MSC-hydrogel was injected into the left knee, whilst right knee was left empty. Rabbits were sacrificed at one (n = 1), six (n = 3) and twelve (n = 3) weeks post-treatment, processed as previously described and cartilage regeneration evaluated using Sellers score3. Impacted condyles exhibited no observed changes histologically (Mean OARSI score = 1 + 1), whereas biopsy punched and dental drilled defects demonstrated equal signs of cartilage erosion (OARSI score = 3 + 1) at assessed time points. However, biopsy punched condyles formed a diffusive defect, whereas dental drilled condyles showed a more defined, compact and reproducible defect. In the pilot study, PKH-labelled MSCs were observed at one and six weeks post-implantation within the defect space where hydrogel was injected. Tissue regeneration assessment indicated no difference between empty (Mean Sellers score = 14 + 2) and MSC treated defects (Sellers score = 16 + 5) at six weeks post-injection. At twelve weeks, MSC treated defects showed improved tissue regeneration with substantial subchondral bone restoration and good integration of regenerative cartilage with surrounding intact tissue (Sellers score = 10 + 1), whereas untreated defects showed no change in regeneration compared to six weeks (Sellers score = 16 + 2). Dental drill model was found to be the appropriate strategy for investigating early OA progression and treatment. Application of MSCs in defects showed good cartilage regeneration after twelve weeks application, indicating their promise in the treatment of early OA defects

Introduction and Objective. Almost 60% of the population can expect to experience low back pain (LBP) during their life. Several radiological tools are used to investigate LBP. However, adequate evidence is unavailable to support the use of single photon emission computer tomography (SPECT) in patients with LBP. The objective of this study is to assess the role and efficiency of SPECT in evaluation and management of patients with LBP. Method. Ninety-two patients with LBP were examined and assessed. All the patients received a magnetic resonance imaging (MRI) scan and were referred for a SPECT. We interpreted the modic and degenerative changes found on the MRI and compared it with SPECT tracer uptake. SPECT was used to identify the pain generator and then a surgical plan was made. Data was analyzed for pain improvement in those who underwent surgical treatment to establish the accuracy of CT SPECT in identification of primary pain generator. Results. A total of 184 patients were included in the study who underwent diagnostic CT-SPECT between January 2013 and December 2019. One hundred of them were females and Eighty four males; the mean age was 47.6 years. 111 patients underwent surgery in the form of interbody fusion or posterolateral fusion. 16 patients positive tracer uptake was at asymptomatic level or unrelated. In 3 patients SPECT identified screw sites as pain generator and in all 3 patients screws were removed with good pain relief. Overall axial pain as measured with Numeric rating scale was preoperatively 9.13 ± 0.7 and improved to 4.54 ± 2.3 at 6 months postoperative follow up. MRI changes have been analyzed and correlation studied with relation to SPECT findings. Conclusion. Due to its high precision and sensitivity compared to other radiological modalities, SPECT demonstrated the ability to aid in clinical diagnosis. CT SPECT reveals information that becomes vital in deciding further management. In this study, we exemplified that SPECT scan can give indication for pain generator in axial spine pain and aid in surgical intervention

Introduction and Objective. Intervertebral disc (IVD) degeneration is one of the major contributors to low back pain, the leading cause of disability worldwide. This multifactorial pathological process involves the degradation of the extracellular matrix, inflammation, and cell loss due to apoptosis and senescence. While the deterioration of the extracellular matrix and cell loss lead to structural collapse of the IVD, increased levels of inflammation result in innervation and the development of pain. Amongst the known regulators of inflammation, toll-like receptors (TLRs) and more specifically TLR-2 have been shown to be specifically relevant in IVD degeneration. As strong post-transcriptional regulators, microRNAs (miRNAs) and their dysregulation has been connected to multiple pathologies, including degenerative diseases such as osteoarthritis and IVD degeneration. However, the role of miRNAs in TLR signalling in the IVD is still poorly understood and was hence investigated in this study. Materials and Methods. Human Nucleus pulposus (hNP) and Annulus fibrosus (hAF) cells (n=5) were treated with the TLR-2/6 specific agonist PAM2CSK4 (100 ng/mL for 6 hours) in order to activate the TLR2 signalling pathway. After the activation both miRNA and mRNA were isolated, followed by next-generation sequencing and qPCR analysis of proinflammatory cytokines respectively. Furthermore, cell supernatants were used to analyze the secretion of proinflammatory cytokines with enzyme-linked immunosorbent assay. TLR-2 knockdown (siRNA) cells were used as a control. Statistical analysis was conducted by performing Kolmogorov-Smirnov test and a two-tailed Student's t-test using GraphPad Prism version 9.0.2 for Windows (GraphPad Software, La Jolla California USA). Results. TLR-2 activation resulted in the induction of an inflammatory cell response, with a significant increase in gene expression of interleukin (IL)-6 (525 ± 180 fold change, p < 0.05) and IL-8 (7513 ± 1907 fold change, p < 0.05) and protein secretion of IL-6 (30.5 ± 8.1 pg/mL) and IL-8 (28.9 ± 5.4 pg/mL). TLR-2 activation was furthermore associated with changes in the miRNA profile of hNP and hAF cells. Specifically, we identified 10 differentially expressed miRNAs in response to TLR-2 activation, amongst which were miR-335–3p (1.45 log2 FC, p < 0.05), miR-125b-1–3p (0.55 log2 FC, p < 0.05), and miR-181a-3p (−1.05 log2 FC, p < 0.05). Conclusions. The identified miRNAs are known to be associated with osteoarthritis (miR-335-3p), inflammation and IVD degeneration (mir-125-1-3p and miR-181a-3p), but the link to TLR signalling has not been previously reported. Experiments to validate the identified miRNAs and elucidate their functional role are undergoing. The identification of these miRNAs provides an opportunity to further investigate miRNAs in the context of TLR activation and inflammation and to enhance our understanding of underlying molecular mechanisms behind disc degeneration, inflammation, and TLR dysregulation

We reviewed 87 patients who underwent revision reconstruction of the anterior cruciate ligament. The incidence of meniscal tears and degenerative change was assessed and related to the interval between failure of the primary graft and revision reconstruction. Patients were divided into two groups: early revision surgery within six months of graft failure, and delayed revision. Degenerative change was scored using the French Society of Arthroscopy system. There was a significantly higher incidence of articular cartilage degeneration in the delayed group (Mann-Whitney U-test, 53.2% vs 24%, p < 0.01). No patient in the early group had advanced degenerative change, compared to 9.2% of patients in the delayed group. There was no significant difference (Mann-Whitney U-test, p = 0.3) in the incidence of meniscal tears between the two groups. We conclude that revision reconstruction should be carried out within six months of primary graft failure, in order to minimise the risk of degenerative change

Introduction and Objective. Scapholunate instability is the most common cause of carpal instability. When this instability is left untreated, the mechanical relationship between the carpal bones is permanently disrupted, resulting in progressive degenerative changes in the radiocarpal and midcarpal joints. Different tenodesis methods are used in the treatment of acute or early chronic reducible scapholunate instability, where arthritis has not developed yet and the scapholunate ligament cannot be repaired. Although it has been reported that pain is reduced in the early follow up in clinical studies with these methods, radiological results differ between studies. The deterioration of these radiological parameters is associated with wrist osteoarthritis as previously stated. Therefore, more studies are needed to determine the tenodesis method that will improve the wrist biomechanics better and will last longer. In our study, two new tenodesis methods, spiral antipronation tenodesis, and anatomic front and back reconstruction (ANAFAB) were radiologically compared with triple ligament tenodesis (TLT), in the cadaver wrists. Materials and Methods. The study was carried out on a total of 16 fresh frozen cadaver wrists. Samples were randomly allocated to the groups treated with 3 different scapholunate instability treatment methods. These are TLT (n: 6), spiral antipronation tenodesis (n: 5) and ANAFAB tenodesis (n: 5) groups. In all samples SLIL, DCSS, STT, DIC, RSC and LRL ligaments were cut in the same way to create scapholunate instability. Wrist CT scans were taken on the samples in 4 different states, in intact, after the ligaments were cut, after the reconstruction and after the movement cycle. In all of these 4 states, wrist CTs were taken in 6 different wrist positions. For every state and every position through tomography images; Scapholunate (SL) distance, Scapholunate (SL) angle, Radioscaphoid (RS) angle, Radiolunate (RL) angle, Capitolunate (CL) angle, Dorsal scaphoid translation (Dt) measurements were made. Results. Scapholunate distances means were different between intact and cut states only in neutral and clenched fist positions for all groups (p values <0.001). Mean differences were similar between the groups (p > 0.100). In neutral position, for SL center distance, mean difference between cut and reconstruction states were not different between the groups (p=0.497) but it was noted that only TLT group could not restore to the intact state. In neutral position, for SL angle, compared with the cut state, TLT and ANAFAB significantly reduced the angle (TLT: 20° (p=0.005), ANAFAB: 28° (p<0.001)) whereas antipronation tenodesis could not (13°, p=0.080). In clenched fist position, for SL angle, compared with the intact state, only ANAFAB group restored the angle, TLT and antipronation groups were significantly worse than the intact state (TLT: p<0.001, antipronation: p=0.001). In clenched fist position, for RL angle, compared with the intact state, ANAFAB and TLT groups restored the angle but antipronation group was significantly worse than the intact state (p<0.001). In neutral position, for RS angle, compared with the cut state, only ANAFAB significantly reduced the angle (11°, p<0.001) whereas TLT and antipronation groups could not (TLT: 6° (p=0.567), antipronasyon: 4° (p=0.128). Conclusions. In the presence of severe scapholunate instability in which a several number of secondary stabilizers are injured, the ANAFAB tenodesis method may be preferred to the classical method, TLT tenodesis. The results of spiral antipronation tenodesis were not better than the TLT

Introduction. Deformity influences the weight bearing stresses on the knee joint. Correction of mechanical alignment is performed to offload the knee and slow the rate of degenerative change. Fixator assisted deformity correction facilitates accurate correction prior to internal fixation. We present our results with standard Ilizarov and UNYCO system assisted deformity correction of the lower limb. Materials and Methods. Retrospective analysis of adult surgical cases of mechanical re-alignment performed between 2010 and 2019 in a tertiary referral centre. We recorded standard demographics and operative time from the electronic patient record. We analysed digitalised radiographs to record pre- and post-operative measurements of: Mechanical axis deviation (MAD), femoral tibial angle (FTA), Medial Proximal tibial angle (MPTA) and Mechanical lateral distal femoral angle (mLDFA). The accuracy of the correction was analysed. Time to healing, secondary interventions and complications were also recorded. Results. 7 patients underwent fixator assisted deformity correction with the UNYCO system and 11 with a standard Ilizarov frame. Mean pre-op MAD was 45.8mm in the UNYCO group and 43.4mm in Ilazrov; Mean post-op MAD was 9.5mm in the UNYCO group (5–15) and 12.3 in the Ilizarov group (1–25) p=0.07. The average surgical time in the UNYCO group was 200 minutes (128–325) and 252 minutes (203–301) in the Ilizarov group p=0.07. The mean post op MPTA was 90.2 (87–96) in the UNYCO group and 87.4 (81–94) in the Ilizarov group. The mean mLDFA was 90.0(81–93.5) in the UNYCO group and 87.3(82.2–93.9) in the Ilizarov group. All the corrections involved a plate or nail fixation and mean time to union was 76.3 days in the UNYCO and 117.3 in the Ilizarov group. Conclusions. Both systems allowed accurate correction of deformity and limb alignment. In this small series we were unable to show a difference in theatre time. The application of the principles of deformity correction are as important as the surgical methods

The purpose of this study was to evaluate the long-term functional and radiological outcomes of arthroscopic removal of unstable osteochondral lesions with subchondral drilling in the lateral femoral condyle. We reviewed the outcome of 23 patients (28 knees) with stage III or IV osteochondritis dissecans lesions of the lateral femoral condyle at a mean follow-up of 14 years (10 to 19). The functional clinical outcomes were assessed using the Lysholm score, which improved from a mean of 38.1 (. sd. 3.5) pre-operatively to a mean of 87.3 (. sd. 5.4) at the most recent review (p = 0.034), and the Tegner activity score, which improved from a pre-operative median of 2 (0 to 3) to a median of 5 (3 to 7) at final follow-up (p = 0.021). The radiological degenerative changes were evaluated according to Tapper and Hoover’s classification and when compared with the pre-operative findings, one knee had grade 1, 22 knees had grade 2 and five knees had grade 3 degenerative changes. The overall outcomes were assessed using Hughston’s rating scale, where 19 knees were rated as good, four as fair and five as poor. We found radiological evidence of degenerative changes in the third or fourth decade of life at a mean of 14 years after arthroscopic excision of the loose body and subchondral drilling for an unstable osteochondral lesion of the lateral femoral condyle. Clinical and functional results were more satisfactory

Abstract. Objectives. Identifying risk factors for inferior outcomes after anterior cruciate ligament reconstruction (ACLR) is important for prognosis and patient information. This study aimed to ascertain if BMI, pre-operative scores, demographic data and concomitant injuries in patients undergoing ACLR affected patient-reported functional outcomes. Methods. A prospective review collected data from a single surgeon series of 278 patients who underwent arthroscopic ACLR. BMI, age, gender, graft choice, pre-op Lysholm score, meniscal and chondral injuries were recorded. The Lysholm score, hop test and KT1000 were used to measure post-op functional outcome at one year. Multiple regression analysis was used to determine factors that predicted Lysholm scores at one year. Results. The mean age was 29 years, with 58 female and 220 male patients. The mean pre-op Lysholm score was 53.8. One hunded and seventy-nine patients had meniscal injuries, of which 81 were medial, 60 lateral, and 38 bilateral. Eighteen patients also had chondral injury and 106 patients had no other associated injury. Age, gender, graft type and presence of meniscal or chondral injuries did not affect one-year post-operative Lysholm scores. A BMI greater than 30, physio compliance and preoperative Lysholm scores helped predict one-year post-operative Lysholm scores (p=0.02). Pearson's correlation found a direct link between BMI and post-operative Lysholm (p=0.03). Conclusions. BMI, physio compliance and pre-operative Lysholm scores are the most significant determinants of short-term functional outcome after ACLR. However, the effects of associated injuries may be apparent in the long-term as degenerative changes set in or the continued detriment resulting from the concomitant injury affect outcome. Declaration of Interest. (b) declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported:I declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research project

Purpose of the study is to investigate the outcome of the patients with Perthes disease who have had a surgical dislocation of their hip for the treatment of resultant symptoms from the disease process. Retrospective review of consecutive patients treated with surgical dislocation of the hip for Perthes disease. Review of clinical case notes and radiological imaging. Patient outcome was assessed at follow-up. Between 2010 and 2015, 31 cases of surgical hip dislocation were performed for Perthes disease at our institution by 2 senior surgeons. Age range at time of surgery was 12–33. Male:female ratio was 13:18; right:left ratio was 15:17. Age at the time of Perthes diagnosis was between 3 and 13 years, with 3 diagnosed retrospectively. Mean follow-up was 18months. All patients had an EUA and arthrogram while 61.3%(19/31) had previous surgery for Perthes. 71%(22/31) required a labral repair, 6.5%(2/31) had a peri-acetabular osteotomy at the time of surgery and 3.2%(1/31) required a proximal femoral valgus osteotomy. 22.5%(7/31) required microfracture (femoral head or acetabulum): all of whom had evidence of contained area of degenerative changes on preoperative MRI. 64.5%(20/31) had the trochanteric screws removed. Complications included 1 greater trochanter non-union, 1 pain secondary to suture anchor impinging on psoas tendon, 1 AVN leading to early THR 12 months post-op. Another 2 had further deterioration of degenerative changes and pain leading to THR 18 and 24 months post-op. All 3(9.7%) had microfracture at the time of the dislocation for established degenerative change and also required custom made prostheses. Surgical hip dislocation is an option in treating Perthes patient with resultant symptoms such as impingement. Improved outcome is seen in patients who are younger with a congruent hip joint in contrast to those with established degenerative change evident on MRI / intraoperatively and have an arrow shaped femoral head

Aim. Mesenchymal stem cells (MSCs) have several properties that may support their use as an early treatment option for osteoarthritis (OA). This study investigated the role of multiple injections of allogeneic bone marrow-derived stem cells (BMSCs) to alleviate the progression of osteoarthritic changes in the various structures of the mature rabbit knee in an anterior cruciate ligament (ACL)-deficient OA model. Materials and Methods. Two months after bilateral section of the ACL of Japanese white rabbits aged nine months or more, either phosphate buffered saline (PBS) or 1 x 10. 6. MSCs were injected into the knee joint in single or three consecutive doses. After two months, the articular cartilage and meniscus were assessed macroscopically, histologically, and immunohistochemically using collagen I and II. Results. Within the PBS injection (control group), typical progressive degenerative changes were revealed in the various knee structures. In the single MSC injection (single group), osteoarthritic changes were attenuated, but still appeared, especially in the medial compartments involving fibrillation of the articular cartilage, osteophyte formation in the medial plateau, and longitudinal tear of the meniscus. In the multiple-injections group, the smoothness and texture of the articular cartilage and meniscus were improved. Histologically, absence or reduction in matrix staining and cellularity were noticeable in the control and single-injection groups, respectively, in contrast to the multiple-injections group, which showed good intensity of matrix staining and chondrocyte distribution in the various cartilage zones. Osteoarthritis Research Society International (OARSI) scoring showed significantly better results in the multiple-injections group than in the other groups. Immunohistochemically, collagen I existed superficially in the medial femoral condyle in the single group, while collagen II was more evident in the multiple-injections group than the single-injection group. Conclusion. A single injection of MSCs was not enough to restore the condition of osteoarthritic joints. This is in contrast to multiple injections of MSCs, which had the ability to replace lost cells, as well as reducing inflammation. Cite this article: Bone Joint J 2019;101-B:824–831

Aims. Our aim was to perform a systematic review of the literature to assess the incidence of post-operative epidural haematomas and wound infections after one-, or two-level, non-complex, lumbar surgery for degenerative disease in patients with, or without post-operative wound drainage. Patients and Methods. Studies were identified from PubMed and EMBASE, up to and including 27 August 2015, for papers describing one- or two-level lumbar discectomy and/or laminectomy for degenerative disease in adults which reported any form of subcutaneous or subfascial drainage. Results. Eight papers describing 1333 patients were included. Clinically relevant post-operative epidural haematomas occurred in two (0.15%), and wound infections in ten (0.75%) patients. Epidural haematomas occurred in two (0.47%) patients who had wound drainage (n = 423) and in none of those without wound drainage (n = 910). Wound infections occurred in two (0.47%) patients with wound drainage and in eight (0.88%) patients without wound drainage. Conclusion. These data suggest that the routine use of a wound drain in non-complex lumbar surgery does not prevent post-operative epidural haematomas and that the absence of a drain does not lead to a significant change in the incidence of wound infection. Cite this article: Bone Joint J 2016;98-B:984–9

Osteoarthritis (OA) is a joint degenerative disease leading to chronic pain and disability, thus resulting in a major socioeconomic health burden. OA, which has long been believed to be a cartilage disease, is now considered a whole-joint disorder affecting various anatomical structures, including subchondral bone. Hyaluronic Acid (HA) is commonly used as intra-articular viscosupplementation therapy for its mechanical features and biological effects. Bisphosphonates (BPs) are antiresorptive agents inhibiting recruitment and maturation of osteoclast precursors and activity of mature osteoclasts in the bone. Pre-clinical evidences in the literature, show that intra-articular BPs could impact on OA progression, slowing down or reversing it. The combination of HA biological and mechanical role and Alendronate (ALD) antiresorptive effect could be an interesting strategy for OA treatment. This study describes the synthesis and characterization of FID-134, a new chemical derivative of HA conjugated with ALD by means of a covalent bond, cleavable in physiological condition. FID-134 was synthesized starting from 500 kDa HA: chemical structure and functionalization degree with ALD were investigated by NMR and ICP-OES. Kinetics of ALD release from FID-134 was determined in TRIS buffer at 37°C and compared to a simple mixture of HA+ALD. 20mg/mL formulations of FID-134 and HA+ALD were investigated for viscoelastic properties, in absence and presence of Ca. 2+. ions. The cytotoxicity of FID-134 and free ALD were tested on Saos-2 osteoblasts (ATCC HTB-85) and on primary bovine chondrocytes (PBC) at day 1, 3 and 7. The efficacy of FID-134 was assessed in an inflammatory arthritis in vitro model, where bovine cartilage biopsies were exposed to IL-1β/OSM (10ng/mL) for 3 weeks; at the same time, cartilage explants were treated with FID-134. Collagen release in the surnatants was quantified and compared to controls. FID-134 structure was confirmed by NMR and the 20% mol/mol functionalization degree was determined by ICP-OES. Only about 50% of total bound ALD was released from FID-134 within 7 days, resulting slower compared to HA+ALD mixture. In presence of Ca. 2+. ions, viscoelastic properties of FID-134 dramatically improved, while HA+ALD formulation remained unaffected. The cytotoxicity of ALD was evident at 100 μM on Saos-2 and PBC after 3 days, while no cytotoxicity was observed at 7 days with FID-134. In the cartilage explant model, a strong collagen release was detected in inflammatory conditions after 3 weeks; this tendency was reversed, and collagen release halved when FID-134 was added to the biopsies. The synthesized HA-ALD adduct, FID-134, opens the door for a new approach for OA treatment. The results suggest that FID-134 could be beneficial in cartilage degradation and in restoration of subchondral bone function. Finally, local administration and controlled BP release would likely overcome the drawbacks of ALD oral administration, such as unspecific features and long-term toxic side effects

Background: Structural hip deformities including developmental dysplasia of the hip (DDH) and femoroacetabular impingement (FAI) are thought to predispose patients to degenerative joint changes. However, the natural history of these malformations is not clearly delineated. Methods: Seven-hundred twenty-two patients ≤55 years that received unilateral primary total hip arthroplasty (THA) from 1980–1989 were identified. Pre-operative radiographs were reviewed on the contralateral hip and only hips with Tönnis Grade 0 degenerative change that had minimum 10-year radiographic follow-up were included. Radiographic metrics in conjunction with the review of two experienced arthroplasty surgeons determined structural hip diagnosis as DDH, FAI, or normal morphology. Every available follow-up AP radiograph was reviewed to determine progression from Tönnis Grade 0–3 until the time of last follow-up or operative intervention with THA. Survivorship was analyzed by Kaplan-Meier methodology, hazard ratios, and multi-state modeling. Results: One-hundred sixty-two patients met all eligibility criteria with the following structural diagnoses: 48 DDH, 74 FAI, and 40 normal. Mean age at the time of study inclusion was 47 years (range 18–55), with 56% females. Mean follow-up was 20 years (range 10 – 35 years). Thirty-five patients eventually required THA: 16 (33.3%) DDH, 13 (17.6%) FAI, 6 (15.0%) normal. Kaplan-Meier analysis demonstrated that patients with DDH progressed most rapidly, followed by FAI, with normal hips progressing the slowest. The mean number of years spent in each Tönnis stage by structural morphology was as follows: Tönnis 0: DDH = 17.0 years, FAI = 14.8 years, normal = 22.9 years; Tönnis 1: DDH = 12.2 years, FAI = 13.3 years, normal = 17.5 years; Tönnis 2: DDH = 6.0 years, FAI = 9.7 years, normal = 8.6 years; Tönnis 3: DDH = 1.6 years, FAI = 2.6 years, normal = 0.2 years. Analysis of degenerative risk for categorical variables showed that patients with femoral head lateralization >10 mm, femoral head extrusion indices >0.25, acetabular depth-to-width index <0.38, lateral center-edge angle <25 degrees, and Tönnis angle >10 degrees all had a greater risk of progression from Tönnis 0 to Tönnis 3 or THA. Among patients with FAI morphology, femoral head extrusion indices >0.25, lateral center-edge angle <25 degrees, and Tönnis angle >10 degrees all increased the risk of early radiographic progression. Analysis of degenerative risk for continuous variables using smoothing splines showed that risk was increased for the following: femoral head lateralization >8 mm, femoral head extrusion index >0.20, acetabular depth-to-width index <0.30, lateral center-edge angle <25 degrees, and Tönnis angle >8 degrees. Conclusions: This study defines the long-term natural history of DDH and FAI in comparison to structurally normal young hips with a presumably similar initial prognostic risk (Tönnis Grade 0 degenerative change and contralateral primary THA). In general, the fastest rates of degenerative change were observed in patients with DDH. Furthermore, risk of progression based on morphology and current Tönnis stage were defined, creating a new prognostic guide for surgeons. Lastly, radiographic parameters were identified that predicted more rapid degenerative change, both in continuous and categorical fashions, subclassified by hip morphology

Progressive degenerative changes in the medial compartment of the knee following lateral unicompartmental arthroplasty (UKA) remains a leading indication for revision surgery. The purpose of this study is to evaluate changes in the congruence and joint space width (JSW) of the medial compartment following lateral UKA. The congruence of the medial compartment of 53 knees (24 men, 23 women, mean age 13.1 years; . sd. 62.1) following lateral UKA was evaluated pre-operatively and six weeks post-operatively, and compared with 41 normal knees (26 men, 15 women, mean age 33.7 years;. sd . 6.4), using an Interactive closest point algorithm which calculated the congruence index (CI) by performing a rigid transformation that best aligns the digitised tibial and femoral surfaces. Inner, middle and outer JSWs were measured by sub-dividing the medial compartment into four quarters on pre- and post-operative, weight bearing tunnel view radiographs. The mean CI of knees following lateral UKA significantly improved from 0.92 . (sd . 0.06) pre-operatively to 0.96 . (sd . 0.02) (p < 0.001) six weeks post-operatively. The mean CI of the healthy control group was 0.99 sd 0.01. Post-operatively, the mean inner JSW increased (p = 0.006) and the outer decreased (p = 0.002). The JSW was restored post-operatively as no significant differences were noted in all three locations compared with the control group (inner JSW p = 0.43; middle JSW p = 0.019, outer JSW p = 0.51). . Our data suggest that a well conducted lateral UKA may improve the congruence and normalise the JSW of the medial compartment, potentially preventing progression of degenerative change. . Cite this article: Bone Joint J 2015;97-B:50–5

Patients with longstanding hip fusion are predisposed to symptomatic degenerative changes of the lumbar spine, ipsilateral knee and contralateral hip. 1. In such patients, conversion of hip arthrodesis to hip replacement can provide relief of such symptoms. 2 – 4. However, this is a technically demanding procedure associated with higher complication and failure rates than routine total hip replacement. The aim of this study was to determine the functional results and complications in patients undergoing hip fusion conversion to total hip replacement, performed or supervised by a single surgeon. Twenty-eight hip fusions were converted between 1996 and 2016. Mean follow up was 7 years (3 to 18 years). The reasons for arthrodesis were trauma 11, septic arthritis 10, and dysplasia 7. The mean age at conversion was 52.4 years (26 to 77). A trochanteric osteotomy was performed in all hips. Uncemented components were used. A constrained liner was used in 7 hips. Heterotopic ossification prophylaxis was not used in this series. HHS improved a mean of 27 points (37.4 pre-op to 64.3 post-op). A cane was used in 30% of patients before conversion and 80% after. Heterotopic ossification occurred in 12 (42.9%) hips. There was 2 peroneal nerve injuries, 1 dislocation, 1 GT non-union and 1 infection. There have been 5 revisions; 2 for aseptic loosening, 1 for infection, 1 for recurrent dislocation and 1 for leg length discrepancy. Conversion of hip fusion to hip replacement carries an increased risk of heterotopic ossification and neurological injury. We advise prophylaxis against heterotropic ossification. When there is concern about hip stability we suggest that the use of a constrained acetabular liner is considered. Despite the potential for complications, this procedure had a high success rate and was effective in restoring hip function

Purpose and Background. Leg length discrepancy (LLD) occurs commonly and has been associated with osteoarthritis of the knee and the hip joints. However, the possible association between LLD and degenerative changes in the lumbar spine has not been investigated. Here we correlate the degree of LLD with degenerative changes in the hip joints and the lumbar spine. Methods and Results. A modification of Friberg's method was used to measure LLD and a novel method was devised to exclude magnification errors in standing radiographs of the lumbopelvic region. 5mm of LLD was considered significant. 75 sets (36 female and 39 male) of radiographs from adult patients presenting to chiropractic teaching clinics were used. Degenerative changes at hip and L4/5 and L5/S1 disc spaces were graded on a 4-point scale. Hip degeneration in men with significant LLD was [mean, 95% confidence interval] [1.35, 1.05–1.66], as opposed to men with no significant LLD [0.31, 0.1–0.53]. Degenerative changes at the L5/S1 spinal level in the group with significant LLD demonstrated values of [1.04, 0.75–1.33], compared to the group without significant LLD with values of [0.41, 0.22–0.61]. The association between LLD and lumbar degeneration was particularly strong in men and also in women at or above the age of 25. Conclusion. Here we demonstrate that LLD of 5mm or above, as measured by our method, is associated with significant degenerative changes in the hip joint in men and the L5/S1 motion segment in both men and women, but may be more significant in older women. This abstract has not been previously published in whole or substantial part nor has it been presented previously at a national meeting

Aims. In the context of tendon degenerative disorders, the need for innovative conservative treatments that can improve the intrinsic healing potential of tendon tissue is progressively increasing. In this study, the role of pulsed electromagnetic fields (PEMFs) in improving the tendon healing process was evaluated in a rat model of collagenase-induced Achilles tendinopathy. Methods. A total of 68 Sprague Dawley rats received a single injection of type I collagenase in Achilles tendons to induce the tendinopathy and then were daily exposed to PEMFs (1.5 mT and 75 Hz) for up to 14 days - starting 1, 7, or 15 days after the injection - to identify the best treatment option with respect to the phase of the disease. Then, 7 and 14 days of PEMF exposure were compared to identify the most effective protocol. Results. The daily exposure to PEMFs generally provided an improvement in the fibre organization, a decrease in cell density, vascularity, and fat deposition, and a restoration of the physiological cell morphology compared to untreated tendons. These improvements were more evident when the tendons were exposed to PEMFs during the mid-acute phase of the pathology (7 days after induction) rather than during the early (1 day after induction) or the late acute phase (15 days after induction). Moreover, the exposure to PEMFs for 14 days during the mid-acute phase was more effective than for 7 days. Conclusion. PEMFs exerted a positive role in the tendon healing process, thus representing a promising conservative treatment for tendinopathy, although further investigations regarding the clinical evaluation are needed. Cite this article: Bone Joint Res 2020;9(9):613–622

The surgical treatment of spinal deformities and degenerative or oncological vertebral diseases is becoming more common. However, this kind of surgery is complex and associated to a high rate of early and late complications. We retrospectively collected all the major complications observed in the perioperative and post-operative period for surgeries performed at our Division of Spine Surgery in the 2010–2012 period,. 285 surgeries were registered in 2010, 324 in 2011 and 308 in 2012. All the complications observed during the procedure and the follow-up period were recorded and classified according to the type (mechanical complications, neurological complications, infection, hematoma, cerebrospinal fluid fistula, systemic complications, death related to the surgery). In 2010, on 285 surgeries 47 patients (16.5 %) had 69 complications (24.2%): 25.7% for the treatment of oncological diseases, 23% for the treatment of degenerative diseases, 27% for the treatment of pathologies of traumatic origin, 11% for the treatment of spondylodiscitis (infectious diseases). In 2011, on 324 surgeries 35 patients (10.8 %) had 54 complications (16.7%): 16.3% for the treatment of oncological diseases, 16.3% for the treatment of degenerative diseases, 20% for the treatment of pathologies of traumatic origin, 28.6% for the treatment of spondylodiscitis. In 2012, on 308 surgeries, 25 patients (8.1 %) had 36 complications (11.7%): 14.4% for the treatment of oncological diseases, 7.2% for the treatment of degenerative diseases, 16.7% for the treatment of pathologies of traumatic origin, 20% for the treatment of spondylodiscitis. On 917 spinal surgeries performed from January 2010 to December 2012, 159 complications (17.3%) were recorded, with a prevalence of mechanical complications and infections. We are also prospectively collecting complications related to 2013–2015, in order to have a larger amount of data and try to detect potential risk factors to be taken into consideration in the decision-making process for complex spinal surgery

Aims. The aim of this study was to evaluate the outcome of Monteggia-like lesions at midterm follow-up and to determine whether the surgical treatment of the radial head influences the clinical and radiological results. Patients and Methods. A total of 78 patients with a Monteggia-like lesion, including 44 women and 34 men with a mean age of 54.7 years (19 to 80), were available for assessment after a mean 4.6 years (2 to 9.2). The outcome was assessed using the Mayo Elbow Performance Score (MEPS), Oxford Elbow Score (OES), Mayo Modified Wrist Score (MMWS), and The Disabilities of the Arm, Shoulder and Hand (DASH) score. Radiographs were analyzed for all patients. A total of 12 Mason type I, 16 type II, and 36 type III fractures were included. Surgical treatment consisted of screw fixation for all type II and reconstructable type III fractures, while radial head arthroplasty (RHA) or excision was performed if reconstruction was not possible. Results. The mean MEPS was 88.9 (40 to 100), mean OES was 40.1 (25 to 48), mean MMWS was 88.1 (50 to 100), mean DASH score was 14.7 (0 to 60.2), and mean movement was 114° (. sd. 27) in extension/flexion and 155° (. sd. 37) in pronation/supination. Mason III fractures, particularly those with an associated coronoid fracture treated with RHA, had a significantly poorer outcome. Suboptimal results were also identified in patients who had degenerative changes or heterotopic ossification on their latest radiograph. In contrast, all patients with successful radial head reconstruction or excision had a good outcome. Conclusion. Good outcomes can be achieved in Monteggia-like lesions with Mason II and III fractures, when reconstruction is possible. Otherwise, RHA is a reliable option with satisfactory outcomes, especially in patients with ligamenteous instability. Whether the radial head should be excised remains debatable, although good results were achieved in patients with ligamentous stability and in those with complications after RHA. Cite this article: Bone Joint J 2019;101-B:1512–1519

Background. The use of the direct anterior approach (DAA) for total hip arthroplasty (THA) has increased in recent years. This is in part due to the proposed benefits of a faster early recovery and a lower risk of dislocation. The purpose of this study is to understand the dislocation rate in a non-selective, consecutive cohort of patients undergoing THA via the DAA including those at high risk for instability due to spinopelvic pathology. Methods. We performed a retrospective review of a large prospectively collected single institution database assessing all patients undergoing THA via the DAA between 2011 and 2017. The primary outcome measure was dislocation at minimum two-year follow-up. We then stratified patients by known risk factors for dislocation including spinopelvic pathology and performed an in-depth analysis of those patients who had a dislocation event. Results. 2,831 hips in 2205 patients were included in the study. Mean age was 64.9 (24–96) and 1,595 (56.3%) were female. Mean BMI was 29.2 (15.1–53.8). There were 11 dislocations within one year of the index operation (0.38%) and 13 total dislocations at terminal follow-up (0.45%). Five dislocations required revision (38.4% of dislocations 0.17% overall). When stratified by experience the dislocation rate for surgeons who had completed their learning curve was 0.15% compared to 1.11% in those who hadn't. There were 666 patients with an established diagnosis of spinopelvic pathology or prior surgical instrumentation, only 2 (0.30%) dislocated and neither required revision. Conclusion. In a non-selective, consecutive cohort of patients undergoing THA via the DAA the risk of dislocation is low. Even amongst patients with lumbosacral stiffness secondary to spinal instrumentation or degenerative changes, the rate of dislocation is low following THA via the DAA. Our data suggests that utilizing the DAA in high risk patients may be protective against dislocation without the need for additional constraint or the use of newer bearing constructs that lack long term outcome studies. The inclusion of seven surgeons suggests that these results are generalizable

We have investigated whether the pattern of subchondral acetabular cyst formation reflects hip pathology and may provide a prognostic indicator for treatment. A single surgeon series of sequential hip arthroscopies was reviewed to identify the most recent 200 cases undertaken on a previously un-operated joint with pre-operative plain radiographs and computed tomography or magnetic resonance scan available for review. Also, serial “non-arthritic hip scores” (NAHS) recorded pre-operatively, at 6 weeks and 3 months post-surgery. The acetabular Lateral Centre Edge Angle, the Acetabular Index, the FEAR index and the Kallgren and Lawrence grade were determined. All images were reviewed by two independent assessors and divided into four groups according to acetabular subchondral cyst distribution. NC - No cysts - 74 cases (mean: 40.1 years), SPC - a Single Peripheral Cyst – 58 cases (mean: 43.1 years), SDC - a Solitary Dome Cyst – 32 cases (mean: 33 years) and MC - Multiple Cysts – 36 cases (mean: 42.7 years). No association was identified between gender and patient reported outcomes. SDC patients were significantly younger than the other three groups (p <0.001). At three months after surgery, the average increase of the NAHS in the four groups was 25.3, 23.5, 4.2 and 4.9 respectively. Acetabular dysplasia was identified in 72% of the SDC group compared to 18%, 16% and 33% in NC, SPC and MC groups. Degenerative change was identified in 86% of the MC group compared to 18%, 40% and 41% of the NC, SPC and SDC groups. The early patient reported outcome following hip arthroscopy was significantly affected by the location and number of acetabular subchondral cysts. A Solitary Dome Cyst is indicative of underling hip dysplasia. Multiple Cysts are indicative of degenerative disease. The majority of patients in these groups have poor three-month outcomes after hip arthroscopy

With the increase in the elderly population, there is a dramatic increase in the number of spinal fusions. Spinal fusion is usually performed in cases of primary instability. However it is also performed to prevent iatrogenic instability created during surgical treatment of spinal stenosis in most cases. In literature, up to 75% of adjacent segment disease (ASD) can be seen according to the follow-up time. 1. Although ASD manifests itself with pathologies such as instability, foraminal stenosis, disc herniation or central stenosis. 1,2. There are several reports in the literature regarding lumbar percutaneous transforaminal endoscopic interventions for lumbar foraminal stenosis or disc herniations. However, to the best our knowledge, there is no report about the treatment of central stenosis in ASD. In this study, we aimed to investigate the short-term results of unilateral biportal endoscopic decompressive laminotomy (UBEDL) technique in ASD cases with symptomatic central or lateral recess stenosis. The number of patients participating in the prospective study was 8. The mean follow-up was 6.9 (ranged 6 to 11) months. The mean age of the patients was 68 (5m, 3F). The development of ASD time after fusion was 30.6 months(ranged 19 to 42). Mean fused segments were 3 (ranged 2 to 8). Preoperative instability was present in 2 of the patients which was proven by dynamic lumbar x-rays. Preoperative mean VAS-back score was 7.8, VAS Leg score was 5.6. The preoperative mean JOA (Japanese Orthopaedic Association) score was 11.25. At 6th month follow-up, the mean VAS back score of the patients was 1, and the VAS leg score was 0.5. This improvement was statistically significant (p = 0.11 and 0.016, respectively). The mean JOA score at the 6th month was 22.6 and it was also statistically significant comparing preoperative JOA score(p = 0.011). The preoperative mean dural sac area measured in MR was 0.50 cm2, and it was measured as 2.1 cm. 2. at po 6 months.(p = 0.012). There was no progress in any patient's instability during follow-up. In orthopedic surgery, when implant related problems develop in any region of body (pseudoarthrosis, infection, adjacent fracture, etc.), it is generally treated by using more implants in its final operation. This approach is also widely used in spinal surgery. 3. However, it carries more risk in terms of devoloping ASD, infection or another complications. In the literature, endoscopic procedures have almost always been used in the treatment of ventral pathologies which constitute only 10%. In ASD, disease devolops as characterized by wide facet joint arthrosis and hypertrophied ligamentum flavum in the cranial segment and it is mostly presented both lateral recess and santal stenosis symptoms (39%). In this study, we found that UBEDL provides successful results in the treatment of patients without no more muscle and ligament damage in ASD cases with spinal stenosis. One of the most important advantages of UBE is its ability to access both ventral and dorsal pathologies by minimally invasive endoscopic aproach. I think endoscopic decompression also plays an important role in the absence of additional instability at postoperatively in patients. UBE which has already been described in the literature given successful results in most of the spinal degenerative diseases besides it can also be used in the treatment of ASD. Studies with longer follow-up and higher patient numbers will provide more accurate results

Fibular head avulsion fractures represent a significant injury to the posterolateral corner of the knee. There is a high rate of concomitant injuries including rupture of the cruciate ligaments. Surgical fixation is indicated to restore stability, protect repaired or reconstructed cruciate ligaments and possibly decrease the likelihood of degenerative change. The current presentation describes a novel technique which provides secure fixation to the fibular head, restoring integrity of the posterolateral ligament complex and facilitating early motion. We also present a case series of our experience by a single surgeon at our tertiary referral center. Twenty patients underwent open reduction and internal fixation between 2006 and 2016 using a large fragment cannulated screw and soft tissue washer inserted obliquely from the proximal fibula to tibia. Fixation was augmented with suture repair of the lateral collateral ligament and biceps tendon. The orientation of the fracture was assessed based on preoperative imaging. Repair / reconstruction of concomitant injuries was performed during the same procedure. Early range of motion was initiated at 2 weeks postoperatively under physical therapy guidance. All patients returned for clinical and radiographic assessment (average 3.5 years). All fractures went on to bony union. There were no reoperations for recurrent instability. All patients regained functional range of motion with mean extension of 0.94 degrees and mean flexion of 121.4 degrees. Two patients underwent hardware removal. One patient developed a late local infection, which occurred greater than 5 years after surgery. Eleven patients underwent postoperative varus stress radiographs which demonstrated less than 1 mm difference between the operated and contralateral side. Fracture morphology typically demonstrated an oblique pattern in the coronal plane and a transverse pattern in the sagittal plane. This study represents a novel surgical technique for the repair of fibular head avulsion fractures with a large fragment cannulated screw placed obliquely from the fibula to tibia. Fixation is augmented with a soft tissue washer and suture repair. Our results suggest that this technique allows for early range of motion with maintenance of reduction, high rates of union, and excellent postoperative stability

In the setting of traumatic elbow injuries involving coronoid fractures, the relative size of the coronoid fragment has been shown to relate to the stability of the joint. Currently, the challenge lies in accurately classifying the amount of bone loss in coronoid fractures. In comminuted fractures, bone loss is difficult to measure with plain radiographs or computed tomography. The purpose of this study is to describe a novel radiographic measure, the Coronoid Opening Angle (COA), on lateral elbow radiographs. We demonstrate the relationship of the COA to coronoid height and describe how this measure can be used to estimate bone loss and potentially predict elbow instability following coronoid fracture. Radiographs were drawn from a regional database in a consecutive fashion. Candidate radiographs were excluded on the basis of radiographic evidence of degenerative changes, previous surgery or injury, bony deformity, and inadequate lateral view of the elbow. The COA was measured as the angle between the long axis of the ulna at the level of the trochlear notch, and the tip of coronoid, from a common origin at the posterior cortex of the olecranon. Images were reviewed by a fellowship trained upper extremity surgeon, an upper extremity fellow, and a junior resident. Normal COA, coronoid height, and calculated COA at varying amounts of bone loss were calculated by three reviewers. A sensitivity analysis was performed to determine how the COA can most effectively predict bone loss at varying coronoid heights. Intraclass correlation coefficient (ICC) was calculated for 39 subjects. Seventy-two subjects were included for analysis (M=40, F=32). The normal coronoid opening angle is 33.19 degrees [32.2 – 34.2]. Coronoid height is 18.8 mm [18.1 – 19.6]. Extrapolating this baseline data, the COA at 20%, 33%, and 50% of coronoid bone loss was calculated to be 27.5, 23.5, and 18 degrees, respectively. ICC was found to be 0.90 or higher. Cutoff values were determined to maximize the sensitivity of the COA. A cutoff value of 21 degrees has a 92% sensitivity in detecting a minimum of 50% bone loss. The COA with similar sensitivity in predicting 20% and 33% bone loss are 32 and 27 degrees. The coronoid opening angle is a novel technique that can be used on a lateral elbow radiograph to predict the minimum coronoid bone loss. This can be used to guide clinical decision making and potentially predict instability. Future research will aim to validate this tool in the clinical setting in predicting instability

Goodfellow & Bullough (1968) first described the pattern of articular cartilage wear in the elbow. More recent post mortem studies have shown that advanced degenerative changes can develop in the radio-capitellar (lateral) compartment of elbow joints of elderly subjects in which the humeroulnar (medial) compartment remains remarkably well preserved. We have reviewed the findings in a consecutive series of 117 elbow arthroscopies performed on patients with elbow pain resistant to conservative treatments (age range 21–80 years: mean age 51 years). We documented established degenerative changes involving articular cartilage in 68 patients (59%). In this group we found that in 60 patients (88%) the degenerative changes were confined to the lateral compartment and contrasted with normal appearances of the articular cartilage of the medial compartment. The post mortem studies carried out on mainly elderly subjects demonstrated that the degree of degenerative change in the elbow is age dependant and involves predominantly the lateral compartment of the joint. Our study would support these observations, but indicates that symptomatic degenerative change occurs at a much earlier age than had previously been thought. We consider that lateral compartment degenerative change is a distinct clinical entity. It begins in relatively young patients in whom the x ray appearance may be normal or near normal and is often diagnosed as lateral epicondylitis. Our observations taken together with the reported post mortem studies indicate that primary osteoarthritis of the elbow begins in the lateral compartment of the joint and may remain confined to the lateral compartment throughout life. We believe that new treat ment strategies need to be developed specifically for patients with primary osteoarthritis as opposed to degenerative joint disease due to other causes

We estimated the long term results of the different methods in chirurgical treatment of lumbar disk herniation in consideration with the presence or absence of degenerative changes and the grade in witch these factors influence the result of this kind of treatment. Seventy eight patents with lumbar disk herniation have been submitted in partial discectomy. The men were 42 and 36 women. The patients were separated in tow groups. In the first group [48 patients, 31 of them (A1) without degenerative changes, while the 17 (A2) with degenerative changes], was applied macrodiscectomi. In the second group [30 patients, 18 of them (B1) without degenerative changes and the 12 (B2) with changes], was applied microdiscectomi with use of magnifying lenses. The mean age during operation was 44 years (18–67) and 38 years (24–62) respectively for the tow groups, and the mean time of follow-up was 7 years and 8 months (18 months-13 years). For all patients, the operation was executed from the same surgeon. The elements that were evaluated were the Visual analog scale (VAS, O-10), the Oswestry Disability Index (ODI), as well as the complications during and after the operation and the cases that required a reoperation. In the first group VAS score was improved from 9.1 to 3.1 and the ODI score was improved from 86% to 24.2%. In the second group VAS score was improved from 9 to 2.6 and the ODI score was improved from 84.2% to 19.2%. From all patients, subgroup B1 without degenerative changes, which was submitted in microdiscectomy presented the biggest improvement. We have had to reoperate 6 patients (7.8%). In cases of lumbar disk hernia both methods are appropriate and lead to a considerable improvement of the symptoms. Degenerative changes of the lumbar spine is a factor that leads in less satisfactory results

Aims. The aims of this study were to compare the mid-term outcomes of patients with late-stage arthritis of the wrist treated with proximal row carpectomy (PRC) and dorsal capsular interposition (DCI) arthroplasty with a matched cohort treated with routine PRC alone. Patients and Methods. A total of 25 arthritic wrists (24 patients) with pre-existing degenerative changes of the proximal capitate and/or the lunate fossa of the radius were treated with PRC + DCI over a ten-year period. This group of patients were matched 1:2 with a group of 50 wrists (48 patients) without degenerative changes in the capitate or lunate fossa that were treated with a routine PRC alone during the same period. The mean age of the patients at the time of surgery was 56.8 years (25 to 81), and the demographics and baseline range of movement of the wrist, grip strength, Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) score, and Patient-Rated Wrist Evaluation (PRWE) score were similar in both groups. . Results. At a mean follow-up of 5.9 years (1.8 to 11.8), significant improvements in mean grip strength, the flexion-extension arc of movement of the wrist, QuickDASH, and PRWE scores were seen in both groups. There was no diifference between the groups for any of the outcomes. One patient in the PRC + DCI group required additional surgery for a deep infection, while two in the PRC group had complications (one wound dehiscence requiring revision closure, one transient radial sensory neuritis). One patient in each group required total arthrodesis of the wrist for progressive degenerative radiocarpal changes. A total of 70 patients (93%) were satisfied with the outcomes. Conclusion. PRC with DCI is an effective form of treatment for late-stage arthritis of the wrist involving the capitolunate joint, with mid-term outcomes that are similar to those in patients without degenerative changes affecting the capitate or lunate fossa who are treated with a routine PRC alone. Cite this article: Bone Joint J 2018;100-B:197–204

Introduction. Femoroacetabular impingement (FAI) is a morphological hip joint deformity associated with pain and early degenerative changes. Cam-type FAI is prevalent in young male athletes. While biomechanical deficiencies (decreased hip muscle strength and range of motion (ROM)) have been associated with symptomatic cam-type FAI (sFAI), results have been conflicting and little is known about biomechanical characteristics during dynamic tasks. Objectives. (1) Compare coronal-plane hip muscle strength, activation and joint rotation during movement tasks in sFAI hips against healthy controls. (2) Investigate the effect of hip internal rotation ROM (IR-ROM) on these outcomes. Methods. 11 sFAI and 24 well-matched healthy control hips from 18 young adult male athletes were recruited (Table.1). Passive hip IR-ROM was measured with goniometry. Weight-normalised hip abductor and adductor isometric maximal voluntary contraction torques were quantified with handheld dynamometry. Gluteus medius and adductor longus activation and hip coronal-plane kinematics were collected with surface electromyography (EMG) and motion-capture during time-defined phases of sit-to-stand (Fig.1) and single-leg-squat (Fig.2) tasks. Effect of sFAI with hip IR-ROM as a separate independent variable was calculated with 1-way MANCOVA. Results. sFAI had significantly less IR-ROM (19.25°±5.94) than controls (28.83°±7.24) (p<0.001). During the sit-to-stand ascent phase, significantly more hip abduction (F=4.93, p=0.03) was observed in sFAI (13.06°±3.16) compared to controls (10.16°±3.72). With IR-ROM differences controlled for, significantly higher gluteus medius:adductor longus EMG activation ratio (F=4.32, p=0.046) was observed in the same phase in sFAI (0.16±0.34) compared to controls (−0.11±0.31). No other significant results were found. Conclusion. sFAI hips demonstrate altered muscle activation and movement patterns when ascending from seated positions compared to controls, with reduced hip IR-ROM in sFAI hips influencing findings. Abductor and adductor function imbalance may explain why sFAI increases risk of early degenerative changes. Despite study limitations (no imaging for sFAI diagnosis), these findings should be considered when optimising rehabilitation in this population. For any figures and tables, please contact the authors directly

Purpose of the study: Although the association between femoroacetabular impingement and degenerative hip disease has been well established, there is no way to detect a subgroup of hips with radiographic signs of impingement which will progress to degeneration. In addition, the majority of publications on the topic have been conducted in populations of patients with an overtly degenerative hip, where the incidence of signs of impingement is higher. There has not been any study searching for the presence of signs of impingement in a symptom free population. For this reason, we searched for signs of femoroacetabular impingement in a general population and attempted to find correlations with degenerative hip disease. Material and method: We examined 200 computed tomography (CT) series of the pelvis performed for reason other than an orthopaedic indication. Four hundred hips were thus analysed with the Amira 4.1 3D software. We measured the classical coxometric parameters, orientation of the acetabulum, alpha angle, and presence or not of a bulge at the head-neck junction. Cartilage thickness was also mapped using a precise protocol. Cartilage thickness less than 0.25mm was considered for the purpose of this study to indicate degenerative disease. All data were processed with SPPS 17.0. Results: There were 103 men and 97 women, mean age 58 years and 59 years respectively. The mean alpha angle was 55.7. Retroversion was noted in 20% of hips and 28% exhibited an anterior bulge at the head-neck junction. The mean cartilage thickness at the anterosuperior part of the hip was 37mm. Degenerative disease was present in 28 patients (14%) whose mean cartilage thickness at the anterosuperior portion of the joint was 21 mm. There was no significant correlation between cartilage thickness and acetabular orientation, alpha angle, presence of a bulge at the head-neck junction. Only age was significantly correlated with degenerative disease r=−0.158 [p< 0.0]. Discussion: Among the parameters currently considered to be risk factors for degenerative disease of the hip joint, age alone was statistically linked with reduced cartilage thickness in our symptom-free population. This would suggest that the essential mechanism underlying degenerative disease remains to be discovered. Conclusion: Our findings suggest we should be prudent when proposing corrective surgery for femoroacetabular impingement. Such surgery should be reserved for symptomatic patients

Introduction: The degenerative changes in the patello-femoral joint after an autologous bone-tendon-bone anterior cruciate ligament reconstruction were studied using plain radiology more than 24 years after the surgical procedure. Material and Methods: One hundred patients out of a total of 148 patients could be reviewed at 24.5 years follow-up. Radiological analysis included joint space width narrowing classification of the medial and lateral facet according to IKDC and patellar height according to Caton-Deschamps index (CDI). Results: Fifty four percent of patients had medial femorotibial moderate or severe degenerative changes. Medial patello-femoral degenerative changes were found more frequently and these lesions were more pronounced: 20% had narrowing < 50% (IKDC C) and 4% had narrowing > 50% (IKDC D). Onset of medial patellofemoral osteoarthritis was correlated with medial femorotibial osteoarthritis (p< 0,001). Patellar height was statistically different between the operated and controlateral knee (CDI = 0.92 and 0.96, p< 0.001). Patella baja (CDI< 0.8, frequency 9.9%) was correlated with medial femoro-patellar osteoarthritis (< 0.001) and postoperative cast immobilisation (p=0.047). Discussion: Patello-femoral degenerative changes observed 24.5 years after ACL reconstruction are part of the global degenerative changes of the knee joint. Harvesting of the patellar tendon for anterior cruciate ligament reconstruction results in a only 0.04 point decrease of the Caton-Deschamps index 24.5 years after surgery

Hemiarthroplasty is a common procedure that is an attractive alternative to total arthroplasty because it conserves natural tissue, allows for quicker recovery, and has a lower cost. One significant issue with hemiarthroplasties is that they lead to accelerated wear of the opposing native cartilage, likely due to the high stiffness of the implant. The purpose of this study was to investigate the range of currently available biomaterials for hemiarthroplasty applications. We employed a finite-element (FE) model of a radial head implant against the native capitellum as our joint model. The FE model was developed in ABAQUS v6.14 (Dassault Systèmes Simulia Corp., Providence, RI, USA). A solid axisymmetric concave implant with seven different materials and the native radial head were evaluated, six modelled as elastic materials with different Young's moduli (E) and Poisson's Ratios (ν), and one modelled as a Mooney-Rivlin hyperelastic material. The materials investigated were CoCr (E=230 GPa, ν = 0.3), PEEK (E=3.7 GPa, ν = 0.36), HDPE (E=2.7 GPa, ν = 0.42), UHMWPE (E=0.69 GPa, ν = 0.49), Bionate 75D (E=0.288 GPa, ν = 0.39), Bionate 55D (E=0.039 GPa, ν = 0.45), and Bionate 80A (modelled as a Mooney-Rivlin hyperelastic material). A load of 100 N was applied to the radius through the center of rotation representing a typical load through the radius. The variable of interest was articular contact stress on the capitellum. The CoCr implant had a maximum contact stress over 114% higher than the native radial head. By changing the material to lower the stiffness of the implant, the maximum contact stress was 24%, 70%, 105%, 111%, 113%, and 113% higher than the native radial head for Bionate 80A, Bionate 55D, Bionate 75D, UHMWPE, HDPE, and PEEK respectively. This work shows that lowering implant stiffness can reduce the contact stress on cartilage in hemiarthroplasty implants. By changing the material below a Young's modulus of ∼100 MPa elevated stresses on the capitellum can be markedly reduced and hence potentially reduce or prevent degenerative changes of the native articulating cartilage. Low stiffness implant materials are not a novel concept, but to date there have been few that investigate materials (such as Bionate) as a potential load bearing material for implant applications. Further work is required to assess the efficacy of these materials for articular bearing applications

Between 1995 and 2006, five intra-articular osteotomies of the head of the radius were performed in patients with symptomatic healed displaced articular fractures. Pre-operatively, all patients complained of persistent painful clicking on movement. Only patients with mild or no degenerative changes of the radial head and capitellum were considered for osteotomy. The operations were performed at a mean of 8.2 months (4 to 13) after injury and the patients were reviewed at a mean of 5.5 years (15 months to 12 years) after the osteotomy. The average Mayo Elbow Performance Index Score improved significantly from 74 before to 88 after operation, with four patients rated as good or excellent (p < 0.05). The subjective patient satisfaction score was 8.4 on a ten-point scale. All osteotomies healed and there were no complications. In this small series intra-articular osteotomy of the head of the radius was a safe and effective treatment for symptomatic intra-articular malunion without advanced degenerative changes

Introduction. Herniated disc tissue removed at surgery usually appears degenerated, and MRI often reveals degenerative changes in adjacent discs and vertebrae. This has fostered the belief that a disc must be degenerated before it can herniate, which has medicolegal significance. We hypothesise that degenerative changes in herniated disc tissues differ from those found in tissues that have degenerated in-situ, and are consistent with being consequences rather than causes of herniation. Methods. Surgically-removed discs were examined using histology, immunohistochemistry and confocal microscopy. 21 samples of herniated tissues were compared with age-matched tissues excised from 11 patients whose discs had reached a similar Pfirrman grade of degeneration but without herniating. Degenerative changes were assessed separately in three tissue types (where present): nucleus, inner annulus, and outer annulus. Mann-Whitney U tests were used to compare ‘herniated’ vs ‘in-situ’ tissues. Results. Herniated tissues showed significantly greater cellularity (annulus), greater proteoglycan loss (outer annulus), greater neovascularisation (annulus), greater innervation (annulus) as judged by PGP 9.5 staining, greater expression of matrix-degrading enzymes MMP1 and MMP3 (inner annulus), but less cell clustering (outer annulus). Some similar but non-significant differences were seen in nucleus tissues. Interpretation. Herniated tissues that escape the pressurised confines of the disc are free to swell, lose proteoglycans and come into contact with blood cells. These events could explain most of the differences between herniated tissues and those that degenerated ‘in situ’. Results support our hypothesis, and warn against assuming that degenerative changes always precede (or cause) disc herniation. No conflicts of interest. No funding obtained. This abstract has not been previously published in whole or in part; nor has it been presented previously at a national meeting

Labral tears are commonly associated with femoroacetabular impingement. We reviewed 151 patients (156 hips) with femoroacetabular impingement and labral tears who had been treated arthroscopically. These were subdivided into those who had undergone a labral repair (group 1) and those who had undergone resection of the labrum (group 2). In order to ensure the groups were suitably matched for comparison of treatment effects, patients with advanced degenerative changes (Tönnis grade > 2, lateral sourcil height < 2 mm and Outerbridge grade 4 changes in the weight-bearing area of the femoral head) were excluded, leaving 96 patients (101 hips) in the study. At a mean follow-up of 2.44 years (2 to 4), the mean modified Harris hip score in the labral repair group (group 1, 69 hips) improved from 60.2 (24 to 85) pre-operatively to 93.6 (55 to 100), and in the labral resection group (group 2, 32 hips) from 62.8 (29 to 96) pre-operatively to 88.8 (35 to 100). The mean modified Harris hip score in the labral repair group was 7.3 points greater than in the resection group (p = 0.036, 95% confidence interval 0.51 to 14.09). Labral detachments were found more frequently in the labral repair group and labral flap tears in the resection group. No patient in our study group required a subsequent hip replacement during the period of follow-up. This study shows that patients without advanced degenerative changes in the hip can achieve significant improvement in their symptoms after arthroscopic treatment of femoroacetabular impingement. Where appropriate, labral repair provides a superior result to labral resection

Aims

Hip arthroscopy has gained prominence as a primary surgical intervention for symptomatic femoroacetabular impingement (FAI). This study aimed to identify radiological features, and their combinations, that predict the outcome of hip arthroscopy for FAI.

Aims

The purpose of this study was to evaluate the mid-term outcomes of autologous matrix-induced chondrogenesis (AMIC) for the treatment of larger cartilage lesions and deformity correction in hips suffering from symptomatic femoroacetabular impingement (FAI).

Aims

Shoulder arthroplasty is effective in the management of end-stage glenohumeral joint arthritis. However, it is major surgery and patients must balance multiple factors when considering the procedure. An understanding of patients’ decision-making processes may facilitate greater support of those considering shoulder arthroplasty and inform the outcomes of future research.

We examined the reliability of radiological findings in predicting segmental instability in 112 patients (56 men, 56 women) with a mean age of 66.5 years (27 to 84) who had degenerative disease of the lumbar spine. They underwent intra-operative biomechanical evaluation using a new measurement system. Biomechanical instability was defined as a segment with a neutral zone > 2 mm/N. Risk factor analysis to predict instability was performed on radiographs (range of segmental movement, disc height), MRI (Thompson grade, Modic type), and on the axial CT appearance of the facet (type, opening, vacuum and the presence of osteophytes, subchondral erosion, cysts and sclerosis) using multivariate logistic regression analysis with a forward stepwise procedure. The facet type was classified as sagittally orientated, coronally orientated, anisotropic or wrapped. Stepwise multivariate regression analysis revealed that facet opening was the strongest predictor for instability (odds ratio 5.022, p = 0.009) followed by spondylolisthesis, MRI grade and subchondral sclerosis. Forward stepwise multivariate logistic regression indicated that spondylolisthesis, MRI grade, facet opening and subchondral sclerosis of the facet were risk factors. Symptoms evaluated by the Short-Form 36 and visual analogue scale showed that patients with an unstable segment were in significantly more pain than those without. Furthermore, the surgical procedures determined using the intra-operative measurement system were effective, suggesting that segmental instability influences the symptoms of lumbar degenerative disease

Low back pain is more common in women than men, yet most studies of intervertebral disc (IVD) degeneration do not address sex differences. In humans, there are sex differences in spinal anatomy and degenerative changes in biomechanics, and animal models of chronic pain have demonstrated sex differences in pain transduction. However, there are few studies investigating sex differences in annular puncture IVD degeneration models. IVD puncture is known to result in progressive biomechanical alterations, but whether these IVD changes correlate with pain is unknown. This study used a rat IVD injury model to determine if sex differences exist in mechanical allodynia, biomechanics, and the relationship between them, six weeks after IVD injury. Procedures were IACUC approved. 24 male & 24 female four-month-old Sprague-Dawley rats underwent a sham or annular puncture injury surgery (n=12 male, 12 female). In injury groups, three lumbar IVDs were each punctured three times with a needle, and injected with tumor necrosis factor-alpha. Mechanical allodynia was tested biweekly using von Frey filaments. Six weeks after IVD injury, rats were euthanized and motion segments were dissected for non-destructive axial tension-compression and torsional rotation biomechanical testing. Two-way ANOVA with Bonferroni corrections identified statistically significant differences (p < 0 .05) and correlations used Pearson's coefficient. Annular puncture injury induced a significant increase in mechanical allodynia compared to sham in male but not female rats up to six weeks after injury. There was a significant sex effect on both torque range and torsional stiffness, with males exhibiting greater stiffness and torque range than females. Tensile stiffness, compressive stiffness, and axial range of motion showed no sex difference. Males and females showed similar patterns of correlation between variables when sham and injury groups were analyzed together, but correlations were stronger in males. Most correlations were clustered within testing approach: axial biomechanics negatively correlated, torsional biomechanics positively correlated, and von Frey thresholds positively correlated. Surprisingly, mechanical allodynia did not correlate with any biomechanics after injury, and the axial and torsional biomechanics showed little correlation. This study demonstrates that males and females respond to IVD injury differently. Given the absence of correlation between pain and biomechanics, pain cannot be attributed completely to biomechanical changes. This may explain why spinal fusion surgery, an intervention limited to the spine, has produced inconsistent results and is controversial for patients with low back pain. Thus, in addressing low back pain, we must consider both spinal tissues and the nervous system. Further, the limited correlation between axial and torsional biomechanics indicates that IVD injury may have distinct effects on nucleus pulposus and annulus fibrosus. Biomechanics did not differ between sham and injury at week six, suggesting healing after injury. It remains possible that acute biomechanical changes may initiate chronic pain pathogenesis. We conclude that the observed sex differences demonstrate the need for inclusion of both males and females in IVD injury and pain studies, and suggest that males and females may require different treatments for conditions that appear similar

Aims

Adenosine, lidocaine, and Mg²⁺ (ALM) therapy exerts differential immuno-inflammatory responses in males and females early after anterior cruciate ligament (ACL) reconstruction (ACLR). Our aim was to investigate sex-specific effects of ALM therapy on joint tissue repair and recovery 28 days after surgery.

Aims

The number of patients undergoing surgery for degenerative cervical radiculopathy has increased. In many countries, public hospitals have limited capacity. This has resulted in long waiting times for elective treatment and a need for supplementary private healthcare. It is uncertain whether the management of patients and the outcome of treatment are equivalent in public and private hospitals. The aim of this study was to compare the management and patient-reported outcomes among patients who underwent surgery for degenerative cervical radiculopathy in public and private hospitals in Norway, and to assess whether the effectiveness of the treatment was equivalent.

Advanced osteoarthritis of knee is associated with low-backache in a significant number of patients and adversely affects the quality of life. There is a paucity of literature describing outcomes of backache after total-knee-arthroplasty (TKA). We evaluated backache in patients of advanced knee-osteoarthritis and their functional and radiological outcomes after TKA after approval from Institutional ethics committee. Fifty-nine patients (40 females and 19 males) were included. Mean body-mass index was 28.7. Mean visual analogue score (VAS) for knee-pain was 7.98 preoperatively and 1.6 in follow-up. For chronic backache, the mean VAS score improved from 6.08 to 2.4, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) improved from 67.5 to 37.8, Knee society score (KSS) from 49.8 to 76.6, Oswestry Disability Index (ODI) Score from 55.44 to 34.65 and SF-36 Quality-of-life score from 44.95 to 74.63. There was a significant correlation between in knee and low-back functional scores. Magnetic resonance imaging-based scoring of degenerative changes (Pfirrmann grading) showed improvement only in 13.5% patients; 56% showed no change and 30.5% showed deterioration of scores. Chronic low backache is a significant co-morbidity in advanced knee-osteoarthritis. TKA has the potential to relieve backache along with knee-pain and improves quality of life

Introduction. Unicompartmental knee arthroplasty (UKA) has seen renewed interest in recent years due to improved surgical techniques and prosthetic design, and the desire for minimally invasive surgery. For patients with limited degenerative disease, UKA offers a viable alternative to total knee arthroplasty. Historically, the outcomes of lateral compartment UKA have been inferior to medial compartment UKA, with suboptimal patient satisfaction and increased revision rates. Robotic-assisted UKA has been shown to improve precision and accuracy of component placement, which may improve outcomes of lateral UKA. The purpose of this study was to compare the outcome of robotic-assisted UKA to conventional UKA for degenerative disease of the lateral compartment. The hypothesis of the study was that robotic-assisted lateral UKA results in superior outcomes compared to conventional UKA. Materials and methods. A search of the institution's joint registry was conducted to identify patients who underwent UKA for limited degenerative disease of the lateral knee compartment. A total of 130 lateral UKAs were identified that were performed between 2004 and 2012. The mean age of the patients was 63.1 years (range, 20 to 88); patients had a mean BMI of 29.9 (range, 18 to 48). The medical records of all patients were reviewed and assessed for the type of surgical procedure used (robotic-assisted versus conventional), length of hospital stay, Oxford knee score, and occurrence of revision surgery. Results. A total of 93 robotic-assisted and 37 conventional UKA were analysed. At a mean follow-up 35 months (range, 1 to 107 months), the mean Oxford scores in the robotic-assisted and conventional group were similar (39.6 versus 35.9, p=0.135). The length of stay was significantly shorter after robotic-assisted UKA (1.7 days) compared to conventional UKA (2.3 days, p<0.001). There were significantly more revisions in the conventional UKA group [6 conversions to total knee arthroplasty (TKA), 2 tibial component exchanges] compared to robotic-assisted UKA (2 conversions to TKA, p<0.001). Conclusions. The findings of this study revealed a decreased revision rate in robotic-assisted lateral UKAs compared to conventional lateral UKA. Furthermore, patients who received robotic-assisted UKAs had a shorter postoperative hospital stay compared to patients who received conventional UKA. However, overall surgical outcomes were similar in both patient cohorts based on similar postoperative Oxford scores. UKA is a technically challenging procedure with limited joint visualisation and less tolerance for acceptable component position; a two-degree error may lead to UKA failure. Malaligned components may lead to impaired joint biomechanics causing pain and disease progression to other knee compartments. Robotic-assisted UKA systems offer increased accuracy of component placement with objective soft-tissue balancing. Improved component positioning with robotic-assisted UKA systems may improve the long-term survival of UKA in patients with limited lateral degenerative disease, which is performed less often than medial UKA

Aims

To investigate the effects of senescent osteocytes on bone homeostasis in the progress of age-related osteoporosis and explore the underlying mechanism.

Goodfellow & Bullough (1968) first described the pattern of articular cartilage wear in the elbow. More recent post mortem studies have shown that advanced degenerative changes can develop in the radio-capitellar (lateral) compartment of elbow joints of elderly subjects in which the humero-ulnar (medial) compartment remains remarkably well preserved. The significance of this post-mortem findings,in an elderly population, with unknown elbow symptom logy, who died from diverse causes, is unknown. There has been no clinically based,in vivo,study of this subject. Our study would support these observations, but indicates that symptomatic degenerative change occurs at a much earlier age than had previously been thought. We have reviewed the findings in a consecutive series of 117 elbow arthroscopies performed on patients with elbow pain resistant to conservative treatments (age range 21–80 years: mean age 51 years). We documented established degenerative changes involving articular cartilage in 68 patients (59%). In this group we found that in 60 patients (88%) the degenerative changes were confined to the lateral compartment and contrasted with normal appearances of the articular cartilage of the medial compartment. The findings presented in this work are in full agreement with previous work on the articular wear and biomechanics of the elbow joint. Previous studies which have been on cadaveric specimens, with findings of uncertain symptomatic relevance. To our knowledge, this finding has not previously been demonstrated in a symptomatic, young population. Unicompartmental lateral degeneration of the elbow is therefore a real clinical entity rather than a interesting post mortem finding. As such, it demands consideration in terms of investigation, diagnosis and treatment. It is likely that in the past, many patients have been misdiagnosed as having chronic lateral epicondylitis. We consider that lateral compartment degenerative change is a distinct clinical entity. It begins in relatively young patients in whom the x ray appearance may be normal or near normal and is often diagnosed as lateral epicondylitis. Our observations taken together with the reported post mortem studies indicate that primary osteoarthritis of the elbow begins in the lateral compartment of the joint and may remain confined to the lateral compartment throughout life. We believe that new treatment strategies need to be developed specifically for patients with primary osteoarthritis as opposed to degenerative joint disease due to other causes