Aims. The aim of this study was to assess arthritis of the basal joint of the thumb quantitatively using bone single-photon emission CT/CT (SPECT/CT) and evaluate its relationship with patients’ pain and function. Methods. We retrospectively reviewed 30 patients (53 hands) with symptomatic basal joint arthritis of the thumb between April 2019 and March 2020. Visual analogue scale (VAS) scores for pain, grip strength, and pinch power of both hands and Patient-Rated Wrist/Hand Evaluation (PRWHE) scores were recorded for all patients. Basal joint arthritis was classified according to the modified Eaton-Glickel stage using routine radiographs and the CT scans of SPECT/CT, respectively. The maximum standardized uptake value (SUVmax) from SPECT/CT was measured in the four peritrapezial joints and the highest uptake was used for analysis. Results. According to Eaton-Glickel classification, 11, 17, 17, and eight hands were stage 0 to I, II, III, and IV, respectively. The interobserver reliability for determining the stage of arthritis was moderate for radiographs (k = 0.41) and substantial for CT scans (k = 0.67). In a binary categorical analysis using SUVmax, pain (p < 0.001) and PRWHE scores (p = 0.004) were significantly higher in hands with higher SUVmax. Using multivariate linear regression to estimate the pain VAS, only SUVmax (B 0.172 (95% confidence interval (CI) 0.065 to 0.279; p = 0.002) showed a significant association. Estimating the variation of PRWHE scores using the same model, only SUVmax (B 1.378 (95% CI, 0.082 to 2.674); p = 0.038) showed a significant association. Conclusion. The CT scans of SPECT/CT provided better interobserver reliability than routine radiographs for evaluating the severity of arthritis. A higher SUVmax in SPECT/CT was associated with more pain and functional disabilities of basal joint arthritis of the thumb. This approach could be used to complement radiographs for the evaluation of patients with this condition. Cite this article: Bone Joint J 2021;103-B(8):1380–1385

Aims. To assess the effect of physical exercise (PE) on the histological and transcriptional characteristics of proteoglycan-induced arthritis (PGIA) in BALB/c mice. Methods. Following PGIA, mice were subjected to treadmill PE for ten weeks. The tarsal joints were used for histological and genetic analysis through microarray technology. The genes differentially expressed by PE in the arthritic mice were obtained from the microarray experiments. Bioinformatic analysis in the DAVID, STRING, and Cytoscape bioinformatic resources allowed the association of these genes in biological processes and signalling pathways. Results. Arthritic mice improved their physical fitness by 42.5% after PE intervention; it induced the differential expression of 2,554 genes. The bioinformatic analysis showed that the downregulated genes (n = 1,371) were significantly associated with cellular processes that mediate the inflammation, including Janus kinase-signal transducer and activator of transcription proteins (JAK-STAT), Notch, and cytokine receptor interaction signalling pathways. Moreover, the protein interaction network showed that the downregulated inflammatory mediators interleukin (IL) 4, IL5, IL2 receptor alpha (IL2rα), IL2 receptor beta (IL2rβ), chemokine ligand (CXCL) 9, and CXCL12 were interacting in several pathways associated with the pathogenesis of arthritis. The upregulated genes (n = 1,183) were associated with processes involved in the remodelling of the extracellular matrix and bone mineralization, as well as with the processes of aerobic metabolism. At the histological level, PE attenuated joint inflammatory infiltrate and cartilage erosion. Conclusion. Physical exercise influences parameters intimately linked to inflammatory arthropathies. Research on the effect of PE on the pathogenesis process of arthritis is still necessary for animal and human models. Cite this article:Bone Joint Res. 2020;9(1):36–48

Aims. The surgical management of ankle arthritis with tibiotalar arthrodesis is known to alter gait, as compared with normal ankles. The purpose of this study was to assess post-operative gait function with gait before arthrodesis. Patients and Methods. We prospectively studied 20 patients who underwent three-dimensional gait analysis before and after tibiotalar arthrodesis. Cadence, step length, walking velocity and total support time were assessed. Kinetic parameters, including the moment and power of the ankle in the sagittal plane and hip power were also recorded. Results. Significant improvement was recorded across numerous parameters compared with pre-operative measurements. Temporal-spatial data demonstrated a significant increase in step length (p = 0.003) and velocity (p = < 0.001). Total support time decreased for the unaffected limb (p = 0.01). Kinematic results demonstrated that in the affected limb, total sagittal range of movement did not change significantly (p = 0.1259). However, the arc of movement had a near congruent shift with mean maximal dorsiflexion increasing from 5° (-17° to 16°) to 12° (5° to 18°) (p < 0.001) and mean maximal plantarflexion decreasing from 6.8° (6° to 21°) to 0.9° (-9° to 8°) (p = 0.003). Mean hip joint range of movement increased by 6° (-7° to 24°; p = 0.003). Kinetic results demonstrated no statistically significant change in ankle power (p = 0.1292). However, there was an increase in ankle moment (p = 0.04) and hip power (p = 0.01) in the surgically treated extremity. Sagittal plane range of movement was not reduced after tibiotalar fusion. Conclusion. Although following tibiotalar arthrodesis the gait demonstrated never matched the gait shown in unaffected ankles, compared with the pre-operative analysis there was improvement in numerous temporal-spatial, kinematic, and kinetic measures. Cite this article: Bone Joint J 2016;98-B:1369–75

We retrospectively reviewed the records of 1150 computer-assisted total knee replacements and analysed the clinical and radiological outcomes of 45 knees that had arthritis with a pre-operative recurvatum deformity. The mean pre-operative hyperextension deformity of 11° (6° to 15°), as measured by navigation at the start of the operation, improved to a mean flexion deformity of 3.1° (0° to 7°) post-operatively. A total of 41 knees (91%) were managed using inserts ≤ 12.5 mm thick, and none had mediolateral laxity > 2 mm from a mechanical axis of 0° at the end of the surgery. At a mean follow-up of 26.4 months (13 to 48) there was significant improvement in the mean Knee Society, Oxford knee and Western Ontario and McMaster Universities Osteoarthritis Index scores compared with the pre-operative values. The mean knee flexion improved from 105° (80° to 125°) pre-operatively to 131° (120° to 145°), and none of the limbs had recurrent recurvatum. These early results show that total knee replacement using computer navigation and an algorithmic approach for arthritic knees with a recurvatum deformity can give excellent radiological and functional outcomes without recurrent deformity

We systematically reviewed all the evidence published in the English language on proximal interphalangeal joint (PIPJ) replacement, to determine its effectiveness on the function of the hand and the associated post-operative complications.

Original studies were selected if they reported clinical outcome with a minimum of one year’s follow-up. Quality was assessed using the Cowley systematic review criteria modified for finger-joint replacements. Of 319 articles identified, only five were adequately reported according to our quality criteria; there were no randomised controlled trials. PIPJ replacements had a substantial effect size on hand pain of -23.2 (95% confidence interval (CI) -27.3 to -19.1) and grip strength 1.2 (95% CI -10.7 to 13.1), and a small effect on range of movement 0.2 (95% CI -0.4 to 0.8). A dorsal approach was most successful. Post-operative loosening occurred in 10% (95% CI 3 to 30) of ceramic and 12.5% (95% CI 7 to 21) of pyrocarbon replacements. Post-operative complications occurred in 27.8% (95% CI 20 to 37).

We conclude that the effectiveness of PIPJ replacement has not been established. Small observational case studies and short-term follow-up, together with insufficient reporting of patient data, functional outcomes and complications, limit the value of current evidence.

We recommend that a defined core set of patients, surgical and outcome data for this intervention be routinely and systematically collected within the framework of a joint registry.

Aims. Contemporary outcomes of primary total hip arthroplasties (THAs) with highly cross-linked polyethylene (HXLPE) liners in patients with inflammatory arthritis have not been well studied. This study examined the implant survivorship, complications, radiological results, and clinical outcomes of THA in patients with inflammatory arthritis. Methods. We identified 418 hips (350 patients) with a primary diagnosis of inflammatory arthritis who underwent primary THA with HXLPE liners from January 2000 to December 2017. Of these hips, 68% had rheumatoid arthritis (n = 286), 13% ankylosing spondylitis (n = 53), 7% juvenile rheumatoid arthritis (n = 29), 6% psoriatic arthritis (n = 24), 5% systemic lupus erythematosus (n = 23), and 1% scleroderma (n = 3). Mean age was 58 years (SD 14.8), 66.3% were female (n = 277), and mean BMI was 29 kg/m. 2. (SD 7). Uncemented femoral components were used in 77% of cases (n = 320). Uncemented acetabular components were used in all patients. Competing risk analysis was used accounting for death. Mean follow-up was 4.5 years (2 to 18). Results. The ten-year cumulative incidence of any revision was 3%, and was highest in psoriatic arthritis patients (16%). The most common indications for the 15 revisions were dislocations (n = 8) and periprosthetic joint infections (PJI; n = 4, all on disease-modifying antirheumatic drugs (DMARDs)). The ten-year cumulative incidence of reoperation was 6.1%, with the most common indications being wound infections (six cases, four on DMARDs) and postoperative periprosthetic femur fractures (two cases, both uncemented femoral components). The ten-year cumulative incidence of complications not requiring reoperation was 13.1%, with the most common being intraoperative periprosthetic femur fracture (15 cases, 14 uncemented femoral components; p = 0.13). Radiological evidence of early femoral component subsidence was observed in six cases (all uncemented). Only one femoral component ultimately developed aseptic loosening. Harris Hip Scores substantially improved (p < 0.001). Conclusion. Contemporary primary THAs with HXLPE in patients with inflammatory arthritis had excellent survivorship and good functional outcomes regardless of fixation method. Dislocation, PJI, and periprosthetic fracture were the most common complications in this cohort with inflammatory arthritis. Cite this article: Bone Joint J 2023;105-B(7):768–774

Aims. Insufficient treatment response in rheumatoid arthritis (RA) patients requires novel treatment strategies to halt disease progression. The potential benefit of combination of cytokine-inhibitors in RA is still unclear and needs further investigation. To explore the impact of combined deficiency of two major cytokines, namely interleukin (IL)-1 and IL-6, in this study double deficient mice for IL-1αβ and IL-6 were investigated in different tumour necrosis factor (TNF)-driven inflammatory bone disorders, namely peripheral arthritis and sacroiliitis, as well as systemic bone loss. Methods. Disease course, histopathological features of arthritis, and micro-CT (µCT) bone analysis of local and systemic bone loss were assessed in 15-week-old IL1-/-IL6-/-hTNFtg in comparison to IL1-/-hTNFtg, IL6-/-hTNFtg, and hTNFtg mice. µCT bone analysis of single deficient and wild-type mice was also performed. Results. Combined deficiency of IL-1/IL-6 markedly ameliorated TNF-mediated arthritis and bilateral sacroiliitis, but without additive benefits compared to single IL-1 deficiency. This finding confirms the important role of IL-1 and the marginal role of IL-6 in TNF-driven pathways of local joint damage, but questions the efficacy of potential combinatorial therapies of IL-1 and IL-6 in treatment of RA. In contrast, combined deficiency of IL-1/IL-6 led to an additive protective effect on TNF-driven systemic bone loss compared to single IL-1 and IL-6 deficiency. This finding clearly indicates a common contribution of both IL-1 and IL-6 in TNF-driven systemic bone loss, and points to a discrepancy of cytokine dependency in local and systemic TNF-driven mechanisms of inflammatory arthritis. Conclusion. Combinatorial treatments in RA might provide different benefits to inflammatory local arthritis and systemic comorbidities. Cite this article: Bone Joint Res 2022;11(7):484–493

Management of ankle arthritis in young patients is challenging. Although ankle arthrodesis gives consistent pain relief, it leads to loss of function and adjacent joint arthritis. Ankle joint distraction (AJD) has been shown to give good outcomes in adults with osteoarthritis or post-traumatic arthritis. The efficacy in children or young adults and those with juvenile idiopathic arthritis is less well evidenced. Clinical notes and radiographs of all patients (n=6) managed with AJD in one tertiary referral centre were retrospectively reviewed. Radiographs were taken pre-surgery, intra-operatively, 1 month following frame removal and at the last follow up, tibiotalar joint space was assessed using ImageJ software. Measurements were taken at the medial, middle and lateral talar dome using frame components as reference. Radiographic data for patients with a good clinical outcome was compared with those who did not. At time of surgery mean age was 16.1 years (12 – 25 years). Mean follow up was 3.4 years (1.5 – 5.9 years). Indications were juvenile idiopathic arthritis (4) post-traumatic (1) and post-infective arthritis (1). Three patients at last follow up had a good clinical outcome. Two patients required revision to arthrodesis (1.3 and 2.4 years following distraction). One patient had spontaneous fusion. One patient required oral antibiotics for pin site infection. Inter-observer reliability was 95%. Mean joint space was 1.17mm (SD = 0.87mm) pre-operatively which increased to 6.72mm (SD = 2.23mm) at the time of distraction and 2.09mm (SD = 1.14mm) at the time of removal. At one-year follow up, mean joint space was 1.96mm (SD = 1.97mm). Outcomes following AJD in this population are variable although significant benefits were demonstrated for 50% of the patients in this series. Radiographic joint space preoperatively did not appear to be associated with need for arthrodesis. Further research in larger groups of young patients is required

Knowledge of the premorbid glenoid shape and the morphological changes the bone undergoes in patients with glenohumeral arthritis can improve surgical outcomes in total and reverse shoulder arthroplasty. Several studies have previously used scapular statistical shape models (SSMs) to predict premorbid glenoid shape and evaluate glenoid erosion properties. However, current literature suggests no studies have used scapular SSMs to examine the changes in glenoid surface area in patients with glenohumeral arthritis. Therefore, the purpose of this study was to compare the glenoid articular surface area between pathologic glenoid cavities from patients with glenohumeral arthritis and their predicted premorbid shape using a scapular SSM. Furthermore, this study compared pathologic glenoid surface area with that from virtually eroded glenoid models created without influence from internal bone remodelling activity and osteophyte formation. It was hypothesized that the pathologic glenoid cavities would exhibit the greatest glenoid surface area despite the eroded nature of the glenoid and the medialization, which in a vault shape, should logically result in less surface area. Computer tomography (CT) scans from 20 patients exhibiting type A2 glenoid erosion according to the Walch classification [Walch et al., 1999] were obtained. A scapular SSM was used to predict the premorbid glenoid shape for each scapula. The scapula and humerus from each patient were automatically segmented and exported as 3D object files along with the scapular SSM from a pre-operative planning software. Each scapula and a copy of its corresponding SSM were aligned using the coracoid, lateral edge of the acromion, inferior glenoid tubercule, scapular notch, and the trigonum spinae. Points were then digitized on both the pathologic humeral and glenoid surfaces and were used in an iterative closest point (ICP) algorithm in MATLAB (MathWorks, Natick, MA, USA) to align the humerus with the glenoid surface. A Boolean subtraction was then performed between the scapular SSM and the humerus to create a virtual erosion in the scapular SSM that matched the erosion orientation of the pathologic glenoid. This led to the development of three distinct glenoid models for each patient: premorbid, pathologic, and virtually eroded (Fig. 1). The glenoid surface area from each model was then determined using 3-Matic (Materialise, Leuven, Belgium). Figure 1. (A) Premorbid glenoid model, (B) pathologic glenoid model, and (C) virtually eroded glenoid model. The average glenoid surface area for the pathologic scapular models was 70% greater compared to the premorbid glenoid models (P < 0 .001). Furthermore, the surface area of the virtual glenoid erosions was 6.4% lower on average compared to the premorbid glenoid surface area (P=0.361). The larger surface area values observed in the pathologic glenoid cavities suggests that sufficient bone remodelling exists at the periphery of the glenoid bone in patients exhibiting A2 type glenohumeral arthritis. This is further supported by the large difference in glenoid surface area between the pathologic and virtually eroded glenoid cavities as the virtually eroded models only considered humeral anatomy when creating the erosion. For any figures or tables, please contact the authors directly

Aim. The aim of this systematic review was to assess the existing published data on tuberculous arthritis involving native joints in adults aged 18 years and older. The specific research questions focused on the diagnosis and management of the disease. Method. This study was performed in accordance with the guidelines provided in the Preferred Reporting Items for Systematic reviews and Meta-Analysis extension for Scoping Reviews (PRISMA-ScR). A systematic literature search was undertaken of Pubmed, Web of Science, Scopus and the Cochrane library. Only studies published in English since 1970 were considered. Case series involving less than 10 patients, systematic and narrative reviews, and laboratory or animal studies were excluded. We also excluded reports of TB infections not involving a “native joint” and tuberculosis of the spine. The level of evidence and strength of recommendations was performed in accordance with the GRADE system. Results. The systematic review of the literature yielded 2023 potential sources. Following deduplication, screening and full-text review, 20 data sources involving 573 patients from nine countries, were included. There was considerable variation amongst the studies in terms of the approach to diagnosis and management. The most common method used to confirm the diagnosis was microbiological culture of tissue obtained by biopsy, with positive findings in 93% of cases. Medical management involved a median 12 months of antitubercular treatment (IQR 8–16; range 4–18 months). Duration of pre-operative treatment ranged from two to 12 weeks in duration. Surgery was performed in approximately 87% of patients and varied from arthroscopic debridement to complete synovectomy combined with total joint arthroplasty. When arthroplasty and arthrodesis cases are excluded, 80% of patients received an open or arthroscopic debridement. The mean follow-up time of all studies was 26 months, with most studies demonstrating a minimum follow-up of at least six-months (range 3–112 months). Recurrence rates were reported in most studies, with an overall average recurrence rate of 7,4% (35 of 475). Conclusions. The current literature on TB arthritis highlights the need for the establishment of standardised diagnostic criteria. Further research is needed to define the optimal approach to medical and surgical treatment. The role of early debridement in active tuberculous arthritis needs to be explored further. Specifically, comparative studies are required to address the questions around use of medical treatment alone versus in combination with surgical intervention

Arthritis is a common and debilitating disease and is associated with an increased fall risk. The purpose of this study was to examine the effect of impacted joint and limb on fall risk as measured by the margin of stability (MOS). There were 110 participants, including healthy controls (HC; n=30), ankle arthritis (AA; n=30), knee arthritis (KA; n=20) and hip arthritis (HA; n=30) patients. All protocols were Institutional Review Board approved and all participants signed informed consent. Participants walked approximately 6 meters at a self-selected pace. MOS was calculated in the foot coordinate system in the anterior/posterior (AP) and medial/lateral (ML) directions at heel strike. A one-way ANOVA was used to examine group effects (HC, AA, KA, HA) on gait speed. A two-way repeated measures ANOVA was used to examine the effects of limb (Non-Surgical, Surgical) and group on AP and ML MOS. HC had the fastest gait speed (1.40±0.24 m/s; p<0.001) when compared to AA (0.85±0.24 m/s), KA (0.94±0.22 m/s) and HA (1.05±0.22 m/s). HA participants had a greater gait speed compared to AA (p=0.004). AP MOS was greater in the surgical limb compared to the non-surgical limb for AA (p<0.001) and HA (p<0.001). AP MOS was smaller in HC compared to AA, KA, and HA, regardless of limb (p<0.030). AP MOS was similar between AA, KA, and HA for the non-surgical limb (p>0.194) and the surgical limb (p>0.096). ML MOS was greater in the surgical compared to non-surgical limb (p=0.003). ML MOS was smaller in KA participants compared to all other groups (p<0.001). Our results demonstrate stability during gait varies between limbs in arthritis patients, with a more conservative pattern for the surgical limb and suggest KA may be at an increased risk of falls with a smaller ML MOS

Trapeziectomy with ligament reconstruction and tendon interposition (LRTI) with the flexor carpi radialis (FCR) tendon is one of the most common procedures for the treatment of thumb carpometacarpal (CMC) arthritis. An alternative method involves trapeziectomy alone (TA). The trapeziectomy with LRTI procedure was developed to theoretically improve biomechanical strength and hand function when compared to TA, which leaves an anatomical void proximal to the first metacarpal. The LRTI procedure takes longer to perform and includes an autologous tendon graft. The goal of this retrospective cohort study was to evaluate the clinical outcomes of trapeziectomy with or without LRTI at a minimum follow-up of 1 year. A total of 43 adult patients who had underwent a total of 58 (TA=36, LRTI=22) surgical procedures for CMC arthritis participated in the study. This single surgeon retrospective cohort study sampled patients who underwent CMC arthroplasty with either TA or LRTI techniques between 2008 and 2020 with a minimum time of 1 year post-operatively. The patients were evaluated subjectively (The Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire) and objectively (hand/thumb strength, pre/post-operative hand radiographs). Both the TA and LRTI procedures provided good pain relief, motion, strength, and stability without any severe complications. There was no statistically significant difference in hand or thumb strength between the two groups. Radiography showed that compared to the preoperative status, the trapezial space decreased similarly between the two groups. There was no difference in size of collapse between TA and LRTI post-operatively. The TA procedure had similar outcomes to LRTI and has the advantages of shorter surgical time, less incision length, and lower surgical complexity. TA provided equivalent trapezial space to LRTI after the operation. Future study should investigate these two procedures in a head-to-head comparison rather than longitudinally where both surgeon experience and time since procedure at follow-up may have impacted results

Introduction. Osteoarthritis in the foot and ankle affects approximately 30,000 patients annually in the UK. Evidence has shown that excess weight exacerbates foot pain, with significant increases in joint forces. However, despite the current trend for Clinical Commissioning Groups to ration surgery for obese patients, studies have not yet determined the effect of weight loss in obese patients with foot and ankle arthritis. Aim. Pilot study to investigate the effect of simulated weight loss on pain scores in obese patients with symptomatic foot and ankle arthritis. Methods. Following ethical approval, a prospective study of 17 obese patients (mean BMI 39.2, range 31.2 – 50.3) with foot and ankle arthritis was undertaken (BOFAS funded). Under physiotherapist supervision, patients walked for one minute on an anti-gravity treadmill, which allowed simulated weight reduction. Following baseline assessment, reduced BMI was simulated, starting at 20, rising in increments of 5, until each patient's usual BMI was reached. Pain was assessed using a Visual Analogue Scale (VAS). Repeated measures ANOVA was used to assess for significant changes in pain, comparing baseline with each simulated BMI category (significance set at p< 0.05). Results. Simulated weight loss caused a significant reduction in pain (p=0.005, power 0.91). Mean VAS pain scores improved by 24% (p=0.003) and 17% (p=0.040) for BMI categories 20 and 25, compared with baseline. Pain scores were not significantly different comparing BMI categories of 25 and 20. Conclusion. Simulated weight loss to normal BMI significantly decreased pain in obese patients with foot and ankle arthritis. The use of the anti-gravity treadmill to demonstrate the feeling of normal BMI has also provided motivation to several patients to lose weight. The current study could be used to power future studies to investigate the effects of weight loss in foot and ankle patients

Aims. The purpose of this study was to validate our hypothesis that centrifugation may eliminate false-positive leucocyte esterase (LE) strip test results caused by autoimmune diseases in the diagnosis of knee infection. Methods. Between January 2016 and May 2019, 83 cases, including 33 cases of septic arthritis and 50 cases of aseptic arthritis, were enrolled in this study. To further validate our hypothesis, another 34 cases of inflammatory arthritis from the Department of Rheumatology of our institution were also included. After aspiration, one drop of synovial fluid was applied to LE strips before and after centrifugation. The results were recorded after approximately three minutes according to the different colour grades on the colour chart. The differences of LE results between each cohort were analyzed. Results. Before centrifugation, 46% (23/50) of the LE strip tests in the aseptic arthritis group were false-positives. Most of the false-positive results were due to inflammatory arthritis; after centrifugation, 78.3% (18/23) of the tests yielded negative results. Similar results were observed in cases from the Department of Rheumatology. The sensitivity of the centrifuged LE strip test was 0.818 (0.639 to 0.924), which is still an acceptable level compared with the uncentrifuged results, which yielded a sensitivity of 0.909 (0.745 to 0.976). However, the specificity was increased from 0.540 (0.395 to 0.679) to 0.900 (0.774 to 0.963) after centrifugation. Conclusion. Although inflammatory arthritis can yield a false-positive LE strip test result in the diagnosis of knee infection, centrifugation may eliminate these false-positive results. Cite this article: Bone Joint Res. 2020;9(5):236–241

Aim. Restarting elective services presents a challenge to restore and improve many of the planned patient care pathways which have been suspended during the response to the COVID-19 pandemic. A significant backlog of planned elective work has built up representing a considerable volume of patient need. We aimed to investigate the health status, quality of life, and the impact of delay for patients whose referrals and treatment for symptomatic joint arthritis had been delayed as a result of the response to COVID-19. Methods. We interviewed 111 patients referred to our elective outpatient service and whose first appointments had been cancelled as a result of the response to the COVID-19 pandemic. Results. Patients reported significant impacts on their health status and quality of life. Overall, 79 (71.2%) patients reported a further deterioration in their condition while waiting, with seven (6.3%) evaluating their health status as ‘worse than death’. Conclusions. Waiting lists are clearly not benign and how to prioritize patients, their level of need, and access to assessment and treatment must be more sophisticated than simply relying on the length of time a patient has been waiting. This paper supports the contention that patients awaiting elective joint arthroplasty report significant impacts on their quality of life and health status. This should be given appropriate weight when patients are prioritized for surgery as part of the recovery of services following the COVID-19 pandemic. Elective surgery should not be seen as optional surgery—patients do not see it in this way

Aims. To analyze the short-term outcome of two types of total wrist arthroplasty (TWA) in terms of wrist function, migration, and periprosthetic bone behaviour. Methods. A total of 40 patients suffering from non-rheumatoid wrist arthritis were enrolled in a randomized controlled trial comparing the ReMotion and Motec TWAs. Patient-rated and functional outcomes, radiological changes, blood metal ion levels, migration measured by model-based radiostereometric analysis (RSA), bone mineral density (BMD) measured by dual-energy X-ray absorptiometry (DXA), complications, loosening, and revision rates at two years were compared. Results. Patient-Rated Wrist and Hand Evaluation (PRWHE) scores, abbreviated version of the Disabilities of the Arm, Shoulder and Hand questionnaire (QuickDASH) scores, and pain improved similarly and significantly in both groups. Wrist motion improved significantly in the Motec group only, and forearm rotation in the ReMotion group only. Cobalt (Co) and chromium (Cr) blood ion levels were significantly higher in the metal-on-metal (MoM) Motec group than in the metal-on-polyethylene (MoP) ReMotion group. Mean total translation was 0.65 mm (95% confidence interval (CI) 0.26 to 1.12) and 0.27 mm (95% CI 0.14 to 0.47) for the ReMotion carpal and radial components, and 0.32 mm (95% CI 0.22 to 0.45) and 0.26 mm (95% CI 0.20 to 0.34) for the Motec metacarpal and radial components, respectively. Apart from dorsal and volar tilts, which were significantly higher for the radial ReMotion than for the Motec component, no significant differences in absolute migration occurred. BMD around the radial components never returned to baseline. Almost one-third of patients required reoperation due to complications. Two ReMotion implants were revised to Motec TWAs due to carpal component loosening, and three Motec MoM articulations were revised to metal-on-polyether ether ketone due to painful synovitis. Conclusion. Both implants provided matched function and were stable at short-term follow-up, but with a high complication rate. This procedure should be restricted to specialist centres undertaking prospective analysis until its role is clarified. Cite this article: Bone Joint J 2022;104-B(10):1132–1141

Numerous studies have demonstrated that concomitant lower back pain (LBP) results in worse functional outcomes in patients undergoing surgical treatment for the management of end stage hip and knee arthritis. However, no equivalent studies have analysed the impact of back pain on the outcomes of patients with end stage ankle arthritis. Furthermore, given that two widely accepted surgical options exist in the treatment of ankle arthritis, namely total ankle arthroplasty (TAA) and ankle arthrodesis (AA), it is possible that one surgical technique may be superior in patients with LBP. The aim of this study was to determine the incidence of LBP in people with ankle arthritis, analyse its effect on functional outcomes, and explore whether there was a treatment advantage from either TAA or AA. Prospectively collected data from the Canadian Orthopaedic Foot and Ankle Society (COFAS) database of ankle arthritis was analysed in this study. All patients with ankle arthritis who underwent surgery performed by three fellowship-trained foot and ankle surgeons at a single institution between January 2003 and July 2012 were studied. Patient demographics were collected pre-operatively, including the absence or presence of back pain, and post-operative follow up was performed at 2 and 5 years, evaluating patient-reported functional outcome measures including the Ankle Arthritis Score (AAS) and the 36-item short form survey (SF-36). Using a linear regression model, a multivariate analysis was performed to examine the relationship between back pain, TAAs and AAs. In total, 451 patients were studied. 164 patients (36.4%) presented with concomitant LBP. At presentation, the LBP group had worse AAS scores (54.8 vs 57.8 p. At 2 years postoperatively, the AAS score was the same in both groups (28.9 vs 26.8 p = 0.3), but patients with LBP had worse SF-36 PCS (42.1 vs 36.6 p 0.05) in any of the functional outcome scores at 2 or 5 years post-operatively. The results of this study suggest there is no advantage of TAA over AA in the treatment of ankle arthritis in patients with concomitant lower back pain. Although pre-operative back pain resulted in worse SF-36 outcomes at 2 and 5 years post- operatively, this was not the case for AAS scores

Thumb carpometacarpal (CMC) arthritis is a common and disabling condition that can be treated with an operative procedure. Before operative measures, patients typically undergo conservative treatment utilizing methods such as physical therapy and injections. This study aims to determine what clinical modalities are being used for preoperative evaluation and nonoperative therapy and the associated cost prior to operative intervention. We queried Truven Market Scan, a large insurance provider database to identify patients undergoing CMC arthroplasty from 2010 to 2017. Patients were identified by common Current Procedural Terminology (CPT) codes for CMC arthroplasty. All associated CPT codes listed for each patient during the 1 year period prior to operative intervention were collected and filtered to only include those codes associated with the ICD-9/10 diagnosis codes relating to CMC arthritis. The codes were then categorized as office visits, x-ray, injections, physical therapy, medical devices, and preoperative labs. The frequency and associated cost for each category was determined. There were 44,676 patients who underwent CMC arthroplasty during the study period. A total of $26,319,848.36 was charged during the preoperative period, for an average of $589.13 per patient. The highest contributing category to overall cost was office visits (42.1%), followed by injections (13.5%), and then physical therapy (11.1%). The most common diagnostic modality was x-ray, which was performed in 74.7% of patients and made up 11.0% of total charges. Only 49% of patients received at least one injection during the preoperative period and the average number of injections per patient was 1.72. Patients who were employed full time were more likely to receive two or more injections prior to surgery compared to patients who had retired (47% of full-time workers; 34% of retirees). The modalities used for the preoperative evaluation and conservative treatment of CMC arthritis and the associated cost are important to understand in order to determine the most successful and cost-effective treatment plan for patients. Surprisingly, despite the established evidence supporting clinical benefits, many patients do not undergo corticosteroid injections. With office visits being the largest contributor to overall costs, further inquiry into the necessity of multiple visits and efforts to combine visits, can help to reduce cost. Also, with the advent of telemedicine it may be possible to reduce visit cost by utilizing virtual medicine. Determining the best use of telemedicine and its effectiveness are areas for future investigation

Arthritis of the wrist is a painful disabling condition that has various causes and presentations. The traditional treatment has been a total wrist fusion at a price of the elimination of movement. However, forms of treatment which allow the preservation of movement are now preferred. Modern arthroplasties of the wrist are still not sufficiently robust to meet the demands of many patients, nor do they restore normal kinematics of the wrist. A preferable compromise may be selective excision and partial fusion of the wrist using knowledge of the aetiology and pattern of degenerative change to identify which joints can be sacrificed and which can be preserved. . This article provides an overview of the treatment options available for patients with arthritis of the wrist and an algorithm for selecting an appropriate surgical strategy. Cite this article: Bone Joint J 2015;97-B:1303–8

Aims. A pragmatic, single-centre, double-blind randomized clinical trial was conducted in a NHS teaching hospital to evaluate whether there is a difference in functional knee scores, quality-of-life outcome assessments, and complications at one-year after intervention between total knee arthroplasty (TKA) and patellofemoral arthroplasty (PFA) in patients with severe isolated patellofemoral arthritis. Methods. This parallel, two-arm, superiority trial was powered at 80%, and involved 64 patients with severe isolated patellofemoral arthritis. The primary outcome measure was the functional section of the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score at 12 months. Secondary outcomes were the full 24-item WOMAC, Oxford Knee Score (OKS), American Knee Society Score (AKSS), EuroQol five dimension (EQ-5D) quality-of-life score, the University of California, Los Angeles (UCLA) Physical Activity Rating Scale, and complication rates collected at three, six, and 12 months. For longer-term follow-up, OKS, EQ-5D, and self-reported satisfaction score were collected at 24 and 60 months. Results. Among 64 patients who were randomized, five patients did not receive the allocated intervention, three withdrew, and one declined the intervention. There were no statistically significant differences in the patients’ WOMAC function score at 12 months (adjusted mean difference, -1.2 (95% confidence interval -9.19 to 6.80); p = 0.765). There were no clinically significant differences in the secondary outcomes. Complication rates were comparable (superficial surgical site infections, four in the PFA group versus five in the TKA group). There were no statistically significant differences in the patients’ OKS score at 24 and 60 months or self-reported satisfaction score or pain-free years. Conclusion. Among patients with severe isolated patellofemoral arthritis, this study found similar functional outcome at 12 months and mid-term in the use of PFA compared with TKA. Cite this article: Bone Joint J 2020;102-B(3):310–318

In patients with primary hip replacement for previous infective arthritis the risk of recurrence of infection is of major concern. In addition, the safe time interval post infective arthritis for primary hip replacement is not known. Clinical & radiological results of consecutive series of 80 primary hip replacements performed for septic / tuberculous arthritis at Wrightington hospital from 1970 to 2008. Data was collected till latest follow up. Re-infection or revision for any reason was considered as primary end point for survivorship. Average age at primary hip replacement was 55.55 years (24 – 75). Mean follow up was 14.47 years (2–41). Twelve patients in septic hip group (n=42) needed revision out of which 6 (14%) were for infection. The survival rate for recent septic arthritis group (<10 years) was 60% at 7.5 years, whereas in old septic arthritis group (>10 years) it was 94.45% at 15.3 years, considering infection as end point. The survival rate was 60% for recent septic arthritis and 78.13% for old septic arthritis group over the same period of time considering revision for any reason as end point. In tuberculous group (n=38), the survival rate was 76.32% at 14.5 years of follow up, considering revision for any reason as end point. Significantly high re-infection rate in patients with recent septic arthritis was noted. No recurrence of infection in patients with old septic arthritis. No reactivation of tuberculosis in tuberculous arthritis group. This is the largest series with longest follow-up on primary total hip replacement for infective arthritis till date. Recent septic arthritis (<10Y) was a statistically high risk factor for recurrence of infection. Old septic arthritis is reasonably safe with 94.45% success rate at 15 years follow up. Old tuberculous arthritis is not a risk factor for hip replacement

End-stage ankle arthritis (ESAA) is a debilitating disease that does not affect all individuals equally. Gender differences have been identified in patients with end-stage hip and knee arthritis and have stimulated research to explain these findings. The present study was undertaken to examine if gender has a significant effect on pre-operative disability and post-operative outcomes in patients with ESAA. Patients undergoing ankle arthrodesis (AA) or total ankle replacement (TAR) with minimum 2-year follow-up were identified in the Canadian Orthopaedic Foot and Ankle Society prospective ankle reconstruction database. Demographic data, revision data, patient satisfaction questionnaires, and outcome data using the Ankle Osteoarthritis Scale (AOS) and Short-form 36 (SF-36) health survey were collected. TAR: 384 patients were included, with 198 females and 186 males. Patient BMI, comorbidities, and duration of follow-up were similar between groups. Males were slightly older at the time of surgery (65.1 vs 62.4 years, p=0.01)). The most common etiology was post-traumatic arthritis for both genders, however females had a higher rate of rheumatoid arthritis (17% vs 5%, p=0.001). Implant types included STAR, Hintegra, and Mobility, and were similar between groups. Preoperatively females had higher rates of pain and disability, demonstrated by lower SF-36 physical component scores (PCS) (31.0 vs 34.5, p<0.001), and higher AOS pain (54.7 vs 51.1, p=0.05) and AOS disability scores (66.5 vs 59.6, p<0.001). Postoperatively, both groups had significant improvement in PCS, AOS pain, and AOS disability scores. Females, however, continued to demonstrate lower PCS scores (38.3 vs 41.9, p<0.001) and higher AOS disability (31.0 vs 25.8, p=0.02) than males. Regression analysis found that preoperative PCS, gender, age, and arthritis etiology all had a significant impact on postoperative PCS scores, with preoperative PCS scores having the largest impact. Preoperative AOS pain and disability scores had the largest impact on postoperative AOS pain and disability scores, respectively. Gender had no significant impact on AOS pain and disability scores postoperatively. Patient satisfaction was similar between males and females postoperatively. Secondary surgery was performed in 13.6% of females and 16.1% of males. Five males and five females underwent revision to arthrodesis. In patients with ESAA, females tend to have higher pre-operative levels of pain and disability compared to males, which persists post-operatively. This is consistent with the hip and knee arthroplasty literature. This finding may be due to females undergoing surgery at more advanced disease states, arthritis etiology, referral bias, or treatment bias. Both males and females have significant and similar degrees of improvement in pain and disability scores after TAR, and reoperation rates and patient satisfaction rates are similar despite the apparent disparity in outcomes

Aims. The primary aim of the study was to compare the knee-specific functional outcome of robotic unicompartmental knee arthroplasty (rUKA) with manual total knee arthroplasty (mTKA) for the management of isolated medial compartment osteoarthritis. Secondary aims were to compare length of hospital stay, general health improvement, and satisfaction between rUKA and mTKA. Methods. A powered (1:3 ratio) cohort study was performed. A total of 30 patients undergoing rUKA were propensity score matched to 90 patients undergoing mTKA for isolated medial compartment arthritis. Patients were matched for age, sex, body mass index (BMI), and preoperative function. The Oxford Knee Score (OKS) and EuroQol five-dimension questionnaire (EQ-5D) were collected preoperatively and six months postoperatively. The Forgotten Joint Score (FJS) and patient satisfaction were collected six months postoperatively. Length of hospital stay was also recorded. Results. There were no significant differences in the preoperative demographics (p ⩾ 0.150) or function (p ⩾ 0.230) between the groups. The six-month OKS was significantly greater in the rUKA group when compared with the mTKA group (difference 7.7, p < 0.001). There was also a greater six-month postoperative EQ-5D (difference 0.148, p = 0.002) and FJS (difference 24.2, p < 0.001) for the rUKA when compared to the mTKA. No patient was dissatisfied in the rUKA group and five (6%) were dissatisfied in the mTKA, but this was not significant (p = 0.210). Length of stay was significantly (p < 0.001) shorter in the rUKA group (median two days, interquartile range (IQR) 1 to 3) compared to the mTKA (median four days, IQR 3 to 5). Conclusion. Patients with isolated medial compartment arthritis had a greater knee-specific functional outcome and generic health with a shorter length of hospital stay after rUKA when compared to mTKA. Cite this article: Bone Joint Res 2019;9(1):15–22

In an osteological collection of 3100 specimens, 70 were found with unilateral clavicular fractures which were matched with 70 randomly selected normal specimens. This formed the basis of a study of the incidence of arthritis of the acromioclavicular joint and the effect of clavicular fracture on the development of arthritis in the ipsilateral acromioclavicular joint. This was graded visually on a severity scale of 0 to 3. The incidence of moderate to severe arthritis of the acromioclavicular joint in normal specimens was 77% (100 specimens). In those with a clavicular fracture, 66 of 70 (94%) had arthritis of the acromioclavicular joint, compared to 63 of 70 (90%) on the non-injured contralateral side (p = 0.35). Clavicles with shortening of 15 mm or less had no difference in the incidence of arthritis compared to those with shortening greater than 15 mm (p = 0.25). The location of the fracture had no effect on the development of arthritis

We describe the results of cemented total hip replacement in 23 patients (23 hips) with active tuberculous arthritis of the hip with a mean follow-up of 4.7 years (4 to 7). In two patients the diagnosis was proved by pre-operative biopsy, whereas all others were diagnosed on a clinicoradiological basis with confirmation obtained by histopathological examination and polymerase chain reaction of tissue samples taken at the time of surgery. All patients received chemotherapy for at least three months before surgery and treatment was continued for a total of 18 months. Post-operative dislocation occurred in one patient and was managed successfully by closed reduction. No reactivation of the infection or loosening of the implant was recorded and function of the hip improved in all patients. Total hip replacement in the presence of active tuberculous arthritis of the hip is a safe procedure when pre-operative chemotherapy is commenced and continued for an extended period after operation

Arthritis of the hip in the young adult can be a disabling condition. Recent years have witnessed extensive research related to the management of this condition. This article reviews the current status with regard to aetiology, diagnosis and treatment of arthritis of the hip in the young adult

Advanced osteoarthritis of the wrist or the distal articulation of the lunate with the capitate has traditionally been treated surgically by arthrodesis. In order to maintain movement, we performed proximal row carpectomy with capsular interposition arthroplasty as an alternative to arthrodesis in eight patients with advanced arthritis and retrospectively reviewed their clinical and radiographic outcomes after a mean follow-up of 41 months (13 to 53). The visual analogue scale (VAS) for pain at its worst and at rest, and the patient-rated wrist evaluation score improved significantly after surgery, whereas ranges of movement and grip strength were maintained at the pre-operative levels. Progression of arthritis in the radiocapitate joint was observed in three patients, but their outcomes were not significantly different from those without progression of arthritis. Proximal row carpectomy with capsular interposition arthroplasty is a reasonable option for the treatment of patients with advanced arthritis of the wrist

Metal on metal hip resurfacing was introduced in 1992 by Derek McMinn initially using an all cementless device and then an all cemented device. A hybrid resurfacing with a cemented femoral component and a cementless acetabular component was introduced in 1994. The manufacturer of the hybrid hip resurfacing was changed in 1996. Since 1997 the Birmingham hip resurfacing has been in continuous use. The device is approved by NICE (National Institute for Clinical Excellence) for use within the NHS in patients with Osteoarthritis of the hip. The device is not yet approved for use in patients with Rheumatoid Arthritis and other types of inflammatory arthritis. There are concerns regarding bone quality in rheumatoid patients, which may result in a high incidence of component loosening or femoral neck fracture. Conventional total hip replacement is a successful procedure in inflammatory arthritis however with modern treatments producing increased activity levels there are concerns about polyethylene wear. The author has performed metal on metal hip resurfacing in patients with inflammatory arthritis over the past 12 years. A total of 170 patients have been operated on with 198 resurfacings. 33% of patients have a diagnosis of some type of inflammatory arthritis. The outcomes have been assessed using Oxford hip scores and long term clinical and radiological review. Our results indicate that there is a minimal risk of femoral neck fracture and a minimal risk of component loosening when the device is used with this approach in patients with inflammatory arthritis

It has been suggested that arthrodesis of the ankle leads to osteoarthritis of the joints of the ipsilateral hind- and midfoot. We believe these studies overlooked the presence of osteoarthritic changes in these joints before the arthrodesis. We reviewed the pre-operative radiographs of 70 patients with osteoarthritis of the ankle who underwent 71 ankle arthrodeses (one was bilateral). The talonavicular, calcaneocuboid, subtalar and naviculocuneiform joints were given an osteoarthritis score according to Kellgren and Lawrence. The mean age at operation was 54.9 years and the most common indication was for post-traumatic osteoarthritis (52 cases). A total of 68 patients showed pre-existing arthritis in either the hind- or mid-foot, with the subtalar joint the most commonly affected. Ipsilateral hind- and mid-foot arthritis is almost universally present in patients with arthritis of the ankle requiring arthrodesis. The presence of such changes may not be a consequence of this arthrodesis

Aim. A prospective cohort of patients undergoing total ankle arthroplasrty for arthritis following pilon fractures was included in the present study. This group of patients generally have poor soft tissue envelope and have had previous surgical interventions prior to the ankle arthroplasty, making the arthroplasty more difficult as well as prone to complications. Methods. The data collected included patient demographics, American Orthopaedic Foot and Ankle Score (AOFAS) and patient reported outcomes (FAOS, SF-36, patient satisfaction) The data was collected preoperatively and at 1 & 2 years postoperatively. The minimum follow-up period was 2 years post-operatively. Results. A total of 167 total ankle arthroplasties were performed by the senior author between Jan 2006 and June 2010. Of this cohort, the indication for 12 arthroplasties was arthritis following pilon fractures of the distal tibia. The average of the patients at the time of the surgery was 64.2yrs. The average number of previous surgeries prior to the ankle arthroplasty was 1.5. There were significant improvements in the AOFAS scores from an average of 18 to 75 at final review. The WOMAC scores improved from 31 to 71 for pain, stiffness improved from 31 to 60 and function improved from 33 to 63. The improvement of the SF36 and patient satisfaction score is similar to the ones for primary ankle osteoarthritis. The complications were: 1 case of superficial wound infection which settled with antibiotics, one fracture of medial malleolus and one case of undisplaced distal tibial fracture treated conservatively to union. Conclusion. The Indications for TAR can be safely broadened to include younger patients with arthritis following pilon fractures of the tibia. The Outcomes after TAR for patients with arthritis following pilon fractures are comparable to those for primary osteo arthritis of the ankle

Aims. Total wrist arthrodesis (TWA) produces a spectrum of outcomes. We investigated this by reviewing 77 consecutive TWA performed for inflammatory and post-traumatic arthropathies, wrist instability and as a salvage procedure. . Patients and Methods. All operations were performed by a single surgeon using a specifically designed pre-contoured dorsally applied non-locking wrist arthrodesis plate at a single centre. . Results. Median post-operative Buck-Gramcko Lohman (BGL), Disabilities of the Arm, Shoulder and Hand and Patient Rated Wrist Evaluation scores at six years (interquartile range (IQR) 3 to 11) were 9 (IQR = 6 to 10), 19 (IQR = 7 to 45) and 13 (IQR = 1 to 31) respectively. Polyarticular inflammatory arthritis and female gender were associated with poorer patient-reported outcomes, although the effect of gender was partly explained by higher rates of inflammatory disease among women. Return to work was negatively influenced by workers’ compensation and non-inflammatory wrist pathology. There was no difference in complication rates for inflammatory and non-inflammatory indications. . Take home message: Polyarticular inflammatory arthritis is a risk factor for adverse patient-reported outcomes in TWA. Furthermore, when compared with patients without inflammatory arthritis, dorsally applied pre-contoured plates can be used for wrist arthrodesis in patients with inflammatory arthritis without an increased risk of complications. Cite this article: Bone Joint J 2016;98-B:647–53

Aims. Plate and screw fixation has been the standard treatment for painful conditions of the wrist in non-rheumatoid patients in recent decades. We investigated the complications, re-operations, and final outcome in a consecutive series of patients who underwent wrist arthrodesis for non-inflammatory arthritis. Patients and Methods. A total of 76 patients, including 53 men and 23 women, with a mean age of 50 years (21 to 79) underwent wrist arthrodesis. Complications and re-operations were recorded. At a mean follow-up of 11 years (2 to 18), 63 patients completed questionnaires, and 57 attended for clinical and radiological assessment. Results. Of the 76 patients, 46 (60.5%) had complications, resulting in 65 re-operations, mainly related to the plate and screws. In the 63 patients who completed the questionnaires, the mean Quick Disabilities of Arm, Shoulder and Hand (QuickDASH) score was 36 (0 to 91), the mean Patient-Rated Wrist and Hand Evaluation (PRWHE) score was 40 (0 to 96), and 14 patients (22%) reported no wrist pain. Grip strength, pinch strength, and pronation and supination were significantly reduced compared with the contralateral forearm. The outcome was worse in patients who had previously undergone surgery to the wrist, and those with complications. A total of 13 are awaiting further re-operations, giving a total re-operation rate of 63% (40/63). Conclusion. We observed complications and re-operations throughout the follow-up period and therefore consider wrist arthrodesis to be more complicated than previously assumed. Many of the patients never got used to or accepted their stiff wrists and reported a substantial reduction in function and residual pain. Motion-sparing surgery should be offered prior to wrist arthrodesis. Cite this article: Bone Joint J 2019;101-B:852–859

Hind and mid foot arthritis is often noted in patients who have previously had an ankle arthrodesis. It has been suggested that this arthritis may be precipitated or exacerbated as a direct result of the ankle fusion. The aim of this study was to investigate the degree and pattern of pre-existing ipsilateral foot arthritis in patients who have subsequently undergone ankle arthrodesis. A retrospective review of the most recent pre-operative radiographs of 70 patients who underwent 71 arthrodeses between 1993-2003 was performed. Patients with rheumatoid disease were excluded. The immediate pre-operative AP and lateral ankle radiographs were assessed and the presence and severity of osteoarthritis for the sub-talar, talo-navicular, naviculo-cuneiform and calcaneo-cuboid joints was recorded using the Kellgren and Lawrence grading score. This was performed simultaneously by two reviewers and a consensus obtained. A total score out of 16 was given for each radiograph. 68 (96%) of the radiographs reviewed showed evidence of pre-existing hind or mid foot arthritis prior to ankle fusion. The sub-talar joint was the most commonly and severely affected. The median total arthritis score for each radiograph was 5. There was no association between age or causative pathology and the degree of arthritis. This study has demonstrated that hind and mid foot arthritis is very common in patients with co-existent ankle arthritis prior to ankle fusion. This has previously been assumed to have developed as a result of the surgery but is, in fact, present at the time of the operation and this needs to be taken into consideration when evaluating the results of ankle arthrodesis

Introduction: Progressive symptomatic tibiofemoral arthritis following PFJR is an important cause of failure. This study is designed to quantify radiologically the degree of tibiofemoral disease progression in patients who have undergone PFJR in our institution. Patients and Methods: A prospective series of 102 consecutive Avon PFJRs in 78 patients with a minimum follow-up of five years was analysed. Available AP weight bearing radiographs of the knee taken at 8 months and 5 years postoperatively were examined in a random order twice by each of two surgeons who were blinded to the patient details and length of follow up. The severity of arthritis was graded using the classifications of Ahlback and Altman, giving a measure of arthritis progression. Results and Discussion: Arthritis was seen to progress in 8.5–17% of medial and 11–17% of lateral compartments after PFJR. Statistically significant progression was demonstrated using the Altman but not the less sensitive Ahlback scoring system, suggesting that the former should be used in scoring the tibiofemoral joint prior to PFJR. Of those patients who had a preoperative tibiofemoral Altman score of zero, 87% showed no radiological evidence of disease progression at minimum 5 year follow up, suggesting that these are the ideal candidates for PFJR

Introduction: The standard implant for patients with rheumatoid arthritis is a cemented system. Early aseptic loosening is a major concern in patients with bad bone quality, usually seen in inflammatory arthritis. Aim of the study: The aim of this retrospective study is to find out, whether the cementless CLS-stem is an appropriate implant for patients with rheumatoid or juvenile arthritis. Material and methods: Between 1984 and 2002 63 patients with rheumatoid or juvenile arthritis were treated with a cementless Stem (CLS) in our clinic. The mean age was 53 years (range from 25 to 71 years). We evaluated the x-rays (aseptic loosening and other complications) as well as the clinical outcome (Harris Hip Score). Patients with a minimum follow-up of 24 months (mean fu 5 years) were included in the study. Results: There was no stem revision due to aseptic loosening. No patient had radiological signs of aseptic loosening. 8 patients suffered a fracture of the greater trochanter or the proximal femur during surgery. Two patients had to be revised for trochanteric problems. Conclusion: The cementless CLS stem is an appropriate implant for patients with rheumatoid or juvenile arthritis. Careful implantation is necessary to avoid trochanteric or femoral fractures

Introduction. Serum erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP), and synovial fluid white blood cell (WBC) count and differential are effective in diagnosing periprosthetic joint infection (PPJI); however their utility in patients with inflammatory arthritis is unknown. The purpose of this study is to determine the utility of these tests in patients with inflammatory arthritis. Methods. 934 Consecutive revision hip and knee arthroplasties were prospectively evaluated for PPJI. 202 Cases were excluded due to acute post-operative or hematogenous infection. 690 Patients had non-inflammatory and 42 had inflammatory arthritis. Receiver operating characteristic (ROC) curves were used to establish optimal ESR, CRP, WBC, and % neutrophil values for diagnosis of PPJI, and the area under the curve (AUC) was calculated to determine the overall accuracy. Results. The optimal thresholds for predicting PPJI were ESR 30mm/hr, CRP 17mg/L, WBC 2667, and differential 75% neutrophils in inflammatory arthritis, and ESR 32mm/hr, CRP 15mg/L, WBC 4000, and 78% neutrophils in non-inflammatory arthritis. The efficacy of these tests was similar in both populations (AUC for inflammatory ESR=86.2%, CRP=86.2%, WBC=93.8, 93.6% neutrophils; AUC for non-inflammatory ESR=85.2%, CRP=90.2%, WBC=94.5, 95% neutrophils); there was no significant difference between groups (ESR p = 0.861, CRP p= 0.549, WBC p=0.8315, % neutrophils p=0.7021). The rate of PPJI was significantly higher in patients with inflammatory (33.3%) than non-inflammatory (18.8%) arthritis (p-value=0.013). Conclusions. These results suggest that the ESR and CRP are useful in diagnosing PPJI in patients with inflammatory as well as non-inflammatory arthritis with similar optimal cut-off values

Intra-articular injection is a common way to deliver biologics to joints, but their effectiveness is limited by rapid clearance from the joint space. This barrier can be overcome by genetically modifying cells within the joint such that they produce anti-arthritic gene products endogenously, thereby achieving sustained, therapeutic, intra-articular concentrations of the transgene products without re-dosing. A variety of non-viral and viral vectors have been subjected to preclinical testing to evaluate their suitability for delivering genes to joints. The first transfer of a gene to a human joint used an ex vivo protocol involving retrovirally transduced, autologous, synovial fibroblasts. Recent advances in vector technology allow in vivo delivery using adeno-associated virus (AAV). We have developed an AAV vector encoding the interleukin-1 receptor antagonist (AAV.IL-1Ra) for injection into joints with osteoarthritis (OA). It showed efficacy and safety in equine and rat models of OA, leading to a recently-completed, investigator-initiated, Phase I, dose-escalation clinical trial in 9 subjects with mid-stage OA of the knee (ClinicalTrials.gov Identifier: NCT02790723). Three cohorts of three subjects with mild to moderate OA in the index knee were injected intra-articularly under ultrasound guidance with a low (10e11 viral genomes) medium (10e12 viral genomes) or high (10e13 viral genomes) dose of AAV.IL-1Ra and followed for one year. The data confirm safety, with evidence of sustained intra-articular expression of IL-1Ra and a clinical response in certain subjects. Funding for a subsequent Phase Ib trial involving 50 subjects (ClinicalTrials.gov Identifier: NCT05835895), expected to start later this year, has been acquired. Progress in this area has stimulated commercial activity and there are now at least seven different companies developing gene therapies for OA and a number of clinical trials are in progress.

Acknowledgement: Clinical trial funded by US Department of Defense Clinical Trial Award W81XWH-16-1-0540.

Introduction. In 1976 the senior author presented to the Associations the results of patellectomy with satisfactory results in less than 50% of cases. In 1989 with the increasing success of TKR we started a prospective study of the Lubinus prosthesis for patellofemoral arthritis. After 4 years results were not satisfactory. The main causes of failure were mal-tracking and instability leading to polythene button wear, and arthritic disease progression. A new prosthesis was designed in 1996 to correct these problems. Methods. We have prospectively recorded the results of a consecutive cohort of 537 Avon arthroplasties. The outcomes have been assessed with survivorship, pain, Oxford and WOMAC scores. We have identified 24 patients from our own series and from tertiary referrals who have persistent pain, due to technical error rather than arthritic disease progression. Results. Survivorship for revision at 5 Years was 96% and overall there were 63 revisions. Results over 10 years show excellent and consistent improvement in both pain and function as judged by the median WOMAC score and are similar to patients with a TKR. The pain score improved from 45% (16) to 87% (7.5), the function score improved from 50% (21) to 80% (12.5). The Oxford score improved from 39.5% (19) to 69% (33). Symptomatic arthritic disease progression occurred in 12% of cases causing recurrent pain. Persistent non-arthritic pain was due to three main causes: minor misplacement of the femoral or patella components or over sizing, leading to retinacular impingement and over stuffing of the patellofemoral joint. Conclusion. This prosthesis has shown consistently good results with few problems over 14 years. New instruments will increase the accuracy of insertion and attention to detail in the performance of the operation will prevent problems. Disease progression remains the main cause of failure and strict pre-operative criteria are essential

Introduction: Hip Resurfacing has always been an attractive concept for the treatment of hip arthritis in young patients. Excellent early and medium-term results have been reported with the Birmingham Hip Resurfacing (BHR) device in single and multi-surgeon all-diagnoses and OA series. In the present report we present the results of BHR in inflammatory arthritis. Methods: This is a single-surgeon consecutive series. There were 15 consecutive hips (12 patients) including 2 women (2 hips) with ankylosing spondylitis (AS) operated at a mean age of 41.7 years (range 29.5 to 54.3 years). Fortytwo hips (31 patients) with seronegative or rheumatoid (RA) arthritis treated with a BHR at a mean age of 40 (13 to 64) years and a follow-up of 2 to 9 (mean 5.9) years were also studied. One patient died 5 years later. Revision for any reason was the end-point and unrevised patients were assessed with Oxford hip scores and reviewed clinico-radiologically with AP and lateral radiographs. Results: In the RA group there was one failure from femoral neck fracture two months after operation giving a failure rate of 2.4%. There were no failures in this cohort at a follow-up of 1.8 to 8.8 (mean 4.9) years. As a combined group the failure rate of BHRs in inflammatory arthritis is 1.75% and the cumulative survivorship at 9 years is 98.2% (figure). Discussion: The good results of Birmingham Hip Resurfacing in inflammatory arthritis in this relatively young cohort of patients make this a viable treatment option for these patients. Selection of patients with a reason-able bone quality and adherence to precise operative technique are vital to the success of this procedure

Introduction: Diabetes mellitus type 2 (DM II) affects 18.2 million Americans and can cause several chronic and morbid complications. Furthermore, 90% of Americans have radiographic evidence of osteoarthritis by age 40. Diabetes may be an important risk factor for symptomatic osteoarthritis later in life. The aim of our study is to determine if diabetic patients are predisposed to osteoarthritis. Methods: We conducted a review of the all total knee arthroplasty (TKA) cases performed at our institute during the past two years for end stage osteoarthritis. We excluded TKAs performed for post-traumatic arthritis and patients with inflammatory diseases. Comorbidities and demographical information including age, gender, BMI, and family history were collected from our database. A cross sectional study was performed to analyze the prevalence of DM II in our population. This prevalence was compared to that of diabetics in the general population available from various sources including the National Center for Health Statistics. Results: Our cohort included a total of 3421 patients (1972 females, 1449 males) who had undergone TKA for end stage osteoarthritis. The average age and BMI were 66 years (range: 39–92) and 32 (range: 21–65) respectively. The prevalence of diabetes mellitus type 2 in our cohort was 12%, while the prevalence of DM II in the general US population currently ranges from 6%–7%. Discussion: Chronic diabetes causes multiorgan failure via microvascular and macrovascular damage and may possibly lead to degeneration of articular cartilage and eventual arthritis. Based on this study, diabetes appears to be a strong predisposing factor for arthritis. Our laboratory has launched an extensive series of experiments delinating the potential cellular mechanism for such association

Introduction. Dislocation after primary total hip arthroplasty (THA) is a devastating and frequent postoperative complication. Many risk factors for dislocation have been identified, however, thus far there has been no consensus whether inflammatory arthritis is a risk factor for dislocation or not. We carried out a prospective study assessing the prevalence of dislocation within 2 years after primary total hip arthroplasty for osteoarthrosis and inflammatory arthritis. Patients and Methods. Between 1996 and 1999 312 patients (342 hips) with either a primary or a posttraumatic osteoarthrosis (OA group) and 59 patients (69 hips) with rheumatoid arthritis or other forms of inflammatory arthritis (IA group) were operated. One single type of prosthesis was implanted (EPF-PLUS. ®. cup and SL-PLUS. ®. stem) using an anterior approach. All dislocations in the two years following surgery were recorded. Both diagnostic groups were compared for known risk factors such as old age, female gender, prior hip surgery, and experience of the surgeon. Radiographs were examined for avulsion fractures of the tip of the trochanter and signs of loosening. The abduction and anteversion angles of the acetabular component were measured. Statistical analysis was performed with the Chi-square test and Student’s t-test. Results. The dislocation rate for inflammatory arthritis patients was significantly greater than that in patients with osteoarthrosis: 10. 1% (7 hips) in the IA group, 2. 9% (10 hips) in the OA group (p = 0. 006). There were no other differences in risk factors favouring dislocation in the IA group, such as old age, female gender, prior hip surgery, experience of the surgeon, trochanteric fractures or malposition of the prosthetic components. All dislocations in the IA group were posterior and occurred without any kind of trauma. In contrast, nearly half of the dislocations in the OA group were anterior and two were of traumatic origin. Discussion. Taking into account the fact that there are no differences in known risk factors for dislocation between our two groups and no differences in complication rate, except for dislocation, we can say that inflammatory arthritis has to be considered an independent risk-factor for dislocation after primary total hip arthroplasty. It may be that inferior quality of the (pseudo) capsule and the muscles stabilising the hip joint due to inflammatory arthritis leads to inadequate soft tissue tension. Another factor can be the concomitant impairments in rheumatoid patients, such as impairments of the upper extremity, ipsilateral knee or contralateral hip, leading to hyperflexion in the operated hip causing a posterior dislocation without trauma

Purpose: Methods: Evaluation of the results of arthroscopic ankle arthrodesis, performed in 49 consecutive patients (52 ankles), with disabling ankle arthritis, between 08/1998 and 12/2004. Thirty ankles had no significant deformity (group A), whereas 22 ankles had a varus or valgus deformity greater than 10° (mean 21.7°, max 45°) (group B). Mean age in groups A and B was 49.7 and 57.5 years respectively (p=0.15). The primary diagnosis in groups A and B was post-traumatic arthritis in 66% and 27% and idiopathic osteoarthritis in 17% and 59%, respectively. Average hospital stay was 3.63 and 3.68 days in groups A and B respectively (p=0.96). Postoperative treatment included ankle immobilization for 3 months. Progressive weight-bearing was initiated at two weeks. Mean follow-up was 14.9 months (range 6–60). Results: No infections or neurovascular problems occurred. Fusion occurred in 29/30 cases in group A at an average time of 11.52±5.2 weeks and in 21/22 patients at 11.67±2.3 weeks in group B (p=0.89). Not planned surgical procedures were required in eight cases (15.4%). Symptomatic arthritis from the adjacent joints developed in three cases during the follow-up period. The arthrodesis position angle measured in the sagittal plane from the lateral post-operative plane film averaged 105°±3° and 103°±6° in groups A and B respectively (p=0.27). The outcome in groups A and B was graded as very good in 73% and 72.7%, fair in 23% and 22.7% and poor in one case in each group, respectively (p=0.26). Conclusions: The arthroscopic technique offers a high fusion rate, decreased time to fusion, short hospital stay and absence of limb-threatening complications. Deformity correction can be attempted with equally good results

Traditional dogma states that anterior knee pain in adolescence does not lead to patello-femoral arthritis. However analysis of 642 new knee referrals seen in one year showed that over 25% had anterior knee pain and that patients were of all ages. This lead to us questioning whether anterior knee pain or adolescent chondromalacia patellae is in fact a benign self limiting condition. Method: A postal questionnaire was sent to 150 patients who had undergone isolated patello femoral replacement (PFR) enquiring about patella problems earlier in life. The same questionnaire was sent to a matched group of patients who had undergone unicompartmental replacement; because of the selection policy of the unit, these would not have had changes of patellofemoral arthritis. Results: 118 patients who had undergone PFR retumed the form. 107 were female; the average age at surgery was 66 years. 26 (22%) reported adolescent anterior knee pain at an average age of 18. 112 forms were returned form the UKR group in which females predominated and who had an average age at surgery of 67 years. Only 7 (6%) reported adolescent anterior knee pain, at an average age of 19. 16 (14%) of the PFR group reported adolescent patella instability as opposed to 1 on the UKR group. Discussion: The finding that significantly more patients with isolated patello-femoral arthritis had suffered from adolescent anterior knee pain suggests a possible causal relationship. Further long-term studies are needed to determine whether adolescent anterior knee pain is benign, as traditionally believed, or whether certain subsets are precursors of patello-femoral arthritis

We report a consecutive series of 16 revision total knee arthroplasties using the Total Condylar III system in 14 patients with inflammatory arthritis which were performed between 1994 and 2000. There were 11 women and three men with a mean age of 59 years (36 to 78). The patients were followed up for 74 months (44 to 122). The mean pre-operative Knee Society score of 37 points (0 to 77) improved to 88 (61 to 100) at follow-up (t-test, p < 0.001) indicating very good overall results. The mean range of flexion improved from 62° (0° to 120°) to 98° (0° to 145°) (t-test, p < 0.05) allowing the patients to stand from a sitting position. The mean Knee Society pain score improved from 22 (10 to 45) to 44 (20 to 50) (t-test, p < 0.05). No knee had definite loosening, although five showed asymptomatic radiolucent lines. Complications were seen in three cases, comprising patellar pain, patellar fracture and infection. These results suggest that the Total Condylar III system can be used successfully in revision total knee arthroplasty in inflammatory arthritis

Aim: To study the carpal geometry in patients with symptomatic scaphoid non-union without arthritis or with early arthritic changes. Method: The preoperative x-rays of 58 patients were retrospectively reviewed and x-rays of 35 of those fulfilling strict criteria for true projections were digitized and measured using CAD methodology. Patients’ mean age was 31,3 years and mean time from fracture 50,4 months. The measured variables concerned the carpal height, possible displacement of the carpal bones and carpal instability. The Herbert and Fisher classification was used and two subgroups concerning the absence (14) or presence (21) of early arthritic changes were created. Results: 62,5% of the patients (including patients without radiologicaly obvious arthritis) were presented with increased radial height and radial inclination, 28% with an affected carpal height, 17% with ulnar translocation of the wrist and up to 48% (varying according to the method of measurement) with a DISI pattern of instability. No statistically significant differences could be established between the morphological groups or between the two subgroups concerning early arthritis. Conclusions: Carpal geometry in scaphoid non-union although altered does not seem to change significantly with the appearance of early arthritis and thus treating non-union with early arthritis with osteosynthesis and bone grafting seems justified. In view of our findings it seems appropriate to supplement this procedure with distal radial osteotomy or with temporary lunate stabilization in selected patients

In recently, reverse shoulder arthroplasty for rotator cuff deficient arthritis is widely used in the world. However, a high complication rate was reported and worried about long-term results after reverse shoulder arthroplasty. From 2001, we performed a novel strategy for these cases such as rotator cuff reconstruction w/ or w/o muscle transfer and a humeral head replacement with using smallest head to decrease joint volume. The aim of this study was to investigate with clinical outcomes after this surgery more than two years follow-up. Materials & methods. Fifty six shoulders underwent humeral head replacement (HHR) with or without tendon transfer for cuff tear arthropathy was able to follow-up more than two years. The mean age was 74 years (60 to 83 years). 42 cuff tear arthropathy, 6 RA, 5 re-tear after cuff repair with arthritis, and 1 arthritis after infection were included. Coracoacromial arch preserved Superior approach with preserving coracoacromial arch was used for replacement the humeral stem and head. Almost of the cases could be repaired with using a smallest head because of the height of humeral head and joint volume were decreased. However, when rotator cuff remained in irreparable condition, a latissimus dorsi tendon or a pectoralis major tendon from same shoulder was transferred for cuff reconstruction. The patients were divided by 2 groups; 36 shoulders of HHR without tendon transfer and 20 shoulders of HHR with tendon transfer. Each patient was evaluated with Japan Orthopaedic Association score (JOA score) and modified Neer's limited goals rating scale after a least 2 year of follow-up. Results. In all cases, preoperative severe pain was dramatically improved. JOA score improve from 40.2 preoperatively to 80.2 postoperatively. Twelve shoulders estimated as excellent in modified Neer's classification, 34 in satisfactory and 10 in unsatisfactory. Half of cases with RA were unsatisfactory results. Postoperative active flexion statistically improved compared to preoperative range of motion. Averaged postoperative flexion was 136 degrees (preop.;68.8) and postoperative external rotation was 28.6 degrees (preop.;13.2). However, there was no significant difference of external rotation in the HHR group between pre and postoperative evaluation. The radiographic evaluation showed four cases of glenoid erosion. One case had arthroscopic Suprascapular nerve release eight years after surgery. Conclusions. The current results were consistent with the prior studies. Our novel strategy is considered as one of useful procedure for cuff tear arthropathy. However, the case which classified with Seebauer type IIB should not be recommended

Aims

To assess the alterations in cell-specific DNA methylation associated with chondroitin sulphate response using peripheral blood collected from Kashin-Beck disease (KBD) patients before initiation of chondroitin sulphate treatment.

We studied retrospectively the results in 24 patients (25 feet) who had been treated by subtalar arthrodesis with internal compression for post-traumatic arthritis from 1988 to 1992. Fifteen patients were men (16 feet) and nine (9 feet) were women. Their mean age was 43 years (22 to 68), and the average duration of follow-up was four years (2 to 6). A single compression screw was used in all feet and iliac-crest bone grafting in ten. Union was achieved in 24 of the 25 feet (96%). Based on a clinical scale the results were excellent in 10 feet, good in 7, fair in 6, and poor in 2 and on the Angus and Cowell score they were good in 19 feet, fair in 4, and poor in 2. The two poor results were due to nonunion in one patient and reflex sympathetic dystrophy in the other. One reoperation was performed for nonunion. Eighteen patients (18 feet) were satisfied with the results, four were satisfied with reservations, and three were dissatisfied. Progressive ankle and midfoot arthritis did not occur in the absence of pre-existing degenerative changes in these joints. We conclude that isolated subtalar arthrodesis with internal compression was effective treatment for post-traumatic subtalar arthritis. Iliac-crest bone grafting was not routinely required

We performed a systematic review to compare outcomes of cemented versus uncemented trapezio-metacarpal joint (TMCJ) replacement for treatment of base-of-thumb arthritis. We assessed improvements in pain and function, range of movement (ROM), strength, complications and need for revision surgery. A thorough literature search was performed. A total of 481 studies were identified from the literature search (179 Medline, 253 Embase, 27 CINAHL, 22 Cochrane). Of 43 relevant titles 28 were selected for full-text review after assessment of the abstracts. Duplicate studies were removed. 18 studies met inclusion criteria on full-text review. All studies were of level IV evidence. There were no randomised controlled trials or meta-analyses. The studies were critically appraised using a validated scoring system. Most studies reported good outcomes for pain and strength, and functional outcome was comparable for both groups. ROM was generally improved for both prosthetic types, however statistical calculation was lacking in many studies. Trapezial component loosening was the main problem for both cemented and uncemented prostheses, however radiological loosening did not necessarily correlate with implant failure. This systematic review has found that both cemented and uncemented replacements generally give good outcomes for the treatment of TMCJ arthritis, however young, male, patients with manual occupations and with disease in the dominant hand and patients with poor trapezial bone stock appear to be at higher risk for implant failure due to cup loosening. We recommend the construction of a joint registry to record implantation and revision rates

Introduction and Objectives: Thumb arthritis, also called basal joint arthritis, or carpometacarpal (CMC) arthritis is a frequent pathological condition for which there are a great variety of surgical treatments. One of the most used is resection-suspension arthroplasty using the tendon of the Flexor Carpi Radialis (FCR), whole or only a hemitendon. Up to now, the clinical repercussion that sacrificing this tendon may cause has not been studied. Our aim was to compare the repercussion this has on the force and mobility of the hand, with a preserved FCR, both when the hemitendon is used and when the complete tendon is used. Materials and Methods: We analyzed the force, mobility, clinical and radiological result in a total of 32 cases of thumb arthritis operated by simple trapezectomy, trapezectomy + plasty with FCR hemitendon and trapezectomy + plasty with complete FCR tendon. A special device has been designed to quantify the force of flexion of the wrist in these patients. Results: Thumb mobility, and grasp strength were more limited in patients in which simple trapezectomy was performed, and no differences were seen between the use of hemitendon or complete FCR. There was no greater loss of wrist flexion force with the use of complete FCR, in comparison with the other techniques. Discussion and Conclusions: The use of complete FCR does not have any greater clinical repercussions than the use of FCR hemitendon