Spontaneous muscle regenerative potential is limited, as severe injuries incompletely recover and result in chronic inflammation. Current therapies are restricted to conservative management, not providing a complete restitutio ad integrum; therefore, alternative therapeutic strategies are welcome, such as cell-based therapies with stem cells or Peripheral Blood Mononuclear Cells (PBMCs). Here, we described two different in vitro myogenic models: a 2D perfused system and a 3D bioengineered scaffold within a perfusion bioreactor. Both models were assembled with human bone marrow-derived mesenchymal stem cells (hBM-MSCs) and human primary skeletal myoblasts (hSkMs) to study induction and maintenance of myogenic phenotype in presence of PBMCs. When hBM-MSCs were cultured with human primary skeletal myoblasts (hSkMs) in medium supplemented with 10 ng/mL of bFGF; cells showed increased expression of myogenic-related gene, such as Desmin and Myosin Heavy Chain II (MYH2) after 21 days, and a prevalent expression of anti-inflammatory cytokines (IL10, 15-fold). Next, PBMCs were added in an upper transwell chamber and hBM-MSCs significantly upregulated myogenic genes throughout the culture period, while pro-inflammatory cytokines (e.g., IL12A) were downregulated. In 3D, hBM-MSCs plus hSkMs embedded in fibrin-based scaffolds, cultured in dynamic conditions, showed that all myogenic-related genes tended to be upregulated in the presence of PBMCs, and Desmin and MYH2 were also detected at protein level, while pro-inflammatory cytokine genes were significantly downregulated in the presence of PBMCs. In conclusion, our works suggest that hBM-MSCs have a versatile myogenic potential, enhanced and modulated by PMBCs. Moreover, our 3D biomimetic approach seemed to better resemble the tissue architecture allowing an efficient in vitro cellular cross-talk.

Poor tendon repair is an unsolved issue in clinical practice, due to complex tendon structure. Tendon stem/progenitor cells (TSPCs) play key roles in homeostasis, regeneration, and inflammation regulation in acute tendon injuries, and rely on TGF-β signaling for recruitment into degenerative tendons. In this study, we aimed to develop an in vitro model for tenogenesis adopting a dynamic culture of a fibrin 3D scaffold, bioengineered with human TSPCs collected from both healthy and tendinopathic surgery explants (Review Board prot./SCCE n.151, 29 October 2020). 3D culture was maintained for 21 days under perfusion provided by a custom-made bioreactor, in a medium supplemented with hTGF-β1 at 20 ng/mL. The data collected suggested that the 3D in vitro model well supported survival of both pathological and healthy cells, and that hTGF-β signaling, coupled to a dynamic environment, promoted differentiation events. However, pathological hTSPCs showed a different expression pattern of tendon-related genes throughout the culture and an impaired balance of pro-inflammatory and anti-inflammatory cytokines, compared to healthy hTSPCs, as indicated by qRT-PCT and immunofluorescence analyses. Additionally, the expression of both tenogenic and cytokine genes in hTSPCs was influenced by hTGF-β1, indicating that the environment assembled was suitable for studying tendon stem cells differentiation. The study offers insights into the use of 3D cultures of hTSPCs as an in vitro model for investigating their behavior during tenogenic events and opens perspectives for following the potential impact on resident stem cells during regeneration and healing events.

Tendon injuries are a common problem that can significantly impact an individual's quality of life. While traditional surgical methods have been used to address this issue, Extracellular Vesicles (EVs) have emerged as a promising approach to promote tendon repair and regeneration mechanisms, as they deliver specific biological signals to neighbouring cells. In this study, we extracted human Tendon Progenitor Stem cells (hTPSCs) from surgery explants and isolated their EVs from perfused and static media.

hTPSCs were isolated from tendon surgery biopsy (Review Board prot./SCCE n.151, 29/10/2020) and cultured in both static and dynamic conditions, using a perfusion bioreactor (1ml/min). When cells reached 80% confluence, they were switched into a serum-free medium for 24 hours for EVs-production. Conditioned media was ultra-centrifuged for 90min (100000g). The recovered pellet was then characterized by size and concentration (Nanosight NS300), Zeta potential (Mastersizer S), morphology (SEM and TEM) and protein quantification.

hTPSCs stemness and multipotency were confirmed through CD73, CD90, and CD105 expression and confirmation of quad-lineage (adipo-osteo-chondro-teno) differentiation. After 7 days, hTPSCs were ready for EVs-production. Ultracentrifugation revealed the presence of particles with a concentration of 7×107 particles/mL consistent across both cultures. Further characterization indicated that EVs collected from perfused conditions displayed an elevated vesicle mean size (mean 143±6.5 nm) in comparison to static conditions (mean 112±7.4 nm). Consistent with, but not in proportion with, the above protein content was measured at 20 ng/ml (dynamic) and 7 ng/mL (static) indicating a nearly 3-fold increase in concentration associated with a ~22% increase in particle size.

Proposed data showed that sub-200 diameter vesicles were successfully collected from multipotent hTPSCs starvation, and the vesicle size and protein concentration were compatible with established EV literature; furthermore, dynamic culture conditions seemed more suitable for EVs-production. Further characterization will be required to better understand, EVs-compositions and their role in tendon regenerative events.

Abstract

Introduction

An additional pathology should be considered for Achillodynia differentials – the intratendinous tear (ITT) – for which we describe symptoms, ultrasound findings and co-presenting pathology.

Introduction

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

We hypothesised that a minimally invasive peroneus brevis tendon transfer would be effective for the management of a chronic rupture of the Achilles tendon. In 17 patients (three women, 14 men) who underwent minimally invasive transfer and tenodesis of the peroneus brevis to the calcaneum, at a mean follow-up of 4.6 years (2 to 7) the modified Achilles tendon total rupture score (ATRS) was recorded and the maximum circumference of the calf of the operated and contralateral limbs was measured. The strength of isometric plantar flexion of the gastrocsoleus complex and of eversion of the ankle were measured bilaterally. Functional outcomes were classified according to the four-point Boyden scale.

At the latest review, the mean maximum circumference of the calf of the operated limb was not significantly different from the pre-operative mean value, (41.4 cm, 32 to 50 vs 40.6 cm, 33 to 46; p = 0.45), and not significantly less than that of the contralateral limb (43.1 cm, 35 to 52; p = 0.16). The mean peak torque (244.6 N, 125 to 367) and the strength of eversion of the operated ankle (149.1 N, 65 to 240) were significantly lower (p < 0.01) than those of the contralateral limb (mean peak torque 289, 145 to 419; strength of eversion: 175.2, 71 to 280). The mean ATRS significantly improved from 58 pre-operatively (35 to 68) to 91 (75 to 97; 95% confidence interval 85.3 to 93.2) at the time of final review. Of 13 patients who practised sport at the time of injury, ten still undertook recreational activities.

This procedure may be safely performed, is minimally invasive, and allows most patients to return to pre-injury sport and daily activities.

Cite this article: Bone Joint J 2015;97-B:353–7.

Introduction

Rotator cuff healing after an arthroscopic repair is discussible because of the high incidence of failures. Among biologic augmentations currently used, platelet-rich plasma (PRP) is one of the most applied, supposed to enhance and accelerate the healing process in different musculoskeletal disorders. However, the evidence supporting its successful administration is still lacking, especially in the field of the rotator cuff repair. Our purpose is to clarify if the recovery is accelerated and the integrity of repaired construct is increased in patients undergoing PRP injections after arthroscopic repair of the rotator cuff.

Introduction

recent studies recognised metabolic abnormalities as additional factors in the development of rotator cuff (RC) tendinopathy. It has been hypothesised that the insertional area of this tendon is susceptible to degenerative changes due to intrinsic hypovascularization. The mechanisms underlying this process are not yet clear. In this study we attempted to confirm if larger lesions of the RC are related to impaired vasodilatatory response of the local circulation in conditions of “hemodynamic stress”.

Introduction

Ostochondral lesion of the knee is a common cause of chronic knee pain. Arthroscopic treatment with subcondral microfracture is a widespread technique leading to noticeable improvement of knee function and pain. To improve the effectiveness of this treatment options, we thought to add intra (PRF) or post-operative (PRP) growth factors. Platelet rich plasma (PRP) is obtained by centrifugation of the blood to produce a plasma with high concentration of platelets and growth factors. This latter represents a promising method to manage degenerative cartilage lesion and can be used postoperatively to improve clinical results of patients treated arthroscopically. Platelet Rich Fibrin (PRF) has been presented as a second-generation platelet concentrate, and it is used intraoperatively to cover the microfracuteres’ holes. No literature was found about using of PRF intraoperative in association with arthroscopic microfracture technique. The aim of this study is to compare clinical outcomes of the treatment of knee osteochondral lesion using arthroscopic microfracture technique alone or in association with PRF Intraoperative application using “Vivostat” system or with PRP “ReGen Lab” postoperative injection.

Wrong-level surgery is a unique pitfall in spinal surgery and is part of the wider field of wrong-site surgery. Wrong-site surgery affects both patients and surgeons and has received much media attention. We performed this systematic review to determine the incidence and prevalence of wrong-level procedures in spinal surgery and to identify effective prevention strategies. We retrieved 12 studies reporting the incidence or prevalence of wrong-site surgery and that provided information about prevention strategies. Of these, ten studies were performed on patients undergoing lumbar spine surgery and two on patients undergoing lumbar, thoracic or cervical spine procedures. A higher frequency of wrong-level surgery in lumbar procedures than in cervical procedures was found. Only one study assessed preventative strategies for wrong-site surgery, demonstrating that current site-verification protocols did not prevent about one-third of the cases. The current literature does not provide a definitive estimate of the occurrence of wrong-site spinal surgery, and there is no published evidence to support the effectiveness of site-verification protocols. Further prevention strategies need to be developed to reduce the risk of wrong-site surgery.

We tested four types of surgical repair for load to failure and distraction in a bovine model of Achilles tendon repair. A total of 20 fresh bovine Achilles tendons were divided transversely 4 cm proximal to the calcaneal insertion and randomly repaired using the Dresden technique, a Krackow suture, a triple-strand Dresden technique or a modified oblique Dresden technique, all using a Fiberwire suture. Each tendon was loaded to failure. The force applied when a 5 mm gap was formed, peak load to failure, and mechanism of failure were recorded. The resistance to distraction was significantly greater for the triple technique (mean 246.1 N (205 to 309) to initial gapping) than for the Dresden (mean 180 N (152 to 208); p = 0.012) and the Krackow repairs (mean 101 N (78 to 112; p < 0.001). Peak load to failure was significantly greater for the triple-strand repair (mean 675 N (453 to 749)) than for the Dresden (mean 327.8 N (238 to 406); p < 0.001), Krackow (mean 223.6 N (210 to 252); p <  0.001) and oblique repairs (mean 437.2 N (372 to 526); p < 0.001). Failure of the tendon was the mechanism of failure for all specimens except for the tendons sutured using the Krackow technique, where the failure occurred at the knot.

The triple-strand technique significantly increased the tensile strength (p = 0.0001) and gap resistance (p = 0.01) of bovine tendon repairs, and might have advantages in human application for accelerated post-operative rehabilitation.

To describe the prevalence and incidence of Methicillin-resistant Staphylococcus aureus (MRSA) colonisation during the patient journey for patients admitted to orthopaedic and trauma wards, we carried out a prospective audit at the University Hospital of North Staffordshire NHS Trust, England.

The Study Population comprised patients admitted to the trauma and elective orthopaedic wards, with an expected stay of 48 hours or more between March and May 2003.

Patients were swabbed for MRSA colonisation on ward admission, transfer to another ward and discharge from hospital. Elective patients undergoing major joint surgery were also swabbed at a pre-operative assessment clinic. Colonised patients were treated depending on individual risk assessment.

Five hundred and fifty-nine eligible patients were admitted to hospital. Of these, 323 (101 elective, 192 trauma and 30 non-orthopaedic) patients were included in the study, of whom 28 elective patients (28%), 43 trauma patients (22%), and seven non-orthopaedic patients (23%) were colonised with MRSA at any time during the audit period. Of the 80 patients identified as negative for MRSA colonisation at pre-assessment screening and included in the audit, ten (9.5%) were found to be colonised on admission.

There is a high prevalence of MRSA colonisation in patients admitted to the orthopaedic and trauma wards in our setting. A policy of pre-admission screening, though able to identify MRSA carriage does not guarantee that patients are not colonised in the period between screening and admission. Consideration should be given to screening all patients for MRSA who are admitted to an orthopaedic ward.

Introduction

Fifty thousand knee replacements are performed annually in the UK at an estimated cost of £150 million. However, there is uncertainty as to the best surgical approach to the knee joint for knee arthroplasty. We undertook a randomised controlled trial to compare a standard medial parapatellar arthrotomy with sub-vastus arthrotomy for patients undergoing primary total knee arthroplasty in terms of short and long term knee function.

Osteoporotic vertebral compression fractures (VCFs) are an increasing public health problem. Recently, randomised controlled trials on the use of kyphoplasty and vertebroplasty in the treatment of these fractures have been published, but no definitive conclusions have been reached on the role of these interventions. The major problem encountered when trying to perform a meta-analysis of the available studies for the use of cementoplasty in patients with a VCF is that conservative management has not been standardised. Forms of conservative treatment commonly used in these patients include bed rest, analgesic medication, physiotherapy and bracing.

In this review, we report the best evidence available on the conservative care of patients with osteoporotic VCFs and associated back pain, focusing on the role of the most commonly used spinal orthoses. Although orthoses are used for the management of these patients, to date, there has been only one randomised controlled trial published evaluating their value. Until the best conservative management for patients with VCFs is defined and standardised, no conclusions can be drawn on the superiority or otherwise of cementoplasty techniques over conservative management.

Introduction

This study was to investigate the association of developmental dysplasia of the hip (DDH) and primary protrusion acetabuli (PPA) with Vitamin D receptor polymorphisms TaqI and FokI and oestrogen receptor polymorphisms Pvu II and XbaI.

This is a prospective analysis on 30 physically active individuals with a mean age of 48.9 years (35 to 64) with chronic insertional tendinopathy of the tendo Achillis. Using a transverse incision, the tendon was debrided and an osteotomy of the posterosuperior corner of the calcaneus was performed in all patients. At a minimum post-operative follow-up of three years, the Victorian Institute of Sports Assessment scale – Achilles tendon scores were significantly improved compared to the baseline status. In two patients a superficial infection of the wound developed which resolved on antibiotics. There were no other wound complications, no nerve related complications, and no secondary avulsions of the tendo Achillis. In all, 26 patients had returned to their pre-injury level of activity and the remaining four modified their sporting activity. At the last appointment, the mean pain threshold and the mean post-operative tenderness were also significantly improved from the baseline (p < 0.001). In patients with insertional tendo Achillis a transverse incision allows a wide exposure and adequate debridement of the tendo Achillis insertion, less soft-tissue injury from aggressive retraction and a safe osteotomy of the posterosuperior corner of the calcaneum.

Multicentre clinical trials in trauma care are gaining prominence as a means of generating good-quality evidence to inform and influence clinical practice. We believe multicentre trials have an important role to play in supporting evidence-based practice, and further investment in such trials is justified.

To evaluate the effects of eccentric strengthening exercises (ESE) in athletic patients with Achilles tendinopathy. Forty five athletic patients (29 men, average age 26 years; 16 women, average age 28 years; average height: 173 ± 16.8, range 158 to 191; average weight 70.8 kg ± 15.3, range 51.4 to 100.5) with clinical diagnosis of unilateral tendinopathy of the main body of the Achilles tendon completed the VISA-A questionnaire at first attendance and at their subsequent visits. The patients underwent a graded progressive eccentric calf strengthening exercises programme for 12 weeks.

The mean pre-management VISA-A scores of 36 (SD 23.8; 95% C.I.: 29 – 46) improved to 52 (SD 27.5; 95% C.I.: 41.3 – 59.8) at the latest follow up (p = 0.001). Twenty seven of the 45 patients responded to the eccentric exercises. Of the 18 patients who did not improve with eccentric exercises, 5 (mean age: 33 years) improved with two peritendinous aprotinin and local anaesthetic injections. 10 of the 18 patients (9 men, mean age 35 years; 1 woman aged 40 years) who did not improve with eccentric exercises and aprotinin injections proceeded to have surgery. The remaining three patients (3 women, mean age 59.6 years; 2 men, mean age 63 years) of the 18 non-responders to eccentric exercises and aprotinin injections declined surgical intervention.

ESE in athletic patients provide comparable clinical outcome compared to our previous results in non-athletic patients. ESE are a viable option for the management of AT in athletes, but, in our hands, only around 60% of our athletic patients benefited from an intensive, heavy load eccentric heel drop exercise regimen alone. If ESE fail to improve the symptoms, aprotinin and local anaesthetic injections should be considered. Surgery is indicated in recalcitrant cases after 3 to 6 months of non operative management.

Repair of chronic Achilles tendon rupture is technically complex. Flexor jallucis longus (FHL) and peroneus brevis (PB) tendon transfers have been described, but the mechanical properties of these tissues have not been well reported.

The FHL, PB and tendo achilles (TA) tendons were harvested from 17 fresh frozen human cadavers free of gross pathology (mean age 69 years). Samples were tested in uniaxial tension at 100% per minute. Samples were secured using special jigs for the bony aspect or by freezing the tendons in cryogrips using liquid carbon dioxide. The peak load (N), linear stiffness (N/mm) and energy to peak load (N*mm) were determined. Mechanical data was analysed using one way analysis of variance (ANOVA) followed by a Games Howell multiple comparison post-hoc test.

Fifty one tendons were harvested and mechanical testing was successfully completed in all samples apart from one PB that slipped from the grips during testing (sample was omitted from the analysis). The mean ultimate loads differed for each group, with the TA tendons being the strongest (1724.5 N ± 514.3) followed by FHL (511.0 N ± 164.3) and PB (333.1 N ± 137.2) (P< 0.05). Similar results were found with respect to energy, with TA tendons absorbing the most energy followed by FHL and PB (P< 0.05). Stiffness for the TA tendons (175.5 N/mm ± 94.8) was greater than FHL (43.3 N/mm ± 14.1) and PB (43.6 N/mm ± 18.9), which did not differ from each other.

FHL is stronger than PB, but have similar stiffness. The mechanical properties of PB and FHL were both inferior to TA. Graft stiffness appears to be an important variable rather than ultimate load based on the clinical success of both techniques.

Our objective was to determine the plasma levels of substance P (SP) in patients with postoperative stiffness after arthroscopic rotator cuff repair.

Plasma samples were obtained at 15 months from surgery from 2 groups of patients who underwent arthroscopic repair of a rotator cuff tear. In Group 1, 30 subjects (14 men and 16 women, mean age: 64.6 years, range 47 to 78) with shoulder stiffness 15 months after arthroscopic rotator cuff repair were recruited. In Group 2, 30 patients (11 men and 19 women, mean age: 57.8 years, range 45 to 77) were evaluated 15 months after successful arthroscopic rotator cuff repair. Immunoassays were performed with commercially available assay kits to detect the plasma levels of SP.

The mean plasma levels of SP in patients with postoperative stiffness were significantly greater than those in the control group (81.06 ± 27.76 versus 23.49 ± 5.64, P < 0.05).

The plasma concentrations of substance P in patients with shoulder stiffness after arthroscopic rotator cuff repair are higher compared to plasma levels of SP in patients with a good postoperative outcome. The neuronal upregulation of SP shown in the plasma of patients with post operative shoulder stiffness may underlay not only the symptoms of adhesive capsulitis, but also its development.

Both acute and chronic hamstring injuries are disabling injuries, and occur almost entirely to elite athletes. We report our experience in the management of injuries of this location. Twenty seven patients (29 injuries) were included in the present study. They completed a questionnaire detailing their pre-injury activity, injury mechanism, rehabilitation and a subjective assessment of their recovery. At clinical examination pain and hip motion were evaluated.

Hamstring injuries predominantly affect males on the left side. Most procedures carried out were explorations with limited debridement and suture of the tendon. One third of patients felt they had returned to 100% of their pre-injury level, and 33% felt they had returned to 80–90% of their pre-injury level, the rest varied between < 20–80%. 45% gave a value of zero on the visual analogue pain scale independent of activity, those who gave a value above this had pain during active sports but not at rest.

Early repair leads to a much better recovery of muscle function, especially when dealing with complete avulsions. Lesions to the origin of the hamstring can be successfully managed if a high suspicion for the condition exerted.

Arthroscopic management has been recommended for some SLAP lesions, but no studies have focused on patients over 50 with rotator cuff tear and Type II SLAP lesion. Our hypothesis was that there was no difference in clinical outcome between repairing of the Type II SLAP lesion and tenotomy of the long head of the biceps tendon after having repaired the rotator cuff tear. This was a randomized controlled clinical trial.

We recruited 63 patients. In 31 patients, we repaired the rotator cuff and the Type II SLAP lesion (Group 1). In the other 32 patients, we repaired the rotator cuff and tenomized the long head of the biceps (Group 2). 7 patients (2 in the group 1 and 5 in the group 2) were lost to final follow up.

At the 5.2 year follow-up, statistically significant differences were seen with respect to the UCLA score and ROM values. In Group 1 (SLAP repair and rotator cuff repair), the UCLA showed a statistically significant improvement from a pre-operative average rating of 10.4 (range 6 to 14) to an average of 27.9 (24–35) postoperatively (P< 0.001). In Group 2 (biceps tenotomy and rotator cuff repair) the UCLA showed a statistically significant improvement from a pre-operative average rating of 10.1 (range 5 to 14) to an average of 32.1 (range 30 to 35) post-operatively (P< 0.001) There was statistically significant difference in total post-operative UCLA scores and ROM when comparing the two groups post-operatively (P< 0.05).

There are no advantages in repairing a Type II SLAP lesion when associated with a rotator cuff tear in patients over 50. Rotator cuff repair alone is sufficient to produce a good post-operative outcome, allowing to avoid post-operative stiffness of the shoulder.

Antibiotic-associated Clostridium difficile diarrhoea may complicate surgery for proximal femoral fracture. We undertook a 4 year case control study to evaluate the effects of a change in antibiotic prophylaxis in our department.

In the period January 2003 to January 2005, patients received three doses of cefuroxime (1.5 g). The new regimen is a single dose of cefuroxime (1.5 g) with gentamicin (240 mg) at induction. Prior to the change in prophylaxis, 912 patients underwent surgery for neck of femur fracture. Following the change, 899 patients underwent surgery over the period March 2005 to March 2007. 38 patients developed C. difficile infection (4.2%) in the initial group, compared with 14 patients (1.6%) in the group following the change in prophylaxis (P=0.009). Patients with C difficile infection also had a statistically significant increase in antibiotic exposure, inpatient stay, morbidity and inpatient mortality.

The main challenges regarding antibiotic selection are failure of prophylaxis, often because of infection with MRSA, and C. difficile-associated diarrhoea as a consequence of antibiotic prophylaxis. Infection with C. difficile is reduced with the new regimen. We advocate the use of the new regimen as an effective alternative to multiple dose cephalosporins for the prevention of C. difficile infection in this group of high risk patients.

The Achilles tendon is commonly operated on, but has associated wound complications, ranging from 7–14% in previously reported series larger than 100 cases. We report a retrospective review of one surgeon’s practice conducted to assess the prevalence of wound complications associated with acute and chronic rupture repair, peritenolysis, tenodesis, debridement, retrocalcaneal exostectomy/bursectomy, and management of calcific tendinopathy of the Achilles tendon. The study evaluated the incidence of infection, and other wound complications such as suture reactions, scar revision, hematoma, incisional neuromas and granuloma formation.

A total of 219 surgical cases were available for review (140 males, 70 females; average age at the time of surgery: 46.5 ± 12.6 years, range 16–75). Seven patients experienced a wound infection, three had keloid formation, six had suture granulomas, and six had suture abscesses, with an overall complication rate of 22 of 219 surgeries (10.1%). There were no hematomas. Seven patients had additional surgery following their wound complications; some had simple granuloma excision, while one necessitated a flap. Patients with risk factors such as diabetes, smoking and Rheumatoid arthritis necessitating steroids were more likely to have a wound complication, (Fisher’s Exact Test, P=.03).

Complications with Achilles tendon surgery may be unavoidable. Suture granulomas may appear in a delayed fashion. Absorbable and non-absorbable suture can be implicated.

Orthopaedic surgeons vary in their surgical approaches to total knee arthroplasty. The aim of this investigation was to compare outcomes after two different surgical approaches. The study was a prospective single-centre longitudinal randomized controlled trial. A sub-vastus approach was compared with a medial para-patellar approach. Participating surgeons elected to randomize their patients to one of the two types of approach. Outcomes included the Knee Society (KS) Clinical Rating System, WOMAC Osteoarthritis Index, SF-36, and EuroQol (measured at 1, 6, 12 and 52 weeks post-operatively compared to baseline) complications, surgeon rated ease of exposure, and proportion of patients who had a lateral release.

Two hundred and thirty one patients were randomized to the two approaches. One hundred and sixteen patients were randomized to the sub-vastus approach. At one week compared to baseline, range of motion, KS global, KS knee, and KS pain scores were significantly better in the sub-vastus group. At six weeks, the medial para-patellar group tended to have better outcomes, but not statistically significantly. At fifty-two weeks compared to baseline, the WOMAC global and pain scores, the SF36 physical function and role-physical scores, and the EuroQol utility and pain score were significantly better in the sub-vastus group. Surgeons reported the ease of exposure in the sub-vastus group was significantly worse on average.

This trial is the largest of its kind to date, and the first, so far as we are aware, to compare clinical outcomes of different surgical approaches at one year post-operatively. The sub-vastus approach to total knee arthroplasty was more effective than a medial para-patellar approach at both one week and fifty-two weeks post-operatively in patients whose surgeons considered either approach would be suitable. However, surgeons reported worse ease of exposure in the sub-vastus group.

Introduction: The management of the small unstable subgroup of slipped upper femoral epiphysis is controversial. This group has a high risk of developing avascular necrosis. Clinicians are keen to treat in a way as to not contribute to this risk, but the optimum treatment pathway is unclear in the literature.

Meta analysis of the available data was done to address two main areas of concern with regards to treatment: Reduction and the timing of treatment.

Methods: Review of the literature revealed 4 relevant studies (with 85 patients) that met the inclusion criteria, which contained adequate data allowing comparison between two patient groups regarding the role of reduction and 5 studies (with 130 patients) regarding the timing of treatment.

Results: All studies were retrospective reviews; no relevant randomised controlled trials have been performed. Analysis of the collected data gave an odds ratio of 2.204 with regards to reduction. Compilation of the data available therefore favoured the unreduced group. They had a lower risk of developing avascular necrosis. In the analysis relating to timing of treatment, there was an odds ratio of 0.591. This showed the evidence in the literature to favour the group treated in less than 24 hours from symptom onset.

Conclusions: Following discussion of the results, it was concluded that reduction should always be undertaken cautiously as it has an association with increased AVN. The ideal time for management is within 24 hours of symptom onset. There are suggestions in the literature that if this is not possible, it should be postponed for one week.

Introduction: The concept of minimally invasive total knee arthroplasty surgery evolved to reduce quadriceps muscle strength loss and improve clinical outcome following total knee replacement. We performed a systematic review of the published literature on Minimally Invasive Total Knee Arthroplasty (MITKA) and to analyse the reported surgical outcomes.

Material and Methods: A comprehensive search of databases using various combinations of the keywords: minimally invasive total knee arthroplasty, mini-incision total knee replacement and minimally invasive arthroplasty was performed. 28 studies published from January 2003 to June 2008 meeting the inclusion criteria were evaluated using the Coleman Methodology Score (CMS).

Results: AT A mean CMS of 60, most studies reporting on outcome of MITKA are of moderate scientific quality. Patients undergoing MITKA tend to have decreased post operative pain, rapid recovery of quadriceps function, reduced blood loss, improved range of motion (mostly reported as a short term gain) and shorter hospital stay in comparison to patients undergoing standard total knee arthroplasty. These benefits however need to be balanced against the incidence of increased tourniquet time and increased incidence of component malaligment in the MITKA group.

Conclusion: Evidence based knowledge regarding results of MITKA comes from prospective studies of moderate quality with short follow up periods. Multicenter studies with longer follow ups are needed to justify the long term advantages of MITKA over standard total knee arthroplasty.

Postoperative stiffness (POS) of the shoulder may occur after an apparently successful reconstruction of a rotator cuff tear.

The role of the peripheral nervous system in tissue healing has only recently been recognized.

We determined the plasma levels of SP in patients with postoperative stiffness after arthroscopic repair of a rotator cuff tear, and compared them with those in patients with a good outcome after arthroscopic rotator cuff repair.

Plasma samples were obtained at 15 months from surgery from 2 groups of patients who underwent arthroscopic repair of a rotator cuff tear. In Group 1, 30 subjects (14 men and 16 women, mean age: 64.6 years, range 47 to 78) with shoulder stiffness 15 months after arthroscopic rotator cuff repair were recruited. In Group 2, 30 patients (11 men and 19 women, mean age: 57.8 years, range 45 to 77) were evaluated 15 months after successful arthroscopic rotator cuff repair. Immunoassays were performed with commercially available assay kits to detect the plasma levels of SP.

Statistical analysis were performed with Wilcoxon Sign Rank test. Significance was set at P< 0.05

The concentrations of the neuropeptide SP in sera were measurable in all patients. Patients with postoperative stiffness had statistically significant greater plasma levels of SP than patients in whom arthroscopic repair of rotator cuff tears had resulted in a good outcome (P < 0.05)

Postoperative stiffness (POS) of the shoulder may occur after an apparently successful reconstruction of a rotator cuff tear.

An increased amount of SP in the subacromial bursa has been correlated with the pain caused by rotator cuff disease.

SP stimulates DNA synthesis in fibroblasts, which are the cellular components of the adhesive capsulitis of the shoulder. Also, SP is a pain transmitter peptide, and pain may cause a secondary muscular and/or capsular contracture.

Our results show that the plasma concentrations of substance P in patients with shoulder stiffness after arthroscopic rotator cuff repair are higher compared to plasma levels of SP in patients with a good postoperative outcome.

We cannot determine the cause of POS in our patients, but the findings of this study suggest a possible neuronal role in the pathophysiology of POS after arthroscopic repair of rotator cuff tears. The knowledge of the pathophysiological role of sensory nerve peptides in tissue repair in these patients could open new therapeutic options to manage conditions of the musculo-skeletal system with impaired tissue-nervous system interaction.

Restoring of anatomic footprint may improve the healing and mechanical strength of repaired tendons. A double row of suture anchors increases the tendon-bone contact area, reconstituting a more anatomic configuration of the rotator cuff footprint.

We aimed to investigate if there were differences in clinical and imaging outcome between single row and double row suture anchor technique repairs of rotator cuff tears.

We recruited 60 patients affected by a rotator cuff tear diagnosed on clinical grounds, magnetic resonance imaging evidence of cuff tear and inadequate response to nonoperative management, an unretracted and sufficiently mobile full-thickness rotator cuff lesion to allow a double row repair found at the time of surgery.

In 30 patients, rotator cuff repair was performed with single row suture anchor technique (Group 1). In the other 30 patients, rotator cuff repair was performed with double row suture anchor technique (Group 2). 8 patients (4 in the single row anchor repair group and 4 in the double row anchor repair group) were lost at follow up.

A modified UCLA shoulder rating scale was used to evaluate preoperative and postoperative shoulder pain, function and range of motion, strength and patient satisfaction. All patients received a post-operative MR arthrography at the final follow up appointment.

At the 2 year follow-up, no statistically significant differences were seen with respect to the UCLA score and ROM values. Post-operative MR arthrography at 2 years of follow up in group 1 showed intact tendons in 14 patients, partial thickness defects in 10 patients and full thickness defects in 2 patients. In group 2, MR arthrography showed an intact rotator cuff in 18 patients, partial thickness defects in 7 patients, and full thickness defects in 1 patient.

Biomechanical studies comparing single versus double row suture anchor technique for rotator cuff repair show that a double row of suture anchors increases the tendonbone contact area and restores the anatomic rotator cuff footprint, providing a better environment for tendon healing.

Our study shows that there are no advantages in using a double row suture anchor technique to restore the anatomical footprint. The mechanical advantages evidenced in cadaveric studies do not translate into superior clinical performance when compared with the more traditionally, technically less demanding, and economically more advantageous technique of single row suture anchor repair.

Several studies showed the efficacy of arthroscopic repair for Type II SLAP lesions without other associated lesions, but the only data reported on the association of arthroscopic repair of Type II SLAP lesion and rotator cuff tears involve young and active patient. To our knowledge, no studies have focused on patients over 50.

We evaluated the results of a randomized controlled trial of arthroscopic repair in patients over 50 with rotator cuff tears and Type II SLAP lesion in whom the repair was effected repairing the two lesions, or repairing the rotator cuff tears and performing a tenotomy of the long head of the biceps.

We recruited 63 patients. In 31 patients, we repaired the rotator cuff and the Type II SLAP lesion (Group 1). In the other 32 patients, we repaired the rotator cuff and tenotomized the long head of the biceps (Group 2). 7 patients (2 in the group 1 and 5 in the group 2) were lost to final follow up.

A modified UCLA shoulder rating scale was used to evaluate pre-operative and post-operative shoulder pain, function, active forward flexion, strength and patient satisfaction.

Of 63 patients randomized to one of the two treatments, 5.2 year results were available for 56. 7 patients (2 in the group 1 and 5 in the group 2) did not return at the final follow up.

Statistically significant differences were seen with respect to the UCLA score and ROM values at final follow-up In Group 1 (SLAP repair and rotator cuff repair), the UCLA showed a statistically significant improvement from a pre-operative average rating of 10.4 (range 6 to 14) to an average of 27.9 (24–35) postoperatively (P< 0.001). In Group 2 (biceps tenotomy and rotator cuff repair), the UCLA showed a statistically significant improvement from a pre-operative average rating of 10.1 (range 5 to 14) to an average of 32.1 (range 30 to 35) post-operatively (P< 0.001) There was statistically significant difference in total post-operative UCLA scores and ROM when comparing the two groups post-operatively (P< 0.05).

Arthroscopic management has been recommended for some SLAP lesions, but no studies have focused on patients over 50 with rotator cuff tear and Type II SLAP lesion.

We compared the clinical outcome of patients over 50 affected with rotator cuff tears and Type II SLAP lesion in whom both the defects were repaired, or the rotator cuff tear was repaired and the long head of the biceps tendon was tenotomized. In our hands, the association of rotator cuff repair and biceps tenotomy provides better clinical outcome compared with repair of Type II SLAP lesion and of the rotator cuff.

The repair of the two defects, in fact, can lead to worst clinical results compared with association Rotator cuff repair alone is sufficient to determine a good post-operative outcome, allowing to avoid post-operative stiffness of the shoulder.

Introduction: The optimal treatment of intra-articular calcaneal fractures remains controversial.

Material and Methods: Electronic databases were searched for randomised trials comparing interventions for treating patients with calcaneal fractures. Two reviewers independently assessed trial quality, using a 12-item scale, and extracted data. Where appropriate results were pooled.

Results: Six trials met the inclusion criteria. Two reports reported on the same group of patients at differing follow-up intervals. All six included trials had methodological flaws. Another two trials are ongoing. Four trials (134 patients) compared open reduction and internal fixation (ORIF) with non-operative management. Pooled results showed no difference in residual pain (24/40 versus 24/42; OR 0.90, 95% CI 0.34 to 2.36), but a lower proportion of the operative group was unable to return to the same work (11/45 vs 23/45; OR 0.30, 95% CI 0.13 to 0.71), and was unable to wear the same shoes as before (12/52 vs 24/54; OR 0.37, 95% CI 0.17 to 0.84). One large-scale study showed that the outcomes (SF-36, visual analogue scale (VAS), Bohler’s angle) after non-operative treatment were not different to those after ORIF. ORIF gave superior results for return to work, return to normal activities and ability to wear the same shoes. The subtalar fusion rate was reduced after ORIF. Excluding patients receiving Workers’ Compensation, the outcomes were significantly better in some groups of surgically treated patients. One trial (23 patients), evaluated impulse compression therapy. At one year there was a mean difference of 1.40 pain VAS units (95% CI 0.02 to 2.82) in favour of the treated group. The impulse compression group had greater subtalar movement at three months, and patients returned to work three months earlier.

Conclusions: The relatively poor quality of existing trials means that current evidence is only tentative. It remains unclear whether the possible advantages of surgery are worth its risks.

Introduction: The use of total ankle arthroplasty for the management of end stage arthritis of the ankle is gaining in popularity. We performed a review of the literature on Total Ankle Arthroplasty to assess the methodology of studies and to detect possible variation in the reported surgical outcomes.

Material and Methods: All relevant articles in peer-reviewed journals were retrieved except those not mentioning outcomes, case reports, review of literature and letters to editors. Studies reporting on implants presently used, with at least 20 subjects followed for a mean of at least two years were included. Two authors independently scored the quality of the studies using the Coleman Methodology Score (CMS). We collected data for type of study, patient numbers, length of follow-up, complications, outcome and prosthesis survival with revision or fusion as an endpoint. Where appropriate, pooling of data was performed.

Results: Twenty-one level IV studies, published from 2003 to 2008, reporting on 2167 ankle replacements followed for a mean of 5.6 years, were included. The CMS was 65 (SD 15), with substantial agreement between the two examiners. Inflammatory arthropathy was present in 31% of ankles. The intra-operative fracture rate was 10.5%. Superficial wound healing complication rate was 6.4%, and deep infections occurred in 1.2% of ankles. Patients’ satisfaction rate was 94%. The failure rate of the primary ankle prosthesis was 11.6% (Agility: 12.2% at 4 years, STAR: 11.7% at 4.6 years and Buechel-Pappas (BP): 12.8% at 7.3 years). Pooling the data the six-year survivorship for the Agility was 0.70 (CI 95%, 0.50–0.90), whereas the 10-year survivorship for the STAR was 0.79 (CI 95%, 0.56–1.00) and for the BP 0.87 (CI 95%, 0.69–1.00).

Conclusions: Studies reporting on total ankle arthroplasty are of overall moderate quality. Survivorship analysis revealed superior results for mobile-bearing implants. Patients’ satisfaction rate was high.

Introduction: Antibiotic-associated Clostridium difficile diarrhoea may complicate surgery for proximal femoral fracture. We sought to determine whether a change in antibiotic policy in our unit influenced rates of infection with C. difficile following hip fracture surgery.

Methods: A 4 year case controlled study. A change in antibiotic prophylaxis was introduced during a 3 month period in 2005. Infection rates with C. difficile were compared for 2 years either side of this period. The initial regimen was one of three doses of cefuroxime (1.5 g). The new regimen is a single dose of cefuroxime (1.5 g) with gentamicin (240 mg) at induction. Infection was defined as diarrhoea with a positive isolate within 30 days of surgery.

Results: Prior to the change in prophylaxis, 912 patients underwent surgery for neck of femur fracture. Following the change, 899 patients underwent surgery over the period March 2005 to March 2007. 38 patients developed C. difficile infection (4.2%) in the initial group, compared with 14 patients (1.6%) in the group following the change in prophylaxis (P=0.009). Patients with C difficile infection also had a statistically significant increase in antibiotic exposure, inpatient stay, morbidity and inpatient mortality.

Discussion: The main challenges regarding antibiotic selection are failure of prophylaxis, often because of infection with MRSA, and C. difficile-associated diarrhoea as a consequence of antibiotic prophylaxis. Infection with C. difficile is reduced with the new regimen. We advocate the use of the new regimen as an effective alternative to multiple dose cephalosporins for the prevention of C. difficile infection in this group of high risk patients.

Cervical spinal disc replacement is used in the management of degenerative cervical disc disease in an attempt to preserve cervical spinal movement and to prevent adjacent disc overload and subsequent degeneration. A large number of patients have undergone cervical spinal disc replacement, but the effectiveness of these implants is still uncertain. In most instances, degenerative change at adjacent levels represents the physiological progression of the natural history of the arthritic disc, and is unrelated to the surgeon. Complications of cervical disc replacement include loss of movement from periprosthetic ankylosis and ossification, neurological deficit, loosening and failure of the device, and worsening of any cervical kyphosis. Strict selection criteria and adherence to scientific evidence are necessary. Only prospective, randomised clinical trials with long-term follow-up will establish any real advantage of cervical spinal disc replacement over fusion.

Background: Locking plates are used frequently in distal tibial fractures. We tested two different types of locking compression plates (LCP): the metaphyseal plate (MP) and the distal tibial plate (DTP). We evaluated the strain imposed on an experimental tibial osteotomy, and the stability of plate-tibia (composite bone) construct using LCP-MP and LCP-DTP.

Materials and methods: Twin strain gauged special composite tibial bones were used to simulate the human tibiae. We tested 5 tibiae: one was used as control, two tibiae were tested using LCP-MP, and two with LCP-DTP. Strain was measured by subjecting each construct to a cyclic load of 700 N at 3 Hz in neutral, flexion, extension and torsion to simulate the normal walking cycle.

Results: When compared with the control tibia, strain during the neutral moment at the proximal and distal strain gauge site in the LCP-MP and LCP-DTP constructs decreased by 6.4%/−41.5% and −39%/−47%, respectively. In flexion, the strain increased consistently in both the proximal and distal strain gauge sites using the LCP-MP by 34% and 109%. Using the LCP-DTP, the strain at the proximal strain gauge site decreased by 0.2% and increased by 18% at the distal strain gauge site. In extension, strain decreased by 25% at the proximal strain gauge site, and by 60% at the distal strain gauge site in the LCP –MP construct. In the LCP-DTP construct, the strain decreased by 13% at the proximal strain gauge site, and by 21% at the distal strain gauge site. There were no statistically significant torsional differences between LCP-MP and LCP-DTP group (P=0.121). In this experimental setup, the LCP-DTPs offer greater control of strain than LCP-MPs. They also confer greater resistance to fracture macro-movements, and improved stiffness consistently in neutral, flexion, and torsion than LCP-MPs.

Conclusion: The strain from osteotomised tibiae stabilised with LCP-MPs and LCP-DTPs were close to the strain of the control tibia. Both these locking plates were equally good and conferred greater stiffness in all loading positions.

Introduction: We studied the extracellular matrix (ECM) of 19 ruptured human Achilles tendons, comparing the tissue composition of specimens taken from area close to the rupture with specimens harvested from an apparently healthy area in the same tendon. The hypothesis was that the metabolism of these molecules is altered in patients with Achilles tendon rupture.

Materials and Methods: We compared the gene expression and the protein localization of the main ECM molecules (collagen type I, decorin and versican) including enzymes involved in their metabolism as matrix metallo-proteases (MMP2 and 9) and tissue inhibitory of metal-loproteinase (TIMP 1 and 2) using a Real Time PCR, zymography and FACE analysis.

Results: The gene expression of proteoglycans core protein, collagen type I, MMPs and TIMPs is more represented in the area close to the tendon rupture (p< 0.05). The expression of MMPs was confirmed by zymography analysis, showing a marked increase of gelatinolytic activity in area close to the tendon rupture (p< 0.05). The chemical composition of tendon changes showing that in the healthy area the carbohydrate content is higher than the ruptured area (p< 0.05).

Discussion/Conclusions: In the ruptured area, the tenocytes tried to restore the normal proteoglycan pattern increasing the core protein synthesis but without the normal glycosaminoglycan production. Our data support the hypothesis that, in human tendons, the tissue in the area of rupture undergoes marked rearrangement at molecular levels based on the MMP2 activity, and support the role of MMPs in the tendon pathology.

Statement of Purpose: We tested the null hypothesis of no significant difference in arthroscopy rates for patients on a waiting list for arthroscopy in patients in which surgeons had a knee magnetic resonance imaging scan report prior to surgery, compared to those who did not have a report.

Methods and Results: This is a single-centre randomised controlled trial. 252 eligible patients consented and randomised. The two groups were similar with respect to a range of baseline factors. Very few arthroscopies were not performed–4.8% in the intervention arm and 5.5% in the control arm (χ2=0.06, df=1, p> 0.05). A longitudinal analysis of the secondary outcomes showed that there were no significant differences between the intervention and the control arms of the study.

Conclusion: Magnetic resonance imaging, prior to knee arthroscopy, does not lead to a reduction in the number of arthroscopies undertaken in the intervention group nor improve patient outcome in a range of secondary measures.

Objectives: Minimally invasive hip arthroplasty (MIHA) has become a trend in last few years. The orthopaedic literature is deficient in well designed scientific studies to support the idea that MIHA provides superior outcomes compared with Total Hip Arthroplasty(THA) performed through standard incisions. We have attempted a comprehensive quantitative review of the published literature to assess the methodology of those studies and reported surgical outcomes.

Methods: We conducted a comprehensive literature search of different online databases. All relevant articles in peer-reviewed journals were retrieved except those not mentioning outcomes, case reports, review of literature and letters to editors. Two independent authors analyzed these articles for year of publication, type of study, patient numbers, surgical method, follow-up, complications and patient satisfaction. Each article was also graded using a validated methodology score; Coleman’s Ten Criteria to assess the quality of study.

Results: 38 studies met our inclusion criteria which contained a total of 6434 hip arthroplasties.78.5% (4031) of these were MIHAs. There was significantly less intra-operative blood loss with MIS technique. However no significant difference was noted between the two groups with respect to operating time, the mean length of hospital stay, pain score, dislocation and revision rates, neurological injury and incidence of peri-operative fracture. In addition the patient characteristics and surgeon experience had a significant effect on outcome. Scores were predominantly low for quality of the studies with patient numbers, follow up time and validated outcome measures being the weakest areas.

Conclusion: Minimally invasive hip arthroplasty is clearly in its infancy and continually evolving with new techniques and instruments being developed to treat a broader range of patients. At the present time there is still a lack of quality evidence to advocate its expansion. The better designed studies in fact suggest that it should perhaps be limited further to recognised expert centres. The complication rates and learning curve may be altered by changes in training and adapting surgical techniques. We emphasize the need for meticulous design in future studies comparing the outcomes of these two procedures.

Aim: To investigate and compare the effects of two types of LCS total knee arthroplasty on joint proprioception and range of motion.

Methods: 47 patients were randomised to receive either a LCS AP glide or Rotating platform prosthesis. Clinical scores (Oxford knee score, American knee society score, EuroQol), range of motion and proprioception were assessed prior to and at 3,6, and 12 months after the operation. Proprioception was assessed in terms of absolute error angle (mean difference between the target angle and the response angle). Knee angles were measured in degrees using an electromagnetic tracking device, Polhemus 3Space Fastrak that detected positions of sensors placed on the test limb. Student’s t-test was used to compare the mean of two groups (with a level of significance of p < 0.05).

Results: Both groups were comparable in terms of pre-operative range of motion, oxford knee score, American knee society score, EuroQol score and proprioception. There was statistically significant improvement in the Oxford knee score, AKSS and EuroQol score in both groups (p< 0.001), but there was no difference between the groups with respect to these parameters. There was improvement in the proprioception (reduction in absolute error angle) in both groups though this was not significant statistically (p> 0.05).

Conclusions: We did not find significant difference between AP glide and RP LCS knee arthroplasty in terms of improvement in proprioception and range of motion.

Introduction: Fifty thousand knee replacements are performed annually in the UK at an estimated cost of £150 million. However, there is uncertainty as to the best surgical approach to the knee joint for knee arthroplasty. We undertook a randomised controlled trial to compare a standard medial parapatellar arthrotomy with sub-vastus arthrotomy for patients undergoing primary total knee arthroplasty in terms of short and long term knee function.

Methods: Two-hundred and thirty-one patients undergoing primary total knee arthroplasty during 2001–2003 were recruited into the study. Patients were randomised into subvastus (116) or medial parapatellar (115) approaches to knee arthroplasty. The primary outcome measures were the American Knee Society and WOMAC Scores. The secondary outcome measures were patient based measures of EuroQol and SF-36. All outcomes were measured pre-operatively, 1, 6, 12 and 52 weeks post-operatively. We also looked at a pain diary, analgesia diary, ease of surgical exposure, and complications.

Results: Pain as measured by WOMAC was significantly less in the subvastus group but only at 52 weeks. The Knee Society Score showed some early benefit at one week to the subvastus group. There was no difference between the two groups in relation to the knee function score, EuroQol, SF-36, pain diary, analgesia usage and length of hospital stay.

Conclusion: There is some benefit to patients receiving sub-vastus arthrotomy relative to medial para-patellar. Although the results show some statistical significance in using the sub-vastus approach the clinical importance of these findings and the costs of the various procedures involved remain to be ascertained.

Introduction: Fifty thousand knee replacements are performed annually in the UK at an estimated cost of £150 million. However, there is uncertainty as to the best surgical approach to the knee joint for knee arthroplasty. We undertook a randomised controlled trial to compare a standard medial parapatellar arthrotomy with sub-vastus arthrotomy for patients undergoing primary total knee arthroplasty in terms of short and long term knee function.

Methods: Two-hundred and thirty-one patients undergoing primary total knee arthroplasty during 2001–2003 were recruited into the study. Patients were randomised into subvastus (116) or medial parapatellar (115) approaches to knee arthroplasty. The primary outcome measures were the American Knee Society and WOMAC Scores. The secondary outcome measures were patient based measures of EuroQol and SF-36. All outcomes were measured pre-operatively, 1, 6, 12 and 52 weeks post-operatively. We also looked at a pain diary, analgesia diary, ease of surgical exposure, and complications.

Results: Pain as measured by WOMAC was significantly less in the subvastus group but only at 52 weeks. The Knee Society Score showed some early benefit at one week to the subvastus group. There was no difference between the two groups in relation to the knee function score, EuroQol, SF-36, pain diary, analgesia usage and length of hospital stay

Conclusion: There is some benefit to patients receiving sub-vastus arthrotomy relative to medial para-patellar. Although the results show some statistical significance in using the sub-vastus approach the clinical importance of these findings and the costs of the various procedures involved remain to be ascertained.

Background: The Achilles tendon is commonly operated on, but has associated wound complications, ranging from 7–14% in previously reported series larger than 100 cases.

Methods: A retrospective review of one surgeon’s practice was conducted to assess the prevalence of wound complications associated with acute and chronic rupture repair, peritenolysis, tenodesis, debridement, retrocalcaneal exostectomy/bursectomy, and management of calcific tendinopathy of the Achilles tendon. The study evaluated the incidence of infection, and other wound complications such as suture reactions, scar revision, hematoma, incisional neuromas and granuloma formation.

Results: A total of 219 surgical cases were available for review (140 males, 70 females; average age at the time of surgery: 46.5 ± 12.6 years, range 16–75). Seven patients experienced a wound infection, three had keloid formation, six had suture granulomas, and six had suture abscesses, with an overall complication rate of 22 of 219 surgeries (10.1%). There were no hematomas. Seven patients had additional surgery following their wound complications; some had simple granuloma excision, while one necessitated a flap.

Conclusion: Knowledge of suture materials, proper incision placement and possibly avoiding tourniquet usage can keep complications low when performing Achilles tendon surgery. Regardless, some complications with Achilles tendon surgery may be unavoidable.

Introduction: Tendon tissue engineering entails the generation of a highly ordered collagen matrix with several organization scales that confer the tendon its mechanical functionality. Endogenous production of proteoglycans account for the typical microscopic organization in bundles of the tendon extracellular matrix, as they prevent lateral fusion of collagen fibril by binding the shaft of the fibres and promoting tip to tip fusion. The approach developed in this study is to rely on this molecular endogenous production and to induce a supramolecular uniaxial alignment of collagen fibres bundles with the help of specially designed scaffolds under continuous fluid shear stress.

Methods: Microchannel chitosan scaffolds were produced by casting 2% chitosan gel on a mould equipped with stainless steel needles array that was imaged by optical coherence tomography with a resolution at ~10microns. From OCT measurements, regularly spaced microchannels with clearly delimited boundaries are obtained inside a microporous core of chitosan. By varying the number and the diameter of needles (from 250 μm (microns)to 500 μm (microns)) different types of microstructure have been produced. Microchannels scaffolds were seeded with primary tenocytes explanted from pig tendons and cultured in static culture, as nonstimulated group, and in a perfusion bioreactor.

Results: There was a general increase in the channels occupation ratio for the group stimulated by perfusion, and inversely proportional to the microchannel diameter. Tenocytes were able to proliferate and to produce collagen extracellular matrix from the inner surface of the microchannel up to the whole channel volume.

Conclusion: The proposed microstructure was appropriate for tendon engineering and its channel structure is adequate for direct OCT monitoring.

Introduction: Repair of chronic Achilles tendon rupture is technically complex. Flexor Hallucis Longus (FHL) and Peroneus Brevis (PB) Tendon transfers have been described, but the mechanical properties of these tissues have not been well reported.

Methods: The FHL, PB and tendo Achilles (TA) tendons were harvested from 17 fresh frozen human cadavers free of gross pathology (mean age 69 years). Samples were tested in uniaxial tension at 100% per minute. Samples were secured using special jigs for the bony aspect or by freezing the tendons in cryogrips using liquid carbon dioxide. The peak load (N), linear stiffness (N/mm) and energy to peak load (N*mm) were determined. Mechanical data was analysed using one way analysis of variance (ANOVA) followed by a Games Howell multiple comparison post-hoc test.

Results: 51 tendons were harvested. Mechanical testing was successfully completed in all samples apart from one PB that slipped from the grips during testing (sample was omitted from the analysis). The mean ultimate loads differed for each group, with the TA tendons being the strongest (1724.5 N ± 514.3) followed by FHL (511.0 N ± 164.3) and PB (333.1 N ± 137.2) (P< 0.05). Similar results were found with respect to energy, with TA tendons absorbing the most energy followed by FHL and PB (P< 0.05). Stiffness for the TA tendons (175.5 N/mm ± 94.8) was greater than FHL (43.3 N/mm ± 14.1) and PB (43.6 N/mm ± 18.9), which did not differ from each other.

Conclusions: FHL is stronger than PB, but have similar stiffness. The mechanical properties of PB and FHL were both inferior to TA. Graft stiffness appears to be an important variable rather than ultimate load based on the clinical success of both techniques.

Introduction: Between 1 and 4 per 1000 births worldwide are affected by clubfoot. Clubfoot etiology is unclear, but both genetic and environmental factors are thought to be involved. Low folate status in pregnant women has been implicated in several congenital malformations and folate metabolism may be affected by polymorphisms in the MTHFR gene.

Methods: Using a case-parent triad design, we investigated whether the MTHFR C677T polymorphism, and maternal peri-conceptional folic acid supplement use, influenced risk of isolated clubfoot. 375 case-parent triads took part.

Results: Among children there was a significant trend of decreasing clubfoot risk with increasing number of Talleles: relative risk (RR ) CT vs CC=0.75 (95% CI: 0.57,0.97); RR TT vs CC=0.57 (95% CI: 0.37,0.91); p trend=0.006. This association was not modified by maternal folic acid use.

Conclusion: Maternal MTHFR genotype did not influence risk of clubfoot in the offspring overall, although a possible interaction with folic acid use was found. This is the first report of a specific genetic polymorphism associated with clubfoot. The direction of the association is intriguing and suggests DNA synthesis may be relevant in clubfoot development. However, clubfoot mechanisms are poorly understood and the folate metabolism pathway is complex. Further research is needed to elucidate these relationships.

Background: Congenital talipes equinovarus (CTEV) is a common developmental disorder of the foot, affecting between 1 and 4.5 babies per 1000 live births. The etiology is not well elucidated. While both genetic and environmental factors are implicated, no specific genes have been identified and little is known about environmental risk factors.

Methods: We conducted a case-control study of idiopathic congenital talipes equinovarus (ICTEV) in the United Kingdom. 194 cases and 60 controls were recruited. Pedigrees were obtained for 162 cases.

Results: The rank of the index pregnancy, maternal education and cesarean delivery were significantly associated with ICTEV risk in a multivariate model. There were suggestions that maternal use of folic acid supplements in the three months before the pregnancy decreased ICTEV risk, and that parental smoking during the pregnancy increased risk. One quarter of pedigrees showed a family history of CTEV, and autosomal dominant inheritance was suggested in some of these.

Conclusion: Uterine restriction did not appear to have a strong influence on ICTEV development in our study. Large population-based studies are needed to clarify the etiology of this common developmental disorder.

Introduction: Tendon ruptures are increasingly common, repair can be difficult and healing poorly understood. Tissue engineering approaches often require expansion of cell numbers to populate a construct, and maintenance of cell phenotoype is essential for tissue regeneration.

Methods: In this study we characterise the phenotype of human Achilles tenocytes and assess how this is affected by passaging. Tenocytes, isolated from tendon samples from 6 patients receiving surgery for rupture of the Achilles tendon, were passaged 8 times. Proliferation rates and cell morphology were recorded at passages 1, 4 and 8. Total collagen, the ratio of collagen types I and III and decorin were used as indicators of matrix formation and expression of the integrin ‘alpha’1 subunit as a marker of cell-matrix interactions.

Results: With increasing passage number, cells became more rounded, were more widely spaced at confluence and confluent cell density declined from 18700 /cm2 to 16100 /cm2 (P=0.009). No change to total cell layer collagen was observed but the ratio of type III to type I collagen increased from 0.60 at passage 1 to 0.89 at passage 8 (P< 0.001). Decorin expression significantly decreased with passage number, from 22.9 ± 3.1 ng/ng DNA at passage 1, to 9.1 ± 1.8 ng/ngDNA at passage 8 (P< 0.001). Integrin expression did not change.

Conclusion: We conclude that the phenotype of tenocytes in culture rapidly drifts with progressive passage.

There is a trend towards the use of double-bundle techniques for the reconstruction of the anterior cruciate ligament. This has not been substantiated scientifically. The functional outcome of these techniques is equivalent to that of single-bundle methods. The main advantage of a double-bundle rather than a single-bundle reconstruction should be a better rotational stability, but the validity and accuracy of systems for the measurement of rotational stability have not been confirmed.

Despite the enthusiasm of surgeons for the double-bundle technique, reconstruction with a single-bundle should remain the standard method for managing deficiency of the anterior cruciate ligament until strong evidence in favour of the use of the double-bundle method is available.

Background: Recurrent peroneal tendon subluxation is uncommon. We report the results of a delayed anatomic repair using suture anchors. Using a case series we tested the null hypothesis that there are no differences between pre- and post-operative status following anatomical repair of the superior peroneal retinaculum.

Methods: In the period 1996 to 2001, we operated on 14 patients (all males; average age 25.3 ± 6.3 years, range 18–37) with traumatic recurrent unilateral peroneal tendon subluxation, with a followed up of 38 ± 3 (range 22 to 47) months.

Results: No patient experienced a further episode of peroneal tendon subluxation, and all had returned to their normal activities. Maximum calf circumference, functional ability, peak torque, total work and average power of plantar flexion were always lower in the operated leg, but the differences did not reach statistical significance. The AOFAS Ankle-Hindfoot Scale increased significantly from 54.3 ± 11.4 to 94.5 ± 6.4 (p = 0.03), with five patients reporting a fully normal ankle.

Conclusion: If an anatomic approach to treating the pathology is utilised, reattachment of the superior retinaculum is a most appropriate technique. It returns patients to a high level of physical activity, and gives high rate of satisfactory results both objectively and subjectively. Randomised control trials may be the way forward in determining the best surgical management method. However, the relative rarity of the condition and the large number of techniques make such a study difficult.