Success treating AIS with bracing is related to time worn and scoliosis severity. Temperature monitoring can help patients comply with their orthotic prescription. Routinely collected temperature data from the start of first brace treatment was reviewed for 14 patients. All were female with an average age of 12.4 years (range 10.3–14.6) and average 49o Cobb angle (30–64).

Our current service recommendation is brace wear for 20 hours a day. Patients complied with this prescription 38.0% of the time, with four patients averaging this or more. Average brace wear was 16.3 hours per day (3.5–22.2).

There were 13 patients who had completed brace treatment. The majority had surgery (7/13; 54%) or were considering surgery (1/13; 8%). There were 5 who did not wish surgery at discharge (5/13; 38%); 1 achieved a 40o Cobb angle, with 4 larger (53o;53o;54o;68o). The Bracing in AIS Trial (BrAIST) study measured “success” as less than a 50o Cobb angle, so using this metric our cohort has had a single “success”.

Temperature monitors allowed an analysis of when patients were achieving their brace wear. When comparing daywear (8am-8pm) to nightwear (8pm-8am), patients wore their brace an average of 7.6 hours a day (2.5–11.2) and 8.7 hours a night (0.4–11.5).

We conclude the minority of our patients comply with our current 20 hour orthotic prescription. The “success” of brace treatment is lower than comparison studies despite higher average compliance but starting with a larger scoliosis. Brace wear is achieved during both the day and night.

Single shot interscalene blocks are an effective analgesic for arthroscopic shoulder surgery. However, patients receiving these blocks are often found to be in significant pain when the block wears off, usually in the late evening or early hours of the morning. Overnight admission is currently routine in our unit, to ensure adequate analgesia can be administered during this period. Recent studies have suggested that adding dexamethasone to the local anaesthetic agent can prolong the duration of the block. We carried out a prospective study to assess whether addition of dexamethasone to brachial plexus blocks could reduce patient's post-operative analgesic demands and allow safe discharge on the same day after surgery.

Twenty-six patients undergoing arthroscopic shoulder surgery during a morning theatre list, had ultrasound guided brachial plexus blocks using a mixture of 0.25% bupivacaine 20–30ml with 2–3mg of dexamethasone. All were admitted to the ward afterwards for analgesia and physiotherapy. Pain numerical rating scores (0–10) were recorded at rest in recovery one hour postoperatively by the attending anaesthetist and on active movement of the shoulder joint 24 hours after surgery by the attending physiotherapist. A standardised analgesia regime was prescribed with regular and as required medication, including as required strong opiates.

Mean pain scores in recovery were 0.31 and on the morning after surgery were 2.38. Sixteen out of 26 required no further analgesia, with only 3 out of the 10 who did requiring opiates.

The use of dexamethasone provides adequate analgesia for a prolonged period for most patients after brachial plexus block for shoulder surgery and does not result in a significant analgesic requirement when the block wears off. This may provide support for avoiding overnight admission in selected patients after arthroscopic shoulder surgery.

Six week old male Sprague-Dawley rats were administered intravenous clozapine, quetiapine, haloperidol or vehicle once daily for a period of 42 days with access to only high fat diet and their weight was monitored regularly. At the end of the study the rats were killed and the tibiae excised and bone mineral density (BMD) measured with dual X-ray absorptiometry and bone architecture assessed with micro-computed tomography (micro-CT) and associated software. Results were subjected to one-way ANOVA and post hoc Dunnetts multiple comparison test.

All treatment groups were compared to control. There were no significant differences in body weight between the different groups at completion of the study. Clozapine treated animals alone showed a significant reduction in bone mineral density (p<0.05) however no differences were seen with haloperidol and quetiapine. Both haloperidol and quetiapine, but not clozapine, treatment showed a significant reduction in the bone to tissue volume ratio (BV/TV) by approximately 23% (p<0.05) and an increase in trabecular number (TbN) by approximately 21% (p<0.05). Trabecular bone architecture parameters for haloperidol and quetiapine, but not clozapine, showed more rod like and disconnected structure as reflected in the increases in structure model index (SMI) of around 15% (p<0.05) and trabecular pattern factor (TbPf) by 22% (p<0.05).

This data demonstrates that in rats receiving a high fat diet, haloperidol and quetiapine have an adverse effect on bone micro-architecture without significant change in whole body bone mineral density.

Clozapine did not affect bony architecture in a significant manner as reported in our earlier study, though bone mineral density was reduced. Reasons for the different effect of clozapine in this study are still uncertain but may be related to the significant weight loss seen at the end point of the previous study. Causes for osteoporosis and increased fracture risk in schizophrenia may include smoking history, malnutrition, limited sun exposure and compliance.

Long term administration of both typical and atypical anti-psychotics may have a negative effect on bone and is a further factor that can influence this risk. An awareness of this relationship is useful in the orthopaedic management of schizophrenic patients.

Introduction: Subtle deformity of the hip joint may cause osteoarthritis. In femoroacetabular impingement (FAI), cam deformities damage acetabular cartilage. Whether surgical removal of cam lesions halts progression is unknown. Sensitive, non-invasive assays of chondral damage are required to evaluate early treatment efficacy.

Delayed gadolinium-enhanced MRI of cartilage (dGEMRIC) permits inference of glycosaminoglycan (GAG) distribution. We aimed to determine whether hips with cam deformities have altered GAG content, using dGEMRIC.

Methods: Subjects were recruited from a prospective cohort study. All were clinically and radiographically assessed. Hips with a normal joint space width (> 2.5mm) were eligible for dGEMRIC. 32 Hips (18 male, 14 female, mean age 51.7 years, none of whom had been investigated for hip pain) with (n=21) and without (n=11) cam deformities were scanned.

2 regions of interest (ROI) were studied:

acetabular cartilage from 12 to 3 O’Clock (T1-Index-acet).

The average of all pixels within the given ROI defined the T1-index.

For each hip, the ratio of the GAG content T1-Index-acet/T1-Indextotal was calculated. Mean T1-Indexto-tal and T1-Indexacet/T1-Indextotal were compared.

Results: T1-Indextotal were similar (689ms v 700ms, p=0.79) but T1-Indexacet/T1-Indextotal was lower in cam hips (0.93 v 1.01, p=0.017), indicating localised depletion of GAG content. Cam hips with positive clinical signs had lower T1-Indextotal than cam hips without (629ms v 717ms, p=0.055), and non-cam hips (629ms v 722ms, p=0.049).

Discussion: Cam hips have lower GAG content of their anterosuperior acetabular cartilage. dGEMRIC identified more generalised disease in cases with positive clinical findings. Ratios of GAG content for specific ROIs enable mapping of chondral damage. This may aid understanding of early disease mechanisms, track progression, and facilitate assessment of the efficacy of surgical procedures.

Purpose: To determine if early MRI diagnosis in the acutely injured knee affects management, use of resources and patient satisfaction compared to conventional management with physiotherapy.

Methods: Patients referred to fracture clinic with acute knee injury in whom a specific clinical diagnosis could not be made were randomised to one of two groups. The MRI group had a scan within 2 weeks and were then reassessed in clinic with management according to the results. The control group received physiotherapy and then reassessed. Patients were assessed in clinic on presentation, at 2 weeks and then by a telephone questionnaire at 3 months. Electronic medical records were also reviewed.

Results: 48 patients were recruited in total: 23 in the MRI group (78.2% male, 21.8% female) and 25 in the control group (68% male, 32% female). The mean age was similar in the two groups (29 years (range 18–61) vs. 30 years (18–50)). The MRI group had significantly less physiotherapy appointments (5 ± 3.42 vs. 2.52 ±1.93, p=0.003) on average until definitive treatment but not outpatient appointments (2.72 ± 1.1 vs. 2.43 ±0.66, p=0.27). Median time to surgery was less in the MRI group (138 (31–199) vs.180 days (33–826) vs.) but not statistically significant (p=0.19). A similar number of patients returned to work in both groups (82.6% vs. 76%) but the MRI group had less time off work (15.82 ±22.26 vs. 20.56 ±25.38 days, p=0.48) and statistically better satisfaction scores (2 ±2.68 vs. 3.5 ±2.75, p=0.048) than the control group.

Conclusion: We have shown that early MRI in acute knee injury can provide early diagnosis of internal derangement and therefore allow targeted treatment. These patients had significantly less physiotherapy appointments and less time off work which may offset the cost of the MRI. Moreover these patients were significantly more satisfied with the service.

Leptin is a major hormonal product of the adipocyte which regulates appetite and reproductive function through its hypothalamic receptors. It has now become clear that leptin receptors are much more widely distributed than just the hypothalamus, and the skeleton has emerged as an important site of action of leptin.

The signalling form of the leptin receptor has been found in several cell types including human osteoblasts, rat osteoblasts and human chondrocytes. In vitro we have shown leptin to an anabolic factor, stimulating osteoblast proliferation and inhibiting osteoclastogenesis. Leptin increases bone mass and reduces bone fragility when administered peripherally but has an indirect inhibitory effect on bone mass via the hypothalamus when administered directly into the central nervous system.

Data from animal models where there is an absence of either leptin production (ob/ob) or its receptor (db/db) have been contradictory. In this study we compared the bone phenotype of leptin receptor-deficient (db/db) and wild-type (WT) mice. Micro-CT analysis was done on proximal tibiae using a Skyscan 1172 scanner. Db/db mice had significantly reduced trabecular bone volume, trabecular thickness and trabecular number and a higher degree of trabecular separation. Cortical bone was also significantly lower in db/db animals in volume, cross-sectional thickness and perimeter.

These results demonstrate that in the absence of leptin signalling there is reduced bone mass indicating that leptin indeed acts in vivo as a bone anabolic factor, mimicking the in vitro results.

Adiponectin, a hormone secreted by adipocytes, regulates energy homeostasis and glucose and lipid metabolism. Plasma levels of adiponectin are negatively correlated with body fat mass. Adiponectin inhibits the formation and activity of osteoclasts and increases the proliferation and differentiation of osteoblasts in vitro. The aim of our study was to determine the bone phenotype of adiponectin knockout mice.

Male adiponectin-deficient (Ad-KO) and wild-type (WT) C57BL/6J mice were sacrificed at 8, 14 and 22 weeks of age. Body weights did not differ between Ad-KO and WT mice. We scanned the left proximal tibia using micro-CT at 5μm resolution and analysed bone microarchitecture by 3D analysis.

We found significant increases in trabecular bone volume (BV/TV) (15.9±1.63 vs. 12.2±0.72%, p=0.02) and trabecular number (3.20±0.18mm-1 vs. 2.32±0.12mm-1, p=0.0009) in 14-week old Ad-KO mice compared to controls. Similar differences between WT and Ad-KO were present in 8 and 22-week old animals but these did not reach statistical significance. Trabecular thickness was significantly greater (0.053±0.001mm vs. 0.048±0.002mm, p=0.04) in 22-week old Ad-KO mice compared to WT.

Ad-KO mice have increased number and volume of trabeculae at 14 weeks of age indicating that the net effect of adiponectin on bone accrual in vivo is inhibitory. These effects are age-dependent. Our data concur with the observations from epidemiological studies in humans that adiponectin negatively correlates with both fat mass and bone mass. Therefore, adiponectin may be a contributor to the link between fat and bone mass.

A bipolar spacer was inserted for severe arthritic destruction of the shoulder in 14 patients, and followed up for a mean of 5.9 years. In one patient the operation failed because of infection. Two others required revision for loss of low-friction properties which caused loosening of the humeral component.

At the end of the follow-up all the patients showed improvement. The Hospital for Special Surgery pain score had increased from 5.3 to 18.9 and the movement score from 7.5 to 20.1.

Thirty-three patients with impingement syndrome of the rotator cuff were studied before and at operation. It was shown that the rotator cuff lengthens and twists during elevation of the arm. Elevation is achieved by early glenohumeral abduction and continuous flexion and external rotation. The range of free rotation at the glenohumeral joint diminishes progressively during elevation. Rotator cuff impingement occurs towards the end of the early glenohumeral abduction. Excision arthroplasty of the acromioclavicular joint and anterior acromioplasty is highly effective for impingement under the acromion, but only moderately effective where impingement is under the acromioclavicular joint.

Major ruptures of the rotator cuff were repaired in 89 patients over a six-year period, using an approach through the split deltoid muscle and the bed of the excised outer centimetre of the clavicle. Review of these patients showed that poor results were associated with larger cuff defects, with more pre-operative steroid injections and with pre-operative weakness of the deltoid muscle. A randomised prospective study showed that repair followed by splinting in abduction gave no better results than repair followed by resting the arm at the side. Excision of the coraco-acromial ligament was associated with worse results than leaving its divided halves in situ. Follow-up showed that the results continued to improve for two years after operation; their quality was maintained in patients less than 60 years old, but in those over 60 there was deterioration with time.

Twenty-three patients with a severe refractory painful arc syndrome have been treated by excision of the outer end of the clavicle and division of the coracoacromial ligament through a deltoid-splitting approach. After a follow-up of more than six months all patients have been relieved of night pain. Six still have slight pain on movement, but the rest are symptom-free.

Ninety-seven patients suffering from painful arc syndrome of the shoulder were studied. Local anaesthetic and radiographic contrast investigations were carried out. One-third of the patients had lesions in the posterior part of the rotator cuff which resolved after injections of local anaesthetic and steroid. One-third had anterior lesions in the subscapularis tendon: almost all resolved under the same regime but two required division of the coraco-acromial ligament. The remaining third had lesions of the supraspinatus tendon, usually associated with degeneration of the acromio-clavicular joint: most of these failed to gain relief from the local anaesthetic and steroid. Twenty-two operations were performed either by a transcromial or by a deltoid splitting approach. Excision of the outer end of the clavicle and division of the coraco-acromial ligament abolished the pain in most cases.