Abstract. Objective. Meta-analysis of clinical trials highlights that non-operative management of degenerative knee meniscal tears is as effective as surgical management. Surgical guidelines though support arthroscopic partial meniscectomy which remains common in NHS practice. Physiotherapists are playing an increasing role in triage of such patients though it is unclear how this influences clinical management and patient outcomes. Methods. A 1-year cohort (July 2019–June 2020) of patients presenting with MRI confirmed degenerative meniscal tears to a regional orthopaedic referral centre (3× ESP physiotherapists) was identified. Initial clinical management was obtained from medical records alongside subsequent secondary care management and routinely collected outcome scores in the following 2-years. Management options included referral for surgery, conservative (steroid injection and rehabilitation), and no active treatment. Outcome scores collected at 1- and 2-years included the Forgotten Joint Score-12 (FJS-12) questionnaire and 0–10 numerical rating scales for worst and average pain. Treatment allocation is presented as absolute and proportional figures. Change in outcomes across the cohort was evaluated with repeated measures ANOVA, with Bonferroni correction for multiple testing, and post-hoc Tukey pair-wise comparisons. As treatment decision is discrete, no direct contrast is made between outcomes of differing interventions but additional explorative outcome change over time evaluated by group. Significance was accepted at p=0.05 and effect size as per Cohen's values. Results. 81 patients, 50 (61.7%) male, mean age 46.5 years (SD13.13) presented in the study timeframe. 32 (40.3%) received conservative management and 49 (59.7%) were listed for surgery. Six (18.8%) of the 32 underwent subsequent surgery and nine of the 49 (18.4%) patients switched from planned surgery to receiving non-operative care. Two post-operative complications were noted, one cerebrovascular accident and one deep vein thrombosis. The cohort improved over the course of 2-years in all outcome measures with improved mean FJS-12 (34.36 points), mean worst pain (3.74 points) average pain (2.42 points) scores. Overall change (all patients) was statistically significant for all outcomes (p<0.001), with sequential year-on-year change also significant (p<0.001). Effect size of these changes were large with all Cohen-d values over 1. Controlling for age and BMI, males reported superior change in FJS-12 (p=0.04) but worse pain outcomes (p<0.03). Further explorative analysis highlighted positive outcomes across all surgical, conservative and no active treatment groups (p<0.05). The 15 (18%) patients that switched between surgical and non-surgical management also reported positive outcome scores (p<0.05). Conclusion(s). In a regional specialist physiotherapy-led soft tissue knee clinic around 60% of degenerative meniscal tears assessed were referred for surgery. Over 2-years, surgical, non-operative and no treatment management approaches in this cohort all resulted in clinical improvement suggesting that no single strategy is effective in directly treating the meniscal pathology, and that perhaps none do. Clinical intervention rather is directed at individual symptom management based on clinical preferences. Declaration of Interest. (b) declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported:I declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research project

The goals of perioperative management are to relieve pain, achieve early mobilization after surgery, reduce length of hospital stay, and obtain adequate patient satisfaction. Several treatment options combining systemic analgesics and/or regional analgesia with or without opioids are available for postoperative pain; however, a gold standard has not been established although there is a progressive shift towards multimodal approaches to improve analgesia while minimizing opioid-related side effects. EX-TRA-05 (DAVID-ART) was a randomised, double-blind, parallel, pivotal study, evaluating the analgesic efficacy and safety of the innovative oral combination of dexketoprofen/tramadol 25mg/75mg in comparison with the individual components (tramadol given at the higher dose of 100mg) on moderate to severe acute pain after total hip replacement. Repeated doses of study drug were administered every 8 hours and pain intensity (PI) was to be scored according to a 100mm visual analogue scale (VAS) on a programmed e-diary every 2 hours over a 56-hour period (i.e. along 7 repeated doses). A placebo arm was included at the first administration to validate the pain model. Rescue medication, metamizole 500mg, was available during the treatment period. The study primary endpoint was the mean sum of the pain intensity difference values throughout the first 8 hours (SPID. 8. ), which considered the 3 active treatment arms and placebo (ITT population; N=641). In this phase, a clear superiority of the combination over the single agents was demonstrated (p<0.05). An additional analysis was performed during the entire 0–56h repeated-dose period excluding those patients who had received placebo at the first dose (N=161). The estimated mean (SE) differences on PI-VAS over 24, 32 and 56 hours post first dose (0–24h, 0–32h, and 0–56h) between the combination and each single agent were evaluated. Patients who received active analgesic from the first dose (mITT population; N=480) were aged 29–80 years (42% were ≥65 years). At randomisation, pain was moderate (≥40–60mm) in 51% patients and severe (>60mm) in 49%. For dexketoprofen/tramadol, mean (SD) PI-VAS values were 22 (4.0) over 24 hours; 21 (4.1) over 32 hours; and 19 (3.8) over 56 hours. The estimated differences versus dexketoprofen 25mg and tramadol 100mg were respectively 10 (0.7) and 7.6 (0.7) over 24 hours; 9.8 (0.6) and 7.2 (0.6) over 32 hours; and 8.1 (0.5) and 6.3 (0.5) over 56 hours (p<0.0001 for all comparisons), which confirmed the superiority of the combination versus both single agents throughout the periods analysed. This significant higher decrease of PI favouring dexketoprofen/tramadol 25mg/75mg over dexketoprofen 25mg and tramadol 100mg, all given every 8 hours, during the first 56 hours post dose confirmed the superior analgesia shown after the first 0–8h post-dose period. The combination of dexketoprofen/tramadol 25mg/75mg is able to provide a level of analgesia above that achievable by each component alone, with a sustained effect when used as a multiple-dose regimen. The addition of this new combo to the analgesic armamentarium may contribute to facilitate early mobilization after surgery, thus positively impacting perioperative co-morbidities and length of in-hospital stay

Intervention is rare following minimally displaced radial head fractures or positive elbow ‘fat pad’ signs. A pilot study (n=20) found no patient required active treatment after discharge following their first fracture clinic visit. We therefore initiated routine discharge from A&E with an advice sheet, and an ‘open-door policy’ if patients failed to progress. 51 patients were managed by A&E according to this protocol over a six-month period. A standardised assessment of symptoms, satisfaction and functional limitation was completed for 24 patients by phone; average time to follow-up 4.2 months (range 2–9 months). Fourteen (58.4%) reported no pain. The 10 patients (41.6%) with on-going pain reported a median visual analogue score (VAS 0–10) of 0.7 (0–4) at rest, 0.25 (0–4) at night, 3.0 (0–10) carrying heavy objects and 2.75 (0–10) during repetitive movement. 4 of 24 (16.7%) reported minor functional impairment. 3 of 24 (12.5%) patients requested orthopaedic review, but all were satisfied with outcome, seeking reassurance and discharged without any intervention. 3 of 24 (12.5%) were unhappy with their progress, but all had suffered from chronic pain or psychological conditions predating their injury. When offered further review, none of these patients accepted. 22 (91%) were satisfied with their treatment and 23 (95.8%) returned to work and hobbies. This data suggests routine discharge from A&E with advice does not compromise care, as no intervention is usually required beyond advice. These findings have obvious positive clinical and financial implications in streamlining clinical workload

Introduction. The STarT Back trial demonstrated that targeting back pain treatment according to patient prognosis (low, medium or high-risk subgroups) is effective. However, the mechanisms leading to these improved treatment outcomes remain unknown. This study aimed to identify which psychological variables included in the study were mediating treatment outcome for all patients and within the low, medium and high-risk subgroups. Methods. Secondary analysis was conducted on 466 patients randomised to the active treatment arm with 4-month follow-up available. Psychological variables included depression (HADs), fear (TSK), catastrophising (PCS), bothersomeness and illness perception constructs (IPQ brief) e.g. personal control. Treatment outcome was characterised using change in disability score (RMDQ) at 4-months. Residualised change scores were calculated for each variable and Pearson's correlations were calculated overall and at the subgroup level to determine potential mediating variables for disability improvement. Results. Overall, correlations with RMDQ change were .62 for change in bothersomeness, .56 for change in catastrophising, .51 for change in fear, .48 for change in anxiety, .58 for change in depression, −.32 for change in personal control and .40 for change in symptom identity. The strength of correlation generally increased from low to high-risk subgroups, e.g. bothersomeness (low=.54, high=.70). However, the predominant variables mediating treatment outcome were common across risk-groups. Conclusion. The psychological variables which were highly correlated with improvements in disability were bothersomeness, depression and catastrophising. This finding was consistent across low, medium and high-risk subgroups. This study is ongoing and further mediation analysis using structural equation modelling is in progress. Conflicts of Interest. None. Source of Funding. NIHR Spinal Pain Programme grant

Objectives

Mesenchymal stem cells have the ability to differentiate into various cell types, and thus have emerged as promising alternatives to chondrocytes in cell-based cartilage repair methods. The aim of this experimental study was to investigate the effect of bone marrow derived mesenchymal stem cells combined with platelet rich fibrin on osteochondral defect repair and articular cartilage regeneration in a canine model.