We performed this systematic overview on the overlapping meta-analyses that analyzed autologous platelet-rich plasma (PRP) as an adjuvant in the repair of rotator cuff tears and identify the studies which provide the current best evidence on this subject and generate recommendations for the same. We conducted independent and duplicate electronic database searches in PubMed, Web of Science, Scopus, Embase, Cochrane Database of Systematic Reviews, and the Database of Abstracts of Reviews of Effects on September 8, 2021, to identify meta-analyses that analyzed the efficacy of PRP as an adjuvant in the repair of rotator cuff tears. Methodological quality assessment was made using Oxford Levels of Evidence, AMSTAR scoring, and AMSTAR 2 grades and used the Jadad decision algorithm to generate recommendations. 20 meta-analyses fulfilling the eligibility criteria were included. The AMSTAR scores of the included studies varied from 6–10 (mean:7.9). All the included studies had critically low reliability in their summary of results due to their methodological flaws according to AMSTAR 2 grades. The initial size of the tear and type of repair performed do not seem to affect the benefit of PRPs. Among the different preparations used, leucocyte poor (LP)-PRP possibly offers the greatest benefit as a biological augment in these situations. Based on this systematic overview, we give a Level II recommendation that intra-operative use of PRPs at the bone-tendon interface can augment the healing rate, reduce re-tears, enhance the functional outcomes and mitigate pain in patients undergoing arthroscopic rotator cuff repair

Abstract. Objective. Open fracture management in the United Kingdom and several other countries is guided by the British Orthopaedic Association's Standards for Trauma Number 4 (BOAST-4). This is updated periodically and is based on the best available evidence at the time. The aim of this study is to evaluate the evidence base forming this guidance and to highlight new developments since the last version in 2017. Methods. Searches have been performed using the PubMed, Embase and Medline databases for time periods a) before December 31, 2017 and from 01/01/2018–01/02/2021. Results have been summarised and discussed. Results. Several contentious issues remain within the 2017 guideline. Antibiotic guidance, the use of antibiotic impregnated PMMA beads and intramedullary devices, irrigation in the emergency department, time to theatre and the use of negative pressure dressings and guidance regarding the management of paediatric injuries have all demonstrated no clear consensus. Conclusion. The advent of the BOAST-4 guideline has been of huge benefit, however the refinement and improvement of this work remains ongoing. There remains a need for further study into these contentious issues previously listed

Chronic lateral ankle instability (CLAI) is treated operatively, whereas acute ligament injury is usually treated nonoperatively. Such treatments have been widely validated. Apoptosis is known to cause ligament degeneration; however, few reports have focused on the possible role of apoptosis in degeneration of ruptured lateral ankle ligaments. The aim of our study is to elucidate the apoptosis that occurs within anterior talofibular ligament (ATFL) to further validate current CLAI treatments by adducing molecular and cellular evidence. Between March 2019 and February 2021, 50 patients were prospectively enrolled in this study. Ruptured ATFL tissues were collected from 21 CLAI patients (group C) and 17 acute ankle fracture patients (group A). Apoptotic cells were counted using the terminal deoxynucleotidyl transferase-mediated dUTP-biotin nick end-labeling (TUNEL) assay. Western blotting for caspases 3, 7, 8, and 9 and cytochrome c, was performed to explore intrinsic and extrinsic apoptotic pathways. Immunohistochemistry was used to detect caspases 3, 7, 8, and 9 and cytochrome c, in ligament vessel endothelial cells. More apoptotic cells were observed in group C than group A in TUNEL assay. Western blotting revealed that the apoptotic activities of group C ligaments were significantly higher than those of group A (all p < 0.001). Immunohistochemistry revealed increased expression of caspases 3, 7, 8, and 9, and cytochrome c, in group C compared to group A. The ATFL apoptotic activities of CLAI patients were significantly higher than those of acute ankle fracture patients, as revealed biochemically and histologically. Our data further validate current CLAI treatments from a molecular and cellular perspective. Efforts should be made to reverse or prevent ATFL apoptosis in CLAI patients

The mechanical alignment (MA) for Total Knee Arthroplasty (TKA) with neutral alignment goal has had good overall long-term outcomes. In spite of improvements in implant designs and surgical tools aiming for better accuracy and reproducibility of surgical technique, functional outcomes of MA TKA have remained insufficient. Therefore, alternative, more anatomical options restoring part (adjusted MA (aMA) and adjusted kinematic alignment (aKA) techniques) or the entire constitutional frontal deformity (unicompartment knee arthroplasty (UKA) and kinematic alignment (KA) techniques) have been developed, with promising results. The kinematic alignment for TKA is a new and attractive surgical technique enabling a patient specific treatment. The growing evidence of the kinematic alignment mid-term effectiveness, safety and potential short falls are discussed in this paper. The current review describes the rationale and the evidence behind different surgical options for knee replacement, including current concepts in alignment in TKA. We also introduce two new classification systems for “implant alignments options” and “osteoarthritic knees” that would help surgeons to select the best surgical option for each patient. This would also be valuable for comparison between techniques in future research

Abstract. Objectives. Tendon and ligament injury poses an increasingly large burden to society. With surgical repair and grafting susceptible to high failure rates, tissue engineering provides novel avenues for treatment. This systematic review explores in vivo evidence whether mesenchymal stem cell-derived extracellular vesicles (MSC-EVs) can facilitate tendon and ligament repair in animal models. Methods. On May 26th 2021, a systematic search was performed on PubMed, Web of Science, Cochrane Library, Embase, using search terms ‘mesenchymal stem cell’ or ‘multipotent stem cell’ AND ‘extracellular vesicles’ or ‘exosomes’ AND ‘tendon’ or ‘ligament’ or ‘connective tissue’. Risk of bias was assessed using SYstematic Review Center for Laboratory animal Experimentation (SYRCLE) tool. Studies administering EVs isolated from human or animal-derived MSCs into in vivo models of tendon/ligament injury were included. In vitro, ex vivo, in silico studies were excluded, and studies without a control group were excluded. Data on isolation and characterisation of MSCs and EVs, and in vivo findings in animal models were extracted. Results. Out of 383 relevant studies, 11 case-control studies were included for data extraction, including a total of 448 animal subjects (range 10–90). Six studies utilised bone marrow-derived MSCs. All studies characterised their MSCs via flow cytometry, which expressed CD44 and CD90, and isolated EVs via ultracentrifugation (average diameter 125nm). Five studies utilised histological scoring systems, all of which reported a lower score with EV treatment, suggesting improved healing ability. Four studies reported increased anti-inflammatory cytokine expression (IL-10, TGF-β1); three studies reported decreased endogenous M1/M2 macrophage ratio with EV treatment. Eight studies reported increased maximum stiffness, breaking load, tensile strength in EV-treated tendons. Conclusion. MSC-EVs are effective therapeutic agents for tendon/ligament pathologies, attenuating the initial inflammatory response, and accelerating tendon matrix regeneration. Future randomised controlled trials are needed to definitely demonstrate MSC-EVs superiority in management of tendon/ligament injury

Osteomyelitis is an infection of bone or bone marrow with a concomitant inflammation involving the bone marrow and the surrounding tissues. Chronic osteomyelitis is historically treated in a two-stage fashion with antibiotic-loaded polymethylmethacrylate as local antibacterial therapy. Two-stage surgeries are associated with high morbidity, long hospitalization and high treatment costs. Next to antibiotic releasing biomaterials, S53P4 bioactive glass is a biomaterial that enables one-stage surgery in local treatment of chronic osteomyelitis. S53P4 bioactive glass is gaining interests in recent years in clinical treatment of chronic osteomyelitis in a one-stage fashion due to its antibacterial and bone regenerating capacities. By changing local pH and osmotic pressure S53P4 bioactive glass attack bacteria in a different way as compared to antibiotics. In this presentation, we will present current clinical treatment options for osteomyelitis, clinical results and level of evidence of various biomaterials used in osteomyelitis treatment. In addition, the clinical results and health-economic results of S53P4 bioactive glass will be detailed. Thereafter a summary of the current standing across the board in osteomyelitis treatment will be provided

Abstract

Hyaluronic acid (HA) is responsible for the viscoelastic properties of synovial fluid and cartilage. Compared to healthy joints, synovial fluid in osteoarthritic joints contains HA of lower concentration and molecular weight. Hyaluronic acid hybrid complexes are composed by long and short HA chains linked by H bonds. These rheological characteristics and viscoelastic properties were produced by thermal patented process without chemical modification. Chondroitin sulfate (CS) is one of the essential components of the articular cartilage matrix and plays a key role in cartilage's mechanical and elastic properties. Biotechnological chondroitin (CB) is produced through fermentative/biotechnological processes and, unlike CS, is not sulfated. It has been shown that CB to play a more significant role in the phenotypic maintenance of chondrocytes than chondroitin sulfate and increases their viability and proliferation. A recent A Single-Arm, Open-Label, Pilot Study was conducted to evaluate the safety and efficacy of a single-dose intra-articular injection of Hybrid Hyaluronic acid and Sodium Chondroitin in the Treatment of Symptomatic Hip Osteoarthritis. A single injection of HS-SC was well tolerated and safe in the treatment of symptomatic hip OA. The treatment demonstrated a rapid significant improvement in pain (VAS) and function (Lequesne's Index) up to 6 months of follow-up.

Purpose. To identify genes showing altered expression in osteoarthritic (OA) cartilage and synovium. Dkk3, a member of the Dickoppf family of Wnt signalling inhibitors was overexpressed and this work highlights the potential function of Dkk3 in OA. Methods. Real-time PCR was used to compare the expression of 270 cytokines, chemokines and their receptors in cartilage and synovium from OA and non-OA patients. Expression of Dkk3 was also measured in ATDC5 cells and in bovine nasal cartilage (BNC) explants treated with inflammatory cytokines. The effect of Dkk3 on hydroxyproline and GAG release was measured in BNC explant cultures. To assess the distribution of Dkk3 in OA cartilage immunohistochemistry was carried out on anteromedial gonarthrosis specimens. The level of Dkk3 in synovial fluid tricompartmental and unicompartmental cartilage lesions was measured using ELISA. Results. Dkk3 expression was increased 10- in OA cartilage (p=0.00011) and 3.5-fold increase in OA synovium (p=0.007) when compared to respective control tissues. Dkk3 expression was shown to decrease during chondrogenic differentiation of ATDC5 cells and to be increased by interleukin 1 and oncostatin-M in BNC explants. Dkk3 inhibited the release of hydroxyproline and proteoglycan from BNC explants co-treated with interleukin-1 and oncostatin-M. Immunohistochemistry of anteromedial gonarthrosis specimens demonstrated increased Dkk3 in superficial zone chondrocytes in damaged compared to undamaged cartilage from within the same knee. Increased Dkk3 protein was found in the synovial fluid of individuals with tricompartmental OA (n=4) versus unicompartmental cartilage lesions (n=10) (182ng/ml v 116 ng/ml, p<0.01, a single non-OA control synovial fluid measured 43ng/ml. Conclusions. Dkk3 is a molecule with poorly ascribed function, especially within the musculoskeletal system. In contrast to other members of the Dkk family, Dkk3 does not act consistently as a Wnt inhibitor. Literature on a number of tumour-derived cells have shown that Dkk3 can regulate Wnt, TGFβ, BMP, FGF and Activin signaling and cell proliferation and apoptosis. These cellular processes are highly relevant to OA. In this preliminary study we have shown that Dkk3 is overexpressed in OA cartilage and synovial tissues. The decreased expression of Dkk3 during chondrogenesis, and its increase in inflammatory cytokine stimulated BNC explants is suggestive of a role of Dkk3 not only in articular cartilage maintenance but also in development. The ability of Dkk3 to regulate collagen and proteoglycan breakdown (hallmarks of OA) is further evidence for a role in OA pathogenesis. Dkk3 is a compelling molecule that shows potential to further our understanding of OA and to be used as a biomarker of disease or as a target in OA therapeutics

INTRODUCTION. Staphylococci species account for ∼80 % of osteomyelitis cases. While the most severe infections are caused by Staphylococcus aureus (S. aureus), the clinical significance of coagulase negative Staphylococcus epidermidis (S. epidermidis) infections remain controversial. In general, S. epidermidis was known to be a protective commensal bacterium. However, recent studies have shown that intra-operative low-grade S. epidermidis contamination prevents bone healing. Thus, the purpose of this study is to compare the pathogenic features of S. aureus and S. epidermidis in an established murine model of implant-associated osteomyelitis. METHODS. All animal experiments were performed on IACUC approved protocols. USA300LAC (MRSA) and RP62A(S. epidermidis) were used as prototypic bacterial strains. After sterilization, stainless steel pins were implanted into the tibiae of BALB/c mice (n=5 each) with or without Staphylococci. Mice were euthanized on day 14, and the implants were removed for scanning electron microscopy (SEM). Tibiae were fixed for mCT prior to decalcification for histology. RESULTS. The histology of S. aureus infected tibiae demonstrated massive osteolysis and abscesses formation. In contrast, the histology from S. epidermidis infected tibiae was indistinguishable from uninfected controls. Gross mCT analyses revealed massive bone defects around the infected implant with reactive bone formation only in the S. aureus group. The osteolysis findings were confirmed by quantitative analysis, as the medial hole area of S. aureus infected tibiae (1.67 ± 0.37 mm2) was larger than uninfected (0.15 ± 0.10 mm2) (p < 0.001) and S. epidermidis (0.19 ± 0.14 mm2) (p < 0.001) groups. Consistently, the %biofilm area on the implants of the S. aureus group (39.0 ± 13.7 %) was significantly larger than uninfected (6.3 ± 2.3 %) (p < 0.001) and S. epidermidis (12.9 ± 7.4 %) (p < 0.001). Although the amount of biofilm of S. epidermidis was much smaller than S. aureus, the presence of bacteria on the implant were confirmed by SEM. In addition, the empty lacunae, which is a feature of mature biofilm and evidence of bacterial emigration, were also present on both S. epidermidis and S. aureus infected implants. DISCUSSION. In this study, we confirmed the aggressive pathologic features S. aureus on host bone, soft tissues and biofilm formation. In contrast, we show that S. epidermidis is incapable of inducing osteolysis, reactive bone formation or soft tissue abscesses, even though it colonizes the implant in small biofilms. Collectively, the results support a potential role for S. epidermidis in implant loosening and fracture non-unions, as the bacteria can form small biofilms that could interfere with osseous integration and bone healing. However, future studies are warranted to assess the effects of S. epidermidis biofilm on implant loosening

Tourniquets have been used for many years during total knee arthroplasty (TKA). With a growing demand for TKA in recent years, tourniquet use has been surrounded by ongoing controversy due to many conflicting advantages and disadvantages of tourniquet use. Quantifying the case for or against tourniquet use in TKA, in terms of patient focused outcomes, is a priority. This meta-analysis analysed, the never before assessed, impact of tourniquet use during TKA on post-operative pain. We completed a systematic review and meta-analysis using PRISMA reporting guidelines to assess the impact of tourniquet use on patients post-TKA. Post-operative pain was the primary outcome. Secondary outcomes were post-operative range of motion (ROM) and length of stay (LOS). The initial search yielded 230 studies, of which 14 met the inclusion criteria. A post-operative increase in pain and reduction in ROM when using a tourniquet appeared significantly more likely when compared to no tourniquet use during TKA, yet with no overall difference in post-operative LOS. Subgroup meta-analysis demonstrated a trend that favoured the half-course tourniquet for reduced post-operative pain in patients when compared to full tourniquet use during TKA. This systematic review and meta-analysis concluded that the after-effects of tourniquet use in TKA patients and its impact on post-operative pain and ROM are indeed significant. We recommend further randomized controlled trials (RCTs) focusing on TKA patient outcomes of post-operative pain and ROM. Conflict of interest: The authors certify that they have NO affiliations with or involvement in any organization or entity with any financial interest (such as honoraria; educational grants; participation in speakers' bureaus; membership, employment, consultancies, stock ownership, or other equity interest; and expert testimony or patent-licensing arrangements), or non-financial interest (such as personal or professional relationships, affiliations, knowledge or beliefs) in the subject matter or materials discussed in this manuscript.

Robust evidence on the effectiveness of peri-operative local anaesthetic infiltration (LAI) is required before it is incorporated into the pain management regimen for patients receiving total hip replacement (THR). We assessed the effectiveness of LAI using a systematic review and a fully powered randomised controlled trial (RCT) with economic evaluation. We searched MEDLINE, Embase and Cochrane databases for RCTs of peri-operative LAI in patients receiving THR. Two reviewers screened abstracts, extracted data, and liaised with authors. Outcomes were pain, opioid use, mobilisation, hospital stay and complications. If feasible, we conducted meta-analysis. In the APEX RCT, we randomised 322 patients awaiting THR to receive additional peri-operative LAI (60mls 0.25% bupivacaine plus adrenaline) or standard anaesthesia alone. Post-operatively, all patients received patient-controlled morphine. The primary outcome was joint pain severity (WOMAC-Pain) at 12 months. Patients and outcome assessors were blinded to allocation. Within APEX, cost-effectiveness was assessed from the health and social-care perspective in relation to quality adjusted life years (QALYs) and WOMAC-Pain at 12-months. Resource use was collected from hospital records and patient questionnaires. In the systematic review, we identified 13 studies (909 patients). Patients undergoing THR receiving LAI experienced greater pain reduction at 24 hours at rest, standardised mean difference (SMD) −0.61 (95%CI −1.05, −0.16; p=0.008) and at 48 hours during activity, SMD −0.43 (95%CI −0.78, −0.09; p=0.014). Patients receiving LAI spent fewer days in hospital, used less opioids and mobilised earlier. Complications were similar between groups. Long-term outcomes were not a focus of these studies. In the APEX RCT, pain levels in hospital were broadly similar between groups, probably due to patient-controlled analgesia. Opioid use was similar between groups. Time to mobilisation and discharge were largely dependent on local protocols and did not differ between groups. Patients receiving LAI were less likely to report severe pain at 12 months than those receiving standard care, odds ratio 10.2 (95%CI 2.1, 49.6; p=0.004). Complications were similar between groups. In the economic evaluation, LAI was associated with lower costs and greater cost-effectiveness than standard care. Using a £20,000 per QALY threshold, the incremental net monetary benefit was £1,125 (95%CI £183, £2,067) and the probability of being cost-effective was greater than 98 %. The evidence suggests that peri-operative LAI is a cost-effective intervention for reducing acute and chronic post-surgical pain after THR

Robust evidence on the effectiveness of peri-operative local anaesthetic infiltration (LAI) is required before it is incorporated into the pain management regimen for patients receiving total knee replacement (TKR). To assess the effectiveness of peri-operative LAI for pain management in patients receiving TKR we conducted a systematic review, fully powered randomised controlled trial (RCT) and economic evaluation. We searched MEDLINE, Embase and Cochrane databases for RCTs of peri-operative LAI in patients receiving TKR. Two reviewers screened abstracts and extracted data. Outcomes were pain, opioid use, mobilisation, hospital stay and complications. Authors were contacted if required. When feasible, we conducted meta-analysis with studies analysed separately if a femoral nerve block (FNB) was provided. In the APEX RCT, we randomised 316 patients awaiting TKR to standard anaesthesia which included FNB, or to the same regimen with additional peri-operative LAI (60mls 0.25% bupivacaine plus adrenaline). Post-operatively, all patients received patient-controlled morphine. The primary outcome was joint pain severity (WOMAC-Pain) at 12 months. Patients and outcome assessors were blinded to allocation. Within APEX, cost-effectiveness was assessed from the health and social-care perspective in relation to quality adjusted life years (QALYs) and WOMAC-Pain at 12-months. Resource use was collected from hospital records and patient questionnaires. In the systematic review, 23 studies including 1,439 patients were identified. Compared with patients receiving no intervention, LAI reduced WOMAC-Pain by standardised mean difference (SMD) −0.40 (95%CI −0.58, −0.22; p<0.001) at 24 hours at rest and by SMD −0.27 (95%CI −0.50, −0.05; p=0.018) at 48 hours during activity. In three studies there was no difference in pain at any time point between randomised groups where all patients received FNB. Patients receiving LAI spent fewer days in hospital, used less opioids and mobilised earlier. Complications were similar between groups. Few studies reported long-term outcomes. In the APEX RCT, pain levels in hospital were broadly similar between groups. Overall opioid use was similar between groups. Time to mobilisation and discharge were largely dependent on local protocols and did not differ between groups. There were no differences in pain outcomes between groups at 12 months. In the economic evaluation, LAI was marginally associated with lower costs. Using the NICE £20,000 per QALY threshold, the incremental net monetary benefit was £264 (95%CI, −£710, £1,238) and the probability of being cost-effective was 62%. Although LAI appeared to have some benefit for reduced pain in hospital after TKR there was no evidence of pain control additional to that provided by femoral nerve block, however it would be cost-effective at the current NICE thresholds

Periprosthetic joint infections (PJIs) are uncommon but are devastating complications of total knee replacement (TKR). We analysed the risk factors of revision for PJI following primary TKR and their association with PJI at different post-operative periods. Primary TKRs and subsequent revision surgeries performed for PJI from 2003–2014 were identified from the National Joint Registry (NJR). Multilevel piece-wise exponential non-proportional hazards models were used to estimate the effect of the investigated factors at different post-operative periods. Patient, perioperative and healthcare system characteristics were investigated and data from the Hospital Episode Statistics for England were linked to obtain information on specific comorbidities. The index TKRs consisted of 679,010 primaries with 3,659 subsequently revised for PJI, 7% within 3 months, 6% between 3–6months, 17% between 6–12months, 27% between 1–2years and 43% ≥2 years from the index procedure. Risk factors for revision for PJI included male sex, high BMI, high ASA grade and young age. Patients with chronic pulmonary disease, diabetes and liver disease had higher risk of revision for PJI, as had patients who had a primary TKR for an indication of trauma or inflammatory arthropathy. Surgical procedure, fixation method, constraint and bearing type influenced the risk of revision for PJI. Their effects were period-specific. No or small associations were found with the operating surgeon grade, surgical volume and hospital surgical volume. These findings from the world's largest joint replacement registry show a more complex picture than the meta-analyses published to date with specific time-dependent effects for the identified risk factors.

Bone loss continues to be a clinical and therapeutic problem. Bone reconstruction of osseous defects is a challenge after fracture and traumatic injuries, infections and tumors. The common objective is to regenerate bone morphology and function. Several techniques have been developed to promote bone formation, but the advent of new biomaterials allows us to take an entirely different approach to the treatment of bone voids. However, the use of bone substitutes should be considered carefully, as not all biomaterials behave the same way in humans. Calcium phosphate ceramics are osteoconductive materials that promote bone regeneration. The aim of this study was to retrospectively evaluate the clinical, radiographic and histological results of bone loss treated with an adjunct injectable biphasic bone substitute (BBS).

We analysed the results of patients with fractures and a bone defect that were treated using an injectable BBS (calcium sulfate + hydroxyapatite) and those that were treated using the same bone substitute with antibiotic (gentamicin and/or vancomycin). Patient outcome was evaluated clinically and radiographically. In 9 cases samples for histological analysis were obtained.

From July 2009 to May 2015, 126 cases (cs) on 111 patients (pt) (calcaneus: 53 cs, 47 pt; tibia: 32 cs, 30 pt; Femur: 14 cs, 9 pt, Elbow: 5 cs, 5 pz; humerus 2 cs, 2 pz; wrist 7cs, 7pz; forearm 6 cs, 4 pz; foot 2 cs, 2 pz; Phalanx 5 cs, 5 pt) were treated at our hospital with a BBS. The mean follow-up was 15 months, and bone ingrowth was assessed at 1, 2, 3, 6 and 12 months by X-ray. In all cases, the calcium sulphate phase of the BBS dissolved within 4–6 weeks, and new bone formation was observed at 6 months. On six patients large bone was treated with a revision surgery (autologous cancellous bone graft combined with BBS and antibiotic). No complications were reported.

The 9 histological samples confirmed gradual remodeling and regeneration of the bone substitute over time.

This biomaterial is versatile, offers a good augment for hardware and bone alignment, is biocompatible and osteoconductive, and has allowed us to manage significant bone voids. Histological analysis of samples from the tibia, ulna and calcaneus have confirmed the ability of this bone substitute to remodel into bone.

Introduction

Prosthetic joint infection (PJI) is an uncommon but serious complication of hip replacement.

A recent systematic review of patient risk factors for PJI identified male gender, smoking status, increasing BMI, steroid use, previous joint surgery and comorbidities of diabetes, rheumatoid arthritis and depression as risk factors for developing PJI. Limitations of the current literature include the short term follow up of most published studies.

We investigated the role of patient, surgical and healthcare factors on the risk of revision of a primary hip replacement for PJI at different time-points in the post-operative follow-up. It is important that those risk factors are identified so that patients can be appropriately counselled according to their individual risk profile prior to surgery and modifiable factors can be addressed to reduce the risk of PJI at an individual and healthcare system level.

Osteoarthritis (OA) is a common, debilitating joint disease involving degeneration of cartilage and bone. It has been suggested that subtle changes in the molecular structure of subchondral bone may precede cartilaginous changes in the osteoarthritic joint. To explore these changes Raman spectroscopy was employed as a diagnostic tool. Raman spectroscopy measures inelastic scattered laser light produced when photons interact with chemical materials. Resultant changes in wavelength form spectra relative to the chemical composition of the given sample: with bone this includes the mineral and matrix components, unlike conventional X-rays. The aim of our study is to explore the hypothesis: Changes in matrix composition of osteoarthritic subchondral bone can be detected with Raman spectroscopy. pQCT and Raman spectroscopy were employed to determine the bone mineral density (BMD) and bone quality, respectively. Ten medial compartment OA and five control (non-OA) tibial plateaus were interrogated and analysis performed to compare OA to control, and medial to lateral compartments. The subchondral bone of the medial OA compartments had higher BMD (p=0.05) and thickness compared to lateral and control samples. Spectral analysis revealed there is no difference between the medial and lateral compartments within either cohort. However, there is a statistically significant (p=0.02) spectral difference between the OA and control specimens. The detection of bone matrix changes in osteoarthritis using Raman spectroscopy contributes to the understanding of the biochemical signature of subchondral bone across diseased and control tibial plateaus. This technique has potential to shed light on the role of bone in osteoarthritis.

Current knowledge regarding upper limb myotomes is based on historic papers. Recent advances in magnetic resonance imaging (MRI) and surgical exploration with intraoperative nerve stimulation now allow accurate identification of nerve root injuries in the brachial plexus. The aim of this study is to identify the myotome values of the upper limb associated with defined supraclvicular brachial plexus injuries.

57 patients with partial supraclavicular brachial plexus injuries were identified from the Scottish brachial plexus database. The average age was 28 years and most injuries secondary to motor cycle accidents or stabbings. The operative and MRI findings for each patient were checked to establish the root injuries and the muscle powers of the upper limb documented.

The main patterns of injuries identified involved (C5,6), (C5,6,7), (C5,6,7,8) and (C8, T1). C5, 6 injuries were associated with loss of shoulder abduction, external rotation and elbow flexion. In 30% of the 16 cases showed some biceps action from the C7 root. C5,6,7 injuries showed a similar pattern of weakness with the additional loss of flexor carpi radialis and weakness but not total paralysis of triceps in 85% of cases. C5,6,7,8 injuries were characterised by loss of pectoralis major, lattisimus dorsi, triceps, wrist extension, finger extension and as well as weakness of the ulnar intrinsic muscles. We identified weakness of the flexor digitorum profundus to the ulnar sided digits in 83% of cases. T1 has a major input to innervation of flexors of the radial digits and thumb, as well as intrinsics.

This is the largest study of myotome values in patients with surgically or radiologically confirmed injuries in the literature and presents information for general orthopaedic surgeons dealing with trauma patients for the differentiation of different patterns of brachial plexus injuries. In addition we have identified new anatomical relationships not previously described in upper limb myotomes.

Prosthetic joint infection (PJI) is an uncommon but serious complication of hip and knee replacement. We investigated the rates of revision surgery for the treatment of PJI following primary and revision hip and knee replacement, explored time trends, and estimated the overall surgical burden created by PJI.

We analysed the National Joint Registry for England and Wales for revision hip and knee replacements performed for a diagnosis of PJI and their index procedures from 2003–2014. The index hip replacements consisted of 623,253 primary and 63,222 aseptic revision hip replacements with 7,642 revisions subsequently performed for PJI; for knee replacements the figures were 679,010 primary and 33,920 aseptic revision knee replacements with 8,031 revisions subsequently performed for PJI. Cumulative incidence functions, prevalence rates and the burden of PJI in terms of total procedures performed as a result of PJI were calculated.

Revision rates for PJI equated to 43 out of every 10,000 primary hip replacements (2,705/623,253), i.e. 0.43%(95%CI 0.42–0.45), subsequently being revised due to PJI. Around 158 out of every 10,000 aseptic revision hip replacements performed were subsequently revised for PJI (997/63,222), i.e. 1.58%(1.48–1.67). For knees, the respective rates were 0.54%(0.52–0.56) for primary replacements, i.e. 54 out of every 10,000 primary replacements performed (3,659/679,010) and 2.11%(1.96–2.23) for aseptic revision replacements, i.e. 211 out of every 10,000 aseptic revision replacements performed (717/33,920). Between 2005 and 2013, the risk of revision for PJI in the 3 months following primary hip replacement rose by 2.29 fold (1.28–4.08) and after aseptic revision by 3.00 fold (1.06–8.51); for knees, it rose by 2.46 fold (1.15–5.25) after primary replacement and 7.47 fold (1.00–56.12) after aseptic revision. The rates of revision for PJI performed at any time beyond 3 months from the index surgery remained stable or decreased over time.

From a patient perspective, after accounting for the competing risk of revision for an aseptic indication and death, the 10-year cumulative incidence of revision hip replacement for PJI was 0.62%(95%CI 0.59–0.65) following primary and 2.25%(2.08–2.43) following aseptic revision; for knees, the figures were 0.75%(0.72–0.78) following primary replacement and 3.13%(2.81–3.49) following aseptic revision.

At a health service level, the absolute number of procedures performed as a consequence of hip PJI increased from 387 in 2005 to 1,013 in 2014, i.e. a relative increase of 2.6 fold. While 70% of those revisions were two-stage, the use of single stage revision increased from 17.6% in 2005 to 38.5% in 2014. For knees, the burden of PJI increased by 2.8 fold between 2005 and 2014. Overall, 74% of revisions were two-stage with an increase in use of single stage from 10.0% in 2005 to 29.0% in 2014.

Although the risk of revision due to PJI following hip or knee replacement is low, it is rising. Given the burden and costs associated with performing revision joint replacement for prosthetic joint infection and the predicted increased incidence of both primary and revision hip replacement, this has substantial implications for service delivery.

Introduction. To develop an international guideline (AOGO) about use of osteobiologics in Anterior Cervical Discectomy and Fusion (ACDF) for treating degenerative spine conditions. Method. The guideline development process was guided by AO Spine Knowledge Forum Degenerative (KF Degen) and followed the Guideline International Network McMaster Guideline Development Checklist. The process involved 73 participants with expertise in degenerative spine diseases and surgery from 22 countries. Fifteen systematic reviews were conducted addressing respective key topics and evidence were collected. The methodologist compiled the evidence into GRADE Evidence-to-Decision frameworks. Guideline panel members judged the outcomes and other criteria and made the final recommendations through consensus. Result. Five conditional recommendations were created. A conditional recommendation is about the use of allograft, autograft or a cage with an osteobiologic in primary ACDF surgery. Other conditional recommendations are about use of osteobiologic for single or multi-level ACDF, and for hybrid construct surgery. It is suggested that surgeons use other osteobiologics rather than human bone morphogenetic protein-2 in common clinical situations. Surgeons are recommended to choose one graft over another or one osteobiologic over another primarily based on clinical situation, and the costs and availability of the materials. Conclusion. This AOGO guideline is the first to provide recommendations for the use of osteobiologics in ACDF. Despite the comprehensive searches for evidence, there were few studies completed with small sample sizes and primarily as case series with inherent risks of bias. Therefore high quality clinical evidence is demanded to improve the guideline