Neoangiogenesis drives the replacement of mineralised cartilage by trabecular bone during bone growth regulated by molecules like e.g. VEGF, OPG and RANKL. The Heparan sulfate proteoglycan Syndecan-1 (Sdc1) plays a role in the interaction of osteoclasts and osteoblasts and the development of blood vessels. We expected Sdc1 to have an influence on bone structure and vessel development. Therefore, bone structure and angiogenesis at the growth plate in mice was compared and the influence of Syndecan-1 deficiency was characterised. Animals: Femura of male and female C57BL/6 WT (5♀, 6♂) and Sdc1-/- (9♀, 5♂) mice were used for native bone analysis at 4 month age. Histology: Bone structure was analysed using microCT scans with a resolution of 9µm. Vascularisation was visualised using an anti-Endomucin antibody in 80µm thick cryosections. In vitro angiogenesis: Bone marrow isolates were used to generate endothelial progenitor cells by sequential cultivation on fibronectin. Microvessel development was analysed 4h after plating on matrigel. Bone structure in male Sdc1 deficient mice was significantly reduced compare to male WT, whereas female mice of both genotypes did not differ. Sdc1 deficient mice at the age of 4 month showed a high decrease in the number of vessel bulbs at the chondro-osseous border (growth plate) compared to WT mice. However, no sex related differences were shown. Quantification of microvessel outgrowth of endothelial cells revealed a decreased amount of sprouting, but increased length of microvessels of Sdc1-/- cells compared to WT. Syndecan-1 has a significant impact on neoangiogenesis at the chondro-osseous border of the native bone, but the impact of Syndecan-1 deficiency on the loss of bone structure was significantly higher in male mice. This emphasises the importance to further characterise the function of Syndecan-1 regulated processes during enchondral ossification in a sex dependent manner

The objectives of this study are to evaluate the impact of the CoVID-19 pandemic on the development of relevant emerging digital healthcare trends and to explore which digital healthcare trend does the health industry need most to support HCPs. A web survey using 39 questions facilitating Five-Point Likert scales was performed from 1.8.2020 – 31.10.2020. Of 260 participants invited, 90 participants answered the questionnaire. The participants were located in the Hospital/HCP sector in 11.9%, in other healthcare sectors in 22.2%, in the pharmaceutical sector in 11.1%, in the medical device and equipment industry in 43.3%. The Five-Point Likert scales were in all cases fashioned as from 1 (strongly disagree) to 5 (strongly agree). As the top 3 most impacted digital health care trends strongly impacted by CoVID-19, respondents named:. - remote management of patients by telemedicine, mean answer 4.44. - shared data governance under patient control, mean answer 3.80. - new virtual interaction between HCP´s and medical industry, mean answer 3.76. Respondents were asked which level of readiness of the healthcare system currently possess to cope with the current trend impacted by CoVID-19. - Digital and efficient healthcare logistics, mean answer 1.54. - Integrated health care, mean answer 1.73. - Use of big data and artificial intelligence, mean answer 2.03. Asked if collaborative research in the form of digital data platforms for research data sharing and increasing collaboration with multi-centric consortia would have a positive impact on the healthcare sector, the agreement was high with a value of mean 4.10 on the scale. We can conclude that the impact of COVID-19 appears to be a high agreement of necessary advances in digitalization in the health care sector and in the collaboration of HCPs with the health care industry. Health care professional are unsure, in how far the national health care sector is capable of transformation in healthcare logistics and integrated health care

The covid-19 pandemic had a great impact in the daily clinical and surgical practice. Concerning patients with a femoral neck fracture, there is the need of a negative Sars-CoV-2 test or an established isolation period for the positive cases, pre-operatively. The goal of this study was to evaluate the impact of the pandemic in the management of patients with femoral neck fractures, who were submitted to surgical treatment with hemiarthroplasty, in our hospital. A retrospective, observational study was performed, analysing the patients with femoral neck fractures submitted to hip hemiarthroplasty, during the years 2019 (before the pandemic) and 2020 (first year of the pandemic). We analysed the first 5 patients operated in each month of the mentioned years. We analysed 56 and 60 patients submitted to surgery in the years 2019 and 2020, respectively. The inpatient days were, in average, 14.1 and 13.1. Patients were operated, in average, 3.0 and 3.8 days after admission (corrected to 2.5 and 3.6 days if the time of discontinuation of anticoagulants or antiplatelets needed before surgery is deducted). There were peri-operative complications in 53.6% and 46.7% of the patients, in 2019 and 2020 respectively. The most common complication in both groups was a low postoperative haemoglobin level needing red blood cell transfusion. One-year postoperative mortality rate was 17.9% and 13.3%, respectively. Despite the changes triggered by the new pandemic, there was an overall maintenance of the quality of the management of these patients, with only a slight increase in the interval between admission and surgery. Some of the remaining variables even showed an improvement when comparing the two groups of patients. Nevertheless, it is important to mention that there were patients infected with Covid-19 who died before being submitted to surgery, therefore not being present in these statistics

There has been a significant increase in waiting times for elective surgical procedures in orthopaedic surgery as a result of the coronavirus disease 2019 (COVID-19) pandemic. As per the hospital policy, patients awaiting elective surgery for more than 52 weeks were offered a consultant-led harm review. The aim of this study was to objectively assess the impact of this service on the field of foot and ankle surgery. The data from harm review clinics at a District General Hospital related to patients waiting to undergo elective foot and ankle procedures in the year 2021 (wait time of more than 52 weeks) were assessed. Clinical data points like change in diagnosis, need for further investigations, and patients being taken off the waiting list were reviewed. The effect of the waiting time on patients’ mental health and their perception of the service was assessed as well. A total of 72 patients awaiting foot and ankle procedures for more than 52 weeks were assessed as a part of the harm review service. It was noted that 25% of patients found that their symptoms had worsened while 66.1% perceived them to be unchanged. Twelve patients (16.9%) were sent for updated investigations. Twenty-one patients (29.5%) were taken off the waiting lists for various reasons with the most common one being other pressing health concerns; 9% of patients affirmed that the wait for surgery had a significant negative impact on their mental health. This study concludes that the harm review service is a useful programme as it helps guide changes in the diagnosis and clinical picture. The service is found to be valuable by most patients, and its impact on the service specialities and multiple centres could be further assessed to draw broad conclusions

The ability of the body to constantly maintain metabolism homeostasis while fulling the heightened energy and macromolecule demand is crucial to ensure successful tissue healing outcomes. Studies investigating the local metabolic environment during healing are scarce to date. Here, using Type 2 Diabetes (T2D) as a study model, we investigate the impact of metabolism dysregulation on scaffold-guided large-volume bone regeneration. Our study treated wild-type or T2D rats with 5 mm critical-sized femoral defects with 3D-printed polycaprolactone (PCL) scaffolds with 70% porosity. Metabolomics was leveraged for a holistic view of metabolism alteration as healing progress and correlated to regenerated bone tissue volume and quality assessed using micro-computed tomography (µ-CT), histology, and immunohistology. Semi-targeted metabolomics analysis indicated dysregulation in the glycolysis and TCA cycle – the main energy production pathways, in T2D compared to healthy animals. The abundance of metabolites substrates, i.e., amino acids – for protein/ extracellular matrix synthesis was also affected in T2D. Tissue-level metabolites observations aligned with morphological observation with less newly formed bone observed in T2D than wild-type rats. This study enlightens the metabolism landscape during scaffold-guided large-volume bone regeneration in wild-type vs. T2D to further guide the personalization of the scaffold to drive successful regeneration

Photobiomodulation (PBM), the use of light for regenerative purposes, has a long history with first documentations several thousand years ago in ancient Egypt and a Nobel Price on this topic at the beginning of last century (by Niels Finsen). Nowadays, it is in clinical use for indications such as wound healing, pain relief and anti-inflammatory treatment. Given the rising numbers of in vitro studies, there is increasing evidence for the underlying mechanisms such as wavelength dependent reactive oxygen production and adenosine triphosphate generation. In cartilage regeneration, the use of PBM is controversially discussed with divergent results in clinics and insufficient in vitro studies. As non-invasive therapy, PMB is, though, of particular importance, since a general regenerative stimulus would be of great benefit in the otherwise only surgically accessible tissues. We therefore investigated the influence of different wavelengths - blue (475 nm), green (516 nm) or red (635 nm) of a low-level laser (LLL) - on the chondrogenic differentiation of chondrocytes and adipose derived stromal cells of different human donors and applied the light in different settings (2D, 3D) with cells in a proliferative or differentiating stage. All assessed parameters (spheroid growth, histology, matrix quantification and gene expression) revealed an influence of LLL on chondrogenesis in a donor-, wavelength- and culture-model-dependent manner. Especially encouraging was the finding, that cells with poor chondrogenic potential could be improved by one single 2D treatment. Amongst the three wave lengths, red light was the most promising one with the most positive impact. Although in vivo data are still missing, these in vitro results provide evidence for a proper biofunctional effect of LLL

Matrix metalloproteinase enzymes (MMPs) play a crucial role in the remodeling of articular cartilage, contributing also to osteoarthritis (OA) progression. The pericellular matrix (PCM) is a specialized space surrounding each chondrocyte, containing collagen type VI and perlecan. It acts as a transducer of biomechanical and biochemical signals for the chondrocyte. This study investigates the impact of MMP-2, -3, and -7 on the integrity and biomechanical characteristics of the PCM. Human articular cartilage explants (n=10 patients, ethical-nr.:674/2016BO2) were incubated with activated MMP-2, -3, or -7 as well as combinations of these enzymes. The structural degradative effect on the PCM was assessed by immunolabelling of the PCM's main components: collagen type VI and perlecan. Biomechanical properties of the PCM in form of the elastic moduli (EM) were determined by means of atomic force microscopy (AFM), using a spherical cantilever tip (2.5µm). MMPs disrupted the PCM-integrity, resulting in altered collagen type VI and perlecan structure and dispersed pericellular arrangement. A total of 3600 AFM-measurements revealed that incubation with single MMPs resulted in decreased PCM stiffness (p<0.001) when compared to the untreated group. The overall EM were reduced by ∼36% for all the 3 individual enzymes. The enzyme combinations altered the biomechanical properties at a comparable level (∼36%, p<0.001), except for MMP-2/-7 (p=0.202). MMP-induced changes in the PCM composition have a significant impact on the biomechanical properties of the PCM, similar to those observed in early OA. Each individual MMP was shown to be highly capable of selectively degrading the PCM microenvironment. The combination of MMP-2 and -7 showed a lower potency in reducing the PCM stiffness, suggesting a possible interplay between the two enzymes. Our study showed that MMP-2, -3, and -7 play a direct role in the functional and structural remodeling of the PCM. Acknowledgements: This work was supported by the Faculty of Medicine of the University of Tübingen (grant number.: 2650-0-0)

The aim of this study was to assess the impact of Covid-19 measures on the rate of surgical site infections (SSI) and subsequent readmissions in orthopaedic patients. Retrospective, observational study in a level 1 major trauma center comparing rates of SSI in orthopaedic patients who underwent surgery prior to the Covid-19 lockdown versus that of patients who underwent surgery during the lockdown period. A total of 1151 patients were identified using electronic clinical records over two different time periods; 3 months pre Covid-19 lockdown (n=680) and 3 months during the Covid-19 lockdown (n=470). Patients were followed up for 1 year following their initial procedure. Primary outcome was readmission for SSI. Secondary outcomes were treatment received and requirement for further surgeries. The most commonly performed procedures were arthroplasty and manipulation under anaesthesia with 119 in lockdown vs 101 non-lockdown (p=0.001). The readmission rate was higher in the lockdown group with 61 (13%) vs 44 (6.5%) in the non-lockdown group (p <0.001). However, the majority were due to other surgical complications such as dislocations. Interestingly, the SSI rates were very similar with 24 (5%) in lockdown vs 28 (4%) in non-lockdown (p=0.472). Twenty patients (4.2%) required a secondary procedure for their SSI in the lockdown group vs 24 (3.5%) in non-lockdown (p=0.381). Mortality rate was similar at 44 (9.3%) in lockdown vs 61 (9.0%; p=0.836). Whilst Covid-19 precautions were associated with higher readmission rates, there was no significant difference in rate of SSI between the two groups

Objectives. Taper junctions between modular hip arthroplasty femoral heads and stems fail by wear or corrosion which can be caused by relative motion at their interface. Increasing the assembly force can reduce relative motion and corrosion but may also damage surrounding tissues. The purpose of this study was to determine the effects of increasing the impaction energy and the stiffness of the impactor tool on the stability of the taper junction and on the forces transmitted through the patient’s surrounding tissues. Methods. A commercially available impaction tool was modified to assemble components in the laboratory using impactor tips with varying stiffness at different applied energy levels. Springs were mounted below the modular components to represent the patient. The pull-off force of the head from the stem was measured to assess stability, and the displacement of the springs was measured to assess the force transmitted to the patient’s tissues. Results. The pull-off force of the head increased as the stiffness of the impactor tip increased but without increasing the force transmitted through the springs (patient). Increasing the impaction energy increased the pull-off force but also increased the force transmitted through the springs. Conclusions. To limit wear and corrosion, manufacturers should maximize the stiffness of the impactor tool but without damaging the surface of the head. This strategy will maximize the stability of the head on the stem for a given applied energy, without influencing the force transmitted through the patient’s tissues. Current impactor designs already appear to approach this limit. Increasing the applied energy (which is dependent on the mass of the hammer and square of the contact speed) increases the stability of the modular connection but proportionally increases the force transmitted through the patient’s tissues, as well as to the surface of the head, and should be restricted to safe levels. Cite this article: A. Krull, M. M. Morlock, N. E. Bishop. Maximizing the fixation strength of modular components by impaction without tissue damage. Bone Joint Res 2018;7:196–204. DOI: 10.1302/2046-3758.72.BJR-2017-0078.R2

Introduction and Objective. Neoangiogenesis drives the replacement of mineralized cartilage by trabecular bone during bone growth regulated by molecules like e.g. VEGF, OPG and RANKL and the close interaction of progenitors of osteoblasts, chondrocytes, endothelial cells and osteoclasts/chondroclasts. The Heparan sulfate proteoglycan Syndecan-1 (Sdc-1) plays a role in the interaction between osteoclasts and osteoblasts and the development of blood vessels. As the processes of osteogenesis and angiogenesis are closely related to each other in bone, we expected Sdc-1 to have an influence on vessel structure during aging. Therefore, angiogenesis at the growth plate in mice of different ages was compared and the influence of Syndecan-1 deficiency was characterized. Materials and Methods. Animals: C57BL/6 (WT) and Sdc1−/− mice were used for native bone analysis at 4, 12 and 18 month age. Femura were dissected, cryoprotected and embedded. Histology: Embedded bones were sectioned into 80um thick slices so that the 3D network of the vascularization of the bone could be visualized using an anti-Endomucin antibody and DAPI as counter staining. For semi-automatical quantification of the vessel bulbs we used a custom made software. In vitro angiogenesis: For aortic ring assay, aortic tissue was isolated from 4 month old mice, cut into 0.5mm rings and embedded in collagen type I matrix. Microvessel outgrowth was quantified after 6 days of culture. Results. We verified our custom-made software using slices of WT mice and showed that there is no variation of the number of bulbs with regard to the width of the growth plate in periphery versus center zones in all age groups which indicates a homogeneous distribution of angiogenesis throughout the interface of cartilage to newly forming bone. Furthermore, in both, WT and Sdc-1 deficient mice the number of bulbs decreased significantly with age. However, Sdc-1 knockout mice at the age of 4 and 12 month showed a highly significant decrease in angiogenesis close to the growth plate compared to WT mice, whereas in older mice these differences were gone. Quantification of microvessel outgrowth of aortic tissue revealed a significant decrease in number of vessels from rings taken from Syndecan-1 deficient mice compared to WT mice. Conclusions. Syndecan-1 has a significant impact on neoangiogenesis in vitro and in vivo during aging as demonstrated at the chondro-osseous border of the native bone, emphasizing the importance to further characterize the function of Syndecan-1 regulated processes during enchondral ossification

Introduction and Objective. Osteochondral allograft (OCA) transplants have been used clinically for more than 40 years as a surgical option for joint restoration, particularly for young and active patients. While immediate graft rejection responses have not been documented, it is believed that the host's immunological responses may directly impact OCA viability, incorporation, integrity, and survival, and therefore, it is of the utmost importance to further optimize OCA transplantation outcomes. The influences of sub-rejection immune responses on OCA transplantation failures have not been fully elucidated therefore aimed to further characterize cellular features of OCA failures using immunohistochemistry (IHC) in our continued hopes for the successful optimization of this valuable surgical procedure. Materials and Methods. With IRB approval, osteochondral tissues that were resected from the knee, hip, and ankle of patients undergoing standard-of-care revision surgeries (N=23) to treat OCA failures and tissues from unused portions of OCAs (N=7) that would otherwise be discarded were recovered. Subjective histologic assessments were performed on hematoxylin and eosin-stained and toluidine blue-stained sections by a pathologist who was blinded to patient demographics, outcomes data, and tissue source. IHC for CD3, CD8, and CD20 were performed to further characterize the and allow for subjective assessment of relevant immune responses. Results. Eleven (48%) of the failed OCAs had aggregates of CD3+, CD8+, and CD20+ lymphocytes around small blood vessels in the bone marrow spaces and adipose/collagenous tissue of the allograft, while the non-implanted healthy control OCA tissues did not show any evidence of inflammation. The remaining failed OCAs (52%) did not show a similar pattern of T- and B-cell infiltrates around blood vessels. Other histologic abnormalities associated with failed OCAs included avascular necrosis, subchondral micro and macro fractures, subchondral collapse, bacterial infection, and/or articular cartilage erosion or delamination. Conclusions. The results from the present study support this possibility in that mixed aggregates of CD3+, CD8+, and CD20+ lymphocytes were observed around small blood vessels in approximately half of the failed OCAs. This potentially cytotoxic immune response may have contributed to the lack of functional survival of the OCA noted in these cases, and warrants further investigation as a possible failure mechanism that may be mitigated using post-transplantation management strategies

Mincing cartilage with commercially available shavers is increasingly used for treating focal cartilage defects. This study aimed to compare the impact of mincing bovine articular cartilage using different shaver blades on chondrocyte viability. Bovine articular cartilage was harvested using a scalpel or three different shaver blades (2.5 mm, 3.5 mm, or 4.2 mm) from a commercially available shaver. The cartilage obtained with a scalpel was minced into fragments smaller than 1 mm. 3. All four conditions were cultivated in a culture medium for seven days. After Day 1 and Day 7, metabolic activity, RNA isolation, and gene expression of anabolic (COL2A1, ACAN) and catabolic genes (MMP1, MMP13), Live/Dead staining and visualization using confocal microscopy, and flow cytometric characterization of minced cartilage chondrocytes were measured. The study found that mincing cartilage with shavers significantly reduced metabolic activity after one and seven days compared to scalpel mincing (p<0.001). Gene expression of anabolic genes was reduced, while catabolic genes were increased after day 7 in all shaver conditions. The MMP13/COL2A1 ratio was also increased in all shaver conditions. Confocal microscopy revealed a thin line of dead cells at the lesion site with viable cells below for the scalpel mincing and a higher number of dead cells diffusely distributed in the shaver conditions. After seven days, there was a significant decrease in viable cells in the shaver conditions compared to scalpel mincing (p<0.05). Flow cytometric characterization revealed fewer intact cells and proportionally more dead cells in all shaver conditions compared to the scalpel mincing. Mincing bovine articular cartilage with commercially available shavers reduces the viability of chondrocytes compared to scalpel mincing. This indicates that mincing cartilage with a shaver should be considered a matrix rather than a cell therapy. Further experimental and clinical studies are required to standardize the mincing process with a shaver. Acknowledgements: This study received unrestricted funding from KARL STORZ SE & Co. KG

Object. The aim of this study was to investigate the impact of the COVID-19 pandemic on the management and outcome of patients with neck of femur fractures. Methods. Data was collected for 96 patients with neck of femur fractures who presented to the emergency department between March 1, 2020 and May 15, 2020. This data set included information about their COVID-19 status. Parameters including inpatient complications, hospital quality measures, mortality rates, and training opportunities were compared between the COVID-19 positive and COVID-19 negative groups. Furthermore, our current cohort of patients were compared against a historical control group of 95 patients who presented with neck of femur fractures before the COVID-19 pandemic. Results. Seven (7.3%) patients were confirmed COVID positive by RT-PCR testing. The COVID positive cohort, when compared to the COVID negative cohort, had higher rates of postoperative complications (71.4% vs 25.9%), increased length of stay (30.3 days vs 12 days) and quicker time to surgery (0.7 days vs 1.3 days). The 2020 cohort compared to the 2019 cohort, had an increased 30-day mortality rate (13.5% vs 4.2%), increased number of delayed cases (25% vs 11.8%) as well as reduced training opportunities for Orthopaedic trainees to perform the surgery (51.6% vs 22.8%). Conclusions. COVID-19 has had a profound impact on the care and outcome of neck of femur fracture patients during the pandemic with an increase in 30-day mortality rate. There were profound adverse effects on patient management pathways and outcomes while also affecting training opportunities

Background. Around 1% of patients who have hip replacement have deep prosthetic joint infection afterwards. Infection is treated with antibiotics and revision surgery. We aimed to characterise the impact of deep joint infection and its treatment, to identify treatment preferences, and to describe surgeons' treatment decisions. Methods. In a qualitative study in the UK we interviewed 19 patients who had infection after hip replacement and 12 orthopaedic surgeons specialising in infection. Face-to-face interviews with patients explored experience of infection, treatment and recovery. Interviews with surgeons explored treatment decisions. With consent, interviews were audio-recorded, transcribed and anonymised. Once imported into QSR NVivo software, data were analysed using constant comparison. Results. Patients with deep joint infection described mobility loss, pain, loss of valued activities, changes to home environments/moving into care, negative impact on personal relationships and financial strain. Physical and psychological trauma was associated with revision surgery and antibiotic treatment. Patients had strong preferences for treatment options, emphasising impact of surgery, side effects of antibiotics and duration of treatment as key considerations. Although eradication of infection was important, patients felt that reducing impact of treatment was high priority and identified a need for more support. Surgeons' treatment decisions focused on patient characteristics and nature of infection to prioritise eradication of infection. During patients' recovery surgeons' were concerned about possible return of infection and patients' mobility and function. Conclusion. Infection after joint replacement causes physical and psychological trauma. Balancing patients' preferences for reducing impact of treatment with surgeons' emphasis on eradication of infection should be an important consideration in care. There is also need to develop new interventions to support patients with infection. Level of evidence. Level 3 – Qualitative Research. Funding statement. This paper presents independent research funded by the National Institute for Health Research (NIHR) under its Programme Grants for Applied Research scheme (grant number: RP-PG-1210-12005). The views expressed in this publication are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health. Ethics. This study has been given a favourable opinion for conduct in the NHS by the National Research Ethics Service Committee South West – Exeter 14/SW/0072

Abstract. Objectives. Our study evaluates financial impact to the Best Practice Tariff (BPT) of hip fracture patients on Novel Oral Anti-Coagulant (NOAC) medication. Since their approval by NICE for the prevention of stroke and systemic embolism in non-valvular atrial fibrillation, the incidence of hip fracture patients admitted to hospitals on NOAC medication (e.g. rivaroxiban, apixaban) has been increasing. BPT for hip fractures has two components: a base tariff and a conditional top-up tariff of £1,335 per patient (applied to patients of 60 years of age). For the top-up tariff, six criteria must be met, of which time-to-surgery within 36 hours is one. Our department currently recommends withholding NOAC medication and delaying surgery for at least 48 hours as per our Trust's haematology guidelines to reduce intra-operative bleeding risk. Therefore, the conditional top-up tariff cannot be claimed for these patients. Method. A retrospective review of our Trust hip fracture patients over 60 years of age admitted during 2019 on NOAC medication using National Hip Fracture Database (NHFD). Results. 545 hip fracture patients had operative treatment at our Trust during the one-year period of 2019. 31 of these patients were admitted on NOAC medication, and therefore had to stop the NOAC and wait for at least 48 hours before having surgery. This translates to a potential hip fracture BPT loss of £41,385 in 2019, as the conditional top-up tariff could not be claimed. Conclusion. This study illustrates the large financial impact to BPT that hip fracture patients admitted on NOAC medications has at our Trust. It raises the argument as to whether the BPT should allow for an increased length of time until surgery for such patients, to allow safe surgical treatment with reduced bleeding risk. 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 international literature base demonstrates that individuals living with diabetes mellitus (DM) are at increased risk of mortality and post-operative complications following hip fracture surgery (HFS) than non-diabetics. Studies investigating databases in American, European or Asiatic populations highlight the impact geography can have on the resultant investigation. We aim to quantify the impact DM has on HFS patients in a single university hospital. The HIPE dataset of fragility fractures occurring in Galway University Hospital from 2014–2016 were analysed and cross referenced with hospital laboratory and public databases. A database of 759 individuals was created including 515 females and 237 males, with a mean age of 78+/−12.2 years, of which 110 patients had DM. The patient length-of-stay (PLOS) was comparable in all groups with patient age being the primary influencing factor. An extended PLOS correlated with an increased long-term mortality. A trend toward increased occurrence of sub-trochanteric fractures was observed in diabetics with fewer periprosthetic and intertrochanteric fractures. Patients with DM had a significant increased risk of post-operative mortality compared to non-diabetics. Males with DM where at a greater risk of death after HFS [HR 2.29, 95% CI 1.26–4.17. p=0.006] than females with DM [HR 1.69, 95% CI 0.99–2.91. p=0.056]. The presence of DM did not directly impact a patient's PLOS or increase the need for a re-operation. DM is associated with increased post-operative patient mortality and may influence the anatomical fracture pattern. This observation will support further investigation into the mechanical and biochemical changes occurring in the femur in individuals living with DM

Head collisions in sport can result in catastrophic cervical spine injuries. Musculo-skeletal (MSK) modelling can help analyse the relationship between players' motion, external loading and internal stresses that lead to injury. However, the literature lacks sport specific MSK models. In automotive research the intervertebral disc behaviour has been represented as viscoelastic elements (“bushing”), whose stiffness and damping parameters are often estimated under quasi-static conditions and may lack validity in dynamic impacts. The aim of this study was to develop a validated cervical spine model for axial impacts for future use in the analysis of head-first rugby collisions. A drop test rig was used to replicate a sub-catastrophic axial head impact. A load of 80 N from 0.5 m was applied to the cranial aspect of a C2-C6 porcine spinal specimen mounted in the neutral position. The 3D motion of C3-C5 vertebras (4 kHz) and the cranial axial load (1 MHz) were measured via motion capture (Qualysis, Sweden) and a uniaxial load cell (RDP Electronics Ltd, UK). Specimen specific models were created in NMSBuilder and OpenSim after the vertebrae geometries were obtained from the segmentation of micro-CT images of the specimens. The compressive viscoelastic properties of four vertebral joints (C2-C3 through to C5-C6) were optimised via a Genetic Algorithm (MATLAB v2016b, The Mathworks Inc) to minimise tracking errors. The optimisation converged to a solution of 140–49000 kN/m and 2000–8000 Ns/m for stiffness and damping respectively (RMSE=5.1 mm). Simulated joint displacements ranged between 0.09 – 1.75 mm compared to experimental 0.1 – 0.8 mm. Optimal bushing parameters were higher than previously reported values measured through quasi-static testing. Higher stiffness and damping values could be explained by the higher-dynamics nature of the event analysed related to a different part of the non-linear intervertebral disc load-displacement curve

Acetabular morphology and orientation differs from ethnic group to another. Thus, investigating the normal range of the parameters that are used to assess both was a matter of essence. Nevertheless, the main aim of this study was clarification the relationship between acetabular inclination (AI) and acetabular and femoral head arcs’ radii (AAR and FHAR).

A cross-sectional retrospective study that had been done in a tertiary center where Computed tomography abdomen scouts’ radiographs of non-orthopedics patients were included. They had no history of pelvic or hips’ related symptoms or fractures in femur or pelvis.

A total of 84 patients was included with 52% of them were females. The mean of age was 30.38± 5.48. Also, Means of AI were 38.02±3.89 and 40.15±4.40 (P 0.02, significant gender difference) for males and females, respectively. Nonetheless, Head neck shaft angle (HNSA) means were 129.90±5.55 and 130.72±6.62 for males and females, respectively. However, AAR and FHAR means for males and females were 21.3±3.1mm, 19.9±3.1mm, P 0.04 and 19.7±3.1mm, 18.1±2.7mm, P 0.019, respectively. In addition, negative significant correlations were detected between AI against AAR, FHAR, HNSA and body mass index (BMI) (r 0.529, P ≤0.0001, r 0.445, P ≤0.0001, r 0.238, P 0.029, r 0.329, P ≤0.007, respectively). On the other hand, high BMI was associated with AAR and FHAR (r 0.577, P 0.0001 and r 0.266, p 0.031, respectively).

This study shows that high AI is correlated with lower AAR, FHAR. Each ethnic group has its own normal values that must be studied to tailor the path for future implications in clinical setting.

BMP-1 is the major procollagen-C-peptidase activating, besides fibrillar collagen types I-III, several enzymes and growth factors involved in the generation of extracellular matrix. This study investigated the effect of adding and inhibiting BMP-1 directly post fracture.

Standardised femoral fractures were stabilized by an intramedullary nail in 12 week-old female C57Bl/6J mice. We injected either 20 µL recombinant active BMP-1, activity buffer or the BMP-1 specific inhibitor “sizzled”. After 7, 14 and 28 days, mice were sacrificed. Femurs were dissected and paraffin slides were prepared. Callus composition was divided into soft tissue, mineralized and cartilaginous callus. Murine MC3T3 pre-osteoblastic cells were kept in culture adding BMP-1 and sizzled during osteoblastic differentiation. Putative cytotoxicity was determined using MTT-vitality assay. Cell calcification, collagen deposition, and BMP-2 and myostatin protein quantity were characterized.

Adding BMP-1 displayed a weak positive effect on the outcome. After 7 days, more mineralised callus was present, meanwhile the cartilaginous callus was apparently remodelled at higher rate. In the case of BMP-1 inhibition, we observed more cartilaginous callus, which may indicate reduced stability. In cell culture, we could observe a high interference with mineralisation capabilities depending on the stage of osteoblastic development when adding BMP-1 or inhibiting it. Addition and inhibition impaired myostatin (anti-osteogen) and BMP-2 (pro-osteogen) expression.

Interfering with BMP-1 homeostasis in this early stage of fracture repair seems to have rather negative effects. Inhibition apparently yields lower callus quality while the addition of BMP-1 does not significantly accelerate the healing outcome. Cell culture experiments show that BMP-1 application after 7 days of healing leads to higher collagen output but has no effect on mineralisation. This may suggest that BMP-1 application at a later time-point may lead to more pronounced beneficial effects on fracture repair.

Objectives. To explore whether orthopaedic surgeons have adopted the Proximal Fracture of the Humerus: Evaluation by Randomisation (PROFHER) trial results routinely into clinical practice. Methods. A questionnaire was piloted with six orthopaedic surgeons using a ‘think aloud’ process. The final questionnaire contained 29 items and was distributed online to surgeon members of the British Orthopaedic Association and British Elbow and Shoulder Society. Descriptive statistics summarised the sample characteristics and fracture treatment of respondents overall, and grouped them by whether they changed practice based on PROFHER trial findings. Free-text responses were analysed qualitatively for emerging themes using Framework Analysis principles. Results. There were complete responses from 265 orthopaedic and trauma surgeons who treat patients with proximal humeral fractures. Around half (137) had changed practice to various extents because of PROFHER, by operating on fewer PROFHER-eligible fractures. A third (43) of the 128 respondents who had not changed practice were already managing patients non-operatively. Those who changed practice were more likely to be younger, work in a trauma unit rather than a major trauma centre, be specialist shoulder surgeons and treat fewer PROFHER-eligible fractures surgically. This group gave higher scores when assessing validity and applicability of PROFHER. In contrast, a quarter of the non-changers were critical, sometimes emphatically, of PROFHER. The strongest theme that emerged overall was the endorsement of evidence-based practice. Conclusion. PROFHER has had an impact on surgeons’ clinical practice, both through changing it, and through underpinning existing non-operative practice. Although some respondents expressed reservations about the trial, evidence from such trials was found to be the most important influence on surgeons’ decisions to change practice. Cite this article: L. Jefferson, S. Brealey, H. Handoll, A. Keding, L. Kottam, I. Sbizzera, A. Rangan. Impact of the PROFHER trial findings on surgeons’ clinical practice: An online questionnaire survey. Bone Joint Res 2017;6:590–599. DOI: 10.1302/2046-3758.610.BJR-2017-0170