Patient-reported outcomes (PROs) are widely used in the orthopaedic field to assess the impact of conservative and surgical interventions from a patient's perspective. Available instruments cover a range of outcome parameters, such as pain, function, stiffness, quality of life or joint awareness. Choice of instrument for a specific study for clinical practice should include the appraisal of the psychometric characteristics of the measure. The presentation will focus on the assessment of the psychometric characteristics of PRO instruments and provide criteria for evaluating those. The concepts of objectivity, reliability and validity will be explained in the context of PRO instrument and the interpretation of score points derived from PRO instruments will be discussed detailing concepts such as minimal important change/difference, norm data, and thresholds based on external criteria. Finally, international guidelines that define standards for the various procedures on development, validation and translation of PRO instruments will be summarised

Patient-reported outcome measures are a cornerstone of outcome assessment in orthopaedics. However, completing the pencil and paper questionnaires in clinic is something of a burden to the individual patient and the health care institution. We do not provide much in the way of incentives to collect PRO data. Lengthy questionnaires and hidden data analysis offer no direct benefit to the individual patient nor the clinician. Employing ePRO, utilising tablet PCs for questionnaire completion, can improve this situation considerably. Swift and cost-effective data management and instant availability of results using intuitive graphical display make questionnaire completion more rewarding. Direct feedback of PRO data during the consultation can inform the individual's care. Completing electronic questionnaires also makes computer-adaptive testing (CAT) possible. CAT creates dynamic questionnaires, adapting to the individual symptom burden of the individual patient. CAT both increases measurement precision and reduces the number of questions required. As such, ePRO assessment may help to maximise the efficiency and the utilisation of PRO data

The purpose of the study was to compare the mechanical properties, oxidation and wear resistance of a vitamin E blended and moderately crosslinked polyethylene for total knee arthroplasty (MXE) in comparison with clinically established polyethylene materials. The following polyethylene materials were tested: CPE (30 kGy e-beam sterilized), XLPE (75 kGy gamma crosslinked @ 100°C), ViXLPE (0.1 % vitamin E blended, 80 kGy e-beam crosslinked @ 100°C), and MXE (0.1 % vitamin E blended polyethylene, 30 kGy gamma sterilized). For the different tests, the polyethylene materials were either unaged or artificially aged for two or six weeks according to ASTM F2003-02. The oxidation index was measured based on ASTM F2102 at a 1 mm depth. Small punch testing was performed based on ASTM F2977. Mechanical properties were measured on unaged materials according to ASTM D638. Wear simulation was performed on a load controlled 3 + 1 station knee wear simulator (EndoLab GmbH, Thansau, Germany) capable of reproducing loads and movement of highly demanding activities (HDA) as well as ISO 14243-1 load profiles. The load profiles were applied for 5 million cycles (mc) or delamination of the polyethylene components. Medium size AS e.motion. ®. PS Pro (Aesculap AG, Tuttlingen, Germany) femoral and tibial components with a ZrN-multilayer surface, as well as Columbus. ®. CR cobalt-chrome alloy femoral and tibial components were tested. Particle analysis was performed on the serum samples of the ISO 14243-1 wear simulations based on ISO 17853:2011 and ASTM F1877. The analysis of the mechanical properties show that moderately crosslinked polyethylene (MXE) might be a superior material for total knee arthroplasty applications [Schwiesau et al. 2021]. The addition of vitamin E in a moderately crosslinked polyethylene prevented its oxidation, kept its mechanical characteristics, and maintained a low wear, even under a HDA knee wear simulation

Introduction. The objective of the work is construction of a multi-bioactive scaffold based on that allows a space/time control over the regeneration of damaged bones by Medication-Related Osteonecrosis of the Jaw using a minimal invasive approach based on the injection of the fast-degrading pro neuro and angiogenic ELR (Elastin-Like Recombinamers) based hydrogels. Method. Chemical crosslinking facilitated the creation of multi-bioactive scaffolds using ELRs with reactive groups. Cell-loaded multi-bioactive scaffolds, prepared and incubated, underwent evaluation for adhesion, proliferation, angiogenic, and neurogenic potential. In vitro assessments utilized immunofluorescence staining and ELISA assays, while live-recorded monitoring and live-dead analysis ensured cytocompatibility. In rat and rabbit models, preformed scaffolds were subcutaneously implanted, and the regenerative process was evaluated over time. Rabbit models with MRONJ underwent traditional or percutaneous implantation, with histological evaluation following established bone histological techniques. Result. A 3D scaffold using ELR that combines various peptides with different degradation rates to guide both angiogenesis and neurogenesis has been developed. Notably, scaffolds with different degradation rates promoted distinct patterns of vascularization and innervation, facilitating integration with host tissue. This work demonstrates the potential for tailored tissue engineering, where the scaffold's bioactivities and degradation rates can control angiogenesis and neurogenesis. In an animal model of medication-related osteonecrosis of the jaw (MRONJ), the scaffold showed promising results in promoting bone regeneration in a necrotic environment, as confirmed by histological and imaging analyses. This study opens avenues for novel tissue-engineering strategies where precise control over vascularization and nerve growth is crucial. Conclusion. A groundbreaking dual approach, simultaneously targeting angiogenesis and innervation, addresses the necrotic bone in MRONJ syndrome. Vascularization and nerve formation play pivotal roles in driving reparative elements for bone regeneration. The scaffold achieves effective time/space control over necrotic bone regeneration. The authors are grateful for funding from the Spanish Government (PID2020-118669RA-I00)

Acute multiligament knee injuries (MLKI) are rare, high energy traumatic injuries associated with an increased risk of lower limb complications. The objectives of this study were to investigate the adequacy of clinical assessment for neurovascular status, compartment syndrome, and deep vein thrombosis in the emergency department (ED) following acute MLKI. The authors conducted a retrospective case note review of 19 patients with MLKI presenting at the ED of a Major Trauma Centre during a 7.5-year period between June 2009 and December 2016. MLKIs were diagnosed by MRI or examination under anaesthesia and confirmed intraoperatively. Arterial assessment consisted of documented capillary refill time, dorsalis pedis and posterior tibial pulse assessment (through palpation or Doppler ultrasound), and ankle-brachial pressure index (ABPI) calculation. Neural assessment was adequate if there was documented assessment of both sensory and motor function of the superficial peroneal, deep peroneal and tibial nerves individually. Data was collected for 19 patients (17 male, 2 female). The mean age was 34 (range: 14–61). The most common injury mechanism was road traffic accident. Neurovascular assessment was suboptimal in all categories: only one patient received a satisfactory lower limb neurological assessment and no patients received complete vascular assessments. Neurovascular assessment of multiligament knee injuries was suboptimal. Reasons for this included poor documentation and lack of certain specific clinical assessments, such as ABPI calculation. We propose the introduction of an acute knee injury pro forma highlighting the components of a full lower limb neurovascular examination to rectify this problem

Background. The Targon FN plate is a combination of the sliding hip screw and multiple cancellous screws. It is used in the fixation of intracapsular fractures of the neck of femur. The aim of this prospective audit was to assess clinical and radiological outcomes of Targon FN. Method. All patients who had a Targon FN fixation over a period of 18 months at a district general hospital were included. A pro forma was completed using medical records, including x-ray images. Results. Thirty-five patients were identified. Median (IQR) age was 73 (57–82). Median (IQR) waiting time for surgery was 27 hours (17–51). Median (IQR) operating time was 58 (50–65) minutes. The patients were followed up at 6, 12 18 and 24 months. Three cases of avascular necrosis were reported and two cases of non-union. Seven cases were found where the Targon FN was not used correctly. No cases of implant failure were reported where the Targon FN was used according to manufacture guidelines. Five revision surgeries took place or were being planned for cases of avascular necrosis, non union and symptomatic hardware. One case was identified which would have been better treated with a hemiarthroplasty than Targon FN. Conclusion. We recommend that the Targon FN plate continue to be used in our department. The success rate of the implant could be improved by educational workshops in our department to ensure that all surgeons adhere strictly to the operating technique described by the manufacturer. We recommend continuing careful selection of patients for Targon FN and to continue a follow up to 24 months

BACKGROUND. Since 1996, the Scottish Hip Fracture Audit (SHFA) group have published reports on the outcomes of patients with hip fractures. In the 2008 report, the group outlined the target standard that “98% of medically fit patients who have sustained a hip fracture should be operated on within 24 hours of ‘safe operating time’ (i.e. between 8 am and 8pm, seven days a week).”. 1. . AIM. We aim to investigate the compliance of our unit to the SHFA target standard. METHODS. We prospectively examined patients who were admitted with hip fractures between 1. st. April to 31. st. July 2011. These included admissions from A&E and inpatients. Patients who did not receive surgical treatment were excluded. Information was collected using the same pro forma as the SHFA group. RESULTS. There were 72 patients with hip fractures in that period. One patient (1.4%) was considered unfit for surgery and therefore excluded. Sixty-five patients were considered fit for surgery on first assessment and 61 (93.8%) had surgery within the target time. There were three patients (4.6%) whose diagnosis was delayed waiting for MRI. The waiting period included a weekend in two patients, when there were no MRI facilities. Only one patient (1.5%) had surgery delayed due to lack of theatre availability. DISCUSSION. Having surgery performed as early as possible is associated with a beneficial impact on morbidity, complications and length of hospital stay. 2–4. , reflected with SIGN guidelines stating “surgery should be performed as soon as the medical condition allows”. 5. and NICE recommending surgery within 48 hours of admission. 6. . CONCLUSION. Although our rate of 93.8% does not meet the target standard, it represents an improvement from the published rate (91.2%) in 2008. It also highlights the areas for improvement in patient care, particularly in getting MRIs swiftly to avoid delays

Summary Statement. Antioxidant containing UHMWPE particles induced similar levels of in vitro macrophage proliferation and in vivo inflammation in the mouse air pouch model as UHMWPE particles alone. Benefit of antioxidant in reducing wear particle induced inflammation requires further investigation. Introduction. Wear particles derived from UHMWPE implants can provoke inflammatory reaction and cause osteolysis in the bone, leading to aseptic implant loosening. Antioxidants have been incorporated into UHMWPE implants to improve their long term oxidative stability. However it is unclear if the anti-inflammatory property of the antioxidant could reduce UHMWPE particle induced inflammation. This study evaluated the effect of cyanidin and vitamin E on UHMWPE induced macrophage activation and mouse air pouch inflammation. Methods. Four types of UHMWPE were used: (1) compression molded (CM) conventional GUR1020 (PE); (2) CM GUR1020 blended with 300 ppm cyanidin (C-PE); (3) CM GUR1020 blended with 1000 ppm α-tocopherol (BE-PE); and (4) CM GUR1020, gamma irradiated at 100kGy, diffused with α-tocopherol, and sterilised at 30kGy (DE-PE). Particles were generated by cryomilling. Particle count, size, and aspect ratio were determined using SEM and Image Pro. Each particle group was cultured with RAW264.7 macrophage cells at four concentrations (0.625, 1.25, 2.5, and 5 μg/mL) in a standard medium for 4 days. Cell numbers were quantified using MTT assay. Cytokine expression (IL-1β, TNFα, and IL-6) was measured using RT-PCR and ELISA. Particles were also suspended in PBS at 2 concentrations (0.2 or 1 mg) and injected into subcutaneous air pouches in BALB/c mice. Control animals were injected with PBS alone. Six days post-injection air pouches were harvested, half of which were fixed for histology to measure membrane thickness and inflammatory cell quantity. Remaining air pouches were frozen and analyzed by ELISA for cytokine production. Data were analyzed using one-way ANOVA with post hoc testing. P<0.05 was considered significant. Results. All 4 materials showed similar particle characteristics after cryomilling. Particle size ranged from 1 to 19 μm with 33% of particle population smaller than 2 μm. All particle groups supported macrophage proliferation, showing an inverse correlation between proliferation rate and particle dose. Gene expression of IL-1β and TNFα also showed an inverse correlation with particle dose. Expression of IL-1β, TNFα, and IL-6 appeared lower in cells cultured with C-PE than the other 3 materials. The accumulative protein productions of IL-1β and TNFα were significantly lower while IL-6 production was moderately lower in C-PE, BE-PE and DE-PE when compared to PE. Injection of polyethylene particles increased the air pouch membrane thickness significantly compared to the PBS control in all particle types and doses. Higher particle dose induced thicker membrane in all 4 materials. A similar trend was also observed in the percentage of inflammatory cell infiltration in the pouch membrane. C-PE and DE-PE particles at low dose and C-PE particles at high dose induced lower levels of IL-1β and TNFα than PE. IL-6 production was similar between PE and other 3 groups. Discussion/Conclusion. Antioxidant incorporated in UHMWPE did not alter the level of macrophage proliferation and air pouch inflammation induced by UHMWPE particles, although it reduced cytokine gene expression. Future investigation in a synovial joint environment is desired to evaluate the chronic inflammation response to antioxidant containing UHMWPE wear particles and to verify the effect of antioxidant in UHMWPE properties

Objectives

Regenerative medicine is an emerging field aimed at the repair and regeneration of various tissues. To this end, cytokines (CKs), growth factors (GFs), and stem/progenitor cells have been applied in this field. However, obtaining and preparing these candidates requires invasive, costly, and time-consuming procedures. We hypothesised that skeletal muscle could be a favorable candidate tissue for the concept of a point-of-care approach. The purpose of this study was to characterize and confirm the biological potential of skeletal muscle supernatant for use in regenerative medicine.

Objectives

We investigated the effects on fracture healing of two up-regulators of inducible nitric oxide synthase (iNOS) in a rat model of an open femoral osteotomy: tadalafil, a phosphodiesterase inhibitor, and the recently reported nutraceutical, COMB-4 (consisting of L-citrulline, Paullinia cupana, ginger and muira puama), given orally for either 14 or 42 days.

Objectives

The major problem with repair of an articular cartilage injury is the extensive difference in the structure and function of regenerated, compared with normal cartilage. Our work investigates the feasibility of repairing articular osteochondral defects in the canine knee joint using a composite lamellar scaffold of nano-ß-tricalcium phosphate (ß-TCP)/collagen (col) I and II with bone marrow stromal stem cells (BMSCs) and assesses its biological compatibility.

Objectives

The objective of this study was to compare the elution characteristics, antimicrobial activity and mechanical properties of antibiotic-loaded bone cement (ALBC) loaded with powdered antibiotic, powdered antibiotic with inert filler (xylitol), or liquid antibiotic, particularly focusing on vancomycin and amphotericin B.

Nanometre-sized particles of ultra-high molecular weight polyethylene have been identified in the lubricants retrieved from hip simulators. Tissue samples were taken from seven failed Charnley total hip replacements, digested using strong alkali and analysed using high-resolution field emission gun-scanning electron microscopy to determine whether nanometre-sized particles of polyethylene debris were generated in vivo. A randomised method of analysis was used to quantify and characterise all the polyethylene particles isolated.

We isolated nanometre-sized particles from the retrieved tissue samples. The smallest identified was 30 nm and the majority were in the 0.1 μm to 0.99 μm size range. Particles in the 1.0 μm to 9.99 μm size range represented the highest proportion of the wear volume of the tissue samples, with 35% to 98% of the total wear volume comprised of particles of this size. The number of nanometre-sized particles isolated from the tissues accounted for only a small proportion of the total wear volume. Further work is required to assess the biological response to nanometre-sized polyethylene particles.

The success of long-term transcutaneous implants depends on dermal attachment to prevent downgrowth of the epithelium and infection. Hydroxyapatite (HA) coatings and fibronectin (Fn) have independently been shown to regulate fibroblast activity and improve attachment. In an attempt to enhance this phenomenon we adsorbed Fn onto HA-coated substrates. Our study was designed to test the hypothesis that adsorption of Fn onto HA produces a surface that will increase the attachment of dermal fibroblasts better than HA alone or titanium alloy controls.

Iodinated Fn was used to investigate the durability of the protein coating and a bioassay using human dermal fibroblasts was performed to assess the effects of the coating on cell attachment. Cell attachment data were compared with those for HA alone and titanium alloy controls at one, four and 24 hours. Protein attachment peaked within one hour of incubation and the maximum binding efficiency was achieved with an initial droplet of 1000 ng. We showed that after 24 hours one-fifth of the initial Fn coating remained on the substrates, and this resulted in a significant, three-, four-, and sevenfold increase in dermal fibroblast attachment strength compared to uncoated controls at one, four and 24 hours, respectively.

One of the most controversial issues in total knee replacement is whether or not to resurface the patella. In order to determine the effects of different designs of femoral component on the conformity of the patellofemoral joint, five different knee prostheses were investigated. These were Low Contact Stress, the Miller-Galante II, the NexGen, the Porous-Coated Anatomic, and the Total Condylar prostheses. Three-dimensional models of the prostheses and a native patella were developed and assessed by computer. The conformity of the curvature of the five different prosthetic femoral components to their corresponding patellar implants and to the native patella at different angles of flexion was assessed by measuring the angles of intersection of tangential lines.

The Total Condylar prosthesis had the lowest conformity with the native patella (mean 8.58°; 0.14° to 29.9°) and with its own patellar component (mean 11.36°; 0.55° to 39.19°). In the other four prostheses, the conformity was better (mean 2.25°; 0.02° to 10.52°) when articulated with the corresponding patellar component. The Porous-Coated Anatomic femoral component showed better conformity (mean 6.51°; 0.07° to 9.89°) than the Miller-Galante II prosthesis (mean 11.20°; 5.80° to 16.72°) when tested with the native patella. Although the Nexgen prosthesis had less conformity with the native patella at a low angle of flexion, this improved at mid (mean 3.57°; 1.40° to 4.56°) or high angles of flexion (mean 4.54°; 0.91° to 9.39°), respectively. The Low Contact Stress femoral component had the best conformity with the native patella (mean 2.39°; 0.04° to 4.56°). There was no significant difference (p > 0.208) between the conformity when tested with the native patella or its own patellar component at any angle of flexion.

The geometry of the anterior flange of a femoral component affects the conformity of the patellofemoral joint when articulating with the native patella. A more anatomical design of femoral component is preferable if the surgeon decides not to resurface the patella at the time of operation.

A complete cement mantle is important for the longevity of a total hip replacement. In the minimally-invasive direct anterior approach used at the Innsbruck University hospital, the femoral component has to be inserted into the femoral canal by an angulated movement. In a cadaver study, the quality and the extent of the cement mantle surrounding 13 Exeter femoral components implanted straight through a standard anterolateral transgluteal approach were compared with those of 13 similar femoral components implanted in an angulated fashion through a direct anterior approach. A third-generation cementing technique was used. The inner and outer contours of the cement mantles was traced from CT scans and the thickness and cross-sectional area determined.

In no case was the cement mantle incomplete. The total mean thickness of the cement mantle was 3.62 mm (95% confidence interval 3.59 to 3.65). The mean thickness in the group using the minimally-invasive approach was 0.16 mm less than that in the anterolateral group. The distribution of the thickness was similar in the two groups. The mean thickness was less on the anteromedial and anterolateral aspect than on the posterior aspect of the femur.

There is no evidence that the angulated introduction of Exeter femoral components in the direct anterior approach in cadavers compromises the quality, extent or thickness of the cement mantle.