Varus malalignment increases the susceptibility of cartilage to mechanical overloading, which stimulates catabolic metabolism to break down the extracellular matrix and lead to osteoarthritis (OA). The altered mechanical axis from the hip, knee to ankle leads to knee joint pain and ensuing cartilage wear and deterioration, which impact millions of the aged population. Stabilization of the remaining damaged cartilage, and prevention of further deterioration, could provide immense clinical utility and prolong joint function. Our previous work showed that high tibial osteotomy (HTO) could shift the mechanical stress from an imbalanced status to a neutral alignment. However, the underlying mechanisms of endogenous cartilage stabilization after HTO remain unclear. We hypothesize that cartilage-resident mesenchymal stem cells (MSCs) dampen damaged cartilage injury and promote endogenous repair in a varus malaligned knee. The goal of this study is to further examine whether HTO-mediated off-loading would affect human cartilage-resident MSCs' anabolic and catabolic metabolism. This study was approved by IACUC at Xi'an Jiaotong University. Patients with medial compartment OA (52.75±6.85 yrs, left knee 18, right knee 20) underwent open-wedge HTO by the same surgeons at one single academic sports medicine center. Clinical data was documented by the Epic HIS between the dates of April 2019 and April 2022 and radiographic images were collected with a minimum of 12 months of follow-up. Medial compartment OA with/without medial meniscus injury patients with unilateral Kellgren /Lawrence grade 3–4 was confirmed by X-ray. All incisions of the lower extremity healed well after the HTO operation without incision infection. Joint space width (JSW) was measured by uploading to ImageJ software. The Knee injury and Osteoarthritis Outcome Score (KOOS) toolkit was applied to assess the pain level. Outerbridge scores were obtained from a second-look arthroscopic examination. RNA was extracted to quantify catabolic targets and pro-inflammatory genes (QiaGen). Student's t test for two group comparisons and ANOVA analysis for differences between more than 2 groups were utilized. To understand the role of mechanical loading-induced cartilage repair, we measured the serial changes of joint space width (JSW) after HTO for assessing the state of the cartilage stabilization. Our data showed that HTO increased the JSW, decreased the VAS score and improved the KOOS score significantly. We further scored cartilage lesion severity using the Outerbridge classification under a second-look arthroscopic examination while removing the HTO plate. It showed the cartilage lesion area decreased significantly, the full thickness of cartilage increased and mechanical strength was better compared to the pre-HTO baseline. HTO dampened medial tibiofemoral cartilage degeneration and accelerate cartilage repair from Outerbridge grade 2 to 3 to Outerbridge 0 to 1 compared to untreated varus OA. It suggested that physical loading was involved in HTO-induced cartilage regeneration. Given that HTO surgery increases joint space width and creates a physical loading environment, we hypothesize that HTO could increase cartilage composition and collagen accumulation. Consistent with our observation, a group of cartilage-resident MSCs was identified. Our data further showed decreased expression of RUNX2, COL10 and increased SOX9 in MSCs at the RNA level, indicating that catabolic activities were halted during mechanical off-loading. To understand the role of cartilage-resident MSCs in cartilage repair in a biophysical environment, we investigated the differentiation potential of MSCs under 3-dimensional mechanical loading conditions. The physical loading inhibited catabolic markers (IL-1 and IL-6) and increased anabolic markers (SOX9, COL2). Knee-preserved HTO intervention alleviates varus malalignment-related knee joint pain, improves daily and recreation function, and repairs degenerated cartilage of medial compartment OA. The off-loading effect of HTO may allow the mechanoregulation of cartilage repair through the differentiation of endogenous cartilage-derived MSCs

Introduction and Objective. Only few studies have investigated the outcome of exercises in patients with glenohumeral osteoarthritis (OA) or rotator cuff tear arthropathy (CTA), and furthermore often excluded patients with a severe degree of OA. Several studies including a Cochrane review have suggested the need for trials comparing shoulder arthroplasty to non-surgical treatments. Before initiation of such a trial, the feasibility of progressive shoulder exercises (PSE) in patients, who are eligible for shoulder arthroplasty should be investigated. The aim was to investigate whether 12 weeks of PSE is feasible in patients with OA or CTA eligible for shoulder arthroplasty. Moreover, to report changes in shoulder function and range of motion (ROM) following the exercise program. Materials and Methods. Eighteen patients (11 women, 14 OA), mean age 70 years (range 57–80), performed 12 weeks of PSE with 1 weekly physiotherapist-supervised and 2 weekly home-based sessions. Feasibility was measured by drop-out rate, adverse events, pain and adherence to PSE. Patients completed Western Ontario Osteoarthritis of the Shoulder (WOOS) score and Disabilities of the Arm, Shoulder and Hand (DASH). Results. Two patients dropped out and no adverse events were observed. Sixteen patients (89%) had high adherence to the physiotherapist-supervised sessions. Acceptable pain levels were reported. WOOS improved mean 23 points (95%CI:13;33), and DASH improved mean 13 points (95%CI:6;19). Conclusions. PSE is feasible, safe and may improve shoulder pain, function and ROM in patients with OA or CTA eligible for shoulder arthroplasty. PSE is a feasible treatment that may be compared with arthroplasty in a RCT setting

Introduction. Progressive resistance training (PRT) as a mean to reduce symptoms in patients with hip dysplasia (HD) has not yet been tried out. The aim of this study was to examine if PRT is feasible in patients with HD. A secondary purpose was to report data on changes of patient reported outcomes, muscle performance and hip muscle strength following PRT. Materials and methods. Patients diagnosed with HD on the waiting list for a periacetabular osteotomy (PAO) were offered to participate in a PRT feasibility study. The PRT intervention consisted of 8-weeks of supervised PRT consisting of 20 training sessions with exercises for the hips and knees. Feasibility was evaluated as adherence, the number of dropouts and adverse events. Furthermore, pain was reported after each exercise and one day after a training session using a 100mm visual analog scale (VAS). Pain was categorized as “safe” (VAS ≤20), “acceptable” (VAS >20–50) and “high risk” (VAS >50). Pre- and post the intervention patients completed the Copenhagen Hip and Groin Outcome Score (HAGOS), performed two hop-tests on each leg and had their peak torque of the hip extensors and flexors assessed by isokinetic dynamometry. Results. 16 patients, mean age 28 (range 22–40) years, completed the PRT intervention. Adherence was high (90.3% ±9.0%). Acceptable pain levels (VAS ≤50) were reported on average of 95% during the completed PRT sessions and after 92.3% of the sessions when assessed on the following day. Four out of six HAGOS subscales improved (P <0.05) after the intervention, as did standing distance jump and countermovement jump (8.3 cm 95% CI [1.2, 15.3], 1.8 cm [0.7, 2.9]) on the affected side. Dynamometry showed significant improved peak torque during isokinetic concentric hip flexion (15.8 Nm 95% CI [5.9, 25.8]) on the affected side. A similar improvement was seen during isometric hip flexion on the non-affected side. Conclusion. Supervised preoperative PRT is feasible in terms of drop outs, adherence, adverse events and pain levels in patients with HD scheduled for PAO. Furthermore, this feasibility study suggests that PRT may improve pain levels, patient reported outcomes, functional performance and hip flexion muscle strength

Previous studies revealed the close relation of anxiety and low back pain. Among people with chronic low back pain, anxiety is the most commonly reported mental disorder. Thus, in the literature, there are several studies considering the anxiety as a risk factor for chronic low back pain. The authors also documented a significant differences between sexes in anxiety and quality of life due to low back pain. US National Institute of Mental Health reports that the lifetime prevalence of an anxiety disorder is 60 % higher in women than in men and that the onset, severity, clinical course, and treatment response of anxiety disorders differ significantly in women. In addition, literature has showed that women may have a worse quality of life when they have low back pain. University students may undergo an undue amount of stress, with negative outcomes in terms of academic resuşts and personal, emotional or health, consequences. Moreover, stress can be experienced at different time periods, not only during university life, but also before, during the transition from undergraduate to professional level, and after, during the transition to the life work. After all these literature knowledge, we designed the study to compare the anxiety and quality of life levels of female and male specifically university students with low back pain aged between 18–26. In this study, 100 female and male university students with low back pain aged between 18–26 were included. The low back pain level were measured by Visual Analogue Scale (VAS) and the disability level due to the pain was measured by Revised Oswestry Low Back Pain Disability Questionnaire (ODI). Beck Anxiety Inventory (BAI) was used to evaluate the anxiety level and also, Short Form 36 survey (SF-36) was used to understand the quality of life for subjects. These questionnaires were asked to participants on online platform via Google Forms between March 2020 and May 2020. SPSS Version 25.0 program was used for statistical analyses. The result of the study showed that there was a statistically significant difference between female and male students on anxiety levels (p<0.05). There were no statistically differences between female and male students on ODI and VAS (p>0.05). In female group, BAI and “Physical function” and “General Health” subgroups of SF-36 have negative correlations (p<0.05). When we correlated BAI and all subgroups of SF-36 in male group, the statistical results were showed that negative correlation with all subgroups (p<0.05) except “Energy and Fatigue” subgroup (p>0.05). We conclude that female university students with low back pain have higher anxiety levels than male students. Future studies can work on young students to cope with the psychological problems for well-being

Background and aims. Hallux rigidus in the metatarsophalangeal joint (MTPJ) can be treated with arthroplasty to reduce pain and enhance motion. Few studies have investigated the functionality and the survival of HemiCap arthroplasty. Primarily we aimed to examine the medium to long-term functionality and the degree of pain after surgery. Secondarily the failure and revision rate of HemiCap implants. Methods. A total of 106 patients were operated with HemiCap arthroplasty (n=114) from 2006 to 2014, median age 53 (16 to 80) years, 78 females, 37 dorsal flange (DF) implants. Patient charts were reviewed retrospectively to collect revision data. Pre operative Coughlin/Shurnas arthrosis degree, hallux valgus (HV), intermetatarsalintermetatarsal (IM) and Distal Metaphyseal Articular Angle (DMAA) angles was were measured. Pre- and post operative 3 weeks, 6 months, 1 and 2 year2-year pain levels of the first MTPJ by Visuel Analog Skala (VAS 1–10), American Orthopaedic Foot and Ankle Score (AOFAS 0 to 100 points) and, Range of Motion (ROM), were available for 51 patients. FortysevenForty-seven of the 70 available for reexamination partook in a cross sectional follow up where the Self-Reported Foot and Ankle Score (SEFAS 0–48 points) was added to the Patients Related Outcome Measures (PROMs). Statistics. Kaplan-Meier for survival analysis, adjusted for sex, radiological angles, degree of arthrosis and dorsal flange. Prospective PROMs and ROM compared by paired t-test. Results. At 3, 5 and 7 years we had an mean implant survival of 85%, 83% and 78%. Almost all were revised due to pain, one due to malalignment and one due to loosening of the Hemicap. Dorsal flange, gender, preoperative arthrosis degree, HV, IM or DMAA angles did not statistically influence the result. For those (n=23) that were re-examined, preoperative dorsal ROM changed from mean(sd) 21 (6) to 42 (18) degrees, VAS from 7 (2) to 2 (2) and AOFAS from 61 (11) to 87 (11) (p < 0.001). At mean 5 year follow up (n=47), mean (sd) dorsal ROM was 46 (17) degrees,. AOFAS was 84 (9), VAS 2 (1) and SEFAS 42 (6) points. The dorsal flange made no statistical significant difference for ROM or PROMs, but DF displayed 51 degrees of extension vs. 44 without (p=0.1). Periprostethic lucency (<2 mm) was observed in 27/47. Conclusions. In general, we saw an acceptable implant survival rate. We did not find any predictors that influenced implant failure and the design alterations with the dorsal flange are not evident clinically. Patients who were not revised had significantly less pain, greater ROM, and better overall foot and ankle conditions than preoperatively, but the data are biased by missing numbers and revisions

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

Patients report similar or better pain and function before revision hip arthroplasty than before primary arthroplasty but poorer outcomes after revision surgery. The trajectory of post-operative recovery during the first 12 months and any differences by type of surgery have received little attention. We explored the trajectories of change in pain and function after revision hip arthroplasty to 12-months post-operatively and compared them with those observed after primary hip arthroplasty. We conducted a single-centre UK cohort study of patients undergoing primary (n = 80) or revision (n = 43) hip arthroplasty. WOMAC pain and function scores and 20-metres walking time were collected pre-operatively, at 3 and 12-months post-operatively. Multilevel regression models were used to chart and compare the trajectories of post-operative change (0–3 months and 3–12 months) between the types of surgery. Patients undergoing primary arthroplasty had a total hip replacement (n=74) or hip resurfacing (n=6). Osteoarthritis was the indication for surgery in 92% of primary cases. Patients undergoing revision arthroplasty had revision of a total hip arthroplasty (n=37), hemiarthroplasty (n=2) or hip resurfacing (n=4). The most common indication for revision arthroplasty was aseptic loosening (n=29); the remaining indications were pain (n=4), aseptic lymphocyte-dominated vasculitis-associated lesion (n=4) or other reasons (n=6). Primary (87%) and revision arthroplasties (98%) were mostly commonly performed via a posterior surgical approach. The improvements in pain and function following revision arthroplasty occurred within the first 3-months following operation (WOMAC-pain, p<0.0001; WOMAC-function, p<0.0001; timed 20-metres walk, p<0.0001) with no evidence of further change beyond this initial period (p>0.05). While the pattern of recovery after revision arthroplasty was similar to that observed after primary arthroplasty, improvements in the first 3-months were smaller after revision compared to primary arthroplasty (p<0.0001). Patients listed for revision surgery reported lower pre-operative pain levels (p=0.03) but similar post-operative levels (p=0.268) compared to those undergoing primary surgery. At 12-months post-operation patients who underwent a revision arthroplasty had not reached the same level of function achieved by those who underwent primary arthroplasty (WOMAC-function p=0.015; Time walk p=0.004). Patients undergoing revision hip arthroplasty should be informed that the majority of their improvement will occur in the first 3-months following surgery and that the expected improvement will be less marked than that experienced following primary surgery. More research is now required to 1.) identify whether specific in-patient and post-discharge rehabilitation tailored towards patients undergoing revision arthroplasty would improve or achieve equivalent outcomes to primary surgery and 2.) whether patients who are achieving limited improvements at 3-months post-operative would benefit from more intensive rehabilitation. This will become all the more important with the increasing volume of revision surgery and the high expectations of patients who aspire to a disease-free and active life

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

Purpose. Even though various factors have been associated with neck pain, skeletal muscle mechanical properties have been cited among the leading causes of neck pain. Changes in skeletal muscle stiffness may be related to chronic neck pain and these changes may be associated with the severity of pain and disability in patients with chronic neck pain. The purpose of the present study was to investigate differences in neck muscle stiffness between patients with chronic neck pain and asymptomatic control group. Another purpose of the study was to investigate the relationship of muscle stiffness with the severity of physical disability and pain in patients with chronic neck pain. Methods. A cross-sectional case-control study with 86 participants (43 patients with chronic neck pain and 43 age-matched asymptomatic controls) was designed. The present study included patients with a pain intensity level of 20 or more based on the Numerical Rating Scale (NRS) and a total disability level of 10 or more based on the Neck Disability Index (NDI). Ultrasonic evaluation of upper trapezius, splenius capitis, and sternocleidomastoid muscle performed with the ACUSON S3000 Ultrasonography Device using Siemens 9L4 (4–9 MHz) linear-array ultrasound probe. Shear Wave Velocity (SWV) of selected muscles was obtained using customized software, Virtual Touch Imaging and Quantification® (Siemens Medical Solution, Mountain View, CA, USA). Results. SWV of splenius capitis was similar in both groups (p=0.979); however, SWV of upper trapezius (p<0.001) and sternocleidomastoid (p=0.003) of the patients with chronic neck pain were higher compared to the asymptomatic controls groups. NRS score did not correlate with SWV of upper trapezius (r=−0.27, p=0.085), sternocleidomastoid (r=−0.02, p=0.879) and splenius capitis (r=0.01, p= 0.990). Similarly, NDI score did not correlate with SWV of upper trapezius (r=−0,09 p=0.567), sternocleidomastoid (r=0.15, p=0.345) and splenius capitis (r=0.18, p= 0.274). Conclusions. SWV of splenius capitis muscle stiffness was found similar in both groups, but SWV of upper trapezius and sternocleidomastoid muscle were found increased in patients with neck pain compared to asymptomatic controls groups. In addition, severity of pain and disability did not relate to stiffness of these muscles in patient with chronic neck pain

We undertook a retrospective cohort study to determine if body mass index (BMI) is an independent factor in determining patient outcome following total hip replacement (THR). Outcomes were determined using the Oxford Hip Score, a questionnaire designed to evaluate self-reported function and pain levels in people with hip pain. We looked at all THRs carried out on patients with a BMI of ≥30 over a 38 month period (220 operations) and compared these with 220 randomly selected THRs carried out on patients with a BMI of <30 within the same 38 month period. For each case we recorded patient BMI, P score and Oxford scores. We calculated the difference between pre-operative and one-year post-operative Oxford hip scores. We used Kendall's rank correlation to assess any potential correlation between BMI and functional change, and the Mann-Whitney U test to establish if functional change between the groups was statistically significant. Our study indicates that BMI is not an independent factor in determining relative subjective functional change following THR. Although it showed that patients with a BMI of ≥30 have worse function both before and after THR, there was no statistically significant difference between the two groups in terms of functional change. We therefore suggest that patients with a higher BMI be considered candidates for THR as they can expect the same degree of functional improvement. Given the trend for increasing numbers of obese patients in the population these findings could have a significant impact on the future of THR operations

Summary Statement. This study assesses the service provision of viscosupplementation within an NHS (British National Health System) hospital. The results of this study show long term efficacy of the treatment, when provided by a dedicated, orthopaedic unit. Introduction. The service provision of viscosupplementation for osteoarthritis within the National Health System (NHS) remains controversial. The treatment was recommended in the 2007 NICE guidelines but support was withdrawn the following year. Furthermore, whether it should be provided by orthopaedic surgeons or in primary care is also a matter of debate. St Helens and Knowsley Trust, runs an orthopaedic outpatient clinic dedicated to the administration of viscosupplementation to patients with symptomatic knee osteoarthritis. This study aims to assess the efficacy of viscosupplementation for knee osteoarthritis when that is provided by a highly specialised, orthopaedic, dedicated service. Patients and Methods. Between January 2011 and June 2011, 103 patients underwent Ostenil® intra articular knee injections in our clinic. The viscosupplement used is Ostenil®, a 20mg/2ml sodium hyaluronate as an isotonic solution contained in a single syringe. Patients are given a regimen of 3 × 20mg/2ml Ostenil® injections. The time interval between injections is two weeks. They were all given a “pain diary” and were asked to document their pain score on a Visual Analogue Scale (from 0 to 10), prior to the treatment, the day of procedure and up to 3 months after the procedure. 72 patients (M:F 34:38, Mean age: 60.3 years) participated in the study (Right knee 31, Left 22 and Bilateral 19). Mean pre treatment and post treatment score amongst all patients were calculated up to three months post treatment. Results. Results show a continuous decreasing trend in pain scores up to three months after the procedure. Indicatively, mean pre treatment pain score was 6.88, mean pain score on day 3 (2 days post first injection) is 4.89, mean pain score on Day 31 (2 days after 3rd injection) is 4.37. Pain levels are maintained low at Week 6 after treatment (4.43) and Month 3 (4.37). A small peak in pain score was identified up to 48hrs after the injections but that has been already identified in current literature as a result of short term inflammation due to the injection process. Conclusion. Viscosupplementation for knee osteoarthritis is an efficient treatment when provided by an orthopaedic, dedicated service. The duration of the reduction in pain with a three injection course is at least 3 months. This study also demonstrates that an overall 3 injection course with a time interval of 2 weeks between injections is sufficient to produce long lasting results

Background. Chronic pain after joint replacement is common, affecting approximately 10% of patients after total hip replacement (THR) and 20% of patients after total knee replacement (TKR). Heightened generalised sensitivity to nociceptive input could be a risk factor for the development of this pain. The primary aim of this study was to investigate whether preoperative widespread pain sensitivity was associated with chronic pain after joint replacement. Methods. Data were analysed from 254 patients receiving THR and 239 patients receiving. TKR. Pain was assessed preoperatively and at 12 months after surgery using the Western Ontario and McMaster Universities Osteoarthritis Pain Scale. Preoperative widespread pain sensitivity was assessed through measurement of pressure pain thresholds (PPTs) at the forearm using an algometer. Statistical analysis was conducted using linear regression and linear mixed models, and adjustments were made for confounding variables. Results. In both the THR and TKR cohort, lower PPTs (heightened widespread pain. sensitivity) were significantly associated with higher preoperative pain severity. Lower PPTs were also significantly associated with higher pain severity at 12 months after surgery in the THR cohort. However, PPTs were not associated with the change in pain severity from preoperative to 12 months postoperative in either the TKR or THR cohort. Conclusions. These findings suggest that although preoperative widespread pressure pain sensitivity is associated with pain severity before and after joint replacement, it is not a predictor of the amount of pain relief that patients gain from joint replacement surgery, independent of preoperative pain severity. Level of Evidence. 2. Approvals. The APEX trials were registered as an International Standardised Randomised Controlled Trial (96095682), approved by Southampton and South West Hampshire Research Ethics Committee(09/H0504/94) and all participants provided informed written consent

Aim. To determine differences in knee valgus angles produced during a single leg squat and hip muscle strength between healthy subjects and patients with patellofemoral pain (PFP). To determine correlations between variables of hip muscle strength, knee valgus angle and pain. Study design: Observational study of 20 (8 male 12 female) healthy (H) subjects, matched for age height and weight with 20 (8 male 12 female) PFP patients (mean symptom duration 46.75 weeks). All subjects fulfilled specific inclusion and exclusion criteria. Appropriate Ethical approval was obtained. Measures for both groups were Knee valgus angle during a single leg squat using 2D motion capture and SiliconCoach software for measurement of knee valgus angles, hip abduction, internal and external rotation muscle strength using hand held dynamometry, visual analogue scale for pain. Strength was reported as a percentage of body weight. All measures were taken on the affected leg for PFP subjects and matched for the equivalent leg in healthy group. SiliconCoach was determined to be reliable for intra-rater reliability of knee valgus angle (ICC.996). Results. There were no significant differences in age, height and weight (p=.59,.51,.26 respectively). Significant differences existed in hip abduction strength p=.001(PFP 19.93(9.2), H 32.22(8.26)), Hip internal rotation p=0.001 (PFP 12.94(4.35), H 19.53(6.36)), Hip external rotation p=0.001(PFP 10.00(3.07), H 16.26 (4.62)), Knee Valgus Angles p=0.001(PFP 5.31(2.59), H 2.29 (2.35)). No correlations existed between any of the variables including pain. This preliminary study shows that patients with PFP have larger knee valgus angles when doing a single leg squat and significantly weaker hip muscle strength when compared to healthy subjects. The reason for larger knee angles during single leg squat could be hypothesised as being due to weak hip abductor muscles not sufficiently controlling the alignment of the femur. However no correlations were found for these measures, nor were they found for any of the other variables including pain level. In summary the results indicate that hip musculature strengthening of the rotators and abductors and measures to reduce knee valgus angle should be included in the rehabilitation programme of patients with PFP. Further research with larger numbers of subjects should be developed to investigate this subject

Post-operative check radiographs following Total Hip Replacements (THR) are routine practice in most orthopaedic units. In our unit an Anteroposterior and Turned Lateral View (TLV) radiograph was used routinely in this assessment, but the TLV method has anecdotally been reported as painful by patients. We undertook a study to evaluate patients' experiences of pain using this technique and to consider if a change to a Horizontal Beam Lateral View (HBLV) radiograph method would result in a reduction in pain. The study was conducted in two phases. Patients who underwent a primary THR and subsequent post-operative TLV over 3months (n=46) were contacted by telephone and asked to grade their experience using a numerical and descriptive pain scale. After a change in practice to HBLV, the study was repeated (n=53) to identify any difference in pain. Ten radiographs were randomly selected from each group and assessed for radiation exposure and quality by two independent assessors. 87.0% of patients who underwent the TLV radiograph described the post-operative radiograph as painful, with a mean pain score of 7.44+1.5. After a change in practice to the HBLV radiograph, only 28.4% of patients experienced any pain, with a significantly lower mean pain score of 1.00+1.89 (p< 0.001). There was a significant increase in radiation dose in the HBLV vs. TLV method (62.4mAs vs. 25.8mAs, p< 0.001). HBLV X-ray quality was only slightly inferior to TLV when evaluating stem alignment and cement mantle quality. There was a dramatic reduction in both number of patients experiencing pain and level of pain experienced when switching from TLV to HBLV radiographs; this is most likely due to reduced direct pressure on the wound post-operatively. X-ray quality was not compromised, and whilst there was increased radiation exposure, the benefits in patient experience were felt to outweigh this. We recommend the HBLV radiograph method when performing a lateral post-operative check x-ray following THR

Objectives

This study reports on a secondary exploratory analysis of the early clinical outcomes of a randomised clinical trial comparing robotic arm-assisted unicompartmental knee arthroplasty (UKA) for medial compartment osteoarthritis of the knee with manual UKA performed using traditional surgical jigs. This follows reporting of the primary outcomes of implant accuracy and gait analysis that showed significant advantages in the robotic arm-assisted group.

Objectives

To explore the therapeutic potential of combining bone marrow-derived mesenchymal stem cells (BM-MSCs) and hydroxyapatite (HA) granules to treat nonunion of the long bone.