Background. Individual illness perceptions have been shown to be important influences on both clinical and work outcomes for those with back pain, yet the influence of ‘significant others’ (spouse/partner/close family member) illness perceptions is rarely explored, particularly in relation to work participation. Method. Semi-structured interviews based on the Illness Perceptions Questionnaire were conducted with two purposive samples of chronic back pain patients (working and work disabled), along with their significant others (n=28). Data were analysed using template analysis. Results. The significant others of patients who were work disabled tended to reinforce the patients' limitations and negative consequences of the back pain condition on every aspect of their lives. They believed that patients needed to be pain-free in order to resume work, and equated treatment success with complete removal of pain. Overall, they perceived patients to be blameless victims. In contrast, the significant others of patients who had managed to remain at work despite persistent back pain focused instead on what the patient could still do, were more accepting of treatment as providing pain management rather than a cure, and tended to describe patients as being stoical and heroic. Conclusions. This exploratory in-depth research reveals novel and interesting insights about the illness beliefs of significant others in relation to persistent back pain, and highlights the wider social circumstances that may act as barriers/facilitators to work participation. No conflicts of interest. Sources of funding: BackCare and the BUPA foundation. This abstract has not been previously published in whole or substantial part nor has been presented previously at a national meeting

Introduction and Objective. Nonunion is incomplete healing of fracture and fracture that lacks potential to heal without further intervention. Nonunion commonly presents with persistent pain, swelling, or instability. Those symptoms affect patient quality of life. It is known that using low intensity pulsed ultrasound (LIPUS) for fresh fractures promotes healing. However, effectiveness of LIPUS for nonunion is still controversial. If LIPUS is prove to be effective for healing nonunion, it can potentially provide an alternative to surgery. In addition, we can reduce costs by treating nonunion with LIPUS than performing revision surgery. Materials and Methods. The two authors carried out a systematic search of PubMed, Ovid MEDLINE, and the Cochrane Library. Meta-analysis of healing rate in nonunion and delayed union patients who underwent LIPUS was conducted based on the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) instruction method using a random effects model. Results. The initial search identified 652 articles. Of these, 541 were excluded on the basis of the title because they were either a review paper or covered an unrelated topic. The abstracts of the remaining 111 articles were examined further. That review resulted in a sample of 12 articles. We performed a meta-analysis with a random effects model using Open Meta Analyst software. The result of pooled effect size of healing rate was 73.4% (95%CI: 65.3–81.6%). Due to the fact that nonunion lacks potential to heal without further intervention, we suggest that the therapeutic effect of 73.4% from LIPUS is sufficiently effective. As far as we know, there are no trials comparing the therapeutic effectiveness of surgery and LIPUS, so it cannot be said which is more advantageous. However, the healing rate of revision surgery was reported between 68–96%; therefore, our result is within that range. Thus, if surgery is difficult due to complications, we can recommend LIPUS. Conclusions. Meta-analysis of healing rate of nonunion treated by low-intensity pulsed ultrasound is 73.4%, which suggests sufficient therapeutic effectiveness. Furthermore, we can say that LIPUS may provide an alternative treatment for nonunion patients who cannot tolerate revision surgery due to complications

Introduction and Objective. Posterior and transforaminal lumbar interbody fusion (PLIF, TLIF) represent the most popular techniques in performing an interbody fusion amongst spine surgeons. Pseudarthrosis, cage migration, subsidence or infection can occur, with subsequent failed surgery, persistent pain and patient’ bad quality of life. The goal of revision fusion surgery is to correct any previous technical errors avoiding surgical complications. The most safe and effective way is to choose a naive approach to the disc. Therefore, the anterior approach represents a suitable technique as a salvage operation. The aim of this study is to underline the technical advantages of the anterior retroperitoneal approach as a salvage procedure in failed PLIF/TLIF analyzing a series of 32 consecutive patients. Materials and Methods. We performed a retrospective analysis of patients’ data in patients who underwent ALIF as a salvage procedure after failed PLIF/TLIF between April 2014 to December 2019. We recorded all peri-operative data. In all patients the index level was exposed with a minimally invasive anterior retroperitoneal approach. Results. Thirty-two patients (average age: 46.4 years, median age 46.5, ranging from 21 to 74 years hold- 16 male and 16 female) underwent salvage ALIF procedure after failed PLIF/TLIF were included in the study. A minimally invasive anterior retroperitoneal approach to the lumbar spine was performed in all patients. In 6 cases (18.7%) (2 infection and 4 pseudarthrosis after stand-alone IF) only anterior revision surgery was performed. A posterior approach was necessary in 26 cases (81.3%). In most of cases (26/32, 81%) the posterior instrumentation was overpowered by the anterior cage without a previous revision. Three (9%) intraoperative minor complications after anterior approach were recorded: 1 dural tear, 1 ALIF cage subsidence and 1 small peritoneal tear. None vascular injuries occurred. Most of patients (90.6%) experienced an improvement of their clinical condition and at the last follow-up no mechanical complication occurred. Conclusions. According to our results, we can suggest that a favourable clinical outcome can firstly depend from technical reasons an then from radiological results. The removal of the mobilized cage, the accurate endplate and disc space preparation and the cage implant eliminate the primary source of pain reducing significantly the axial pain, helping to realise an optimal bony surface for fusion and enhancing primary stability. The powerful disc distraction given by the anterior approach allows inserting large and lordotic cages improving the optimal segmental lordosis restoration

Introduction. Long-term use of bisphosphonates has been known to induce femoral insufficiency fracture in osteoporotic patients. We followed patients who had femoral insufficiency fractures after a long-term use of bisphosphonates. Methods. Eleven patients (14 hips) were diagnosed as having an insufficiency fracture of the femur after long-term (> 4 years) use of bisphosphonate to treat osteoporosis between January 2002 and December 2008. All patients were women who had a mean age of 68 years (range, 57 to 82 years). The fracture site was located in the subtrochanteric area in 6 hips and the femoral shaft in 8 hips. Three patients had bilateral involvement. These patients were followed-up for a mean of 27 months (range, 12 to 60 months). Results. Five hips in five patients displaced during the follow-up period. The mean period from the diagnosis of insufficiency fracture to the displacement was 10 months (range, 1 to 19 months). Five hips (five patients) underwent internal fixation due to persistent pain. Thus, during the follow-up of 27 months, operation was necessary in 71% (10 hips) of 14 insufficiency fractures. Four hips (four patients) that did not undergo any operation had persistent pain at the latest follow-up. Conclusion. The insufficiency fractures after prolonged bisphosphonate therapy seldom healed spontaneously and most of them required operation due to fracture displacement or persistent pain. We recommend preventive surgery to prevent further fracture displacement and persistent pain

Acute lateral ankle sprain accounts for 85% of sprains. The lateral sprain is associated with other ligament injuries e.g. medial and syndesmosis sprain. Long-term, approximately 20% of acute lateral sprains develop into chronic lateral ankle instability (CLAI) which includes persistent pain, and recurring ankle sprains. This study evaluated the grade of an ankle ligament injury by ultrasonography (US) and compared the findings to the outcome of patient-reported questionnaires. 48 subjects (18–40 years) diagnosed with an ankle sprain attended a clinical and US examination of ankle ligaments within two weeks after the sprain. Evaluation was done by US of acute lateral ligament injuries (ATFL, CFL), syndesmosis injury (AiTFL), and medial injury (dPT, TCt) only in participants with the positive clinical signs of medial injury. Participants were then mailed a questionnaire (PROMQ) every third month for a year. 29 women and 19 men participated with a mean age at 26.50 years. One-year follow-ups need to be analyzed further for final results. Temporary results include data based on the initial 26 patients: Two clinical signs statistically correlated. Multiple logistic regression analysis confirmed the results. Positive palpated tenderness AiTFL predicted with partial ruptured ATFL and reported pain during active plantar flexion of ankle predicted with normal CFL confirmed by the US. Patients with partial rupture of ATFL presented with tenderness at AiTFL point. Patients presenting with intact CFL reported pain during active plantar flexion. Compared to the US findings, the overall examinations were inconclusive in predicting ATFL, CFL, AiTFL, and medial ligament injuries

Introduction. The management of adolescent hallux valgus (AHV) remains controversial, with reservations about both conservative and surgical treatments. Non-operative management has a limited role in preventing progression. Surgical correction of AHV has, amongst other concerns, been associated with a high prevalence of recurrence of deformity after surgery. We conducted a systematic review to assess clinical and radiological outcomes following surgery for AHV. Methods & Materials. A comprehensive literature search was performed in the Cochrane Library, CINAHL, EMBASE, Google Scholar, and Pubmed. The study was performed in accordance with the recommendations of the PRISMA guidelines. Demographic data, radiographic parameters, and results of validated clinical scoring system were analysed. Results. Nine contemporary studies reporting on 201 osteotomies in 140 patients were included. The female to male ratio was 10:1. Mean age at operation was 14.5 years (10.5–22). Mean follow-up was 41.6 months (12–134). The mean post-operative AOFAS score was 85.8 (sd ±7.38). The mean AOFAS patient satisfaction showed that 86% (sd ± 11.27) of patients satisfied or very satisfied with their outcome. On the DuPont BRS, 90% rated their outcome as good or excellent. There was a statistically significant improvement in the IMA (p=0.0003), HVA (p<0.0001), and DMAA (p=0.019). The main complication was persistent pain (12%); others included infection (2%), scar hypersensitivity (4.5%), and non-union, metatarsalgia, and CRPS (each at 0.5%), and no reports of metatarsal head AVN. Conclusion. Based on the most current published evidence, surgery for AHV shows excellent clinical and radiological outcomes, with high patient satisfaction. The rates of recurrence and other complications are lower than the historically reported figures. There is, however, a need for high level, multi-centre collaborative studies with prospective data to establish the long-term outcomes and optimal surgical procedure(s)

The Purpose and background to Study. The purpose of the study is to develop a new and more effective approach to the management of the return to work process in employees troubled by musculoskeletal symptoms. For the last decade, secondary prevention of persistent pain and unnecessary disability has been identified as a major challenge. The importance in particular of psychosocial obstacles to recovery been recognised (Hopkinkon Conferemce, 2005) and stimulated the Decade of the Flags Think-Tank and Conference at Keele University in 2007, where clinical, occupational and wider contextual factors were explored leading to a number of publications on clinical Yellow Flags (Nicholas et al, 2011) and occupational Blue flags (primarily perceptions of work (Shaw et al.,2009) and organisational factors (Main et al, 2013), the conclusions and recommendations from which are the subject of this abstract. Methods and results. There are insufficient workplace-focused RCTs, systematic reviews or meta-analyses from which to develop an evidence-based intervention strategy and narrative review of the clinical and organisation literature into the management of work disability and return-to-work was undertaken of research. The review considers evidence of the efficacy of interventions for addressing absenteeism and presenteeism, distinguishing worker-centred and workplace-centred interventions, and continues with consideration of new ways in which these challenges might be addressed. Conclusion. It recommends a shift from sickness management to the enhancement of well-being, with an evaluation of new organisational research into the psychology of engagement Implications for re-integrating the injured worker into the working environment, are considered not only from a biopsychological but also from a social perspective. The presentation will conclude with consideration of issues of implementation with design of interventions using strategies such as intervention-mapping, a focus on the determinants of behaviour change and advocation of an integrated approach to the optimisation of successful and sustained return to work. No conflicts of interest. No funding obtained. I confirm that the abstract has not been previously published in whole or substantial part not has it been presented at a national meeting

Introduction. Osteonecrosis of the femoral head occurs in young patients. The preservation of the hip joint is vitally important, because hip arthroplasty does not guarantee satisfactory long-term results in young and active patients. Curved intertrochanteric varus osteotomy is one of several joint preserving procedures used for this disease. Methods. Between June 2004 and June 2007, 52 patients (55 hips) who had osteonecrosis of the femoral head were treated with curved intertrochanteric varus osteotomy. There were 29 men and 23 women who had a mean age at the time of osteotomy of 33 years (range, 18 to 52 years). The osteotomy was fixed with a 120 degree compression hip screw in the first 34 hips and with a 95 degree dynamic condylar screw in the remaining 21 hips. Clinical evaluation was performed using the scoring system of Merle d'Aubigne et al. Results. The mean duration of follow-up was 32 months (range, 24 to 60 months). Six patients (six hips) required a total hip arthroplasty, due to loss of fixation in two hips, shortening of the operated limb in two hips, and further collapse with persistent pain in two hips. In two patients (two hips), the plate fractured at 3 and 4 months after the operation, which was changed to a new plate. Thus, 49 of the 55 hips survived at a mean follow-up 32 months. In these hips, the mean Merle d'Aubigne hip score was 17.4 points at the latest evaluation. Conclusion. Curved intertrochanteric varus osteotomy is a satisfactory joint preserving method to treat osteonecrosis of the femoral head

Introduction. Unicompartmental Knee Replacement (UKR) is an appealing alternative to Total Knee Replacement (TKR) when the patient has isolated compartment osteoarthritis (OA). A common observation post-operatively is radiolucency between the tibial tray wall and the bone. In addition, some patients complain of persistent pain following implantation with a UKR; this may be related to elevated bone strains in the tibia. The aim of this study was to investigate the mechanical environment of the tibia bone adjacent to the tray wall, following UKR, to determine whether this region of bone resorbs, and how altering the mechanical environment affects tibia strains. Materials and methods. A finite element (FE) model of a cadaver tibia implanted with an Oxford UKR was used in this study, based on a validated model. A single static load, measured in-vivo during a step-up activity was used. There was a 1 mm layer of cement surrounding the keel in the cemented UKR, and the cement filled the cement pocket. In accordance with the operating procedure, no cement was used between the tray wall and bone. For the cementless UKR a layer of titanium filled the cement pocket. An intact tibia was used to compare to the cemented and cementless UKR implanted tibiae. The tibia was sectioned by the tray wall, defining the radiolucency zone (parallel to the vertical tray wall, 2 mm wide with a volume of 782.5 mm. 3. ), corresponding to the region on screened x-rays where radiolucencies are observed. Contact mechanics algorithms were used between all contacting surfaces; bonded contact was also introduced between the tray wall and adjacent bone, simulating a mechanical tie between them. Strain energy density (SED), was compared between the intact and implanted tibia for the radiolucency zone. Equivalent strains were compared on the proximal tibia between the intact and implanted tibia models. Forty patients (20 cemented, 20 cementless) who had undergone UKR were randomly selected from a database, and assessed for radiolucency. Results. The SED in the radiolucency zone was 80% lower in the cemented and cementless tibia, compared to the intact tibia, without a mechanical tie between the tibial tray wall and adjacent bone. When a mechanical tie was introduced the SED in the radiolucency zone was 35% higher in the cemented and cementless tibia, compared to the intact tibia. The strain on the proximal tibia was reduced by 20% when a mechanical tie was used between the tray wall and adjacent bone. Radiolucency at the tray wall was observed in all forty radiographs examined. Discussion. This work has presented a static snapshot of the load being carried through the proximal tibia following implantation with an Oxford UKR. It has been shown that by introducing a mechanical tie between the tibial tray wall and the adjacent bone, the SED in the region observed to have radiolucency is increased; this has the potential of reducing the likelihood of a radiolucency occurring in that region. Moreover, the strain observed in the proximal tibia was reduced when a mechanical tie was introduced, which may reduce the incidence of pain following implantation with a UKR. It is recommended that integration between the bone and the tray wall is important for UKR

Primary bony tumours of the elbow account for approximately 1% of all osseous tumours. The delayed diagnosis is commonly reported in the literature as a result of lack of clinician familiarity. We present the largest series of primary bone tumours of the elbow in the English literature. We sought to identify characteristics specific to primary elbow tumours and compare these to the current literature. We discuss cases of misdiagnosis and reasons for any delay in diagnosis. The authors also recommend a collaborative protocol for the diagnosis and management of these rare tumours. A prospectively collected national database of all bone tumours is maintained by an independent clerk. The registry and case notes were retrospectively reviewed from January 1954 until June 2013. Eighty cases of primary osseous elbow tumours were studied. Tumours were classified as benign or malignant and then graded according to the Enneking spectrum. There were no benign latent cases in this series. All cases in this series required surgical intervention. These cases presented with persistent rest pain, with or without swelling. The distal humerus was responsible for the majority and most aggressive of cases. The multidisciplinary approach at a specialist centre is integral to management. Misdiagnosis was evident in 12.5 % of all cases. Malignant tumours carried a 5-year mortality of 61%. Benign tumours exhibited a 19% recurrence rate and in particular, giant cell tumour was very aggressive. The evolution in treatment modalities has clearly benefited patients. Clinicians should be aware that elbow tumours can be initially misdiagnosed as soft tissue injuries or cysts. The suspicion of a tumour should be raised in the patient with unremitting, unexplained non-mechanical bony elbow pain. We suggest an investigatory and treatment protocol to avoid a delay to diagnosis. With high rates of local recurrence, we recommend regular postoperative reviews

Objectives

In this study, we compared the pain behaviour and osteoarthritis (OA) progression between anterior cruciate ligament transection (ACLT) and osteochondral injury in surgically-induced OA rat models.

Malrotation of the femoral component is a cause of patellofemoral maltracking after total knee arthroplasty. Its precise effect on the patellofemoral mechanics has not been well quantified. We have developed an in vitro method to measure the influence of patellar maltracking on contact. Maltracking was induced by progressively rotating the femoral component either internally or externally. The contact mechanics were analysed using Tekscan. The results showed that excessive malrotation of the femoral component, both internally and externally, had a significant influence on the mechanics of contact. The contact area decreased with progressive maltracking, with a concomitant increase in contact pressure. The amount of contact area that carries more than the yield stress of ultra-high molecular weight polyethylene significantly increases with progressive maltracking. It is likely that the elevated pressures noted in malrotation could cause accelerated and excessive wear of the patellar button.