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The Journal of Bone & Joint Surgery British Volume
Vol. 81-B, Issue 5 | Pages 936 - 936
1 Sep 1999
Walsh HPJ


The Journal of Bone & Joint Surgery British Volume
Vol. 54-B, Issue 1 | Pages 208 - 208
1 Feb 1972
Barnes R


The Journal of Bone & Joint Surgery British Volume
Vol. 84-B, Issue 7 | Pages 1088 - 1088
1 Sep 2002
Gibson T


The Journal of Bone & Joint Surgery British Volume
Vol. 53-B, Issue 2 | Pages 362 - 362
1 May 1971
Ellis J


Bone & Joint 360
Vol. 12, Issue 1 | Pages 48 - 48
1 Feb 2023


Bone & Joint 360
Vol. 11, Issue 3 | Pages 48 - 48
1 Jun 2022


The Journal of Bone & Joint Surgery British Volume
Vol. 89-B, Issue 2 | Pages 284 - 284
1 Feb 2007
Laurence M


Bone & Joint 360
Vol. 11, Issue 2 | Pages 56 - 56
1 Apr 2022



Bone & Joint Research
Vol. 9, Issue 5 | Pages 236 - 241
1 May 2020
Li R Wang C Ji X Zheng Q Li X Ni M Zhang G Chen J

Aims. The purpose of this study was to validate our hypothesis that centrifugation may eliminate false-positive leucocyte esterase (LE) strip test results caused by autoimmune diseases in the diagnosis of knee infection. Methods. Between January 2016 and May 2019, 83 cases, including 33 cases of septic arthritis and 50 cases of aseptic arthritis, were enrolled in this study. To further validate our hypothesis, another 34 cases of inflammatory arthritis from the Department of Rheumatology of our institution were also included. After aspiration, one drop of synovial fluid was applied to LE strips before and after centrifugation. The results were recorded after approximately three minutes according to the different colour grades on the colour chart. The differences of LE results between each cohort were analyzed. Results. Before centrifugation, 46% (23/50) of the LE strip tests in the aseptic arthritis group were false-positives. Most of the false-positive results were due to inflammatory arthritis; after centrifugation, 78.3% (18/23) of the tests yielded negative results. Similar results were observed in cases from the Department of Rheumatology. The sensitivity of the centrifuged LE strip test was 0.818 (0.639 to 0.924), which is still an acceptable level compared with the uncentrifuged results, which yielded a sensitivity of 0.909 (0.745 to 0.976). However, the specificity was increased from 0.540 (0.395 to 0.679) to 0.900 (0.774 to 0.963) after centrifugation. Conclusion. Although inflammatory arthritis can yield a false-positive LE strip test result in the diagnosis of knee infection, centrifugation may eliminate these false-positive results. Cite this article: Bone Joint Res. 2020;9(5):236–241


The Bone & Joint Journal
Vol. 103-B, Issue 1 | Pages 32 - 38
1 Jan 2021
Li R Li X Ni M Fu J Xu C Chai W Chen J

Aims. The aim of this study was to further evaluate the accuracy of ten promising synovial biomarkers (bactericidal/permeability-increasing protein (BPI), lactoferrin (LTF), neutrophil gelatinase-associated lipocalin (NGAL), neutrophil elastase 2 (ELA-2), α-defensin, cathelicidin LL-37 (LL-37), human β-defensin (HBD-2), human β-defensin 3 (HBD-3), D-dimer, and procalcitonin (PCT)) for the diagnosis of periprosthetic joint infection (PJI), and to investigate whether inflammatory joint disease (IJD) activity affects their concentration in synovial fluid. Methods. We included 50 synovial fluid samples from patients with (n = 25) and without (n = 25) confirmed PJI from an institutional tissue bank collected between May 2015 and December 2016. We also included 22 synovial fluid samples aspirated from patients with active IJD presenting to Department of Rheumatology, the first Medical Centre, Chinese PLA General Hospital. Concentrations of the ten candidate biomarkers were measured in the synovial fluid samples using standard enzyme-linked immunosorbent assays (ELISA). The diagnostic accuracy was evaluated by receiver operating characteristic (ROC) curves. Results. BPI, LTF, NGAL, ELA-2, and α-defensin were well-performing biomarkers for detecting PJI, with areas under the curve (AUCs) of 1.000 (95% confidence interval, 1.000 to 1.000), 1.000 (1.000 to 1.000), 1.000 (1.000 to 1.000), 1.000 (1.000 to 1.000), and 0.998 (0.994 to 1.000), respectively. The other markers (LL-37, HBD-2, D-dimer, PCT, and HBD-3) had limited diagnostic value. For the five well-performing biomarkers, elevated concentrations were observed in patients with active IJD. The original best thresholds determined by the Youden index, which discriminated PJI cases from non-PJI cases could not discriminate PJI cases from active IJD cases, while elevated thresholds resulted in good performance. Conclusion. BPI, LTF, NGAL, ELA-2, and α-defensin demonstrated excellent performance for diagnosing PJI. However, all five markers showed elevated concentrations in patients with IJD activity. For patients with IJD, elevated thresholds should be considered to accurately diagnose PJI. Cite this article: Bone Joint J 2021;103-B(1):32–38


Orthopaedic Proceedings
Vol. 105-B, Issue SUPP_7 | Pages 102 - 102
4 Apr 2023
Lu V Zhou A Hussain H Thahir A Krkovic M
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A hot swollen joint is a commonly encountered condition in clinical practice. With a broad range of differentials, septic arthritis (SA) is perhaps one of the most concerning. Treated by culture-specific antibiotics and arthroscopic lavage, some patients require multiple washouts. We aimed to determine:. (1) What are the risk factors for development of SA?. (2) What are the risk factors for repeat washout in SA patients?. (3) What are the important clinical differences between a periprosthetic joint infection (PJI) and SA cohort?. All patients presenting to the emergency department, orthopaedic, and rheumatology clinics between January 2020 to January 2021 with a hot, swollen joint were retrospectively evaluated. Patients with previous trauma on the ipsilateral joint, with data missing from their medical records in any of the variables required for analysis, <24 months follow-up were excluded. Variables of interest in the three-month period preceding the diagnosis of SA were compared between SA and non-SA patients. Factors with a p-value of p<0.100 in univariate analysis were included in a stepwise multivariate logistic regression model. Similar analyses were performed to compare SA patients with multiple washouts with those needing one washout. Demographical and clinical data for PJI patients were collected to delineate important differences with SA cohort. 211 patients were included (SA:28;PJI:24;pseudogout:32;gout:26;others:101). Multivariate analysis showed rheumatoid arthritis (RA), skin infection, and liver disease were risk factors for SA. Amongst patients with septic arthritis, multivariate analysis showed that WBC levels above normal limits (3.6-10.5×109 cells/L) and RA were risk factors for multiple washouts. Between the SA and PJI cohorts, BMI (p=0.002) was significantly lower in the former, whilst WBC level (p=0.023) and CRP (p<0.0001) was significantly higher in the former. Early diagnosis of septic arthritis requires understanding the risk factors, namely RA, skin infection, and liver disease. Considering PJI and septic arthritis as the same entity can lead to wrong clinical judgement, and clinicians should be aware of important differences. We believe that the models in this study are of prognostic value to clinicians who are presented with the common presenting compliant of a hot swollen joint


Orthopaedic Proceedings
Vol. 105-B, Issue SUPP_4 | Pages 7 - 7
3 Mar 2023
Hughes I May J Carpenter C
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Introduction. Chronic recurrent multifocal osteomyelitis (CRMO) is a rare condition characterised by bony pain and swelling which may be initially mistaken for bacterial osteomyelitis. The episodic course of the disease may confound the diagnosis and potentially be mistaken for a partial response to antimicrobial therapy. It is an orphan disease and consequently results in many unclear aspects of diagnosis, treatment and follow up for patients. The aim of this study is to evaluate a national tertiary centre's experience with the clinical condition and present one of the largest cohorts to date, emphasizing the vast array of clinical spectrum, course and response to treatment. Methods. We retrospectively evaluated all children identified with CRMO from the period 2000–2022 within Wales. Demographic data and clinical parameters were selectively identified through the utilisation of a national clinical platform (Welsh Clinical Portal). The diagnosis was based on clinical findings, radiological images, histopathological and microbiological studies. Results. A total of 21 patients were identified as suitable for inclusion. The mean age of diagnosis was 9.4 ±2 years. The age range of children being diagnosed was 6–14 years. Of the 21 patients, only 2 reported feeling unwell prior to their first presentation with generalized coryzal illness reported. The most common presenting site for CRMO was knee (33%) followed by back pain (28%). 19% of the included cases at initial presentation had localised warmth and had nocturnal pain. 4 of the patients went on to have dermatological conditions of which psoriasis was the most common (14%). Bilateral symptoms developed in 38% of the included patients. Biochemical investigations revealed only 19% of patients had a raised C-reactive protein level and erythrocyte sedimentation rate whilst 9/21 patients went on to have a bone biopsy to aid diagnosis. 100% of patients had MRI whilst whole body MRI was utilised in 8/21 patients. NSAID's were utilised for 81%, Pamidronate for 33% and methotrexate for 14%. Biologics were utilised for a further 24% of the total population in failed medical therapy. Surgical intervention was utilised for a single individual in this cohort of patients in the form of posterior spinal stabilisation. The most common referring speciality for these patients was Rheumatology (71%) followed by Orthopaedics (33%). Discussion. CRMO represents a challenging diagnosis to make with such varied clinical and biochemical presentations for this condition. The absence of diagnostic Radiological features on X-ray could argue over early MRI imaging. The utilisation of whole body-MRI can now identify multifocal disease burden which may facilitate a timely diagnosis and ensure that effective medical treatment is started promptly without delay. This study is the largest cohort of CRMO patients conducted in this country. Future work will serve to build upon a framework and national referral pathway so that these patients can be seen by the appropriate specialist in a timely manner


Orthopaedic Proceedings
Vol. 87-B, Issue SUPP_II | Pages 206 - 207
1 Apr 2005
Plant M Chadwick R Strachan R Murray MM Greenough CG Milligan K Carter E Puttick S
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Introduction: Referrals for Low Back Pain (LBP) are common and many patients appear to see more than one specialist. In one acute trust, a dedicated Spinal Assessment Clinic (SAC) run by nurse practitioners was developed. Objective: To determine patterns of referral for LBP from primary to secondary care. Method: All new referrals to the hospital for LBP in an index period June–November 1998 were included. Consultations for these patients in the preceding six months and the subsequent two years were studied. Results: A total of 801 patients were referred in the audit period. The patients were seen in the SAC 75%, orthopaedics 5.5%, rheumatology 4.5%, neurosurgery 12% and the pain clinic 4%. Onward referrals made after the initial appointment from the SAC 4.9%, from orthopaedics 26.7%, from rheumatology 8.6%, from neurosurgery 33.7% and from the pain clinic 10.3%. Subsequent repeat referrals made by the GP occurred in 3.7%of patients initially seen in the SAC, 11.1% from orthopaedics, 2.9% from Rheumatology, 3.2% from Neurosurgery and 17.2% from the pain clinic. The average wait in days for a first appointment was SAC 42, orthopaedics 103, Rheumatology 82, Neurosurgery 78 and pain clinic 77. Conclusion: The SAC offers a shorter wait for patients and an extremely low “churn” rate, implying high rates of satisfaction in patients and GP’s. The wait for other specialities is longer, and in orthopaedics and neurosurgery the re-referral rate is almost one third. Referral procedures to secondary care might need to be streamlined for more efficiency


The Journal of Bone & Joint Surgery British Volume
Vol. 92-B, Issue 1 | Pages 7 - 11
1 Jan 2010
Williams SC Gulihar A Dias JJ Harper WM

This study assessed whether undergraduate performance improved following the introduction in 2006 of a musculoskeletal teaching programme lasting for seven weeks. Different methods were used to deliver knowledge and skills in trauma and orthopaedic surgery, rheumatology and allied specialties. The programme combined four main elements: traditional firm-based teaching, weekly plenary sessions, a task-based workbook and additional specialist clinics. The block of 139 students who attended in its first year were assessed using a multiple choice question examination just before their final examinations in 2008. They showed a 6% improvement in performance over a control group of 130 students assessed in 2005 before the programme had commenced. There was no difference in performance between the students assessed in 2005 and a second group of 46 students from 2008 who did not attend the new teaching programme. Performance was improved by providing more focused musculoskeletal training using available resources, as well as increasing the length of the programme


Orthopaedic Proceedings
Vol. 101-B, Issue SUPP_10 | Pages 20 - 20
1 Oct 2019
McCrum C Kenyon K Cleaton J Dudley T
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Background and purpose of the study. Axial Spondyloarthritis (axSpA) is commonly mistaken as chronic mechanical back pain. Delayed diagnosis averages 5- 8 years with impacts on effective and timely management, outcomes and quality of life. NICE Guidance (2017) highlights the importance of the recognition and referral of suspected axial spondyloarthritis. This study investigated the occurrence of physiotherapy care prior to diagnosis of axSpA within physiotherapy outpatient settings. Methods and results. A retrospective review was performed of all patients diagnosed with axSpA who had received physiotherapy care prior to their diagnosis from 1990–2016. Three or more episodes of care prior to diagnosis was taken as unrecognised axSpA. Information was obtained on diagnostic codes, number of episodes of care and contacts per episode from nine outpatient physiotherapy services. Analysis showed that 263 people (17–69 years) diagnosed with axSpAs had received physiotherapy care prior to diagnosis. Within this population, 103 (44%) had received ≥3 episodes of care. Number of contacts within each episode ranged from 3 (47 people) to 58 (1 person) [median=11 contacts-10 people]. Average time from initial physiotherapy episode to date of diagnosis was 6.4 years (range=0.3–12.8 years, median=8.8 years). The most common assigned diagnostic code was back pain (49.6%), followed by shoulder (11.1%), knee (8.5%), neck (7.7%), ankle/foot (4.3%), tendonitis (4.2%), joint pain (3.4%), osteoarthritis (3.4%) and sacroiliac joint (2%). Conclusion. Findings illustrate the extent of unrecognised axial spondyloarthritis referred to and missed in musculoskeletal physiotherapy practice. It is essential to improve screening and recognition of inflammatory back pain and possible axSpA in musculoskeletal assessments, supported by rheumatology referral guidance. No conflicts of interest. No funding obtained


Orthopaedic Proceedings
Vol. 85-B, Issue SUPP_I | Pages 35 - 36
1 Jan 2003
Williams J
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At least 10% of consultations in General Practice are for musculoskeletal problems. It would seem appropriate that the diagnosis and management of common musculoskeletal problems should form an important part of the “core” curriculum of any undergraduate medical training. Time is always short in an undergraduate teaching program and the pressures not to overload the curriculum are constant. The planned increased in student numbers is likely to stretch the ability of most teaching departments to provide a high level of undergraduate training in musculoskeletal disease. A postal survey of the provision of undergraduate teaching in T& O was performed in the UK. All 23 medical schools in England, Scotland, Wales and Northern Ireland were. To gain further insight into non-specialist general training in T& O after qualification a survey of the Vocational Training Schemes (VTS) for General practitioners in the Northern Deanery was performed. Ninety-one percent of Medical Schools replied. The average length of the orthopaedic attachments (all years combined) was five weeks. However, all but two programs were combined with other clinical subjects. The dilutional effect of these other subjects resulted in the average duration of the T& O attachment being reduced to 2.7 weeks (range 1.5 – 6). All the modules in orthopaedic surgery except one included trauma within the curriculum. There are four VTSs in the Northern Deanery. All of these had schemes that included A& E but not for every trainee. No scheme had either a rheumatology or orthopaedic surgery placement, although some exposure to rheumatology occurred during attachments in general medicine. This study shows that there is a significant discrepancy between the amount of time, within the curriculum (4%), devoted to musculoskeletal/orthopaedic teaching and the number of consultations in General Practice (10%); this discrepancy is not made up during VTS placements. In addition, such short exposure to a large subject may encourage superficial learning which medical education is specifically trying to avoid


Orthopaedic Proceedings
Vol. 85-B, Issue SUPP_III | Pages 225 - 225
1 Mar 2003
Foufoulas E Giannakis I Tzegas S Artopoulos I
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The purpose of our presentation is to propose a asimple and reliable method which does not expose the doctor and the patient to radiation for hip arthrocentesis and to be used by inexperienced doctors as well as for studies. Hip Arthrocentesis (HA) on every day practice is performed by the anatomic knowledge and experience. But as a study has shown there is a high failure rate as it concerns the correct position of the needle in the joint, even in joints as the knee and shoulder where the intraarticular injections as usual. According to the American College of Rheumatology hip arthrocentesis should be performed by experienced Rheumatologists, Orthopaedic Surgeons and Radiologists, and always under radiological control. HA at first has been performed for diagnostic purposes, mainly infections, for fluid aspiration. Later for therapeutic reasons (corticosteroids), and for the differential diagnosis between abdominal and osteoarthritic pain of the hip with the intraarticular injection of local anaesthetic. HA under ultrasound control was initially performed in 1989 for diagnostic reasons and later in 2001 has been used for intraarticular injections of Hyalouronic Acid for the treatment of hip osteoarthritis. In the international literature publications about the help that Ultrasonography provides at hip arthrocentesis are sporadic (sparse). Since 2000 we performed 50 intraarticular injections at the hip joint in our out -patient department under ultrasonographic control for the confirmation of the correct position of the needle in the articulation. All patients suffered from hip osteoarthritis according to the criteria of the American College of Rheumatology, and all were female, 50 – 75 years old. 30 injections were performed with simple head (Convex) of 6 MHz and 20 with linear head of 9 MHz. There was no difference concerning the accuracy of needle placement, but a more clear picture had the linear head. There was no complication. In the Hellenic area, to our knowledge, this method is applied and announced for the first time. In conclusion we believe that it is an accurate and safe method which does not expose neither the patient nor the doctor to radiation and is much less time – consuming than CT. it can be recommended for inexperienced collegues, for studies that need confirmation, as well as for control of the correct placement of the needle intraarticular for therapeutic purposes. In general it can be used for every hip arthrocentesis


Orthopaedic Proceedings
Vol. 100-B, Issue SUPP_13 | Pages 34 - 34
1 Oct 2018
Sculco TP Goodman SB Nocon AA Sculco PK
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Introduction. Patients with rheumatoid arthritis (RA) have a higher risk of surgical site infection (PJI) than patients with osteoarthritis (OA). Disease modifying therapy is in widespread use in RA patients, and biologic medications may increase Staphylococcus aureus colonization rates. Because S. aureus colonization likely increases risk of surgical infection, perioperative assessments and therapies to decrease the risk of invasive S.aureus infections may be warranted. The objective of this study was to determine if there was a difference in S. aureus carriage among patients with RA, OA, and RA on biologics (RA+B). Methods. An a priori power analysis determined 123 participants per group were needed to detect a relative difference of 20% among groups with 80% power. After IRB approval, patients were screened; included patients met American College of Rheumatology classification criteria. Patients were approached between April 2017 and May 2018 and asked to perform a nasal swab while on site using the Center for Disease Control's swabbing protocol; questionnaires pertaining to their current health status were collected. Swabs were inoculated onto ChromAgar/ChromID MRSA plates for detection of S. aureus. Mann-Whitney U and Chi-square tests were used to evaluate baseline differences between groups. Logistic regression evaluated the associations between groups and S. aureus carriage. All statistical analyses were performed using SAS Software version 9.3 (SAS Institute, Cary, NC); statistical significance was defined as p<0.05. Results. Overall the patient cohort evaluated had a mean age of 66 (+/-13.7), BMI of 29 (+/-28.2), and were predominantly female (78%) .28% of the cohort was on antibiotics within three months prior to the nasal swab, 18% were currently on steroids, and 24% had been hospitalized within the last year. We found differences in age (p<0.001), BMI (p<0.001), sex (p<0.001), diabetes (p=0.04), steroid use (p=0.02), antibiotic use (p<0.001), and hospitalizations within the last year (p<0.001). S. aureus carriage was most prevalent in RA+B37%, followed by RA (24%), and OA (20%). After multivariate adjustment, RA+B was found to have increased odds of S. aureus (OR=1.80, 95% CI 1.00–3.22); p=0.047) compared to RA group. Use of glucocorticoids, hospitalization, or diabetes did not increase the odds of S. aureus carriage. The OA group had decreased odds of S. aureus growth when compared to the RA group; however, this was not found to be statistically significant (p=0.987). Conclusion. RA patients treated with biologics have an increased prevalence of S. aureus colonization. Since nasal S. aureus carriage may play a role in the pathogenesis of surgical infections, S. aureus decolonization should be considered in RA patients on biologics prior to elective surgery


Orthopaedic Proceedings
Vol. 100-B, Issue SUPP_16 | Pages 103 - 103
1 Nov 2018
Jorgensen C
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Adipose derived mesenchymal stromal cells (ASC) are adult stem cells exhibiting functional properties that have open the way for cell-based clinical therapies. Primarily, their capacity of multilineage differentiation has been explored in a number of strategies for skeletal tissue regeneration. More recently, MSCs have been reported to exhibit immunosuppressive as well as healing capacities, to improve angiogenesis and prevent apoptosis or fibrosis through the secretion of paracrine mediators. Among the degenerative diseases associated with aging, osteoarthritis is the most common pathology and affects 16% of the female population over 65 years. Up to now, no therapeutic option exists to obtain a sustainable improvement of joint function beside knee arthroplasty. This prompted us to propose adipose derived stem cells as a possible cell therapy. We performed pre-clinical models of osteoarthritis and showed that a local injection of ASC showed a reduction of synovitis, reduction of osteophytes, joint stabilization, reducing the score of cartilage lesions. This work was completed by toxicology data showing the excellent tolerance of the local injection of ADSC and biodistribution showing the persistence of cells after 6 months in murine models. The aim of the ADIPOA trial is to demonstrate the efficacy of adipose derived stem cells therapy in knee osteoarthritis (OA) in a phase 2/3 controlled multicenter study controlled against standard of care. Safety and feasibility as well as dose response was previously assessed in the ADIPOA FP7 project. The bi-centric phase I clinical trial in Montpellier (France) and Würzburg (Germany) included 18 patients with moderate to severe knee OA, each patient received a single injection of autologous ADSC, in a open scale up dose trial, starting form 2 10 6 cells to 50 106 cells. The 107 dose appears to be well tolerated and showed preliminary response in terms of decreasing local inflammation. This first study confirmed the feasibility and safety of local injection of ADSC in knee OA and suggested the most effective dose (107 autologous ADSC). This work constituted a significant step forward treating this disease with ADSC to demonstrate safety of the procedure. we conduct a prospective multicenter randomized Phase 2/3 study with 86 patients with moderate to severe knee OA to demonstrate superiority of stem cell-based therapy compared to standard of care (SOC) in terms in reduction in clinical symptoms (WOMAC score) and structural benefit (assessed by T1rhoMRI that allow quantification of cartilage proteoglycan content). This project will offer EU a unique leadership in OA with strong positions in EU and US due to patents and quality of the methodology to demonstrate efficiency of ADSC. ADIPOA brings together a unique combination of expertises and leaders in clinical rheumatology, MRI specialists, Stem cell Institutes, national GMP grade adipose derived stem cell production platform (ECELLFRANCE) and SME specialized in cell therapy trials in the EU. The production of the cells will be granted to EFS through ECELLFRANCE national platform, which have the GMP facility and will work as a contracting manufacturing organization. The expertise, leadership and critical mass achieved by this Consortium should enable breakthroughs in ASC engineering directly amenable for clinical applications in OA