Knee joint distraction (KJD) has been associated with clinical and structural improvement and synovial fluid (SF) marker changes. However, structural changes have not yet been shown satisfactorily in regular care, since radiographic acquisition was not fully standardized. AI-based modules have shown great potential to reduce reading time, increase inter-reader agreement and therefore function as a tool for treatment outcome assessment. The objective was to analyse structural changes after KJD in patients using this AI-based measurement method, and relate these changes to clinical outcome and SF markers. 20 knee OA patients (<65 years old) were included in this study. KJD treatment was performed using an external fixation device, providing 5 mm distraction for 6 weeks. SF was aspirated before, during and immediately after treatment. Weight-bearing antero-posterior knee radiographs and WOMAC questionnaires were collected before and ~one year after treatment. Radiographs were analysed with the Knee Osteoarthritis Labelling Assistant (KOALA, IB Lab GmbH, Vienna, Austria), and 10 pre-defined biomarker levels in SF were measured by immunoassay. Radiographic one-year changes were analysed and linear regression was used to calculate associations between changes in standardized joint space width (JSW) and WOMAC, and changes in JSW and SF markers. After treatment, radiographs showed an improvement in Kellgren-Lawrence grade in 7 of 16 patients that could be evaluated; 3 showed a worsening. Joint space narrowing scores and continuous JSW measures improved especially medially. A greater improvement in JSW was significantly associated with a greater improvement in WOMAC pain (β=0.64;p=0.020). A greater increase in MCP1 (β=0.67;p=0.033) and lower increase in TGFβ1 (β=-0.787;p=0.007) were associated with JSW improvement. Despite the small number of patients, also in regular care KJD treatment shows joint repair as measured automatically on radiographs, significantly associated with certain SF marker change and even with clinical outcome

Introduction. Polyacrylamide hydrogel (iPAAG. 1. ), is CE marked for treating symptomatic knee osteoarthritis (OA), meeting the need for an effective, long-lasting, and safe non-surgical option. This study evaluates the efficacy and safety of a single 6 ml intra-articular injection of iPAAG in participants with moderate to severe knee OA over a 5-year post-treatment period, presenting data from the 4-year follow up. Method. This prospective multicentre study (3 sites in Denmark) involved 49 participants (31 females) with an average age of 70 (range 44 – 86 years). They received a single 6 mL iPAAG injection. All participants provided informed consent and re-consented to continue after 1 year. The study followed GCP principles and was approved by Danish health authorities and local Health Research Ethics committees. Twenty-seven participants completed the 4-year follow-up. The study evaluated WOMAC pain, stiffness, function, and Patient Global Assessment (PGA) of disease impact. Changes from baseline were analysed using a mixed model for repeated measurement (MMRM). Sensitivity analyses were applied on the extension data, where the MMRM analysis was repeated only including patients in the extension phase and an ANCOVA model was used, replacing missing values at 4-years with baseline values (BOCF). Results. The planned MMRM analysis (n=49) revealed a statistically significant decrease in WOMAC pain subscale scores (-22.0; 95%CI: -29.5; -14.4) from baseline to 4-years. Analysis of the extension phase (n=27) showed similar results (-21.8; 95%CI: -29.0; -14.6) compared to the initial analysis. Furthermore, BOCF analysis indicated a statistically significant reduction in WOMAC pain subscale scores from baseline (-13.0 units). Four new adverse events were reported between the 3-year and 4-year visits; none were related to treatment. Conclusions. This study shows that single injections of 6 ml intra-articular iPAAG were well tolerated and continued to provide clinically important effectiveness at 4-years after treatment. Acknowledgements. The study was sponsored by Contura International A/S

Introduction and Objective. An important subset of patients is dissatisfied after total joint arthroplasty (TJA) due to residual functional impairment. This study investigated the assessment of objectively measured step-up performance following TJA, to identify patients with poor functional improvement after surgery, and to predict residual functional impairment during early postoperative rehabilitation. Secondary, longitudinal changes of block step-up (BS) transfers were compared with functional changes of subjective patient reported outcome measures (PROMs) following TJA. Materials and Methods. Patients with end stage hip or knee osteoarthritis (n = 76, m/f = 44/32; mean age = 64.4 standard deviation 9.4 years) were measured preoperatively and 3 and 12 months postoperatively. PROMs were assessed using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) function subscore. BS transfers were assessed by wearable-derived measures of time. In our cohort, subgroups were formed based on either 1) WOMAC function score or 2) BS performance, isolating the worst performing quartile (impaired) of each measure from the better performing others (non-impaired). Subgroup comparisons were performed with the Man-Whitney-U test and Wilcoxon Signed rank test resp. Responsiveness was calculated by the effect size, correlations with Pearson's correlation coefficient. A regression analysis was conducted to investigate predictors of poor functional outcome. Results. WOMAC function scores were strongly correlated to WOMAC pain scores (Pearson's r=0.67–0.84) and moderately correlated to BS performance (Pearson's r = 0.31–0.54). Prior to surgery, no significant differences for WOMAC function scores and BS performance were found between the impaired and non-impaired subgroups. One year after TJA, our cohort performed significantly better at WOMAC and BS with largest effect size for the non-impaired subgroups (0.62 and 0.43 resp.) At 12 months postop, 56% of patients allocated to the impaired subgroup defined by WOMAC, represented the impaired subgroup defined by BS. Allocation to the impaired subgroup at 3 months postop, raised the odds for belonging to the impaired subgroup at 12 months for WOMAC with an odds ratio=19.14 (67%) and for BS with an odds ratio=4.41 (42%). Conclusions. Assessment of BS performance following TJA reveals residual functional impairment that is not captured by pain-dominated PROMs. Its additional use may help to early identify those patients at risk for a poor outcome

Knee osteoarthritis (KOA) diagnosis is based on symptoms, assessed through questionnaires such as the WOMAC. However, the inconsistency of pain recording and the discrepancy between joint phenotype and symptoms highlight the need for objective biomarkers in KOA diagnosis. To this end, we study relationships among clinical and molecular data in a cohort of women (n=51) with Kellgren-Lawrence grade 2–3 KOA through Support Vector Machine (SVM) and a regulation network model (RNM). Clinical descriptors (i.e., pain catastrophism (CA); depression (DE); functionality (FU); joint pain (JP); rigidity (RI); sensitization (SE); synovitis (SY)) are used to classify patients. A Youden's test is performed for each classifier to determine optimal binarization thresholds for the descriptors. Thresholds are tested against patient stratification according to baseline WOMAC data from the Osteoarthritis Initiative, and the mean accuracy is 0.97. For our cohort, the data used as SVM inputs are KOA descriptors, synovial fluid (SL) proteomic measurements (n=25), and transcription factors (TF) activation obtained from RNM [2] stimulated with the SL measurements. The relative weights after classification reflect input importance. The performance of each classifier is evaluated through AUC-ROC analysis. The best classifier with clinical data is CA (AUC = 0.9), highly influenced by FU and SE, suggesting that kinesophobia is involved in pain perception. With SL input, leptin strongly influences every classifier, suggesting the importance of low-grade inflammation. When TF are used, the mean AUC is limited to 0.608, which can be related to the pleomorphic behaviour of osteoarthritic chondrocytes. Nevertheless, FU has an AUC of 0.7 with strong importance of FOXO downregulation. Though larger and longitudinal cohorts are needed, this unique combination of SVM and RNM shall help to map objectively KOA descriptors. Acknowledgements: Catalan & Spanish governments 2020FI_b00680; STRATO-PID2021126469ob-C21-2, European Commission (MSCA-TN-ETN-2020-Disc4All-955735, ERC-2021-CoG-O-Health-101044828). ICREA Academia

Abstract. Osteoarthritis (OA) is a degenerative disorder associated with cartilage loss and is a leading cause of disability around the world. In old age, the capacity of cartilage to regenerate is diminished. With an aging population, the burden of OA is set to rise. Currently, there is no definitive treatment for OA. However, cell-based therapies derived from adipose tissue are promising. A PRISMA systematic review was conducted employing four databases (MEDLINE, EMBASE, Cochrane, Web of Science) to identify all clinical studies that utilized adipose tissue derived mesenchymal stem cells (AMSCs) or stromal vascular fraction (SVF) for the treatment of knee OA. Eighteen studies were included, which met the inclusion criteria. Meta-analyses were conducted on fourteen of these studies, which all documented WOMAC scores after the administration of AMSCs. Pooled analysis revealed that cell-based treatments definitively improve WOMAC scores, post treatment. These improvements increased with time. The studies in this meta-analysis have established the safety and efficacy of both AMSC therapy and SVF therapy for knee OA in old adults and show that they reduce pain and improve knee function in symptomatic knee OA suggesting that they may be effective therapies to improve mobility in an aging population

Introduction and Objective. Ceramic on Ceramic bearings in Total Hip Arthroplasty (THA) afford a low friction coefficient, low wear rates and extreme hardness. Significant complications include hip squeak, ceramic fracture and poor polyethylene performance in revision procedures due to imbedding of abrasive microscopic ceramic fragments. We report on the results of this bearing at a minimum of 10 years. Materials and Methods. A single-centre retrospective review of 449 THAs was performed. Primary outcome measures included aseptic revision and all-cause revision rates at a minimum of 10 years post operatively. Evaluation of functionality was performed with WOMAC and SF-36 scores which were performed pre-operatively and at intervals of 6 months, one year, 2 years, 5 years and 10 years post operatively. Results. There was a 6.2% (n=28) all-cause and 5.3% (n=24) aseptic revision rate for ceramic on ceramic total hip arthroplasty at minimum of 10 years with a mean time to revision 4.8 years (range 2 months − 11.6 years). Notably, there were 2 revisions for ceramic head fracture, one for ceramic liner fracture, 3 for aseptic loosening and 3 revisions for squeaking. Pain of unknown origin was the most common reason for revision. There was an improvement in postoperative WOMAC scores from a mean of 59.8 (range 15–95) pre-operatively to a mean of 15.6 (range 0–78) at 10 years. Conclusions. This study showed good functional outcomes but high revision rates for CoC THA at a minimum of 10 years. The role for CoC bearings in THA has been called into question in recent years and may continue to decline in popularity, even in younger patients. Further large scale studies are important to assess the long-term outcomes of this bearing surface

Abstract. Objectives. To compare the effectiveness of phonophoresis (PH) and conventional therapeutic ultrasound (US) on the functional and pain outcomes of patients with knee osteoarthritis. Methods. We conducted an electronic search through PubMed, Cochrane Central Register of Clinical Trials (CENTRAL), Web of Science (WOS), and Scopus databases. We screened the retrieved articles to include only English full-text randomized controlled trials that examined the effect of phonophoresis versus conventional therapeutic ultrasound on patients with knee osteoarthritis. Two reviewers screened, extracted the data, and independently assessed the quality of the included articles. Results. A total of five randomized controlled trials met our inclusion criteria out of 267 studies screened. Our results showed no statistically significant differences between the PH and US groups (1), (2), (3),(4), and (5). The PH group demonstrated more significant effects than the UT group in reducing VAS pain scores (P=0.009) and improving WOMAC scores, although this did not reach the level of significance (P=0.143) (5). In the long term, PH therapy was found to be superior to US in improving painless walking duration and distance VAS scores (p=0.034, 0.017) respectively, as well as walking and resting walking VAS scores (p=0.03, 0.007) respectively, which were found to be permanent (3). Conclusions. Both therapies improve pain and function. However, we suggest conducting more high-quality trials with larger sample sizes and do not recommend the use of these therapies in clinical practice due to limitations in gender selection and high risk of bias. Declaration of Interest. (b) declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported:I declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research project

Introduction. Recent studies suggested that the progression of osteoarthritis (OA), a chronic degenerative joint disease, may be affected by the autonomic nervous system (ANS). Under healthy conditions, the sympathetic (SNS) and parasympathetic (PNS) branches of the ANS are well coordinated to maintain homeostasis. However, pathological conditions are frequently associated with a disturbance of this fine-tuned balance. Therefore, we analyzed whether an autonomic dysfunction occurs in OA patients. Method. 225 participants with early- or late-stage knee OA as well as 40 healthy age-matched probands were included in this study. Autonomic activity was investigated by analyzing heart rate variability (HRV), which decreases under chronic sympathetic overactivity. Time- and frequency-domain HRV indices SDRR, RMSSD, pRR50 and LF were examined. Linear regression analysis was performed to adjust for clinical characteristics, such as age, sex, BMI, or medication. Moreover, perceived chronic stress (PSQ) and pain (WOMAC) were assessed via questionnaires. In addition, the serum stress hormones cortisol, DHEA-S and IL-6 were analyzed via ELISA. Result. SDRR, RMSSD, and pRR50 were slightly reduced in the early stage of OA and showed significant decrease in the later stage of the disease. Also LF decreased significantly with OA progression. HRV was significantly influenced by the grade of OA, but not other patient characteristics. Moreover, late-stage OA patients demonstrated significantly higher PSQ and WOMAC levels compared to healthy controls. In addition, cortisol/DHEA-S ratio and IL-6 serum concentrations were significantly higher in late-stage than in early-stage OA patients and healthy controls. Conclusion. Reduced HRV, increased cortisol/DHEA-S ratio and PSQ level as well as elevated systemic IL-6 concentration indicated an autonomic shift towards a more pronounced SNS activity due to PNS deficiency in OA patients, particularly in the late-stage of the disease. Therefore, modulation of the ANS, for example by vagus nerve stimulation, might be a potential treatment strategy for of knee OA patients

Precision health aims to develop personalised and proactive strategies for predicting, preventing, and treating complex diseases such as osteoarthritis (OA). Due to OA heterogeneity, which makes developing effective treatments challenging, identifying patients at risk for accelerated disease progression is essential for efficient clinical trial design and new treatment target discovery and development. To create a reliable and interpretable precision health tool that predicts rapid knee OA progression over a 2-year period from baseline patient characteristics using an advanced automated machine learning (autoML) framework, “Autoprognosis 2.0”. All available 2-year follow-up periods of 600 patients from the FNIH OA Biomarker Consortium were analysed using “Autoprognosis 2.0” in two separate approaches, with distinct definitions of clinical outcomes: multi-class predictions (categorising disease progression into pain and/or radiographic progression) and binary predictions. Models were developed using a training set of 1352 instances and all available variables (including clinical, X-ray, MRI, and biochemical features), and validated through both stratified 10-fold cross-validation and hold-out validation on a testing set of 339 instances. Model performance was assessed using multiple evaluation metrics. Interpretability analyses were carried out to identify important predictors of progression. Our final models yielded higher accuracy scores for multi-class predictions (AUC-ROC: 0.858, 95% CI: 0.856-0.860) compared to binary predictions (AUC-ROC: 0.717, 95% CI: 0.712-0.722). Important predictors of rapid disease progression included WOMAC scores and MRI features. Additionally, accurate ML models were developed for predicting OA progression in a subgroup of patients aged 65 or younger. This study presents a reliable and interpretable precision health tool for predicting rapid knee OA progression. Our models provide accurate predictions and, importantly, allow specific predictors of rapid disease progression to be identified. Furthermore, the transparency and explainability of our methods may facilitate their acceptance by clinicians and patients, enabling effective translation to clinical practice

Background. Assessment of functional outcome after total hip arthroplasty (THA) often involves subjective patient-reported outcome measures (PROMs) whereas analysis of gait allows more objective assessment. The aims of the study were to compare longitudinal changes of WOMAC function score and ambulatory gait analysis after THA, between patients with low and high self-reported levels of physical function. Methods. Patients undergoing primary THA (n=36; m/f=18/18; mean age=63.9; SD=9.8yrs; BMI=26.3 SD=3.5) were divided in a high and low function group, on their preoperative WOMAC function score. Patients were prospectively measured preoperatively and 3 and 12 months postoperatively. WOMAC function scores 0–100) were compared to inertial sensor based ambulatory gait analysis. Results. WOMAC function scores significantly improved in both low and high groups at 3 months postoperatively whereas gait parameters only improved in with a low pre-operative function. Between 3 and 12 months postoperatively, function scores had not significantly further improved whereas several gait parameters significantly improved in the low function group. WOMAC function scores parameters were only moderately correlated (Spearman's r = 0.33–0.51). Discussion. In routine longitudinal assessment of physical function following THA, ambulatory gait analysis can be supplementary to WOMAC. As gait significantly improved during the first 3 months and following 9 months after THA in patients with a low preoperative level of physical function only, assessment of more demanding tasks than gait may be more sensitive to capture functional improvement in patients with high preoperative function. Acknowledgements. This article presents independent research funded by the National Institute for Health Research (NIHR) under its Programme Grants for Applied Research programme (RP-PG-0407-10070). The views expressed in this article are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health. The research team acknowledges the support of the NIHR, through the Comprehensive Clinical Research Network

Introduction and Objective. Kinesiophobia, the fear of physical movement and activity related to injury vulnerability, has been linked to sub-optimal outcomes following total knee replacement (TKR). This systematic review has two aims: to define the relationship between kinesiophobia and functional outcomes, pain and range of motion following TKR, and to evaluate published treatments for kinesiophobia following TKR. Materials and Methods. A primary search was performed in March 2020. English-language studies recruiting adult primary TKR patients, using the Tampa Scale of Kinesiophobia (TSK) were included. Study quality was assessed using the Newcastle Ottawa Scale for cohort or case control studies, and the Cochrane Collaboration Risk of Bias tool for randomised controlled trials. Results. All thirteen included papers (82 identified) showed adequately low risk of methodological bias. TSK1 (activity avoidance) correlated with WOMAC functional score at 12 months in three studies (r=0.20 p<0.05, R=0.317 p=0.001, and correlation coefficient 0.197 p=0.005). TSK score significantly correlated with mean active range of motion (ROM) at six months (105.33 (SD=12.34) vs 85.53 (SD=14.77) p=0.000) post-operation. Three post-operative interventions improved TSK score vs control following TKR: a home-based functional exercise programme (TSK −14.30 (SD=0.80) vs −2.10 (SD=0.80) p<0.001)), an outpatient CBT programme (TSK 27.76 (SD=4.56) vs 36.54 (SD=3.58), and video-based psychological treatment (TSK 24 (SD=5) vs 29 (SD=5) p<0.01). Conclusions. Kinesiophobia negatively affects functional outcomes up until one year post-operatively, while active ROM is reduced up to six months post procedure. Post-operative functional and psychological interventions can improve kinesiophobia following TKR

Knee osteoarthritis is a common, debilitating condition. Intra articular corticosteroid injections are a commonly used non-operative treatment strategy. Intra articular hip injection with Ketorolac (an NSAID) has proven to be as efficacious as corticosteroids. No prior study compares the efficacy of Ketorolac relative to corticosteroids for relief of discomfort in knee osteoarthritis. The study design was a single centre double blinded RCT. Severity of osteoarthritic changes were graded on plain film weightbearing radiographs using the Kellgren and Lawrence system. Injection was with either 30mg Ketorolac or 40mg Methylprednisolone, given by intra-articular injection, in a syringe with 5mls 0.5% Marcaine. Pre-injection clinical outcomes were assessed using the Numerical Pain Score (NPS), WOMAC, and Oxford knee scores. Patients' NPS scores were assessed at Day 1 and Day 14 post-injection. An assessment of all clinical outcomes took place in clinic at six weeks. There were 72 participants (83 knees) in the study. No patients were lost to follow-up. Mean age was 62.66 years (Range 29–85). 42 knees received a corticosteroid injection, 41 a NSAID injection. Mean Kellgren and Lawrence score was 3.1. There was no significant difference in pre-injection clinical scores in either group. There was a significant improvement of NPS on Day 1 and 14 in both injection groups(p<0.05). These improved pain scores were sustained at 6 weeks in both groups. WOMAC and Oxford Knee Scores showed a statistically significant improvement in the corticosteroid group. WOMAC scores showed significant improvement in the NSAID group, however these improvements didn't achieve statistical significance using the Oxford Knee Score. Corticosteroid or NSAID injectate are a safe and effective non-operative treatment strategy in the patient with knee osteoarthritis. Ketorolac appears to provide effective medium-term improvement of pain and clinical scores. Further follow-up is recommended to investigate if this trend in sustained

The aim of this study was to determine the outcomes and survivorship of the Triathlon knee replacement at 7 years after surgery. A cohort of 266 patients receiving a Triathlon knee replacement were assessed before surgery and at 3 months, 1 year, 2 years, 3 years, 5 years and 7 years post-operation. Patient-reported outcomes were assessed using the WOMAC, KOOS Knee-Related Quality of Life scale, Satisfaction Scale and questions on kneeling ability and whether they regretted having the operation. Data on survivorship was collected from self-report and medical records. At 7 years after surgery, 32 patients were deceased, and 17 patients were withdrawn. Of the 217 patients remaining in the study, 164 (76%) returned a completed study questionnaire. At 7 years after surgery, 92% of patients reported an improvement in their WOMAC Pain score greater than the minimally clinically important improvement (defined as improvement of ≥9 points from before surgery) and 82% reported this in their WOMAC Function score (defined as improvement of ≥12 points). Knee-related quality of life was good, with a mean score of 66.8 (SD 26.0) (0–100 scale, worst to best). A high percentage of patients (89%) were somewhat or very satisfied with their outcome at 7 years. Survivorship with revision as the endpoint was 96.4% (95% CI 93.2–98.1%) at 7 years post-operation. Five percent of patients regretted having their operation and 68% reported much difficulty or an inability to kneel. In conclusion, this study observed good long-term patient outcomes and survivorship of the Triathlon knee replacement

Background. Osteoarthritis (OA) pain treatment has limitations in terms of serious adverse effects and low efficacy. We aimed to evaluate efficacy and safety of naproxen sodium/codeine phosphate combination in these patients. Methods. In this prospective, randomised, double blind, placebo controlled clinical trial, 135 patients with osteoarthritis, who were 40–65 years; applied to our institution's orthopaedics outpatient clinic; had grade 1, 2, or 3 primary osteoarthritis diagnosed in last 1 year; and had Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score≥40, and Visual Analogue Scale score≥40, were enrolled. Subjects were randomised (1:1) to placebo (n= 67) or combination (n= 68) arms, in which 550 mg naproxen sodium/30mg codeine phosphate was given orally twice a day for 7 days. Rescue medicine was 500 mg paracetamol (max= 6 tablets/day). Demographic characteristics, medical history, adverse events, VAS and WOMAC scores were collected in study visits performed within 10 days. The study was approved by local institutional ethics committee and written informed consents were obtained from all participants. Results. Patients were evenly matched in both arms. The mean age was 52.3±6.6 years (89.7% female). WOMAC and VAS scores decreased significantly within each group (p<0.001 for all). For the study group (n=43) the mean (+ SD) and median (min-max) VAS Score was −29.8 (+21.0) and −30 (−70−0), respectively. In contrast, for the control group (n=36) the mean and median (min-max) VAS Score was −16.1 (+24.4) and −12.5 (−65−40), respectively. WOMAC score was decreased more in combination group (p= 0.044). Changes in VAS scores between visits were significantly different (more in combination receivers) between groups (p= 0.018). Ratio of patients requiring no rescue medicine was higher among combination receivers than controls (64.8% vs. 35.2%, respectively). Most common adverse events were constipation, dyspepsia, and somnolence; no fatality was encountered. Conclusions. Naproxen sodium/codeine phosphate combination is effective and safe in osteoarthritis patients. Level of Evidence. Level 1

Physical functioning in patients undergoing hip surgery is commonly assessed in three ways: patient-reported outcome measure (PROM), performance test, or clinician-administered measure. It is recommended that several types of measures are used concurrently to capture an extended picture of function. Patient fatigue and burden, time, resources and logistical constraints of clinic and research appointments mean that collecting multiple measures is seldom feasible, leading to focus on a limited number of measures, if not a single one. While there is evidence that performance-tests and PROMs do not fully correlate, correlations between PROMs, performance tests and clinician-administrated measures are yet to be evaluated. It is also not known if the associations between function and patient characteristics depend on how function is measured. The aim of our study was to use different measures to assess function in the same group of patients before their hip surgery to determine 1. how well PROMs, performance tests and clinician-administrated measures correlate with one another and 2. Whether these measures are associated with the same patient characteristics. We conducted a cross-sectional analysis of the pre-operative information of 125 participants listed for hip replacement. The WOMAC function subscale, Harris Hip Score (HHS) and walk-, step- and balance-tests were assessed by questionnaire or during a clinic visit. Participant socio-demographics and medical characteristics were also collected. Correlations between functional measures were investigated with correlation coefficients (r). Regression models were used to test the association between the patient's characteristics and each of the three types of functional measures. None of the correlations between the PROM, clinician-administrated measure and performance tests were very high (r<0.90). The highest correlations were found between the WOMAC-function and the HHS (r=0.7) or the Walk-test (r=0.6), and between the HHS and the walk-test(r=0.7). All the other performance-tests had low correlations with the other measures(r ranging between 0.3 and 0.5). The associations between patient characteristics and functional scores varied by type of measure. Psychological status was associated with the WOMAC function (p-value<0.0001) but not with the other measures. Age was associated with the performance test measures (p-value ranging from ≤0.01 to <0.0001) but not with the WOMAC function. The clinician-administered (HHS) measure was not associated with age or psychological status. When evaluating function prior to hip replacement clinicians and researchers should be aware that each assessment tool captures different aspects of function and that patient characteristics should be taken into account. Psychological status influences the perception of function; patients may be able to do more than they think they can do, and may need encouragement to overcome anxiety. A performance test like a walk-test would provide a more comprehensive assessment of function limitations than a step or balance test, although performance tests are influenced by age. For the most precise description of functional status a combination of measures should be used. Clinicians should supplement their pre-surgery assessment of function with patient-reported measure to include the patient's perspective

Background. Over 96% of primary total hip replacements (THR) recorded in the National Joint Registry (NJR) are performed through a posterior or lateral surgical approach. There is no high quality evidence available to support the use of one approach over the other in primary THR and even less evidence when the outcome of revision THR is considered. Methods. Questionnaires were sent to 267 patients who had revision hip replacements between January 2006 and March 2010 for aseptic loosening. They rated their pain from 0–10, and used the Self-Administered Patient Satisfaction Scale (SAPS), Oxford Hip Score (OHS), Western Ontario and McMaster University Osteoarthritis Index (WOMAC) and Short form-12 (SF-12). Results. We performed 275 revision total hip replacements for aseptic loosening on patients in whom the primary operation details were available. Their mean age was 69 years (SD12) with 43% male and 57% right-sided procedures. 205 patients responded to our questionnaires (209/275 hips, 76%). Unfortunately 19 patients had died, 4 had dementia and 13 declined to participate. We were unable to contact a further 33.Grouping by approach, 20% (43/209) had primary and revision lateral approaches, 20% (43/209) had primary lateral and revision posterior and 60% (123/209) had both primary and revision via posterior approaches. The WOMAC and OHS were significantly better in patients who had a posterior approach for both primary and revision surgery, compared to those that did not (OHS p=0.028, WOMAC p=0.026). We found no significant differences in pain, satisfaction or health-related quality of life between the groups. Conclusions. Registry data may help further explore the relationship between surgical approach and outcome in revision hip surgery. A randomised controlled trial of the posterior versus lateral approach for revision surgery would provide a definitive answer. Level of Evidence. 2b - retrospective cohort study. Disclosures. No financial disclosures or conflicts of interests from any authors

It is known that excessive varus alignment of the femoral stem in total hip replacement (THR) creates a sub-optimal biomechanical environment which is associated with increased rates of revision surgery and component wear. Little is known regarding the effect of femoral stem alignment on patient functional outcome. Methods. Retrospective study of primary THR patients at the RNOH. Alignment of the femoral stem component in-situ was measured subjectively by a consultant musculoskeletal radiologist in both coronal and sagittal planes using post-operative anterior-posterior and lateral pelvic radiographs. Each THR was grouped into valgus, minor-valgus, neutral, minor-varus or varus coronal plane alignment and posterior, minor-posterior, neutral, minor-anterior or anterior sagittal plane alignment. Patient reported functional outcome was assessed by Oxford Hip Score (OHS) and WOMAC questionnaires. Data analysed using a linear regression model. Results. 90 THRs were studied in 87 patients (55 Female). Mean age at THR=62 (22-86). Mean follow-up=17 months (11-39 months). Median OHS=16, WOMAC=8. Coronal plane alignment of the femoral stem was not associated with any change in OHS (p>0.05) or WOMAC score (p>0.05). Sagittal plane alignment of the femoral stem was not associated with any change in OHS (p>0.05) or WOMAC score (p>0.05). Conclusion. Although it is known that alignment of the femoral stem on sagittal and coronal planes has a direct effect on survivorship of the prosthesis, our study does not demonstrate any relationship between femoral stem alignment and functional outcome in patients undergoing primary THR

Diffuse noxious inhibitory control (DNIC) works through the “pain-inhibits-pain” principle in which an additional painful (conditioned) stimulus can suppress the initial experienced pain through the descending and inhibiting pathways. Painful stimulation produced less pain inhibition in patients with knee osteoarthritis patients (KOA) than in controls, suggesting an impaired DNIC function and a loss of endogenous pain modulation. Electroacupuncture (EA) is widely used to treat acute pain associated with KOA, but the available evidence of its benefit on chronification of acute pain is scarce. This is a single-arm clinical study aims to evaluate the effect of EA on the chronification of pain associated with KOA and provide a profile of various cytokines underlying the pathogenesis of KOA. Participants are recruited through hospital-based recruitment and advertisements, diagnosis was based upon the criteria formulated by the American College of Rheumatology. Each participant was administered with EA (2 mA < current < 5 mA) at the ipsilateral EX-LE5, ST35, ST34 and SP10 for two weeks (once a day, 30 minutes per session, in 5 sessions per week). Visual Analog Scale (VAS), DNIC function, the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Numerical Rating Scale (NRS), Emotional Scale (ES) and Present Pain Intensity (PPI) are evaluated before treatment and after 5 to 10 sessions of treatment. Cytokines including GRO, TNF-α, VEGF, IP-10, IL-1β, IL-17, IL-8, MCP-1 and IL-10 levels in plasma were measured using a Human Cytokine/Chemokine Magnetic Bead Panel on MAGPIX instrument before and after two weeks of treatment. A total of 39 patients with KOA were enrolled in our study (age: 63.46±9.89 years; height: 1.63±0.07 m; BMI: 22.83±2.89), all of them completed the trial. After 5 sessions of EA treatment, a significant decrease of VAS, WOMAC scores, NRS, ES and PPI was detected, but no significant difference in DNIC was observed. After two weeks' treatment, all clinical parameters (VAS, DNIC, WOMAC, NRS, ES, PPI) reduced significantly when compared with baseline; GRO, IL-17A, IL-1b, IL-8, MCP-1, TNF-a, VEGF levels in plasma reduced significantly while IL-10 and IP-10 concentrations were elevated. This study appeared to provide evidence that EA was effective in improving chronic pain associated with KOA through repairing the impaired DNIC function and down-regulation of OA detrimental cytokines. A randomized controlled prospective study with large sample size is required to clarify the effect of EA in reversing the chronification of pain in KOA

Patients with knee prosthetic joint infection (PJI) frequently receive one- or two-stage revision. To explore the feasibility of a randomised controlled trial (RCT) comparing methods, we analysed a UK registry, interviewed patients and surgeons, systematically reviewed literature, held a consensus meeting, and assessed progress of an RCT in hip PJI. In 2014, in England and Wales, knee PJI was treated with one- or two-stage procedures in 19% and 71% of patients respectively. Between 2007 and 2014, use of one-stage procedures doubled and, in major centres, up to 42% of treatments were one-stage. We conducted in-depth interviews with 16 patients with knee PJI and 11 surgeons performing one- or two-stage revision. Patients considered randomisation acceptable with appropriate counselling and, depending on infecting organisms and health status, surgeons would randomise treatments. In meta-analysis, two-year re-infection rates in 10 one-stage series (423 patients) and 108 two-stage series (5,129 patients) were 7.6% (95%CI 3.4,13.1) and 8.8% (7.2,10.6) respectively. In a series of patients with knee PJI, surgeons from 2 major centres considered 6/15 patients eligible for either treatment, with 4 more potentially eligible after treatment of soft tissue infection. In an ongoing RCT of surgical treatment of hip PJI, 116 patients have been randomised at 14 centres in 3 years. Randomising patients with PJI is feasible but, as knee PJI is uncommon, a multicentre RCT would be required. Based on WOMAC score outcome and appropriate assumptions on eligibility and acceptability, 170 patients would need to be randomised over 4 years at 14 major centres