Objectives . The effects of disease progression and common tendinopathy treatments on the tissue characteristics of human rotator cuff tendons have not previously been evaluated in detail owing to a lack of suitable sampling techniques. This study evaluated the structural characteristics of torn human supraspinatus tendons across the full disease spectrum, and the short-term effects of subacromial corticosteroid injections (SCIs) and subacromial decompression (SAD) surgery on these structural characteristics. . Methods . Samples were collected inter-operatively from supraspinatus tendons containing small, medium, large and massive full thickness tears (n = 33). Using a novel minimally invasive biopsy technique, paired samples were also collected from supraspinatus tendons containing partial thickness tears either before and seven weeks after subacromial SCI (n = 11), or before and seven weeks after SAD surgery (n = 14). Macroscopically normal subscapularis tendons of older patients (n = 5, mean age = 74.6 years) and supraspinatus tendons of younger patients (n = 16, mean age = 23.3) served as controls. Ultra- and micro-structural characteristics were assessed using atomic force microscopy and polarised light microscopy respectively. . Results. Significant structural differences existed between torn and control groups. Differences were identifiable early in the disease spectrum, and increased with increasing tear size. Neither SCI nor SAD surgery altered the structural properties of partially torn tendons seven weeks after treatment. . Conclusions . These findings may suggest the need for early clinical intervention strategies for torn rotator cuff tendons in order to prevent further degeneration of the tissue as tear size increases. Further work is required to establish the long-term abilities of SCI and SAD to prevent, and even reverse, such degeneration. Cite this article: Bone Joint Res 2014;3:252–61

Objective. Lumbar spinal stenosis (LSS) is a common spinal disorder mostly caused by the arthritic process. In cases with refractory complaints or significant neurologic deficit, decompressive surgery with or without instrumented fusion may be indicated. We aimed to investigate the surgical outcome of multi-level LSS in the patient with stable spine treated by simple decompression versus decompression and instrumented fusion. Methods: We retrospectively studied 51 patients (25 male, 26 female) with stable multi-level (>2 levels) LSS who were treated by decompressive surgery alone (group A, 31 cases) and decompression and instrumented fusion (group B, 20 cases) and followed them for more than two years. The patients’ disability and pain were assessed with Oswestry Disability Index (ODI) and Visual Analogue Scale (VAS), respectively. At the last follow-up visit, patient satisfaction with surgery was also scored. Results: The two groups were homogeneous in terms of age, sex, severity of disability and pain. Surgery could significantly improve pain and disability in both groups. Preoperative ODI in group A and B were 51.0±23.7 and 54.5±22.9, respectively, however at the last follow-up visit these parameters improved to 23.1±21.1 and 36.6±21.4 showing a statistical significance. Mean patient satisfaction with surgical intervention was also higher in the simple decompression group, but this difference was not significant. Conclusion: In surgical treatment of the patients with multi-level but stable LSS, simple decompression versus decompression and instrumented fusion could achieve more disability improvement for more than two years of follow-up

Introduction. Histology remains the gold standard in morphometric and pathological analyses of osteochondral tissues in human and experimental bone and joint disease. However, histological tissue processing is laborious, destructive and only provides a two-dimensional image in a single anatomical plane. Micro computed tomography (μCT) enables non-destructive three-dimensional visualization and morphometry of mineralized tissues and, with the aid of contrast agents, soft tissues. In this study, we evaluated phosphotungstic acid-enhanced (PTA) μCT to visualize joint pathology in spine osteoarthritis. Methods. Lumbar facet joint specimens were acquired from six patients (5 female, age range 31–78) undergoing decompression surgery. Fresh osteochondral specimens were immediately fixed in formalin and scanned in a benchtop μCT scanner (65 kV, 153 mA, 25 μm resolution). Subsequently, samples were completely decalcified in 5% formic acid, equilibrated in 70% ethanol and stained up to ten days in 1% PTA (w/v) in 70% ethanol. PTA-stained specimens were scanned at 70 kV, 140 mA, 15 μm resolution. Depth-dependent analysis of X-ray attenuation in cartilage tissues was performed using ImageJ. Bone structural parameters of undecalcified and PTA-stained specimens were determined using CT Analyser and methods were compared using correlation and Bland-Altman analysis. Results. The maximal penetration depth of PTA in decalcified facet joint was 5 mm. Bone tissue showed strong and uniformly distributed X-ray attenuation, while mild to moderate and differentially distributed attenuation was observed in articular cartilage and subchondral marrow spaces. Measurements of bone volume (r=0.90, p=0.01) and bone surface (r=0.95, p=0.004) were strongly correlated between undecalcified and PTA-stained samples. Compared with PTA-stained samples, measurements in undecalcified specimens were consistently higher (∼14%). PTA-enhanced μCT visualization of cartilage tissues enabled the identification of individual chondrocytes and their pericellular microenvironment (chondrons). Owing to loss of collagen lower X-ray attenuation was observed in the middle and deep cartilage layers at the central, but not peripheral, regions of the degenerated facet joint specimens. Depth-dependent analysis of PTA-staining intensity suggested that the extent of collagen loss in articular cartilage might correlate with the thickness of the subchondral cortical plate. Conclusion. PTA-enhanced μCT is a low-cost, non-toxic and highly feasible method for ex vivo 3D-visualization of osteochondral pathology in human osteoarthritis. The method enables bone morphometric analysis, as well as collagen distribution in all anatomical planes. Contrast enhanced μCT has several applications in bone and osteoarthritis research including 3D histopathological grading, tissue stratification, and imaging and analysis of aberrant collagen metabolism in osteochondral disease

Introduction. Limited physical activity (PA) is one indication for orthopaedic intervention and restoration of PA a treatment goal. However, the objective assessment of PA is not routinely performed and in particular the effect of spinal pathology on PA is hardly known. It is the purpose of this study using wearable accelerometers to measure if, by how much and in what manner spinal stenosis affects PA compared to age-matched healthy controls. Patients & Methods. Nine patients (m/f= 5/4, avg. age: 67.4 ±7.7 years, avg. BMI: 29.2 ±3.5) diagnosed with spinal stenosis but without decompressive surgery or other musculoskeletal complaints were measured. These patients were compared to 28 age-matched healthy controls (m/f= 17/11, avg. age: 67.4 ±7.6 years, avg. BMI: 25.3±2.9). PA was measured using a wearable accelerometer (GCDC X8M-3) worn during waking hours on the lateral side of the right leg for 4 consecutive days. Data was analyzed using previously validated activity classification algorithms in MATLAB to identify the type, duration and event counts of postures or PA like standing, sitting, walking or cycling. In addition, VAS pain and OSWESTRY scores were taken. Groups were compared using the t-test or Mann-Whitney U-test where applicable. Correlations between PA and clinical scores were tested using Pearson”s r. Results. Spinal stenosis patients showed much lower PA than healthy controls regarding all parameters like e.g. daily step count (2946 vs 8039, −63%, p<0.01) or the relative daily time-on-feet (%) (8.6% vs 28.3%, −70%, p<0.01) which is matched with increased sitting durations (80.3% vs 58.8%, p<0.01). Also qualitative parameters such as walking cadence was reduced in stenosis patients (83.7 vs 97.8 steps/min). With stenosis no patient ever walked >1000 steps without interruption. Also the number of walking bouts between 250–1000 steps was 4.5 times lower than in healthy controls (p<0.01). When the relative distribution of walking bout length was calculated, it became visible that stenosis patients showed more short walking bouts of 10–50 steps (p<0.05). There were no strong and significant correlations between the clinical scores and PA parameters. Discussion & Conclusions. Spinal stenosis greatly reduced physical activity to levels below WHO guidelines (e.g. <5000 steps= sedentary lifestyle) where the risk for general health (overall mortality), cardiovascular or endocrinological health is significantly increased. Activity levels are lower than reported for end-stage hip or knee osteoarthritis. Therefore, spinal stenosis patients should not only receive pain medication, but be made aware of their limited PA and its detrimental health effects, participate in activation programs, or be considered for surgical intervention. The absence of long walking bouts and the relatively more frequent short walking bouts seem indicative of intermittent claudication as typical in spinal stenosis

Background. The majority of studies assessing minimal clinical important difference in outcome do so for management of chronic low back pain. Those that identify MCID following spinal surgical intervention fail to differentiate between the different pathologies and treatments or use variable methods and anchors in the calculation. Aim. To identify the MCID in scores across the most common spinal surgical procedures using standardised methods of calculation. Method. Prospective longitudinal study following elective lumbar spinal surgery. All patients had a complete set of spinal outcome assessments (ODI and VAS) and self perceived rating of the global and Mcnab criteria. MCID was calculated as defined by Hagg et al. Results. 244 patients of average age 53 years were followed up for 62 months post surgery. The MCID across the range of spinal surgeries was a 10 point change in ODI and 28 points for the VAS. A MCID following lumbar decompression surgery was a 3 point change in ODI and 29 points for VAS; 24 points in ODI and 37 points in the VAS for a discectomy, and 13 points in ODI and 23 point change in VAS for revision surgery. This value also varied depending on the anchor and method used for calculation. Conclusion. The MCID in score varies between different spinal procedures, method of calculation and the external anchor used. Standardised methods of calculating MCID in outcome measures should be used to allow comparative research and assessment. Generalisation of MCID in scores across a range of spinal procedures should be strongly discouraged. Conflicts of Interest. None. Source of Funding. None. This abstract has not been previously published in whole or substantial part nor has it been presented previously at a national meeting

Introduction. This study sought to determine whether the functional outcome of two common spinal operations could be improved by a programme of post-operative rehabilitation and/or an educational booklet each compared with usual care. Methods. This was a multi-centre, factorial, randomised controlled trial on the post operative management of spinal surgery patients, with randomisation stratified by surgeon and operative procedure. The study compared the effectiveness of a rehabilitation programme and an education booklet for the postoperative management of patients undergoing discectomy or lateral nerve root decompression surgery, each compared with “usual care” using a 2 × 2 factorial design, randomising patient to four groups; rehabilitation-only, booklet-only, rehabilitation-plus-booklet, and usual care only. The primary outcome measure was the Oswestry Disability Index (ODI) at 12 months, with secondary outcomes including visual analogue scale measures of back and leg pain. An economic analysis was also performed. Results. 338 patients were recruited into the study with outcomes preformed pre-operatively, and postoperatively at 6 weeks, 3, 6, 9 and 12 months post-operatively. At the one year review the effect of rehabilitation on ODI was −2.7 (95% CI −6.8 to 1.5) and the effect of booklet was 2.7 (95% CI −1.5 to 6.9). There were no significant differences in costs or outcomes associated with either intervention and neither intervention was cost-effective. Discussion. This study found that neither intervention had a significant impact on long term outcome or cost. There was some evidence to suggest that the impact of the interventions was different between patients undergoing discectomy and those having spinal decompression. Conflicts of Interest. None. Source of Funding. Arthritis Research UK. Previously presented at International Society for the Study of the Lumbar Spine 2011

Summary. Arthroscopic decompression of the lunate decreases clinical symptoms and slows progression of Kienböck's Disease. Introduction. The purpose of this study was to investigate the outcomes of patients suffering from avascular necrosis of the lunate, or Kienböck's Disease, who received arthroscopic decompression to treat the ischemic lunate. Previous studies have demonstrated an elevated intraosseus pressure in the ischemic lunate, and it has been hypothesised that ischemia in the lunate is secondary to this elevated pressure and subsequent venous congestion, as opposed to diminished arterial supply. Based on this work we have used decompression of the lunate to prevent progression of the disease. Patients and Methods. 21 patients, (22 wrists), reported to a single surgeon with a chief complaint of unremitting wrist pain and the subsequent diagnosis was Kienböck's disease, stages I, II, IIIA or IIIB. Range of motion measurement and grip strength, as well as self-reported outcome measures such as Disabilities of the Arm, Shoulder and Hand (DASH) and Modified Mayo, were obtained preoperatively and post operatively at 2, 7 and 12 months. The patients were treated operatively with arthroscopic decompression of the lunate. The lunate was approached dorsally at the interosseous lunotriquetral and the scapholunate ligament areas with an arthroscopic shaver until brisk bleeding was achieved upon deflating the tourniquet. In some cases, the core of the lunate had to be penetrated with a 45 k-wire until bleeding was obtained. Of the 22 wrists treated arthroscopically with lunate decompression, 18 had both pre-surgical and post-surgical follow-up evaluations. Results. The patients who underwent lunate arthroscopic decompression surgery demonstrated a statistically significant improvement in DASH score at 7 and 12 months postoperatively (p<0.05). The preoperative DASH score average for this cohort was 51, while post-operative DASH scores averaged 23 and 17 at 7 and 12 months, respectively. The patients also demonstrated some overall improvement in pain, functionality, range of motion, and grip strength as demonstrated by the Modified Mayo wrist score. Notably, the patients demonstrated statistically significant improvement in grip strength post-operatively at 7-months (p<0.05) and 12-months (p<0.01). In addition, there was noted to be improvement in supination and ulnar deviation measurements post-operatively at 7 months and 12 months, respectively. Conclusion. This study demonstrates the clinical outcome of arthroscopic decompression of the lunate in patients suffering from Kienböck's Disease using the patient's subjective evaluations as well as range of motion and grip strength measurements. Arthroscopic decompression of the lunate decreases clinical symptoms and slows progression of Kienböck's Disease using a less invasive surgical intervention

Introduction. Changes in central nervous system (CNS) pathways controlling trunk and leg muscles in patients with low back pain(LBP) and lumbar radiculopathy have been observed and this study investigated whether surgery impacts upon these changes in the long term. Methods. 80 participants were recruited into the following groups: 25 surgery(S), 20 chronic LBP(CH), 14 spinal injection(SI), and 21 controls(C). Parameters of corticospinal control were examined before, at 6, 26 and 52 weeks following lumbar decompression surgery and equivalent intervals. Electromyographic(EMG) activity was recorded from tibialis anterior(TA), soleus(SOL), rectus abdominis(RA), external oblique(EO) and erector spinae(ES) muscles at the T12&L4 levels in response to transcranial magnetic stimulation of the motor cortex. Motor evoked potentials (MEP) and cortical silent periods(cSP) recruitment curves(RC) were analysed. Results. Trunk muscles in all patients had reduced raw EMG (P<0.001), increased motor thresholds (MTh;P<0.001) and MEP RC slopes. MTh in ESL4 correlated with back pain in all patients (r=0.201, P=0.016) and soleus MTh laterality with disability in surgery patients (r=0.49, P=0.018). S&SI patients displayed bilaterally increased soleus cSP (p<0.001), MEP latencies on the painful side (P<0.001), and cSP asymmetry (cSPA;P<0.001). cSPA resulted from abnormal soleus late responses on the painful side, indicating compromised agonist-antagonist control in patients with radiculopathy. In contrast to SI, surgery significantly reduced soleus cSPA and MEP latencies at 6 weeks (P≤0.034). Discussion. These results show long term changes in CNS control of trunk and leg muscles in radiculopathy and LBP, which are only partly reversed by surgery, and may provide future therapeutic targets to address the altered inhibitory processes within the brain. No conflicts of Interest. Sources of funding: The DISCS foundation. This abstract has not been previously published in whole or substantial part nor has it been presented previously at a national meeting