High tibial osteotomy (HTO) is an effective surgical treatment for isolated medial compartment knee osteoarthritis; however, widespread adoption is limited due to difficulty in achieving the planned correction, and patient dissatisfaction due to soft tissue irritation. A new HTO system – Tailored Osteotomy Knee Alignment (TOKA®, 3D Metal Printing Ltd, Bath, UK) could potentially address these barriers having a custom titanium plate and titanium surgical guides featuring a unique mechanism for precise osteotomy opening as well as saw cutting and drilling guides. The aim of this study was to assess the accuracy of this novel HTO system using cadaveric specimens; a preclinical testing stage ahead of first-in-human surgery according to the ‘IDEAL-D’ framework for device innovation. Local ethics committee approval was obtained. The novel opening wedge HTO procedure was performed on eight cadaver leg specimens. Whole lower limb CT scans pre- and post-operatively provided geometrical assessment quantifying the discrepancy between pre-planned and post-operative measurements for key variables: the gap opening angle and the patient specific surgical instrumentation positioning and rotation - assessed using the implanted plate. The average discrepancy between the pre-operative plan and the post-operative osteotomy correction angle was: 0.0 ± 0.2°. The R2 value for the regression correlation was 0.95. The average error in implant positioning was −0.4 ± 4.3 mm, −2.6 ± 3.4 mm and 3.1 ± 1.7° vertically, horizontally, and rotationally respectively. This novel HTO surgery has greater accuracy and smaller variability in correction angle achieved compared to that reported for conventional or other patient specific methods with published data available. This system could potentially improve the accuracy and reliability of osteotomy correction angles achieved surgically

Introduction. Adolescent Idiopathic Scoliosis (AIS) is a three-dimensional deformity of the spine with unclear etiology. Due to the asymmetry of lateral curves, there are differences in the muscle activation between the convex and concave sides. This study utilized a comprehensive thoracic spine and ribcage musculoskeletal model to improve the biomechanical understanding of the development of AIS deformity and approach an explanation of the condition. Methods. In this study, we implemented a motion capture model using a generic rigid-body thoracic spine and ribcage model, which is kinematically determinate and controlled by spine posture obtained, for instance, from radiographs. This model is publicly accessible via a GitHub repository. We simulated gait and standing models of two AIS (averaging 15 years old, both with left lumbar curve and right thoracic curve averaging 25 degrees) and one control subject. The marker set included extra markers on the sternum and the thoracic and lumbar spine. The study was approved by the regional Research Ethics Committee (Journal number: H17034237). Results. We investigated the difference between the muscle activation on the right and left sides including erector spinae (ES), psoas major (PS), and multifidus (MF). Results of the AIS simulations indicated that, on average throughout the gait cycle, the right ES, left PS and left MF had 46%, 44%, and 23% higher activities compared to the other side, respectively. In standing, the ratios were 28%, 40%, and 19%, respectively. However, for the control subject, the differences were under 7%, except ES throughout the gait, which was 17%. Conclusion. The musculoskeletal model revealed distinct differences in force patterns of the right and left sides of the spine, indicating an instability phenomenon, where larger curves lead to higher muscle activations for stabilization. Acknowledgement. The project is funded by the European Union's Horizon 2020 program through Marie Skłodowska-Curie grant No. [764644]

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

Abstract. Introduction. Skeletal muscle wasting is an important clinical issue following acute traumatic injury, and can delay recovery and cause permanent functional disability particularly in the elderly. However, the fundamental mechanisms involved in trauma-induced muscle wasting remain poorly defined and therapeutic interventions are limited. Objectives. To characterise local and systemic mediators of skeletal muscle wasting in elderly patients following acute trauma. Methods. Experiments were approved by a local NHS Research Ethics Committee and all participants provided written informed consent. Vastus lateralis biopsies and serum samples were taken from human male and female patients shortly after acute trauma injury in lower limbs (n=6; mean age 78.7±4.4 y) and compared to age-matched controls (n=6; mean age 72.6±6.3 y). Atrogenes and upstream regulators (MuRF1; MAFbx; IL6, TNFα, PGC-1α) mRNA expression was assessed in muscle samples via RT-qPCR. Serum profiling of inflammatory markers (e.g. IL6, TNFα, IL1β) was further performed via multiplex assays. To determine whether systemic factors induced by trauma directly affect muscle phenotype, differentiated primary human myotubes were treated in vitro with serum from controls or trauma patients (pooled; n=3 each) in the final 24 hours of differentiation. Cells were then fixed, stained for myogenin and imaged to determine minimum ferret diameter. Statistical significance was determined at P<0.05. Results. There was an increase in skeletal muscle mRNA expression for E3 ligase MAFbx and inflammatory cytokine IL-6 (4.6 and 21.5-fold respectively; P<0.05) in trauma patients compared to controls. Expression of myogenic determination factor MyoD and regulator of mitochondrial biogenesis PGC-1α was lower in muscle of trauma patients vs controls (0.5 and 0.39-fold respectively; P<0.05). In serum, trauma patients showed increased concentrations of circulating pro-inflammatory cytokines IL-6 (14.5 vs. 0.3 pg/ml; P<0.05) and IL-16 (182.7 vs. 85.2 pg/ml; P<0.05) compared to controls. Primary myotube experiments revealed serum from trauma patients induced atrophy (32% decrease in diameter) compared to control serum-treated cells (P<0.001). Conclusion. Skeletal muscle from patients following acute trauma injury showed greater expression of atrophy and inflammatory markers. Trauma patient serum exhibited higher circulating pro-inflammatory cytokine concentrations. Primary human myotubes treated with serum from trauma patients showed significant atrophy compared to healthy serum-treated controls. We speculate a mechanism(s) acting via circulating factors may contribute to skeletal muscle pathology following acute trauma. 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

Abstract. Cranial cruciate ligament (CrCL) disease/rupture causes pain and osteoarthritis (OA) in dogs. α-amino-3-hydroxy-5-methyl-4-isoxazole propionate (AMPA)-2 and kainate (KA)-1 glutamate receptors (GluR) and the excitatory amino acid transporter-1 (EAAT-1) and EAAT-3 are expressed in joint tissues from OA patients and rodent arthritis models and represent potential therapeutic targets. Objectives. To evaluate glutamate signalling in canine diseased and normal CrCL and meniscus by immunohistochemistry (IHC). Methods. Surgical waste (CrCL, n=5 and medial meniscus, n=3) were obtained from canines with CrCL disease (RCVS ethics approval:2017/14/Alves) and normal analogous tissues (n=2). IHC optimization was performed for rabbit polyclonal (AMPA-2:ab52176, KA-1:ab67402, EAAT-1:ab416) and monoclonal (EAAT-3:ab124802) antibodies from Abcam. IHC was optimised over antibody dilutions from 1:100 to 1:5000 alongside equivalent IgG isotype controls (ab37415 and ab172730) and negative controls (TBS/Tween buffer without primary antibodies). IHC staining was compared in diseased and normal tissues and disclosed with 3,3’-Diaminobenzidine (DAB). Results. Specific immunostaining was observed for all primary antibodies, at concentrations between 2.0×10. −4. mg/mL to 1.0×10. −2. mg/mL, depending on the tissue and primary antibody. All GluR and transporters were expressed in the cellular membrane, in the normal and diseased CrCL and meniscus. Healthy CrCL showed a well-organized microstructure, with normal positively labelled ligamentocytes, whereas diseased CrCL microstructure was disrupted, with many positively stained fibroblastic cells in the epiligamentous region and evident neovascularization, indicative of ongoing repair. The normal and diseased meniscal tissues showed similar chondrocytes-like cells labelling and microstructure. Negative controls demonstrated no labelling. Conclusions. GluR and transporters expression is altered in canine diseased CrCLs, implicating glutamate signalling in this pathology. Since AMPA/KA GluR antagonists alleviate joint degeneration in post-traumatic OA in rodent models, they may be useful for the treatment of CrCL disease in dogs, as well as translated to other veterinary and human orthopaedic diseases

Introduction and Objective. Hip osteoarthritis (OA) is the leading cause for total hip arthroplasty (THA). Although, being considered as the surgery of the century up to 23% of the patients report long-term pain and deficits in physical function and muscle strength may persist after THA. Progressive resistance training (PRT) appear to improve several outcomes moderately in patients with hip OA. Current treatment selection is based on low-level evidence as no randomised controlled trials have compared THA to non-surgical treatment. The primary objective of this trial is to determine the effectiveness of THA followed by standard care compared to 12 weeks of supervised PRT followed by 12 weeks of optional unsupervised PRT, on changes in hip pain and function, in patients with severe hip OA after 6 months. Materials and Methods. This is a protocol for a multicentre, parallel-group, assessor blinded, randomised controlled superiority trial. Patients aged ≥50 years with clinical and radiographic hip OA found eligible for THA by an orthopaedic surgeon will be randomised to THA or PRT (allocation 1:1). The primary outcome will be change in patient-reported hip pain and function, measured using the Oxford Hip Score. Key secondary outcomes will be change in the Hip disability and Osteoarthritis Outcome Score subscales, University of California Los Angeles Activity Score, 40-meter fast-paced walk test, 30-second chair stand test, and number of serious adverse events. Results. The trial has been approved by The Regional Committees on Health Research Ethics for Southern Denmark (Project-ID: S-20180158) in February 2019 and registration was performed at . ClinicalTrials.gov. (NCT04070027) in August 2019. Recruitment was initiated on the 2. nd. of September 2019 and the final deadline will be on the 30. th. of June 2021, or when a sample size of 120 patients has been accomplished. Conclusions. The results of the current trial are expected to enable evidence-based recommendations, which may be used to facilitate the shared-decision making process in the discussion of treatment strategy for the individual patient with severe hip OA. All results will be presented in peer-reviewed scientific journals and international conferences

Introduction and Objective. Septic arthritis is an acute infective presentation of the joint calling for urgent intervention, thus making the differential diagnosis process difficult. An increase in temperature in the area containing the suspected septic arthritis is one of the clinically important findings. In this study, it was aimed to investigate whether or not the temperature changes obtained through thermal camera can be used as a new additional diagnostic tool in the differential diagnosis of septic arthritis. Materials and Methods. The study was approved by the local ethics committee as a prospective cohort. A total of 49 patients, 15 septic and 34 non-septic ones, both male and female ones from all ages admitted to the emergency room or evaluated with the consultation of another clinics who were also present with a pre-diagnosis of arthritis (septic or non-septic) in the knee (with complaints of redness, swelling, pain, effusion, increased temperature, edema, and inability to walk) were included in the study. The patients with non-joint inflammatory problems and a history of surgery in the same joint were excluded from the study. The temperature increase in the joint area with suspected septic arthritis was observed, and the difference in temperature changes of this suspicious area with the joint area of the contralateral extremity was compared after which the diagnosis of septic arthritis was confirmed by taking culture with routine intra-articular fluid aspiration, which is the gold standard for definitive diagnosis. Results. The mean age of the patients was 39.89 ± 27.65°C. A significant difference was found between the group with and without septit arthritis in terms of ASO, sedimentation, and leukocyte increase in the analysis of joint fluid (p <0.05). When the thermal measurements were compared, the mean temperature was 37.93°C in the septic group, while it was 36.79°C in the non-septic group, which showed a significant difference (p <0.000∗). The mean temperature difference in both joints was 3.40°C in the septic group, while 0.94°C in the non-septic group (p <0.000∗). While the mean temperature was 37.10°C in the group with septit arthritis, it was measured to be 35.89 °C in the group without (p <0.020). A very strong positive correlation was found between the difference between the mean temperatures of both groups and the values of the hottest and coldest temperature points (r = 0.960, r = 0.902). Conclusions. In the diagnosis of septic arthritis, a thermal imager can be used as a non-invasive diagnostic tool. With the help of this device, a quantitative value, in addition to palpation, can be given to the local temperature increase in the joint, which is an important finding in the clinic of septic arthritis. In future studies, specially designed thermal devices developed with special software for septic arthritis can be developed

Abstract. Cranial cruciate ligament (CrCL) disease in dogs causes pain and osteoarthritis (OA) and surgical treatment does not prevent OA progression. Glutamate receptor (GluR) antagonists alleviate pain and degeneration in rodent models of OA, but it is unknown whether they are a suitable treatment for dogs. Understanding GluR signalling in CrCL disease may lead to novel therapeutics in both veterinary and human medicine. Objectives. To determine whether age, breed, sex, weight, and therapeutic(s) influence lameness and pre-operative radiographic OA scoring in dogs with CrCL disease and whether GluRs are expressed, in this disease. Methods. Surgical waste (CrCL and medial meniscus), clinical data, stifle radiographs, lameness scores (1–4, mild-unloading limb) were obtained with full informed consent (RCVS ethics approval, ref: 2017/14/Alves). OA scoring was performed on radiographs [VCOT, 2017, 30(6):377–384, 15–60, normal-severe OA], and α-amino-3-hydroxy-5-methyl-4-isoxazole propionate (AMPA)-2 and kainate (KA)-1 GluR expression compared in diseased versus control tissues by immunohistochemistry (IHC). Results. We studied 25 dogs (various breeds, 4.88±3.02 years; 44% male; 56% female; 27.13±9.12kg). At the time of surgery, 44% dogs were on meloxicam alone, 40% on other therapeutic(s) and 16% on no therapeutics. Linear regression showed that OA score (mean 21.72±3.47) did not correlate with lameness score (mean 1.98±1.08), age or weight (p values of 0.7483, 0.4597, 0.1463; R. 2. values of 0.004563, 0.02400, 0.08951, respectively). Radiographic OA scores and lameness scores did not differ between therapeutic groups (one-way ANOVA, p=0.9229 and p=0.5541, respectively). GluRs (AMPA-2/KA-1) were expressed in CrCL and medial meniscus, with increased labelling in the CrCL epiligamentous region in diseased tissues, where microanatomy was disrupted. Conclusions. In this population, OA scores do not correlate with lameness scores, age, weight, and therapeutics at the time of surgery. Variable GluR expression in diseased tissues implicates glutamate signalling in this pathology. 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

The course of secondary fracture healing typically consists of four major phases including inflammation, soft and hard callus formation, and bone remodeling. Callus formation is promoted by mechanical stimulation, yet little is known about the healing tissue response to strain stimuli over shorter timeframes on hourly and daily basis. The aim of this study was to explore the hourly, daily and weekly variations in bone healing progression and to analyze the short-term response of the repair tissue to well-controlled mechanical stimulation. A system for continuous monitoring of fracture healing was designed for implantation in sheep tibia. The experimental model was adapted from Tufekci et al. 2018 and consisted of 3 mm transverse osteotomy and 30 mm bone defect resulting in an intermediate mobile bone fragment in the tibial shaft. Whereas the distal and proximal parts of the tibia were fixed with external fixator, the mobile fragment was connected to the proximal part via a second, active fixator. A linear actuator embedded in the active fixator moved the mobile fragment axially, thus stimulating mechanically the tissue in the osteotomy gap via well-controlled displacement being independent from the sheep's functional weightbearing. A load sensor was integrated in the active fixation to measure the force acting in the osteotomy gap. During each stimulation cycle the displacement and force magnitudes were recorded to determine in vivo fracture stiffness. Following approval of the local ethics committee, experiments were conducted on four skeletally mature sheep. Starting from the first day after surgery, the daily stimulation protocols consisted of 1000 loading events equally distributed over 12 hours from 9:00 to 21:00 resulting in a single loading event every 44 seconds. No stimulation was performed overnight. One animal had to be excluded due to inconsistencies in the load sensor data. The onset of tissue stiffening was detected around the eleventh day post-op. However, on a daily basis, the stiffness was not steadily increasing, but instead, an abrupt drop was observed in the beginning of the daily stimulations. Following this initial drop, the stiffness increased until the last stimulation cycle of the day. The continuous measurements enabled resolving the tissue response to strain stimuli over hours and days. The presented data contributes to the understanding of the influence of patient activity on daily variations in tissue stiffness and can serve to optimize rehabilitation protocols post fractures

Introduction. The transition from resident to registrar constitutes a steep learning curve in most medical practitioners’ careers, regardless of speciality. We aimed to determine whether a six-week orthopaedic surgical skills course could increase resident skills and confidence prior to transitioning to orthopaedic registrar within the Gold Coast University Hospital, Queensland, Australia. Materials. Unaccredited registrars, orthopaedic trainees, and orthopaedic consultants, through a departmental peer reviewed process and survey, developed a six-session course (“Registrar Academy”) that included basic knowledge and essential practical skills training for residents with an interest in becoming orthopaedic registrars. This course was implemented over a 3-month period and assessed. Mixed method quantitative and qualitative evidence was sought via a 14-item and 18-item Likert scale questionnaire coupled with open-ended questions. Ethical approval was granted by our institutions Human Research and Ethics Comittee, reference no.: HREC/16/QGC336. Results/Discussion. Results were qualitatively synthesised using quantitative and qualitative data. Thirteen residents participated in the course. All residents agreed to statements indicating they felt unprepared to work as an orthopaedic registrar and were not confident in performing various core tasks required. After completing the course, residents indicated greater confidence or comfort in all these areas and felt better prepared for the transition to registrar. There was broad approval of the course among participants. Every participant who completed the final questionnaire agreed or strongly agreed that they enjoyed the course and that it taught usable, reproducible practical skills and increased their orthopaedic knowledge. This group also uniformly agreed or strongly agreed that the course improved their patient care and patient safety. Conclusion. Residents feel unprepared for their transition to orthopaedic registrar and lack confidence in several core competencies. A supplemental “Registrar Academy” within an institution is an effective way to improve knowledge, confidence, and practical skills for residents wishing to transition to a registrar position

The use of antifibrinolytic drugs and many other agents have a critical importance in bleeding control. Tranexamic acid [4- (aminomethyl) cyclohexanecarboxylic acid] is a synthetic amino acid lysine derivative with antifibrinolytic activity in humans. There are many studies in the literature that show that it is effective and effective both systemically and locally in spinal surgery. However, all of these studies have investigated the effects of topical tranexamic acid on bleeding and its effect on fusion has not been investigated yet. Aim of this study is to investigate the effect of topical tranexamic acid on fusion using macroscopic, radiologic and microscopic techniques. After approve of ethics committee with the protocol number 19/2019 for 28 Wistar Albino rats underwent intertransvers fusion. All rats were randomized into four (4) groups, using sealed envelopes. Local tranexamic acid (Transamin® 100 mg/ml, Teva İlaç, İstanbul) doses was determined based on previously conducted studies; 1mg/kg (D1 group), 10mg/kg (D10 group), 100 mg/kg (D100 group) and no tranexamic acid (D0 group). At the end of 8. th. weeks all rats were evaluated with manuel palpation, mammography and histopathologic analysis. Radiographic examination was performed two times to evaluate the intra and inter observer differences. 2 rats in-group D0 died after the radiographic examination. Assessment of fusion with manual palpation revealed that use of local 1mg / kg tranexamic acid had no effect on fusion (p=0.32), however with increasing doses of tranexamic acid had negative effect on fusion (p=0.002). On radiologic examination, spearman's rho correlation coefficient was found to be moderate in the first evaluation (r=0.46) and high in second evaluation (r=0.61). Radiological examination revealed that the control group was the best in fusion (p=0.007), and that tranexamic acid affected fusion adversely, independent of dosage (p=0.27). Among the groups in histopathologic examination, no statistical difference was found (p=0.134). Local administration of tranexamic acid affects the intertransverse fusion adversely depending on the dosage macroscopically and it also affects fusion adversely independent of the dosage radiologically and histopathologically

In the UK and USA in 2016 more than 263,000 primary knee replacements were performed. Around 20% of patients report chronic post-surgical pain (CPSP) at three or more months after total knee replacement (TKR). A large proportion of adults with all types of chronic musculoskeletal pain do not use services for a number of reasons, despite being in constant or daily pain. Given the high prevalence of CPSP, there is potentially a large hidden population with an unexpressed need for care, experiencing ongoing pain and disability; understanding why they do not use health services may herald further insight into why many remain dissatisfied with knee replacement surgery. The aim of this study is to understand why some people with CPSP after TKR do not access services or make little use of healthcare. We conducted face-to-face in-depth interviews with 34 patients from 2 high-volume orthopaedic hospitals in England, to investigate their experience of long-term pain after knee replacement; their knowledge and understanding of CPSP; and their decisions about consulting for CPSP. The sample size was based on achievement of saturation and participants provided written informed consent. Interviews were transcribed and analysed using an inductive thematic approach with double coding for rigor. Ethical approval for the study was granted by the West Midlands Solihull Research Ethics Committee (15/WM/0469). A core theme within the analysis suggests that participants do not seek healthcare because they believe that nothing further can be done, either by themselves or by healthcare professionals. Surgeons' satisfaction with the knee surgery and reassurances that pain would improve, left patients feeling uncertain about whether to re-consult, and some assumed that further consultation could lead to further surgery or medication, which they wish to avoid. Some participants' comorbidities took precedence over their knee pain when seeking healthcare. Others felt they had received their “share” of healthcare resources and that others were more deserving of treatment. People's descriptions of pain varied, from dull, or aching to shooting pains. Many described their pain as “discomfort” rather than pain. The majority described pain that was better than their pre-surgical pain, though others described pain that was worse, which they believed to be nerve damage. Many expressed disappointment in the outcome of their TKR. Expectations of pain varied, where most had expected some post-surgical pain, others underestimated it, and some had expected to be completely pain free following their TKR. Our analysis suggests that the reasons that some people with CPSP after TKR do not consult are varied and complex, spanning psychosocial, structural, moral, and organisational domains. There was an overriding sense that further consultation would be futile or may lead to unwanted treatment. Results suggest that improved information for patients about CPSP and appropriate post-surgical healthcare services may help patients and clinicians to manage this condition more effectively

Background. Bone is a hierarchically structured hard tissue that consists of approximately 70 wt% low-crystallinity hydroxyapatite. Intricate tubular channels, such as Haversian canals, Volkman's canals, and canaliculi are a preserved feature of bone microstructure. These structures provide pathways for vasculature and facilitate cell-to-cell communication processes, together supporting viability of cellular components and aiding in remodeling processes. Unfortunately, many commercial bone augmentation materials consist of highly crystalline phases that are absent of the structuring present within the native tissue they are replacing. This work reports on a the development of a novel bone augmentation material that is able to generate biologically analogous tubular calcium phosphate mineral structures from hydrogel-based spheres that can be packed into defects similar to those encountered in vivo. Experimental. Calcium loaded spheres were made by adding 5 wt% agar powder to 1 M calcium nitrate solutions, before heating the mixture to 80–90 oC and feeding droplets of gel into a reservoir of liquid nitrogen. Deposition of tubular mineral was initiated by exposure to ammonium phosphate solutions at concentrations between 500 mM and 1 M, and was characterized by micro-XRF mapping, XRD and SEM techniques. For an ex vivo model, human bone tissue was collected from patients undergoing elective knee replacement surgery. The United Kingdom National Research Ethics Service (East of Scotland Research Ethics Service) provided ethical approval (11/ES/1044). The augmented defect of the model was characterised by micro-XRF mapping and micro-CT techniques. Results and Discussion. Immersion of calcium-loaded hydrogel spheres in physiological solutions rich in phosphate promotes the release of calcium rich streams from the sphere surface, resulting in the precipitation of tubule structures. Micro-XRF mapping, XRD and SEM, revealed tubules possessed hierarchically structuring and consisted of low-crystallinity hydroxyapatite, making them analogous in composition and structure to incritate features of bone microstructure. When brought into close proximity with one another, spheres become fused in a matter of minutes by the entanglement and subsequent interstitial mineralisation of the mineral tubules. Micro-XRF mapping and micro-CT analysis of an augmented ex vivo human tissue defect model demonstrated the extensive deposition of low-crystallinity tubular mineral throughout a tissue defect. Conclusions. This is possibly the first example of a bone augmentation material that is able to generate biologically analogous structures in situ, and therefore may serve as a better scaffold for bone formation over synthetic alternatives. Moreover, the formation of structured mineral aids in achieving rapid hardening of the augmenting calcium-loaded hydrogel shperes within the defect space

Fracture healing is an issue that has not yet been fully elucidated. It is generally accepted in the literature that head trauma accelerates fracture healing and causes higher volume callus tissue. Recent studies have examined the relationship between head trauma and fracture healing more molecularly. Based on this research; the aim of this study is to show the effect of head trauma on fracture healing radiologically and histologically and to investigate the relationship between serum β-Catenin level and fracture healing with the experiment we performed on rats. A total of 36 Wistar Albino female rats with a mean age of 24 weeks were included in the study with the permission of Mersin University Animal Experiments Local Ethics Committee. Six rats in the first group were not traumatized and their blood samples were collected on the day of the experiment started, end of the third week and end of the sixth week. In the second group, only head trauma was performed and blood samples were collected at the end of the third and sixth weeks. In the third group, only open femoral fracture model was applied, blood samples were collected at the third and sixth weeks and AP and Lateral radiographs of the fractured femurs were taken. After sacrification, femurs were dissected from the surrounding soft tissues and subjected to histological examination. In the fourth group, both head trauma and open femur fracture model were applied, blood samples were collected at the end of third and sixth weeks and AP and Lateral radiographs of the fractured femurs were taken. After sacrification, femurs were dissected from the surrounding soft tissues and subjected to histological examination. The expression level of β-Catenin was measured by PCR from all blood samples. Direct radiographs of the third and fourth groups at 3 and 6 weeks were evaluated by two orthopedists according to Rust and Lane & Sandhu scoring system. The histomorphometric examination was performed by evaluating the Huo scoring and the ratio of fracture callus components (cartilage callus, bone callus, fibrous callus) to areas. According to PCR analysis, the change of expression of β-Catenin by weeks was not statistically significant in the first and second groups. However, a statistically significant decrease was observed in the 0–6 week interval in the third and fourth groups (p = 0.002, p <0.0001, respectively). In the radiological examination, the union scores of the rats with head trauma + femoral fracture were higher than the isolated femoral fractures at 3 weeks and 6 weeks. In histomorphometric examination, no statistically significant difference was found between head trauma + femur fracture group and isolated femur fracture group. In addition, there was no correlation between the groups in the correlation studies between radiological findings, histomorphmetric findings and PCR findings. Considering that each molecule involved in fracture healing processes has a time interval and concentration; We concluded that the expression levels of β-catenin can be repeated in smaller time periods including the early stages of fracture healing

Background. Hip fracture care has evolved, largely due to standardisation of practice, measurement of outcomes and the introduction of the Best Practice Tariff, leading to the sustained improvements documented by the National Hip Fracture Database (NHFD). The treatment of distal femoral fractures in this population has not had the same emphasis. This study defines the epidemiology, current practice and outcomes of distal femoral fractures in four English centres. Methods. 105 patients aged 50 years or greater with a distal femoral fracture, presenting to four UK major trauma centres between October 2010 and September 2011 were identified. Data was collected using an adapted NHFD data collection tool via retrospective case note and radiograph review. Local ethics approval was obtained. Results. Mean age was 77 years (range 50–99), with 86% female. 95% of injuries were sustained from a low energy mechanism, and 72% were classified as either 33-A1 or 33-C1. The mean Parker mobility score and Barthel Independence Index were 5.37 (0–9) and 75.5 (0–100) respectively. Operative management was performed in 84%, and 86% had their surgery within 36 h. Three quarters were fixed with a peri-articuar locking plate. There was no consensus on post operative rehabilitation, but no excess of complications in the centres where weight bearing as tolerated was the standard. 45% were seen by an orthogeriatrician during their admission. Mean length of stay was 29 days. Mortality at 30 days, 6 months, and 1 year was 7%, 16% and 18% respectively. Conclusions. This study demonstrates that the distal femoral and hip fracture populations are similar, and highlights the current disparity in their management. The metrics and standards of care currently applied to hip fractures should be applied to the treatment of distal femoral fractures. Optimal operative treatment and rehabilitation remains unclear, and further research is in progress. Level of evidence. 2b. Ethics. Local approval was obtained

Background. Articular cartilage has poor repair properties and poses a significant challenge in orthopaedics. Damage as a result of disease or injury frequently leads to formation of an osteochondral defect. Conventional repair methods, including allograft, autograft and microfracture, have a number of disadvantages in terms of cost, associated technical challenges and the requirement for multiple operations. A novel tri-layered scaffold developed in our lab, addresses this issue as it closely matches the structure and composition of osteochondral tissue. Methods. In vivo assessment was carried out in a caprine model by creating 6 mm × 6 mm defects in the medial femoral condyle and lateral trochlear ridge of each joint. Defects were implanted with the tri-layered scaffold and for comparison also with a market-leading scaffold, while some of defects were left empty, acting as a control. Assessment was carried out at 3 month, 6 month and 12 month time points. The quality of the repair at the various time points was graded macroscopically and microscopically by histological staining of the samples and also assessed using micro-CT (computed tomography) analysis. Results. From 3 to 6 months the tri-layered scaffold group showed improved macroscopic repair compared to the empty defect group. Greater levels of bone formation in the tri-layered scaffold group were evident on micro-CT evaluation, and this was confirmed by histological staining. Finally, at 12 months superior results were seen in the tri-layered scaffold group with formation of hyaline-like cartilage within the defect and regeneration of the subchondral bone. Conclusions. Positive results to date show that the tri-layered to be a promising method for cartilage repair and regeneration by promoting natural cartilage re-growth. It negates the need for other biological agents such as genes and growth factors by stimulating the native tissue osteochondral repair mechanism. Level of evidence. Animal research. Ethics Approval. The Ethics Committee of the University College Dublin (UCD) (AREC-P-11-31) approved this study and the Irish Government Department of Health (B100/4317) granted an animal license

Background. Around 1% of patients who have hip replacement have deep prosthetic joint infection afterwards. Infection is treated with antibiotics and revision surgery. We aimed to characterise the impact of deep joint infection and its treatment, to identify treatment preferences, and to describe surgeons' treatment decisions. Methods. In a qualitative study in the UK we interviewed 19 patients who had infection after hip replacement and 12 orthopaedic surgeons specialising in infection. Face-to-face interviews with patients explored experience of infection, treatment and recovery. Interviews with surgeons explored treatment decisions. With consent, interviews were audio-recorded, transcribed and anonymised. Once imported into QSR NVivo software, data were analysed using constant comparison. Results. Patients with deep joint infection described mobility loss, pain, loss of valued activities, changes to home environments/moving into care, negative impact on personal relationships and financial strain. Physical and psychological trauma was associated with revision surgery and antibiotic treatment. Patients had strong preferences for treatment options, emphasising impact of surgery, side effects of antibiotics and duration of treatment as key considerations. Although eradication of infection was important, patients felt that reducing impact of treatment was high priority and identified a need for more support. Surgeons' treatment decisions focused on patient characteristics and nature of infection to prioritise eradication of infection. During patients' recovery surgeons' were concerned about possible return of infection and patients' mobility and function. Conclusion. Infection after joint replacement causes physical and psychological trauma. Balancing patients' preferences for reducing impact of treatment with surgeons' emphasis on eradication of infection should be an important consideration in care. There is also need to develop new interventions to support patients with infection. Level of evidence. Level 3 – Qualitative Research. Funding statement. This paper presents independent research funded by the National Institute for Health Research (NIHR) under its Programme Grants for Applied Research scheme (grant number: RP-PG-1210-12005). The views expressed in this publication are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health. Ethics. This study has been given a favourable opinion for conduct in the NHS by the National Research Ethics Service Committee South West – Exeter 14/SW/0072

Background. Total hip replacement (THR) and total knee replacement (TKR) are usually effective at relieving pain; however, 7–23% of patients experience chronic post-surgical pain. These trials aimed to investigate the effect of local anaesthetic wound infiltration on pain severity at 12 months after primary THR or TKR for osteoarthritis. Methods. Between November 2009 and February 2012, 322 patients listed for THR and 316 listed for TKR were recruited into a single-centre double-blind randomised controlled trial. Participants were randomly assigned (1:1) to receive local anaesthetic infiltration and standard care or standard care alone. Participants and outcomes assessors were masked to group allocation. The primary outcome was pain severity on the WOMAC Pain scale at 12 months post-surgery. Analyses were conducted using intention-to-treat and per-protocol approaches. Ethics approval was obtained from Southampton and South West Hampshire Research Ethics Committee. Results. In the hip trial, patients in the intervention group had significantly less pain at 12 months post-operative than patients in the standard care group (differences in means 4.74; 95% CI 0.95, 8.54; p=0.015), although the difference was not clinically significant. Post-hoc analysis found that patients in the intervention group were more likely to have none to moderate pain than severe pain at 12 months than those in the standard care group (odds ratio 10.19; 95% CI 2.10, 49.55; p=0.004). In the knee trial, there was no strong evidence that the intervention influenced pain severity at 12 months post-operative (difference in means 3.83; 95% CI −0.83, 8.49; p=0.107). Conclusions. In conclusion, routine use of infiltration could be beneficial in improving long-term pain relief for some patients after THR. Level of evidence. Randomised controlled trial. Funding. This article presents independent research funded by the National Institute for Health Research (NIHR) in England 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 acknowledge the support of the NIHR, through the Comprehensive Clinical Research Network

Background. Although there are predictive equations that estimate the total fat mass obtained from multiple-site ultrasound (US) measurements, the predictive equation of total fat mass has not been investigated solely from abdominal subcutaneous fat thickness. Therefore, the aims of this study were; (1) to develop regression-based prediction equations based on abdominal subcutaneous fat thickness for predicting fat mass in young- and middle-aged adults, and (2) to investigate the validity of these equations to be developed. Methods. The study was approved by the Local Research Ethics Committee (Decision number: GO 19/788). Twenty-seven males (30.3 ± 8.7 years) and eighteen females (32.4 ± 9.5 years) were randomly divided into two groups as the model prediction group (19 males and 12 females) and the validation group (8 males and 6 females). Total body fat mass was determined by dual-energy X-ray absorptiometry (DXA). Abdominal subcutaneous fat thickness was measured by US. The predictive equations for total fat mass from US were determined as fat thickness (in mm) × standing height (in m). Statistical analyses were performed using R version 4.0.0. The association between the total fat mass and the abdominal subcutaneous fat thickness was interpreted using the Pearson test. The linear regression analysis was used to predict equations for total body fat mass from the abdominal subcutaneous fat thickness acquired by US. Then these predictive equations were applied to the validation group. The paired t-test was used to examine the difference between the measured and the predicted fat masses, and Lin's concordance correlation coefficient (CCC) was used as a further measure of agreement. Results. There was a significant positive moderate correlation between the total fat mass and the abdominal subcutaneous fat thickness × height in the model prediction group of males (r = 0.588, p = 0.008), whereas significant positive very strong correlation was observed in the model prediction group of females (r = 0.896, p < 0.001). Predictive equations for DXA-measured total body fat mass from abdominal subcutaneous fat thickness using US were as follows: for males “Fat mass-DXA = 0.276 × (Fat thickness-US × Height) + 17.221” (R. 2. = 0.35, SEE = 3.6, p = 0.008); for females “Fat mass-DXA = 0.694 x (Fat thickness-US × Height) + 7.085” (R. 2. = 0.80, SEE = 2.8, p < 0.001). When fat mass prediction equations were applied to the validation groups, measured- and estimated-total fat masses in males and females were found similar (p = 0.9, p = 0.5, respectively). A good level of agreement between measurements in males and females was attained (CCC = 0.84, CCC = 0.76, respectively). Conclusion. We developed and validated prediction equations that are convenient for determining total fat masses in young- and middle-aged adults using abdominal subcutaneous fat thickness obtained from the US. The abdominal subcutaneous fat thickness obtained from a single region by US might provide a noninvasive quick and easy evaluation not only in clinical settings but also on the field

The aim of this study was to evaluate the trochlear bone and cartilaginous regeneration of rabbits using a composite based on platelet rich plasma (PRP), chitosan and hydroxyapatite. The study was approved by the ethics committee of the Federal University of Campina Grande under number 72/2017. Surgical holes measuring four millimetres in diameter were performed in rabbit trochleae, one surgical hole in each animal remained empty and another one was filled with the composite. Clinical-orthopaedic and radiographic evaluations were carried out for 60 days, after which the animals were euthanized for histomorphometric evaluations. Clinical-evaluations exhibited lameness of two members of the treatment (T) group and one member of control (C) group. The radiographic evaluation of T group exhibited absence of subchondral bone reaction (33%); nonetheless, presence of moderate subchondral bone reaction was more frequently reported in group C with 67%. Microscopic evaluation revealed the presence of tissue neoformation, composed of dense connective tissue. Microscopic findings were similar in both groups, with a difference in the amount of neoformed tissue, which was confirmed after the morphometric analysis, revealing a significant difference in the quantity of newly formed tissue at the bone / cartilage / implant interface in the T group. The results indicate that the composite based on chitosan, hydroxyapatite and PRP enhanced bone and cartilage healing