Thumb carpometacarpal joint (CMCJ) arthritis is a common and debilitating condition. The mainstay of surgical management is Trapeziectomy. Concerns about possible functional implications of collapse of the metacarpal into the arthroplasty space as well as the potential for scaphometacarpal led to the development of techniques to try and prevent this. The purpose of this study was to investigate if there were any significant differences in the long-term outcomes of patients who participated in a randomized trial of trapeziectomy alone compared with trapeziectomy with ligament reconstruction and tendon interposition (LRTI).

Sixty-five patients participated in our original trial, the 1 year findings of which were published in 2007. These patients were invited for a follow-up visit at a mean of 17 years (range 15–20) postoperatively. Twenty-eight patients attended, who had 34 operations, 14 trapeziectomy alone and 20 with LRTI. Patients were asked to complete a visual analogue scale (VAS) for satisfaction with the outcome of their procedure, rated on a scale from 0 (most dissatisfied) to 100 (most satisfied). They also completed the short version of the Disabilities of the Arm, Shoulder and Hand Score (QuickDASH) at their appointment. They underwent a functional assessment with a hand therapist and had a radiograph of the thumb.

There were no statistically significant differences between the two groups in terms of satisfaction with surgery or functional outcomes, with most measurements showing minimal or no differences in means between the two groups. There was no difference in the space between the metacarpal and scaphoid on radiograph. Radial abduction was the only parameter that was significantly greater in the patients with simple trapeziectomy (median 79°) compared with trapeziectomy with LRTI (median 71°) (p = 0.04). Even at 17 years there is no significant benefit of LRTI over trapeziectomy alone for thumb carpometacarpal joint osteoarthritis.

Cervical spine fractures are frequent in impact sports, such as rugby union. The consequences of these fractures can be devastating as they can lead to paraplegia, tetraplegia and death. Many studies have been conducted to understand the injury mechanisms but the relationship between player cervical spine posture and fracture pattern is still unclear. The aim of this study was to evaluate the influence of player cervical spine posture on fracture pattern due to an impact load. Nineteen porcine cervical spines (C2 to C6) were dissected, potted in PMMA bone cement and mounted in a custom made rig. They were impacted with a mean load of 6 kN. Eight specimens were tested in an axial position, five in flexion and six in lateral bending. All specimens were micro-CT imaged (Nikon XT225 ST Scanner, Nikon Metrology, UK) before and after the tests, and the images were used to assess the fracture patterns. The injuries were classified according to Allen-Ferguson classification system by three independent observers. The preliminary results showed that the main fracture modalities were consistent with those seen clinically. The main fractures for the axial orientation were observed in C5-C6 level with fractures on the articular process and endplates. These findings support the concept that the fracture patterns are related to the spine position and give an insight for improvements on sports rules in order to reduce the risk of injury.

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.

Summary Statement

Developing titanium (Ti) surfaces that are biocompatible yet serve as deterrents for bacterial attachment and growth are particularly appealing in tackling the ongoing problem of sepsis-induced implant failures. Realising this could include coating Ti with the bioactive lipid, lysophosphatidic acid.

The Enhanced Recovery Pathway aims to improve the patient experience as well as expediting discharge. We aim to discharge 85% of patients by day 3. This audit retrospectively looked at primary total hip replacements (THR) and total knee replacements (TKR) patients who had 7 days length of stay and evaluated the factors contributing to the delay.

There were 24 patients who stayed 7 days, 12 THR and 12 TKR. There were 15 females and 7 males, the mean age was 77 years (52 to 89). Causes for the delay included patient's reluctance to engage in their rehabilitation (21/24) and Occupational Therapists (OT) identifying difficulties in patient's home circumstances on admission (12/24). Medical problems also delayed early mobilisation, particularly urethral catheterisation (9/24), investigation for venous thromboembolism (6/24) and blood transfusion (3/24).

Delay in discharge is multifactorial and requires involvement of MDT. We have identified ways to enhance patient engagement, including a “patient journey” DVD shown preoperatively at “Joint School” and individual white boards for daily goal setting. Fostering greater self-efficacy in patients may improve participation in preoperative discharge planning with OTs. Specific preoperative education may help patients understand the importance of continuing their rehabilitation while medical problems are managed.

Successful osseointegration requires the production of a mechanically competent collagenous matrix, by osteoblasts, at the implant site. Lysophosphatidic acid (LPA) is a bioactive lipid which we discovered interacts with vitamin D3 (D3) to secure human osteoblast (hOB) maturation on both titanium (Ti) and hydroxyapatite.

We therefore covalently attached LPA and a related compound, (3S) 1-fluoro-3-hydroxy-4-butyl-1-phosphate (FHBP), to both solid and porous Ti discs and seeded them with hOBs to assess their ability to support D3-induced cell maturation. Solid functionalised discs were washed and reused a further two times, whilst other discs were stored for 6 months.

Increased alkaline phosphatase (ALP) activity indicated that both LPA and FHBP-modified Ti serve as superior substrates for securing D3-induced hOB maturation compared to unmodified metal (p < 0.001). Although total ALP activity was less for cells on recycled discs and after storage, enzyme levels were still significantly greater compared to hOBs grown on control Ti. LPA and D3 co-treatment also resulted in an increase in osteocalcin (∼17ng/ml versus 6ng/ml for D3 alone, P < 0.001) and collagen synthesis (∼310pg/ml versus <10pg/ml for D3 alone, P < 0.001).

Research is ongoing to evaluate the efficacy of our modified Ti surfaces to secure hOB formation from their stem cell progenitors.

Approximately one-fifth of patients are not satisfied with total knee arthroplasty (TKA). Preoperative variables associated with poorer outcomes are severity and chronicity of pain and psychological disease, which may present as anxiety and depression. It is unclear whether this is constitutional or the result of knee pain. To address this, we explored the association of anxiety and depression with knee disability before and after TKA.

Forty patients undergoing TKA completed Hospital Anxiety and Depression Scale (HADS) and Oxford Knee Scores (OKS) preoperatively and at three and six months postoperatively. Both were elevated preoperatively and improved significantly post-operatively (P<0.001). The severity of preoperative anxiety and depression was associated with worse knee disability (coefficient −0.409, p=0.009). Postoperatively reduction in anxiety and depression was associated with improvement in knee disability after three (coefficient −0.459, p=0.003) and six months (coefficient −0.428, p=0.006).

The difficulty in interpreting preoperative anxiety and depression and the outcome of TKA is establishing whether they are the cause or effect of pain in the knee. As anxiety and depression improves with knee pain and function, this study suggests that knee pain contributes to the psychological symptoms and that a successful TKA offers an excellent chance of improving both.

Proximal femoral fractures affect around 60 000 patients annually in the UK. A delay in excess of 48 hours from admission to theatre has been shown to have an adverse effect on mortality, morbidity and length of inpatient stay in this patient group (Hollingworth 1993). We set out to identify the causes and effects of any delay to theatre and make suggestions in order to improve the quality and efficiency of our service.

We tracked 224 consecutive patients all admitted with a proximal femoral fracture over an eight month period. We recorded a number of details including whether or not a delay occurred and why, on a session-by-session basis.

Of the 214 patients included, 75.7% were considered fit enough for surgery at admission; 83.2% of these suffered some sort of delay to theatre. Only 5.6% of patients (8 in total) were considered fit enough for surgery at admission, suffered a delay to theatre and subsequently became unfit causing a further delay.

We were reassured to find that our patients are not suffering a longer than average delay to theatre and that those patients who were waiting longer were not becoming ill as a result. We also found that patients admitted on certain days of the week seemed to wait longer, indicating that certain sub-specialty elective lists were taking up theatre time and exacerbating the delay. We have suggested changes to the theatre rota in order to maximise efficiency and aim to repeat this audit to evaluate the effect of these changes.

Introduction: The main problem facing the longevity of total hip replacements (THR) is wear particle induced osteolysis, particularly around the acetabular component. The articulating surfaces produce wear particles that migrate in the fibrous tissue membrane along the acetabular implant-bone interface causing osteolysis and subsequent implant loosening. The hypothesis that we investigated was that uncemented acetabular interfaces are more effective than cemented implants at resisting progressive osteolysis through bone attachment and the formation of a biological seal.

Methods: THR surgery was performed in an ovine model. Implants remained in vivo for 1 year. Femoral heads were roughened in order to generate wear debris and aseptic loosening of the acetabular component. Sheep were randomly assigned to one of three experimental groups: cemented polyethylene, grit blasted or plasma sprayed porous acetabular components with a polyethylene insert. Ground Reaction Force (GRF) data was collected pre-op and at 12, 24, 36 and 52 weeks post op. Retrieved specimens were analysed radiographically, histologically and using Scanning Electron Microscopy (SEM). A mould was made of the polyethylene liner and head penetration rates quantified using a shadowgraph technique. Thin sections through the acetabuli were prepared and image analysis used to quantify fibrous tissue (FT) thickness at the bone-implant interface. Mann-Whitney U tests were used for comparative statistical analysis where p< 0.05 were classified as significant.

Results: GRF demonstrated functional hips. A gradual increase was seen until week 36 followed by a decrease until retrieval suggesting the onset of aseptic loosening. 42.86% of control, 60% of grit blasted and 50% of porous coated components were deemed radiographically loose. Mean linear penetration rates demonstrated significantly less penetration within the porous cups (p=0.003, control and p=0.036, grit blasted). SEM established that wear particles generated were < 1μm in size. Light microscopy of thin sections revealed the common mechanism of loosening involving a resorption wedge at the interface with progressive bone loss. In all cases, the FT layer was greatest at the rim of the cup and gradually decreased towards the apex. The grit blasted group had the thickest FT layer adjacent to the cup. Under polarised light, wear debris was seen packed within macrophages in all sections.

Discussion: GRF data demonstrated grit blasted cups to have least function. This was confirmed through histology as they had the thickest FT layer surrounding the acetabular shell suggesting increased aseptic loosening of its component due to wear particles being able to access the interface more easily. Data corroborates radiographic results. In conclusion, porous and control cups performed better than grit blasted cups. Acknowledgments: EPSRC.