Studies have shown that 10–30% patients do not achieve optimal function outcomes after total hip replacement (THR). High quality randomised controlled trials (RCTs) evaluating the clinical and cost-effectiveness of techniques to improve functional outcomes after THR are lacking. We performed this study to evaluate the feasibility of a RCT comparing patient-reported functional outcomes after hybrid or fully cemented THR (ISRCTN11097021).

Patients were recruited from two centres and randomised to receive either a fully cemented or hybrid THR. Data collection included Patient Reported Outcome Measures (PROMs), non-serious adverse events of special interest (AESI), serious adverse device effects (SADE) and NHS resource use. Qualitative interviews were undertaken to understand a) patient experiences of study processes and their reasons for taking part or not, and b) to understand surgeons’ perceptions of the study, factors affecting willingness to participate, and barriers to implementation of the future RCT findings.

The target of 40 patients were successfully recruited for the feasibility RCT; the ratio of successful recruitment to eligible patients was 0.61 across both sites. Treatment crossovers occurred in four patients, all related to bone quality. Four patients were withdrawn due to not undergoing surgery within the study window because of the pandemic. Follow-up was 100% and PROMs were completed by all patients at all time points. The feasibility of conducting a within-trial cost-utility analysis was demonstrated. Interviews were conducted with 27 patients and 16 surgeons. Patients and surgeons generally found the study procedures acceptable and workable. Some declined participation because they did not want treatment allocated at random, or because blinding was off-putting. Surgeons’ perceptions of equipoise varied, and implementation of findings from the future RCT would need to recognise the ‘craft’ nature of surgery and the issue of training.

We conclude that a full RCT with economic analysis will be both feasible and practicable, although mechanisms to safely implement potential changes to practice because of RCT findings may need consideration by the wider arthroplasty community.

Abstract

The radiographic or bony landmark techniques are the two most common methods to determine Medial patellofemoral ligament (MPFL) femoral tunnel placement. Their intra/inter-observer reliability is widely debated. The palpation technique relies on identifying the medial epicondyle (ME) and adductor Tubercle (AT). The central longitudinal artery and associated vessels (CLV) are consistently seen in the surgical dissection during MPFL reconstruction. The aim of this study was to investigate the anatomic relationship of CLV to ME-AT and thereby use CLV as an important vascular landmark during MPFL reconstruction.

A retrospective review of MRI scans in skeletally mature patients presenting to a tertiary referral knee clinic was undertaken. Group-N consisted of any presentation without patellofemoral instability or malalignment (PFI). Group-P with PFI. MRI's were reviewed and measured by two Consultant Radiologists for the CLV-ME-AT anatomy and relationship.

Following exclusions 50 patients were identified in each group. The CLV passed anterior to the AT and ME in all patients. ME morphology did not differ greatly between the groups except in the tubercle height, where there was a statically but not clinically significant difference (larger in the non-PFI group, 2.95mm vs 2.52mm, p=0.002). The CLV to ME Tip distance was consistent between the groups (Group PFI group 3.8mm & ‘normal’ non-PFI Group 3.9mm).

The CLV-ME-AT relationship remained consistent despite patients presenting pathology. The CLV consistently courses anterior to ME and AT. The CLV could be used as a vascular landmark assisting femoral tunnel placement during MPFL reconstruction.

Abstract

Research into the treatment of Femoro-Acetabular Impingement (FAI) has focussed on surgical correction of structural abnormalities and tended to overlook the dynamic process of impingement. The role of Physiotherapy in addressing abnormal hip movement and any resulting effect on the symptoms of FAI remains untested. A pilot study was therefore instigated to evaluate the effect of physiotherapy on pain and function in patients with FAI.

30 adults aged between 18 and 50 years with a diagnosis of symptomatic FAI were recruited. 23 (77%) completed the study.

Intervention was 3 months of specialist physiotherapy focused on improving pelvic and proximal femoral control. The control group received routine care.

All functional outcomes improved in the Physiotherapy group and this included improvement beyond minimal clinically important difference and measurement error on the Hip Outcome Score.

There was marginal improvement in pain in both groups

Results suggest that physiotherapy treatment can improve function in adults with symptomatic FAI. Larger studies are needed to evaluate the role of conservative management in FAI.

Purpose and Background

This pilot study aimed to determine the accuracy of lumbar spine combined movement (CM) testing for diagnosing facet joint mediated pain, by comparing CM to medial branch blocks (MBB) - the gold standard in the diagnosis of facet joint pain. A regular compression pattern of CM combines active extension and lateral flexion, which is believed to compress the facet joints greater than physiological uni-planar movements.

The aim of this prospective study was to determine the prevalence of bone marrow oedema (BME) in asymptomatic knees of athletes and to investigate the factors associated with appearance of BME in this group.

A total of 25 asymptomatic athletes who competed at an international, national or county level during their most recent sport season were recruited in this study and had MRI scan of both knees (n=50). MRI scans were reported independently by two experienced musculoskeletal radiologists. Statistical analysis included Cohen's kappa test to identify inter-observer agreement for MRI diagnosis of bone marrow oedema and multiple logistic regression model to identify the factors associated with BME on MRI scan.

There was very good agreement between radiologists for diagnosis of BME (Kappa = 0.896). Seven participants (28%) were found to have BME. Six of the participants had BME in unilateral knees and one participant had BME in bilateral knees. The commonest location of BME was medial femoral condyle (62.5%) The amount of time spent in preseason training (34-38 weeks) was significantly associated with appearance of BME (P=0.048)

BME seems to be common in asymptomatic athletes and one should realize that this finding might not be related to the clinical complaints of the patients. The results of the present study show that there is a training effect associated with BME. Knowing what is a ‘normal’ or ‘abnormal’ scan is important for a competitive athlete, as erroneously diagnosing BME as the underlying cause of athletes' symptoms could lead to decreased playing time or inappropriate therapy.

Aim: Subtle intra-articular screw penetration of the distal radius during fracture fixation is difficult to determine using standard PA and lateral radiographs. The purpose of our study was to determine which radiographs most reliably identify penetration into the joint.

Methods: A distal volar locking plate was applied to an isolated cadaveric radius bone and a series of plain radiographs taken. The radius, fixed along its long axis, was allowed to rotate through 180 degrees and inclined, in increments, to 40 degrees. In the control group the distal screws did not breach the articular surface. In the study group the screws penetrated the articular surface by 1mm. In each group 65 plain radiographs were taken and the presence or absence of screw penetration scored by two blinded observers.

Results: Using Weighted Kappa analysis the overall inter-observer agreement for all views was 0.5 (CI 0.39 –0.63). However in 7 radiographs there was complete inter-observer agreement correctly identifying screw penetration of the articular surface. The articular surface was correctly identified as intact in 13 views. Only a 75 degrees pronated view, without inclination, was 100% sensitive and specific for identifying the absence or presence of screw penetration through the articular surface.

Conclusion: The intra-operative use of a 75 degrees pronated view may reduce the need for repeated use of the image intensifier and excessive irradiation during plate fixation of distal radius fractures.

Aim: Subtle intra-articular screw penetration of the distal radius during fracture fixation is difficult to determine using standard PA and lateral radiographs. The purpose of our study was to determine which radiographs most reliably identify penetration into the joint.

Methods: A distal volar locking plate was applied to an isolated radius bone and a series of plain radiographs taken. The radius, fixed along its long axis, was allowed to rotate through 180 degrees and inclined, in increments, to 40 degrees. In the control group the distal screws did not breach the articular surface. In the study group the screws penetrated the articular surface by 2mm. In each group 65 plain radiographs were taken and the presence or absence of screw penetration scored by two blinded observers.

Results: Using Weighted Kappa analysis the overall inter-observer agreement for all views was 0.5 (CI 0.39–0.63). However in 7 radiographs there was complete inter-observer agreement correctly identifying screw penetration of the articular surface. The articular surface was correctly identified as intact in 13 views. Only a 75 degrees pronated view, without inclination, was 100 % sensitive and specific for identifying the absence or presence of screw penetration through the articular surface.

Conclusion: The intra-operative use of a 75 degrees pronated view may reduce the need for repeated use of the image intensifier and excessive irradiation during plate fixation of distal radius fractures.

Background: A totally new double-threaded cone-shaped modular femoral stem has been designed, using rotational rather than percussive hammer insertion of the prosthesis. The vertical height, the neck length, the neck anteversion angle and the medial offset can all be adjusted after preparation of the femoral canal has been completed.

Methods: The new stem design and the technique of insertion are described. A consecutive series of the first 110 hip joints in 103 patients were followed clinically and radiographically for an average of 28 months.

Results: The Harris hip score average rose from 43.6 points preoperatively to 91 points postoperatively. The pain score average changed from 7.9 points to 42 points, respectively. Thirteen hips (11.8%) had mid-thigh pain, most of them mild. One hip (0.9%) showed clinical and radiographic signs of early loosening and was revised.

Conclusions: The short-term clinical and radiographic outcomes were encouraging. The double-threaded cone-shaped stem locking mechanism was shown to be able to withstand the torsional and vertical forces applied to a hip-replacement prosthesis.

Background: A total new double-threaded cone-shaped modular femoral stem has been designed, using rotational rather than percussive hammer insertion of the prosthesis. The vertical height, the neck length, the neck anteversion angle and the medial offset can all be adjusted after preparation of the femoral canal has been completed.

Methods: A consecutive series of the first 110 hip joints in 103 patients were followed clinically and radiographically for an average of 28 months.

Results: The mean Harris hip score rose from 43.6 points preoperatively to 91 points postoperatively. The mean pain score changed from 7.9 points to 42 points, respectively.

13 hips (11.8%) had mid-thigh pain, most of them mild. One hip (0.9%) showed clinical and radiographic signs of early loosening and was revised.

Conclusion: The short-term clinical and radiographic outcomes are encouraging. The double-threaded cone-shaped stem locking mechanism has been shown to be able to withstand the torsional and vertical forces applied to hip replacement prosthesis.

Aim: To determine the pattern of gene expression induced in cultured human chondrocytes in response to compressive mechanical loads.

Methods: Chondrocytes were obtained from tissue discarded at the time of a number of total knee replacements and where established in primary cell culture. The cultured chondrocytes were then subjected to compressive and tensile loads using a Flexcell machine. The RNA was subsequently extracted from these chondrocytes and the alterations in gene expression determined using the Affymetrix Gene Array machine.

Results: Intended as an in vitro model for Osteoarthritis, it was found that mechanical stimulation of human chondrocytes caused a significant alteration in the expression of a number of classes of compounds. These included enzymes, inflammatory mediators and structural proteins.

Conclusions: This study identified several interesting candidate genes whose expression was significantly altered after being exposed to a laboratory model for osteoarthrosis. Further study of these genes and their expression may lead to important clinical applications.