Aims

Metabolic profiling is a top-down method of analysis looking at metabolites, which are the intermediate or end products of various cellular pathways. Our primary objective was to perform a systematic review of the published literature to identify metabolites in human synovial fluid (HSF), which have been categorized by metabolic profiling techniques. A secondary objective was to identify any metabolites that may represent potential biomarkers of orthopaedic disease processes.

Magnetic resonance imaging (MRI) was used to compare the appearance of the spine in 20 adolescents with proven symptomatic intervertebral disc herniations with that in 20 asymptomatic patients who acted as controls. Abnormality in the signal from the nucleus pulposus of one or more discs was present in all patients, while only four of the 20 controls had any abnormal signals. In all the patients the symptomatic disc produced an abnormal signal and in most a herniated fragment of the nucleus pulposus was identified. Fifteen of the 20 patients had multiple-disc abnormality: six had three abnormal discs and nine had two. This suggests there was an underlying diathesis in patients who later developed disc herniation

Aims

The first death in the UK caused by COVID-19 occurred on 5 March 2020. We aim to describe the clinical characteristics and outcomes of major trauma and orthopaedic patients admitted in the early COVID-19 era.

We followed, prospectively, 77 patients (90 hips) with early-stage, non-traumatic osteonecrosis of the femoral head for a mean period of nine years. At the time of final review, 56 (62%) were symptomatic. Using the Cox model, the initial radiological stage, the progression of staging, the reduction in size of the lesions and the percentage of necrotic volume on MRI were identified as risk factors. Using the Harris score of < 70 or surgery as the endpoint, the cumulative rates of survival were 60.0% at one year, 43.3% at two years, 38.9% at five years and 37.2% at ten years. Survival curves demonstrated that clinical deterioration could occur 90 months after the initial diagnosis, suggesting that asymptomatic patients should be followed carefully for several years. Radiological time-dependent reduction in size without progressive collapse may represent repair even when the collapse is minimal

Aims

COVID-19 necessitated abrupt changes in trauma service delivery. We compare the demographics and outcomes of patients treated during lockdown to a matched period from 2019. Findings have important implications for service development.

We used MRI to examine the hips of 32 asymptomatic patients at 9 to 21 months after renal transplantation covered by high-dose corticosteroids. Five hips in three patients showed changes which indicate avascular necrosis, although radiographs, CT scans and isotope scans were normal. These patients had repeat MRI scans after another two years and three years. One patient with bilateral MRI changes developed symptoms and abnormal radiographs and CT and isotope scans in one hip nine months after the abnormal MRI. Intraosseous pressure was found to be raised in both hips, and core biopsies revealed necrotic bone on both sides. The other three hips have remained asymptomatic with unchanged MRI appearances three years after the initial MRI. It seems that idiopathic avascular necrosis does not always progress to bone collapse in the medium term

1. Forty-two previously asymptomatic patients presenting with a recent rupture of the lateral ligament of the ankle, and twenty similar patients with a simple sprain of this ligament, have been followed for one year. The physical and radiological findings upon the completion of treatment have been related to functional instability of the foot one year later. 2. Persistent mechanical varus instability of the talus in the ankle mortise was a possible cause of functional instability one year after injury in four (or perhaps six) patients. 3. Adhesion formation was a possible cause of functional instability in one patient. 4. Seventeen patients finally displayed no clinical or radiological abnormality after injury, but noted functional instability of the foot one year later. 5. It is concluded that the pathological process which is usually responsible for functional instability of the foot after a lateral ligament injury is at present unknown

The coronavirus disease 2019 (COVID-19) pandemic has led to unprecedented challenges to healthcare systems worldwide. Orthopaedic departments have adopted business continuity models and guidelines for essential and non-essential surgeries to preserve hospital resources as well as protect patients and staff. These guidelines broadly encompass reduction of ambulatory care with a move towards telemedicine, redeployment of orthopaedic surgeons/residents to the frontline battle against COVID-19, continuation of education and research through web-based means, and cancellation of non-essential elective procedures. However, if containment of COVID-19 community spread is achieved, resumption of elective orthopaedic procedures and transition plans to return to normalcy must be considered for orthopaedic departments. The COVID-19 pandemic also presents a moral dilemma to the orthopaedic surgeon considering elective procedures. What is the best treatment for our patients and how does the fear of COVID-19 influence the risk-benefit discussion during a pandemic? Surgeons must deliberate the fine balance between elective surgery for a patient’s wellbeing versus risks to the operating team and utilization of precious hospital resources. Attrition of healthcare workers or Orthopaedic surgeons from restarting elective procedures prematurely or in an unsafe manner may render us ill-equipped to handle the second wave of infections. This highlights the need to develop effective screening protocols or preoperative COVID-19 testing before elective procedures in high-risk, elderly individuals with comorbidities. Alternatively, high-risk individuals should be postponed until the risk of nosocomial COVID-19 infection is minimal. In addition, given the higher mortality and perioperative morbidity of patients with COVID-19 undergoing surgery, the decision to operate must be carefully deliberated. As we ramp-up elective services and get “back to business” as orthopaedic surgeons, we have to be constantly mindful to proceed in a cautious and calibrated fashion, delivering the best care, while maintaining utmost vigilance to prevent the resurgence of COVID-19 during this critical transition period.

Cite this article: Bone Joint Open 2020;1-6:222–228.

Aims

The lack of disease-modifying treatments for osteoarthritis (OA) is linked to a shortage of suitable biomarkers. This study combines multi-molecule synovial fluid analysis with machine learning to produce an accurate diagnostic biomarker model for end-stage knee OA (esOA).

1. The results of three forms of treatment (mobilisation, immobilisation for six weeks, and suture with immobilisation for six weeks) for ruptures of the lateral ligament of the ankle have been compared in previously uninjured asymptomatic patients. 2. Only suture and immobilisation ensured final mechanical stability of the ankle as assessed by stress radiography. Unstable ankles were found after both mobilisation and immobilisation, but in these groups no ankle finally displayed more than 8 degrees of relative talar tilt. 3. The mean duration of disability in patients who finally became symptom-free was: after mobilisation, twelve weeks; after immobilisation, twenty-two weeks; and after suture and immobilisation, twenty-six weeks. 4. One year after injury 58 per cent of patients treated by mobilisation, 53 per cent of patients treated by immobilisation, but only 25 per cent of patients treated by suture and immobilisation, had become perfectly symptom-free. 5. For these reasons, and because simple sprains are satisfactorily treated by mobilisation, it is suggested that mobilisation may be the treatment of choice for most, perhaps all, ruptures of the lateral ligament of the ankle

Aims

The direct posterior approach with subperiosteal dissection of the paraspinal muscles from the vertebrae is considered to be the standard approach for the surgical treatment of adolescent idiopathic scoliosis (AIS). We investigated whether or not a minimally-invasive surgery (MIS) technique could offer improved results.

The transition from shutdown of elective orthopaedic services to the resumption of pre-COVID-19 activity presents many challenges. These include concerns about patient safety, staff safety, and the viability of health economies. Careful planning is necessary to allow patients to benefit from orthopaedic care in a safe and sustainable manner.

Cite this article: Bone Joint J 2020;102-B(7):807–810.

Aims

Elective operating was halted during the COVID-19 pandemic to increase the capacity to provide care to an unprecedented volume of critically unwell patients. During the pandemic, the orthopaedic department at the Aneurin Bevan University Health Board restructured the trauma service, relocating semi-urgent ambulatory trauma operating to the isolated clean elective centre (St. Woolos’ Hospital) from the main hospital receiving COVID-19 patients (Royal Gwent Hospital). This study presents our experience of providing semi-urgent trauma care in a COVID-19-free surgical unit as a safe way to treat trauma patients during the pandemic and a potential model for restarting an elective orthopaedic service.

Aims

Magnetically controlled growing rods (MCGR) have been gaining popularity in the management of early-onset scoliosis (EOS) over the past decade. We present our experience with the first 44 MCGR consecutive cases treated at our institution.

From 1982 to 1987, we randomised prospectively 413 patients requiring primary total hip replacements to receive either a Stanmore or Charnley prosthesis. They were reviewed by an independent observer in an attempt to correlate a number of factors including femoral head size with longevity. There were 213 Stanmore hips and 200 Charnley prostheses. At five to ten years (mean 6.5) 76 patients had died and 16 arthroplasties had required revision. Seven were radiologically loose in asymptomatic patients. There was only one case of deep infection. We found no difference statistically in the clinical outcome or in the revision rate of 4% in the two types of prosthesis. The revision rate was greater for trainees than for senior operating surgeons, and there were recognisable technical errors in seven of the nine Stanmore, and four of the seven Charnley replacements which required revision. Retrospective radiological analysis of a random subset of 51 Charnley and 57 Stanmore femoral components showed no difference in femoral subsidence, but in 14 patients who had had bilateral replacements with one femoral component of each type, there was greater early subsidence of the Stanmore prosthesis. Our results confirm that conventional cemented total hip replacements give acceptable results in a general teaching unit, and we found no evidence of any effect of the size of the femoral head on wear or loosening at five to ten years

Aims

The safe resumption of elective orthopaedic surgery following the peak of the COVID-19 pandemic remains a significant challenge. A number of institutions have developed a COVID-free pathway for elective surgery patients in order to minimize the risk of viral transmission. The aim of this study is to identify the perioperative viral transmission rate in elective orthopaedic patients following the restart of elective surgery.

Aims

The COVID-19 pandemic presents an unprecedented burden on global healthcare systems, and existing infrastructures must adapt and evolve to meet the challenge. With health systems reliant on the health of their workforce, the importance of protection against disease transmission in healthcare workers (HCWs) is clear. This study collated responses from several countries, provided by clinicians familiar with practice in each location, to identify areas of best practice and policy so as to build consensus of those measures that might reduce the risk of transmission of COVID-19 to HCWs at work.