Introduction: In 1974 NZ adopted a state funded universal no fault Accident compensation scheme “ACC” to provide cover to the injured person. The ACC act was amended in 2005 to provide cover for patients suffering “treatment injuries (Medical error and mishap) caused as a result of treatment from a registered health professional. Methodology:A series of 1200 cases, assessed by a single orthopaedic surgeon were analyzed for various parameters including: Age, sex, diagnosis, basis for the claim, causation for ongoing symptoms (Pre-existing, new structural injury, unexpected complications, surgical errors or misdiagnosis, Ordinary consequence of a surgery etc on an excel version 16.34. Opinion was based on evidence base medicine. Results: This study was based on assessment of 1200 orthopaedic patients meeting the criteria for “treatment injury”. 89% of these cases were claims for spine, hip, knee and foot surgeries. Mean age was 52.6 years. Injury related to a pre-existing condition, caused by refusal to provide consent, did not achieve desired result and related to an ordinary consequence are not considered as being treatment injury. Summary: With the low costs of the treatment injury scheme, it is seen as beneficial to the country. With no blaming and shaming culture, health professionals are gaining increasing confidence in the “treatment injury” and there is more reporting of complications. Not all surgical complications are considered as being related to a treatment injury. Rarity of complication, serious gravity of injury, related to a defective implant, technical inadequacies and missed diagnosis are considered to be treatment injury.

Introduction: When evaluating functional outcomes after surgery, minimal clinically important difference (MCID) values help to distinguish if a change is clinically significant or merely a statistical finding. There are many methods to calculate the MCID including distributive, anchor-based, and receiver operating characteristic (ROC) curve thresholds. In the context of total hip (THA) and knee (TKA) arthoplasty, many different MCID values have been published for the same outcome measure. This can lead to confusion as to which MCID value to use in clincal research.

Objective: The aim of this study is to evaluate the consistency of published MCID values in predicting THA and TKA outcomes after surgery.

Methods: A systematic review was performed to extract all MCID values that describe clinical improvement after THA and TKA. Articles were limited to include only those that report MCID values for the Western Ontario and McMasters Universities Osteoarthritis Index (WOMAC) and Short-form 12 (SF12) questionnaires. A meta-analysis was used to evaluate the consistency of MCID values. Furthermore, the differing MCID values were used in existing predictive models (SMART Knee and SMART Choice) to measure the effect on predictive performance.

Results: At 1 year post-surgery (TKA), the SF12 physical component score (PCS) ranged from 1.8 to 5.0, and the mental component score ranged from 1.4 to 5.4. Similar results were seen in WOMAC score parameters and with THA cohorts. The effect on predictive performance for existing models when different MCID values were inputted ranged from a c-statistic of 0.629 - 0.712.

Further results to folllow.

Intra-articular injuries and degenerative changes affect millions of people each year. Conventional treatments are limited in scope and present potential side effects. The last decade has seen a tremendous interest in using biologics for orthopaedic regenerative medicine applications including stem cells. Despite therapeutic benefits, stem cells present several disadvantages. Recent evidence has attributed the beneficial effects of stem cells to their ability to secrete bioactive molecules such as growth factors (GFs), cytokines (CKs) and extracellular vesicles (EVs), including exosomes. We present a novel cell-free stem cell-derived extract (CCM), formulated from human progenitor endothelial stem cells (hPESCs), characterized for biologically active factors using enzyme-linked immunosorbent assay (ELISA), nanoparticle tracking analysis and single particle interferometric reflectance imaging sensing. The effect on fibroblast proliferation and ability to induce stem cell migration was analyzed using Alamar Blue proliferation and Transwell migration assays, respectively. GFs including IGFBP 1, 2, 3, and 6, insulin, growth hormone, PDGF-AA, TGF-α, TGF-β1, VEGF, and the anti-inflammatory cytokine, IL-1RA were detected. Membrane enclosed particles within exosome size range and expressing exosome tetraspanins CD81 and CD9 were identified. CCM significantly increased cell proliferation and induced stem cell migration. Analysis of CCM revealed presence of GFs, CKs, and EVs, including exosomes. The presence of multiple factors including exosomes within one formulation, the ability to promote cell proliferation and induce stem cell migration may reduce inflammation and pain, and augment tissue repair.

Introduction: Ingrown-toenails/ onychocryptosis is a common incidence in the United Kingdom with people of all ages and genders being affected. This can be a longstanding condition and affects the mobility of patients. It usually affects the great toe and can lead to pain, infection, disability with mobilisation and subsequent increase in workplace absenteeism. Currently, a wide variety of treatment options exist - both conservative and surgical. However, many are associated with poor cosmetic results, low rates of patient satisfaction and high rates of recurrence. Objective: The aim of this study is to assess the long term outcomes of the Modified Zadik’s procedure for the ingrowing toe nail done by a single foot and ankle surgeon in a small DGH in the UK. Methods: We retrospectively reviewed the long term outcomes in patients who underwent the Modified Zadik’s procedure. (Age range was 17 years to 76 years. Male to female ratio 7:9. A total of 21 toes in 16 patients; of which 4 were for the lesser toes and the remaining were for the big toe). In this procedure, the proximal nail bed was removed along with the curettage and phenolisation of the germinal layer as the treatment of choice for ingrown toenails. Results: The recurrence rate was very low and patient satisfaction and ability to return to their activities of daily living with ease was almost 100%. Conclusion: Modified Zadik’s procedure as the surgical treatment of ingrowing-toenails is a simple, safe and effective technique for treatment of ingrown-toenails.

Introduction The aim of this study was to examine our methods in obtaining and documenting an informed consent for surgery and discuss methods of improving the process of consenting. Methods Prospective analysis of the documentation of the serious complications of primary total hip and knee arthroplasty surgery by the consenting surgeon in the consent forms of 100 patients. Results In THR, the risk of DVT achieved 94% documentation, bleeding 96%, neurovascular damage 94% and infection 98%. However the documentation of other risks such as fractures (40%), leg length discrepancy (62%), PE (84%), prosthesis wear/loosening (76%) and dislocation (68%) was not as comprehensive. In TKR, the risk of DVT was documented in 90%, bleeding 92%, neurovascular damage 90% and infection 96% while other risks such as fractures (22%), leg length discrepancy (4%), nerve injury (70%), PE (80%) and dislocation (4%) was not as comprehensive. Conclusions Frequent and serious complications of surgery were incorrectly or insufficiently documented which may result in the surgeon being held liable for a negligent failure to inform and leave the door open to litigation. This study proposes improving the consenting process through adopting procedure specific consent forms that can be accessed easily through the website endorsed by the British Orthopaedic Association .

Introduction: In orthopedic surgery, autologous bone grafting is commonly used to treat bone defects. However, the insufficient amount of obtained autologous bone and the additional trauma caused by autologous bone grafting limit its use in clinical practice. The present study aimed to evaluate the effect of platelet-rich plasma (PRP) and zoledronic acid (ZOL)-impregnated bone allograft on reparative bone tissue regeneration in bone defects. Materials and methods: Seventy-two healthy rabbits (24 rabbits in each group) were used for this study. Bone defects (6-mm diameter) were created in the femur. The human femoral head prepared according to the Marburg bone bank system was used as a bone allograft. In the experimental groups, in 1 group - the defects were filled with bone allograft combined with autologous PRP, in 2 group – bone allograft combined with ZOL (5µg), in 3 group (control) – with allograft. The 8 animals from each group were sacrified after 14, 30, and 60 days. Evaluations consisted of X-ray plain radiography, histology at 14-, 30- and 60-days post-surgery. Results: According to histomorphometric analysis, the new bone formation inside the bone allograft was significantly greater in those impregnated with both PRP and ZOL than in those from the control group at 30 and 60 days after implantations (p<0,05). The radiological findings were in accordance with the histomorphometric results. Conclusion: The local co-administration of both PRP and ZOL on heat-treated allograft promoted and maintained newly formed bone structure in the bone defect.

Background: Patients of osteogenesis imperfecta (OI), a lifelong genetic disorder primarily affecting the skeletal system, tend to suffer from short stature, underweight and lower bone mineral densities (BMD). Here, we retrospectively assess growth curves of height and BMD and their treatment-responses. Methods: In total, 759 BMD scans of 316 OI patients were retrieved, spanning a ten-year period since 2012. Height, weight and BMD were measured concurrently. Results: Among these patients, 140 (44.3%) are females and 176 (55.7%) are males. Clinically, 251 were graded by the Sillence classification, with 43, 1, 33, 150 and 24 classified as types I, II, III, IV and V, respectively. Among those aged below 18, the weight’s average percentile in the normal reference, adjusting for gender, is 0.27 (inter-quartile range [IQR] 0.0 ~ 0.40) and that for height is 0.08 (IQR 0.0 ~ 0.07). Further, 44.7% (n=298) and 44.6% (n=297) of the weight and height percentiles were absolute zeroes, with data points lying much lower than the -2 standard deviation curves. Fitting with a non-linear mixture model, we found no difference between the two genders in weight (Wilcox p=0.82) and height (Wilcox p= 0.64). For BMDs, where most patients were treated with bisphosphonates, we calculated the slope and found that the steepest slopes occur in the 10-15 age-group (11.7 years for female and 13.4 years for male). Conclusion: For Chinese OI patients, weight and height are severely lower than their normal peers and BMD is most responsive to drug treatments during adolescence.

Introduction: Selective arthrodesis is a surgical procedure used to be done in the advanced wrist joint arthritis. The aim of the surgery is to achieve a stable joint, by intercarpal ankylosis, which removes the pain syndrome and restores the strength of the hand, unfortunately with the risk of decreasing the range of motion in the wrist joint. Material and methods: Our study is based on experimental research on 16 New Zealand rabbits. In the first study group, 8 laboratory animals was performed standard arthrodesis of the wrist joint. In the second study group, on other 8 laboratory animals, was developed the new treatment technique, using the combined graft with stem cells, obtained by tissue engineering. Results: In all cases, an immediate postoperative radiograph was performed. The clinical and radiological evaluations- were performed at 4, 8, and 12 weeks after the surgery. Computer tomography of each operated wrist was done 12 weeks postoperatively. Imagistic results showed us, that the group performed arthrodesis using a combined graft with stem cells and the ankylosis was achieved faster. Preliminary histological examinations of experiments indicate more active involvement in the process of osteogenesis in the use of combined stem cell transplantation. Conclusions: Our experimental research highlights an innovative method of surgical treatment - arthrodesis using the combined graft with stem cells. It turned out to be a harmless and safe method. The imaging and preliminary histological results of this study are encouraging.

A primary reason that hinders the clinical application of disease-modifying osteoarthritis drugs (DMOADs) is the unmet challenges in their effective delivery to cartilage. Cationic macromolecules represent promising carriers to enhance the drug delivery to cartilage through their electrostatic interaction with the negatively charged cartilage matrix. However, current candidate cationic macromolecular carriers (CMCs) must solve the intractable challenges in scalable production and biosafety before being used clinically. ε-poly-l-lysine (ε-PLL) is a unique poly (amino acid) that has favorable features to conquer the above issues. In this study, we evaluated the potential of ε-PLL as cost-effectiveness, biosafety, and effective CMC for drug delivery to cartilage. Cartilage explant from pig knee was used as a model for the in vitro analysis of ε-PLL’s interaction with, penetration into, and resident in cartilage tissue. The results showed that ε-PLL had a strong distribution tendency in cartilage with partition coefficient K ~ 4.3 and weak cartilage matrix binding ability (K D ~ 310 μM) with abundant intracartilage binding sites (N ~ 9900 μM).
Furthermore, ε-PLL could also penetrate full-thickness cartilage and showed long-time retention in cartilage explants and mouse joint cavity. The in vitro and in vivo toxicity tests showed nearly no negative impact of ε-PLL (100 μg/mL) on chondrocytes or local tissue. Using kartogenin as a model drug, the effectiveness of ε-PLL to improve the drug bioavailability in a mouse OA model was proved. Together, these results suggest that ε-PLL can be used as an effective and safe CMC for effective DMOAD delivery to cartilage.

Introduction: Bacterial infection, wide inflammation, and osteoporosis are the most common factors in the failure of orthopedic implants. The present study aims to design an orthopedic implant based on Titania nanotubes (TiO2-NTs) which not only have a high biocompatibility but also are characterized by anti-bacterial property. Methods: In order to improve the osseointegration of the TiO2-NTs structures (110–120 nm in diameter, 40 μm in length), they were used to coat the Titania implant by electrochemical anodizing. Vancomycin, which is soluble in water, was loaded as a main clinical drug to control intensive infections caused by positive gram bacteria. For the first time, Silk Fibroin (SF) Nanofibers coating was used to control drug release by the implementation of electrospinning on the TiO2-NTs surface. In order to investigate the anti-bacterial activities, S. aureus bacterium culture test was used. The cell culture of MG63 was conducted for both coated and non-coated samples of TiO2-NTs. Results: The results showed that the SF Nanofibers coating not only controls the drug being freely released from TiO2-NTs but also effects adhesion and development of osteoblast cells. In this regard, this coating inhibits biofilm formation and development, as well as bacteria colonization due to anti-bacterial drug release. Conclusion: This system can be considered as a promising alternative for orthopedic implants, preventing bone infection, osteomyelitis, bone cancer treatment, and other orthopedic diseases.