A novel method of articular cartilage repair.

Articular cartilage repair of post-traumatic articular cartilage defects and well-defined articular cartilage pathology is challenging in clinical practice and has been the focus of investigations for many years. In the present thesis a newly developed polymer system, based on poly-ethyl-methacrylate PEMA polymer and tetra-hydro-furfuryl methacrylate THFMA monomer has been exploited for the repair of large, full-thickness articular cartilage defects, created in a weight-bearing surface in the rabbit knee joint. The method of implantation is simple and easily reproducible and can be performed in one stage with open arthrotomy or arthroscopy in clinical applications. Intravenous administration of the monomer did not elicit significant cardiorespiratory side effects. The repair tissue in defects treated with PEMA/THFMA was compared to control defects that healed 'naturally'. Macroscopic and histological/histochemical evaluation using the newly developed Articular Cartilage Repair Scoring System, immunohistochemistry, electron microscopy, image analysis as well as biochemical analysis were used for the characterisation of the repair tissue. The results demonstrated that the PEMA/THFMA polymer enhanced significantly the quality of repair up to 1 year postoperatively. The repair tissue contained numerous chondrocytes producing large amounts of proteoglycans and collagen type II, and it was completely bonded to the adjacent normal articular cartilage in the vast majority of the specimens. The enhancing effect of PEMA/THFMA in articular cartilage defects was also demonstrated in three age groups of rabbits at 6 weeks, thus increasing the potential clinical applications of the polymer. Furthermore, PEMA/THFMA was compared to the conventional bone cement PMMA/MMA. At 6 weeks post-implantation PEMA/THFMA produced significantly superior repair tissue, compared to PMMA/MMA, confirming the importance of the properties of the new polymer. Finally, PEMA/THFMA was exploited as a potential drug delivery system in vivo by loading human growth hormone in the polymer. It was shown that the loaded polymer repaired the defects with a proliferative type of tissue, resembling immature articular cartilage

Plaster cast versus functional brace for non-surgical treatment of Achilles tendon rupture (UKSTAR): a multicentre randomised controlled trial and economic evaluation

This is the final version. Available from Elsevier via the DOI in this record. Background Patients with Achilles tendon rupture who have non-operative treatment have traditionally been treated with immobilisation of the tendon in plaster casts for several weeks. Functional bracing is an alternative non-operative treatment that allows earlier mobilisation, but evidence on its effectiveness and safety is scarce. The aim of the UKSTAR trial was to compare functional and quality-of-life outcomes and resource use in patients treated non-operatively with plaster cast versus functional brace. Methods UKSTAR was a pragmatic, superiority, multicentre, randomised controlled trial done at 39 hospitals in the UK. Patients (aged ≥16 years) who were being treated non-operatively for a primary Achilles tendon rupture at the participating centres were potentially eligible. The exclusion criteria were presenting more than 14 days after injury, previous rupture of the same Achilles tendon, or being unable to complete the questionnaires. Eligible participants were randomly assigned (1:1) to receive a plaster cast or functional brace using a centralised web-based system. Because the interventions were clearly visible, neither patients nor clinicians could be masked. Participants wore the intervention for 8 weeks. The primary outcome was patient-reported Achilles tendon rupture score (ATRS) at 9 months, analysed in the modified intention-to-treat population (all patients in the groups to which they were allocated, excluding participants who withdrew or died before providing any outcome data). The main safety outcome was the incidence of tendon re-rupture. Resource use was recorded from a health and personal social care perspective. The trial is registered with ISRCTN, ISRCTN62639639. Findings Between Aug 15, 2016, and May 31, 2018, 1451 patients were screened, of whom 540 participants (mean age 48·7 years, 79% male) were randomly allocated to receive plaster cast (n=266) or functional brace (n=274). 527 (98%) of 540 were included in the modified intention-to-treat population, and 13 (2%) were excluded because they withdrew or died before providing any outcome data. There was no difference in ATRS at 9 months post injury (cast group n=244, mean ATRS 74∙4 [SD 19∙8]; functional brace group n=259, ATRS 72∙8 [20∙4]; adjusted mean difference –1∙38 [95% CI –4∙9 to 2∙1], p=0·44). There was no difference in the rate of re-rupture of the tendon (17 [6%] of 266 in the plaster cast group vs 13 [5%] of 274 in the functional brace group, p=0·40). The mean total health and personal social care cost was £1181 for the plaster cast group and £1078 for the functional bract group (mean between-group difference –£103 [95% CI –289 to 84]). Interpretation Traditional plaster casting was not found to be superior to early weight-bearing in a functional brace, as measured by ATRS, in the management of patients treated non-surgically for Achilles tendon rupture. Clinicians may consider the use of early weight-bearing in a functional brace as a safe and cost-effective alternative to plaster casting.UK National Institute for Health Research Health Technology Assessment Programm

The impact of immediate breast reconstruction on the time to delivery of adjuvant therapy: the iBRA-2 study

Background: Immediate breast reconstruction (IBR) is routinely offered to improve quality-of-life for women requiring mastectomy, but there are concerns that more complex surgery may delay adjuvant oncological treatments and compromise long-term outcomes. High-quality evidence is lacking. The iBRA-2 study aimed to investigate the impact of IBR on time to adjuvant therapy. Methods: Consecutive women undergoing mastectomy ± IBR for breast cancer July–December, 2016 were included. Patient demographics, operative, oncological and complication data were collected. Time from last definitive cancer surgery to first adjuvant treatment for patients undergoing mastectomy ± IBR were compared and risk factors associated with delays explored. Results: A total of 2540 patients were recruited from 76 centres; 1008 (39.7%) underwent IBR (implant-only [n = 675, 26.6%]; pedicled flaps [n = 105,4.1%] and free-flaps [n = 228, 8.9%]). Complications requiring re-admission or re-operation were significantly more common in patients undergoing IBR than those receiving mastectomy. Adjuvant chemotherapy or radiotherapy was required by 1235 (48.6%) patients. No clinically significant differences were seen in time to adjuvant therapy between patient groups but major complications irrespective of surgery received were significantly associated with treatment delays. Conclusions: IBR does not result in clinically significant delays to adjuvant therapy, but post-operative complications are associated with treatment delays. Strategies to minimise complications, including careful patient selection, are required to improve outcomes for patients

Improving Escalation of Care A Double-blinded Randomized Controlled Trial

Objective: This study aimed to determine whether an intervention could improve the escalation of care skills of junior surgeons. Summary Background Data: Escalation of care involves the recognition, communication, and response to patient deterioration until a satisfactory outcome has been achieved. Although failure to escalate care can lead to increased morbidity and mortality, there is no formal training in how to perform this vital process safely. Methods: This randomized controlled trial recruited postgraduate year (PGY)-1 and PGY-2 surgeons to participate in 2 scenarios involving simulated patients requiring escalation of care. A control group performed both scenarios before receiving the intervention; the intervention group received the educational intervention before their second scenario. Scenarios were video recorded and rated by 2 independent, blinded assessors using validated scales to measure patient assessment, communication, management and nontechnical skills of participants, and the number of medical errors they detected. Results: A total of 33 PGY-1 and PGY-2 surgeons, all with equivalent skill at baseline, participated. Postintervention, the intervention group demonstrated significantly better patient assessment (P < 0.001), communication (P < 0.001), and nontechnical skills (P < 0.001). They also detected more medical errors (P < 0.05). Conclusions: Teaching junior surgeons a systematic approach to escalation of care improved multiple core skills required to maintain patient safety and avoid preventable harm

Trabecular Analysis of the Distal Radial Metaphysis during the Acquisition of Crawling and Bipedal Walking in Childhood: A Preliminary Study

In modern day populations, children following a normal pattern of development acquire independent bipedal locomotion between the ages of 9 and 18 months. Variability in the timing of this psychomotor developmental milestone depends on various factors, including cultural influences. It is well known that trabecular bone adapts to changes in biomechanical loading and that this can be influenced by alternative locomotor modes, such as crawling, which may be adopted before the acquisition of bipedal locomotion. With the onset of crawling, increased loading of the distal metaphysis of the radius, a component of the wrist, may lead to changes in trabecular bone architecture. To test this hypothesis, eight distal metaphyses of the radius of nonpathological children aged 0 to 3 years from the Bologna collection of identified skeletons were μCT-scanned at a resolution of 10.7 μm. The microarchitectural parameters of the trabecular bone (trabecular bone volume fraction, trabecular thickness, trabecular spacing, and trabecular ellipsoid factor) were quantified for the entire metaphysis and 3D morphometric maps of the distribution of the bone volume fraction were generated. Analysis of these microarchitectural parameters and the 3D morphometric maps show changes in the trabecular bone structure between 6 and 15 months, the period during which both crawling and bipedalism are acquired. This preliminary study analyzed the trabecular structure of the growing radius in three dimensions for the first time, and suggests that ontogenetic changes in the trabecular structure of the radial metaphysis may be related to changes in the biomechanical loading of the wrist during early locomotor transitions, i.e. the onset of crawling. Moreover, microarchitectural analysis could supply important information on the developmental timing of locomotor transitions, which would facilitate interpretations of locomotor development in past populations