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BACKGROUND AND PURPOSE: To our knowledge, there is no evidence to support the use of local infiltration analgesia (LIA) for postoperative pain relief after periacetabular osteotomy (PAO). We investigated the effect of wound infiltration with a long-acting local anesthetic (ropivacaine) for postoperative analgesia after PAO.PATIENTS AND METHODS: We performed a randomized, double-blind, placebo-controlled trial (ClinicalTrials.gov: NCT00815503) in 53 patients undergoing PAO to evaluate the effect of local anesthetic infiltration on postoperative pain and on postoperative opioid consumption. All subjects received intraoperative infiltration followed by 5 postoperative injections in 10-hour intervals through a multi-holed catheter placed at the surgical site. 26 patients received ropivacaine and 27 received saline. The intervention period was 2 days and the observational period was 4 days. All subjects received patient-controlled opioid analgesia without any restrictions on the total daily dose. Pain was assessed at specific postoperative time points and the daily opioid usage was registered.RESULTS: Infiltration with 75 mL (150 mg) of ropivacaine did not reduce postoperative pain or opioid requirements during the first 4 days.INTERPRETATION: The clinical importance of ropivacaine as single component in postoperative treatment of pain is questionable, and we are planning further studies to explore the potential of LIA in larger volume-and also a multimodal regimen-to treat pain in this category of patients.

Auf ihr 20-jahriges Kongressjubilaum vom 5. bis 7. Juni 2019 in Lissabon freut sich die European Federation of National Associations of Orthopaedics and Trauma (EFORT), denn als Institution auf dem orthopadischen Sektor wird sie mit einem ausergewohnlichen Programm einmal mehr europaweit fur den notwendigen Wissensaustausch sorgen.

Background and purpose — The increased use of patient-reported outcomes (PROs) in orthopedics requires data on estimated minimal clinically important improvements (MCIIs) and patient-acceptable symptom states (PASSs). We wanted to find cut-points corresponding to minimal clinically important PRO change score and the acceptable postoperative PRO score, by estimating MCII and PASS 1 year after total hip arthroplasty (THA) for the Hip Dysfunction and Osteoarthritis Outcome Score (HOOS) and the EQ-5D. Patients and methods — THA patients from 16 different departments received 2 PROs and additional questions preoperatively and 1 year postoperatively. The PROs included were the HOOS subscales pain (HOOS Pain), physical function short form (HOOS-PS), and hip-related quality of life (HOOS QoL), and the EQ-5D. MCII and PASS were estimated using multiple anchor-based approaches. Results — Of 1,837 patients available, 1,335 answered the preoperative PROs, and 1,288 of them answered the 1-year follow-up. The MCIIs and...

In recent years, a number of approaches to social cognition research have emerged that highlight the importance of embodied interaction for social cognition (Reddy, How infants know minds, 2008; Gallagher, J Conscious Stud 8:83–108, 2001; Fuchs and Jaegher, Phenom Cogn Sci 8:465–486, 2009; Hutto, in Seemans (ed.) Joint attention: new developments in psychology, philosophy of mind and social neuroscience, 2012). Proponents of such ‘interactionist’ approaches emphasize the importance of embodied responses that are engaged in online social interaction, and which, according to interactionists, present an alternative to mindreading as a source of social understanding. We agree that it is important to take embodied interaction seriously, but do not agree that this presents a fundamental challenge to mainstream mindreading approaches. Drawing upon an analogy between embodied interaction and the exercise of expert skills, we advocate a hierarchical view which claims that embodied social responses generally operate in close conjunction with higher-level cognitive processes that play a coordinative role, and which are often sensitive to mental states. Thus, investigation of embodied responses should inform rather than conflict with research on mindreading.

Background and purpose Large–size hip articulations may improve range of motion (ROM) and function compared to a 28–mm THA, and the low risk of dislocation allows the patients more activity postoperatively. On the other hand, the greater extent of surgery for resurfacing hip arthroplasty (RHA) could impair rehabilitation. We investigated the effect of head size and surgical procedure on postoperative rehabilitation in a randomized clinical trial (RCT). Methods We followed randomized groups of RHAs, large–head THAs and standard THAs at 2 months, 6 months, 1 and 2 years postoperatively, recording clinical rehabilitation parameters. Results Large articulations increased the mean total range of motion by 13° during the first 6 postoperative months. The increase was not statistically significant and was transient. The 2–year total ROM (SD) for RHA, standard THA, and large–head THA was 221° (35), 232° (36), and 225° (30) respectively, but the differences were not statistically significant. The 3 groups were sim...

Allogenic bone graft has been considered the gold standard in connection with bone graft material in revision joint arthroplasty. However, the lack of osteogenic potential and the risk of disease transmission are clinical challenges. The use of osteoinductive materials, such as demineralized bone matrix (DBM), alone or in combination with allograft or commercially available human cancellous bone (CB), may replace allografts, as they have the capability of inducing new bone and improving implant fixation through enhancing bone ongrowth. The purpose of this study was to investigate the effect of DBM alone, DBM with CB, or allograft on the fixation of porous-coated titanium implants. DBM100 and CB produced from human tissue were included. Both materials are commercially available. DBM granules are placed in pure DBM and do not contain any other carrier. Titanium alloy implants, 10 mm long × 10 mm diameter, were inserted bilaterally into the femoral condyles of eight skeletally mature sheep. Thus, four implants with a concentric gap of 2 mm were implanted in each sheep. The gap was filled with: (a) DBM; (b) DBM:CB at a ratio of 1:3; (c) DBM:allograft at a ratio of 1:3; or (d) allograft (gold standard), respectively. A standardized surgical procedure was used. At sacrifice 6 weeks after implantation, both distal femurs were harvested. The implant fixation was evaluated by mechanical push-out testing to test shear mechanical properties between implant and the host bone and by histomorphometry. Non-parametric tests were applied; p

Dual energy X‐ray absorptiometry (DXA) is the reference standard method used to study bone mineral density (BMD) after total hip arthroplasty (THA). However, the subtle, spatially complex changes in bone mass due to strain‐adaptive bone remodeling relevant to different prosthesis designs are not readily resolved using conventional DXA analysis. DXA region free analysis (DXA RFA) is a novel computational image analysis technique that provides a high‐resolution quantitation of periprosthetic BMD. Here, we applied the technique to quantitate the magnitude and areal size of periprosthetic BMD changes using scans acquired during two previous randomized clinical trials (2004 to 2009); one comparing three cemented prosthesis design geometries, and the other comparing a hip resurfacing versus a conventional cementless prosthesis. DXA RFA resolved subtle differences in magnitude and area of bone remodeling between prosthesis designs not previously identified in conventional DXA analyses. A mean bone loss of 10.3%, 12.1%, and 11.1% occurred for the three cemented prostheses within a bone area fraction of 14.8%, 14.4%, and 6.2%, mostly within the lesser trochanter (p

AIM: This study was done as the first phase of a Ph.D.-project where the overall aim is to investigate whether the fast-track treatment of patients with osteoporotic hip fracture can be improved by a telemedicine/tele-health solution, which promotes patients’ self-care and empowerment. CONTEXT: Hip fracture is the most common cause of hospitalization in an orthopaedic ward. The demographic changes with an increasing number of older people and lifestyle factors such as poor diet, smoking, alcohol and lack of exercise, have a negative impact on bone health. Worldwide, the osteoporotic fracture is costly (Schiller et al., 2015). The incremental societal burden is an important health problem - both for the patient in the form of functional decline and pain, for the families and for the society in a health economic perspective (Hansen et al., 2013).Denmark is in the midst of a restructuring of health care. Fast-track treatment has increasingly become an essential tool for quality development and efficient use of resources. Fast-track programmes, also referred to as fast-track surgery, fast-track regimen or fast-trackrehabilitation, is an interdisciplinary, evidence-based multimodal concept aimed at improving peri-operative treatment (Walter et al., 2006, Husted, 2012). The short stay in hospitals will put more pressure on other health practitioners, municipalities, practitioners, rehabilitation teams, etc. Similarly, it is likely to put pressure on the patients and their network - especially the relatives.Telemedicine has proven to be an effective tool for supporting communication and cooperation between individuals and health professionals. However, is not widely used in orthopaedic surgery (Clemensen et al., 2007). METHOD: The study uses Participatory Design(PD) as the overall research design. Participatory design (hereinafter PD) has its roots in action research and is a way to describe users’ knowledge so that it can be used to design new tools and workflows that empower the users (Spinuzzi, C. 2005). PD has over the last 10 years been adopted in health research and has developed technologies that have changed the way health services are offered (Clemensen et al., 2005, Danbjorg et al., 2014). PD is conducted in three phases and this paper reports from the initial phase where focus is on identifying needs and generating ideas to address these needs. FINDINGS AND DISCUSSION: It is evident that recovering from a hip fracture is a complex and subjective experience.This study shows that individuals want to be in charge of their own life and they want to have autonomy. Acquiring a hip fracture and recovering from this is a violent break – not only in a physiological manner but also in the individuals’ everyday life. Acquiring a hip fracture is also a forceful reminder of the frailty of life: this stressful situation complicates the ability to understand information and knowledge given during the fast-track treatment. Thereby, the conventional way of communicating health knowledge in fast-track treatment in order to empower the individuals is challenged.A new way of promoting and enabling patient-empowerment is required if we want to support autonomy and self-care and individuals’ zest for life.This study illustrates the gaps in the patient pathway and suggests ways to fill these gaps. REFERENCES CLEMENSEN, J., LARSEN, S. B. & EJSKJAER, N. 2005. Telemedical treatment at home of diabetic foot ulcers. J Telemed Telecare, 11 Suppl 2, S14-6.CLEMENSEN, J., LARSEN, S. B., KYNG, M. & KIRKEVOLD, M. 2007. Participatory design in health sciences: Using cooperative experimental methods in developing health services and computer technology. Qual Health Res, 17, 122-30.DANBJORG, D. B., WAGNER, L. & CLEMENSEN, J. 2014. Do families after early postnatal discharge need new ways to communicate with the hospital? A feasibilility study. Midwifery, 30, 725-32.HANSEN, L., MATHIESEN, A. S., VESTERGAARD, P., EHLERS, L. H. & PETERSEN, K. D. 2013. A health economic analysis of osteoporotic fractures: who carries the burden? Arch Osteoporos, 8, 126.HUSTED, H. 2012. Fast-track hip and knee arthroplasty: clinical and organizational aspects. Acta Orthop Suppl, 83, 1-39.SCHILLER, C., FRANKE, T., BELLE, J., SIMS-GOULD, J., SALE, J. & ASHE, M. C. 2015. Words of wisdom – patient perspectives to guide recovery for older adults after hip fracture: a qualitative study. Patient preference and adherence, 9, 57-64.SPINUZZI, C. 2005. The Methodology of Participatory Design. Technical Communication, Volume 52, pp.163-174(12).WALTER, C. J., SMITH, A. & GUILLOU, P. 2006. Perceptions of the Application of Fast-Track Surgical Principles by General Surgeons. Annals of The Royal College of Surgeons of England, 88, 191-195.

OBJECTIVE: Chronic synovial inflammation causes primary osteoarthritis, but it is unknown whether chronic systemic inflammation does, too. Patients with cirrhosis have chronic systemic inflammation and therefore we examined the association between cirrhosis and primary osteoarthritis of the hip and knee.METHODS: In Danish healthcare databases we identified all residents over 60 years diagnosed with cirrhosis in 1994-2011, and for each of them we sampled five age- and gender-matched reference persons from the general population. We excluded everyone with risk factors for secondary osteoarthritis and computed incidence rates of primary osteoarthritis of the hip or knee. We used stratified Cox regression to estimate the hazard ratios of primary osteoarthritis for cirrhosis patients vs. reference persons in strata defined by gender, age, cirrhosis etiology, and ascites vs. no ascites. We also computed separate HRs for primary osteoarthritis of the hips or knees.RESULTS: We identified 10,049 cirrhosis patients. Their median age was 67 years, and 65% were men. Among the cirrhosis patients the crude incidence rate of primary osteoarthritis was 8.40 (95% CI: 7.30-9.63) per 1000 person-years. The rate was similar in the reference persons: 8.76 (95% CI: 8.43-9.12) per 1000 person-years. Accordingly, the hazard ratio for primary osteoarthritis for cirrhosis patients vs. reference persons was 0.99 (95% CI: 0.85-1.16), and we found the same null association in all patient strata and in both joints.CONCLUSION: Cirrhosis, and thus chronic systemic inflammation, is not a risk factor for primary osteoarthritis.

BACKGROUND: Hip osteoarthritis (OA) is the most common diagnosis in primary care adult patients presenting with hip pain but pain location and pain distribution in primary care patients with hip OA have been reported inadequately.OBJECTIVE: To describe pain location and pain distribution in primary care patients with clinical and radiographic confirmed hip OA.METHODS: Primary care patients with unilateral clinical and radiographic hip OA living on the island of Funen, Denmark were recruited from primary care to participate in a randomized clinical trial. At baseline, patients recorded pain intensity using an 11-box numeric rating scale and the distribution of hip pain using a manikin displaying three separate views: front, back and lateral. Pain drawings were analysed using a template to determine the most frequent pain locations and distribution of pain.RESULTS: Pain drawings were completed by 109 patients of which 108 (99%) were valid. The mean age of patients was 65 (SD 9) years and 44% were females. The mean pain intensity was 5.4 (SD 2.0). A total of 77% had marked the greater trochanter area, 53% the groin area, 42% the anterior/lateral thigh area, 38% the buttock area, 17% the knee and 15% the lower leg area. No patients marked pain exclusively in the areas of the knee, posterior thigh or lower leg.CONCLUSION: The most common pain locations of patients with hip OA presenting to primary care are the greater trochanter, groin, thigh and buttock areas. No patients recorded pain exclusively in the knee or lower leg.

The International Society of Arthroplasty Registries (ISAR) Steering Committee established the Patient-Reported Outcome Measures (PROMs) Working Group to convene, evaluate, and advise on best practices in the selection, administration, and interpretation of PROMs and to support the adoption and use of PROMs for hip and knee arthroplasty in registries worldwide. The 2 main types of PROMs include generic (general health) PROMs, which provide a measure of general health for any health state, and specific PROMs, which focus on specific symptoms, diseases, organs, body regions, or body functions. The establishment of a PROM instrument requires the fulfillment of methodological standards and rigorous testing to ensure that it is valid, reliable, responsive, and acceptable to the intended population. A survey of the 41 ISAR member registries showed that 8 registries administered a PROMs program that covered all elective hip or knee arthroplasty patients and 6 registries collected PROMs for sample populations; 1 other registry had planned but had not started collection of PROMs. The most common generic instruments used were the EuroQol 5 dimension health outcome survey (EQ-5D) and the Short Form 12 health survey (SF-12) or the similar Veterans RAND 12-item health survey (VR-12). The most common specific PROMs were the Hip disability and Osteoarthritis Outcome Score (HOOS), the Knee injury and Osteoarthritis Outcome Score (KOOS), the Oxford Hip Score (OHS), the Oxford Knee Score (OKS), the Western Ontario and McMaster Universities Arthritis Index (WOMAC), and the University of California at Los Angeles Activity Score (UCLA).

s / Osteoarthritis and Cartilage 24 (2016) S63eS534 S495 therapy, chiropractic, and CAM are becoming more common among younger generations. 852 END-FEEL ASSESSMENT OF HIP JOINT DYSFUNCTION AND PAIN AT FULL RANGE OF MOTION IN PATIENTS WITH HIP OSTEOARTHRITISeA RELIABILITY STUDY E. Poulsen y, S. Overgaard zy, H.W. Christensen x, J. Hartvigsen yx. yUniv. of Southern Denmark, Odense, Denmark; zOdense Univ. Hosp., Odense, Denmark; xNordic Inst. of Chiropractic and Clinical Biomechanics

Aims The purpose of this study was to validate the diagnosis of periprosthetic joint infection (PJI) in the Danish Hip Arthroplasty Register (DHR). Patients and Methods We identified a cohort of patients from the DHR who had undergone primary total hip arthroplasty (THA) since 1 January 2005 and followed them until first-time revision, death, emigration or until 31 December 2012. Revision for PJI, as registered in the DHR, was validated against a benchmark which included information from microbiology databases, prescription registers, clinical biochemistry registers and clinical records. We estimated the sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) for PJI in the DHR alone and in the DHR when combined with microbiology databases. Results In total, 1382 of the 37 826 primary THAs in the DHR were registered as having been revised for any cause once 26 patients with errors in registration had been excluded: 232 of these were for PJI. For this group, the sensitivity was 67%, specificity 95%, PPV 77%, and NPV 92%. Combining the data from the DHR with those from microbiology databases increased the sensitivity to 90% and also improved specificity (100%), PPV (98%) and NPV (98%). Conclusion Only two thirds of revisions for PJI were captured in the DHR and only 77% of the PJI reported to the DHR could be confirmed to be infected. Take home message: combining the data from the DHR with those from microbiology databases substantially improved the validity of the diagnosis of PJI and should enable future register-based studies. Cite this article: Bone Joint J 2016;98-B:320–5.

The objective of this study was to test the precision and agreement between bone mineral density measurements performed in micro CT, single and dual energy computed tomography, to determine how the keV level influences density measurements and to assess the usefulness of quantitative dual energy computed tomography as a research tool for longitudinal studies aiming to measure bone loss adjacent to total hip replacements. Samples from 10 fresh-frozen porcine femoral heads were placed in a Perspex phantom and computed tomography was performed with two acquisition modes. Bone mineral density was calculated and compared with measurements derived from micro CT. Repeated scans and dual measurements were performed in order to measure between- and within-scan precision. Mean density difference between micro CT and single energy computed tomography was 72 mg HA/cm

Background and purpose The risk of complications in cirrhosis patients after orthopedic surgery is unclear. We examined this risk after total hip arthroplasty (THA) or total knee arthroplasty (TKA). Patients and methods Using Danish healthcare registries, we identified all Danish residents who underwent a THA or TKA for primary osteoarthritis in the period 1995–2011. We compared the risk of complications in patients with or without cirrhosis. Results The surgical technique was similar in the 363 cirrhosis patients and in 109,159 reference patients, but cirrhosis patients were more likely to have been under general anesthesia (34% vs. 23%), were younger (median age 66 vs. 69 years), had a predominance of males (54% vs. 41%), had more comorbidity, and had had more hospitalizations preoperatively. Their risk of intraoperative complications was similar to that for reference patients (2.5% vs. 2.0%), but they had greater risk of dying during hospitalization or within 30 days of discharge (1.4% vs. 0.4%; aOR = 3.9, 95% CI: 1.5–10); greater risk of postoperative transfer to an intensive care unit (0.6% vs. 0.06%; aOR = 5.8, CI: 1.3–25) or a medical department (4.4% vs. 2.5%; aOR = 1.7, CI: 0.99–2.9); greater risk of readmission within 30 days of discharge (15% vs. 8%; aOR = 1.8, CI: 1.3–2.4); and greater risk of deep prosthetic infection (3.1% vs. 1.4%) or revision (3.7% vs. 1.7%) within 1 year. The chance of having an uncomplicated procedure was 81.0% (CI: 76.6–85.0) for cirrhosis patients and 90.0% (CI: 89.6–90.0) for reference patients. Interpretation Cirrhosis patients had a higher risk of postoperative complications after THA or TKA for primary osteoarthritis than patients without cirrhosis. This may have implications for orthopedic surgeons’ postoperative management of cirrhosis patients, and preoperative assessment by a hepatologist may be indicated.

Background: Symptomatic knee osteoarthritis is a highly age and sex associated complex disease. Little is known about the causes behind this age and sex associated increase, or if genetic and environmental factors impacts differently by gender. Our study examined the risk and heritability of primary knee osteoarthritis leading to total knee arthroplasty and whether these differences were attributable to sex and age differences in heritability. Methods: All twins of known zygosity from The Danish Twin Register alive in 1997 were examined in a nationwide population based follow-up study collecting information on all twins recorded in The Danish Knee Arthroplasty from 1997 to follow-up in 2010. Our main outcomes were the cumulative incidence, probandwise concordance rates, heritability, within pair correlations in monozygotic and dizygotic twin pairs and the genetic and environmental influence estimated in models taking into account that individuals may not have had a total knee arthroplasty at follow up. Results: 92,748 twins were eligible for analyses and 576 twins had a record of primary knee osteoarthritis in The Danish Knee Arthroplasty Register at follow-up comprising 358 female and 218 male twin cases. The risk increased particular after the age of 50years displaying significant sex differences in the elderly. In the sex stratified analyses a discrete genetic component was found in females, but in males no genetic component could be detected. In both genders common and unique environmental factors were highly significant. In the sex-adjusted analysis an additive genetic component of 18% (0; 62), a shared environmental component of 61% (25; 97) and an individual environmental component of 21% (6; 36) accounted for the variation in liability to primary total knee arthroplasty. Conclusion: The risk of primary total knee arthroplasty increases significantly after the age of 50years, in particular in females, displaying significant sex differences in the elderly. After sex-adjustment 82% of the variation in liability to primary total knee arthroplasty was attributable to common and unique environmental factors; the remaining 18% of this variation was attributable to additive genetic factors indicating a pivotal impact of environmental factors on this disease.

Background The lateral and the posterior approach are the most commonly used procedures for total hip arthroplasty. Due to the detachment of the hip abductors, lateral approach is claimed to cause reduced hip muscle strength and altered gait pattern. However, this has not been investigated in a randomised controlled trial. The aim was to compare the efficacy of total hip arthroplasty performed by lateral or posterior approach on gait function and hip muscle strength up to 12 months post-operatively. We hypothesised that posterior approach would be superior to lateral approach. Methods Forty-seven patients with primary hip osteoarthritis were randomised to total hip arthroplasty with either posterior or lateral approach and evaluated pre-operatively, 3 and 12 months post-operatively using 3-dimensional gait analyses as objective measures of gait function, including Gait Deviation Index, temporo–spatial parameters and range of motion. Isometric maximal hip muscle strength in abduction, flexion and extension was also tested. Findings Post-operatively, no between-group difference in gait function was observed. However, both hip abductor and flexor muscle strength improved more in the posterior approach group: − 0.20(Nm/kg)[95%CI:− 0.4 to 0.0] and − 0.20(Nm/kg)[95%CI:− 0.4 to 0.0], respectively. Interpretation Contrary to our first hypothesis, the overall gait function in the posterior approach group did not improve more than in the lateral approach group. However, in agreement with our second hypothesis, patients in the posterior approach group improved more in hip abductor and flexor muscle strength at 12 months. Further investigation of the effect of reduced maximal hip muscle strength on functional capacity is needed. ClinicalTrials.gov. No.: NCT01616667

Early fixation of total joint arthroplasties is crucial for ensuring implant survival. An alternative bone graft material in revision surgery is needed to replace the current gold standard, allograft, seeing that the latter is associated with several disadvantages. The incubation of such a construct in a perfusion bioreactor has been shown to produce viable bone graft materials. This study aimed at producing larger amounts of viable bone graft material (hydroxyapatite 70% and β-tricalcium-phosphate 30%) in a novel perfusion bioreactor. The abilities of the bioreactor-activated graft material to induce early implant fixation were tested in a bilateral implant defect model in sheep, with allograft as the control group. Defects were bilaterally created in the distal femurs of the animals, and titanium implants were inserted. The concentric gaps around the implants were randomly filled with either allograft, granules, granules with bone marrow aspirate or bioreactor-activated graft material. Following an observation time of 6 weeks, early implant fixation and bone formation were assessed by micro-CT scanning, mechanical testing, and histomorphometry. Bone formations were seen in all groups, while no significant differences between groups were found regarding early implant fixation. The microarchitecture of the bone formed by the synthetic graft materials resembled that of allograft. Histomorphometry revealed that allograft induced significantly more bone and less fibrous tissue (p 0.05). In conclusion, bone formation was observed in all groups, while the bioreactor-activated graft material did not reveal additional effects on early implant fixation comparable to allograft in this model. © 2016 Wiley Periodicals, Inc. J Biomed Mater Res Part B: Appl Biomater, 105B: 2465-2476, 2017.

BACKGROUND: The Gait Deviation Index summarizes overall gait 'quality', based on kinematic data from a 3-dimensional gait analysis. However, it is unknown which clinical outcomes may affect the Gait Deviation Index in patients with primary hip osteoarthritis. The aim of this study was to investigate associations between Gait Deviation Index as a measure of gait 'quality' and hip muscle strength and between Gait Deviation Index and patient-reported outcomes in patients with primary hip osteoarthritis.METHOD: Forty-seven patients (34 males), aged 61.1 ± 6.7 years, with BMI 27.3 ± 3.4 (kg/m2) and with severe primary hip osteoarthritis underwent 3-dimensional gait analysis. Mean Gait Deviation Index, pain after walking and maximal isometric hip muscle strength (flexor, extensor, and abductor) were recorded. All patients completed the 'Physical Function Short-form of the Hip disability and Osteoarthritis Outcome Score (HOOS-Physical Function) and the Hip disability and Osteoarthritis Outcome Score subscales for pain (HOOS-Pain) and quality-of-life (HOOS-QOL).RESULTS: Mean Gait Deviation Index was positively associated with hip abduction strength (pCONCLUSION: Patients with the strongest hip abductor and hip flexor muscles had the best gait 'quality'. Furthermore, patients with higher physical function, quality of life scores and lower pain levels demonstrated better gait 'quality'. These findings indicate that interventions aimed at improving hip muscle strength and pain management may to a moderate degree improve the overall gait 'quality' in patients with primary hip OA.

BACKGROUND: Osteoporosis drugs might affect fracture-healing. We therefore studied the effects of teriparatide in comparison with risedronate on recovery after pertrochanteric hip fractures.METHODS: The study was a randomized, multicenter, active-controlled, 78-week trial comparing teriparatide (20 μg/day) with risedronate (35 mg/week) initiated within 2 weeks after fixation of a low-trauma pertrochanteric hip fracture (AO/OTA 31-A1 or 31-A2). The main inclusion criteria were a bone mineral density T-score of ≤-2.0 and 25-OH-vitamin D of ≥9.2 ng/mL. During the first 26 weeks, patients received study medication with oral or injectable placebo plus calcium and vitamin D in a double-blinded fashion. Secondary (Timed Up-and-Go [TUG] test, hip pain, Short Form [SF]-36 health status, and safety) and exploratory (radiographic outcomes and ability to walk) 26-week end points are reported.RESULTS: Of the 224 patients who were randomized, 171 (86 teriparatide, 85 risedronate) were included in the analysis. The mean age was 77 ± 8 years, 77% were female, and 26% had a prior history of low-trauma fracture. The teriparatide group completed the TUG test in a shorter time at 6, 12, 18, and 26 weeks (differences of -5.7, -4.4, -3.1, and -3.1 seconds, respectively; p = 0.021 for the overall difference). They also reported less pain on a visual analog scale immediately after the TUG test at 12 and 18 weeks (adjusted absolute differences of 10.6 and 11.9 mm, respectively; p < 0.05). There were no significant between-group differences in the SF-36 score, Charnley hip pain score, ability to walk, or use of walking aids during follow-up. Radiographic healing at 6, 12, and 26 weeks, mechanical failure of the implant (teriparatide, 7; risedronate, 8), loss of reduction (teriparatide, 2; risedronate, 4), and nonunion (0 cases) were not significantly different. Mild hypercalcemia and hyperuricemia were more frequent with teriparatide.CONCLUSIONS: Teriparatide was associated with less pain and a shorter time to complete the TUG test between 6 and 26 weeks compared with risedronate. Other fracture-recovery outcomes were similar. The results should be interpreted with caution as these were secondary end points.LEVEL OF EVIDENCE: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

OBJECTIVE: To investigate the efficacy and feasibility of progressive explosive-type resistance training (RT) in patients with osteoarthritis (OA) of the hip scheduled for total hip arthroplasty (THA).METHOD: Randomized controlled trial (1:1) in patients diagnosed with hip OA and scheduled for THA. The intervention group (IG) performed supervised preoperative progressive explosive-type RT twice a week for 10 weeks; four exercises (hip/thigh) performed in three series each (8-12 repetition maximum). The control group (CG) received 'care as usual'. Efficacy was reported as the between-group difference in the Hip Osteoarthritis Outcome Score (HOOS) (primary endpoint; ADL function), and leg muscle power at post intervention follow-up immediate before surgery. Intention-to-treat analyses were performed in a multilevel regression model adjusting for baseline, sex, age and weight. Feasibility was reported as adherence, exercise related pain and adverse effects. Post-surgical follow up will be reported separately. ClinicalTrials.gov registration: NCT01164111.RESULTS: Eighty patients (age 70.4 ± 7.6 years, BMI 27.8 ± 4.6, 52 females (65%) were included. Adherence was high (93%) with acceptable exercise related pain (VAS score ≤ 5) reported in 83% of sessions and no adverse events. Changes in HOOS 'function' was 10.0 points 95%CI [4.7; 15.3] higher in IG compared to CG (P < 0.001). For all the remaining HOOS subscales IG scored significantly better (P < 0.03) and had higher leg extension muscle power (P < 0.0001) compared to CG.CONCLUSION: Progressive explosive-type RT was feasible in the included group of hip OA patients scheduled for THA and resulted in significant improvement in self-reported outcomes and increased leg muscle power.

Background: Preoperative patient characteristics may influence patient choice for participating in RCT’s. Purpose / Aim of Study: This study aimed to compare patient characteristics, level of pain, physical function and joint space width in patients with severe hip osteoarthritis (OA) who accepted or refused to participate in a RCT.Materials and Methods: In this prospective cohort study a total of 137 patients with primary hip OA were asked to choose between surgical or non- surgical treatment. We then compared the characteristics of each patient cohort (demographics, pain level and duration, analgesic use, exercise habits), the radiographic hip OA state and their responses to Hip dysfunction and Osteoarthritis Outcome Score (HOOS, 0-100) and European Quality of Life Scale (EQ-5D-5L) questionnaires.Findings / Results: The between-group HOOS scores were significantly different in three out of the five HOOS subscales analyzed; HOOSpain 6.1 (95% CI: 0.3 to 12.5), HOOSADL 8.3 (95% CI: 2.3 to 14.4) and HOOSsport/rec 8.6 (95% CI: 3.2 to 13.9) with higher scores recorded in the non-surgical patient cohort indicating less symptoms. Overall health status (EQ-5D-5L) showed surgical patients had more problems in all the dimensions except for the EQanxity/depression responses. The surgical patients had significantly reduced joint space width (1.2 ± 1.0 mm vs. 1.8 ± 1.2 mm, p = 0.004) and both cohorts had values below the defined 2 mm cut-off (Jacobsen et al.).Conclusions: Patients, who choose surgical treatment had preoperatively more pain, reduced physical function, lower health status and joint space width compared with patients who choose non-surgical treatment.

Background: Few studies have combined preoperative patient-reported and objective outcome measures to predict outcomes after total hip arthroplasty (THA). Purpose / Aim of Study: to identify predictors of outcome 3 and 12 months after THAMaterials and Methods: A cohort of 107 consecutive patients with primary hip osteoarthritis responded to Hip dysfunction and Osteoarthritis Outcome Score (HOOS) questionnaires prior to and 3 and 12 months after THA. Preoperative pain intensity; joint space width (JSW), age, gender, and body mass index (BMI) were used to predict changes in pain and physical function after surgery. Preoperative pain level scores were categorized into; none (76-100, reference), mild (51-75), moderate (26- 50) and severe (0-25). Single and multilevel repeated measures random effects linear regression models (MLM) were usedFindings / Results: Preoperative pain levels predicted improvement in postoperative pain in such a way that patients with mild pain improved; 20 points (95% CI: 2.5 to 36.8), while patients with moderate and severe pain improved; 32 (95% CI: 15.5 to 48.7) and 47 (95% CI: 29.3 to 64.3), points, respectively. Preoperative pain also predicted improvements in postoperative physical function scores; mild improved; 18 (-2.6 to 38.3), moderate 26 (6.7 to 46.2) and severe 44 points (23.2 to 64.9), respectively. Age, gender, BMI, and JSW had no predictive value. The patients achieved the same postoperative level of pain and function irrespective of pre- operative score.Conclusions: Preoperative pain predicted changes in pain and physical function up to one year after THA. Such knowledge should be taken into consideration, when assessing OA patients prior to surgery. This study provides useful insight for clinicians, regarding the overall improvement patients can expect to achieve following their total hip arthroplasty

The past few years have seen the emergence of interaction as a central topic within social cognition research. This has involved an increasing interest in the development of ecological, interactive contexts for the empirical study of social cognition, and also in theoretical reflection upon the relationship between interaction and social cognition. One particularly prominent contribution to this trend has been Auvray et al., 2006, June 23 , Auvray et al., 2009 minimalist perceptual crossing experiment (as well as follow-up studies conducted by Di Paolo, Ezequiel, Rohde and Iizuka (2008) and Froese and Di Paolo, 2010 , Froese and Di Paolo, 2011a ). The experiment provides an elegant illustration of the complexity of the relationship between social cognition and the interactive settings in which it usually occurs, and has proven to be a fruitful basis for the articulation of theoretical options for conceptualizing that relationship. In this contribution, we criticize one particular theoretical option that has recently been advanced by theorists working within the enactivist tradition (e.g. De Jaegher et al., 2010 , Froese and Di Paolo, 2010 ), who maintain that the results of the experiment corroborate the claim that interaction can play a constitutive role in social cognition. We disagree that the results of the experiment support this claim, and defend the more moderate interpretation that the role of interaction in this experiment is best conceived as that of providing scaffolding for social judgments and thereby simplifying the tasks performed by the individual participants.

This study investigated microarchitectural, mechanical, collagen and mineral properties of normal adolescent cancellous bone, and compared them with adult and aging cancellous bone, to obtain more insight into the subchondral bone adaptations during development and growth. Twenty-three human proximal tibiae were harvested and divided into 3 groups according to their ages: adolescence (9 to 17 years, n=6), young adult (18 to 24 years, n=9), and adult (25 to 30 years, n=8). Twelve cubic cancellous bone samples with dimensions of 8×8×8 mm(3) were produced from each tibia, 6 from each medial and lateral condyle. These samples were micro-CT scanned (vivaCT 40, Scanco Medical AG, Switzerland) resulting in cubic voxel sizes of 10.5*10.5*10.5 μm(3). Microarchitectural properties were calculated. The samples were then tested in compression followed by collagen and mineral determination. Interestingly, the adolescent cancellous bone had similar bone volume fraction (BV/TV), structure type (plate, rod or mixtures), and connectivity (3-D trabecular networks) as the adult cancellous bone. The adolescent cancellous bone had significantly lower bone surface density (bone surface per total volume of specimen) but higher collagen concentration (collagen weight per dry weight of specimen) than the adult cancellous bone; and significant greater trabecular separation (mean distance between trabeculae), significant lower trabecular number (number of trabeculae per volume), tissue density (dry weight per volume of bone matrix excluding marrow space) and mineral concentration (ash weight per dry weight of specimen) than the young adult and adult cancellous bones. Despite these differences, ultimate stress and failure energy were not significantly different among the three groups, only the Young's modulus in anterior-posterior direction was significantly lower in adolescence. Apparent density appears to be the single best predictor of mechanical properties. In conclusion, adolescent cancellous bone has similar bone volume fraction, structure type, and connectivity as the young adult and adult cancellous bones, and significant lower tissue density, bone surface density and mineral concentration but higher collagen concentration than in the young adult and adult bone. Despite these differences, the mechanical properties did not show significant difference among the three groups except less stiffness in anterior-posterior direction in the adolescents.

Background The results of primary total hip arthroplasties (THAs) after pediatric hip diseases such as developmental dysplasia of the hip (DDH), slipped capital femoral epiphysis (SCFE), or Perthes’ disease have been reported to be inferior to the results after primary osteoarthritis of the hip (OA). Materials and methods We compared the survival of primary THAs performed during the period 1995–2009 due to previous DDH, SCFE, Perthes’ disease, or primary OA, using merged individual-based data from the Danish, Norwegian, and Swedish arthroplasty registers, called the Nordic Arthroplasty Register Association (NARA). Cox multiple regression, with adjustment for age, sex, and type of fixation of the prosthesis was used to calculate the survival of the prostheses and the relative revision risks. Results 370,630 primary THAs were reported to these national registers for 1995–2009. Of these, 14,403 THAs (3.9%) were operated due to pediatric hip diseases (3.1% for Denmark, 8.8% for Norway, and 1.9% for Sweden) an...

WOS:000310015700004 Background and purpose The risk of revision due to infection after primary total hip arthroplasty (THA) has been reported to be increasing in Norway. We investigated whether this increase is a common feature in the Nordic countries (Denmark, Finland, Norway, and Sweden). Materials and methods The study was based on the Nordic Arthroplasty Register Association (NARA) dataset. 432,168 primary THAs from 1995 to 2009 were included (Denmark: 83,853, Finland 78,106, Norway 88,455, and Sweden 181,754). Adjusted survival analyses were performed using Cox regression models with revision due to infection as the endpoint. The effect of risk factors such as the year of surgery, age, sex, diagnosis, type of prosthesis, and fixation were assessed. Results 2,778 (0.6%) of the primary THAs were revised due to infection. Compared to the period 1995-1999, the relative risk (with 95% CI) of revision due to infection was 1.1 (1.0-1.2) in 2000-2004 and 1.6 (1.4-1.7) in 2005-2009. Adjusted cumulative 5-year revision rates due to infection were 0.46% (0.42-0.50) in 1995-1999, 0.54% (0.50-0.58) in 2000-2004, and 0.71% (0.66-0.76) in 2005-2009. The entire increase in risk of revision due to infection was within 1 year of primary surgery, and most notably in the first 3 months. The risk of revision due to infection increased in all 4 countries. Risk factors for revision due to infection were male sex, hybrid fixation, cement without antibiotics, and THA performed due to inflammatory disease, hip fracture, or femoral head necrosis. None of these risk factors increased in incidence during the study period. Interpretation We found increased relative risk of revision and increased cumulative 5-year revision rates due to infection after primary THA during the period 1995-2009. No change in risk factors in the NARA dataset could explain this increase. We believe that there has been an actual increase in the incidence of prosthetic joint infections after THA.

Background and purpose Feasibility is an important parameter when choosing which patient-reported outcomes (PRO) to use in a study. We assessed the feasibility of PROs in a hip registry setting. Methods Primary total hip arthroplasty (THA) patients (n = 5,747) who had been operated on 1–2, 5–6, or 10–11 years previously were randomly selected from the Danish Hip Arthroplasty Register and sent 2 PRO questionnaires: 1 generic (EuroQoL-5D or SF-12 health survey) and 1 disease-specific (hip dysfunction and osteoarthritis outcome score (HOOS) or Oxford 12-item hip score). We compared response rates, floor and ceiling effects, missing items, and the need for manual validation of forms. Results 4,784 patients (mean age 71 years, 57% females) were included (83%). The response rates ranged from 82–84%. Statistically significantly different floor and ceiling effects ranged from 0% to 0.5% and from 6.1% to 46%, respectively. Missing items ranged from 1.2% to 3.4%, and 0.8–4.3% required manual validation (p < 0.009)....

To evaluate the effect of a large perfusion-bioreactor cell-activated bone substitute, on a two-level large posterolateral spine fusion sheep model.A 50 mm long porous biphasic-calcium-phosphate bone substitute reinforced with poly(D,L-lactide) and, activated with bone marrow derived mononuclear-cells (BMNC) was used. Eighteen sheep were divided into two groups and one group (n = 9) had BMNC-activated bone substitutes and cell-free substitutes implanted. The second group (n = 9) had autograft supplemented with BMNC and regular autograft implanted. The implant material was alternated between spine level L2-L3 and L4-L5 in both groups. MicroCT was used to compare the spine fusion efficacy and bone structure of the two groups as well as the implanted bone substitutes and non-implanted substitutes.After 4½ months six sheep survived in both groups and we found five spine levels were fused when using activated bone substitute compared to three levels with cell-free bone substitute (p = 0.25). Five sheep fused at both levels in the autograft group. A significant increased bone density (p0.05) and anisotropy (p0.05) was found in the group of activated bone substitutes compared to cell-free bone substitute and no difference existed on the other parameters. The implanted bone substitutes had a significant higher bone density and trabecular thickness than non-implanted bone substitutes, thus indicating that the PLA reinforced BCP had osteoconductive properties (p0.05). No effect of the supplemented BMNC to autograft was observed. The autograft group had a significant higher bone density, trabecular thickness and degree of anisotropy than the implanted bone substitutes (p0.05), but a lower connectivity density existed (p0.05). This indicates that though the activated substitute might have a similar fusion efficacy to autograft, the fusion bridge is not of equal substance.We found that bioreactor-generated cell-based bone substitutes seemed superior in fusion ability when compared to cell-free bone substitute and comparable to autograft in fusion ability, but not in bone structure. This combined with the favorable biocompatible abilities and strength comparable to human cancellous bone indicates that it might be a suitable bone substitute in spine fusion procedures.

Objective The purposes of this study were to measure the prevalence of clinical and radiographic hip osteoarthritis (OA) and first-time diagnosis of hip OA in consecutive patients presenting to chiropractic practices in Denmark and to report the components of the initial treatment rendered by the chiropractic practitioner. Methods A total of 2000 patient records and 1000 radiographs were reviewed retrospectively in 20 chiropractic clinics throughout Denmark. Information obtained included patients' primary complaint, physical examination and radiographic findings of hip OA, and treatment. Subsequently, the 20 clinics participated in a prospective survey where they collected equivalent information over a 2-week period. Results Retrospective review of records revealed that 1.4% of patients in Danish chiropractic practice had signs of clinical hip OA. Of these, 59% demonstrated radiographic signs of hip OA. Prospective data collection revealed that 3.4% of new patients had signs of clinical hip OA. Fifty-four percent of these demonstrated radiographic signs of hip OA, and of these 70% were diagnosed as having OA of the hip for the first time. Initial treatment involved manual treatment and advice on over-the-counter pain medication and/or supplements. Of all 1000 retrospectively reviewed radiographs in patients 40 years or older, 19.2% demonstrated radiographic signs of hip OA. Conclusion Osteoarthritis of the hip is diagnosed and managed in primary care chiropractic practice in Denmark; however, it is likely underdiagnosed. In those newly presenting to chiropractic practitioners, first-time diagnosis with clinical and radiographic signs of hip OA appears to be common.

Objective The purpose of this study was to test the reproducibility and clinical feasibility of three functional performance measures and five single-joint or multijoint muscle power measures. Design Twenty patients with a mean age of 68.7 ± 7.2 yrs with severe hip or knee osteoarthritis were assessed for test-retest reliability and agreement on two occasions 1 wk apart. The outcomes were maximal single-joint muscle power (hip extension/abduction and knee extension/flexion), maximal muscle power during multijoint leg extension press, and functional performance measures (20-m walk, five-time repeated chair stands, and repeated unilateral knee bending). Results For single-joint and multijoint maximal peak power and functional performance measures, we demonstrated poor (CV(ws), approximately 25%, single-joint hip extension) and moderate (CV(ws), approximately 15%, multijoint leg extension press, single-joint knee extension, chair stands, and knee bending) to good (CV(ws), 0.81, single-joint knee extension, knee flexion, hip abduction, 20-m walk, and chair stands) reliability. Conclusions Isolated muscle power over the hip and knee can safely be evaluated with poor to good agreement and good to excellent reliability in patients with advanced hip or knee osteoarthritis. Functional performance and muscle power may be assessed concurrently.

The purpose was to compare radiographic parameters with a sex-matched and age-matched control group at the onset of disease and at skeletal maturity. The study comprised 143 patients with Legg-Calvé-Perthes disease, treated using a Thomas splint. Wiberg's centre-edge angle and the acetabular index angle were applied. The age at diagnosis was 6.6 years with no difference between boys and girls. At the time of diagnosis, the centre-edge angle was decreased from 18° in the control group to 10° in the affected hip. The age at follow-up was 16 (SD 2) years for the boys and 15 (SD 3) years for the girls. At the time of skeletal maturity, the centre-edge angle was decreased and the acetabular index angle increased in the affected hip and the nonaffected hip in Stulberg class III/IV/V hips compared with the control group. Initially radiographic changes only occur on the affected hip. At skeletal maturity both hips show radiographic changes.

Objectives: To evaluate the effect of resurfacing versus standard total hip replacement on post26 surgery hip and knee muscle strength recovery in a prospective randomized controlled trial at the 27 Department of Orthopaedics, University Hospital, Odense, Denmark. Methods: Forty-three patients 28 were randomized into (A) standard total hip arthroplasty (S-THA) and (B) resurfacing total hip 29 arthroplasty (R-THA). Pre-surgery assessment and follow-up were conducted (8, 26 and 52 wks). 30 Maximal isometric muscle strength (Nm) and between-limb asymmetry for the knee 31 extensors/flexors, hip adductors/abductors, hip extensors/ flexors were analysed Results: Maximal 32 knee extensor and hip abductor strength were higher in S-THA than R-THA at 52 wks post surgery 33 (P ≤ 0.05) and hip extensors tended to be higher in S-THA at 52 wks (P=0.06). All muscle groups 34 showed substantial between-limb strength asymmetry (7 to 29%) with the affected side being 35 weakest (P ≤ 0.05) and hip flexors being most affected. Asymmetry was present in half of the 36 muscle groups at 26 wks (P ≤ 0.05), and remained present for the hip flexors and hip adductors at 37 52 wks (P ≤ 0.05). Conclusions: R-THA patients showed an attenuated and delayed recovery in 38 maximal lower limb muscle strength (in 2/6 muscle groups) compared to S-THA. Notably, the 39 attenuated strength recovery following R-THA was most markedly manifested in the late phase (1 40 yr) of post surgical recovery, and appeared to be due to the detachment of the lower half of the 41 gluteus maximus muscle rather than implant design per se. Thus, the present data failed to support 42 the hypothesis that R-THA would result in an enhanced strength rehabilitation compared to S-THA. 43 Further, between-limb asymmetry remained present for hip flexors and adductors after 52 wks OBJECTIVES: To evaluate the effect of resurfacing vs standard total hip replacement on post-surgery hip and knee muscle strength recovery in a prospective randomised controlled trial at the Department of Orthopaedics, University Hospital, Odense, Denmark. METHODS: Forty-three patients were randomised into (A) standard total hip arthroplasty (S-THA) and (B) resurfacing total hip arthroplasty (R-THA). Pre-surgery assessment and follow-up were conducted (8, 26 and 52 wks). Maximal isometric muscle strength (Nm) and between-limb asymmetry for the knee extensors/flexors, hip adductors/abductors, hip extensors/flexors were analysed. RESULTS: Maximal knee extensor and hip abductor strength were higher in S-THA than R-THA at 52 wks post-surgery (P ≤ 0.05) and hip extensors tended to be higher in S-THA at 52 wks (P = 0.06). All muscle groups showed substantial between-limb strength asymmetry (7-29%) with the affected side being weakest (P ≤ 0.05) and hip flexors being most affected. Asymmetry was present in half of the muscle groups at 26 wks (P ≤ 0.05), and remained present for the hip flexors and hip adductors at 52 wks (P ≤ 0.05). CONCLUSIONS: R-THA patients showed an attenuated and delayed recovery in maximal lower limb muscle strength (in 2/6 muscle groups) compared to S-THA. Notably, the attenuated strength recovery following R-THA was most markedly manifested in the late phase (1 yr) of post-surgical recovery, and appeared to be due to the detachment of the lower half of the gluteus maximus muscle rather than implant design per se. Thus, the present data failed to support the hypothesis that R-THA would result in an enhanced strength rehabilitation compared to S-THA. Further, between-limb asymmetry remained present for hip flexors and adductors after 52 wks. Trial registration: NCT01229293.

In this study, 18 female skeletally mature sheep were randomly allocated into three groups of six each. Group 1 (glucocorticoid-1) received prednisolone treatment (0.60 mg/kg/day, five times weekly) for 7 months. Group 2 (glucocorticoid-2) received the same treatment regime followed by observation of 3 months without treatment. Group 3 was left untreated and served as controls. All sheep received a restricted diet with low calcium and phosphorus. At sacrifice, cortical bone samples from the femur midshaft of each sheep were harvested, micro-CT scanned and subjected to three-point bending and tensile strength testing. Bone collagen and mineral were determined. Cortical porosity was significantly increased in the glucocorticoid-2 compared with the glucocorticoid-1 and control groups. Apparent density was significantly decreased in the glucocorticoid-2 compared with the glucocorticoid-1 group. Collagen content was significantly increased in the glucocorticoid-2 compared with the glucocorticoid-1 and control groups. Bone mineral content did not differ between the groups. Neither the three-point bending mechanical properties nor the tensile mechanical properties differed significantly between the groups, while there was a trend towards decreasing bending mechanical properties in the glucocorticoid-2 group. In conclusion, 7 months of glucocorticoid treatment with malnutrition had a significant impact on the cortical microarchitecture of the sheep femur midshaft. These observed changes occurred 3 months after glucocorticoid cessation, suggesting a delayed effect of glucocorticoid on cortical bone. Thus, changes in cortical bone beyond cancellous bone might further increase fracture risk in patients treated with glucocorticoids. This model might be used as a glucocorticoid-induced osteoporotic model for orthopaedic biomaterial, joint prosthesis and medical device researches. Copyright © 2011 John Wiley & Sons, Ltd. In this study, 18 female skeletally mature sheep were randomly allocated into three groups of six each. Group 1 (glucocorticoid-1) received prednisolone treatment (0.60 mg/kg/day, five times weekly) for 7 months. Group 2 (glucocorticoid-2) received the same treatment regime followed by observation of 3 months without treatment. Group 3 was left untreated and served as controls. All sheep received a restricted diet with low calcium and phosphorus. At sacrifice, cortical bone samples from the femur midshaft of each sheep were harvested, micro-CT scanned and subjected to three-point bending and tensile strength testing. Bone collagen and mineral were determined. Cortical porosity was significantly increased in the glucocorticoid-2 compared with the glucocorticoid-1 and control groups. Apparent density was significantly decreased in the glucocorticoid-2 compared with the glucocorticoid-1 group. Collagen content was significantly increased in the glucocorticoid-2 compared with the glucocorticoid-1 and control groups. Bone mineral content did not differ between the groups. Neither the three-point bending mechanical properties nor the tensile mechanical properties differed significantly between the groups, while there was a trend towards decreasing bending mechanical properties in the glucocorticoid-2 group. In conclusion, 7 months of glucocorticoid treatment with malnutrition had a significant impact on the cortical microarchitecture of the sheep femur midshaft. These observed changes occurred 3 months after glucocorticoid cessation, suggesting a delayed effect of glucocorticoid on cortical bone. Thus, changes in cortical bone beyond cancellous bone might further increase fracture risk in patients treated with glucocorticoids. This model might be used as a glucocorticoid-induced osteoporotic model for orthopaedic biomaterial, joint prosthesis and medical device researches. Copyright © 2011 John Wiley & Sons, Ltd.

BACKGROUND: Legg-Calvé-Perthes disease (LCPD) was described a century ago. In previous long-term reports of patients with LCPD, nonoperative treatment varied considerably. The likelihood of hip osteoarthritis (OA) developing in patients with LCPD and possible need for THA are not well defined. QUESTIONS/PURPOSES: The purpose of the study was to determine whether nonoperatively treated patients with LCPD (1) had an increased prevalence of THA compared with gender- and age-matched control subjects, (2) if patients with Stulberg Classes III/IV/V femoral heads had an increased risk of THA compared with those with Classes I/II femoral heads. Given the limitation in the study, we (3) evaluated whether patients with LCPD were at risk for having radiographic hip OA more commonly than control subjects and (4) whether hips with Classes III/IV/V femoral heads had an increased prevalence of OA compared with hips with Classes I/II femoral heads. PATIENTS AND METHODS: The study population consisted of 167 patients with LCPD treated with a Thomas splint. The control population consisted of gender- and age-matched control subjects who were participants in the Copenhagen City Heart Study: the Osteoarthritis Substudy. Radiographs at skeletal maturity were classified according to the classification system of Stulberg et al. Data from the Danish Hip Arthroplasty Register and the Registries of the National Board of Health were collected to obtain the number of patients with LCPD having THA. At a mean followup of 47 years later (range, 37-58 years), weightbearing pelvic radiographs were obtained. Radiographic OA was defined as a joint space width of 2.0 mm or less. RESULTS: Thirteen percent of patients with LCPD had THAs compared with none in the control group. Seven percent of the patients with LCPD had OA compared with 1% in the control group. The prevalence of THA and OA was increased in hips with Classes III/IV/V femoral heads compared with hips with Classes I/II femoral heads. CONCLUSIONS: Patients with LCPD have an increased risk of having THA compared with a gender- and age-matched control group. Our data suggest that patients with LCPD have a greater risk of having radiographic OA develop than a gender- and age-matched control group. It seems that patients with Classes III/IV/V femoral heads have an increased risk of THA and OA compared with patients with Classes I/II femoral heads. LEVEL OF EVIDENCE: Level III, prognostic study. See Guidelines for Authors for a complete description of levels of evidence.

This paper argues that McDowell is right to claim that disjunctivism has anti-sceptical implications. While the disjunctive conception of experience leaves unaffected the Cartesian sceptical challenge, it undermines another type of sceptical challenge. Moreover, the sceptical challenge against which disjunctivism militates has some philosophical urgency in that it threatens the very notion that perceptual experience can acquaint us with the world around us.

In various publications, Stanley Cavell and Stanley Rosen have emphasized the philosophical importance of what they both call “the ordinary.” They both contrast their recovery of “the ordinary” with traditional philosophy, including the phenomenological philosophy of Edmund Husserl. In this paper, I address Rosen’s claims in particular. I argue that Rosen turns the real situation on its head. Contra Rosen, it is not the case that the employment of Husserl’s epoche distorts the authentic voice of “the” ordinary—a voice that is clearly audible only from within everyday life. For (pace both Cavell and Rosen) there is no single “voice” of the ordinary: There are many such “voices,” not all of which are to be relied upon. Therefore, if we want to achieve an adequate grasp of ordinary experience, and Rosen does want this, we precisely need the epoche to curtail the misleading messages of certain other “voices of the ordinary.” Moreover, and somewhat surprisingly, this positive evaluation of the Husserlian epoche finds support in Heidegger’s writings from the twenties. I argue that Heidegger, too, believed that the epoche was an indispensable tool for the philosophical attempt to capture ordinary experience.