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Objective: To examine the relationship between the type of skin incision and postoperative wound complications in an obese population.Methods: A hospital-based perinatal database was used to identify women with a body mass index (BMI) of greater than 35 undergoing their first cesarean delivery. Hospital and outpatient medical records were reviewed for the following variables: age, insurance status, BMI, gestational age at delivery, birth weight, smoking history, prior abdominal surgery, existing comorbidities, preoperative hematocrit, chorioamnionitis, duration of labor and membrane rupture, dilation at time of cesarean delivery, type of skin and uterine incision, estimated blood loss, operative time, antibiotic prophylaxis, use of subcutaneous drains or sutures, endometritis, and length of stay. The primary outcome variable was any wound complication requiring opening the incision. Multiple logistic regression analysis was completed to determine which of these factors contributed to the incidence of wound complications.Results: From 1994 to 2000, 239 women with a BMI greater than 35 undergoing a primary cesarean delivery were identified. The overall incidence of wound complications in this group of severely obese patients was 12.1%. Factors associated with wound complications included vertical skin incisions (odds ratio [OR] 12.4, P < .001) and endometritis (OR 3.4, P = .03). A high preoperative hematocrit was protective (OR .87, P = .03). No other factors were found to impact wound complications.Conclusion: Primary cesarean delivery in the severely obese parturient has a high incidence of wound complications. Our data indicate that a vertical skin incision is associated with a higher rate of wound complications than a transverse incision. [ABSTRACT FROM AUTHOR]

Background: Femoroacetabular impingement syndrome is an important cause of hip pain in young adults. It can be treated by arthroscopic hip surgery or with physiotherapist-led conservative care., Objective: To compare the clinical effectiveness and cost-effectiveness of hip arthroscopy with best conservative care., Design: The UK FASHIoN (full trial of arthroscopic surgery for hip impingement compared with non-operative care) trial was a pragmatic, multicentre, randomised controlled trial that was carried out at 23 NHS hospitals., Participants: Participants were included if they had femoroacetabular impingement, were aged ≥ 16 years old, had hip pain with radiographic features of cam or pincer morphology (but no osteoarthritis) and were believed to be likely to benefit from hip arthroscopy., Intervention: Participants were randomly allocated (1 : 1) to receive hip arthroscopy followed by postoperative physiotherapy, or personalised hip therapy (i.e. an individualised physiotherapist-led programme of conservative care). Randomisation was stratified by impingement type and recruiting centre using a central telephone randomisation service. Outcome assessment and analysis were masked., Main Outcome Measure: The primary outcome was hip-related quality of life, measured by the patient-reported International Hip Outcome Tool (iHOT-33) 12 months after randomisation, and analysed by intention to treat., Results: Between July 2012 and July 2016, 648 eligible patients were identified and 348 participants were recruited. In total, 171 participants were allocated to receive hip arthroscopy and 177 participants were allocated to receive personalised hip therapy. Three further patients were excluded from the trial after randomisation because they did not meet the eligibility criteria. Follow-up at the primary outcome assessment was 92% ( N  = 319; hip arthroscopy, n  = 157; personalised hip therapy, n  = 162). At 12 months, mean International Hip Outcome Tool (iHOT-33) score had improved from 39.2 (standard deviation 20.9) points to 58.8 (standard deviation 27.2) points for participants in the hip arthroscopy group, and from 35.6 (standard deviation 18.2) points to 49.7 (standard deviation 25.5) points for participants in personalised hip therapy group. In the primary analysis, the mean difference in International Hip Outcome Tool scores, adjusted for impingement type, sex, baseline International Hip Outcome Tool score and centre, was 6.8 (95% confidence interval 1.7 to 12.0) points in favour of hip arthroscopy ( p  = 0.0093). This estimate of treatment effect exceeded the minimum clinically important difference (6.1 points). Five (83%) of six serious adverse events in the hip arthroscopy group were related to treatment and one serious adverse event in the personalised hip therapy group was not. Thirty-eight (24%) personalised hip therapy patients chose to have hip arthroscopy between 1 and 3 years after randomisation. Nineteen (12%) hip arthroscopy patients had a revision arthroscopy. Eleven (7%) personalised hip therapy patients and three (2%) hip arthroscopy patients had a hip replacement within 3 years., Limitations: Study participants and treating clinicians were not blinded to the intervention arm. Delays were encountered in participants accessing treatment, particularly surgery. Follow-up lasted for 3 years., Conclusion: Hip arthroscopy and personalised hip therapy both improved hip-related quality of life for patients with femoroacetabular impingement syndrome. Hip arthroscopy led to a greater improvement in quality of life than personalised hip therapy, and this difference was clinically significant at 12 months. This study does not demonstrate cost-effectiveness of hip arthroscopy compared with personalised hip therapy within the first 12 months. Further follow-up will reveal whether or not the clinical benefits of hip arthroscopy are maintained and whether or not it is cost-effective in the long term., Trial Registration: Current Controlled Trials ISRCTN64081839., Funding: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment ; Vol. 26, No. 16. See the NIHR Journals Library website for further project information.

Background: Many surgeons prefer to perform total knee replacement surgery with the aid of a tourniquet. A tourniquet is an occlusive device that restricts distal blood flow to help create a bloodless field during the procedure. A tourniquet may be associated with increased risk of pain and complications., Objectives: To determine the benefits and harms of tourniquet use in knee replacement surgery., Search Methods: We searched MEDLINE, Embase, and Cochrane Central Register of Controlled Trials (CENTRAL) up to 26 March 2020. We searched clinicaltrials.gov, the World Health Organization trials portal, and several international registries and joint registries up to March 2020., Selection Criteria: We included randomised controlled trials (RCTs) comparing knee replacement with use of a tourniquet versus without use of a tourniquet and non-randomised studies with more than 1000 participants. Major outcomes included pain, function, global assessment of success, health-related quality of life, serious adverse events (including venous thromboembolism, infection, re-operation, and mortality), cognitive function, and survival of the implant. Minor outcomes included blood loss, economic outcomes, implant stability, and adverse events., Data Collection and Analysis: Two review authors screened abstracts and full texts, extracted data, performed risk of bias assessments, and assessed the certainty of the evidence using the GRADE approach., Main Results: We included 41 RCTs with 2819 participants. Trials included from 20 to 199 participants. Mean age ranged between 58 and 84 years. More than half of the RCTs had unclear risk of selection bias and unclear risk of performance and detection bias due to absence of blinding of participants and surgeons. Major outcomes Pain: at postoperative day 1, pain (on a scale from zero to 10, with higher scores indicating worse pain) was ranked at 4.56 points after surgery without a tourniquet and at 1.25 points (MD) higher (95% CI 0.32 higher to 2.19 higher) with a tourniquet (8 studies; 577 participants), for an absolute difference of 12.5% higher pain scores (95% CI 3.2% higher to 21.9% higher) and a relative difference of 19% higher pain scores (95% CI 3.4% higher to 49% higher) with a tourniquet. Evidence for these findings was of moderate certainty, downgraded due to risk of bias. Knee replacement with a tourniquet probably led to higher postoperative pain scores at day 1, although this difference may or may not be noticeable to patients (based on a minimal clinically important difference (MCID) of 1.0). Function: at 12 months, tourniquet use probably makes little or no difference to function, based on an MCID of 5.3 for Knee Society Score (KSS) and 5.0 for Oxford Knee Score (OKS). Mean function (on a scale from 0 to 100, with higher scores indicating better outcomes) was 90.03 points after surgery without a tourniquet and was 0.29 points worse (95% CI 1.06 worse to 0.48 better) on a 0 to 100 scale, absolute difference was 0.29% worse (1.06% worse to 0.48% better), with a tourniquet (5 studies; 611 participants). This evidence was downgraded to moderate certainty due to risk of bias. Global assessment of success: low-certainty evidence (downgraded due to bias and imprecision) indicates that tourniquet use may have little or no effect on success. At six months, 47 of 50 (or 940 per 1000) reported overall successful treatment after surgery without a tourniquet and 47 of 50 (or 940 per 1000) with a tourniquet (risk ratio (RR) 1.0, 95% CI 0.91 to 1.10) based on one study with 100 participants. Health-related quality of life: at six months, tourniquet may have little or no effect on quality of life. The 12-Item Short Form Survey (SF-12) score (mental component from zero to 100 (100 is best)) was 54.64 after surgery without a tourniquet and 1.53 (MD) better (95% CI 0.85 worse to 3.91 better) with a tourniquet (1 study; 199 participants); absolute difference was 1.53% better (0.85% worse to 3.91% better). Evidence was of low certainty, downgraded due to risk of bias and small number of participants. Serious adverse events: the risk of serious adverse events was probably higher with tourniquet; 26 of 898 (29 per 1000) reported events following surgery without a tourniquet compared to 53 of 901 (59 per 1000) with a tourniquet (RR 1.73, 95% CI 1.10 to 2.73) in 21 studies (1799 participants). Twenty-nine more per 1000 patients (95% CI 3 to 50 more per 1000 patients) had a serious adverse event with a tourniquet. Forty-eight (95% CI 20 to 345) participants would need to have surgery without a tourniquet to avoid one serious adverse event. This evidence was downgraded to moderate certainty due to risk of bias. Cognitive function: one study reported cognitive function as an outcome; however the data were incompletely reported and could not be extracted for analysis. Survival of implant: it is uncertain if tourniquet has an effect on implant survival due to very low certainty evidence (downgraded for bias, and twice due to very low event rates); 2 of 107 (19 per 1000) required revision surgery in the surgery with a tourniquet group compared to 1 of 107 (9 per 1000) without a tourniquet group at up to two years' follow-up (RR 1.44, 95% CI 0.23 to 8.92). This equates to a 0.4% (0.7% lower to 7% more) increased absolute risk in surgery with a tourniquet., Authors' Conclusions: Moderate certainty evidence shows that knee replacement surgery with a tourniquet is probably associated with an increased risk of serious adverse events. Surgery with a tourniquet is also probably associated with higher postoperative pain, although this difference may or may not be noticeable to patients. Surgery with a tourniquet does not appear to confer any clinically meaningful benefit on function, treatment success or quality of life. Further research is required to explore the effects of tourniquet use on cognitive function and implant survival, to identify any additional harms or benefits. If a tourniquet continues to be used in knee replacement surgery, patients should be informed about the potential increased risk of serious adverse events and postoperative pain., (Copyright © 2020 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.)

Introduction: This study is designed to determine whether a full randomised controlled trial (RCT) examining the clinical effectiveness and safety of total knee replacement surgery with or without a tourniquet is warranted and feasible., Method and Analysis: Single centre, patient-blinded and assessor-blinded RCT. A computer-generated randomisation service will allocate 50 participants into one of two trial treatments, surgery with or without a tourniquet. The primary objective is to estimate recruitment, crossovers and follow-up of patients. All patients will have an MRI scan of their brain preoperatively and day 1 or 2 postoperatively to identify ischaemic cerebral emboli (primary clinical outcome). Oxford Cognitive Screen, Montreal Cognitive Assessment and Mini-Mental State Examination will be evaluated as outcome tools for measuring cognitive impairment at days 1, 2 and 7 postoperatively. Thigh pain, blood transfusion requirements, venous thromboembolism, revision surgery, surgical complications, mortality and Oxford knee and five-level EuroQol-5D scores will be collected over 12 months. Integrated qualitative research study : 30 trial patients and 20 knee surgeons will take part in semistructured interviews. Interviews will capture views regarding the pilot trial and explore barriers and potential solutions to a full trial. Multicentre cohort study : UK National Joint Registry data will be linked to Hospital Episode Statistics to estimate the relationship between tourniquet use and venous thromboembolic event, length of hospital stay, risk of revision surgery and death. The study will conclude with a multidisciplinary workshop to reach a consensus on whether a full trial is warranted and feasible., Ethics and Dissemination: National Research Ethics Committee (West Midlands-Edgbaston) approved this study on 27 January 2016 (15/WM/0455). The study is sponsored by University of Warwick and University Hospitals Coventry and Warwickshire. The results will be disseminated via high-impact peer-reviewed publication., Trial Registration Number: ISRCTN20873088; Pre-results., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Introduction: Femoroacetabular impingement (FAI) syndrome is increasingly recognised as a cause of hip pain. As part of the design of a randomised controlled trial (RCT) of arthroscopic surgery for FAI syndrome, we developed a protocol for non-operative care and evaluated its feasibility., Methods: In phase one, we developed a protocol for non-operative care for FAI in the UK National Health Service (NHS), through a process of systematic review and consensus gathering. In phase two, the protocol was tested in an internal pilot RCT for protocol adherence and adverse events., Results: The final protocol, called Personalised Hip Therapy (PHT), consists of four core components led by physiotherapists: detailed patient assessment, education and advice, help with pain relief and an exercise-based programme that is individualised, supervised and progressed over time. PHT is delivered over 12-26 weeks in 6-10 physiotherapist-patient contacts, supplemented by a home exercise programme. In the pilot RCT, 42 patients were recruited and 21 randomised to PHT. Review of treatment case report forms, completed by physiotherapists, showed that 13 patients (62%) received treatment that had closely followed the PHT protocol. 13 patients reported some muscle soreness at 6 weeks, but there were no serious adverse events., Conclusion: PHT provides a structure for the non-operative care of FAI and offers guidance to clinicians and researchers in an evolving area with limited evidence. PHT was deliverable within the National Health Service, is safe, and now forms the comparator to arthroscopic surgery in the UK FASHIoN trial (ISRCTN64081839)., Trial Registration Number: ISRCTN 09754699., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/)

Introduction: Femoroacetabular impingement (FAI) syndrome is a recognised cause of young adult hip pain. There has been a large increase in the number of patients undergoing arthroscopic surgery for FAI; however, a recent Cochrane review highlighted that there are no randomised controlled trials (RCTs) evaluating treatment effectiveness. We aim to compare the clinical and cost-effectiveness of arthroscopic surgery versus best conservative care for patients with FAI syndrome., Methods: We will conduct a multicentre, pragmatic, assessor-blinded, two parallel arm, RCT comparing arthroscopic surgery to physiotherapy-led best conservative care. 24 hospitals treating NHS patients will recruit 344 patients over a 26-month recruitment period. Symptomatic adults with radiographic signs of FAI morphology who are considered suitable for arthroscopic surgery by their surgeon will be eligible. Patients will be excluded if they have radiographic evidence of osteoarthritis, previous significant hip pathology or previous shape changing surgery. Participants will be allocated in a ratio of 1:1 to receive arthroscopic surgery or conservative care. Recruitment will be monitored and supported by qualitative intervention to optimise informed consent and recruitment. The primary outcome will be pain and function assessed by the international hip outcome tool 33 (iHOT-33) measured 1-year following randomisation. Secondary outcomes include general health (short form 12), quality of life (EQ5D-5L) and patient satisfaction. The primary analysis will compare change in pain and function (iHOT-33) at 12 months between the treatment groups, on an intention-to-treat basis, presented as the mean difference between the trial groups with 95% CIs. The study is funded by the Health Technology Assessment Programme (13/103/02)., Ethics and Dissemination: Ethical approval is granted by the Edgbaston Research Ethics committee (14/WM/0124). The results will be disseminated through open access peer-reviewed publications, including Health Technology Assessment, and presented at relevant conferences., Trial Registration Number: ISRCTN64081839; Pre-results., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/)

Objective: Cam hip shape morphology is a recognised cause of femoroacetabular impingement (FAI) and is associated with hip osteoarthritis. Our aim was to systematically review the available epidemiological evidence assessing the prevalence of cam hip shape morphology in the general population and any studied subgroups including subjects with and without hip pain., Design: All studies that reported the prevalence of cam morphology, measured by alpha angles, in subjects aged 18 and over, irrespective of study population or presence of hip symptoms were considered for inclusion. We searched AMED, MEDLINE, EMBASE, CINAHL and CENTRAL in October 2015. Two authors independently identified eligible studies and assessed risk of bias. We planned to pool data of studies considered clinically homogenous., Results: Thirty studies met inclusion criteria. None of the included studies were truly population-based: three included non-representative subgroups of the general population, 19 included differing clinical populations, while eight included professional athletes. All studies were judged to be at high risk of bias. Due to substantial clinical heterogeneity meta analysis was not possible. Across all studies, the prevalence estimates of cam morphology ranged from 5 to 75% of participants affected. We were unable to demonstrate a higher prevalence in selected subgroups such as athletes or those with hip pain., Conclusions: There is currently insufficient high quality data to determine the true prevalence of cam morphology in the general population or selected subgroups. Well-designed population-based epidemiological studies that use homogenous case definitions are required to determine the prevalence of cam morphology and its relationship to hip pain., (Copyright © 2016 Osteoarthritis Research Society International. Published by Elsevier Ltd. All rights reserved.)

Background: Total Hip Replacement (THR) is an effective treatment for end-stage hip osteoarthritis. Since the introduction of total joint replacement, the effect on the Sexual Quality of Life (SQoL) following THR has been addressed in scant studies. The aim of our study was to systematically review the literature, to summarise effects of THR on patients' SQoL., Methods: We searched PubMed, EMBASE and PsycINFO between January 1970 and February 9th, 2015 with search terms including Total Hip, Osteoarthritis, SQoL, and THR. Eligible studies were identified and two independent authors extracted data including details of SQoL, study quality and risk of bias., Results: There were 12 eligible studies, which included a total of 2099 patients with an age range of 20-85 years. The methodological quality of ten studies was rated as low, and of two as moderate. Amongst the majority of patients, SQoL improved after surgery, both in terms of physical-functional and psychosocial well-being. However, changes between pre-operative and postoperative SQoL ranged extensively: for example, Sexual Dysfunction Δ 8-51% and Sexual Activity (SA) Δ 0-77%. Three studies reported that some patients never resumed SA again after surgery., Conclusion: In over 40 years of THR treatment, scant studies have examined the effect of THR on patients' SQoL. This review suggests that SQol improves after THR, although the magnitude of effects varies highly. However, the quality of the supporting evidence was rated as low to moderate. This suggests a need for more high quality evidence about the effects of THR on SQoL.

Introduction: Total knee arthroplasty (TKA) surgery causes postoperative pain. The use of perioperative injections around the knee containing local anaesthetic, opiates and non-steroidal anti-inflammatory drugs has increased in popularity to manage pain. Theoretical advantages include reduced requirements for analgesia and earlier mobilisation. We propose a single-centre randomised controlled trial of multimodal periarticular anaesthetic infiltration versus femoral nerve anaesthetic blockade as analgesia for TKA. The aim is to determine, in patients undergoing TKA, if there is a difference in patient-reported pain scores on the visual analogue scale (VAS) prior to physiotherapy on day 1 postoperatively between treatment groups., Methods and Analysis: Patients undergoing a primary unilateral TKA at University Hospitals Coventry and Warwickshire Hospitals will be assessed for eligibility. A total of 264 patients will provide 90% power to detect a difference of 12 mm on the VAS on day 1 postoperatively at the 5% level. The trial will use 1:1 randomisation, stratified by mode of anaesthetic. Primary outcome measure will be the VAS for pain prior to physiotherapy on day 1. Secondary outcome measures include VAS on day 2, total use of opiate analgesia up to 48 h, ordinal pain scores up to 40 min after surgery, independent functional knee physiotherapist assessment on days 1 and 2. Oxford knee Scores (OKS), EuroQol (EQ-5D) and Douleur Neuropathic Pain Scores (DN2) will be recorded at baseline, 6 weeks and 12 months. Adverse events will be recorded up to 12 months. Analysis will investigate differences in VAS on day 1 between the two treatment groups on an intention-to-treat basis. Tests will be two-sided and considered to provide evidence for a significant difference if p values are less than 0.05., Ethics and Dissemination: NRES Committee West Midlands, 23 September 2013 (ref: 13/WM/0316). The results will be disseminated via peer-reviewed publications and conference presentations., Trial Registration Numbers: ISRCTN 60611146 and EUDRACT Number 2013-002439-10 (protocol code number PAKA-33601-AS117013); Pre-results., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/)

Objective: To develop a plan for harmonizing outcomes for people undergoing total joint replacement (TJR), to achieve consensus regarding TJR outcome research., Methods: The TJR working group met during the 2014 Outcome Measures in Rheumatology (OMERACT) 12 meeting in Budapest, Hungary. Multiple conference calls preceded the face-to-face meeting. Brief presentations were made during a 1.5-h meeting, which included an overview of published systematic reviews of TJR trials and the results of a recent systematic review of TJR clinical trial outcome domains and measures. This was followed by discussion of potential core set areas/domains for TJR clinical trials (as per OMERACT Filter 2.0) as well as the challenges associated with the measurement of these domains., Results: Working group participants discussed which TJR clinical trial outcome domains/areas map to the inner versus outer core for core domain set. Several challenges were identified with TJR outcomes including how to best measure function after TJR, elucidating the source of the pre- and post-TJR joint pain being measured, joint-specific versus generic quality of life instruments and the importance of patient satisfaction and revision surgery as outcomes. A preliminary core domain set for TJR clinical trials was proposed and included pain, function, patient satisfaction, revision, adverse events, and death. This core domain set will be further vetted with a broader audience., Conclusion: An international effort with active collaboration with the orthopedic community to standardize key outcome domains and measures is under way with the TJR working group. This effort will be further developed with new collaborations.

Background: Surgery is sometimes recommended for femoroacetabular impingement where non-operative interventions have failed., Objectives: To determine the benefits and safety of surgery for femoroacetabular impingement., Search Methods: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (2013, Issue 11); MEDLINE (Ovid) (1946 to 19 November 2013); and EMBASE (Ovid) (1980 to 19 November 2013) for studies, unrestricted by language., Selection Criteria: Randomised and quasi-randomised clinical trials assessing surgical intervention compared with placebo treatment, non-operative treatment or no treatment in adults with femoroacetabular impingement., Data Collection and Analysis: Two authors independently selected trials for inclusion, assessed risk of bias and extracted data., Main Results: There were no studies that met the inclusion criteria, with 11 studies that were excluded following detailed review. There were four ongoing studies identified that may meet the inclusion criteria when they are completed; the results from these ongoing studies may begin to become available within the next five years. Three of the four ongoing studies are comparing hip arthroscopy versus non-operative care. The fourth study is comparing hip arthroscopy versus a sham arthroscopic hip procedure. All of the ongoing studies are recording at least one of our preferred clinical outcome measures for benefit and safety., Authors' Conclusions: There is no high quality evidence examining the effectiveness of surgery for femoroacetabular impingement. There are four ongoing studies, which may provide evidence for the benefit and safety of this type of surgery in the future.

Slipped capital femoral epiphysis (SCFE) is a rare adolescent hip disease that leads to a hip shape abnormality. Typical treatment involves in-situ fixation. It is not known if the degree of initial hip shape abnormality associated with SCFE has a significant effect on long-term hip function. A cohort of patients aged 18-50 who had undergone in-situ fixation for SCFE from 1970 onwards in our institution provided IHOT-33 (hip function) outcome data. Frog lateral radiographs from the time of surgery were used to measure radiological hip shape using both Southwick angle and alpha angle. There were 38 patients (46 hips) SCFE patients who met the eligibility criteria. We obtained follow-up data for 32 patients (38 hips), 83% follow-up. Ten patients (20 hips) had bilateral SCFE. The mean follow-up was 12.7 years (95% CI 10.7-14.7). 32 patients matched for age and sex who had no history of SCFE provided control IHOT-33 outcome data. There was a significant difference (p<0.05) in long-term hip function between patients undergoing in-situ fixation for SCFE and the control population (mean IHOT-33 scores of 71.8 and 95.8 respectively). There was no significant (p>0.05) correlation between long-term hip function and Southwick angle or lateral alpha angle. The initial severity of hip shape abnormality due to SCFE was not a strong predictor of long-term hip function. Other extraneous factors not related to hip shape may have an equally if not more important role to play in the subsequent long-term outcome of SCFE.

Objective: Femoroacetabular impingement (FAI) has been identified as a common cause of hip pain in young adults. However, it is not known whether an effective nonoperative treatment exists and whether there is any evidence to support such a treatment. The purpose of this review is to establish whether nonoperative treatments exist for FAI in the published literature and whether there is any evidence to support their use. TYPE: A systematic review. LITERACY SURVEY: PubMed, Medline, EMBASE, CINAHL, AMED, and Cochrane Library databases were searched by using the following terms: femoroacetabular impingement, femoro-acetabular impingement, and hip impingement. The search was limited to English only but with no time constraints., Methodology: The review was undertaken at 2 academic institutions within the United Kingdom; any article that described or provided evidence that related to a nonoperative treatment for FAI was included. Fifty-three articles met our criteria, of which, 48 were review and/or discussion based., Synthesis: Five articles summarized primary experiments that described or evaluated nonoperative treatment, of which, 3 reported favorable outcomes. Many review and/or discussion articles (31 [65%]) indicated that a trial of conservative care was appropriate. Activity modification was most frequently recommended (39 [81%]), and nearly half promoted physical therapy as a treatment (23 [48%])., Conclusion: The review literature appears to promote initial nonoperative treatment for FAI. Although the available literature with experimental data is limited, there is a suggestion that physical therapy and activity modification confer some benefit to patients. Nonoperative treatment regimens, particularly physical therapy, need to be evaluated more extensively and rigorously, preferably against operative care, to determine the true clinical effectiveness., (Copyright © 2013 American Academy of Physical Medicine and Rehabilitation. Published by Elsevier Inc. All rights reserved.)

The relationship between contralateral hip arthritis and co-morbid medical conditions that affect a patient's ability to walk, and outcome following total hip arthroplasty (THA) is not fully understood. We investigated this relationship in a prospective, multi-centre study. 1497 hips (1428 patients) were recruited. At five years follow-up there was complete data for 1053 hips. We recorded Oxford Hip Score (OHS) and Charnley Class (CC) both preoperatively and at one and five years after surgery. Preoperatively there was a significant difference in OHS between CC categories and OHS deteriorated from CC-A to CC-C (p<0.001). The absolute OHS was significantly worse in CC-C compared to CC-A. Patients who remained in CC-A at five year follow-up had a larger change in OHS (mean 24) compared to those who had changed from CC-A to CC-C at five years (mean 21) p<0.001. The OHS an outcome measure frequently used for THA is influenced by several extraneous factors which may be present preoperatively but also change over time. These factors include the condition of the opposite hip as well as other disease processes that affect a patient's locomotion and therefore interpretation of OHS in isolation without additional information may not be appropriate.

It is not clear if regaining sexual activity is important for patients undergoing total hip arthroplasty (THA) or whether hip surgeons are aware of and manage the concerns of their patients in this context. A questionnaire survey was conducted on 100 patients undergoing THA immediately before and six months after surgery. All members of the British Hip Society with a valid email address were surveyed. 86 patients responded. 71 were sexually active and of these, 55 (77%) believed their hip pathology had been limiting their sex lives. 39 (55%) would have preferred further information than was provided. 51 (72%) patients had recommenced sexual activity by six months post operation. 83 of 140 surgeons responded. 30 (36%) surgeons enquired preoperatively if symptoms were interfering with patients' sex lives and 32 (39%) provided written information about sexual activity following THA. 55 (66%) surgeons believed four weeks after surgery patients could resume sexual activity but only 21 (25%) surgeons regularly advised patients about an appropriate time to resume sexual activity. Sexual activity is adversely affected in many patients awaiting THA and regaining sexual function is important to these patients. Most surgeons do not discuss this with their patients and may not be aware of their patients' expectations in this respect.

Objective: Elevated interleukin-6 (IL-6) level in midtrimester amniotic fluid is associated with preterm delivery. We hypothesized that, in patients with elevated IL-6, vitamin C and alpha-fetoprotein may provide protection from spontaneous preterm delivery through antioxidant functions., Study Design: Antioxidant potential of alpha-fetoprotein was assessed in vitro. Amniotic fluid was collected from a prospective cohort of patients who underwent midtrimester amniocentesis. In patients with IL-6 >600 pg/mL, alpha-fetoprotein, vitamin C, tumor necrosis factor-alpha, tumor necrosis factor receptors, and antioxidant capacity were compared between subjects with spontaneous preterm and term deliveries., Results: Alpha-fetoprotein demonstrated 75% the antioxidant capacity of albumin in vitro. Of 388 subjects, 73 women had elevated IL-6 levels. Among these subjects, alpha-fetoprotein, but not vitamin C, was significantly lower in 9 women with preterm birth. Antioxidant capacity correlated with vitamin C and tumor necrosis factor receptors, but not with alpha-fetoprotein or pregnancy outcome., Conclusion: Amniotic fluid alpha-fetoprotein, but not vitamin C, may protect against preterm birth in patients with elevated midtrimester IL-6 levels., (Copyright © 2011 Mosby, Inc. All rights reserved.)

Background: We assessed mirror visual feedback (MVF) to test the hypothesis that incongruence between motor output and sensory input produces complex regional pain syndrome (CRPS) (type 1) pain., Methods: Eight subjects (disease duration > or =3 weeks to < or =3 yr) were studied over 6 weeks with assessments including two controls (no device and viewing a non-reflective surface) and the intervention (MVF). Pain severity and vasomotor changes were recorded., Results: The control stages had no analgesic effect. MVF in early CRPS (< or =8 weeks) had an immediate analgesic effect and in intermediate disease (< or =1 yr) led to a reduction in stiffness. At 6 weeks, normalization of function and thermal differences had occurred (early and intermediate disease). No change was found in chronic CRPS., Conclusions: In early CRPS (type 1), visual input from a moving, unaffected limb re-establishes the pain-free relationship between sensory feedback and motor execution. Trophic changes and a less plastic neural pathway preclude this in chronic disease.

In this study we examined the primary afferent input to rat area X of Rexed, and characterized sensory receptive fields (RFs) of the cells therein. This poorly understood area contains primary afferent fibres, some of which are arranged into a compact bundle beneath the central canal. Anterograde transport of the B fragment of cholera toxin (CTB) from the sciatic nerve showed a strictly ipsilateral projection to segments in L4 and L5 but both ipsi- and contralateral projections in L6 and more caudal segments. The response of cells in area X to mechanical cutaneous stimuli was recorded through extracellular microelectrodes in decerebrate, decerebrate-spinal, and urethane-anaesthetised preparations. The lateral edge of area X was marked by an abrupt change in the RFs: Lateral to area X in the dorsal horn, they were strictly unilateral and relatively small. At a mean of 90 microm from the midline, there was an abrupt expansion of the RFs to cover at least the entire ipsilateral dermatome. Within area X, 70% of the cells' RFs extended across the midline to include contralateral skin. In 35% of cells recorded in rats with intact spinal cords, the RF extended rostrally onto the forelimb. In a small number of cells, the RF included ear pinnae and nose. The precise function of area X cells remains unknown; although they have been shown to be involved in visceral reflexes, the fact that they receive convergent input from a wide variety of tissues and from local and remote body parts implies a more generalized, integrative function., (Copyright 2002 Wiley-Liss, Inc.)

Aim: To discuss the role of oxidant stress in preterm, premature rupture of the membranes (PPROM)., Results: There is evidence to suggest that preterm, premature rupture of the membranes occurs secondary to focal collagen damage in the fetal membranes., Conclusion: Oxidant stress caused by increased ROS formation and/or antioxidant depletion may disrupt collagen and cause premature membrane rupture. We propose that supplementation with vitamins C and E may synergistically protect the fetal membranes, and decrease the risks of PPROM.

We examined the relation between ectopic afferent firing and tactile allodynia in the Chung model of neuropathic pain. Transection of the L5 spinal nerve in rats triggered a sharp, four- to six-fold increase in the spontaneous ectopic discharge recorded in vivo in sensory axons in the ipsilateral L5 dorsal root (DR). The increase, which was not yet apparent 16 h postoperatively, was complete by 24 h. This indicates rapid modification of the electrical properties of the neurons. Only A-neurons, primarily rapidly conducting A-neurons, contributed to the discharge. No spontaneously active C-neurons were encountered. Tactile allodynia in hindlimb skin emerged during precisely the same time window after spinal nerve section as the ectopia, suggesting that ectopic activity in injured myelinated afferents can trigger central sensitization, the mechanism believed to be responsible for tactile allodynia in the Chung model. Most of the spike activity originated in the somata of axotomized DRG neurons; the spinal nerve end neuroma accounted for only a quarter of the overall ectopic barrage. Intracellular recordings from afferent neuron somata in excised DRGs in vitro revealed changes in excitability that closely paralleled those seen in the DR axon recordings in vivo. Corresponding changes in biophysical characteristics of the axotomized neurons were catalogued. Axotomy carried out at a distance from the DRG, in the mid-portion of the sciatic nerve, also triggered increased afferent excitability. However, this increase occurred at a later time following axotomy, and the relative contribution of DRG neuronal somata, as opposed to neuroma endings, was smaller. Axotomy triggers a wide variety of changes in the neurochemistry and physiology of primary afferent neurons. Investigators studying DRG neurons in culture need to be alert to the rapidity with which axotomy, an inevitable consequence of DRG excision and dissociation, alters key properties of these neurons. Our identification of a specific population of neurons whose firing properties change suddenly and synchronously following axotomy, and whose activity is associated with tactile allodynia, provides a powerful vehicle for defining the specific cascade of cellular and molecular events that underlie neuropathic pain.

Increased excitability of dorsal horn neurones may play a critical role in producing some pain states and there is evidence that the excitability of neurones lying throughout the dorsal horn is subject to regulation by cells in its most superficial laminae. This paper examines the effect on dorsal horn cell receptive fields and excitability of the specific activation of Lissauer's tract, a tract containing propriospinal axons which arise from cells in the substantia gelatinosa and which project to the substantia of neighbouring spinal segments. Experiments were carried out on anaesthetised spinal rats in the L3-4 spinal segments with microelectrode stimulation on the surface of the Lissauer tract (LT) and microelectrode recording of single cells or small groups of cells that responded to gentle brushing on the skin. Single shocks or brief trains of low-level stimuli to the LT produced a characteristic long-latency dorsal root potential (DRP) on the L3 dorsal root and a brief burst of firing in superficial cells with no stimulation of primary afferents. Generally, this was accompanied by no excitation of deeper dorsal horn cells but commonly by a period of inhibition, often followed by facilitation. We then turned to the effect of long periods (30-90min) of continual LT stimulation because we had seen hints of prolonged facilitation of the deeper cells after periods of such stimulation. Trains of 5 stimuli separated by 2ms and repeated every 200ms were used with individual pulses of 200 micros duration and less than 10 microA amplitude. This resulted in a shift of the effect on deep cells from primarily inhibition to mainly facilitation. We then examined in detail the effect of these long periods of LT stimulation on the size of receptive fields (RFs) of dorsal horn cells first on single units and then by repeated mapping of the RFs of small groups of cells. Control periods of 60min with no LT stimulation produced no significant RF changes but 30, 60 or 90min of LT stimulation produced successively greater expansions of RFs. When the LT stimulus was turned off after 1h, the RFs remained expanded for at least 2h. The spike height of these cells remained unchanged. The effect was not influenced by the NMDA antagonist MK801 but was imitated by the GABA(A) antagonist picrotoxin. It is concluded that the prolonged expansion of RFs could not be produced by modulation of descending control since the animals had spinal transections. Neither was it dependent on an NMDA-sensitive mechanism. With these data it is not possible to conclude whether the mechanism is pre-synaptic, post-synaptic or both. It is proposed that the most likely explanation is a decrease in the normal tonic inhibition operated in part by a GABA dependent mechanism. This phenomenon may play a role in prolonged pathological states of increased spinal cord excitability.

It is difficult to know which afferent types preferentially develop ectopic firing characteristics following nerve injury because axotomy disconnects the sensory receptor ending from the remainder of the afferent neuron. We compared the prevalence of ectopic firing originating in nerve-end neuromas of nerves serving muscle and skin in the rat. Spontaneous firing was much more prevalent in the injured medial gastrocnemius nerve, a hindlimb muscle nerve, than in the saphenous and sural nerves which primarily innervate hindlimb skin. Ectopic mechanosensitivity, on the other hand, was more prominent in neuromas of the cutaneous nerves. In neuromas of the facial nerve, a cranial nerve which serves striated muscles of the face, there was no spontaneous discharge and very little ectopic mechanosensitivity. We conclude that the development of spontaneous ectopic discharge and ectopic mechanosensitivity depends on the type of myelinated afferent fiber involved., (Copyright 1999 Elsevier Science B.V.)

Following peripheral-nerve lesions there are well-documented events that affect the contralateral nonlesioned structures. These contralateral effects are qualitatively similar to those occurring at the ipsilateral side, but are usually smaller in magnitude and have a briefer time course. It is unclear whether the findings are an epiphenomenon or serve a biological purpose, but in either case the existence of these effects implies the presence of unrecognized signalling mechanisms that link the two sides of the body. Strong circumstantial evidence argues against a peripheral mechanism (for example, via circulating factors) and in favour of a central mechanism, in particular signalling via the system of commissural interneurons that is present in spinal cord and brainstem. While an altered pattern of activity in this system might underlie the phenomenon, there are several reasons for proposing that the changes depend upon chemical signals, possibly growth factors. Because of its relative easy access for experimental manipulation, the spinal cord could serve as a model system to study these transmedian signalling systems.

We have examined the role of dorsal horn cells that respond to Lissauer tract stimulation in regulating primary afferent depolarization (PAD). PAD was monitored by recording the dorsal root potential (DRP) in the roots of the lumbar cord. Recordings were made of the discharges of Lissauer tract-responsive cells, and their discharges were correlated with the DRPs occurring spontaneously and those evoked by stimulation. Electrical microstimulation of the Lissauer tract (<10 microA; 200 micros) was used to activate the tract selectively and evoke a characteristic long-latency DRP. Cells that were excited by Lissauer tract stimulation were found in the superficial laminae of the dorsal horn. They exhibited low rates of ongoing discharge and responded to Lissauer tract stimulation typically with a burst of impulses with a latency to onset of 5.6 +/- 2.7 ms (mean +/- SD) and to termination of 13.6 +/- 4.1 ms (n = 105). Lissauer tract-responsive cells in L5 were shown to receive convergent inputs from cutaneous and muscle afferents as they responded to stimulation of the sural nerve (100%, n = 19) and the nerve to gastrocnemius (95%, n = 19). The latency of the response to sural nerve stimulation was 3.7 +/- 1.5 ms and to gastrocnemius nerve stimulation, 8.3 +/- 3.6 ms. Stimulation through a microelectrode at a depth of 1.5 mm in the sensorimotor cortex (100 microA, 200 micros) evoked a response in 17 of 31 Lissauer tract-responsive cells (55%) with a latency to onset of 21.9 +/- 2.8 ms (n = 17). Stimulation of the sural nerve, nerve to gastrocnemius or sensorimotor cortex was shown to depress the response of Lissauer tract-responsive cells to a subsequent Lissauer tract stimulus. The ongoing discharges of Lissauer tract-responsive cells were correlated to the spontaneous DRP using spike-triggered averaging. Of 123 cells analyzed in this way, 117 (95%) were shown to be correlated to the DRP. In addition, the peaks of spontaneous negative DRPs in spinally transected animals were detected in software. Perievent time histograms triggered from these peaks showed the discharge of Lissauer tract-responsive cells to be correlated to the spontaneous DRPs in 57 of 62 cells (92%) recorded. We conclude that these data provide compelling evidence that the Lissauer tract, and the dorsal horn cells that it excites, mediate the PAD evoked from multiple neural pathways.

The dorsal root potential (DRP) was measured on the lumbar dorsal roots of urethan anesthetized rats and evoked by stimulation of five separate inputs. In some experiments, the dorsal cord potential was recorded simultaneously. Stimulation of the L3 dorsal root produced a DRP on the L2 dorsal root containing the six components observed in the cat including the prolonged negative wave (DRP V of Lloyd 1952). A single shock to the myelinated fibers in the sural nerve produced a DRP on the L6 dorsal root after the arrival in the cord of the afferent volley. The shape of this DRP was similar to that produced by dorsal root stimulation. Repetitive stimulation of the myelinated fibers in the gastrocnemius nerve also produced a prolonged negative DRP on the L6 dorsal root. When a single stimulus (<5 microA; 200 micros) was applied through a microelectrode to the superficial Lissauer Tract (LT) at the border of the L2 and L3 spinal segments, a characteristic prolonged negative DRP (LT-DRP) began on the L2 dorsal root after some 15 ms. Stimulation of the LT evoked DRPs bilaterally. Recordings on nearby dorsal roots showed this DRP to be unaccompanied by stimulation of afferent fibers in those roots. The LT-DRP was unaffected by neonatal capsaicin treatment that destroyed most unmyelinated fibers. Measurements of myelinated fiber terminal excitability to microstimulation showed that the LT-DRP was accompanied by primary afferent depolarization. Repetitive stimulation through a microelectrode in sensorimotor cortex provoked a prolonged and delayed negative DRP (recorded L2-L4). Stimulation in the cortical arm area and recording on cervical dorsal roots showed that the DRP was evoked more from motor areas than sensory areas of cortex. Interactions were observed between the LT-DRP and that evoked from the sural or gastrocnemius nerves or motor cortex. The LT-DRP was inhibited by preceding stimulation of the other three sources but LT stimulation did not inhibit DRPs evoked from sural or gastrocnemius nerves on the L6 dorsal root or from motor cortex on the L3 root. However, LT stimulation did inhibit the DRP evoked by a subsequent Lissaeur tract stimulus. Recordings were made from superficial dorsal horn neurons. Convergence of input from LT sural, and gastrocnemius nerves and cortex was observed. Spike-triggered averaging was used to examine the relationship between the ongoing discharge of superficial dorsal horn neurons and the spontaneous DRP. The discharge of 81% of LT responsive cells was correlated with the DRP.

Dorsal root potentials (DRPs) and dorsal cord potentials (DCPs) were recorded from the lumbar spinal cord in anaesthetised rats. With the spinal cord intact, low-voltage low-frequency spontaneous DRPs were recorded in synchrony on all lumbar dorsal roots. When the cord was cut at T12, spontaneous large-voltage approximately 10 Hz DRPs appeared immediately in synchrony on all dorsal roots. Section of the dorsolateral funiculus (DLF) was necessary to release these 10 Hz waves. They persisted unchanged for at least 2 h and were not affected by section of all lumbar, sacral and coccygeal dorsal roots. Selective transverse lesions were made to locate the fibres responsible for the synchrony of the oscillations of DRPs recorded on L1 and L6 dorsal roots. Synchrony was maintained with lesions of the entire cord medial to the Lissauer tract but disappeared when the lesion was extended to include the Lissauer tract. We conclude that the isolated cord contains a synchronous oscillatory mechanism inhibited by impulses descending in the DLF and synchronised by way of intrinsic axons in the Lissauer tract.

In 1976, Noordenbos and Wall studied sensory functions in a woman with a surgically verified T3 spinal cord transection which spared only a part of the left anterolateral quadrant, We re-investigated this unique case 18 years after the lesion and included a comparable sensory examination, MRI of the spinal cord, somatosensory evoked potentials, PET-activation study during hand and foot vibration and analysis of flexion reflex modulation during the Jendrassik manoeuvre. Our results show that the residual anterolateral quadrant contains ascending pathways carrying a wide range of sensory information as well as descending pathways modulating flexion reflex activity at the spinal level. Moreover, the changes in sensory functions and the unique pattern of cortical activation suggest a functional reorganization of the connectivity between the periphery and the cerebral cortex. Changes of facilitation and/or of inhibition at different levels of the somatosensory system may account for these longterm plastic changes.

The prolonged dorsal root potential (DRP) and its associated primary afferent depolarisation and presynaptic inhibition had been shown in previous studies to be reduced by GABAA antagonists. However we show here that picrotoxin only reduces the rat DRP to 60% of its control amplitude. We have therefore searched for antagonists to other neurotransmitters that might also contribute to the DRP. The GABAB antagonist CGP 36742 had no significant effect. Similarly, antagonists specific to the serotonin (5-HT)1A receptor (MDL73005EF) and to the 5-HT3 receptor (granisetron) had no significant effect. However, methysergide significantly reduced the DRP to 71% of its control level. Combined methysergide and picrotoxin reduced the DRP to 20% of control level. We therefore propose that both GABAA and 5-HT2 receptor mechanisms may play a role in generating the DRP.

Is there clear evidence that action potentials travelling in a parent axon reach all of their terminals? In spinal afferents, many fibres extend their arborizations beyond the area in which cells can be shown to respond to the afferents. In addition, impulses fail to propagate in the long-range reach of myelinated fibres in dorsal columns when a GABA-operated Cl- shunt in the terminals is operating. When the mechanism is immobilized by antagonists of GABAA receptors, impulse blockade is relieved. This suggests an additional control mechanism, which is located in axons proximal to the synaptic area. Such a control could focus or defocus those parts of a terminal arborization that affect postsynaptic cells.