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Orthopaedics articles from across Nature Portfolio

Orthopaedics is a medical specialty concerned with the prevention and treatment of disorders of the musculoskeletal system by use of surgical and non-surgical methods.

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What’s New in Orthopaedic Rehabilitation

Cleland, Travis L. DO; Gharib, Mahmood MD; Williams, Reed MD, RMSK; Jain, Nitin B. MD, MPH

1 Department of Physical Medicine and Rehabilitation, Crystal Clinic Orthopaedic Center, Akron, Ohio

2 Department of Physical Medicine and Rehabilitation, University of Minnesota Medical Center, Minneapolis, Minnesota

3 Department of Physical Medicine and Rehabilitation, University of Texas Southwestern Medical Center, Dallas, Texas

Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article ( https://links.lww.com/JBJS/G702 ).

Orthopaedic surgery and rehabilitation medicine continue to remain synergistic fields of medicine. This article reviews articles published from March 2020 through February 2021. We considered articles from the American Journal of Physical Medicine & Rehabilitation, The American Journal of Sports Medicine, Archives of Physical Medicine & Rehabilitation, The BMJ (British Medical Journal), The Journal of Bone & Joint Surgery, JAMA (The Journal of the American Medical Association), Journal of Rehabilitation Medicine, Journal of Shoulder and Elbow Surgery, The New England Journal of Medicine, Pain Medicine, PM&R, Regional Anesthesia & Pain Medicine, and Spine.

Adhesive capsulitis in patients with diabetes is a common yet challenging diagnosis to treat for musculoskeletal physicians. Furthermore, it can be a frustrating diagnosis for patients given the functional impairment and pain that commonly occur. In a recent randomized controlled trial (RCT), El Naggar et al. randomized 103 subjects into 2 parallel arms, 1 of which underwent 4 sessions of extracorporeal shockwave therapy and 1 of which received a single intra-articular glenohumeral joint injection 1 . Both arms demonstrated improvement at a 12-week follow-up, and the extracorporeal shockwave arm demonstrated significantly more improvement in the visual analog scale (VAS) for pain (1.6 ± 1.2 compared with 2.8 ± 1.7; p < 0.001) and the QuickDASH (the abbreviated version of the Disabilities of the Arm, Shoulder and Hand [DASH] questionnaire) score (40.4 ± 12.9 compared with 50.5 ± 13.3; p < 0.001) compared with the injection group. This study demonstrated promise for utilizing a novel, corticosteroid-free treatment for a debilitating diagnosis in patients with diabetes.

Subacromial bursitis is a common diagnosis with a treatment consisting of corticosteroid injections into the subacromial space. In an RCT with a total of 68 patients, Zhu et al. compared those receiving corticosteroid injections into the subacromial space alone with those receiving a corticosteroid injection plus resistance band training 2 . Although both groups demonstrated improvement in multiple outcome measures with early follow-up, at 24 weeks, the group that received an injection with resistance-band training demonstrated continued improvement. This study confirms the importance of rehabilitation following corticosteroid injections.

Debate on operative and nonoperative treatment of rotator cuff tears continues to remain a hot topic in the literature. In a multicenter cohort study comparing 96 patients undergoing nonoperative treatment with 73 patients undergoing operative treatment 3 , Song et al. compared the 2 groups utilizing the minimal clinically important difference (MCID) for the reduction of the Shoulder Pain and Disability Index (SPADI) and the American Shoulder and Elbow Surgeons (ASES) score at multiple time periods. At 3.25 months, the nonoperative cohort demonstrated the maximum between-group difference in the proportion of patients achieving the MCID for the SPADI, which was 0.06 (95% confidence interval [CI], 0.00 to 0.12) for the operative group compared with 0.40 (95% CI, 0.29 to 0.50) for the nonoperative group. With longer follow-up, the rate of MCID achievement was greater in the operative arm. The operative arm had a greater probability of achieving >50% reduction in the SPADI score at 15.49 months (0.20 [95% CI, 0.12 to 0.29] for the operative group compared with 0.04 [95% CI, 0.00 to 0.09] for the nonoperative group) and in the ASES score at 24.74 months (0.96 [95% CI, 0.84 to 0.99] for the operative group compared with 0.66 [95% CI, 0.53 to 0.75] for the nonoperative group).

Following traumatic full-thickness rotator cuff tears, surgical intervention is a common treatment option. Postoperative rehabilitation is typically recommended as well. In an RCT, Kjær et al. compared postoperative progressive active exercise therapy with limited passive exercise therapy 4 . Eighty-two subjects were randomized into the 2 rehabilitation groups, with follow-up of 12 weeks and 1 year. There were no between-group differences found in any of the outcome measures assessed, including the Western Ontario Rotator Cuff Index, DASH questionnaire score, pain, range of motion, or strength.

Elbow stiffness has been treated both conservatively and surgically in the past. In an RCT assessing the effect of treatment on subjects with elbow stiffness for >6 months 5 , 30 subjects were randomized into either a rehabilitation-only group or a surgical treatment group followed by rehabilitation. The rehabilitation-only group utilized a static progressive orthosis for extension and a dynamic orthosis for flexion, as well as continuous passive motion. The surgical group utilized a posterior release. The flexion-extension range of motion in the surgical group (108°) was significantly greater (p = 0.002) compared with that in the rehabilitation-only group (88°).

Lateral epicondylosis is a common and frustrating syndrome for both clinicians and patients. Multiple treatments have been studied in the past, with variable conclusions from year to year. In a recent RCT, Uygur et al. assessed 108 subjects with lateral epicondylosis, comparing dry needling and corticosteroid injection, with 6-month follow-up 6 . The authors found that both treatments effectively improved the Patient-Rated Tennis Elbow Evaluation scores (p < 0.01); however, the dry needling group demonstrated more improvement than the corticosteroid group (p < 0.01). Additionally, in a recent systematic review and meta-analysis, Acosta-Olivo et al. assessed 15 RCTs to determine the effect of normal saline solution for the treatment of lateral epicondylosis 7 . The authors concluded that there was a significant functional improvement with decreased pain at ≥6 months. The durability of normal saline solution injections was surprising, given that this has been utilized as a placebo in many previous studies. In another RCT, Lee et al. assessed 2 doses (10 IU and 50 IU) of botulinum toxin to treat lateral epicondylosis in 60 subjects 8 . At the 6-month follow-up, 63.3% of patients in the 10-IU group and 70% of patients in the 50-IU group demonstrated continued pain reduction of ≥50%.

Carpometacarpal joint instability may arise from a variety of underlying pathologies including hypermobility, congenital disorders, or trauma and its results. The literature for nonoperative management of symptomatic carpometacarpal instability remains limited. In a recent prospective cohort study at 20 outpatient hand clinics (431 patients), Wouters et al. evaluated the effect of nonoperative treatment with therapy and orthosis 9 . The VAS scores for pain improved at 3 months compared with baseline (p < 0.001). There was no difference in the total Michigan Hand Outcomes Questionnaire score at 3 months; however, the subscales of activities of daily living, work, pain, and satisfaction did show significant improvement (p < 0.001 to 0.007). Fourteen percent of patients (58) converted to a surgical procedure, suggesting that nonoperative management may be a successful treatment option.

In an effort to identify factors that may predict which patients with femoroacetabular impingement syndrome proceed to a surgical procedure, Glaws et al. assessed 77 patients with femoroacetabular impingement syndrome in a prospective cohort study 10 . Interest in pursuing surgery, previous hip injection, younger age, and worsening hip function were found to be predictive of subjects who had surgical intervention within 90 days of the initial orthopaedic evaluation (p ≤ 0.02).

Knee osteoarthritis has been identified as a leading cause of disability 11 . Physical therapy and glucocorticoid injections have been used as the standard of care, and both have shown benefit in the treatment of knee osteoarthritis. In the primary care setting in the U.S. Military Health System, Deyle et al. randomized 156 patients and compared the results of the use of physical therapy with those of intra-articular glucocorticoid injections 12 . At 1 year, the mean Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores were 55.8 ± 53.8 points for the glucocorticoid injections group and 37.0 ± 30.7 points for the physical therapy group, with a mean between-group difference of 18.8 points (95% CI, 5.0 to 32.6 points), favoring physical therapy. The secondary outcome measure changes showed the same pattern as the primary outcome, with the physical therapy group having less pain and functional disability compared with the glucocorticoid injection group.

Another study evaluating knee pain and physical function in patients with knee osteoarthritis assessed the efficacy of a 12-week aquatic cycling training program 13 . Pool therapy in patients with knee osteoarthritis may be preferred because of the low-impact nature of an aquatic program 14 . There were 111 patients with unilateral mild to moderate osteoarthritis randomized to either the aquatic cycling or usual care group 13 . The Knee Injury and Osteoarthritis Outcome Score for knee pain and function was assessed at baseline, after intervention, and at a 24-week follow-up; the aquatic cycling group had better results compared with the usual care group.

In a secondary analysis of pain and functional performance in a single-blinded 4-month RCT in older adults with knee osteoarthritis, Vincent and Vincent compared 88 patients randomized into 3 groups: patients who underwent no exercise, those who underwent concentrically focused resistance training, and those who underwent eccentrically focused resistance training 15 . Compared with the no-exercise control group, functional pain scores during chair rise and stair climb tasks were lower for both the concentrically and eccentrically focused resistance training groups (p < 0.05). However, pain scores were lower during the 6-minute walk test and in early recovery for the concentrically focused resistance training group compared with the other 2 groups (p < 0.05). The authors concluded that, clinically, either concentric or eccentric resistance exercise can be used to treat knee osteoarthritis pain; however, concentric exercises may provide added pain relief during ambulation.

For patients who are not candidates for total knee arthroplasty, nonoperative measures may be limited. In a multicenter RCT of 158 patients, Chen et al. compared efficacy and safety between cooled radiofrequency ablation and a single hyaluronic acid injection 16 . The cooled radiofrequency ablation group had significantly better Numeric Rating Scale, WOMAC, and Global Perceived Effect scores compared with the hyaluronic acid group at 6 months (p < 0.0001). Patients who underwent cooled radiofrequency ablation demonstrated significantly better pain and function compared with the hyaluronic acid group. The adverse event profiles of both the cooled radiofrequency ablation and hyaluronic acid groups were similar, with neither group experiencing any serious adverse events.

Foot and Ankle

The plantar fascia provides important structural support on the plantar surface of the foot and may be a common source of heel pain from mechanical overload 17 . In a recent RCT, Mansiz-Kaplan et al. evaluated the efficacy of dextrose prolotherapy in the treatment of chronic, resistant plantar fasciopathy. The patients were randomized to a treatment group receiving palpation-guided dextrose prolotherapy injections (n = 32) and a control group (n = 33) receiving a mixture of saline solution (0.9% NaCl) and 2% lidocaine 18 . Patients were followed for 15 weeks after treatment and were evaluated on pain (VAS), function (Foot Function Index), and plantar fascia thickness measured on ultrasound. Improvements in all outcome measures were significantly greater in the prolotherapy group compared with the control group (p < 0.001), indicating both clinical and sonographic effects on resistant plantar fasciopathy when treated with prolotherapy at 15 weeks.

As the rate of lumbar spinal fusion has increased over the last several decades, there is evidence demonstrating postoperative pain, biomechanical dysfunction, psychological, and physical limitations to recovery. The optimal postoperative rehabilitation strategies have also remained under debate. In a single-blinded, parallel-group RCT, Elsayyad et al. evaluated 60 patients who had undergone lumbar spinal fusion with regard to the effects of adding neural mobilization or myofascial release to stabilization exercises 19 . The Oswestry Disability Index, VAS, and back range of motion were assessed before starting treatment, immediately after treatment, and after 1 month. Patients who received either neural mobilization or myofascial release combined with stabilization exercises had significantly better disability and pain (p < 0.05) but not better lumbar range of motion (p > 0.05) at the 1-month follow-up.

Patients with chronic low back pain attributed to degenerative changes of the intervertebral discs may undergo total disc replacement as an alternative to spinal fusion surgery. The clinical implication of facet arthropathy after total disc replacement remains unclear. In a Level-II prospective study, Furunes et al. assessed 126 subjects to determine the development of facet arthropathy after total disc replacement compared with rehabilitation and the association between facet arthropathy and clinical outcomes at an 8-year follow-up 20 . There was an increased incidence of facet arthropathy following total disc replacement compared with nonoperative management; however, this was not associated with differences in the Oswestry Disability Index or back pain. Four patients in the total disc replacement group required posterior decompression surgery due to lateral recess stenosis. No patients in the nonoperative group required a surgical procedure at the time of follow-up, suggesting that index-level facet arthropathy may contribute to the need for reoperation in the total disc replacement group.

Arthroplasty

Outcomes after arthroplasty are of preeminent concern. In an RCT, Hamilton et al. evaluated 334 patients who were determined to be at risk for poor outcomes after total knee arthroplasty 21 . The patients were randomized into either outpatient physical therapy, in which a physical therapist leads the outpatient rehabilitation protocol in a progressive, goal-oriented approach and 1-to-1 therapist contact, or a single physical therapy review with home-based exercises and no physical therapist input. At follow-up of 52 weeks, the outpatient rehabilitation arm had a better final outcome measured via the Oxford knee score; however, the difference in the Oxford knee score between the groups was not clinically important or meaningful.

Barnett et al. assessed the Medicare Bundled Payments for Care Improvement (BPCI) Model 3 in a national voluntary payment demonstration and evaluated institutional spending for lower-extremity joint replacement surgical procedures in association with skilled nursing facilities 22 . In this model, skilled nursing facilities assumed accountability for patients’ Medicare spending for 90 days after the initial skilled nursing facility admission. Without significant change in mortality or 90-day readmissions, among Medicare patients undergoing lower-extremity joint replacement, the BPCI Model 3 was significantly associated with a decrease in mean institutional spending on episodes initiated by admission to skilled nursing facilities by 5.6% (−$1,008 [95% CI, −$1,603 to −$414]; p < 0.001) and a decrease in length of stay by −2.0 days (95% CI, −2.9 to −1.1 days).

Pain Management

Arthroscopic surgical procedures have continued to grow in utilization for the treatment of a variety of intra-articular hip pathologies. In a systematic review of available RCTs, Kunze et al. evaluated the effect of adjunctive analgesia on postoperative pain, opioid use, and hospital length of stay 23 . Fourteen Level-I studies were included assessing 3 categories of intervention including regional anesthesia blocks, local infiltration of anesthetic, and nonsteroidal anti-inflammatory drug (NSAID) use, specifically celecoxib. Twelve (86%) of the 14 studies showed immediate and perioperative pain reduction. In most of the 7 studies that compared an intervention with a placebo, patients receiving the intervention had significantly lower opioid consumption. Only 2 of the same 7 studies showed a significantly shortened length of stay, with 4 studies showing no significant difference. The greatest benefit in pain reduction and reduced opioid consumption appeared to be for patients who received local infiltration analgesia.

In the setting of the ongoing opioid epidemic, there is continued interest in opioid reduction following orthopaedic surgical procedures. In a recent study, Burns et al. assessed patients who underwent either total shoulder arthroplasty (78 patients) or rotator cuff repair (79 patients) from February 2014 to February 2018 to assess the effect of celecoxib 1 hour prior to the procedure and for 3 weeks postoperatively 24 . In patients who were prescribed celecoxib, opioid consumption as determined by morphine-equivalent dosing (MED) was significantly less (p < 0.01 for all) in both the total population and patients who underwent a total shoulder arthroplasty at 3 and 6 weeks. However, there was no significant difference in the group undergoing rotator cuff repair. The study concluded that analgesia through multimodal pain control, particularly including celecoxib use, for patients who undergo total shoulder arthroplasty is effective in reducing opioid consumption. Cheesman et al. determined the effect of preoperative opioid education on opioid dependence following arthroscopic rotator cuff repair 25 . In this prospective, single-center, single-blinded, 2-arm RCT, opioid education prior to the surgical procedure was found to be an independent factor reducing opioid dependence at a 2-year follow-up.

Orthobiologics

Orthobiologics remains a popular area of study in the literature. In a recent systematic review and network meta-analysis of 20 RCTs (1,271 patients), Tang et al. compared platelet-rich plasma, autologous blood, and corticosteroid injections for the treatment of lateral epicondylosis 26 . This analysis demonstrated that platelet-rich plasma was associated with more improvement in pain intensity and function in the long term and corticosteroid injections were associated with improvement in the short term. This conclusion was also demonstrated in another recent systematic review and meta-analysis of 20 studies (1,268 patients), which also included plantar fasciopathy 27 .

Rotator cuff disease was recently assessed by Jo et al. in an RCT of 60 subjects to investigate the safety and efficacy of platelet-rich plasma injections into the subacromial space compared with corticosteroid injections 28 . All injections were completed with ultrasound guidance to ensure accuracy. The subjects were randomly assigned to either a 4-mL allogenic pure platelet-rich plasma injection or a 4-mL mixture of 40-mg/mL triamcinolone acetonide with 3 mL of 2% lidocaine. No adverse events were reported, and the Constant score at 1 month did not significantly differ between the 2 groups. At 6 months, the platelet-rich plasma group had significantly better results with regard to the DASH score, overall function, and external rotation range of motion. This conclusion appears to be consistent with the findings of the epicondylosis and plantar fasciopathy studies.

In an RCT of 40 subjects who had sustained an Achilles tendon rupture within the previous 72 hours, Boesen et al. randomized the patients into a group that had placebo injections or a group that had platelet-rich plasma injections and subsequently followed them for 12 months 29 . All patients were treated with an orthosis for 8 weeks and weight-bearing was allowed from day 1; patients were given the same exercise instructions to begin at week 9. Patients underwent a series of 4 injections at 2 weeks apart. Although both groups showed improvement at all time points (p < 0.001), there was no difference between groups at any time points. This study demonstrates that the application of platelet-rich plasma has no significant clinical or functional benefit compared with controls in patients with Achilles tendon ruptures.

In a recent systematic review and meta-analysis of RCTs comparing platelet-rich plasma and hyaluronic acid for knee osteoarthritis, Belk et al. identified 18 studies, all meeting Level-I evidence criteria, with 811 patients undergoing intra-articular platelet-rich plasma injections and 797 patients undergoing intra-articular hyaluronic acid injections followed for a mean of 11.1 months 30 . The WOMAC score improvement (p < 0.01) and VAS improvement (p < 0.05) were significantly superior for subjects treated with platelet-rich plasma compared with those treated with hyaluronic acid. Furthermore, a subanalysis was also performed isolating results from patients receiving leukocyte-poor or leukocyte-rich platelet-rich plasma. The patients who received leukocyte-poor platelet-rich plasma had significantly better Subjective International Knee Documentation Committee (IKDC) scale scores (p < 0.05). In a similar vein, in another RCT (n = 110), Park et al. compared participants with symptomatic knee osteoarthritis after they received a single dose of either leukocyte-rich platelet-rich plasma or hyaluronic acid and were followed for 6 months 31 . The Subjective IKDC score at 6 months was significantly better in the platelet-rich plasma group, at 11.5, compared with the hyaluronic acid group, at 6.3 (p = 0.029). Another subanalysis measured cell counts and concentrations of growth factors and cytokines in the injected platelet-rich plasma samples, which showed that patients who achieved the MCID for the pain VAS at 6 months had received higher concentrations of platelet-derived growth factors. It is refreshing to see further analysis with regard to the content of the platelet-rich plasma used in studies.

Running remains a popular form of exercise. In a recent RCT, Taddei et al. assessed 118 runners who were randomly allocated to a control group (n = 61) or an intervention group that received a foot core-strengthening program (n = 57) and were followed for 12 months. The intervention group underwent an 8-week training course focused on foot and ankle muscles, followed by remotely supervised training thereafter 32 . The runners treated with the foot core-strengthening program experienced a rate of running-related injuries that was 2.42 [95% CI, 1.98 to 3.62] times lower compared with the control group at 4 to 8 months of training.

Reverse shoulder arthroplasty has continued to grow in utilization for the treatment of glenohumeral osteoarthritis. Davey et al. performed a systematic review of the literature, based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines for clinical studies, showing return to sport after reverse shoulder arthroplasty 33 . Eight studies with 455 patients (464 shoulders) met inclusion criteria. The overall rate of return to sport was 79.1%, with 66.7% of golfers, 74.3% of swimmers, 50.0% of tennis players, 94.4% of joggers, and 69.7% of cyclists returning. The mean time to return to sport was 3.4 months, with a mean follow-up of 34 months. Additionally, 71.4% of patients returned to their previous level of sporting activity. The study did note that it is of concern that overhead athletes, as portrayed by the tennis group, had a larger percentage (50.0%) who were unable to return to tennis after a reverse shoulder arthroplasty.

Physiatry Societies and Upcoming Events

There are 3 medical societies in the United States for physical medicine and rehabilitation (PM&R): the Association of Academic Physiatrists (AAP), the American Academy of Physical Medicine and Rehabilitation (AAPM&R), and the American Congress of Rehabilitation Medicine (ACRM). The AAP had a record-setting year for participants in the 2021 virtual conference held in February 2021. The 2022 annual conference will be held in New Orleans, Louisiana, from February 1 to 5, 2022. The AAP publishes the American Journal of Physical Medicine & Rehabilitation . The AAPM&R’s 2021 annual assembly was held in person in Nashville, Tennessee, on November 11 to 14, 2021, with a virtual option available. The 2022 annual assembly will be held in Baltimore, Maryland, from October 20 to 23, 2022. The AAPM&R publishes the journal PM&R . The 2021 ACRM annual conference was held virtually from September 26 to 29, 2021. The ACRM publishes the Archives of Physical Medicine & Rehabilitation.

Evidence-Based Orthopaedics

The editorial staff of JBJS reviewed a large number of recently published studies related to the musculoskeletal system that received a higher Level of Evidence grade. In addition to articles cited already in this update, 4 other articles relevant to orthopaedic rehabilitation surgery are appended to this review after the standard bibliography, with a brief commentary about each article to help guide your further reading, in an evidence-based fashion, in this subspecialty area.

Evidence-Based Medicine

Nguyen A, Vather M, Bal G, Meaney D, White M, Kwa M, Sungaran J. Does a hand strength-focused exercise program improve grip strength in older patients with wrist fractures managed nonoperatively? A randomized controlled trial. Am J Phys Med Rehabil. 2020 Apr;99(4):285-90.

When patients are treated nonoperatively for distal radial fractures, they are typically immobilized, which may affect pain and function, in particular, grip strength. In this single-center, prospective, parallel-design RCT, Nguyen et al. sought to determine whether a focused hand-strengthening exercise program would improve grip strength and function in 52 elderly patients (>60 years of age). The primary outcome measured grip strength with the use of a dynamometer at follow-ups of 2, 6, and 12 weeks. The secondary outcome measures evaluated function with the QuickDASH score and pain with a VAS. Compared with the control group, who underwent range-of-motion exercises alone, the strength-focused exercise group had significantly greater strength at 6 weeks (p = 0.0044) and 12 weeks (p = 0.0035); however, there was no significant difference in QuickDASH between groups at 12 weeks. Interestingly, 3 cases of complex regional pain syndrome were diagnosed in the control group (11%) compared with 0 cases in the intervention group. This study demonstrated that, although strength was greater in the strength-focused exercise group, function and pain were comparable in both groups.

Okoroha KR, Ussef N, Jildeh TR, Khalil LS, Hasan L, Bench C, Zeni F, Eller E, Moutzouros V. Comparison of tendon lengthening with traditional versus accelerated rehabilitation after Achilles tendon repair: a prospective randomized controlled trial. Am J Sports Med. 2020 Jun;48(7):1720-6.

After Achilles tendon repair, there is concern for tendon elongation and risk of rerupture. In an RCT of 18 patients undergoing primary repair for Achilles tendon ruptures, patients were randomized to a traditional 6-week weight-bearing rehabilitation group or a 2-week accelerated (graduated) rehabilitation group. The primary outcome was postoperative tendon elongation as measured by radiostereometry using implanted tantalum beads. Although both groups demonstrated postoperative lengthening after the surgical procedure, there was no significant difference at any time point. The secondary outcomes were the Achilles Tendon Total Rupture Score (ATRS) and the Patient-Reported Outcomes Measurement Information System Pain Interference Short Form (PROMIS PI-SF) score, and there were no significant differences between the control and treatment groups. Although further studies are needed, this demonstrates the possibility of a more rapid approach to postoperative rehabilitation after Achilles tendon repair.

Sakata J, Miyazaki T, Akeda M, Yamazaki T. Predictors of failure of return to play in youth baseball players after capitellar osteochondritis dissecans: focus on elbow valgus laxity and radiocapitellar congruity. Am J Sports Med. 2021 Feb;49(2):353-8.

In a case-control study on 81 elementary school-aged baseball players diagnosed with osteochondritis dissecans of the humeral capitellum (capitellar osteochondritis dissecans), the authors suggested that the early stage of capitellar osteochondritis dissecans in youth baseball players can be treated nonoperatively in most cases and that the presence of proximal radial translation can predict the outcome of nonoperative capitellar osteochondritis dissecans treatment. All participants underwent rehabilitation after the injury, with return to the same level of play or higher in 57 (70.4%) of the 81 players. Multivariate logistic regression analysis identified the proximal radial translation distance on an anteroposterior radiograph as a significant predictive factor for outcome after nonoperative treatment. This suggests that young baseball players with capitellar osteochondritis dissecans lesions may utilize nonoperative management in lieu of a surgical procedure.

Wallace P, Bezjian Wallace L, Tamura S, Prochnio K, Morgan K, Hemler D. Effectiveness of ultrasound-guided platelet-rich plasma injections in relieving sacroiliac joint dysfunction. Am J Phys Med Rehabil. 2020 Aug;99(8):689-93.

In this prospective, nonrandomized, interventional trial, Wallace et al. evaluated 50 patients with sacroiliac joint pain who underwent ultrasound-guided platelet-rich plasma injections. The primary outcome measure was the Oswestry Disability Index, and the secondary outcome measure was the Numeric Rating Scale for pain. Patients were assessed before injection and at 2 and 4 weeks and 3 and 6 months. Both outcomes showed significant improvements compared with baseline at all post-injection time points. However, improvement tapered off after 4 weeks; the improvement from 4 weeks to 6 months was not significant. The authors concluded that there is improvement in disability and pain at up to 6 months following ultrasound-guided platelet-rich plasma injections of the sacroiliac joint. This is an interesting conclusion and warrants further studies to not only determine the use of platelet-rich plasma for this syndrome, but further explore the utilization of ultrasound for sacroiliac injections.

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Orthopedic Surgery

• New directions for orthopedic surgery research

Aug. 06, 2021

Matthew P. Abdel, M.D. , an orthopedic surgeon at Mayo Clinic in Rochester, Minnesota, answers questions about artificial intelligence (AI) and other research goals in Orthopedic Surgery. Dr. Abdel was recently named chair of Mayo Clinic's Orthopedic Surgery Research.

Why is AI a primary focus of Mayo Clinic's orthopedic surgery research?

All of our research priorities are based on the needs of our patients. Our basic science researchers as well as our clinician-investigators are all engaged in research that is directly translatable to clinical practice.

Musculoskeletal innovation goals

Schematic describes Mayo Clinic's goals for musculoskeletal (MSK) innovation.

AI has a strong potential to improve patient care through the development of predictive analytics to guide surgical decision-making. One example is AI analytics to predict whether or not a prosthetic implant is fixed or loose. But the potential applications of AI touch all nine of our Orthopedic Surgery clinical divisions. Our goal is to transform musculoskeletal care through predictive algorithms and AI .

What infrastructure does Mayo Clinic have for building predictive analytics?

In addition to orthopedic surgical subject matter experts, Mayo Clinic has robust data sets for most orthopedic subspecialties. For example, in hip and knee arthroplasty, we have a patient registry that has captured clinical, radiographic, demographic and operative details going back to March 1969. That type of longitudinal data is key to developing the algorithms that drive predictive analytics.

Applying predictive analytics to individual patients requires state-of-the-art imaging. Mayo Clinic also has a long tradition of imaging expertise that will facilitate the development of AI -based applications.

What additional priorities is the research division pursuing?

In addition to AI , our 2030 strategic vision focuses on cartilage regeneration, infection prevention and treatment, fibrosis, arthritis, and orthopedic oncology.

How might research focused on cartilage regeneration benefit patients?

Pharmacological and gene therapies that slow the degeneration of cartilage can help individuals avoid joint replacement surgery. Patients are eager for nonsurgical options. Like AI , cartilage regeneration can impact many of the services we provide, including our upper and lower extremity practices, spine practice, pediatric orthopedics, and sports medicine.

What does Mayo Clinic hope to achieve regarding orthopedic infection research?

One particular issue we hope to clarify is whether bacteriophages play any role in treating periprosthetic joint infections. As described in Clinical Infectious Diseases, Mayo Clinic successfully used phage therapy to treat a 62-year-old man with a history of knee arthroplasty and multiple episodes of prosthetic knee infection — avoiding the need for amputation.

Infections can plague any bone, muscle, ligament, tendon or joint. The prevention and treatment of these orthopedic infections is evolving rapidly, and Mayo Clinic is committed to innovation.

What are Mayo Clinic's goals in fibrosis and arthritis research?

We are working to develop pharmacological modalities that both prevent and treat fibrosis in the musculoskeletal system. Similarly, learning more about the pathogenesis of arthritis, and how we might slow or prevent its development, is key.

All of our research aims ultimately focus around curing musculoskeletal diseases with innovative diagnostics and therapeutics. Moreover, we want to connect patients to optimal care through predictive analytics and advanced registry technologies.

For more information

Cano EJ, et al. Phage therapy for limb-threatening prosthetic knee Klebsiella pneumoniae infection: Case report and in vitro characterization of anti-biofilm activity. Clinical Infectious Diseases. 2021;73:e144.

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Osteoarthritis is a prevalent and disabling disease affecting an increasingly large swathe of the world population. While clinical osteoarthritis is a late-stage condition for which disease-modifying opportuni...

Journal of Orthopaedic Surgery and Research

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Prof Peter V. Lee holds a full Professor position at the University of Melbourne since 2015. He has held several leadership positions including Deputy Head and Acting Head of Department of Mechanical Engineering, and currently as the Deputy Head (Research and Engagement) of Department of Biomedical Engineering, and the Melbourne School of Engineering Research Program Leader for Medical and Pharmaceutical Technologies. He also leads the Cell and Tissue Biomechanics Laboratory in Engineering, where his research aims to better understand the behaviour of biological cells and tissues under mechanical forces.

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The Department of Orthopaedic Surgery’s distinguished history is grounded on Johns Hopkins Medicine’s principle that laboratory research and bedside teaching need to coexist in the instruction and practice of medicine. The creation of a formal Research Division and the Center for Musculoskeletal Research in 2009 provided a nexus for basic and translational research related to the musculoskeletal system.

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For a complete list of available clinical trials, search the database at the  Johns Hopkins Institute for Clinical and Translational Research . You can search by condition, researcher or doctor’s name.

Experimental Procedure for Children With Knee Cartilage Defects

Summary: A study of MACI in patients aged 10 to 17 years with symptomatic chondral or osteochondral defects of the knee (PEAK). 

Objective: To evaluate an experimental treatment for knee cartilage defects called membrane-induced autologous chondrocyte implantation (MACI).

Principle Investigator: R. Jay Lee, M.D.

Eligibility Criteria: Children age 11-17 with knee cartilage defects

Contact: Gabrielle Richard ( [email protected] )

Learn more about this study.

Integra® Titan™ Modular Shoulder System Generation 2.5 for Primary Shoulder Joint Replacement

Summary: A Post-Market, Prospective, Multi-Center, Open-Label, Single Arm Clinical Evaluation of the Integra TitanTM Modular Shoulder System 2.5 for Primary Shoulder Joint Replacement (IRB00169712).

Objective: To evaluate 2-year implant survivorship in subjects who receive the TSS-2.5 when used for primary shoulder arthroplasty.

Principle Investigator: Umasuthan Srikumaran, M.D., M.P.H., M.B.A.

Eligibility Criteria: Candidate for total shoulder arthroplasty.

Contact: Sanjana Vattigunta ( 443-516-1550  or  [email protected] )

Post-operative Pain Control Following Shoulder Surgery

Summary: A study of MACI in patients aged 10 to 17 years with symptomatic chondral or osteochondral defects of the knee (PEAK). 

Objective: Evaluate overall pain medication consumption following surgical treatment for shoulder pathology

Eligibility Criteria: Opioid-naive adults age 18-90 years old planning to undergo surgical treatment for shoulder pathology with Dr. Uma Srikumaran.

Optimize Low Back Pain

Objective: Improve health care for patients with chronic lower back pain (LBP) and increase the likelihood that patients obtain outcomes that matter most to them.

Principle Investigator: Richard Skolasky, Sc.D.

Eligibility Criteria: Adults age 18 - 64 years old, meets NIH Task Force definition of chronic LBP, had a healthcare visit for LBP in the past 90 days and have moderate levels of pain and disability.

Contact: Tricia Kirkhart ( 410-502-4453  or  [email protected] )

Dysport® (abobotulinumtoxinA) as an Adjunctive Treatment to Bracing in the Management of Adolescent Idiopathic Scoliosis (AIS)

Objective: To evaluate the combined effect of botulinum toxin A (administered as Dysport®) and bracing in children with adolescent idiopathic scoliosis.

Principle Investigator: Paul D. Sponseller, M.D.

Eligibility Criteria: Diagnosed with AIS, 10 to 16-year-old children.

Contact: Vivian Tran and Varun Puvanesarajah ( 410-955-3136  or  [email protected] )

Participants in this study will be compensated.

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Our orthopaedic research division and its faculty members are recognized internationally as leading innovators in musculoskeletal science and training. Our investigators conduct basic, translational and clinical research in topics that represent the great diversity of problems that impact the musculoskeletal system. Focus areas include integrative musculoskeletal biology, stem cells and regenerative medicine, skeletal neurobiology, bone metastasis and clinical outcomes.

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Masanobu Komatsu, PhD

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Spine Outcomes Research Center

Richard Leroy Skolasky, ScD

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Innovation in Spine Surgery

Orthopaedic spine surgeon Khaled Kebaish discusses the latest innovations and research in the spine division at the Johns Hopkins Department of Orthopaedic Surgery.

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Predicting Major Complications and Discharge Disposition After Adult Spinal Deformity Surgery

Surgical Setting in Achilles Tendon Repair: How Does It Relate to Costs and Complications?

Predicting Risk of 30-day Postoperative Morbidity Using the Pathologic Fracture Mortality Index

The Use of Weakly Supervised Machine Learning for Necrosis Assessment in Patients with Osteosarcoma: A Pilot Study

Is Delayed Anterior Cruciate Ligament Reconstruction Associated with a Risk of New Meniscal Tears? Reevaluating a Longstanding Paradigm

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Vanderbilt Sports Medicine leads the orthopaedic community in cutting edge research both locally and nationally. Our physicians have been published in medical journals and have presented at both state and national level conferences. It is our mission to improve the lives of others through science, education and clinical skill. To be the best, we continuously are working on creating better surgical techniques, and rehabilitation through our research.

Vanderbilt’s Sports Medicine Department is fortunate to be the coordinating center for   several research projects  that seek to measure the short and long-term prognosis of both knee and shoulder injuries using patient-oriented outcome tools.

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• v.43(4); Oct-Dec 2009

Basic research in orthopedic surgery: Current trends and future directions

Chuanyong lu.

Orthopaedic Trauma Institute, Department of Orthopaedic Surgery, University of California at San Francisco, San Francisco General Hospital, 2550 23rd St., San Francisco, CA 94110 USA

Jenni M. Buckley

Céline colnot, ralph marcucio, theodore miclau.

Musculoskeletal problems continue to represent a growing source of death and disability world-wide, particularly with the growing burden of disease associated with an aging population and increase in the rates of road traffic accidents. To address the societal and economic burdens presented by musculoskeletal disorders, research in the normal biology of musculoskeletal tissues, the diseases and injuries associated with these tissues, and the underlying mechanisms of musculoskeletal tissue regeneration continue to gain importance. These investigations often require multidisciplinary approaches ranging from basic cellular and molecular biology, bioengineering, biomechanics, and clinical research. It is clear that collaboration between disciplines and centers with expertise in biology, mechanics, and clinical research is essential to continue to advance the field. The purpose of this review is to address issues that may be of interest to the development of new basic science research programs and initiatives, including a brief review of current and developing areas of orthopaedic research, and the resources required for the successful creation of new biology and mechanical research laboratories.

D IRECTIONS IN O RTHOPEDIC R ESEARCH

The musculoskeletal system involves a diverse organization of tissues exposed to a complex series of biological and mechanical stimuli. A thorough understanding of the normal biology of the musculoskeletal tissues, the behavior of these tissues associated with disease and injury, and the underlying mechanisms of musculoskeletal tissue regeneration is necessary to address the growing burden of disease. Research programs, both in developed and developing countries, must target those orthopedic conditions of greatest importance to their populations in order to diminish the societal and economic burdens caused by an inability to resume necessary physical function. The potential areas for investigation within the field of orthopedics continue to grow, particularly as the basic and applied body of scientific knowledge and technology develop. While these areas for basic research in orthopedics are too numerous to list, below are examples of some of the current and future directions in the field.

Musculoskeletal injury and repair

Bone repair, whether it happens following a fracture or a bone graft, involves a well organized set of events that lead to reconstitution of the biological and mechanical integrity of bone. The regeneration process is initiated by an inflammatory response, which plays an important role in stimulating repair. 1 Simultaneously, skeletal progenitor cells are recruited and begin differentiating into chondrocytes and osteoblasts that will deposit new cartilage and bone matrix necessary for bone bridging. The origins of these progenitor cells and the influence of the inflammatory response on their recruitment are not well understood. Following extracellular matrix deposition, cartilage is replaced by bone and new trabecular bone is converted to lamellar bone during the remodeling phase of repair. 2 – 4

Numerous molecules and growth factors are keys to each step of the repair process and their functions are slowly being elucidated through analyses of various animal models of bone repair. 2 , 5 These investigations will lead to a better understanding of the cellular and molecular bases of bone repair, better diagnosis of skeletal repair defects, and development of new strategies to accelerate healing. Surgeons have now the choice between various surgical techniques, improved implants and biological approaches to treat complex injuries. Current approaches use autografts, allografts, or bone morphogenetic proteins (BMPs). However, these approaches are not always successful and are costly, which necessitates the development of new therapies.

The muscles, tendons and ligaments along with blood vessels and nerves are closely associated with the bone. Musculoskeletal injuries may involve one or more of these tissues and the extent of injury is highly linked to the success of repair. For example, delayed union or non-union occurs in 5 to 10% of all fractures but is increased up to 46% in patients with extreme trauma and soft tissue damage. 6 Therefore the role of numerous tissues must be taken in account in the majority of musculoskeletal diseases or injuries. Advances are being made in the basic biology of bone and individual soft tissues surrounding bone. The basic biology of muscle and muscle repair is well understood compared to other soft tissues. Muscle repair is composed of three phases including degeneration/ inflammation, regeneration and fibrosis. Many molecular markers and disease models are available. Muscle has been an ideal target to test new gene therapies and cell based therapies, however further advances are needed to treat devastating diseases such as Duchenne Muscular Dystrophy and to improve muscle repair. Vascular biology is also an area of intense investigation but more efforts need to be made to apply the data to the orthopedic field. The biology of tendons and ligaments is now being better understood with the identification of key molecular pathways involved in these tissues. Injury of tendons and/or ligament independent of bone can lead to complications and extended periods of recovery, which can also have debilitating effects. Like muscle and bone healing, tendon and ligament healing is initiated by an inflammatory response that may be modulated to stimulate repair. Little is know about the intrinsic capacities of tendon and ligament to heal and the cell sources that participate in repair.

Cartilage biology

Regeneration of cartilage is a hot topic. Cartilage can be damaged by injury, inflammation, infection, and degeneration. Destruction of articular cartilage in rheumatoid arthritis and osteoarthritis involves inflammatory cytokines such as TNF-α, IL-1, or IL-6, which have been the target for current therapies. 7 – 11 After injury, articular cartilage has a poor capacity to repair itself and tends to heal through the formation of fibrocartilage, which has inferior biomechanical characteristics to resist compression stress compared to normal articular hyaline cartilage. For decades scientists and surgeons have been exploring treatments that facilitate cartilage repair, including micro fractures and more recently cell-based tissue engineering using autologous chondrocytes and mesenchymal stem cells combined with scaffolds. Mesenchymal stem cells can be collected from many sources including bone marrow, adipose tissue, synovium, and muscles. Study on embryonic stem cells has also been initiated and this research direction could be very fruitful. Many cell factors may be exploited to improve these approaches, among which are TGF-β, IGF-1, FGF-2, and BMP-7. 12 Nanotechonology may also improve the biomaterial properties of scaffolds. A better understanding of the cellular and molecular mechanisms of chondrocyte differentiation and phenotype maintenance may provide insights to develop novel techniques that can guide cultured chondrocytes and stem cells differentiation.

Regeneration of intervertebral discs (IVD) is equally, if not more challenging. A clinical study has shown that injection of disc chondrocytes reduces back pain and improves fluid contents of the treated disc. 13 Experimental studies have demonstrated that injected mesenchymal stem cells can maintain viability and proliferate within the IVD. 14 Although there are significant advances in the research of IVD regeneration, this area of research is still in its early stages. The intervertebral disc is composed of three tissues, the cartilage endplate, nucleus pulposus, and annulus fibrosus, and is more complex than articular cartilage. Successful regeneration of IVD may require the regeneration of all three tissues in one implant. The right scaffolds, cells, and techniques of implantation need to be determined and developed. 15

Orthopedic biomechanics

Orthopedic biomechanics is a specific sub-field of orthopedic research that involves the application of engineering principles to examine the mechanical behavior of the human musculoskeletal system. Topics of interest within orthopaedic biomechanics include mechanical testing of orthopaedic tissues and structures, medical implant design and testing, kinesiology (the study of human motion), and tissue engineering. A select list of currently popular research topics in Orthopedic Biomechanics for particular subspecialties is presented in Table 1 .

Examples of cutting-edge research topics in orthopedic biomechanical research

MEMS = Microelectro mechanical system

In order to develop more effective surgical and non-surgical techniques for treating orthopedic diseases, orthopedic biomechanical research is performed to characterize the mechanical factors contributing to orthopaedic injury or resulting from underlying orthopaedic biological conditions. One example of this type of research is the investigation of the contribution of ligamentous structures to the stability of the knee 16 or elbow 17 and may apply to optimizing diagnostic tests for clinical instability or modifying joint replacement designs to better preserve surrounding soft tissues. Another active area of biomechanical research is the characterization of the mechanical threshold for micro- and macro-level bone failure. These studies are primarily focused on common anatomic sites of fragility fractures, such as the hip, 18 distal radius 19 , 20 and thoracolumbar spine 21 and acute trauma of the skull, 22 acetabulum 23 and distal tibia and fibula. Lastly, there is a large body of research focused on characterizing differences between normal versus diseased orthopedic tissues at the tissue-level, such as elastic compressive behavior of the annulus fibrosus as a function of intervertebral disc degeneration. 24 , 25 The potential applications of this work include specifying design parameters for tissue-engineered implants, quantifying the effects of different drug therapies on tissue-level mechanical behavior, and providing accurate material property information for computational models.

The application of new technology to the prevention and treatment of orthopaedic disease is another ongoing area of research in orthopedic biomechanics. Advancements in medical imaging, such as rapid-scanning MRI and low radiation dosage CT scans, have allowed for the development of patient-specific volumetric models of specific anatomy that can be used for pre-operative planning or injury prevention. For example, there have been clinical 26 and cadaver-based biomechanical studies demonstrating the benefits of pre-operative planning using CT-based 3-D image processing for periacetabular osteotomy surgery (PAO) software to reduce operative time and improve surgical outcomes. Additionally, biomechanical studies have been instrumental in integrating recent advancements in materials science into orthopaedic implant design. For example, shape-memory alloys are now being used increasingly in minimally-invasive spinal surgeries, and cadaver-based biomechanical studies have been instrumental in demonstrating the safety and efficacy of these new implants.

Finally, a substantial portion of orthopedic biomechanical research is focused on the evaluation of existing orthopaedic techniques. These studies frequently involve head-to-head comparisons of the ex-situ or in-situ mechanical performances of currently used orthopedic implants or surgical techniques. These types of studies determine which procedure is most mechanically competent, and the data can be interpreted in the context of any existing clinical information regarding relative rates of patient morbidity and mortality, the amount of surgical skill needed to perform the procedure, and cost and availability of any technology necessary to perform the procedure. Examples of this type of research include overload of flexor tendons repaired with different stitching techniques 27 and the effect of bone cement to augment laterally plated tibial plateau constructs.

D EVELOPMENT OF AN O RTHOPEDIC R ESEARCH P ROGRAM

The initiation of research programs requires complex decision-making as directional, logistical, financial, and other considerations must be evaluated. The greatest barriers to the development of new basic research facilities include available technical expertise, space, and finances. This section reviews the basic infrastructure and equipment needs for the development of orthopedic molecular biology and biomechanical research laboratories, as well as some of the financial considerations required to develop these facilities.

Infrastructure and equipments: Molecular biology laboratory

The infrastructure required to run an Orthopaedic Surgery Research laboratory is similar to any other biological laboratory. Fume hoods are required to vent noxious and dangerous chemicals. An animal housing facility is necessary if work is performed on any number of model organisms. If work is to be performed on established or primary cell lines, then a separate cell culture room should be considered. By isolating cell culture facilities, reduced foot traffic in and around the incubators and hoods will aid in keeping cultures free of bacteria and mold. Another part of the laboratory should be set aside for processing, sectioning, and staining of histological specimens. This area should be located in a “dust-free” area away from drafts that will create difficulty handling ribbons of sections. Work with radioactive materials can be made safer by defining and restricting use of these materials to dedicated areas of the laboratory. Similarly a dedicated imaging suite that contains all the microscopes that will be used for documentation and analysis of data will allow undisturbed specimen viewing, will allow the room to be darkened for specialized imaging such as epifluorescence, and will reduce the amount of dust that accumulates on working parts of the microscope.

Equipment for an Orthopedic Surgery laboratory performing molecular and cellular biology experiments includes microtomes, thermal cyclers, bacterial shaking incubators and incubator ovens, electrophoresis equipment for assessing DNA, RNA, and proteins, table top microfuge, centrifuge, safety cabinets to store flammable liquids. If work is primarily focused on in vitro analyses, then cell culture incubator(s), laminar flow hoods, and at least one inexpensive inverted phase contrast microscope for visualizing cells are required. More specialized equipment can be used as the necessity of the laboratory dictates. For example, quantitative reverse transcriptase PCR (qPCR) can be used to assess gene expression patterns in cells and tissues.

Infrastructure and equipment: Orthopedic biomechanics laboratory

Research programs of Orthopedic Biomechanics generally have either experimental or computational focus, with a select group of more established laboratories undertaking both investigative approaches. The computational approach is generally preferred by new research groups in the US and Europe with limited financial resources. It can be established with minimal investment in infrastructure [ Table 2 ] and may be staffed effectively by mechanical or computer engineers with basic familiarity with 3-D software and finite element techniques. As projects are fundamentally computer-based, collaborations may be established internationally with communication largely through video conferencing, secure file transfer protocols, and other forms of electronic communication.

Recommended lab design for developing orthopedic biomechanics programs (Designs for both computationally-focused and experimentally-focused programs are provided)

Experimentally-focused orthopedic biomechanics research programs are substantially more challenging to develop, as they involve substantial up-front investment in laboratory infrastructure, have high operational costs, and require close clinical collaboration and experienced technical staff. Well-established, experimentally-based biomechanics programs in the US and Europe typically: 1) own $500K-$1M (United States Dollars, USD) of custom laboratory equipment; 2) occupy temperature-controlled, 1000+ assignable square foot laboratory spaces with Biosafety-level 2 certification to handle human cadaveric tissue; 3) have two to four full-time staff. It is possible for new programs to successfully participate in the international research community with a scaled-down version [ Table 2 ] of the aforementioned “established” experimental laboratory design; however, these programs must carefully select research projects to not over-tax their in-house resources.

R ESEARCH C OLLABORATIONS AND O PPORTUNITIES

Numerous countries around the world have highly developed infrastructures for the support of basic research. While there are often opportunities for young scientists to obtain research training in these countries, including graduate and post-graduate instruction, perhaps the greatest long-term opportunities exist through the creation of productive collaborations. The first step to assuring a successful collaboration is to define a specific question and identify particular needs, which can be adapted to the local environment based on the available techniques, expertise, and models. The perceived needs should be well-defined before seeking outside expertise, and will facilitate the identification of appropriate collaborators. Potential collaborators may be identified through research or other professional societies, publications, or scientific meetings. In the US, for example, such collaborations could be identified through organizations such as the Orthopedic Research Society or the Society of Mechanical Engineers Bioengineering Division and journals such as the Journal of Orthopedic Research or Journal of Biomechanics, where the major orthopedic research centers in the United States are generally represented. New techniques or models may be learned via sending laboratory members to the collaborating laboratory. More advanced collaboration may be based on sharing research efforts on a project and might involve the acquisition of funding from one or all of the collaborating centers.

C ONCLUSIONS

The field of orthopedic research will continue to grow in order to address the increasing global burden of musculoskeletal injury and disease. New basic scientific discoveries in biological and mechanical research will continue to advance rapidly, and present opportunities to bring these new discoveries to the clinic. The complex nature of the musculoskeletal system requires multi-disciplinary collaborations between investigators that possess a wide diversity of expertise. Although the development of research laboratories and opportunities require extensive planning and resource development, ultimately basic discoveries have the potential to develop into translational projects that can impact patient care. Several such discoveries have already developed into large-scale multi-national clinical trials, which are the end-goal for basic science research.

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Public trust in charities at ten-year high, new research shows

People receiving charitable support grows threefold in four years, as cost of living pressures bite.

The Charity Commission, the regulator of charities in England and Wales, has published fresh research that shows public trust in charities at highest level since 2014.  

The research reveals that information about how money is spent by a charity is the single most important factor for most people. This is followed closely by knowing that the charity achieves its purpose, that it makes a difference and that it operates to high ethical standards.  

Overall, trust in charities is high and continues to recover. Charities now score 6.5 out of 10 for trust, up from 6.3 in 2023, from a low of 5.5 in 2018 following a series of scandals. 58% of people have “high” trust in charities (7 out of 10 or higher), placing it among the most trusted groups in society, second only after doctors.  

In a challenging financial environment, the research illustrates a growing reliance on charities for support, alongside a declining percentage of people donating to charities. 47% of people say they donated money or goods, or raised funds for charity, compared with 62% in 2020. By contrast, there has been an increase in people saying they have received charitable services, such as financial help, food or medical support from a charity – 9%, up from 3% in 2020.  

Around half of people say they have heard of the Charity Commission, with 19% knowing it ‘well’. Awareness of the Charity Commission is associated with higher trust in charities, with those who have heard of the regulator being more likely to report high trust (63% vs. 52%). Around 4 in 10 people are aware of the online Register of charities.  

Charity Commission Chief Executive, David Holdsworth, says: 

These findings are encouraging, demonstrating that charities collectively are once again firmly trusted by the public, making a visible, essential difference locally, nationally and globally. But there is no room for complacency, for charities or for us as regulator. The new findings point to the challenging financial environment charities are operating in, with a decline in the number of people giving to charity, whilst the high cost of living appears to be driving more people to access charity services. In these financially challenging times, charities must continue to show people how they deliver on their purpose, including how every penny makes a positive difference. Anyone can look up this information on our public Register of charities, which gives details of each charity’s purpose and spending.

Research into trustee attitudes  

Alongside the research into public trust, the regulator has published the findings of a survey into charity trustees’ attitudes towards their role.  

The research finds that most trustees share the public’s high expectations of conduct in charities – 61% agree that because of its registered status, their charity’s standards of behaviours and conduct ought to be higher than that in other organisations.  

Overall, trustees have high stated levels of confidence in their responsibilities, and generally understand what they should do when making decisions, with those who are aware of the Charity Commission demonstrating they are better informed.   

But the research, also conducted by BMG, finds that trustees are less clear on things they should not be doing, including making decisions based on their personal views, or avoiding awkward questions. They are also less confident about dealing with conflicts of interest, and overseeing charity finances. 

For the first time, the Commission asked charity trustees about their charity’s use of Artificial Intelligence. Only 3% of trustees said their charity has used AI, however this rose to 8% of larger charities (income £1m+). 

Previously published data from the research confirms how widespread problems with banking services are for trustees – 2 out of 5 trustees said their charity has experienced a banking issue over the past year. The Commission has previously spoken out on its concerns about the impact on charities of poor service from the banks. Earlier this year, the Commission said it was “shocked, but not surprised” by “undeniable evidence of the extent and impact of the appalling service charities receive from some banks.” 

The full research is available on GOV.UK

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• The Charity Commission is the independent, non-ministerial government department that registers and regulates charities in England and Wales. Its ambition is to be an expert regulator that is fair, balanced, and independent so that charity can thrive. This ambition will help to create and sustain an environment where charities further build public trust and ultimately fulfil their essential role in enhancing lives and strengthening society. Find out more: About us - The Charity Commission - GOV.UK (www.gov.uk)  

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