joint action impact report 2011-2012

Joint Action is the research fundraising arm of The British Orthopaedic Association Registered Address: 35-43 Lincoln's Inn Fields, London WC2A 3PE Registered Charity No. 1066994, Limited Company No. 3482958

J o i n t A c t i o n I m p a c t R e p o r t

2 0 1 1 - 2 0 1 2

C o n t e n t s

Joint Action Impact Report 2011-2012

Page 11 The Next Steps Our vision for the future and how we can work together to make them a reality by changing clinical practice to restore mobility

Page 3 Four Key Facts An example of the burden of musculoskeletal disease on society.

Page 6 Chairman's Message What we have achieved in our fledgling years Ian Leslie, FRCS Ed, Chairman, Board of Management

Pages 7-8 How We Judge Research & Why It’s So Important Andrew McCaskie, MBChB, FRCS (Eng), MD, FRCS (TR & Orth) Chairman, Grants Committee

Pages 12-23 How Our Project Funding Is Changing People’s Lives A short overview of each of our funded projects

Pages 4-5 Why I Believe In Trauma & Orthopaedic Research HRH The Prince of Wales Patron

Pages 9-10 Statement of Financial Activities (SOFA) 2010 comparative income figures and Grant payments

Sources referenced in this document: The Wishbone Trust, ‘Another Infrastructure that’s seriously underfunded’

Department of Health, ‘The Musculoskeletal Services Framework’ World Health Organisation, ‘The Bone and Joint Decade’

ARMA, ‘Arthritis and Musculoskeletal Alliance’ UK Government, ‘The 2006/2007 Cooksey Review’

The National Osteoporosis Society, ‘Primary Care Strategy for Osteoporosis and Falls’ UK Government, ‘Health and Safety Executive, Faculty of Sport and Exercise Medicine’


F o u r K e y F a c t s

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As I complete my five year Chairmanship of our Board of Management, I wish to share with you the progress we have made since the birth of Joint Action (JA) seven years ago. I hope to assure you that the future of JA is secure and well worth supporting. One of the effective ways of realising the core objective of the BOA - Caring for Patients, Supporting Surgeons - is by improving clinical practice through research. Joint Action is the component of the BOA that has established an effective method of raising funds and giving grants to surgeons and scientists with dedication and commitment to Trauma and Orthopaedic research. The quality of the research projects we support is assured by an approved peer review mechanism established by the Grants Committee.

We are indebted to our lay member Sir Chris O’Donnell and our former Trust Fundraiser, Julia Smith for their foresight and proposals for change. We acknowledge the contribution during our early years of Sir Rodney Sweetnam (Past President, Royal College of Surgeons), Professor John Kenwright (Emeritus Professor of Orthopaedic Surgery, Oxford University), BOA Presidents David Jones and Mike Benson and David Adams our former Chief Executive. We have established secure financial policies and a comprehensive Risk Strategy. A Reserve Fund, sufficient to cover fully our operating expenses for a period of two years is held in highly secure deposit accounts as are monies committed to research projects. This ensures that the research projects will continue despite any future downturn in our financial status. The task of developing a successful fundraising and grant giving organisation also requires considerable administrative input. Initially this additional work was undertaken by David Adams, then Chief Executive, and we shall be forever grateful for his efforts and dedication. The workload became too demanding and, in order to progress, it became necessary to employ a full time administrator. In May 2008, we appointed Peter Foy as Development Manager who has helped to build a vibrant, financially viable organisation, the aim of which is to increase the funding for research grants year on year. Peter has developed a highly acclaimed online grant application system and the JA website, as well as the OrthocardTM which is becoming very popular with patients who have had a joint replacement. Earlier this year, using the salary of our Trust Fundraiser, we employed an Administrative Assistant, Lauren Bickles who is now an essential member of the team. Looking back at our achievements we find that we have distributed just under £1.4million in research grants which, according to the grant recipients, has resulted in: 22 scientific papers published in peer reviewed scientific journals, 57 oral presentations or posters at international scientific meetings, 12 academic theses, and 7 projects producing proposals for clinical change to improve patient outcomes. Six grants (pump primers) have enabled researchers to apply successfully for further funds from other major grant giving bodies. Raising funds is difficult in these austere times and we urgently need help from all sectors of the community to achieve our goal of distributing £300,000 in research grants each year. The time has come for me to pass on the chairmanship of JA and I am pleased that the BOA has appointed Professor Neil Rushton (University of Cambridge) as my successor. Joint Action is now a well established, financially viable and a successful research funding organisation. I know Neil will take it forward enthusiastically. I wish him and JA many years of growth so that orthopaedic research in the UK can continue to flourish and improve patient care. Ian Leslie MCh.Orth. FRCS Chairman, Board of Management - Joint Action Past President of the British Orthopaedic Association


C h a i r m a n ’ s M e s s a g e

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According to the World Health Organisation, 'One in two of us will need Orthopaedic intervention at some point in our lives'. In fact, musculoskeletal disorders are the most common cause of illness in our country and are the number one reason for time off work. They affect over 9.3 million people, account for more than 11 million lost working days, which costs our society over £7.6 billion each year and accounts for more than 30% of GP visits and 40% of all recorded pain.

Because of our rapidly-ageing population, musculoskeletal conditions which involve bones, muscles and joints are predicted to be the single largest cause of disability in the UK in the not-too-distant future. Our aim is to stimulate, enable and promote Trauma & Orthopaedic research that will have the most significant impact on this enormous burden on our society; research that has the potential to vastly improve the lives of many thousands of people throughout the UK. We formed a research committee to advise us on the burden of musculoskeletal disease as it affects the population of the UK and they have mapped out a “Research Agenda”. This agenda helps guide our priority areas of fundraising. More recently, under the new chairmanship of Professor David Marsh (Professor of Orthopaedic Surgery, London University), the committee has expanded its remit within the BOA to the stimulation of orthopaedic research nationally and to make the case for more funding for orthopaedic research from government and major grant giving bodies as well. By focusing on six priority areas, we hope to achieve maximum impact from our research grants and provide a road map for the future of orthopaedic research in the UK: Arthritis and Arthroplasty, Soft Tissue Injuries, Major Limb Trauma, Osteoporosis and Fragility Fractures, Spinal Disorders, Paediatric Orthopaedics. Our grants committee initially chaired by Professor Bob Dickson (University of Leeds) and now by myself, assess each Grant Application and then seek further opinion from specialist independent peer reviewers. The Committee then makes a recommendation to the Board. We ask each grant recipient to produce a progress report every quarter and further funding is conditional upon satisfactory progress. Our Grant Application methodology has been reviewed the Association of Medical Research Charities (AMRC) and we are regularly audited on both our processes and outcomes to ensure complete impartiality and best-practice delivery.

Professor Andrew McCaskie MMus MD FRCS Chairman, Joint Action Grants Committee Professor of Orthopaedic Surgery Institute of Cellular Medicine Newcastle University

Joint Action Grants Committee

Mr M Costa Prof S T Donell Prof F S Haddad Mr D Limb Prof A W Miles Mr W Khan

Associate Professor of Trauma & Orthopaedics University of Warwick

Consultant Orthopaedic Surgeon Norfolk & Norwich University Hospital Honorary Professor University of East Anglia

Divisional Clinical Director – Surgical Specialties / Director – Institute of Sport, Exercise & Health University College London

Consultant Orthopaedic Surgeon / Hon. Senior Lecturer in Orthopaedic Surgery Leeds Teaching Hospitals Trust

Prof. of Biomechanics / Director, Centre for Orthopaedic Biomechanics Dept of Mechanical Engineering University of Bath

British Orthopaedic Trainee Association / Orthopaedic Registrar RNOH, Stanmore / Clinical Lecturer University College London


H o w W e J u d g e R e s e a r c h . . . Professor Andrew McCaskie, Chairman of the Joint Action Grants Committee

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. . . W h y I t ’ s S o I m p o r t a n t


Following extensive discussion with other leading orthopaedic professional bodies including the supporters of the Bone and Joint Decades, the British Orthopaedic Research Society, the American Academy of Orthopaedic Surgeons, the British Geriatrics Society, the International Society for Fracture Repair, the National Osteoporosis Society, the International Osteoporosis Foundation, the BOA’s Research Committee published a Research Agenda in 2005. This agenda maps out the direction for orthopaedic research in the UK. By focusing on the following priority areas, we are able to achieve maximum potential from our research grants for the benefit of orthopaedic patients throughout the country. The following is just a very simple explanation of the six priority areas. The full Research Agenda can be downloaded from our website, or available in the post on request.

Arthritis and Arthroplasty About 25% of people over 60 years have significant pain and disability from osteoarthritis. It also accounts for 50% of all chronic conditions in people over the age of 65. Osteoarthritis causes pain, deformity and stiffness as protective cartilage within the joint is damaged, leaving sensitive bone exposed. The incidence of osteoarthritis increases with age and is more common in women. It is a leading cause of disability worldwide and the social and economic consequences are enormous.

Soft Tissue Injuries Ligaments, muscles, tendons and nerves are all soft tissues and can be damaged in accidents at work, on the roads, whilst playing sport or during the activities of daily living. Soft tissue injury accounts for about 3 million Emergency Department visits each year, about 2 million of which are related to sport. Disorders related to occupational activity account for 64% of all occupational illness.

Major Limb Trauma Anyone of any age can suffer injuries such as fractures, dislocations, amputations and damage to nerves and blood vessels. Occupational injury and road traffic accidents are major causes of musculoskeletal trauma, with traffic accidents alone causing 360,000 injuries each year in the UK. By 2010, 25% of worldwide health care expenditure will be on trauma care.

Osteoporosis and Fragility Fractures As we age, so to do our bones. Osteoporosis is a progressive loss of bone density resulting in fragile bones which break after minor falls, especially in the hip, spine and wrist. Approximately 3.2 million women over the age of 50 suffer from osteoporosis in the UK. Whilst fewer men suffer from osteoporosis, death rates one year after fracture are higher in men. The personal cost of fragility fractures is enormous. Approximately 34% of hip fracture patients die within the first year following fracture, and only 30% of patients return to living independently in their own home following a hip fracture. The social and health cost to the nation of fragility fractures is nearly £1.7 billion each year in the UK.

Spinal Disorders Over 70% of people in developed countries will experience low back pain at some point in their life. General Practice consultations for low back pain have been estimated at 1,415 million per year in the UK. Back pain is the second leading cause of sick leave in the United Kingdom. Disability resulting from low back pain has become a public health problem accounting for 119 million days of incapacity. The annual incidence of spinal cord injury resulting in paralysis remains at 1,540 cases per million population.

Paediatric Orthopaedics Children can be born with skeletal abnormalities (congenital defects) such as Clubfoot, Duchene Muscular Dystrophy, Cerebral Palsy and hip dislocations. Musculoskeletal diseases such as Perthes’ Disease and Juvenile Rheumatoid Arthritis affect the long-term mobility of children. In addition, every year, 25% of otherwise healthy children sustain an injury severe enough to require medical attention. Fast and effective treatment is particularly important in the growing child to maximise mobility and reduce deformity. The subsequent deformity may produce uneven growth in bone as well as life-long disability and pain.

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F i n a n c i a l A c t i v i t i e s

Joint Action, Statement of Financial Activities (SOFA) The summarised financial information shows the income raised for our activities, the cost of raising the income and the amounts spent on our charitable activities. The information is taken from the full financial statements of the British Orthopaedic Association, approved by the trustees on 19th July 2011.

INCOME 2010

Fundraising * 287,808

Grant Income from Trusts & Foundations 22,475

Investment Income 12,741

TOTAL INCOME 323,024

EXPENDITURE 2010

Fundraising ** 187,807

Investment Fees 2,761

Research Grants Issued 105,000

TOTAL EXPENDITURE 295,568

* Fundraising income is made up of income from: Individuals, Corporates, Regional Events and Legacies

* * Fundraising expenditure includes the cost of generating funds, direct staff salaries and expenses, but excludes building and supplies and support which are provided by the British Orthopaedic Association

RESERVES 2010

Transferred to / from 27,456

Grant Payments Made 299,589

Total Investments (including Grant Liabilities) 1,385,250

Annual Movement -272,133

Continuing Grant Commitments 652,219

In order to gain a fuller understanding of the financial affairs of the charity, the full audited financial statements, trustee’s annual report and auditors’ report should be consulted. Copies can be obtained from the Charity Commission, Companies House, or from Joint Action, 35-43 Lincoln’s Inn Fields, London WC2A 3PE

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Fundraising Grant Income from Trusts & Foundations Investment Income

Fundraising Investment Fees Research Grants Issued


F i n a n c i a l A c t i v i t i e s . . . e x p l a i n e d Sometimes it’s not clear to understand where the money comes from and where it goes. The question I always ask myself when a charitable cause approaches me asking for funds is, how effective are they going to be at spending my hard-earned donation where they said they would. It is by this yard-stick that I try to run Joint Action, based on a loose application of the ‘Pareto Principle’ for income and the ‘Pareto Efficiency’’ for expenditure. The Pareto principle (also known as the 80-20 rule, is based on the law of the vital few), which states that, for many events, roughly 80% of the effects come from 20% of the causes. The original mind behind this, the Italian economist, Vilfredo Pareto, observed in 1906 that 80% of the land in Italy was owned by 20% of the population; he then developed his principle further by observing that 20% of the pea pods in his

garden contained 80% of his peas. If we translate and apply the same theory in running any charity or business, you find the same sort of statistics occurring, that "80% of your sales or fundraising income will come from 20% of your clients or donors". We then need to apply a variation of this, called the Pareto Efficiency, in which expenditure is looked at in a similar way, that 80% of your expenditure should go towards your main goal, whilst only 20% can be absorbed in achieving this goal, or ‘running costs’. Obviously, we don’t live in such a perfect world, especially in times of financial austerity or when an organisation is in start-up mode as costs are always certainly going to be higher for a short period of time in order to get the ball rolling.

Where our money came from in 2010

I just want to say a very warm thank you to all who have given both their time and money. Without your belief in the value of our work, we would not have been able to achieve anything you read in this document. We could not do what we do without you. Thanks you.

Mr Peter Foy Joint Action Development Manager

...and this is how we’ve been spending the money

52% of our total income (£168,995), came from voluntary donations; Orthopaedic Surgeons, GP’s, Patients, Family members and friends. Individuals who have all been directly or indirectly affected by Trauma & Orthopaedic research.

8% came from industry (£27,292). Primarily from Orthopaedic product manufacturers, but also Banks, Patients’ employers, Give as you earn schemes, and matched funding for staff activities.

7% of our income (£22,475), came from the work we do applying to other Charitable Trusts & Foundations for grants.

13% was made up of Regional events (£41,739), all round the country that our donors and supporters took part in or organised. Things like the two brothers who rode their bikes from Lands End to John O’Groats, or the London Marathon.

15% was left in legacies (£49,783) in people’s wills from; individuals, nursing homes and funeral directors. Normally from people who had directly benefitted from Orthopaedic treatment in their lives and wanted to give something back to help future generations.

4% came directly from strict management of our research investments (£12,741).

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T h e N e x t S t e p s

With approximately one third of all expenditure on medical and health research in the UK coming from medical research charities, we are unique internationally in terms of our scale and impact. Britain has always been at the forefront of orthopaedic innovation and it is important to keep the talent of our young orthopaedic surgeons and researchers in the UK and to stimulate them into even greater innovations. Each year we aim to increase the funding that we award to top quality UK research. We rely entirely on your generosity to realise this goal and for the last three consecutive years you have enabled us to increase our annual research allocation. Thankyou. Research is the life-blood of medical advance. The innovative hip replacement surgery pioneered by British orthopaedic surgeons in the 1960’s still remains one of the most important advances in surgical treatment throughout the world. As our population ages, so too do our bones and joints. The NHS and orthopaedic surgeons are facing one of their most pressing challenges - keeping people mobile and independent as long as possible, enhancing their quality of life. Just as a building needs a solid foundation, our bodies need a strong skeleton to enable us to withstand life’s knocks and blows. Whether it is a congenital bone disorder, an accident or a disease of ageing bones, Joint Action is here to help repair that structure and restore mobility. • Companies can benefit from working with a professional organisation which represents over 4,300 orthopaedic

surgeons who treat thousands of orthopaedic patients throughout the UK. • Charitable trusts can become involved with research in their area of interest, receiving regular updates and being

acknowledged in the dissemination of results. • Schools and associations can learn more about how Joint Action is keeping Britain mobile and how they can

become involved locally. • Local fundraising groups are developing throughout the country, where enthusiastic and like-minded

orthopaedic patients get together to raise research funds through local activities. • Individuals can leave a bequest to fund a research project in their name. Donations can be made in memory of a

loved-one, or can be arranged as a regular Standing Order contribution. Individuals can contribute to a lasting legacy for future generations.

Please turn over and read about some of the projects that we have funded which are already well on their way to making demonstrable impact to people’s lives and then please support Joint Action’s work to build strong foundations for the very best orthopaedic care for you and those around you in whatever way you can.

Thank you

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This project ran from early 2007 through to the end of 2008

Fibular hemimelia is a birth defect in which there is partial or complete absence of the fibular bone. It affects 1 in 25,000 live births and there are many associated anomalies, such as the tibia bone being unusually short.

Amputation of the foot and the fitting of an artificial prosthesis is often recommended to equalise limb lengths and facilitate walking, for children with a severe condition. This research is validating a treatment currently used in Oxford that obviates the need for amputation by lengthening the limb with an Ilizarov frame.

Results: The results of our study were presented to the British Society of Children’s Orthopaedic Surgeons at their Annual General Meeting in June 2008, held in Bristol. It was very well received with valuable feedback being gained prior to submission of the work as a scientific paper in the British Journal of Bone and Joint Surgery, the definitive periodical for clinical change and best practice amongst Orthopaedia, received and read by the largest number of orthopaedic physicians worldwide with the largest world circulation of any orthopaedic journal, reaching subscribers in over 130 countries.

Outcome with Gait Analysis of limb preservation for severe forms of fibular hemimelia PRINCIPAL INVESTIGATOR: Simon Thomas HOST INSTITUTION: Nuffield Orthopaedic Centre, Oxford AWARDED: £3,530


This project ran from August 2007 through to January 2009

Rupture of the Achilles tendon is a serious and disabling injury. This condition typically affects young active adults and is associated with prolonged periods off work and much longer abstinence from sporting activity. It is currently not clear whether it is best to operate or to let the tendon heal naturally.

Our previous research showed that immediate weight bearing rehabilitation provides functional advantages to patients who have sustained a rupture of the Achilles tendon. This is the first randomised clinical trial conducted in the UK to compare operative to non-operative management using the same immediate weight bearing rehabilitation programme for both groups, paving the way for the definitive trial in this important clinical area.

The research physiotherapist who collected the data for this project has subsequently won an Arthritis Research Campaign Allied Health Professional Fellowship for further studies into the orthotics used for immediate weight bearing rehabilitation.

Results: We have demonstrated that there are no functional differences between operatively and non-operatively managed patients. With this new information, patients are now offered the option of how they wish to be treated.

Management of Acute Achilles Tendon Ruptures PRINCIPAL INVESTIGATOR: Matthew Costa HOST INSTITUTION: University of Warwick University Hospitals of Coventry and Warwick AWARDED: £11,000

H o w O u r P r o j e c t F u n d i n g I s C h a n g i n g P e o p l e ’ s L i v e s

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This project has started in December 2010 and will conclude August 2012

Osteoporosis as a disease and the resulting fragility fractures are anticipated to become an epidemic in the years to come. The elderly population will increasingly consume more hospital resources, especially for the treatment of fractures of both the upper and lower extremities, and the optimisation of their management is a high priority issue. Besides the advances being made in implant technology to improve stabilisation of osteoporotic fractures, manipulation of both the local fracture environment as well as systemic administration of agents promoting bone formation and bone strength has been considered as a treatment option.

This Pilot study aims to produce preliminary evidence testing the hypothesis that it is possible to accelerate the healing of trochanteric and distal femoral fractures of the elderly, with the administration of therapeutic agents and thus reduce pain and functional impairment at 3 and 6 months postoperatively. A randomised, assessor-blinded comparison of the systemic use of Vitamin-D/Calcium (control), bisphosphonate (Alendronate), or Parathyroid hormone (Forsteo) in patients with intertrochanteric hip and distal femoral fractures is conducted.

We anticipate that this pilot study will lead to a pivotal large multicentre trial of using these agents to this indication in order to evaluate clinically the efficacy and safety of these agents, compare their effect to the same population and potentially influence clinical practice.

Improving the outcome for patients after osteoporotic femoral fracture PRINCIPAL INVESTIGATOR: Pete Giannoudis HOST INSTITUTION: Leeds AWARDED: £148,268

This project ran from February 2007 through to February 2008 Osteoarthritis (OA) is a leading cause of disability in the UK. Numerous instruments are available to measure the level of disability in OA patients. However, none consider the impact of their disability. For example, being able to do the gardening will be of little importance to someone who does not have a garden. As a result they do not show that similar levels of disability may affect individuals very differently. A questionnaire has previously been validated in rheumatoid arthritis, which measures the personal impact of disability. This uses a questionnaire called the Personal Impact Health Assessment Questionnaire (PI HAQ). The impact of disability is calculated by balancing the difficulty in performing each activity on the HAQ with the personal importance of performing the activity. The aim of this study was to validate this questionnaire in OA patients and replicate its findings. Results: We have produced the first ever instrument in OA to measure the personal impact of a patients disability rather than just the level of their disability. This has provided healthcare professionals with a true reflection of the impact of the disability that their patients face, which in turn, reduces the treatment of their patients based principally on the level of their functional limitation, rather than the impact of their disability.

The Personal Impact of disability in osteoarthritis PRINCIPAL INVESTIGATOR: Ashley Blom HOST INSTITUTION: Bristol AWARDED: £19,000

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This Project ran from July 2007 through to June 2009 Driving is considered an essential skill to acquire and maintain throughout life. It needs complicated coordination skills involving various sensory modalities and motor effectors. Though many studies have been conducted on the neurological integration of visual and auditory components of the skill and some studies on brake response time involving the lower limb, no studies have been done on the upper limb, especially shoulder joint involvement in these skills. The essential components of driving involve turning steering wheels, changing gears in manual cars and the application of the hand brake. Little is known about the role of the shoulder joint in these movements and also how they can be affected in various pathological conditions affecting the components of the shoulder joint. Results: Our funding has enabled the creation of a database of normal steering response times in adults of both sexes between the ages 18-65 years. Against this standard we can now demonstrate that response times return to normal approximately two weeks after arthroscopic subacromial decompression and that patients who undergo rotator cuff operations return to normal approximately 6 weeks later. As a consequence of this work we are now able accurately advise patients about fitness to return to driving, based on objective scientific evidence.

Driving reaction time after shoulder surgery PRINCIPAL INVESTIGATOR: Andrew L. Wallace PhD FRACS HOST INSTITUTION: The Shoulder Unit Hospital of St John & St Elizabeth Imperial College London AWARDED: £10,000

This project started in January 2005 and is ongoing Overview: The Beit Cure Hospital is the first dedicated orthopaedic hospital in Malawi. Since its opening in 2002 it has established a national joint register. This register is unique because it is the only national joint registry in the world to include all arthroplasties ever undertaken in that country, and it is the first national registry in Africa or any country in the developing world. The UK registry was introduced in 2004, but it was unable to include retrospective data. This project is supporting four years of development of the registry. Results: Worldwide, there is very little research on arthroplasty in HIV positive populations. We routinely counsel and test all our patients for HIV. Some get to know their status for the first time upon our testing but the majority of the people we see, already know their status but are not usually on Anti-retroviral therapy despite being eligible for it. The tentative data suggests that arthroplasty is feasible in HIV positive individuals but that their T-Cell count has to be optimised using HAART (Highly Active Anti-Retroviral Therapy. We are creating definitive changes in both clinical practice and changing the everyday quality in the lives of the people of Malawi.

Total Hip and Knee National Arthroplasty Registry for Malawi PRINCIPAL INVESTIGATOR Dr Nicholas Lubega / Dr Jim Harrison HOST INSTITUTION Beit Cure Hospital, Blantyre, Malawi AWARDED £21,634

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The project started in June 2009 and is due to conclude mid 2011

The public health benefits of physical activity in greatly reducing risk of serious disease (heart disease, stroke, hypertension, diabetes, osteoporosis, obesity, colon cancer, breast cancer, depression) are well recognised. Increasing physical activity however increases risks of injury, especially in an increasingly aged population. Tendon injuries are common and incapacitating for months. This translational study aims to optimise the use of platelets derived from a patient's own blood in accelerating the healing of Achilles tendon injuries. We are studying the accelerant effects of the growth factors released by platelets and their time-dependent mechanical healing properties on tendon tissue and human tenocytes in the laboratory. Concurrently we are developing an ultrasound elasticity imaging tool to enable objective measurements of the mechanical quality of healing tendon tissue in patients. These studies will enable us to carry out an effective clinical trial of this novel regenerative therapy for Achilles tendon ruptures, with the aim of establishing this as an effective and widely used treatment.

Regenerative Tendon Repair: Platelet rich plasma concentrate (PRP) PRINCIPAL INVESTIGATOR: Keith Willett HOST INSTITUTION: Oxford (John Radcliffe) AWARDED: £97,806

This project ran from July 2008 through to June 2010 Children with diplegic type of cerebral palsy, mainly affecting both legs, often experience significant walking difficulties. These difficulties usually deteriorate over time due to the development of joint deformities and increasing height and weight. Both the deformities and walking difficulties can be greatly improved with orthopaedic surgery, which involves lengthening several muscles and realignment of bones, at the same time (multi-level surgery). However, patients with cerebral palsy invariably experience muscle weakness and loss of function after surgery and the rehabilitation time is very prolonged. It is clear that surgical techniques and post-operative rehabilitation need to improve further to preserve and improve muscle strength and motor function. We have therefore developed minimally invasive surgical techniques that allow earlier mobilisation and rehabilitation. Results: Minimally invasive multi-level surgery for children with Cerebral Palsy is now routinely carried out at the Nuffield Orthopaedic Hospital, Oxford. Compared with conventional multi-level surgery, operating time, blood loss and time to mobilise are significantly reduced and muscle strength improved. These clinical advantages will also benefit the resources associated with complex multi-level orthopaedic surgery. This approach has generated interest nationally and internationally. Other centres have expressed interest in joining in a multi-centre trial (Bristol, Edinburgh and Swindon).

Minimally Invasive Multi-level Surgery and Rehabilitation: A New Concept in the Management of Diplegic Cerebral Palsy PRINCIPAL INVESTIGATOR: Tim Theologis HOST INSTITUTION: Oxford (Nuffield Orthopaedic Centre) AWARDED: £61,083

Joint Action Impact Report 2011-2012 15


This project started in August 2008 and will conclude in July 2012

Hypothesis: A joint surface deemed clinically irrecoverable contains a sub-population of viable cartilage stem cells, which have the potential to regenerate under permissive conditions to reverse clinical symptoms”. Data obtained from this investigation will have direct clinical benefit as it could prevent or delay total knee replacement by the use of minimal or conservative gait realignment to allow for joint surface regeneration through mobilisation of autologous cartilage stem cells. Currently, it is thought that once damaged, hyaline cartilage cannot regenerate and current forms of treatment involve invasive techniques to reduce pain and allow for a greater range of movement. In the process of characterising human osteoarthritic cartilage, and identifying viable stem cells within the damaged knee, we are aiming to offer a new idea in terms of potentially regenerating damaged hyaline cartilage through a sub-population of viable chondroprogenitors. Instead of growing cells in a laboratory and implanting them back into the knee, we now think that the joint may be able to re-heal itself under permissive conditions. This will offer hope for future patients with osteoarthritis in the knee, as it could lead to a less invasive and more effective treatment for the pain and suffering endured by patients.

Evaluation of the potential for spontaneous repair of degenerate hyaline cartilage re-growth in the osteoarthritic knee by cartilage stem cells PRINCIPAL INVESTIGATOR: Charles Archer HOST INSTITUTION: Cardiff AWARDED: £139,725

This project started in June 2009 and is due to conclude in May 2014.

Periprosthetic femoral fracture is a complication associated with total hip arthroplasty. There are several clinical studies reporting the failure of fixation methods used for treatment of these fractures. The aim of this study is to use laboratory and computational models to optimise the fixation methods for periprosthetic fractures.

A series of fracture fixation scenarios will be mechanically tested in a laboratory. The outputs from these tests will be used to validate computer models, which will then be used to evaluate a range of fixation methods for different fracture configurations and patient variables. In this way, we aim to provide a biomechanically tested fixation protocol for the management of different types of periprosthetic femoral fractures.

Results: Initial results show that poor bone quality can lead to an unstable fracture configuration and both factors can increase the risk of mechanical failure of the fixation. In addition, the fracture angle and screw configuration play a significant role in the construct stiffness. The extent to which increasing the rigidity of the fixation method affects the fracture movement and healing process is currently under investigation.

Optimised Periprosthetic Fracture Management PRINCIPAL INVESTIGATOR: Eleftherios Tsiridis HOST INSTITUTION: Leeds AWARDED: £398,895 (through Latta Fellowship)

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The purpose of this study is to evaluate the use of Whole Body MRI scanning in the detection of metastatic disease from malignant primary bone tumours and compare it to the standard investigation in these patients which is bone scintigraphy. Bone scintigraphy is currently used routinely as an investigation to detect evidence of bony metastatic disease in this group of patients. This enables staging of the disease in conjunction with other investigations including Computerised Tomography of the chest and an MRI scan of the compartment in which the primary tumour has originated. Whole body MRI has been used to detect metastatic disease in patients with abdominal and other solid tumours and it has been shown to be superior to bone scintigraphy with respect to the detection of skeletal metastases and the extent of metastatic disease. No study has been done to date in malignant primary bone tumours. If it is shown that Whole Body MRI is as effective or superior to bone scintography then the routine use of bone scintigraphy could be discontinued and the patient spared the associated radiation exposure from this investigation. Also Whole Body MRI can potentially pick up soft tissue metastases which would not be shown on bone scintigraphy alone.

Whole Body MRI in Comparison To Whole Body Scintigraphy For The Detection Of Metastases In Patients With Primary Bone Tumours PRINCIPAL INVESTIGATOR: Will Aston HOST INSTITUTION: Royal National Orthopaedic Hospital Stanmore AWARDED: £15,000


This project started in October 2008 and will conclude early 2011

Many children with cerebral palsy have orthopaedic surgery aimed at improving the way in which they walk. Muscle weakness is a common problem for these children, limiting their ability to walk, even after successful surgery. The muscles that are used to straighten the hips and the knees are often weak, causing the child to walk in a crouched posture. Physiotherapists spend a lot of time trying to strengthen these muscles. Neuromuscular electrical stimulation (NMES) of muscles may be able to help patients perform their strengthening exercises. We believe that NMES will be more effective if it is used with the patient in the correct posture, and is initiated by the patient so that they have to practice control of their own muscles. We propose to see if NMES is effective in strengthening the hip and knee muscles thus reducing the crouch posture and making walking easier.

We anticipate that this pilot study will lead to a larger randomised controlled trial of the use of NMES in a rehabilitation context for children with cerebral palsy. If NMES is shown to be effective then its application could be rapidly integrated into current physiotherapy regimes for patient rehabilitation. Moreover, the intervention could enable more efficient use of physiotherapy resources in that it would allowing a therapist to treat several patients concurrently and provide for treatment in a community setting more efficiently and for substantially less cost to the NHS.

Application of Neuromuscular Electrical Stimulation (NMES) in the management of hip and knee extensor weakness in children with cerebral palsy: A pilot study PRINCIPAL INVESTIGATOR: Andrew Roberts HOST INSTITUTION: Oswestry AWARDED: £53,021

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This project started in September 2008 and concluded August 2009 Increasing numbers of young people receive metal on metal (CoCr on CoCr) total hip replacements. These implants generate nanoparticles and ions of Cobalt and Chrome. The Department of Health (Committee of mutagenicity) have concluded that there is increased genotoxicty in patients with CoCr implants. The MHRA have concluded that there is a need to determine whether there is a corresponding health risk during pregnancy from CoCr implants. We aim to test this risk and establish whether human cells could show chromosome aberrations and DNA damage if separated from CoCr and ceramic nanoparticles and ions by a placental cell barrier in tissue culture. If so, we will establish whether this can occur at concentrations of Co and Cr that are found in patients’ blood with well functioning or loose implants and whether it could be prevented by antioxidants (vitamin C). Our research will allow better advice for orthopaedic patients during pregnancy. Results: These results were reviewed by the expert advisory group at the MHRA who published further recommendations and advice for patients with metal on metal hip replacements, “Advice from the CSD Expert Advisory Group on the biological effects of metal wear debris generated from hip implants” Published March 2010.

Can orthopaedic metals and ceramic cause chromosomal and DNA damage to human cells across a placental cell barrier? Can this be prevented? PRINCIPAL INVESTIGATOR: Patrick Case HOST INSTITUTION: Bristol AWARDED: £113,490

This project started in April 2009 and is due to conclude in October 2010 The most modern designs of replacement hip joints are known as hip resurfacings. They are intended to conserve bone, permit a full range of motion at the joint and minimise the chance of the hip dislocating. They are engineered from the latest materials and manufactured to the tightest tolerances. These features mean that replacement hip joints can be offered to patients who might otherwise be considered too young for such an operation, but still suffer from crippling arthritic diseases. Unfortunately, a small number of these resurfacing hip joints have failed. Repeat hip replacement surgery poses a much greater risk to the life of the patient and often leads to unacceptable clinical results. Fortunately, these failed joints can offer invaluable information as to how the implants can be improved. Using state-of-the-art equipment, an orthopaedic surgeon and bioengineer will work together to examine the failed joints, determine why they failed and suggest solutions to prevent similar failures in future. Results: We have published and presented our results nationally and internationally. Our work has highlighted concerns over one particular design of resurfacing hip which, subsequently was withdrawn worldwide.

Why are the latest designs of artificial hip joint failing? PRINCIPAL INVESTIGATOR: Thomas Joyce HOST INSTITUTION: Newcastle AWARDED: £160,716

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Proximal femoral fractures (PFF) are increasingly common in an ageing population. Up to 30% of such patients suffer an hospital acquired infective complication (e.g. wound, respiratory or urinary infection), leading to high NHS treatment costs. It is believed that impaired immune function occurs following injury and subsequent surgery leading to an increased risk of infection and other problems. Such changes have not been confirmed in patients with PFF before, and it is, therefore, not clear whether immune system support would be of benefit in this vulnerable group.

Immunonutrition involves the provision of certain key nutrients, in excess of daily requirements, in order to modulate key immune, metabolic and inflammatory functions. This approach has been applied to critically ill patients in other clinical situations with reported beneficial effects in reducing rates of infective complications. Before such an approach can be applied to patients with PFF, it is first necessary to characterise their post-operative immune and inflammatory response. In this pilot study, we wished to examine the immune state in patients undergoing surgical treatment for PFF, in order to define a base line against which immunonutrition intervention can be assessed.

Results Sixteen elderly female patients with low energy proximal femoral fractures were entered to the study and gave blood samples before and one and seven days after hip fracture surgery. These samples have been assessed for multiple markers of immune function and inflammatory response, including specific white blood cell function markers. Data analysis is ongoing, but initial results suggest, in particular, a depression of specific Natural Killer Cell function, which may be germane to the increased infection rate in this patient group. Further analysis of the data will provide a valuable baseline for future intervention studies.

Immune System Changes after Hip Fracture PRINCIPAL INVESTIGATOR: Alasdair Sutherland HOST INSTITUTION: Aberdeen AWARDED: £19,950

Total hip replacement (THR) is an increasingly common and successful operation. One of the main reason for failure of THRs is the components becoming loose. This is thought to be due to the body’s reaction to particles produced from the bearing surface of the new hip joint. In order to reduce loosening, THRs with articulations made of metal were developed. Metal on metal THRs have been shown to wear less and are therefore thought to last longer. However there are now increasing reports of unusual tissue reactions around metal on metal THRs causing pain and failure of the implants. This has been called Aseptic Lymphocyte-dominated Vasculitis -associated Lesions (ALVAL). We aim to try and find out what is causing these reactions. We hope to identify the chemicals produced by the cells seen in ALVAL which are causing these cells to gather and the chemicals responsible for the tissue destruction around the new hip joints.

An investigation into the pathogenesis of local tissue reactions around metal on metal articulations PRINCIPAL INVESTIGATOR: Asim Rajpura HOST INSTITUTION: Manchester AWARDED: £5,000



The aim of the study is to try and improve the healing rates of rotator cuff tendon repairs in the shoulder by injecting platelets. Patient’s blood when spun in a centrifuge allows us to concentrate all the natural growth factors. These growth factors have been shown to have healing potential on bone and tendon. We hypothesize that if we inject these growth factors in and around tendon repairs then we will improve the healing rates and patients function. Patients undergoing repair of the rotator tendons in the shoulder will be asked to enter the trial. Any patients found to have other problems within the shoulder will be excluded. Patients will be randomised to receive a platelet injection at 2 weeks or no injection. Outcome scores will be performed pre-operatively and at 6 weeks, 3,6, and 12 months post-operatively by a blinded researcher. At 12 months post operation a MRI scan will be performed to assess how many of the tendon repairs have healed.

Subacromial autologous plasma injection therapy in patients following rotator cuff repair PRINCIPAL INVESTIGATOR: Martyn Snow HOST INSTITUTION: Birmingham AWARDED: £50,000

This project is due to start in 2011 and will run for 3 years. One of the most challenging problems facing surgeons performing revision hip and knee replacements is how to restore the bone that has been destroyed around the first replacement. The purpose of this research is to investigate the possibility of producing commercially available tissue engineered bone allograft. This engineered bone will allow surgeons to reconstruct the skeleton around the new joint. Allograft bone will be used as the substrate and the patients own cells will be seeded on the bone and allowed to proliferate, creating and effective “new bone”. It is hoped that this new bone will be one of the first commercially available tissue engineered tissue available for general use. This project is collaboration between Wrightington Hospital, the NHS Blood and Transplant Tissue Services and Manchester University.

Production of a safer, osteogenic, tissue engineered bone allograft PRINCIPAL INVESTIGATOR Tim Board HOST INSTITUTION: Wrightington AWARDED: £20,000

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This project was awarded Joint Action funding in September 2010 and is due to conclude in February 2012. Over 4 million individuals in the UK have radiographic evidence of Osteoarthritis (OA). Although at present the cause of OA is not fully understood, we know that both environmental and genetic factors contribute. This study will make use of a group of approximately 5,000 patients with hip and knee OA and 6,000 “normal” individuals that have all previously undergone genetic testing. We intend to study the radiographs of the OA individuals, and describe their appearances in depth. By linking this data with that of the genetic testing, we aim to identify specific genes that can contribute to clinically important patterns and appearances of radiographic OA, thereby having three important clinical implications. Firstly, it will lead to a better understanding of the causes of OA. Secondly, assist in identifying those that may in the future suffer from OA, and lastly, it may provide new targets for therapeutic intervention.

The genetic basis for radiographic pattern of osteoarthritis at the hip and knee PRINCIPAL INVESTIGATOR: Mark Wilkinson HOST INSTITUTION: Sheffield AWARDED: £50,000

This project is due to start in 2011 and conclude in 2012. Primary bone tumours such as Ewing sarcoma occur in children and young adults. Despite significant advances in diagnosis, imaging, and treatments, both medical and surgical survival remains at approximately 60% at the 5 year stage. Many of the treatments used are prolonged and cause significant morbidity (for example infertility, second malignancy, and amputation). One of the major impediments to the effective development of new molecular therapies has been the lack of clear biomarkers and hence the targets for drug management. It is known that Ewing sarcoma is dependent on Insulin like Growth Factor (IGF) however 70% of patients treated with an antibody inhibitor to the IGF receptor respond poorly which cannot presently be explained. The aim of this work is to in part, provide an explanation for this variation in response. I will use basic scientific techniques such as cell culture, fluorescence digital imaging in order to identify and quantify differences in the major signaling pathway implicated in such tumours. Initially this will be carried out on cell lines and then applied to human tissue (EuroBoNet consortium) bringing in a clinical component to the research and results correlated against patient outcome data. These experiments will confirm whether there is a global deregulation of the signaling pathway compared with normal bone and cell lines and the extent of variation within such tumours. By relating this back to outcome data we can directly relate pathway activation to response to therapy. These approaches will be directly translated in to a Phase I/IIa trial in to primary bone tumours using IGF1R inhibitors being co-ordinated directly from Oxford and involving leading bone tumour units across Europe.

Localisation and quantification of novel signaling biomarkers and modifiers by genomic and cellular analysis in Ewing sarcoma PRINCIPAL INVESTIGATOR: Harriet Branford-White HOST INSTITUTION: Oxford AWARDED: £50,000

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With the increasing life expectancy and expanding aging population, osteoarthritis is set to become a leading slow epidemic. In the United Kingdom alone the estimated load of the disease stands at 8.5 million with 36 million working days lost to the disease. The enormous economic impact of OA on the NHS and on the quality of life of the majority of the population justifies constant progressive research to evolve new diagnostic and prognostic tools like CD59. Current evidence indicates towards a cartilage protective role for CD59 in rheumatoid arthritis and psoriatic arthritis but its role in osteoarthritis remains unexplored. We aim to investigate whether there is such a cartilage protective role for CD59 in age related cartilage degeneration in osteoarthritis and fill the current gap in scientific knowledge. In Phase 1, we studied the hypothesis in knee joints of mice with and without CD59 gene by histopathological techniques. The early results indicate towards accelerated cartilage degeneration in knee joints of mice without CD59 gene in comparison with those with the CD59 gene. Phase 2 will be the human translational research phase involving studying the human articular cartilage with histopathology and grouping them in diseased and normal groups. A quantitative gene and protein analysis will be performed of these two cartilage groups for the CD59 gene and protein expression and will be compared with validated bio-markers of cartilage degeneration. With increase in the ageing population, the field of biomarkers for osteoarthritis is constantly expanding. Due to the unpredictable nature of the osteoarthritis, CD59 as a biomarker can aid in drug discovery, drug trials and forming a diagnostic and prognostic tool for osteoarthritis.

CD59 - a target to arrest age-related cartilage destruction in osteoarthritis PRINCIPAL INVESTIGATOR: Vishal Paringe HOST INSTITUTION: Cardiff AWARDED: £5,000

Our Key People Apart from the volunteers and donors who support us financially and with their gifts of time and dedication, we are indebted to both the members of the UK Orthopaedic community and our staff who have tirelessly given of themselves to achieve what we have to date.. Patron: HRH The Prince Of Wales Chairman: Mr Ian Leslie / Prof Neil Rushton 2005—2010 / 2011—to date Chief Executive: Mr Mike Kimmons CB Development Manager: Mr Peter Foy Support Assistant: Mrs Lauren Bickles Board of Management: Mr I J Leslie - Chairman of the Board of Management, Mr P R Kay - BOA President, Prof J J Dias - BOA Vice-president, Prof T W R Briggs - BOA Council delegate, Prof. D R Marsh - Chairman, BOA Research Committee, Prof A W McCaskie - Chairman Joint Action Grants Committee, Mr W Khan - BOTA representative, Mr I A Trail - BOA Honorary Treasurer, Sir Chris O’Donnell - Lay Member Grants Committee: Mr M Costa, Prof S T Donell, Prof F S Haddad, Mr D Limb, Prof A W Miles, Mr W Khan. Research Committee: Prof D R Marsh, Mr A Blom, Mr C N A Esler, Mr D Griffin, Mr F S Haddad, Mr W Khan, Prof B Scammell, Mr J Timperley, Prof A J Carr, Prof A W McCaskie, Mr A Price, Mr H Simpson, Mr J M Wilkinson


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joint action impact report 2011-2012

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