Abstract Review and Selection
We were really pleased to have received over 1,500 submissions across the 19 abstract categories. All abstracts were reviewed by a number of Specialist Society representatives and BOA Executive, Council and Committee members. Abstracts selected will either be presented as a live webinar (Podium Presentation) or as a poster on the BOA website. Any abstracts submitted that have been published previously may not be selected. 

Abstract Notification
Abstract authors will have received notification regarding their submission. Please be aware that notification has been sent to the email address of the presenting author. 

Podium Presentation
Podium abstract presenters will be allocated 5 minutes to present their abstract followed by a 2 minute Q&A discussion at the end of their presentation. There is no requirement for podium abstract presenters to register for their session as we will register them for their webinar as a presenter.

Download the podium guidance document which contains detailed information about presenting at the BOA Virtual Congress. 

Abstract Published on the BOA website
Due to the current climate, the cancellation of meetings this year and the opportunity therefore to present at national meetings the BOA Honorary Secretary, Simon Hodkinson, had a discussion with the Chairman of the SAC who has agreed that if the abstract reached the cut off mark for presentation, it would be accepted as a podium presentation for this year. Download the full agreement here.

Please note: Even though the event is for BOA members only, both members and non-members are eligible to submit an abstract on one or more of the abstract categories. You will not need to become a BOA member in order to present your paper virtually in September. However, if you are a non-member and would like to access the content at any point during or after the event you can join the BOA hereTerms and conditions apply, see full details on the website here.

If you have any queries, please contact the BOA events team on 0207 406 1765, events@boa.ac.uk 

We are pleased to announce below the abstracts that were selected to be presented both as Podium presentation presentations. 

Virtual Podium and Accepted Abstracts 2020


Virtual Podium Presentations

56 - A Study of the Validity, Reliability and Interpretability of the Olerud Molander Ankle Score in Adults with Ankle Fracture

R McKeown1, H Parsons1, DR Ellard1, RS Kearney1,2

1University of Warwick, Warwick Clinical Trials Unit, Coventry, United Kingdom, 2University Hospitals Coventry and Warwickshire, Trauma and Orthopaedics, Coventry, United Kingdom

Background: The Olerud Molander Ankle Score (OMAS) is frequently reported in clinical trials of interventions for ankle fracture, yet there is a lack of evidence for its measurement properties. The aim is to assess the validity, reliability and interpretability of OMAS in adults with ankle fracture.

Methods: We used data collected in a clinical trial comparing immobilisation methods for adults with closed ankle fractures (ISRCTN15537280). Outcomes were collected at baseline, 6, 10 and 16 weeks post-randomisation. Outcomes collected were OMAS, Manchester-Oxford Foot and Ankle Questionnaire (MOXFQ), Disability Rating Index (DRI) and EuroQol EQ-5D questionnaire. The construct validity of OMAS was assessed by correlating the scores of OMAS with MOXFQ, DRI and EQ-5D scores using Pearson’s correlation coefficient. The internal consistency of OMAS was assessed using Cronbach’s alpha, with sufficient internal consistency defined as 0.70 – 0.95. The minimally important change (MIC) of OMAS was estimated by calculating the mean change in OMAS of patients who reported to be minimally improved between 10-16 weeks. The frequency of highest (100) and lowest (0) possible scores assessed whether edge effects were present, with effects defined as ≥15% of scores being 0 or 100.

Results: 620 participants were included, of which 331 (53%) were operatively managed fractures and 345 (56%) were female. Age range=18-94 years, mean=45.9 years. Correlations of scores of OMAS with MOXFQ was r= -0.85, OMAS with DRI was r= -0.77 and OMAS with EQ-5D was r = 0.73. Cronbach’s alpha=0.76. Of all OMAS scores (1767), 62 (3.5%) =0 and 42 (2.4%) =100. The mean change in OMAS of the minimally improved group was 9.7 points.

Conclusions: The OMAS demonstrates acceptable construct validity, internal consistency and no observed edge effects in this sample. The estimated MIC is 9.7points which is consistent with those used in clinical trials in this population.

There is NO Conflict of Interest: Yes

298 - Rehabilitation following shoulder arthroplasty: A survey of protocols

M. Morgan1, L. Pitt1, M. Moffatt2, P. Edwards3, R. Davies4, C. Peach4, C. Littlewood5

1University of Derby and Burton Hospitals NHS Trust, Derby Shoulder Unit, Orthopaedic Outpatients, Derby, United Kingdom, 2Wrightington, Wigan and Leigh NHS Foundation Trust, Upper Limb Research Unit, Wigan, United Kingdom, 3Curtin University, School of Physiotherapy and Exercise Science, Perth, Australia, 4Manchester University NHS Foundation Trust, Shoulder and Elbow Service, Manchester, United Kingdom, 5Manchester Metropolitan University, Department of Health Professions, Faculty of Health, Psychology and Social Care, Manchester, United Kingdom

The prevalence of TSA is rising year on year. Despite this, there is limited research evaluating rehabilitation following TSA and hence whether there is an optimal approach remains unknown.
Two reviewers independently undertook an electronic search for publicly available information booklets and protocols from websites of NHS Trusts. Protocols including some detail about rehabilitation following TSA, for example length of immobilisation, time to return to driving, were retrieved. One reviewer extracted data from the protocols and a second reviewer verified this.
43 protocols from 40 Trusts were identified and 25 of these were dated 2016 onwards. Of the 43 protocols, 24 referred to more than one type of arthroplasy (Anatomic, Reverse or Hemiarthroplasty), but did not describe different approaches to rehabilitation based on prosthesis type.
25 of 43 protocols provided some instruction with regard to movement restrictions and varied considerably, including avoidance of abduction, external rotation, resisted internal rotation, hand behind back, and weight bearing.
All protocols referred to post-operative immobilisation, typically with a sling. The mean duration was four (SD 1.5) weeks. 34 protocols reported commencing passive exercise immediately (within three days). Mean time to commencing active exercise was four (SD 1.7) weeks and five (SD 4.0) weeks for resisted exercise.
Mean time to returning to light work was six (SD 2.0) weeks and 15 (SD 5.4) weeks for general work.
Mean time to return to driving was 7 (SD 1.9) weeks and 14 (SD 3.8) weeks for return to sport.
Through this study we have informed understanding of the current approach to rehabilitation following TSA in the NHS. This understanding will facilitate development and testing of optimal rehabilitation strategies following TSA in future randomised controlled trials.
There is NO Conflict of Interest: Yes

400 - Discharge after hip fracture surgery by mobilisation timing: secondary analysis of the UK National Hip Fracture Database

KJ Sheehan1, A Goubar1, O Almilaji1, FC Martin2,1, C Potter2, GD Jones2, C Sackley1, S Ayis1

1King's College London, School of Population Health and Environmental Sciences, London, United Kingdom, 2Guy's and St Thomas's National Health Service Foundation Trust, London, United Kingdom

Objective: To determine whether mobilisation timing was associated with the cumulative incidence of hospital discharge by 30-days after hip fracture surgery, accounting for potential confounders and the competing risk of in-hospital death.

Method: We examined data for 135,105 patients 60 years or older who underwent surgery for nonpathological first hip fracture between January 1st 2014 and December 31st 2016 in any hospital in England or Wales. We tested whether the cumulative incidences of discharge differed between those mobilised early (within 36-hours of surgery) and those mobilised late accounting for potential confounders and the competing risk of in-hospital death.

Results: 106,722 (79%) of patients first mobilised early. The average rate of discharge was 60.1 (95% CI 59.8 – 60.5) per 1000 patient days, varying from 65.2 (95% CI 64.8 -65.6) among those who mobilised early to 44.5 (95% CI 43.9– 45.1) among those who mobilised late, accounting for the competing risk of death. By 30-days postoperatively, the crude and adjusted odds ratios of discharge were 2.26 (95% CI 2.21 – 2.32) and 1.93 (95% CI 1.86 – 1.99) respectively among those who first mobilised early compared to those who mobilised late, accounting for the competing risk of death.

Conclusion: Early mobilisation led to a near two-fold increase in the adjusted odds of discharge by 30-days postoperatively. We recommend inclusion of mobilisation within 36-hours of surgery as a new UK Best Practice Tariff to help reduce delays to mobilisation currently experienced by one-fifth of patients surgically treated for hip fracture.

There is NO Conflict of Interest: No

Disclosure: This paper presents independent research funded by the National Institute for Health Research (NIHR) under its Research for Patient Benefit (RfPB) Programme (Grant Reference Number PB-PG-1216-20031). The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care.

523 - The effectiveness of preoperative rehabilitation programmes on postoperative outcomes following anterior cruciate ligament (ACL) reconstruction: a systematic review

H. Carter1, C. Littlewood2, K. Webster3, B. Smith1,4

1University Hospitals of Derby and Burton NHS Foundation Trust, Physiotherapy Outpatients, Derby, United Kingdom, 2Manchester Metropolitan University, Department of Health Professions, Manchester, United Kingdom, 3La Trobe University, School of Allied Health, Human Services and Sport, Melbourne, Australia, 4University of Nottingham, Division of Rehabilitation, Ageing and Wellbeing, Nottingham, United Kingdom

Background: To explore the effectiveness of preoperative rehabilitation programmes (PreHab) on postoperative physical and psychological outcomes following anterior cruciate ligament reconstruction (ACLR). 
Methods: A systematic search was conducted from inception to November 2019. Randomised controlled trials (RCTs) published in English were included. Risk of bias was assessed using Version 2 of the Cochrane risk-of-bias tool, and the Grading of Recommendations Assessment system was used to evaluate the quality of evidence.
Results: The search identified 739 potentially eligible studies, three met the inclusion criteria. All included RCTs scored ‘high’ risk of bias.
PreHab in all three RCTs was an exercise programme, each varied in content (strength, control, balance and perturbation training), frequency (10 to 24 sessions) and length (3.1- to 6-weeks). 
Statistically significant differences (p<0.05) were reported for quadriceps strength (one RCT) and single leg hop scores (two RCTs) in favour of PreHab three months after ACLR. One RCT reported no statistically significant between-group difference for pain and function. No RCT evaluated post-operative psychological outcomes.  
Conclusion: Low-quality evidence suggests that PreHab that includes muscular strength, balance and perturbation training offers a small benefit to quadriceps strength and single leg hop scores three months after ACLR. There is no consensus on the optimum PreHab programme content, frequency and length; this requires future consideration including the development of PreHab programmes that consider psychosocial factors and the measurement of relevant post-operative outcomes such as psychological readiness.

PROSPERO trial registration number 

There is NO Conflict of Interest: Yes

636 - Rehabilitation following rotator cuff repair: Multi-centre pilot and feasibility randomised controlled trial (RaCeR)

C. Littlewood1,2, M. Bateman3, S. Butler-Walley4, S. Bathers4, T. Cookson5, K. Bromley4, M. Lewis4, L. Funk6, M. Moffatt6, J. Denton7, R. Winstanley8, S. Mehta8, G. Stephens9, L. Chesterton2, L. Dikomitis10, N. Foster2

1Manchester Metropolitan University, Department of Health Professions, Manchester, United Kingdom, 2Keele University, School of Primary, Community and Social Care, Keele, United Kingdom, 3University Hospitals Derby & Burton NHS Foundation Trust, Derby Shoulder Unit, Derby, United Kingdom, 4Keele University, Keele Clinical Trials Unit, Keele, United Kingdom, 5Keele University, Sandbach, United Kingdom, 6Wrightington, Wigan and Leigh NHS Foundation Trust, Wigan, United Kingdom, 7The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust, Oswestry, United Kingdom, 8University Hospitals of North Midlands NHS Trust, Stoke, United Kingdom, 9The Royal Orthopaedic Hospital NHS Foundation Trust, Birmingham, United Kingdom, 10Keele University, School of Medicine, Keele, United Kingdom

The purpose of the RaCeR study was to assess the feasibility of a substantive, multi-centre randomised controlled trial (RCT) to test whether, compared to standard rehabilitation (SR) incorporating sling immobilisation for four weeks, early patient-directed rehabilitation (EPDR), where the patient is directed to move their arm as symptoms allow, is more clinically- and cost-effective following surgical repair of the rotator cuff.

We conducted a two-arm, multi-centre pilot and feasibility RCT. Patients diagnosed with non-traumatic tears of the rotator cuff and listed for surgical repair were recruited from five NHS hospitals and randomly allocated to EPDR or SR.

Participants received weekly SMS text messages for 12 weeks and postal questionnaires at six and 12 weeks asking about pain, function and health-related quality of life. A blinded diagnostic ultrasound scan was undertaken at 12 weeks to assess re-tear rate. Participants also completed an exercise diary to record time out of sling over the first four weeks.

389 patients were screened; 185 potentially eligible; 73 randomised (39.4%). 20 participants were withdrawn, 11 due to not receiving rotator cuff repair surgery. The difference in time out of sling between the two groups was 50.4% (80% CI=28.6%, 72.1%) with the EPDR group reporting 414 hours out of the sling and the SR group reporting 178 hours (8 hour difference/ day). Follow up was 71.2% and 98.1% at 12 weeks when withdrawals were included and excluded respectively. 18 full-thickness re-tears were reported at 12-weeks via ultrasound (EPDR=7, SR=11). Five serious adverse events were reported: detached biceps tendon (SR=2), pulmonary embolism (EPDR=1), rotator cuff re-tear requiring further surgery (EPDR=1; SR=1).

These results suggest that a main RCT is feasible but requires a minor change to randomly allocate participants following surgery, rather than pre-surgery, to counter the issue of withdrawal due to not receiving surgery.

There is NO Conflict of Interest: No

1232 - Important Functional Measures in Pre- and Post-operative patients undergoing Total Knee Replacement

R. Walker1, R. Stroud1, B. Waterson1, J. Phillips1, V. Mandalia1, K. Eyres1, A. Toms1

1Exeter Knee Reconstruction Unit, Princess Elizabeth Orthopaedic Centre, Exeter, United Kingdom

Whilst the literature abounds with patient reported outcomes following total knee replacement there is a paucity of literature covering objective functional outcomes. Awareness of various objective functional outcomes following surgery is key to preoperative discussions with patients to ensure they have realistic expectations and relating it to pre-operative function enables a tailored approach to patient care.
We prospectively gathered data from 82 patients undergoing total knee replacement surgery, examining over twenty functional measures preoperatively and postoperatively at 6 weeks, 3 months, 6 months and 1 year. Our functional lab incorporated a list of validated functional assessments selected by surgeons & physiotherapists seen to be critical to outcomes following knee replacement surgery, such as: kneeling ability, 6 minute walking distance, time to ascend/descend stairs, quadricep moment strength, single stance leg difficulty, ability to walk on an uneven surface, “Time to get up and go” test, upslope/downslope speed.
Our results showed over two thirds of patients were able to kneel 1 year postoperatively, but if the patient was able to kneel preoperatively they had an 82.5% chance of being able to kneel postoperatively, and if they could not kneel preoperatively they had a 50% of being able to kneel postoperatively. Other selected results include: 49% increase in 6-minute walking distance, 45% reduction in time to ascend then descend stairs, over 50% increase in quadriceps moment strength, over 40% increase in both upslope/downslope speed and over a 70% reduction in difficulty walking on an uneven surface.
With these results we can not only discuss specific functional outcomes with patients, but also relate these to preoperative function level, empowering a more tailored and detailed discussion with the patient reducing un-realistic goals and improving patient expectation.

There is NO Conflict of Interest: No

Accepted Abstracts


Basic Science

Virtual Podium Presentations

244 - A metabolomic study into the effect of non-lethal dispersion on antimicrobial tolerance in Staphylococcus aureus biofilms

S-TJ Tsang1,2, M Gallagher2, H Simpson1

1University of Edinburgh, Department of Trauma and Orthopaedic Surgery, Edinburgh, United Kingdom, 2University of Edinburgh, School of Biological Sciences, Edinburgh, United Kingdom

Objective: Staphylococcus aureus is one of the most common pathogens in orthopaedic biomaterial-associated infections. The transition of planktonic S. aureus to its biofilm phenotype is critical in the pathogenesis of biomaterial-associated infections and the development of antimicrobial tolerance, which leads to ineffective eradication in clinical practice. This study sought to elucidate the effect of non-lethal dispersion on antimicrobial tolerance in S. aureus biofilms.

Methods: Using a methicillin-sensitive S. aureus reference strain, the effect of non-lethal dispersion on gentamicin tolerance, cellular activity, and the intracellular metabolome of biofilm-associated bacteria were examined. Gentamicin tolerance was estimated using the dissolvable bead biofilm assay. Cellular activity was estimated using the triphenyltetrazolium chloride assay. Metabolome analysis was performed using tandem high-performance liquid chromatography and mass spectrometry.

Results: Non-lethal dispersion of biofilm-associated S. aureus was associated with a four-fold reduction in gentamicin tolerance and a 25% increase in cellular respiration of both dispersed and adherent cells. Metabolome analysis found non-lethal dispersion reduced intracellular levels of L-ornithine and L-proline, with increased levels of cyclic nucleotides (p<0.05) in both liberated cells and the remaining biofilm-associated bacteria. These metabolomic changes have previously been shown to be associated with inactivation of the carbon catabolite repression mechanism, which is a key regulatory gatekeeper in the cellular resuscitation of dormant S. aureus cells.

Conclusions: The metabolomic pipeline described in this study presents a valuable tool in the elucidation of molecular mechanistic pathways in biofilm pathogenesis. Kreb’s cycle reactivation, through the carbon catabolite repression regulatory mechanism, has been shown to be associated with the reversal of biofilm-associated gentamicin tolerance. Understanding of the biosynthetic changes associated with the biofilm state will assist in the discovery of novel therapeutic targets in the management of biomaterial-related infections.

There is NO Conflict of Interest: Yes

353 - Vitamin D levels in Irish Children with Fractures: a prospective case-control study with 5 year follow-up

D Moore1, M O'Sullivan1, P Kelly1

1Children's Health Ireland at Crumlin, Orthopaedics, Dublin 12, Ireland

Introduction: Twenty-five-hydroxy-vitamin-D3 is a prohormone that is essential for calcium homeostasis and bone metabolism. Understanding its role is an important component of the proper care of the paediatric orthopaedic patient. The aim of this study was to determine whether children in Ireland with fractures have increased prevalence of 25-hydroxy-vitamin-D3 deficiency.

Methods: A prospective case-control study at a large urban tertiary referral hospital in Dublin was completed over a 14 month period. A total of 116 subjects, distributed equally as cases and controls were included. Whole blood was taken from each patient. Serum 25-hydroxy-vitamin-D3 levels were measured. An age matched control group was generated from other children attending the hospital. We followed up both the fracture and control group for the next 5 years to assess the repeat fracture rate.

Results: Fifty-eight patients with fracture requiring operative intervention were included in the study. Statistical analysis was performed with 58 age-matched controls. The mean vitamin D level for the fracture group was 63.2nmol/L, which was higher than the mean of the controls (62.5 nmol/L), this difference was found not to be statistically significant. There was no difference in the number of patients classified with low serum Vitamin D levels (<50nmolL), with the fracture group consisting of 22 (37.9%) patients, and the control group of 17 patients (29.3%) with a level below 50nmol/L. At 5 year follow-up, 11 of the 58 patients in the fracture group went on to suffer a further fracture compared with 8 patients from the control group.

Conclusion: The results of this study reject the claim that children with fractures have a higher prevalence of 25-hydroxy-vitamin D deficiency. There was no relationship between vitamin D deficiency and fracture risk in our population. Our findings suggest that in an Irish paediatric population vitamin D status does not impact fracture risk.

There is NO Conflict of Interest: Yes

631 - Validating the 'Cambridge Protocol': Assessing the reliability of hip muscle strength measurements using a kinematic dynamometer

A. Memarzadeh1, A. Morrison2, V. Merzbach3, M. Ferrandino3, L. Claydon4, V. Khanduja5

1Addenbrooke's hospital, Trauma and Orthopaedics, Cambridge, United Kingdom, 2Anglia Ruskin University, Sport and Exercise Science, Cambridge, United Kingdom, 3Anglia Ruskin University, Cambridge, United Kingdom, 4Anglia Ruskin University, Faculty of Health, Education, Medicine and Social Care, Chelmsford, United Kingdom, 5Addenbrooke's Hospital, Trauma and Orthopaedics, Cambridge, United Kingdom

BACKGROUND: Muscle strength is difficult to measure accurately due to large number of variable factors. Although muscle strength is key to stability and post-operative recovery, it is difficult to compare findings from different studies as the measurements are seldom taken in the same manner. To standardise the measurement of hip muscle strength, a protocol was devised based on a systematic review of the literature. The reliability of the measurements of the protocol was assessed in this study.
METHODS: Sixteen healthy male volunteers were recruited from a young adult population, aged 28.3 ±7.9 years. Those with previous or existing hip pain, investigations or treatment were excluded. Participants underwent muscle strength testing on four occasions, by two separate assessors. 
The protocol included a five-minute warm-up on a stationary bicycle, followed by testing using an isokinetic dynamometer. The participants were stabilised on the dynamometer and six muscle groups were tested for six hip joint motions: abduction, adduction, flexion, extension, and internal and external rotation. Three 10-second maximal isometric muscle contractions were performed for each motion. The maximal voluntary contraction from the three attempts was recorded. 
RESULTS: The interclass coefficient (ICC) values were analysed to assess reliability. Intra-observer reliability was ‘good’ to ‘excellent’ across all hip movements except flexion (ICC 0.79-0.94). Hip extension had the highest intra-observer reliability (ICC 0.94).
Inter-observe reliability was tested using limits of agreements and ICC. The results revealed ‘good’ to ‘excellent’ correlation for all hip movements except abduction (ICC 0.78-0.96). Hip extension had the highest inter-observer reliability.
CONCLUSION: The ‘Cambridge Protocol’ is a reliable tool for the measurement of hip muscle strength. We highly recommend its use in future studies to ensure data is transferable between studies and centres. Hip extension was the most reliable measurement.

There is NO Conflict of Interest: Yes

740 - A Novel mechanical inclinometer device to measure acetabular cup inclination in total hip arthroplasty

B. van Duren1, M. Al-Ashqar2, J. Lamb1, H. Pandit3, C. Brew2

1University of Leeds, Leeds Orthopaedic Trauma Sciences, Leeds, United Kingdom, 2Bradford Royal Infirmary, Bradford, United Kingdom, 3University of Leeds, Leeds, United Kingdom

Background: It is well recognised that acetabular cup orientation influences patient function and implant survivalvpost-THR. Reliable intra-operative determination of cup orientation remains a challenge. Innovators have described the use of digital inclinometers or mechanical alignment guides (MAGs). However, difficulties with sterilization and practicality remain. We describe the design and testing of a novel mechanical inclinometer to measure intra-operative acetabular cup inclination.

Methods: The aim was to design a generic inclinometer to measure acetabular inclination to within +/- 2.5o without requiring modification to existing instrumentation while remaining easy to handle & visualise, be robust/reusable, and sterilizable. The device was drafted using computer aided design software, prototyped using a 3D printer and constructed using stainless steel. Two experiments were undertaken to test accuracy:
1) the absolute accuracy of the prototype device was tested against against a digital device
2) placement of an acetabular component using the device was compared to the standard freehand technique using a sawbone pelvis.
18 surgeons (6 expert, 6 intermediate, 6 novice) were asked to place an uncemented acetabular cup in a saw bone pelvis to a target of 400.

Results: The average root-mean-square error for the device was 1.10o (SD: 0.90). Comparison of the inclinometer to the freehand technique showed that with the freehand component placement 50% of the surgeons were outside the specified range of 350-450. Inclinometer use resulted in all participants to achieving placement within range. Expert surgeons were more accurate at achieving the target inclination than less experienced surgeons both with free hand as well as whilst using inclinometer.

Conclusion: This work demonstrates that on initial testing a novel mechanical inclinometer is suitable for use in determining the acetabular cup inclination in THR. Experimental testing showed that the device is accurate to within acceptable limits and allowed surgeons to improve their accuracy reliably.

There is NO Conflict of Interest: Yes

966 - VTE risk assessment: Is it reliable?

S. Barkley1, P. Sutton1

1Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom

Background: Venous thrombo-embolism (VTE) risk assessment was first recommended by the National Institute for Health and Care Excellence (NICE) in 2007.
A Department of Health (DoH) VTE assessment tool in use since 2010 remains unvalidated.
Anecdotal data suggested this was being used with great variability between clinicians.

Methods: We produced 20 vignettes based on elective and emergent orthopaedic patients. These were distributed to practitioners whose normal clinical practice involves VTE risk assessment.
The practitioners risk assessed each of the patient vignettes using the DoH tool and repeated this a minimum of 2 weeks later. Using these data, the inter- and intra- observer reliabilities were calculated using Fleiss and Cohen Kappa scores respectively and assessed against the Landis and Koch criteria.
We then reviewed all the evidence considered by NICE before issuing the VTE guideline (CG46). Using this evidence, we revised the DoH risk assessment, exchanging subjective criteria for more objective criteria. For example, ‘dehydration’ was changed to ‘Urea level >8’.
We repeated the reliability study using the revised tool.

Results: The DoH assessment tool demonstrated low reliability between criteria considered subjective. Using the revised risk assessment tool all subjective risk factors that previously demonstrated poor or weak inter-observer reliability improved to moderate or very good reliability (Kappa >0.40).
The revised document improved the inter-observer reliability for the prescription of thromboprophylaxis from weak to good.

Conclusion: The DoH VTE risk assessment tool is currently unreliable and therefore cannot be validated. Our study shows that making simple changes to the wording improves the document's reliability.

Implication: Improving the reliability of a mandatory risk assessment tool could improve patient safety and care.

There is NO Conflict of Interest: Yes

1217 - Is coating of titanium implants effective at preventing Staphylococcus aureus infections? A meta-analysis of animal model studies.

K. Tsikopoulos1, K. Sidiropoulos2, D. Kitridis3, A. Hassan4, L. Drago5, A. Mavrogenis6, D. McBride7

1Royal Surrey Hospital, Guildford, United Kingdom, 2General Hospital of Serres, SerresDramaGreece, Greece, 3G. Papanikolaou General Hospital, Exohi, Greece, 4East & North Hertfordshire NHS, Trauma & Orthopaedics, Stevenage, United Kingdom, 5University of Milan, Milan, Italy, 6National and Kapodistrian University of Athens, Athens, Greece, 7University Hospitals of North Midlands, Stoke-on-Trent, United Kingdom

Aim of the study: To assess the effects of the available coating methods against methicillin-resistant Staphylococcus aureus (MRSA) and methicillin-susceptible S. aureus (MSSA) biofilm development on titanium implants.

Methods: We searched the MEDLINE, Embase, and CENTRAL databases until May 18, 2019, for studies that used animal models of infections to evaluate various titanium implant coating methods to prevent S. aureus infection. Twenty-seven studies were eligible for inclusion in qualitative synthesis. Of those, twenty-three were considered in pair-wise meta-analysis. In addition, subgroup analysis of implant protection strategies relative to uncoated controls was performed, and any adverse events stemming from the coating applications were reported. Quality assessment was performed using SYRCLE’s risk of bias tool for animal studies.

Results: Meta-analysis showed that active coating with antibiotics was favoured over uncoated controls (standardised mean differences [SMD] for MRSA and MSSA were – 2.71 [95% CI, − 4.24 to − 1.18], p = 0.0005, and − 2.5 [− 3.79 to − 1.22], p = 0.0001, respectively). Likewise, large effect sizes were demonstrated when a combination of active and conventional non-degradable passive coatings was compared with controls (SMDs for MRSA and MSSA were – 0.62 [95% CI, − 1.15 to − 0.08], p = 0.02, and − 1.93 [95% CI, − 2.87 to − 0.98], p < 0.001, respectively).

Discussion/conclusion: As a standalone prevention method, active titanium coating with antibiotics yielded promising results against both MSSA and MRSA. Combinations between active and non-degradable passive coatings, potentially allowing for sustained antimicrobial substance release, provided consistent hardware infection protection. Thus, we recommend that future research efforts focus on combined coating modalities against S. aureus biofilm infections in the presence of titanium implants.

There is NO Conflict of Interest: Yes


M. Beverly1, D. Murray1

1University of Oxfrod, OOEC, NDORMS, Oxford, United Kingdom

Background: Steroids may raise intraosseous pressure (IOP) and cause osteonecrosis by fat cell swelling. We explored the effect of vascular occlusion on IOP in a steroid treated animal model.

Methods: IOP was measured in 41 sites among 15 control and 6 steroid treated rabbits through upper tibial intraosseous needles connected to pressure transducers, with and without proximal vascular occlusion. After angiography the femora were removed, photographed and x-rayed.

Results: Resting basal IOP (IOPb) varied widely (24.8 mmHg, SD 11.6) but had a proportionate pulse pressure (PP) (R2=0.64). Proximal arterial occlusion (IOPa) lowered (p<0.0001) and proximal venous occlusion (IOPv) increased IOP (p<0.0001). Subtracting IOPv-IOPa gave a delta pressure which may be a better measure of perfusion pressure range at the needle tip than IOPb alone. Six steroid treated subjects showed a raised IOPb (p<0.002) but without a significant change in delta pressure range IOPv-IOPa (p=0.59). Steroids caused cachexia and weight loss (p<0.003). The raised IOP appeared to be secondary to increased intraosseous vascular space and perfusion confirmed on photographs of the femora and x-ray micro angiography.

Conclusions: We suggest that basal IOPb varies but has a proportionate PP as a needle variably accesses the vascular tree. We describe a new subtraction technique IOPv-IOPa which gives a delta perfusion pressure at the needle tip. In this particular model, corticosteroids reduced intraosseous fat cell volume thereby improving circulation pressure at the needle tip rather than by raising IOP by fat cell swelling.

Implications: Our work offers a new insight into bone perfusion physiology and the effects of steroids.

There is NO Conflict of Interest: No

1622 - Carbon dioxide levels in surgical helmets in the operating theatre

J. Barrow1, C. Whelton1, T. Board1

1Wrightington, Centre for Hip Surgery, Wigan, United Kingdom

Introduction: There have been concerns that retention of CO2 inside surgical helmets may reach levels which impair cognition. We monitored the CO2 levels in the helmets of an all-in-one toga (Tg) and a two-piece hood and gown (Hg) spacesuit.

Method: Using a Bluetooth CO2 probe in the hood and an external CO2 monitor in a laminar flow theatre, we monitored the CO2 levels of 2 subjects. 4-minute time segments (with 1 min equalization) under different conditions in both Tg and Hg were assessed. Variables included: fan speed, head position (up or down), and exertion rate. Results were compared against the HSE exposure limits of 5000ppm (8hr) and 15000ppm (15 min) and the 2500ppm level known to produce cognitive impairment in airline pilot studies.

Results: In the Tg in all conditions, levels were above 2500ppm 100% of the time. Performing slow step ups in Tg or Hg kept levels above 2500ppm at all times despite high fan speed. When stepping with a low fan speed the CO2 was over 15000ppm for 95% of the time for both subjects in Tg but only 25% of the time in Hg. The same scenario with a high fan speed produced levels over 15000ppm for 50% of the time Tg, but 0% in the Hg.

Discussion: Worryingly high levels of CO2 were observed in this study. High fan speed, Hg and low activity were associated with lower levels. Mild exertion produced dangerous levels of CO2. Further work is required to validate this pilot study.

There is NO Conflict of Interest: No
Disclosure: J. Barrow: None Declared, C. Whelton: None Declared, T. Board received grant/research support from: DePuy Synthes, is consultant for: DePuy Synthes, is a paid instructor for: DePuy
Synthes, has a conflict with: Royalties from Springer, Associate Editor of Hip International, Research Committee Member for British Orthopaedic Association

1667 - Differences between infected and non-infected synovial fluid: a Nuclear Magnetic Resonance (NMR) spectroscopy observational study of metabolic profiles

P. Akhbari1, M. Jaggard1, C. Boulange1, U. Vaghela1, G. Graca1, R. Bhattacharya1, J. Lindon1, H. Williams1, C. Gupte1

1Imperial College, London, London, United Kingdom

Background: Periprosthetic joint infection (PJI) is one of the most devastating complications of joint arthroplasty. Microscopy, culture and sensitivity (MC&S) remains the gold standard for identifying infecting organisms. The aim of this study was to identify differences between infected and non-infected SF using metabolic phenotyping with Nuclear Magnetic Resonance (NMR) spectroscopy.

Methods: Sixteen SF samples (eight infected, eight non-infected) were collected from patients undergoing hip/knee aspiration, knee arthroscopy, hip/knee arthroplasty and revision arthroplasty. Samples were matched for age, gender, the joint from which the SF was taken and medical comorbidities. NMR spectroscopy was used to analyse the metabolites present in each sample. Principal Component Analysis and univariate statistical analysis were undertaken to investigate metabolic differences between the two groups.

Results: Sixteen metabolites were found in significantly different concentrations between the groups. Three were in higher relative concentrations (lipids, cholesterol and N-acetylated molecules) and 13 in lower relative concentrations (citrate, glycine, glycosaminoglycans, creatinine, histidine, lysine, formate, glucose, proline, valine, dimethylsulfone, mannose and glutamine) in the infected group.
Conclusions: This is the first study to demonstrate differences in the metabolic profile of infected and non-infected human SF. Metabolites found in significantly greater concentrations in the infected cohort represented those which are markers of inflammation and infection, have a role in lipid metabolism and the inflammatory response. Metabolites found in significantly reduced concentrations in the infected cohort can broadly be grouped into those involved in carbohydrate metabolism, nucleoside metabolism, the metabolic pathway of glutamate, increased oxidative stress in the diseased state and reduced articular cartilage breakdown. These findings may reflect differences in human metabolites secondary to infection and/or metabolites produced or consumed by bacteria. Further research may confirm putative biomarkers that form the basis of new diagnostic tests for infected SF.

There is NO Conflict of Interest: Yes

1727 - Single Stage Surgical Management Of Diabetic Foot Infection With Antibiotic Loaded Biocomposite

S. Gurusinghe1, B. Srinivasan2, A. Tarik2, M. Subramaniam3, N. Htwe2, N. Vasukutty1

1Pilgrim Hospital, Trauma and Orthopaedics, Boston, United Kingdom, 2Pilgrim Hospital, Endocrine, Boston, United Kingdom, 3Pilgrim Hospital, Vascular, Boston, United Kingdom

Background: Management of infection in diabetic foot ulcers are challenging due to unfavourable biological environment and redundant dead space management techniques. Traditionally, multiple surgical procedures were required to control infection. This led to significant cost implication and increased patient morbidity.
Aim of this study is to evaluate infection control and wound healing with single stage surgery with antibiotic loaded bio composite.

Methodology: This is a retrospective analysis of prospectively collected data of 22 feet (21 patients) with foot infection. All patients assessed by the same multidisciplinary team (MDT), which included vascular imaging where applicable. Protocol included wound debridement, deep tissue sampling, application of antibiotic loaded bio composite (Cerament G) and wound closure. Post operatively patients were managed with culture specific antibiotic and strict non-weight bearing period.

Results: Mean patient follow up duration was 23 weeks and mean age in this cohort was 56 years. 2 patients were Cierny-Mader(CM) class B/C hosts and the rest 22 subjects were class B host. 21 feet had foot ulcers with osteomyelitis, 2 were non-diabetic osteomyelitis. According to CM system, only one had type 1 lesion, 5 feet were type 2 involvement, 7 were type 3 and 8 feet were type 4 osteomyelitis. One patient (2 feet) had revascularisation prior to orthopaedic procedure, which included 3 partial calcanectomies, 3 exostectomies, 7 toe/ray amputations, 4 sequestrectomies and 3 wound debridements. 14 wounds were closed primarily and the rest were managed with NPWT. 19 were had only single Procedure, 15 wounds mean healing duration of 13 weeks, 3 patients had below knee amputation.

Conclusions: Single stage wound debridement protocol with MDT management and antibiotic loaded bio composite yielded 86.4% success in this cohort. Use of antibiotic loaded biocomposite has improved chances of limb salvage and reduced the number of theatre episodes in these high risk surgical candidates.

There is NO Conflict of Interest: Yes

1743 - Validation and Comparison of the Imperial Joint Line Height Measurement Technique for Total Knee Arthroplasty: Novices vs Experts

R. Popat1, K. Dhillon2, P. Mahapatra1, M.H.F. Khan2, D. Nathwani1

1Imperial College Healthcare NHS Trust, Department of Trauma & Orthopaedic Surgery, London, United Kingdom, 2Imperial College London, London, United Kingdom

Background: Measurement techniques that have previously been used to assess change in joint line height following a Total Knee Arthroplasty (TKA) on plain radiographs have not been validated. This is the first study to assess the accuracy and reliability of measurement techniques that can be used to measure joint line height.

Methods: The reliability and accuracy of two techniques used to measure joint line height on pre-operative and post-operative plain radiographs is presented.
Measurements were performed on imaging from 120 patients that underwent TKA at 6 different centres worldwide.
Images were blinded and measurements were performed by two experts (senior orthopaedic surgeons) to assess inter and intra-rater reliability using an intra-class correlation coefficient (ICC).
Two medical students also performed double examinations.
Average values, standard deviations, variance and margin of error were calculated for each technique.
Cronbach’s alpha was calculated for internal validity.
Student’s T-test, analysis of variance (ANOVA) and ICC were used to compare measurements performed by experts and novices

Results: The Imperial Joint Line Measurement Technique (IJMLT) has an average absolute difference of 1.83mm (CI 1.56 – 2.10mm) and excellent inter and intra-rater reliability between experts (>0.92 [CI 0.88 – 0.94]).
Crohnbach’s alpha >0.92 confirmed internal consistency.
The technique described by Figgie et al. in their seminal work had an average absolute difference of 5.75mm (5.17 – 6.32mm) between observers.
Comparison of measurements by experts and novices using the IJLMT with ANOVA and Student’s t-test demonstrated acceptable agreement and inter-rater reliability (ICC>0.92 (0.87 – 0.95)).

Conclusion: The present study describes the IJLMT, which provides better accuracy, precision and reliability than previous techniques used to measure joint line height in TKA.

Implications: The IJLMT can be used to accurately measure change in joint line height and it's effect on functional outcomes.

There is NO Conflict of Interest: Yes


Virtual Podium Presentations

399 - 30-day mortality following trauma and orthopaedic surgery during the peak of the SARS-CoV-2 pandemic; a multicentre regional analysis of 484 patients

P Karayiannis1, V Roberts1, R Cassidy2, A Mayne3, D McAuley4, D Milligan5, O Diamond4

1Craigavon Area Hospital, Trauma and Orthopaedics, Craigavon, United Kingdom, 2Musgrave Park Hospital, Outcomes Department, Belfast, United Kingdom, 3Ulster Hospital, Trauma and Orthopaedics, Belfast, United Kingdom, 4Royal Victoria hospital, Trauma and Orthopaedics, Belfast, United Kingdom, 5Altnagevlin Area Hospital, Trauma and Orthopaedics, Londonderry, United Kingdom

Introduction: Now in the deceleration phase of the SARS-CoV-2  pandemic the focus has shifted to how to safely reinstate elective operating.  Regional and specialty specific data is important to guide this decision-making process. This study aimed to review 30-day mortality for all patients undergoing orthopaedic surgery during the peak of the pandemic within our region.
Methods: This multicentre study reviewed data on all patients undergoing Trauma and Orthopaedic surgery in a region, from 18th March 2020 to 27th April 2020. Information was collated from regional databases. Patients were  SARS-CoV-2 positive if they had positive laboratory testing and/or imaging consistent with the infection. 30-day mortality was assessed for all patients. Secondly, 30-day mortality in fracture neck of femur patients was compared to the same time period in 2019.
Results: 496 operations were carried out in 484 patients. The overall 30-day mortality was 1.9%. 7 of the 9 deceased patients underwent surgery for a fractured neck of femur, (all ASA 3 or 4). Paradoxically, the mortality for neck of femur fracture was reduced in 2020 compared to 2019(3.4% versus 6%,p=0.2). 27 patients contracted SARS-CoV-2 in the peri-operative period and of these 4 patients died within 30 days(14.8%). 21 of the 27 patients in this group had a fractured neck of femur, 22 were over the age of 70(81.5%). 
Conclusions: Overall 30-day post-operative mortality in Trauma and Orthopaedic Surgery patients remains low at 1.9%. There was no 30 day mortality in patients ASA 1 or 2. Patients with significant co-morbidities, increasing age and ASA 3 or above remain at the highest risk. For patients with SARS-CoV-2 infection post-operative 30-day mortality was 14.8%. The reintroduction of elective services should consider individual patient risk profile (including for ASA grade). Effective post-operative strategies should also be employed to try and reduce post-operative exposure to the virus.

There is NO Conflict of Interest: Yes

365 - Population mobility and adult orthopaedic trauma services during the COVID-19 pandemic: fragility fracture provision remains a priority

C Brennan1, C Scott1, G Holland1, M Powell-Bowns1, M Gillespie1, S Mackenzie1, N Clement1, A Amin1, TO White1, A Duckworth1

1Royal Infirmary Edinburgh, Trauma and Orthopaedics, Edinburgh, United Kingdom

Aims: This study aims to define the epidemiology of trauma presenting to a single centre providing all orthopaedic trauma care for a population of ∼ 900,000 over the first 40 days of the COVID-19 pandemic compared to that presenting over the same period one year earlier. The secondary aim was to compare this with population mobility data obtained from Google.

Methods: A cross-sectional study of consecutive adult (> 13 years) patients with musculoskeletal trauma referred as either in-patients or out-patients over a 40-day period beginning on 5 March 2020, the date of the first reported UK COVID-19 death, was performed. This time period encompassed social distancing measures. This group was compared to a group of patients referred over the same calendar period in 2019 and to publicly available mobility data from Google.

Results: Orthopaedic trauma referrals reduced by 42% (1,056 compared to 1,820) during the study period, and by 58% (405 compared to 967) following national lockdown. Outpatient and inpatient referrals reduced by 44% and 36% respectively, and the number of surgeries performed by 36%. The regional incidence of traumatic injury fell from 5.07 (95% confidence interval (CI) 4.79 to 5.35) to 2.94 (95% CI 2.52 to 3.32) per 100,000 population per day. Significant reductions were seen in injuries related to sports and alcohol consumption. No admissions occurred relating to major trauma (Injury Severity Score > 15) or violence. Changes in population mobility and trauma volume from baseline correlated significantly (Pearson’s correlation 0.749, 95% CI 0.58 to 0.85, p < 0.001). However, admissions related to fragility fractures remained unchanged.

Conclusion: The profound changes in social behaviour and mobility during the early stages of the COVID-19 pandemic have directly correlated with a significant decrease in orthopaedic trauma referrals, but fragility fractures remained unaffected and provision for these patients should be maintained.

There is NO Conflict of Interest: No

Disclosure: Scott: editorial board membership of BJJ and BJR, consultancy and grants/grants pending from Stryker Orthopaedics.
White: consultancy from Acumed, and grants/grants pending from Acumed and Smith & Nephew.
Duckworth: grants from Scottish Government Quality Improvement Grant, Smith & Nephew, and Acumed, and book royalties from Elsevier and Taylor & Francis.

417 - 30 Day Mortality Following Surgical Management of Hip Fractures During the COVID19 Pandemic: findings from a prospective multi-centre UK study

AM Narang1, G Chan2, A Aframian3, Z Ali1, A Carr1, H Goodier4, C Morgan3, C Park5, K Sugand5, T Walton6, M Wilson4, A Belgaumkar7, K Gallagher4, K Ghosh2, C Gibbons3, A Keightley8, Z Nawaz9, C Wakeling2, K Sarraf5, B Rogers6, W Kieffer1

1Surrey & Sussex Healthcare NHS Trust, Trauma and Orthopaedics, Redhill, United Kingdom, 2Western Sussex Hospitals NHS Foundation Trust, Chichester, United Kingdom, 3Chelsea and Westminster Hospital NHS Foundation Trust, London, United Kingdom, 4Poole General Hospital NHS Foundation Trust, Poole, United Kingdom, 5Imperial College Healthcare NHS Trust, London, United Kingdom, 6Brighton and Sussex University Hospitals NHS Trust, Brighton, United Kingdom, 7Surrey & Sussex Healthcare NHS Trust, Redhill, United Kingdom, 8Royal Surrey Hospital NHS Foundation Trust, Guildford, United Kingdom, 9Frimley Health Foundation Trust, Frimley, United Kingdom

Background: 30-day mortality of patients with hip fracture is well researched and predictive, validated scoring tools have been developed (Nottingham Hip Fracture Score, NHFS). COVID-19 has significantly greater mortality in the elderly and comorbid patients which includes hip fracture patients. Non-operative treatment is not appropriate due to significantly higher mortality and therefore these patients are often exposed to COVID19 in the peri-operative period. What is unclear is the effect of concomitant COVID-19 infection in these patients.

Methods: A multicentre prospective study across 10 sites in the United Kingdom (responsible for 7% of hip fracture patients per annum in the UK). Demographic and background information were collected by independent chart review. Data on surgical factors included American Society of Anesthesiologists (ASA) score, time to theatre, Nottingham Hip fracture score (NHFS) and classification of fracture were also collected between 1st March 2020 and 30th April 2020 with a matched cohort from the same period in 2019

Findings: Actual and expected 30-day mortality was found to be significantly different between 2020 COVID-19 positive (RR 3.00 95% CI 1.57-5.75, p<0.001), 3x higher for COVID19 positive patients with 30 deaths recorded within 30-days compared against the 10 expected from NHFS risk stratification.

Interpretation: COVID-19 infection appears to be an independent risk factor for increased mortality in hip fracture patients. Whilst non-operative management of these fractures is not suggested due to the documented increased risks and mortality, this study provides evidence to the emerging literature of the severity of COVID-19 infection in surgical patients and the potential impact of COVID-19 on elective surgical patients in the perioperative period.

There is NO Conflict of Interest: Yes

721 - Impact of COVID-19 on clinical outcomes for patients with fractured hip: a multicentre observational cohort study (NOF-COV19 Study)

D. Rasidovic1, I. Ahmed2, C. Thomas1, P. Kimani3, P. Wall2, K. Mangat1, ^. NOF-COV19 Study Collaborative4

1South Warwickshire NHS Foundation Trust, Trauma and Orthopaedics, Warwick, United Kingdom, 2University Hospitals Coventry and Warwickshire, Trauma and Orthopaedics, Coventry, United Kingdom, 3University of Warwick, Warwick Medical School, Coventry, United Kingdom, 4Mulitcentre Observational Study, Trauma and Orthopaedics, England, United Kingdom

Background: There are reports of a markedly increased perioperative mortality in patients admitted to hospital with a fractured hip during the COVID-19 pandemic in USA, Spain and Italy. Our study aims to describe the risk of mortality among patients with a fractured neck of femur in England during the early stages of the COVID-19 pandemic.

Methods: We completed a multicentre cohort study across 10 hospitals in England. Data were collected from 1st of March till 6th of April 2020, in which the World Health Organisation declared COVID-19 to be a pandemic. Patients ≥60 years of age admitted with hip fracture and a minimum follow up of 30 days were included for analysis. Primary outcome of interest was mortality at 30 days post-surgery or post admission in non-operative patients. Secondary outcomes included length of hospital stay and discharge destination.

Results: In total, 404 patients were included for final analysis with a COVID-19 diagnosis being made in 114 (28.2%) patients. Overall, 30 day mortality stood at 14.4%. COVID-19 cohort experienced a mortality rate of 32.5% (37/114) compared to 7.2% (21/290) in the non-COVID cohort, p = <0.001. In adjusted analysis, 30 day mortality was greatest in patients who were confirmed to have COVID-19 (OR 5.64, CI 2.95-10.80, p = <0.001) with an adjusted excess risk of 20%, male sex (OR 2.69, CI 1.37-5.29, p = 0.004) and in patients with ≥2 co-morbidities (OR 4.68, CI 1.5 – 14.61, p = 0.008). Length of stay was also extended in the COVID-19 cohort, on average spending 17.6 days as an inpatient vs. 12.04 days in the non-COVID-19 group, p = <0.001.

Conclusion: This study demonstrates that patients who sustain a neck of femur fracture in combination with COVID-19 diagnosis have a significantly higher risk of mortality than would be normally expected.

There is NO Conflict of Interest: Yes

728 - A Comparative Review of 1004 Orthopaedic Trauma Patients: Before and During the COVID-19 Pandemic

K. Dayananda1, S.T. Mercer1, R. Agarwal1, T. Yasin1, R.W. Trickett1

1Cardiff & Vale University Health Board (University Hospital Wales & University Hospital Llandough), Trauma and Orthopaedic Surgery, Cardiff, United Kingdom

Aims: COVID-19 necessitated abrupt changes in trauma service delivery. We compare the demographic and outcomes of patients treated during lockdown, to a matched period from 2019. Findings have important implications for service development. 

Methods & Materials: A split-site service was introduced, with a COVID-19 free site treating the majority of trauma. Polytrauma, spinal and paediatric trauma, plus COVID-19 confirmed or suspicious cases were managed at another site. Prospective data on all trauma patients undergoing surgery at either site, between 16/03/2020 and 31/05/2020 was collated and compared with retrospective review of the same period in 2019. Patient, injury and surgical details, length of stay (LOS), COVID-19 status, and outcome were compared.

Results: There were 1004 urgent orthopaedic trauma patients (604 in 2019; 400 in 2020). Significant reductions in time to theatre and LOS stay were observed. COVID-19 positive status was confirmed in 4.5%. COVID-19 mortality was 1.8%. Day-case surgery comprised 47.5%, with none testing positive for or developing clinically significant COVID-19 symptoms requiring readmission, at a minimum of 17 days. 

Conclusion: The novel split-site service, segregating suspected or confirmed COVID-19 cases, minimised onward transmission and demonstrated improved outcomes regarding time to surgery and LOS, despite altered working patterns and additional constraints. Day-surgery pathways appear safe regarding COVID-19 transmission. Lessons learnt require dissemination and should be sustained in preparation for a potential second wave or the return of a “normal” non-COVID workload. 
Clinical Relevance:

  • Segregation of COVID-19 suspicious or confirmed cases from the remainder of the trauma workload minimises opportunity for transmission. 
  • Well-structured day surgery pathways appear safe regarding COVID-19 transmission, with important ramifications for the reintroduction of planned surgical care.
  • A consultant delivered service (at the expense of planned surgical care) is effective at minimising the burden on hospital infrastructure.

There is NO Conflict of Interest: Yes

790 - Impact of COVID-19 on UK orthopaedic training during the 2020 pandemic season: a prospective cohort analysis

D. Bodansky1, L. Thornton2, N. Sargazi1, M. Philpott1, R. Davies3, J. Banks4

1Merseyside Deanery, Liverpool, United Kingdom, 2Macclesfield Hospital, Cheshire, United Kingdom, 3Central Manchester University Hospitals NHS Foundation Trust, Manchester, United Kingdom, 4Liverpool Foundation Trust, Liverpool, United Kingdom

Background: Drastic restructure of the NHS was undertaken in response to the pandemic with alterations to service delivery introduced from March 2020, which has impacted surgical training programmes. Here we quantify the impact of the COVID-19 pandemic on postgraduate Orthopaedic training.

Methods: A prospective study was undertaken between 16th March-3rd May 2020   to capture alterations to training activity in response to the COVID-19 pandemic. Data was collected regionally by all Trauma and Orthopaedic specialist registrars on the Health Education North West, West Sector (HENW West Sector/ Mersey) training programme using a live online electronic proforma.

Results: A total of 1,018 entries were analysed, from 10 hospitals, with a median of 21 (IQR 17.5-26) entries per trainee. Altogether, 382 elective and 169 trauma lists were cancelled during the study period in addition to 155 elective and 132 fracture clinics. Seven trainees self-isolated during this period, losing 39 sessions. All nine candidates due to sit the Fellowship of the Royal Colleges of Surgeons (FRCS) were cancelled. Trainees were redeployed to other specialties in 231 (22.7%) of entries, with altered duties undertaken within intensive care (24.4%), accident and emergency (25.1%) and general medicine (50.3%). Trainees had no assigned alternative duties in 192 (18.9%) of sessions and provided 90 extra fracture clinics and 70 extra trauma lists during this period. Teaching and admin were logged for the remaining 8 entries.

Conclusion: The Covid-19 pandemic has resulted in a 43% reduction in overall training opportunities which must be addressed in order for trainees to achieve their CCT competencies.

There is NO Conflict of Interest: Yes

940 - Is it safe yet? Patient readiness and perceptions about returning to hospital for planned orthopaedic care.

S. Mercer1, A. Kinghorn1, T. Yasin1, A. John1, R. Trickett1

1Cardiff and Vale University Health Board, Trauma & Orthopaedics, Cardiff, United Kingdom

Objectives: To investigate patient perceptions concerning attendance for planned orthopaedic surgery during the COVID-19 pandemic.

Design: Cross-sectional study.

Setting: Secondary and tertiary orthopaedic care.

Participants: 250 adult patients from the top of the elective orthopaedic waiting list at Cardiff and Vale University Health Board.

Interventions: Patients were telephoned between 25th May and 3rd June 2020 whilst lockdown remained in force in Wales. They were taken through a COVID-19 screening tool based upon British Orthopaedic Association guidance and stratified into one of four risk categories for their outcome following potential COVID-19 infection. Having shared this information a discussion was held to determine patients’ willingness to proceed with surgery. Reasoning was explored with those who chose to decline or defer.

Primary and Secondary Outcome Measures: Primary: Patients’ willingness to proceed with surgery. Secondary: Patient risk stratification.

Results: In total, 196 patients met the inclusion criteria and responded. Mean age of respondents was 57.4, varying significantly between subspecialties. There were 129 patients willing to attend for surgery, leaving over a third of those contacted wishing to cancel or defer. The most frequent reason given for not wishing to attend was fear of contracting COVID-19. There was a statistically significant difference in the willingness to proceed observed with increasing clinical risk (χ2(3) = 50.073, p=.000) with almost double the expected count of patients unwilling to proceed in the high and very high risk groups.

Conclusions: This study illustrates the variable and personal decisions patients are making regarding orthopaedic care due to COVID-19. It highlights the need for radical change to departmental processes regarding patient prioritisation upon the recommencement of planned surgical lists. However, it also reconfirms the vital importance of regular communication and shared decision making between a well-informed patient and a holistic orthopaedic team.

There is NO Conflict of Interest: Yes

1174- IMPACT-Restart: the influence of COVID-19 on postoperative mortality and risk factors associated with SARS-CoV-2 infection after orthopaedic and trauma surgery

A. Hall1, N. Clement1, N. Makaram2, P. Robinson2, R. Patton3, A. Duckworth1, M. Moran2, G. Macpherson4, P. Jenkins5

1University of Edinburgh, SORT-IT / Dept of Orthopaedics & Trauma, Edinburgh, United Kingdom, 2University of Edinburgh, Dept of Orthopaedics & Trauma, Edinburgh, United Kingdom, 3NHS Lothian, Edinburgh, United Kingdom, 4NHS Lothian, Department of Orthopaedics and Trauma, Edinburgh, United Kingdom, 5Glasgow Royal Infirmary, SORT-IT / Dept of Orthopaedics & Trauma, Glasgow, United Kingdom

The primary aim of this study was to assess the independent association of COVID-19 on postoperative mortality for patients undergoing orthopaedic and trauma surgery. The secondary aim was to identify factors that were associated with developing COVID-19 during the postoperative period.

A multicentre retrospective study was conducted of all patients presenting to nine centres over a 50-day period during the COVID-19 pandemic (1st March to 19th April 2020) with a minimum of 50-days follow up. Patient demographics, ASA grade, priority (urgent or elective), procedure type, COVID-19 status and postoperative mortality were recorded.

During the study period 1659 procedures were performed in 1569 patients. There were 68 patients that were diagnosed with COVID-19. There were 85 deaths postoperatively. Patients that had COVID-19 had a significantly lower survival rate when compared to those without a proven SARS-CoV-2 infection (67.6% versus 95.8%, p<0.001). When adjusting for confounding variables a diagnosis of COVID-19 was associated with an increased mortality risk (hazard ratio 1.89, 95% confidence intervals (CI) 1.14 to 3.12, p=0.014). Sixty-two patients had COVID-19 postoperatively of which two were in the elective and 60 were in the urgent group. Regression analysis demonstrated an age >77 years (odds ratio (OR) 3.16, p=0.001), increasing ASA grade (OR 2.74, p<0.001), hip (OR 4.56, p=0.008) and periprosthetic (OR 14.70, p<0.001) fractures were associated with developing postoperative COVID-19.

Patients at risk of developing postoperative COVID-19 (patients >77years, increasing morbidity, sustaining a hip or periprosthetic fractures) may benefit from shielding to prevent them from infection that resulted in nearly twice the postoperative mortality rate, which is recognised to be higher in this frail group of patients.

There is NO Conflict of Interest: Yes

1238 - Efficacy of Surgical Helmet Systems for Protection Against COVID-19: A Double-Blinded Randomised Control Study

G. Schaller1, S.K. Nayar1, M. Erotocritou1, A. Overton1, T. Stelzhammer1, O. Berber1

1Whittington Health NHS Trust, Trauma and Orthopaedics, London, United Kingdom

Background: Surgical helmet systems are used in elective orthopaedic surgery to reduce the risk of infectious agent transfer from surgeon to patient. There has been debate as to whether they provide additional protection to the surgeon from respiratory droplet borne pathogens. The aim of this study was to assess whether these helmet systems delivered additional benefit or pose potential risks to the surgeon.

Methods: A double-blinded randomised controlled study was undertaken investigating the efficacy of the Stryker Flyte Surgical Helmet as protection against respiratory droplets. The helmet systems were tested using a validated qualitative test, whereby the participant is exposed to a nebulised saccharin solution protocol whilst wearing the apparatus. A positive taste test indicates failure of the equipment. 35 tests were undertaken in accordance with a power analysis and following randomisation, 20 were allocated to the saccharin group with 15 to placebo. Taste tests were performed with the helmet fan turned on and off. Chi squared and Student’s t-test analysis of results were undertaken.

Results: Surgical helmets did not protect against the tasting of saccharin with a significant statistical difference between the saccharin and placebo cohort (p<0.0001). Within the saccharin cohort, 40% had a positive taste test with the fan on and 100% with the fan off.
There was a statistically different mean time to taste saccharin (p=0.049) when comparing the surgical helmets with their fan on (123.5 seconds, r=34-200 seconds) and off (62.6 seconds, r=20-160 seconds).

Conclusion: Current surgical helmet systems do not protect against aerosol borne particulate and therefore COVID-19. Such systems may increase risk to the surgeon by drawing in particulate and delay the recognition of intraoperative cues that point to respirator mask leak.

There is NO Conflict of Interest: Yes

1299 - Waiting for treatment with major joint arthritis in the era of COVID-19 can be ‘worse than death’. Elective arthroplasty waiting lists in COVID-19

J. Morris1, T. Ashdown1, D. Huntley1, S. McKeon1, W. Harland1, J. Super1, R. Anakwe1

1Imperial College Healthcare Trust, Trauma and Orthopaedic Department, London, United Kingdom

Aims: We undertook a study to evaluate the health status and quality of life for patients referred to our outpatient orthopaedic service with symptomatic major joint arthritis and for consideration of surgery whose appointments had been cancelled or deferred as a result of the response to the COVID-19 pandemic.
Patients & Methods: We identified 210 eligible adult patients referred to our elective orthopaedic service between 18 March 2020 and 13 May 2020.  These patients had scheduled first appointments with the orthopaedic service at the height of the pandemic and these appointments had been cancelled or deferred. Patients were invited to complete a telephone interview to assess their health status and quality of life using the EQ-5D-5L questionnaire.
Results: 111 (52.3%) patients agreed to participate in this study. Of these, 79 (71.2%) patients reported that their health status had deteriorated since they were referred to the service and had been awaiting assessment. There was a statistically significant correlation between the EQ-Visual Analogue Score (p = 0.007) and mean EQ-5D index score (0.420 (±0.285 SD) P = 0.000) in those patients who self-reported deterioration in health status since they were first referred for outpatient assessment.
Discussion: Our study showed that patients who are awaiting their assessment and treatment for symptomatic joint arthritis report measurable impairment of their health status, quality of life and deteriorate whilst they wait. A particular subset of patients evaluate their status as ‘worse-than-death’. Waiting lists are not benign and in establishing the recovery programme following the COVID-19 pandemic it is important that the impact of delayed treatment for this particular group of patients is not underestimated.

There is NO Conflict of Interest: No

1371 - The Impact of COVID 19 on the Management and Outcomes of Patients with Proximal Femoral Fractures: a Multi-centre Study of 580 Patients.

V. Giannoudis1, A. Jimenez1, C. De2, A. Wignall3, S. Sturdee1, P. Giannoudis3, H. Pandit4, A. Gulat2, J. Palan5

1Huddersfield Royal Infirmary, Trauma & Orthopaedics, Huddersfield, United Kingdom, 2Sandwell and West Birmingham Hospitals NHS Trust, Trauma & Orthopaedics, Birmingham, United Kingdom, 3Leeds General Infirmary, Trauma & Orthopaedics, Leeds, United Kingdom, 4LIRMM University of Leeds, Trauma & Orthopaedics, Leeds, United Kingdom, 5Leeds Teaching Hospital NHS Trust, Trauma & Orthopaedic Surgery, Leeds, United Kingdom

Background: In March 2020, the World Health Organisation declared the COVID-19 outbreak a pandemic. Multiple new guidelines were proposed and existing models of social, domestic and hospital care altered. This study aimed to assessing the impact of COVID-19 on the demographics, presentation and clinical management of patients with proximal femoral (hip) fractures.
Methods: This retrospective multicentre cohort study compared all patients admitted with hip fractures, between 1st March and 30th May in 2019 (Group PC: Pre-COVID) with hip fracture patients admitted over the same time period during the pandemic in 2020 (Group C: COVID). The data was obtained from hospitals’ local and National Hip Fracture Databases. Primary outcomes were time to theatre, in-patient length of stay and 30-day mortality.
Results: In total there were 580 patients identified in the PC (n=304) and C group (n=276).
There were no significant differences in the numbers of DHS (75 [PC] vs 71 [C], p=0.770) and hemiarthroplasties (110 [PC] vs 110 [C], p=0.363) performed. There was a significant reduction in percentage of THRs (11% to 5%, p=0.006) and an increase in those managed conservatively (1% to 5%) in group C (p=0.002). The time to theatre (hours) was significantly longer in Group C (43.7) Vs Group PC (34.6) (p=0.0009). Length of hospital stay was similar in both groups (16.6 [PC] Vs 15 [C], p=0.0891). 30-day mortality rate for both cohorts was 8% (p=0.828). For COVID positive patients, it was significantly higher 35.3% Vs 5.4% (COVID negative) (p<0.0001) in Group C.
Conclusions/ Findings: This is the largest literature series, examining the impact of the COVID-19 pandemic on hip fracture patients. The COVID-19 pandemic and subsequent hospital restructuring has had major effects on time to theatre and poses very high 30-day mortality rates for COVID positive hip fracture patients. 

There is NO Conflict of Interest: Yes

1938 - Urgent Bone and Soft tissue sarcoma surgery during the COVID19 pandemic; the experience from seven UK centres; a BOOS study

T.D. Cosker1, R.B. Rajasekaran1, D. Whitwell1, C.L. Gibbons1, R. Ashford1

1Nuffield Orthopaedic Centre, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Oxford, United Kingdom

Purpose: Deferring cancer surgeries can have devastating complications including patient mortality. During the unprecedented COVID-19 pandemic, departmental re-organisation and adherence to guidelines enabled expeditious surgical care for patients with primary and malignant bone and soft tissue tumour (BST) patients. We analyzed the outcomes of surgeries on BST during the first two months of the pandemic across seven sarcoma centers in UK.

Materials & methods: Between March 12th 2020 and May 20th 2020, 283 patients of a median age of 59 years (18-87) underwent surgery across seven sarcoma centres in the UK for primary and metastatic bone tumours and urgent soft tissue sarcomas. The decision to operate was made in conjunction with guidelines issued by the NHS, British Sarcoma Group (BSG) and the British Orthopaedic Oncology Society (BOOS) and on patients who were deemed to benefit most from surgery.

Results: At a minimum follow-up of 30 days post-surgery, 274 patients (96.8%) were recovering well post-surgery. Fifty-six patients (19.7%) had post-operative complications which included 9 patients (3.1%) developing pulmonary embolism. The majority of complications (48/56 = 85.7%) occurred in ASA III and ASA IV category patients. Seven patients (2.4%) contracted COVID-19 and out of those, 5 patients required escalation of care due to pulmonary complications and 4 patients (1.4%) died. Patients less than 60 years of age had lesser complications than those above 60 years (p<0.001).

Conclusion: Our results show that favorable outcomes are possible following BST surgeries even during the COVID-19 pandemic. Surgery in patients less than 60 years and in ASA I&ASA II category are associated with better and safer outcomes. Intentional postponement of surgery in patients with co-morbidities and above 60 years must be considered if we encounter a further peak of the disease in future or a similar unprecedented challenge. All primary bone and soft tissue units across the UK have risen to the challenge of making complex decisions during periods of exceptional strain and have developed safe and robust systems to triage these patients.

There is NO Conflict of Interest: Yes

Accepted Abstracts - Part 1

372 - The financial burden of COVID-19 on trauma theatre efficiency at a major trauma centre

T Packer1, A Davies1, T Ashdown1, S Sabharwal1, P Reilly1

1Imperial NHS Trust, T&O Dept, London, United Kingdom

Introduction: The COVID-19 Pandemic has caused major disruption to the delivery of care across the National Health Service (NHS). Surgical pathways have been adapted to ensure the safety of staff and patients. The aim of this study is to access the financial implications of inefficiencies caused by changes to trauma operating at a major trauma centre.

Design: Time Driven Activity Based Costing analysis.

Setting: Single major trauma centre

Method: Inefficiency costs are defined as staffing costs and overheads for the time in operating theatres where there is no patient contact (NPC). Patient contact is inclusive of anaesthetic and operative time. Data was collected for a trauma theatre for a six week period pre- and post- the onset of COVID-19. Staffing cost were extract from national pay scales.

Results: The average number of cases per day were 2.6 pre-COVID and 1.9 post-COVID. Pre COVID the average NPC time was 1hrs 41minutes per day. Post-COVID the NPC time increased to 5hrs 13minutes. The extra cost of additional NPC time including estimated overhead costs, was a mean of £1,269.36. With two trauma theatres during weekdays, and a single theatre at weekends, we usually have a total of 625 theatre days a year. Total additional cost of inefficiency and staffing for 3 extra hours, would be estimated at £1,438,311.88 a year.

Discussion: We found theatre inefficiency increased considerably and demonstrated a sizeable financial annual burden which is likely to impact on hospital economies across the UK. We recommend an uplift to tariffs during the COVID-19 pandemic period to help support costly but safe surgical practices.

There is NO Conflict of Interest: Yes

397 - The effects of Covid-19 on perioperative morbidity and mortality in patients with hip fractures: A multi-centre cohort study

B Kayani1, E Onochie2, F Begum3, V Patil4, R Cuthbert5, D Ferguson6, J Bhamra7, A Sharma8, P Bates9, F Haddad3

1University College London Hospital and Royal London Hospital, London, United Kingdom, 2Newham General Hospital and Whipps Cross Hospital, London, United Kingdom, 3University College London Hospital, London, United Kingdom, 4Basildon University Hospital, Basildon, United Kingdom, 5Queens Hospital, Romford, United Kingdom, 6King George Hospital, Illford, United Kingdom, 7Wexham Park Hospital, Slough, United Kingdom, 8Hillingdon Hospital, Uxbridge, United Kingdom, 9Royal London Hospital, London, United Kingdom

Background: The objectives of this study were to establish the effects of Covid-19 on perioperative morbidity and mortality, and determine any risk factors for increased mortality in patients with Covid-19 undergoing hip fracture surgery.

Methods: This multicentre cohort study included 340 coronavirus negative patients versus 82 coronavirus positive patients undergoing surgical treatment for hip fractures across nine NHS hospitals within Greater London, United Kingdom. Predefined study outcomes relating to patient demographics, fracture configuration, operative treatment, perioperative complications and mortality were recorded by observers using a standardised data collection proforma. Univariate and multivariate analysis were used to identify risk factors associated with increased risk of mortality.

Results: Coronavirus positive patients had increased risk of postoperative complications (89.0% vs 35.0%, p<0.001), higher rates of admission to high dependency and intensive care units (61.0% vs 18.2%, p<0.001), and increased length of hospital stay (13.8 ± 4.6 days vs 6.7 ± 2.5 days, p<0.001) compared to coronavirus negative patients. Postoperative complications in coronavirus positive patients included respiratory infections (13.4%), thromboembolic disease (13.4%), acute kidney injury (12.2%), and multi-organ dysfunction (12.2%). Coronavirus positive patients had increased risk of postoperative mortality (30.5% vs 10.3%, p<0.001) compared to coronavirus negative patients, with positive smoking status (Hazard ratio: 15.4 (95% CI: 4.55-52.2, p<0.001) and more than three comorbidities (Hazard ratio: 13.5 (95% CI: 2.82-66.0, p<0.001) associated with increased risk of mortality.

Conclusion: Surgery in coronavirus positive patients was associated with increased length of hospital stay, more admissions to the critical care unit, higher risk of perioperative complications and increased mortality compared to coronavirus negative patients. Multivariate analysis revealed that smoking and multiple (>3) comorbidities were associated with increased risk of postoperative mortality.

Implications: Neck of femur surgery in patients with Covid-19 is associated with increased morbidity and mortality. Smoking and >3 comorbidities are risk factors for increased mortality in these patients.

There is NO Conflict of Interest: No

549 - Managing Patients with Fragility Fractures of the Femur During the COVID-19 Pandemic: The Experiences of Two London Hospitals

C. Porte1, F. Wong1, C. Smith1, V. Dorrell1, J. Simms1, T. White1

1Lewisham and Greenwich NHS Trust, London, United Kingdom

The COVID-19 global pandemic has disrupted healthcare services worldwide. People who suffer from a fragility fracture of the femur are usually in the high-risk age bracket for COVID-19 related death.

The aim of our study was to assess the impact of the COVID-19 pandemic on patients presenting with fragility fractures of the femur. The primary outcome measure was 30-day mortality. Secondary outcome measures included the National Hip Fracture Database (NHFD) 6 Key Performance Indicators (KPIs).

Retrospective analysis of prospectively collected data was performed for all 96 patients presenting to the Lewisham and Greenwich NHS Trust with a fragility fracture of the femur between 01/02/20 and 30/04/20. Patients were classified as COVID-C (confirmed), COVID-S (suspected) or COVID-N (negative) for subgroup analysis. All patients were followed up for a minimum of 30 days or until death. Outcomes were compared to data extracted from the NHFD for the same time period in 2018 and 2019.Twelve patients had positive swab results (COVID-C), 44 patients had strong clinical or radiological evidence of COVID-19 without positive swab results (COVID-S) and 40 patients had no evidence of COVID-19 infection (COVID-N). The 30-day mortality rate was 12.5% and overall morality during the study was 16.7%. The COVID-C group had an overall mortality rate of 50%, significantly higher than the other groups. COVID-N patients had a significantly shorter length of stay in hospital (mean 10.6 days vs 13.9 days). Logistic regression analysis found COVID-19 positive swab and admission haemoglobin <12g/dL contributed significantly to mortality with an odds ratio of 5.88 and 4.38 respectively (p = 0.016).

All of our KPIs were maintained at levels comparable to previous years, if not improved, therefore the increase in mortality is attributed to COVID-19. An accelerated care pathway may reduce mortality rates in this vulnerable patient group should subsequent outbreaks of COVID-19 occur.

There is NO Conflict of Interest: Yes

571 - The impact of the Coronavirus Disease (COVID-19) crisis on surgical training: A global survey and a proposed framework for recovery

M. Yiasemidou1, J. Tomlinson2, C. Lewis3, I. Chetter1, S. Biyani3

1Hull Royal Infirmary, Hull, United Kingdom, 2Sheffield Teaching Hospitals, Sheffield, United Kingdom, 3Leeds Teaching Hospitals, Leeds, United Kingdom

Introduction: SARS-Cov-2 has had a profound worldwide impact over the last six months, with the World Health Organisation declaring a pandemic on March 11th 2020.  Radical changes were made to the running of surgical services worldwide, to reduce the risk of peri-operative illness in patients undergoing non-urgent surgery. This also allowed redeployment of staff to work in other areas of hospitals. These changes have had a profound impact on surgical services, and thus training opportunities.

Methods: A cross-sectional, web-based survey was conducted. This was designed by the steering committee and validated prior to dissemination.

Results: 608 responses were obtained by thirty-four countries and fifteen specialties. The results demonstrated great disruption in all aspects of training. The impact was higher for conferences (525/608), hands-on courses (e.g. simulation) (517/608), less for in-patient care (268/608) related training. Training in Australia and Asia was affected less than in Europe (P-value<0.001)
Alternative resources (webinars: 359/608, educational videos: 234/608), have developed rapidly, interestingly trainees express some dissatisfaction with them for a variety of reasons, with accessibility and hardware issues the most common problems.
A five-pillar framework for training recovery is proposed: (1) Prioritise trainee and public safety (2) Guidance from training stakeholders – involvement of trainees (3) Prioritise training – the role of senior surgeons/trainers (4) Providing access to alternative/new teaching methods and (5) Addressing trainee anxiety.

Conclusion: Training has been disrupted to a great degree. Introduction of new teaching methods and focus on training after the pandemic are imperative for trainees to make up for lost time.

Implications: COVID-19 has significantly disrupted training, and may continue to do so for a significant period of time. Urgent discussion is needed to minimise the impact on training and trainee wellbeing.

There is NO Conflict of Interest: Yes

609 - COVID-19: The effects of a UK national lockdown on the workload in a regional hand trauma unit

J. Murray1, M. Hampton2, M. Clark2, I. Baxter2, R. Stevens1, E. Flatt1, K. Wembridge2, M. Birks1

1Sheffield Teaching Hospitals, Sheffield, United Kingdom, 2Rotherham NHS Foundation Trust, Rotherham, United Kingdom

Introduction: On the 23rd of March 2020 the UK government issued requirements for a national lockdown to slow the spread of COVID-19 and reduce hospital admissions. The aim of this study was to determine the impact lockdown had on hand trauma attendances at a regional hand trauma unit.
Patients and Methods: A retrospective analysis was performed at a regional hand trauma unit. Data was collected from the first 2 weeks of lockdown in the UK (23/03/20–07/04/20), and compared with the corresponding 2-week period in 2019. The total number of referrals to a hand specialist, the mechanism of injury and the types of injury were recorded.
Results: There was a 61.5% (50 lockdown Vs 130 2019) reduction in attendances to the hand unit. We observed a significant change in the mechanisms of injury involved in sustaining hand injuries. There was a substantial increase in the proportion of DIY/garden related injuries (26% lockdown Vs 8.5% 2019) and animal bites (14% lockdown Vs 5% 2019) during lockdown. This change in mechanism of injury also led to a change in the injury types treated. We saw a significant increase in nerve injuries requiring nerve repair (12% lockdown Vs 2.3% 2019) and hand infections requiring surgical drainage and/or admission for intravenous antibiotics (24% lockdown Vs 6.2% 2019) during lockdown. Crush injuries and sports related injuries reduced, as did fractures of the hand. There was no difference in injuries caused by assaults/punches, falls, or accidental lacerations sustained at home
Conclusions: The national lockdown dramatically reduced the incidence of hand injury attendances. The incidence of DIY injuries and animal bites increased, leading to comparatively more significant nerve injuries and infections requiring treatment.

There is NO Conflict of Interest: Yes

717 - Increased proportion of alcohol related trauma in a South London major trauma centre during lockdown, a cohort study

O.S. Brown1, P. Tsinaslanidis1, C.B. Hing1

1St George's University Hospitals NHS Foundation Trust, Trauma and Orthopaedics, London, United Kingdom

Background: Alcohol has been implicated in 10-35% trauma admissions and up to 40% trauma-related deaths globally. Alcohol intoxication is linked to an increased risk of trauma, with violent crime associated with consumption. In response to the Covid-19 pandemic, the United Kingdom (UK) entered a state of ‘lockdown’ on 23rd March 2020 with citizens largely expected to remain at home. Personal isolation, pub and restaurant closures, cancellation of sports, and financial stress are all expected to influence the pattern of alcohol-related trauma during lockdown, although this has not yet been quantified.

Methods: All patients over 16 years admitted as ‘trauma calls’ during April 2018 and April 2019 (pre-lockdown), and April-May 2020 (during lockdown) had electronic patient records (EPR) analysed. Patients’ blood alcohol level (BAC) combined with records of intoxication were used to identify alcohol-related trauma. Unpaired Student’s t tests and Pearson chi squared tests were performed using IBM SPSS v25.

Results: Alcohol-related trauma was present in a significantly higher proportion of adult trauma calls during lockdown (lockdown 60/191 (31.41%), versus pre-lockdown 62/316 (19.62%) X2=9.061, p=0.003). Lockdown was also associated with increased daytime and weekday admissions of alcohol related trauma (lockdown 30/60 (50.00%) versus pre-lockdown 17/62 (27.42%) X2=6.565 p=0.010); lockdown 36/60 (60.00%) vs 26/62 (41.94%) X2=3.981 p=0.046). Head or neck injuries were more common among alcohol-related trauma during lockdown (22/60 (36.67%) vs 14/62 (22.58%) X2=133.099, p<0.001). No significant difference existed between the age, gender, mechanism, or length of stay between pre-lockdown and lockdown cohorts.

Conclusion: UK lockdown was associated with an increased proportion of alcohol-related trauma at a London MTC. The weekly pattern of trauma was altered, but the demographics and associated mechanisms were not.

Implications: With the possibility of a global ‘second wave’ of Covid-19, a further lockdown may result in increased alcohol-related trauma.

There is NO Conflict of Interest: Yes

819 - Machine Learning continuous fall risk classification in an elderly population from inertial measurements during activities of daily living

K. Hewage1,2, S. Fosker1,2, S. Lee3, O. Armitage3

1East Sussex Healthcare Trust, Hastings, United Kingdom, 2CUSH Health, Hastings, United Kingdom, 3BIOS Health, Cambridge, United Kingdom

Introduction: The COVID-19 global pandemic has highlighted the need for solutions to protect our most vulnerable members of society. Falls are one of the most common causes of injury in people over the age of 65, with one in ten falls resulting in a serious injury which can have life-threatening or life-altering consequences. However, fall risk assessment methods typically require specific equipment or a specially trained clinician’s time, thus limiting their feasibility and frequency. Therefore, there is a need for monitoring systems that can use motion from daily activities to bridge the gap between the clinic and everyday life, continuously assessing fall risk without clinician intervention.

Methods & Results: A pilot study to train and test a remote monitoring system. Wearable inertial measurement unit (IMU) data, and online real-time Machine Learning, to an elderly patient population for automatic, continuous and high-accuracy fall risk estimation. Participants then carried out a series of stereotypical activities of daily living such as walking, sitting down and getting out of bed. The fall risk classifier is a gradient boosting classifier that was trained on selected segments of the IMU data (e.g. walking or transitional segments). The most accurate model used walking data from the hip-mounted sensor to achieve an accuracy of 87.5% with 88.9% sensitivity and 88.9% specificity, which is comparable to the most accurate classifiers in the literature.

Conclusion: This work validates the potential of an inertial measurement-based system that uses meaningful segments from freely moving data to classify elderly fall risk. Fall risk is a holistic metric which encompasses comorbidities, adverse events and living conditions; the aim of this system is to extract relevant gait information, and in the future combine it with other information about an individual to accurately assess their fall risk.

There is NO Conflict of Interest: Yes

842 - COVID 19 and Trauma and Orthopaedic telephone clinics – how this pandemic has changed the world of clinics. A single centre experience

M. Raad1, S. Ndlovu1, D. Neen1

1Darent Valley Hospital, Trauma & Orthopaedics, Dartford, United Kingdom

Background: Our department runs a number of elective and fracture clinics with about 70 – 100 new referrals and follow-up patients on a daily basis. Overbooked clinics, staff and resource constraints are ongoing challenges. During the COVID 19 pandemic our aim was to minimise exposure, to protect staff and patients. Therefore, on a daily basis clinic lists were analysed and only patients requiring a physical appointment were brought in, all other patients had a telephone clinic.

Method: In this study we retrospectively compared two groups of patients: those seen in traditional clinics pre-COVID 19 and those who had telephone clinics during the COVID-19 pandemic. We had a cohort of 60 patients in each group with various Orthopaedic complaints; both groups had elective and trauma patients. We compared four clinical parameters; the ability to reach a definitive clinical diagnosis and treatment plan, the necessity of a clinical examination, and outcomes from the consultation.

Results: Clinicians were able to make a definitive diagnosis in 93% of patient during telephone clinics compared to 83% in face to face clinics. 92% of patients from telephone clinics did not require examination to reach a diagnosis, 97% of patients from telephone clinics had a definitive plan compared to 92% in traditional clinics. However traditional clinics had a superior discharge rate at 56% compared to 30% for telephone clinics.

Conclusion: Face to face clinics have always been the gold standard in the management of both trauma and elective patients in Trauma and Orthopaedics. COVID-19 presented us with a chance to show that telephone clinics are equally effective, and may be superior to traditional clinics in a specific set of patients. Further studies should be performed to confirm our findings and investigate cost-effectiveness. We should prepare to adapt to using telephone clinics on a regular basis in the future.

There is NO Conflict of Interest: No

867 - “Sedate, Straight, No Wait” - Mini C-Arm; Lessons Learnt from the COVID-19 Pandemic

T. Cash1, N. Sargazi1, C. Barton1, N. Boyce-Cam1

1Mid Cheshire Hospitals NHS Foundation Trust, Trauma and Orthopaedics, Crewe, United Kingdom

Background: The COVID-19 pandemic has altered the management of acute orthopaedic injuries with focus on avoiding unnecessary admissions. At the start of the pandemic, the trust’s mini c-arm was relocated to fracture clinic where manipulations were performed at the point of presentation. We aim to highlight the clinical and financial impact of this intervention.

Methods: Data was collected prospectively regarding the number of manipulations undertaken in fracture clinic between 03/04/20 to 01/05/20 and compared to the same period in 2019. All clinicians completed IR(ME)R training. A standard operating procedure was written to guide administration of analgesia for both paediatric and adult cases. Essential bedside monitoring, resuscitation equipment and senior ED doctor support (airway trained) were made available to ensure patient safety.

Results: The mini c-arm was used on 34 patients, mean age 46 years (range 2-92). The majority were upper limb injuries (88.2%). Manipulations using the mini c-arm were performed in 70.1% with 15 patients (44.1%) avoiding admission for theatre. Only 1 patient (2.9%) required repeat manipulation and k-wiring in theatre for a displaced paediatric supracondylar fracture. No adverse events were recorded. Compared to 2019, the total number of patients requiring manipulation in theatre decreased by 66.7% with an 88.9% reduction in upper limb manipulations. NHS references costs from 2018-19 were used to calculate a potential cost saving of £8445 over the 28-day period.

Conclusion: Utilisation of a mini c-arm in the fracture clinic setting reduces the need for manipulations in theatre and avoids unnecessary hospital admission for patients. This reduces the burden on trauma lists, decreases time to definitive treatment and minimises nosocomial COVID-19 transmission. This model is both a safe and cost-effective method of providing definitive orthopaedic care, which can be used by other trusts for service planning during the ongoing pandemic and beyond.

There is NO Conflict of Interest: Yes

899 - The experience of patients with traumatic injuries and urgent orthopaedic conditions during the coronavirus pandemic treated via a ‘one stop shop’ T+O-led minor injuries unit

S. Howles1, T. Mahmood1, S. Lala1, A. Pearse1, C. Docker1

1Worcestershire Acute Hospitals NHS Trust, Worcester, United Kingdom

Background: In line with the British Orthopaedic Association guidance on the management of patients with traumatic injuries and urgent orthopaedic conditions during the coronavirus pandemic, the orthopaedic team at Worcester Royal Hospital set up a ‘one-stop-shop’ minor injuries clinic (MIU) for the management of minor injuries.   This seven-day service provided a direct pathway to trauma clinic for patients who would usually be managed in the ‘minor injuries’ stream within the emergency department.  

Aims: The aim of this project was to evaluate the service we provided, and to audit local outpatient management of trauma and orthopaedic patients during the Covid 19 pandemic against the guidance set out by the BOA in the Covid-specific ‘BOAST’: 'Management of patients with traumatic injuries and urgent orthopaedic conditions during the coronavirus pandemic.'

Methodology: Data was collected retrospectively from several sources including a database kept by clinic staff, dictated clinic letters and scanned patient notes. Data collected included patient age and gender, time of arrival and departure, grade of the reviewing clinician, diagnosis, management and the outcome of clinic attendance, including timing of follow up. The data collection period was over 6 weeks from 20/04/2020 to 01/06/2020.

Results: 700 patients were seen in MIU over the 6 week data collection period. 98% of patients were seen by middle grade or consultant and 85% were seen and treated within an hour. 71% of patients were discharged from their first appointment, and only 9 patients (1%) required a fracture clinic appointment within 72 hours. A total of 15 patients (2%) reattended, with just four of these requiring additional intervention.

Conclusions: We delivered a seven-day minor injuries service in which the majority of patients received consultant-led definitive management at first appointment, in keeping with BOA guidance. The lessons learned through this experience will inform future quality improvement activity.

There is NO Conflict of Interest: Yes

923 - The effect of COVID-19 lockdown on orthopaedic trauma: a multicentre study across Scotland

D. MacDonald1, D. Neilly1, P. Davies2, C. Crome3, A. Lee4, G. Scicluna3, T. Ha5, C. Donoghue6, J. Bashyam1, T. Greensmith2, A. Faulkner2, A. Macinnes2, R. Pennington2, M. Kennedy3, L. Guiot3, B. Wheelwright3, T. Noteman5, C. Harte5, M. Torkington5, B. Jamal3, S. Gill3, A. Jariwala2, D. Boddie1, I. Stevenson1, G. Ashcroft4,4

1Aberdeen Royal Infirmary, Aberdeen, United Kingdom, 2Ninewells Hospital, Dundee, United Kingdom, 3Queen Elizabeth University Hospital, Glasgow, United Kingdom, 4University of Aberdeen, Aberdeen, United Kingdom, 5Glasgow Royal Infirmary, Glasgow, United Kingdom, 6Raigmore Hospital, Inverness, United Kingdom

Background: The UK government declared national lockdown on 23rd March 2020 to reduce transmission of COVID-19. The aim of this study was to identify the effect of lockdown on the rates, types, mechanisms and mortality of musculoskeletal trauma across Scotland.

Methods: Data for all musculoskeletal trauma requiring operative treatment was collected prospectively from five key orthopaedic units across Scotland during lockdown (23/03/2020-28/05/2020). This was compared with data for the same timeframe in 2018 and 2019. Data collected included all cases requiring surgery, injury type, mechanism of injury, and inpatient mortality.

Results: 1315 patients received operative treatment from 23/03/2020 – 28/05/2020 compared to 1791 in 2019 and 1719 in 2018. The numbers of all injury types decreased, but the relative frequency of hip fractures increased (36·3% (2020) vs 30·2% (2019), p<0·0001 & 30·7% (2018), p<0·0001). Significant increases were seen in proportion of DIY-related injuries (3·1% (2020) vs 1·7% (2019) ,p=0·01 & 1·6% (2018) ,p<0·01) and injuries caused by falls (65·6% (2020) vs 62·6% (2019), p=0·08 & 61·9% (2018), p=0·05). Significant decreases were seen in proportion of RTCs (2·6% (2020) vs 5·4% (2019), p<0·0001 & 4·2% (2018), p=0·02), occupational injuries, (1·8% (2020) vs 3·0% (2019), p=0·03 & 2·3% (2018), p=0·01) and infections (6·8% (2020) vs 7·8% (2019), p=0·27 & 10·3% (2018), p<0·01). Cycling injuries increased (78 2020 vs 64 2019 vs 42 2018). A significant increase in proportion of self-harm injuries was seen (1·7% (2020) vs 1·1% (2019), p=0·19 & 0·5% (2018), p<0·0001). Mortality of trauma patients was significantly higher in 2020 (4·9%), than in 2019 (3·2%,p=0·02) and 2018 (2·6%,p<0·0001).

Conclusion: The UK COVID-19 lockdown has resulted in a marked reduction of musculoskeletal trauma requiring surgery in Scotland. There have been major changes in types and mechanisms of injury, and concerningly mortality of trauma patients has risen significantly.

There is NO Conflict of Interest: Yes

965 - UK COST Study: The impact of COVID-19 on surgical training. A survey of 100 UK surgeons

H. Rajgor1, M. Almajee1, A. Rajgor2, F. Hossain3, T. Moores3

1Royal Orthopaedic Hospital, Birmingham, United Kingdom, 2Newcastle University, Newcastle, United Kingdom, 3Walsall Manor Hospital, Walsall, United Kingdom

Background: The coronavirus pandemic has had a significant impact on the UK medical workforce. The aim of the survey was to assess the impact of COVID-19 on surgical training in the UK from trainee surgeons’ perspectives.
Method: A cross-sectional descriptive survey was designed with 27 questions and sent to a representative sample distributed nationally via trainee collaboratives, surgical training programme directors and trainee societies. Significance was set at p<0.05.
Results: 100 responses were received including 64 from orthopaedic trainees. 77 respondents were male and 23 were female. The mean score of COVID-19 having an impact on surgical training was 8.94/10. No difference was demonstrated between senior and junior trainees. Trainees were concerned about achieving indicative elective and trauma numbers with a mean score of 7.94/10. Trainees were not happy to be re-deployed (p<0.01). Trainees were also concerned about achieving appropriate number of work based assessments with no difference between junior and senior trainees (p=0.10). No difference was shown between trainees regarding the impact of COVID-19 on mental health (p=0.97). Simulation and cadaveric training were alternate forms of training assessments recommended by trainees who were unable to achieve due to COVID-19 (p<0.05). 94% of trainees have performed less than 20 cases per month during the coronavirus pandemic.
Conclusion: COVID-19 has changed the training landscape for junior surgeons. Trainees are concerned about progression and achieving indicative numbers for elective and trauma cases. Simulation and cadaveric training could provide an alternative method for surgical training.

There is NO Conflict of Interest: Yes

1027 - Providing a paediatric trauma and orthopaedics service during the peak of the COVID-19 pandemic. The Royal National Orthopaedic Hospital experience

A.D. Iliadis1, D.M. Eastwood1, L. Bayliss2, M. Cooper3, A. Gibson4, R. Hargunani5, P. Calder1

1Royal National Orthopaedic Hospital, Paediatric and Limb Reconstruction Unit, Stanmore, United Kingdom, 2Royal National Orthopaedic Hospital, Sarcoma Unit, Stanmore, United Kingdom, 3Royal National Orthopaedic Hospital, Anaesthetics Unit, Stanmore, United Kingdom, 4Royal National Orthopaedic Hospital, Spinal Unit, Stanmore, United Kingdom, 5Royal National Orthopaedic Hospital, Radiology Unit, Stanmore, United Kingdom

Background: In response to the COVID-19 pandemic, there was a rapidly implemented restructuring of UK healthcare services. The Royal National Orthopaedic Hospital became a central hub for the provision of Trauma Services for North Central/East London (NCEL) while providing a musculoskeletal tumour Service for South of England, Midlands and Wales and an urgent Spinal service for London. We review our practice over this period in order to share our experience and lessons learned. Our admission pathways are described and the safety of surgical and interventional radiological procedures performed under general anaesthesia (GA) with regards to COVID-19 in a paediatric population are evaluated.

Methods: All paediatric patients (≤16yo) treated in our institution during the six week peak period of the pandemic were included. Prospective data for all paediatric trauma and urgent elective admissions and retrospective data for sarcoma admissions were collected. Telephone interviews were conducted with patients and families to assess Covid-19 related morbidity at 14-days post discharge.

Results: 100 children underwent surgery or interventional radiological procedures under GA between 20 March and 8 May 2020. There were 35 trauma cases, 20 urgent elective orthopaedic cases, 2 spinal emergency cases, 25 admissions for Interventional Radiology procedures under GA and 18 tumour cases. 78% of trauma cases were performed within 24 hours of referral. In the 97% who responded at two weeks following discharge , there were no cases of symptomatic COVID -19 in any patient or member of their households.

Conclusion: Despite the extensive restructuring of services and widespread concerns over the surgical and anaesthetic management of paediatric patients during this period, we treated 100 asymptomatic patients across different orthopaedic subspecialties without apparent COVID-19 or unexpected respiratory complications in the early post-operative period.

Implications: The data provides assurance for health care professionals and families and informs the consenting process.

There is NO Conflict of Interest: No

Disclosure: D. Eastwood; royalties from Oxford University Press. P. Calder: payment for development of educational presentations from Smith & Nephew, travel and accomodation expenses from S&N and Nuvasive. A. Gibson; expert testimony legal firms, grants AO Spine, payment for lectures from DePuy Synthes, All are unrelated to this article.

1101 - Utilising a day surgery unit to undertake same day discharge uni-compartmental knee replacements (UKR) - Is this the answer to re-starting elective knee arthroplasty in the post Covid-19 era?

M. Hampton1, A. Legg1, A. Anderson1

1Rotherham District Genreal Hospital, Trauma and Orthopaedics, Rotherham, United Kingdom

Introduction: The COVID-19 pandemic has led to all inpatient arthroplasty surgery being postponed for the foreseeable future. Same day discharge arthroplasty surgery will be essential to reduce growing waiting lists. We improved our same day discharge rate from 56% to 100% by utilising a day surgery unit, rather than planning same day discharge through an inpatient ward.
Materials and Methods: Prospective data was collected on all patients eligible for day surgery UKR. An initial ‘Phase 1’ pathway was developed with guidelines for patients, surgeons, anaesthetist and physiotherapists. Phase 1 was lead through the elective orthopaedic inpatient ward. 
‘Phase 2’ was developed with adjustments to the guidelines, specifically postoperative analgesics, anaesthetic techniques and a bladder management protocol. The principal difference between phases was that all patients were admitted and discharged through the day surgery unit. 
Results: All patients eligible for day surgery UKR were included. 
Phase 1 ran from September 2017. 29 out of 40 UKRs met the inclusion criteria. 56% (15/29) of patients were successfully discharged on the same day of surgery from the inpatient ward. Reasons for failed discharge included pain, nausea and vomiting, dizziness, wound problems and urinary retention. 
Phase 2 was implemented from April 2019. 21 out of 26 UKRs met the inclusion criteria. 100% (21/21) of patients were successfully discharged the same day, after being admitted and discharged through the day surgery unit. There were no re-admission following discharge. No patients were admitted to the inpatient ward for any period of time. 
Conclusion: Discharge on the day of surgery following UKR can be reliably and safely achieved by using a day surgery unit rather than an inpatient ward. This has allowed us to begin offering patients arthroplasty surgery during the COVID-19 pandemic.

There is NO Conflict of Interest: Yes

1155 - IMPACT-Scot Report on COVID-19 and Hip Fracture: A multicentre study assessing mortality, predictors of SARS-CoV-2 infection and the effects of social lockdown on epidemiology

A. Hall1, N. Clement1, L. Farrow2, I.-S. Study Group1, A. MacLullich3, G. Dall4, C. Scott5, P. Jenkins6, T. White1, A. Duckworth1

1University of Edinburgh, SORT-IT / Dept of Orthopaedics & Trauma, Edinburgh, United Kingdom, 2University of Aberdeen, Aberdeen, United Kingdom, 3University of Edinburgh, Geriatric Medicine, Usher Institute, Edinburgh, United Kingdom, 4Borders General Hospital, Dept of Orthopaedics & Trauma, Melrose, United Kingdom, 5University of Edinburgh, Dept of Orthopaedics & Trauma, Edinburgh, United Kingdom, 6Glasgow Royal Infirmary, SORT-IT / Dept of Orthopaedics & Trauma, Glasgow, United Kingdom

The primary aim was to assess the independent influence of COVID-19 on 30-day mortality for hip fracture patients. The secondary aims were to determine whether (1) there were clinical predictors of COVID-19 status and (2) whether social lockdown influenced the incidence and epidemiology of hip fracture.

A national multicentre retrospective study was conducted of all patients presenting to six trauma centres or units with a hip fracture over a 46-day period (23 days pre- and post-lockdown). Patient demographics, residence, place of injury, presentation blood tests, Nottingham Hip Fracture Score, time to surgery, operation, ASA grade, anaesthetic, length of stay, COVID-19 status and 30-day mortality were recorded.

Of 317 patients with acute hip fracture, 27 (8.5%) had a positive COVID-19 test. Only 7 (26%) had suggestive symptoms on admission. COVID-19 positive patients had significantly lower 30-day survival compared to those without COVID-19 (67% versus 92%, p<0.001). COVID-19 was independently associated with increased 30-day mortality risk adjusting for: (1) age, sex, residence (hazard ratio (HR) 2.93, p=0.008); (2) Nottingham Hip Fracture Score (HR 3.52, p=0.001), and (3) ASA (HR 3.45, p=0.004). Presentation platelet count predicted subsequent COVID-19 status; a value of <217 x109/L was 68% specific and sensitive (95% CI 58 to 77, p=0.002). A similar number of patients presented with hip fracture in the 23 days pre-lockdown (n=160) and 23 days post-lockdown (n=157); there was no significant (all p>0.15) difference in patient demographics, place of injury, Nottingham Hip Fracture Score, time to surgery, ASA, or management.

COVID-19 was independently associated with an increased 30-day mortality rate for patients with hip fracture. Notably, most patients with hip fracture and COVID-19 lacked suggestive symptoms at presentation. Platelet count was an indicator of risk of COVID-19 infection. These findings have implications for the management of hip fracture, in particular the need for COVID-19 testing.

There is NO Conflict of Interest: Yes

1164 - Effect of COVID-19 on best practice care of hip fracture patients: An analysis from National Hip Fracture Database (NHFD)

B. Tyas1, J. Lukic1, M. Wilkinson2, K. Singisetti1

1Queen Elizabeth Hospital, Gateshead Health NHS Foundation Trust, Trauma & Orthopaedics, Gateshead, United Kingdom, 2Queen Elizabeth Hospital, Gateshead Health NHS Foundation Trust, Orthogeriatric Medicine, Gateshead, United Kingdom

Background: The aim of our study was to look at the impact of COVID-19 on the best practice care of hip fracture management. This was done through the publicly available national data from NHFD.

Methods: NHFD dashboard data and charts for England, Wales and Northern Ireland were analysed for the months of March to June 2020 (lockdown period related to COVID-19) to look for national trends in change in care.

Results: Best practice dropped from 61.4% in February 2020 to 58.2% in March, 45.4% in April and 43.2% in May 2020.
Prompt surgery (within 36 hours of presentation) dropped from 72.1% in February 2020 to 70.8% in March, 69.9% in April and 66.1% in May 2020.
Orthogeriatric review dropped from 91.8% in February 2020 to 90.2% in March, 78.8% in April and 78.0% in May 2020.
Non-operative treatment of hip fractures changed from an average of 2.3% in February 2020 to 3.1% in March, 3.3% April and 2.6% in May 2020.
The proportion of total hip replacements changed from 29.4% in February 2020 to 24.2% in March, 18.3% in April and 23.3% in May 2020.

Conclusion: The majority of hip fracture patients continued to be treated with an operation. There was a significant drop in best practice nationally for hip fracture management with the lowest recorded in April and May 2020. Whilst there was a small drop in the proportion of patients getting prompt surgery during the crisis, the predominant detrimental effect to best practice appears to be the lack of timely Orthogeriatric assessment of patients during the COVID-19 pandemic.

Implications: It is important to continue a high standard of multidisciplinary care for this vulnerable group of patients by avoiding redeployment of the Orthogeriatric team during any future spikes of COVID-19.

There is NO Conflict of Interest: Yes

1178 - Restarting elective orthopaedic services during the COVID-19 pandemic: Do patients want to have surgery?

W. Wignadasan1, J. Chang2, B. Kayani1, C. Kontoghiorghe1, R. Plastow2, A. Magan2, S. Singh2, F.S. Haddad1

1University College London Hospital, Trauma and Orthopaedics, London, United Kingdom, 2University College London Hospital, London, United Kingdom

Introduction: As the peak of the COVID-19 pandemic passes, the challenge shifts to safe resumption of routine medical services including elective orthopaedic surgery. Protocols including preoperative self-isolation, COVID-19 testing, and surgery at a non-COVID site have been developed to minimise risk of transmission. Despite this, it is likely that many patients will want to delay surgery for fear of contracting COVID-19. The aim of this study is to identify the number of patients who still want to proceed with planned elective orthopaedic surgery in this current environment.
Patients and methods: This is a prospective, single surgeon study of 102 patients who were on the waiting list for an elective hip or knee orthopaedic operation during the COVID-19 pandemic. Baseline characteristics including age, ASA grade, COVID-19 risk, procedure type, surgical priority, and admission type were recorded. The primary outcome was patient consent to continue with planned surgical care after resumption of elective orthopaedic services. Subgroup analysis was also performed to determine if any specific patient factors influenced the decision to proceed with surgery. 
Results: Overall, 58 patients (56.8%) wanted to continue with planned surgical care at the earliest possibility. Patients classified as ASA I and ASA II were more likely to agree to surgery (60.5% and 60.0%, respectively) compared to ASA III and ASA IV patients (44.4% and 0.0%, respectively) (p=0.01). In addition, patients undergoing soft tissue knee surgery were more likely to consent to surgery (90.0%) compared to patients undergoing primary hip arthroplasty (68.6%), primary knee arthroplasty (48.7%), revision hip or knee arthroplasty (0.0%), or hip and knee injections (43.8%) (p=0.03). 
Conclusion: Restarting elective orthopaedic services during the COVID-19 pandemic remains a significant challenge. Given the uncertain environment, it is unsurprising that only 56% of patients were prepared to continue with their planned surgical care upon resumption of elective services.

There is NO Conflict of Interest: Yes

1305 - COVID-19: The T&O Impact in a Rural District General Hospital

D. M Navaratnam1, S. Lanckmans1, R. Rambani1

1Pilgrim Hospital, Boston, United Kingdom

Background: The COVID-19 global pandemic has led to the restructuring of surgical services nationwide, in order to combat the strain the virus was predicted to place on the NHS. This study provides an insight into our experience of the orthopaedic department at a rural district general hospital during the pandemic, the changes that occurred in order to provide surgical care in the COVID-19 era.

Method: This is a case control study. All patients with neck of femur fracture admitted to the hospital at the start of the UK lockdown were included in the study. Data collection period was from 25/03/20- 17/05/20.This was retrospectively compared with 2019 data during the same time period to minimise risk of bias. Data was obtained through admission notes and national hip fracture database.

Results: A total of 50 patients pre-COVID-19 pandemic and during COVID-19 pandemic were assessed. Median age group was 82.5 and 83 respectively. There were more female admissions in both groups, 37 patients (74%) pre-COVID and 34 patients (68%) during COVID-19. Post-operative respiratory complications were similar in both groups, 3 patients(6%) vs 4 patients(8%) respectively. One patient contracted COVID-19 during their stay which only required ward based treatment. There was no inpatient mortality recorded during the COVID-19 pandemic. A positive outcome noted was length of hospital stay was shorter in the COVID-19 setting (12 days versus 8 days, respectively) and this finding was statistically significant (p<0.001).

Conclusion: Our outcomes for COVID-19 related complications were better than those reported in the literature and this could be due to the low prevalence of COVID-19 in our region. As there is regional variation in the prevalence of COVID-19 across the United Kingdom, we suggest that surgical departments could make local decisions and follow a multi-disciplinary team approach rather than following a national ‘one-size fits all’ guidelines.

There is NO Conflict of Interest: Yes

1521 - FFP3 masks usage by frontline Healthcare Professionals during COVID-19 pandemic: A snapshot survey

R.M. Raghavendra1, V. Vardarajan2, K. Mohanty3

1University Hospital of Wales, Trauma and orthopaedics, Cardiff, United Kingdom, 2Princess of Wales Hospital, Department of Anaesthetics, Bridgend, United Kingdom, 3University Hospital of Wales, Trauma and Orthopaedics, Cardiff, United Kingdom

Purpose: Usage of protective masks such as FFP3 (Filtering Face Piece mask class 3) during the COVID-19 pandemic resulted in some healthcare professionals reporting symptoms such as skin damage and facial bruising. This snapshot survey was aimed at evaluating the extent and severity of such adverse physical effects experienced by users of FFP3 disposable masks.

Methodology: Healthcare staff working at secondary and tertiary care hospitals from two neighbouring health boards were invited to answer an online questionnaire between 25-04-2020 and 17-05-2020. Data on duration of mask usage, tolerance time, extent of pain or discomfort, general and facial symptoms experienced were collected.

Results: A total of 209 responses were collected of which 47.4% (n = 99) reported moderate-to-severe pain or discomfort after wearing FFP3 masks. Pressure marks over the face and nose (83.7%, n = 175), and 'thirst' (66.1%, n = 138) were the most common facial and general symptoms experienced respectively. The average duration of FFP3 mask usage was 2 hours or more in 83% (n = 175) but only 66.5% (n = 139) could tolerate it for 60 minutes or less. There was a statistically significant association between duration of usage and severity fo pain or discomfort experienced (Kruskal-Wallis test, p= 0.0007). Certain groups of professionals such as Doctors and Nurses working in Intensive care and theatre settings were more likely to experience severe symptoms than others (Kruskal-Wallis test, p = 0.008)

Conclusion: Adverse physical symptoms were experienced by a high proportion of health care professionals following the usage of disposable FFP3 masks. The severity worsens with increased duration of use. Certain groups of professionals were more prone to adverse symptoms.

Implications: For the safety and well-being of healthcare staff caring for patients with COVID-19, safer alternatives such as full-face-masks or powered-respirators may need to be considered.

There is NO Conflict of Interest: Yes

1529 - The timing of a COVID-19 diagnosis and its impact on 30-day mortality in neck of femur (NOF) fracture patients

J. Hadfield1, G. Dietz-Collin1, S. Wales1, A. Gray1

1James Cook University Hospital, Trauma and Orthopaedics, Middlesbrough, United Kingdom

Background: 2020 has seen the spread of novel coronavirus (COVID-19), leading to large numbers of deaths globally. Locally, the number of orthopaedic admissions through the pandemic has decreased, but the incidence of NOF fractures has remained the same. Our aim was to compare the NOF patients who tested positive for COVID-19 pre-operatively with patients who were diagnosed post-operatively and examine how the timing of diagnosis impacted their 30-day mortality.

Methods: NOF fracture patients were identified at James Cook University Hospital using the National Hip Fracture Database (NHFD) between 01/03/20 and 31/05/20 inclusively. All patients with a NOF fracture were included and their 30-day mortality was recorded. Patients were logged as COVID-19 positive if they swabbed positive during in the 30 days from admission. Those who were COVID-19 suspects, but had a negative sample were recorded as negative.

Results: 117 NOF patients were included. 27 patients had a positive COVID-19 sample. 15 patients were recorded as COVID-19 positive pre-operatively and 12 post-operatively. 30-day mortality for patients with a NOF fracture and a positive COVID-19 sample was 29.6% compared to 6.7% in those who did not. 30-day mortality in COVID-19 positive pre-operative patients was 40%, compared to 16.7% in those found to be COVID-19 positive post-operatively.

Conclusions/findings: During the study period a large proportion of patients presenting to hospital with a NOF fracture and a negative COVID-19 sample became COVID-19 positive following surgery (10.3%). The impact on mortality when testing positive post-operatively does not appear to be as dramatic as those diagnosed with COVID-19 pre-operatively. However, this group of patients still continue to have a worse 30-day mortality than those who remained COVID-19 negative (16.7% v 6.7%).

There is NO Conflict of Interest: Yes

1543 - The Impact of COVID-19 Pandemic on proximal femoral fracture fixation and its effect on Theatre time - An unexpected long-term threat to surgical training?

Z. Ansar1, E. Barlow1, M.P. Larsen1, M. Cronin1, M. Dodd1

1Morriston Hospital, Trauma and Orthopaedics, Swansea, United Kingdom

Background: The novel coronavirus was declared a global pandemic on 11th March 2020 and continues to test healthcare systems worldwide. Following the emergence of COVID-19 there were modifications to theatre operating practice at Swansea Bay University Health Board to increase efficiency, reduce viral exposure and manage reduced theatre staffing. Measures included the introduction of full personal protective equipment and consultant led operating. 

Methods: Two patient cohorts that underwent hip hemiarthroplasty and Dynamic Hip Screw fixation between April and June 2019 and 2020 – during and pre-COVID-19 - were retrospectively analysed to evaluate surgical and total theatre times.

Results: The pre-COVID-19 cohort (n=83) had a mean operating time of 77.43 minutes. The COVID-19 cohort (n=97) had a mean operating time of 63.47 minutes. Both data sets were normally distributed. A T-test was performed, and a significant difference was observed between the two cohorts for both surgical and total theatre time, with p-values of <0.00001 and 0.004823 respectively.

Conclusion: Changes to operating practice due to COVID-19 have resulted in a significant decrease in operating time driven by consultant led operating. Hip fracture surgery has traditionally been the domain of the registrar, an arena where they can develop their skills, improve surgical technique and receive consultant training and feedback. Implemented changes have led to a reduction in junior surgical exposure at a detriment to training. With continuing pressures in a post-COVID, resource poor environment, such changes have not gone unnoticed by allied specialities and hospital management. Following the pandemic there is a risk of continuing this self-perpetuating cycle, driving for these efficiency savings under the guise that this is in the patient’s best interest, especially while resources remain restrictive. It is important not to lose sight of the long-term implications of these lost training opportunities and the impact on surgeons of the future.

There is NO Conflict of Interest: Yes

1639 - Short term outcomes of femoral fragility fractures during the COVID-19 pandemic managed at a tertiary elective orthopaedic centre. The blueprint for future periprosthetic fracture management

S. Khan1, A. Palmer1, S. Key1, C. Jayadev1, J. Donaldson1, A. Hart1, J. Miles1, R. Carrington1, J. Skinner1

1Royal National Orthopaedic Hospital, Joint Reconstruction, London, United Kingdom

Introduction: In response to the COVID-19 pandemic the Royal National Orthopaedic Hospital (RNOH), for the first time in its history, transformed itself into a regional trauma centre with a focus on fragility fractures. This study sought to identify the short term (30 day) outcomes of neck of femur and periprosthetic fractures in this at risk cohort.

Methods: All patients above 65 admitted to the RNOH during its time as a trauma centre sustaining a femoral fracture were included. COVID-19 status was assessed based on either a positive antigen test or a clinical picture consistent with indicative of COVID-19. Patient demographics, length of stay, mortality and discharge destination were recorded. Indices within the “best practice tariff” were prospectively noted to ensure compliance with national guidelines.

Results: 152 fragility femoral fractures were included. 63 cemented bipolar hemiarthroplasty, 56 DHS/IM nail, 17 THR’s, and 13 revision arthroplasty procedures were performed. One patient was unfit for surgery and died as an inpatient. 19 patients were COVID positive on admission (10 confirmed on test and 9 clinical diagnosis) and 5 become positive after surgery (2 confirmed on test and 5 clinical diagnosis). 30-day mortality rate was 9.5% (12 patients) when patients were not COVID positive at any time, and 32.0% (8 patients) for patients who were COVID positive during the perioperative period (p=0.006).

Conclusion: Patients sustaining fragility fractures of the femur who develop COVID-19 during the perioperative period have significantly increased 30 day mortality. This should be discussed with patients and their families when developing patient-specific care plans. From our experience a centralised fragility fracture service is capable of delivering high quality care, going forward this may function as a blueprint for “NOF centres”. Moreover, with the increasing burden of peri-prosthetic fractures this model represents a paradigm shift in the delivery of care.

There is NO Conflict of Interest: Yes

Accepted Abstracts - Part 2

1676 - Validating waiting list patients using Torbay Charts Patient Decision Aid post COVID

R. Ramesh1

1Torbay Hospital, Department of Trauma & Orthopaedics, Torquay, United Kingdom

Background: Getting it Right First Time’s (GIRFT) Good Clinical and Operational Practice Guidance Post-COVID Transformation & Recovery programme (July 2020), makes numerous recommendations for restarting elective joint replacement surgery. This includes Shared Decision Making (SDM) to reaffirm patient choice. However, it has not identified any specific tool enabling this at the shop-floor level.
Numerous studies show Patient Decision Aids (PDA) could be the key to unbiased decision making, enhance knowledge, and decrease regret. Efficient use of PDA in orthopaedics decreased the choice of surgery by a minimum of 11.5% (Sepucha et al, 2017). Current PDAs have many shortfalls e.g. offering inappropriate choices, which is recognised by NICE review of PDA Tools (June 2020).
TC is a novel PDA with a multi-layer, multi-formatted approach addressing many of the identified limitations. The infographic overview allows appropriate treatments to be selected based on the stage of the disease, providing a focal point for SDM conversations. The web-version allows user-driven side-by-side comparisons of pros and cons, with links to a comprehensive video library.

Methods: Pilot testing over 8 weeks with 121 patients was conducted (pre-COVID) to evaluate TC in SDM using a questionnaire.

Results: 92% strongly agreed TC helped their SDM process. 91% strongly agreed they understood various treatment options. Healthcare Practitioners felt the consultation was engaging and focused. 13.2% chose non-operative treatment, with 7.4% expecting surgery but opting for conservative methods.

Conclusion: This unique approach allows for efficient remote consultations. This will help in validating waiting lists, reconfirming patient choice, and may allow some to choose non-operative alternatives if appropriate.

Implications: If choice is to be offered following the Montgomery verdict reappraisal, then it should be all-encompassing with options for surgical and conservative lines being discussed. TC’s revolutionary approach enhances SDM and can be the tool to meet GIRFT’s guidance.

There is NO Conflict of Interest: Yes

1683 - COVID19 and Its Impact on Scottish Orthopaedic Trainee

J.W. Lim1, H. Rehman1, D. Cairns1

1Aberdeen Royal Infirmary, Trauma and Orthopaedic, Aberdeen, United Kingdom

Due to the outbreak of coronavirus disease 2019 (COVID-19), majority of elective orthopaedic services have ceased and some trainees have been redeployed. The Scottish Government’s approach to COVID-19 is different to England. The immediate future of elective orthopaedic training remains unclear. We conducted a trainee survey to investigate the impact of COVID-19 on the Scottish orthopaedic trainee. An online survey was distributed to all Scottish orthopaedic trainees. All data collection was anonymous.
Across all 4 Scottish regions, 44 trainees have responded: 36% from North, 25% from East, 23% from West and 16% from South East. Trainees at all stages of training responded to the survey, with the most responses received from specialist trainees in third year of training (ST3) (21%). In response to the pandemic, 20% of trainees have been redeployed, with majority of them from North Scotland. Since the reconfiguration of service, only 25% of trainees have done >20 operations in a month. Most units (36%) have 3 to 4 trauma admissions and majority of the units (73%) only managed to complete 2 to 3 trauma cases during 8am to 5pm working day. The majority of trainees received online teaching (95%) and find them useful (96%). Outcome 10 was deemed a reasonable ARCP option during the pandemic by 70% of trainees. Majority of trainees (91%) report no difficulty engaging with supervisors in completing relevant reports for ARCP. If COVID-19 outbreak is likely going to reduce operating opportunities for a long period, only 32% of trainees would be open to the idea of making standard surgical specialty training longer whereas 52% of trainees would be open to longer working hours to achieve certification in Trauma and Orthopaedic surgery within 96 months.
The outbreak of COVID-19 has clearly affected Scottish orthopaedic training. Attempts at teaching are still being made consistently across Scotland.

There is NO Conflict of Interest: Yes

1737 - Resuming elective services in the COVID-19 era: A unique insight into patient risk aversion

S. Madanipour1, O. Al-Obaedi1, A. Ayub1, F. Iranpour1, P. Subramanian1

1Royal Free London NHS Foundation Trust (Barnet Hospital), Department of Trauma and Orthopaedic Surgery, London, United Kingdom

Background: There has been a wealth of guidance from the government and orthopaedic community on how best to ensure the safety of our patients and colleagues as we recommence elective surgery in the UK.  

The primary objective was to determine what proportion of patients felt they should be prioritised with proceeding with elective hip and knee arthroplasty surgery, having been counselled on the contemporary evidence available regarding the additional risks posed by COVID-19. The secondary objective was to investigate what variables affected this decision. 

Method: Patient demographics and medical history from a single-surgeon's waiting list in a district general hospital were recorded. A standardised telephone discussion was had with all the patients noting the severity of pain and the reasons for not wanting to proceed with surgery at this time. 

Statistical analysis was performed to determine what factors impacted the decision-making process. 

Results: 70.6% (96/136) patients wished to proceed with surgery as soon as possible, with a mean age of 68.5 years compared with 72.4 years for patients who did not wish to proceed (p=0.03).  The decision to proceed with surgery was not correlated with gender, ASA or COVID-19 risk. Within the matched subgroups, patients under the age of 70 years were more willing to proceed with hip arthroplasty surgery (87.9%) compared to knee arthroplasty surgery (57.1%) (p=0.007). 75% of the patients who did not wish to proceed with surgery expressed concerns about peri-operative COVID-19 infection. 

Conclusion: There is a significant proportion of arthroplasty patients on waiting lists who would be willing to accept the increased risks associated with COVID-19 to undergo surgery on an urgent basis.  

The subgroup of younger hip arthroplasty patients are more willing than knee arthroplasty patients to proceed with surgery. This study provides a reflection of patient attitudes to risk aversity when considering arthroplasty surgery.  

There is NO Conflict of Interest: Yes

1739 - Rapid Transformation of Orthopaedic Management during COVID-19: A Closed Loop Audit of the British Orthopaedic Association (BOAST) Guidelines of Outpatient Orthopaedic Fracture Management

L. Kurar1, S. Dunkerley1, K. Butler1, M. James1, I. Lowdon1

1Great Western Hospital, Swindon, United Kingdom

Background: COVID-19 has had profound management implications for orthopaedic management due to balancing patient outcomes with clinical safety and limited resources. The BOAST guidelines on outpatient orthopaedic fracture management took a pragmatic approach. At Great Western Hospital, Swindon, a closed loop audit was performed looking at a selection of these guidelines, to assess if our initial changes were sufficient and what could be improved.
Methods: An audit was designed around fracture immobilisation, type of initial fracture clinic assessment, default virtual follow up clinic and late imaging. Interventions were implemented and re-audited.
Results: Initially 223 patients were identified over 4 weeks. Of these, 100% had removable casts and 99% did not have late imaging. 96% of patients were initially assessed virtually or had initial orthopaedic approval to be seen in face to face clinic. 97% had virtual follow up or had documented reasons why not. The 26 patients who were initially seen face to face were put through a simulated virtual fracture clinic. 22 appointments and 13 Xray attendances could have been avoided. We implemented a change of requiring all patients to be assessed at consultant level before having a face to face appointment. The re-audit showed over 99% achievement in all areas. 
Conclusion: Virtual fracture clinics, both triaging new patients and follow-up clinics have dramatically changed our outpatient management, helping the most appropriate patients to be seen face to face. Despite their limitations, they have been well tolerated by patients and improved patient safety and treatment.

There is NO Conflict of Interest: Yes

1747 - COVID-19 and the Irish National Spinal Injuries Unit: Impact on service provision and strategies to protect urgent care

F. Power1, A. Juhdi1, M. Macken1, K.A. Synnott1, J.S. Butler1

1Mater Misericordiae University Hospital, National Spinal Injuries Unit, Dublin, Ireland

Background: The COVID-19 pandemic has had a dramatic impact on the provision of healthcare worldwide. The delivery of a national spinal service for emergent surgery, elective surgery and outpatient assessment has been incredibly challenging. Both the volume and aetiology of spinal cases is markedly different to those seen in previous years.
Methods: Prospectively collected data regarding referrals to, and operative workload of, the Irish National Spinal Injuries Unit (NSIU) during the period of national lockdown in response to the COVID-19 pandemic was compared to the same period in 2019. Strategies employed to protect the capacity to deliver urgent spinal care are outlined.
Results: During the period of national lockdown there was a 47% decrease in the number of urgent referrals to the NSIU and a 61% reduction in the number of surgical cases performed. A particularly concerning finding was that for surgical cases there was a 400% increase in attempted suicide as the cause of injury with this cohort representing 11% of all surgical cases performed during the pandemic lockdown. The introduction of a national instant messaging application (Siilo) referral group resulted in a median time to first response by a National Spinal Injuries Unit (NSIU) surgeon of 15.5 minutes.
Conclusions: The COVID-19 pandemic has had a significant impact on the provision of a national spinal service, however innovative strategies have been adopted to protect the capacity to provide urgent care. The impact of the lockdown on mental health is reflected in the increased number of operative cases secondary to attempted suicide.

There is NO Conflict of Interest: Yes

1811 - The Outcomes of Orthopaedic Trauma During the COVID-19 Pandemic

A. Chowdhury1, R. Collins1, D. Marsland1

1Hampshire Hospitals Foundation Trust, Basingstoke, United Kingdom

Background: During the Coronavirus (COVID-19) outbreak of 2020, the provision of operative treatment for orthopaedic trauma has continued. Uncertainty exists, including the risk of contracting COVID-19 during an orthopaedic surgical admission and the risk of mortality. An initial study from Wuhan reported a mortality rate of 20.5% for patients with coronavirus undergoing elective surgery.
The aim of this study was to evaluate the outcomes of patients undergoing orthopaedic trauma surgery during the COVID-19 pandemic, including mortality and in-hospital virus contraction.

Methods: A database was populated prospectively, from the 1st May 2020, of all patients undergoing trauma surgery at Basingstoke and North Hampshire Hospital. Data collected included demographic information, COVID-19 swab results, mortality, and length of stay. Furthermore, a telephone COVID-19 symptom screening questionnaire was conducted at seven days following hospital discharge.

Results: Between the 1st of May and the 30th June 2020, 324 patients underwent orthopaedic trauma surgery. Eight (2.5%) had a positive COVID-19 swab on admission; 312 (96.3%) had a negative swab and four (1.2%) did not have a swab. Of the patients who tested positive on admission, two (25.0%) were symptomatic, of whom one died (12.5% mortality). There were 6 (1.9%) mortalities in total. Two patients (0.64%) converted from a negative admission swab to a positive subsequent swab, both of whom remained asymptomatic. There were 206 post-discharge telephone responses, of which all were negative.

Conclusion: There is a high risk of mortality for hip fracture patients with symptomatic COVID-19 undergoing trauma surgery. However, the local prevalence of COVID-19 is low and the risk of contraction during surgical admission for trauma surgery is low.

Implications: The findings from trauma surgery are reassuring and indicate that, with careful screening and pre-operative isolation, elective orthopaedic surgery may be safe to resume in areas of low COVID-19 prevalence.

There is NO Conflict of Interest: Yes

1845 - Safely Performing Urgent Revision Arthroplasty During Pandemic of COVID-19

A. Elsiofy1, S. Perkins1, A. Ringrose1, J. Stammers1, S. Alazzawi1, P. Mitchell1

1St Georges University Hospital, Trauma & Orthopaedics, London, United Kingdom

Background: The COVID-19 pandemic has severely affected health care systems. Non-life or limb threatening operations were put on hold. Parallel to that, many patients who were waiting urgent operations experienced an increased degree of symptoms and presented acutely to the emergency department. We present the outcome of performing urgent revision arthroplasty surgery during the COVID-19 pandemic in a major teaching hospital.  

Methods: Our hospital is a tertiary referral centre for arthroplasty, major trauma and has the largest intensive care capacity in the region. We continued to receive urgent arthroplasty emergencies either through our emergency department or transferred from regional hospitals. The hospital infrastructure adapted to have red, amber and green pathways with matched wards, theatres and ICU. Patients underwent risk stratification and screening of COVID-19 status. Between March and June 2020, we performed 13 urgent revision knee or hip arthroplasties. The medical notes were reviewed, and postoperative complications were recorded. All patients underwent discussion through a virtual arthroplasty MDT meeting. 

Results: 13 revisions were performed (6 male, 7 female). Average age was 69.6 years (36 – 86). All patients were ASA 3 or 4. The indication for surgery was infection (10) patients, periprosthetic fracture (1) and periprosthetic fracture of chronically infected joints (2). Five patients required endoprosthetic replacement. Three patients underwent debridement and implants retention (DAIR). 85% were managed perioperatively in the ICU. We have no mortality in short term and none of the patients were tested positive or become symptomatic from covid-19 infection. 

Discussion: The systems setup ensured complex revision arthroplasty patients were successfully managed despite the pandemic of COVID-19. If second wave of COVID occurs, the pathways can be rapidly initiated to minimise the impact on emergency arthroplasty cases. The role of arthroplasty MDT, pragmatic pathway and risk stratification of patients can ensure safe care for these patients. 

1856 - Drill Splatter in Orthopaedics Procedures and Its Importance During the COVID-19 Pandemic: An Experimental Study

R. Kabariti1, N. Green1, R. Turner1

1Princess Royal Hospital, Shrewsbury & Telford NHS Trust, Trauma & Orthopaedics, Telford, United Kingdom

Background: During the COVID-19 pandemic, drilling has been classified as an aerosol generating procedure. However, there is limited evidence in the literature to quantify the effects of bone drilling on splatter generation and its subsequent risk to the operating surgeons’ safety.

Objective: To quantify the effect of drilling on splatter generation within the orthopaedic operative setting.

Methods: This study was performed using a Stryker System 7 dual rotating drill at full speed. Fluorescein was used as a fluid medium to simulate drill splatter conditions, with similar viscosity to blood. A UV light was used to detect macroscopic droplets arising from the drill splatter. A surgical microscope with x10 magnification was used to detect microscopic droplets. The investigators drilled directly into a saw bone (0cm). Freehand use of the drill at 20cm, 50cm and 100cm above the saw bone was also undertaken to simulate the surgeon “testing the drill battery” (working arm’s length). The furthest droplets were then marked and the distance between the droplet displacement and the drill was measured in centimetres (cm). This was repeated using a drill guide/sleeve.

Results: Drilling directly into bone produced drill splatter with a 7cm droplet displacement away from the target. Operating the drill at 100cm height above the target produced the greatest splatter generation with a 95cm droplet displacement. Microscopic fluorescein droplet generation was not noticed at farther distances than what can be macroscopically seen. Using the drill guide, there was negligible drill splatter generation.

Conclusion: Our study has shown lower than anticipated drill splatter generation. The use of a drill guide/sleeve protects against splatter. We recommend using a drill guide at all times and avoiding free hand drilling to reduce the effect of viral transmission in the operative setting.

There is NO Conflict of Interest: Yes

Developing World Orthopaedics

Virtual Podium Presentations

161 - 10 year experience of outcomes in management of congenital pseudoarthrosis of the tibia

S. Dorman1, J. Shelton1, Y. Kim2, J. Gollogoly2

1Mersey Deanery, Liverpool, United Kingdom, 2Childrens Surgical Centre, Phnomn Penh, Cambodia

Objectives: Primary outcome was to identify the rate of successful limb salvage (bony union) vs. amputation for congenital pseudoarthrosis tibia in a low resource setting. Secondary outcomes were to identify common complications and changing trends in surgical management.

Methods: All children with a diagnosis of CPT where identified using the hard copy theatre logbook and the electronic CSC database. Electronic case notes, clinical photographs and radiographs were reviewed. Basic demographics, operation details and final outcomes were recorded including union, time to union or late amputation.

Results: A total of 19 children with CPT were identified. Children were referred from all regions within Cambodia and the average distance travelled for treatment was 128km (approx. 3 hours). The majority of cases were associated with neurofibromatosis. Average age at presentation was 10 years and most children had already had at least 1 operation elsewhere. Most children required multiple surgeries at CSC (mean 4, range 1-9). Overall union rate at most recent visit was 47% with 3/19 known to undergo a late amputation.

Conclusion: CPT is a difficult condition to treat and even with aggressive surgical intervention union rates are unpredictable and time to union can be lengthy. Undertaking multiple operations is costly to the hospital and may be difficult for patients due to long travelling distances, negative impact on family income, prolonged rehabilitation and negative impact on schooling and education. In our hospital we have recently moved to undertaking a single stage surgery of osteotomy, excision, periosteal and bone grafting and robust bony stabilization in an effort to reduce the “ annual surgery” phenomenon. If union is not achieved then consideration should be given to early amputation, which may provide earlier return to function.

There is NO Conflict of Interest: Yes

304 - Low cost arthroscopic simulation utilising video calling in a resource poor setting

M Stoddart1, L Rolt1

1Bedford Orthopaedic Hospital, Mthatha, South Africa

Background: There is high demand for arthroscopic procedures in the developing world. Simulation allows trainees to develop basic arthroscopic skills away from theatre, where there may be reduced surgical exposure compared to centres with established arthroscopic practice. Smartphones are widely available and accessible throughout the world. We propose a method to create a low cost, low fidelity arthroscopic simulator that can be used at home by utilising the video call function of smart phones.

Methods: We used readily available materials from a local market. Smartphones with video call function allow visualisation without the need to purchase additional equipment.

Results: The arthroscopic simulator can be built simply and is easily portable. Established training exercises can be practiced and allow development of basic arthroscopic skills.

Discussion: Our homemade simulator is inexpensive, simple to construct, and does not require additional hardware (or software) purchases by the trainee. It is a perfect solution for individuals to want to practice their arthroscopic skills, either at home or at the workplace.

There is NO Conflict of Interest: Yes

754 - Seven years of International Ward Rounds Video Link Complex Case Conference between Bristol and Phnom Penh

A. Bott1, D. Yeomans1, F. Monsell2

1North Bristol NHS Trust, Bristol, United Kingdom, 2Bristol Childrens Hospital, Bristol, United Kingdom

Background: Children’s Surgical Centre in Phnom Penh Cambodia is a charitable hospital providing complex reconstructive surgery for patients across the country since 1998. The hospital provides tertiary surgical care for complex neglected trauma and deformity correction in children and adults in a country with a nascent medical association and limited local support. It is the institution offering free hip and knee arthroplasty in country. 
Method: Since 2013 ‘International Ward Rounds’ has supported CSC’s nine Cambodian orthopaedic and plastic surgeons in pre-operative decision making and planning by conducting video-link case conferences via Google Hangout on a six-weekly basis. The video-link meetings are conducted for an hour between panels of UK experts from children’s orthopaedics, plastic surgery and limb reconstruction sub-specialists in Bristol and the surgical workforce at CSC. Cases from CSC and Bristol Children’s are exchanged via anonymised PowerPoint case studies, maintaining a two-way exchange of expertise.
Results: Through this sustained long-term collaboration, we found clinical benefits to patient care in resource limited healthcare setting. We previously reported that through the case discussions, CSC’s surgical plans were amended in 69% of cases. Highlighting the educational benefit in both directions, we reported that in 16% cases UK consultants were unable to advise as cases were beyond their area of expertise.
Conclusion: We have found using google hangouts to conduct video-link cases conferences to be a cheap and effective way of maintaining a close working relationship with our surgical colleagues in Phnom Penh. In developing this long-term, sustainable collaboration the video-link has not only helped support patient care, but enormous educational benefit to surgeons and trainees on both sides of the relationship.

There is NO Conflict of Interest: Yes


S.N. Kapadi1, A.H. Shanthappa2

1Wrightington Wigan and Leigh NHS FT, trauma and orthopaedics, Wigan, United Kingdom, 2Sri Devaraj Urs Medical College, Orthopaedics, Kolar, India

Background: Total hip arthroplasty has now become the primary treatment modality in treating displaced fracture neck of femur in the elderly patients who are active, relatively healthy and mentally lucid in the developed world. However, the demography and lifestyle of rural Indian population is significantly different and thus poses an unique challenge to an Indian orthopaedic surgeon. We thus attempted to study the treatment of elderly rural Indian patients with fracture neck femur by primary total hip arthroplasty.

Methods: 30 elderly rural Indian patients with a predominant agricultural background who presented to our teaching hospital in rural India were included in this study. While 12 patients underwent a cemented fixation, the rest had either an un-cemented (n=12) or a hybrid fixation (n=6). Patients had an average post operative follow up of 12 months with a functional outcome analysis using the Harris hip score.

Results: With an average follow up period of 12 months, 14 patients had an excellent outcome while 14 had a good functional outcome. The remaining 2 patients had a fair functional outcome as per the Harris hip score. The complications encountered were a case each of iatrogenic fracture and superficial surgical site infection. Two patients had a prosthetic hip dislocation. We did not find any significant correlation between the type of fixation and the functional outcome. With methodical rehabilitation and regular physio therapist follow up, 20 of these patients were able to get back to a milder form of their pre injury occupation.

Conclusion: We conclude that total hip arthroplasty is an ideal treatment option for elderly rural Indian patients with a displaced fracture neck of femur.Furthermore, pre operative patient education and preparation is extremely important in these patients to have favourable outcomes. Overall the functional results are good and there is good patient satisfaction.

There is NO Conflict of Interest: Yes

1071 - Orthopaedic training worldwide: a survey of 50 countries

N. Kader1, E. Hara2, S. Shah3, J. Fernandes3, P. Banaszkiewicz4,5, D. Kader1,5, F. Ali2

1South West London Elective Orthopaedic Centre, Epsom, United Kingdom, 2Chesterfield Royal Hospital NHS Foundation Trust, Chesterfield, United Kingdom, 3Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom, 4Gateshead Health NHS Foundation Trust, Gateshead, United Kingdom, 5Northumbria University, Newcastle Upon Tyne, United Kingdom

Background: Despite a long-recognised need to improve orthopaedic training worldwide there is insufficient literature exploring its current state. We aim to establish the status of training across several countries in order to better direct our efforts in improving education and training.
Methods: A survey was disseminated to orthopaedic trainees and seniors world-wide asking to report on their training experience. Responses were broken down by International Monetary Fund (IMF) classification into low-income developing countries (LIDCs), emerging and developing countries (EDCs) and advanced economies (AEs); statistical analysis was done using one-way ANOVA.
Results: 277 respondents from 50 different countries participated in the survey, 73.6% of responses were from 24 EDCs, 17.7% from 13 AEs and 8.7% from 13 LIDCs. Respondents estimated that 4.4% of LIDC trainees were female compared to 7% and 12% in EDCs and AEs respectively (P= 0.006). Estimated mean training length was longer in more developed countries (LIDC= 4.88yrs ±2.08, EDC= 5.89yrs ±1.92, AE= 6.17yrs ±1.33, P= 0.017). Estimated number of arthroplasty and hemiarthroplasty procedures performed increased with development status (P= 0.001, P= 0.003). Estimated fellowship uptake was significantly higher in more developed countries (P< 0.00001). End of training exams were not required in LIDCs, in the rest of the world 174 participants reported that they were, 55% of which reported there was no suitable exam course. 105 respondents felt the FRCS, or an international degree, would improve their profile; 88 said it would help their development as a surgeon, 44 regarded the cost as prohibitive.
Conclusion: The training in LIDCs is shorter and less structured than in EDCs or AEs and is not followed by an exit exam. LIDCs trainees have the lowest female representation and specialised fellowship uptake. Efforts should be co-ordinated to support an international curriculum and promote the international FRCS.

There is NO Conflict of Interest: Yes

1466 - British Iraqi Orthopaedic Initiative (BIOI); utilising the power of diaspora

S. Ismael1, A. Khunda2, H. Abdul-Jabar3, M. Al-Maiyah4, D. Kader5

1The Robert Jones and Agnes Hunt Orthopaedic hospital, Trauma and Orthopaedics, Oswestry, United Kingdom, 2Salford Royal NHS Foundation Trust, Trauma and Orthopaedics, Manchester, United Kingdom, 3Imperial College Healthcare NHS Trust, Trauma and Orthopaedics, London, United Kingdom, 4The James Cook University Hospital, Middlesbrough, United Kingdom, 5SWLEOC Epsom NHS, Trauma and Orthopaedics, London, United Kingdom

Iraq is one of the strategic countries in the Middle East due to its location and resources. Multiple wars and years of embargo have left the country with a life expectancy of 69 and large numbers of trauma related disabilities.  
The medical training and education system reached its peak during the 1980s with high level standards comparable to western countries.  Following 1991 and 2003 wars, medical education suffered from regression in content and delivery to both undergraduate and postgraduate students. Today,  postgraduate medical education and training in Iraq face multiple challenges resulting from the lack of facilities, financial support and Doctors' emigration due to violence. Post-graduate orthopaedic surgical training in Iraq starts following 2 years of internship followed by 5 years of high speciality training. 
Diaspora-led organisations can play an important role in addressing the unmet surgical needs in low-income and middle-income countries. British Iraqi Orthopaedic Initiative (BIOI) is a newly formed group of British Trauma and Orthopaedic surgeons based in the UK with Iraqi roots. The main aims of the BIOI are to facilitate the exchange of trauma and Orthopaedics knowledge and skills between Surgeons in the UK and Iraq, and to create a platform to share experience and expertise in managing complex orthopaedic cases. BIOI lobbied hard among orthopaedic community in the UK especially to the BOA to formalise planned support. End of 2019, BIOI representatives developed an Iraqi Support letter to amalgamate support behind our demands and successfully met Prof Philip Turner.  
In December 2019, BIOI successfully organised the first orthopaedic British / Iraqi conference in Baghdad with over 200 delegates registered from different parts of Iraq. The conference included knowledge updating lectures and workshops. During that meeting BIOI and IBTO agreed a joint protocol to facilitate activities in rebuilding orthopaedic education and building bridges of collaboration.

There is NO Conflict of Interest: No

Education and Simulation

Virtual Podium Presentations

37 - An Innovative Distal Locking Image Intensifier Simulator: Results Of A Pilot Validation Study

D Howard1, C Wildin1, E Fowler2

1University Hospitals of Leicester, Leicester, United Kingdom, 2University of Bristol, Bristol, United Kingdom

Background: Simulation has been highlighted as an important aspect of surgical training and has been mapped to the training curricula, of which intramedullary nailing is a key skill. Successful distal locking can be a challenging new skill faced by early years trainees, requiring a combination of effective communication, perceptual and psychomotor skills. ‘Dry bone’ simulation training for essential procedural skills has become commonplace, but simulated image intensification tasks are absent from this training setup.

Objectives: A distal locking image intensifier simulator was devised to support training within these skill domains. The aim of this study was to investigate the suitability of the simulator as a training tool for early years trainees.

Study Design & Methods: Trainees and trainers were invited to perform distal locking tasks using the simulator. Time, number of images and frequency metrics were extracted from simulator generated images and used to establish the relationship between training levels and improvements with training. Pre- and post-training confidence were assessed for trainees. Simulator content evidence specific to the skill sub-domains were collected from trainers.

Results: Participants consisted of nine trainees and six trainers. Mean time for initial task completion was 7.94 minutes (SD 3.00) for trainees and 3.36 (SD 0.91) for trainers (p=0.003). Mean images taken were 25.1 (SD 5.8) for trainees and 18.7 (SD 5.2) for trainers (p=0.047). Mean time for trainee post-training task completion reduced to 4.12 minutes (SD 0.59). Trainers reported realism and effectiveness in all domains and trainees reported improved self-efficacy.

Conclusions: This study introduces a novel image intensifier simulation tool for distal locking and demonstrates validity evidence for its suitability for training early years trainees.

There is NO Conflict of Interest: Yes

159 - Inequality, discrimination and regulatory failure in surgical training during pregnancy

S. Dorman1, J. Shelton1, D. Wharton2

1Mersey Deanery, Liverpool, United Kingdom, 2Whiston Hospital, Liverpool, United Kingdom

Objective: The primary aim was to identify whether statutory requirements for safe working in pregnancy are being met. Secondary aims were to identify common difficulties and cross speciality issues.

Design: Trainee and Trainer questionnaires were created using Google forms. Orthopaedic TPD’s and AES were invited to complete the Trainer questionnaire. Trainees with a T&O or O&G NTN who had taken maternity leave in the last 5 years were invited to complete the trainee questionnaire. Qualitative data was assessed using thematic analysis (Braun & Clarke).

Results: 45 T&O registrars (68 pregnancies) from 25 deaneries participated. For the same time period ISCP registered 81 episodes of OOP for maternity leave in T&O. In addition, 23 O&G registrars and 22 T&O Trainers participated.
Statutory health and safety compliance was poor. Only 1 in 5 trainees received adequate risk assessment.
Broad themes included:
(1) statutory issues; lack of guidance, inappropriate risk assessment, poor systems integration
(2) emotional & physical wellbeing; bullying, negative attitudes, illness
(3) training compromise; inappropriate placements, reduced opportunities
(4) patient safety; lone operating and expectation for immediate return to independent practice.
There were no differences in the experiences between T&O and O&G trainees.
30-50% of trainers felt inadequately prepared to support a pregnant or a returning to work trainee. T&O trainers had poor knowledge of guidance for managing pregnant trainees at trust (33%), deanery (50%) and national level (22%). Knowledge of guidance for returning to work was also poor (50%).

Conclusion: Occupational risk assessment is not currently adequate.There are issues to be addressed in practical job planning, workplace bias, effective loss of training and lack of awareness from key trainers. This appears to be a cross speciality problem. It is anticipated that T&O specialty guidance could pave the future with current and consistent ‘user friendly’ recommendations for trainees and trainers.

There is NO Conflict of Interest: Yes


M Powell-Bowns1, L Yapp1, CE Scott1, TO White1, AD Duckworth1

1Royal Infirmary of Edinburgh, Trauma and Orthopaedics, Edinburgh, United Kingdom

Background: The Scottish Training Survey (STS) is used to assess the quality of training programmes in Scotland. Foundation Doctors (FDs) working in T&O at the RIE had expressed persistent dissatisfaction with the FP. In 2017 the STS identified the department as the worst-performing FP in Scotland for T&O. This study reviewed the FP, evaluated the perspective of FDs working within the unit and proposed changes to the FP.
Research questions:
1. Why do foundation doctors in T&O at the RIE persistently produce poor feedback via the national training surveys?
2. Can changes be made to the T&O RIE Foundation Programme that results in a positive improvement in the NTS results?

Methods: Baseline STS responses from 2017 were compared with prospective data collected over a one-year period (Aug 2018-Sept 2019). A mixed-method approach was utilised. Quantifiable and qualitative data was obtained from the STS and from focus-groups. Using this data, changes were made to the FP, focussing on induction, rota-management, workload, and clinical support. Impact of changes were analysed by continued reassessment. 

Results: 48 (92%) FY doctors took part in the focus-groups across the study. Pre-intervention focus-groups revealed high levels of discontent, frustration and anger as a consequence of perceived excess workload, poor rota planning, limited clinical support, and poor educational opportunities. Post-intervention, overall median STS scores significantly increased on a yearly basis (2017: 39.3, IQR 19.2 vs. 2019: 62.7, IQR 13.9, 95% confidence intervals 15.2-29.0; p=0.015). Focus-group data revealed a positive change in group attitudes to the FP, citing a manageable workload, improved access to teaching and encouragement of FY2 development as key. 

Conclusion: This study indicates that focused changes to the T&O RIE FP have had a positive and significant impact on the satisfaction of FDs within the service.

There is NO Conflict of Interest: Yes

259 - Improving the orthopaedic teaching experience for foundation doctors

C. Kocialkowski1, L. Hainsworth1, O. Pearce1

1Musgrove Park Hospital, Taunton, United Kingdom

Background: Foundation training rotations in Trauma and Orthopaedics offer an opportunity for junior doctors to receive teaching in musculoskeletal medicine, which is frequently under prioritised in undergraduate curriculums.

Methods: This study assessed the efficacy of different modalities of foundation doctor teaching in Orthopaedics over the course of one academic year. Foundation trainees were divided into three cohorts. Group 1 received only didactic teaching, group 2 received didactic teaching and case-based discussion, and group 3 received only case-based discussion. Efficacy was assessed by standardised progress tests and junior doctor feedback.

Results: Progress test performance improved in all groups, throughout the course of the year, with a mean initial assessment score of 54%, a mean interim score of 76% and mean final assessment score of 80%.
The best performance was achieved by group 2, who had received a combination of didactic and case-based learning (final assessment score 90%). The largest improvement in performance occurred in group 1, who had received purely didactic teaching, with a mean initial assessment score of 37% improving to a final score of 80%. 
Foundation doctor feedback during the teaching curriculum indicated that they enjoyed having a case-based discussion component to their learning, however; group 3, who had received purely case-based learning felt that their teaching was too unstructured and lacked direction. 
Other perceived benefits from the teaching curriculum included: a regular point of contact for foundation doctors, an opportunity to discuss other clinical concerns, and an improved sense of belonging to ‘a team’.

Conclusion: This study demonstrates that a combination of didactic and case-based discussion is most effective for foundation doctor learning in Orthopaedics. In addition, there are many non-academic benefits to junior doctor teaching, which supports the institution of a regular evidence-based teaching programme.

There is NO Conflict of Interest: Yes

540 - Piloting games-based trauma teaching for foundation doctors: Trauma-PETE

A. Hoyle1, P. Luthra1

1Health Education England North West, Manchester, United Kingdom

Background: There is currently a paucity of trauma training for Foundation doctors. Postgraduate courses (ATLS, ETC) are only open to FY2+ trainees, leaving a lacuna where trainees are managing trauma patients within the trauma team, despite a lack of formal training. We sought to address this gap by piloting a novel Playful Environment Trauma Education (PETE) session for Foundation trainees.

Methods: A 3-hour games-based teaching session was delivered to 39 FY1 trainees, based around key trauma care concepts. Knowledge acquisition was measured via pre- and post- session MCQ test. Qualitative measurement of learner experience of the session was conducted via session evaluation and self-assessments, using Likert-scale and free text feedback. Statistical analysis was conducted using paired t-testing.

Results: Learners demonstrated a significant improvement in knowledge test scores (p<0.00001). Confidence in managing trauma patients significantly increased from “not very confident” to “somewhat confident” (p<0.00001). The learner group found the use of games “very useful” to the session, and found the session “very useful” for their future practice

Conclusions/findings: This pilot demonstrates that there is a role and appetite for trauma teaching in the FY1 curriculum. Techniques used in this pilot demonstrate that effective trauma teaching can be provided with limited resources and minimal faculty, in a small space of time within the existing foundation teaching programme, using a novel games-based approach. Our PETE session may help fill the lacuna in existing trauma training for Foundation doctors, improving knowledge and confidence for trainees who may be responsible for trauma patients before they have undertaken formal trauma care courses.

There is NO Conflict of Interest: No

628 - Micro-Journal-Club: Size isn’t everything!

S. Woods1, C. Lewis1, W. Jessica2, T. Pigott1, J. Tomlinson3

1Leeds Teaching Hospitals NHS Trust, Trauma and Orthopaedics, Leeds, United Kingdom, 2Leeds Teaching Hospitals NHS Trust, Obstetrics and Gynaecology, Leeds, United Kingdom, 3Sheffield Teaching Hospitals NHS Trust, Trauma and Orthopaedics, Sheffield, United Kingdom

Background: Traditional trainee-delivered teaching usually entails registrars delivering side-presentations related to a consultant delivered topic. We developed Micro-Journal-Club as an alternative peer-to-peer teaching format for regional teaching. Micro-Journal-Club involves structured, succinct presentations of key papers. The objectives of Micro-Journal-Club include: facilitating student-centred learning; engaging trainees with teaching; summarising key papers, facilitating FRCS preparation; and familiarising trainees with critical appraisal.

Methods: Trainees were provided with a prescribed presentation format and a 10-minute time limit, with instructions that ‘less-is-more’ should form a key principle in their preparation. Trainees had 1 slide outline the paper’s take-home message, 1 summarising the study, and 3 slides running through the CASP (Critical-Appraisal Skills Program) checklist. A further slide to mention further information was allowed, but was not presented. Trainees completed questionnaires before a term of Micro-Journal-Club and after comparing how the learning objectives were met.

Results: Previous journal-club sessions usually occurred outside normal working hours, indirectly discriminating against those with caring responsibilities. Accordingly, only half of trainees had portfolio evidence of attendance. Integrating Micro-Journal-Club into weekly teaching eliminated this barrier. Following the term all participants could evidence journal-club participation. Regular utilisation of CASP appraisal checklists improved trainee awareness of critical appraisal tools. 
Qualitative feedback described Micro-Journal-Club as “concise and effective” and “an excellent recap…for the FRCS”, highlighting improved trainee engagement. The overall response was overwhelmingly positive, with 80% finding it beneficial to FRCS preparation and a good addition to weekly teaching and 90% recommending it to a friend or peer.

Conclusions: Micro-Journal-club encourages trainee-centred teaching, effectively engaging trainees in teaching. It provides concise summaries of key papers that trainees felt helped with FRCS preparation, developed critical appraisal skills, and helps trainees fulfil CCT requirements. The teaching format was incredibly well received and we would recommend other regions consider implementing similar teaching formats.

There is NO Conflict of Interest: Yes

874 - Cost of Registrar Training in Hip and Knee Arthroplasty

J. Ting1, V. Garikapati1, R. Muir1

1Hull Royal Infirmary, Trauma and Orthopaedic, Hull, United Kingdom

Background: Orthopaedic departments in the NHS have long faced competing pressures to deliver surgical tuition to trainees but also service provision to meet performance targets. However there is sparse data on the costs of training orthopaedic registrars to perform procedures, vs consultant operating alone. This study aims to evaluate the financial, time and morbidity cost of training registrars in large joint arthroplasty in our trust.

Methods: Retrospective review of all patients undergoing elective primary hip and knee arthroplasty over a 12 month period in our unit. We recorded: training grade of the primary surgeon, patient demographics, surgical time, length of stay (LOS), readmission and reoperation at 30 days, and 12 month mortality. Means were compared using z test with significance p<0.05.

Results: 898 patients were identified. There was no significant patient age or sex difference between registrar- and consultant-performed operations.
For primary hip arthroplasty, mean trainee operation time was 126 ± 22 minutes compared to 101 ± 34 minutes for consultant operations (p<0.05). Mean LOS was 5.1 ± 4.3 days in trainees vs 4.4 ± 2.8 days in consultants (p=0.24).
For primary knee arthroplasty, mean trainee operation time was 114 ± 20 minutes compared to 101 ± 26 minutes for consultant operations (p<0.05). Mean LOS was 4 ± 2.7 days in trainees vs 4.6 ± 3.4 days in consultants (p=0.15).
No significant difference was found in complications, readmissions, reoperations or mortality.

Conclusion: As services return to normal in the aftermath of COVID-19, training opportunities are at even more of a premium. Our study demonstrates no increased morbidity cost to patients following trainee-performed arthroplasty. Implant choice was equivalent, and the major cost for training was in the increase in surgical time associated with trainee-performed procedures. Understanding this, careful operating list planning can maximise training opportunities, while maintaining the efficiency of the unit as a whole.

There is NO Conflict of Interest: No

Disclosure: Nothing to disclose

1173 - Face validity of passive vs active haptic arthroscopy simulators: which is most realistic?

A. Trockels1, K. Vaghela2

1The Royal London Hospital, A&E Department, London, United Kingdom, 2The Royal London Hospital, Department of Trauma and Orthopaedics, London, United Kingdom

Background: VR simulators are playing an increasingly prominent role in orthopaedic training and education. Face-validity - the degree to which reality is accurately represented - underpins the value of a Virtual Reality (VR) simulators as a learning tool for trainees. Despite the importance of tactile feedback in arthroscopy, there is a paucity for evidence regarding the role of haptics in VR arthroscopy simulator realism. 

Purpose: To assess the difference in face validity between two high fidelity VR simulators employing passive and active haptic feedback technology respectively. 

Method: 38 participants were recruited and divided into intermediate and expert groups based on arthroscopy experience and orthopaedic training grade. Each participant completed a 12-point diagnostic knee arthroscopy VR module using the active haptic Simbionix ARTHRO Mentor and passive haptic VirtaMed ArthroS simulators. Subsequently, each participant completed a previously validated simulator face validity questionnaire.

Results: The ARTHRO Mentor failed to achieve face validity with mean scores for external appearance (6.61), intra-articular appearance (4.78) and instrumentation (4.36) falling below the acceptable threshold (≥7.0). The ArthroS simulator demonstrated satisfactory scores in all domains: external appearance (8.42), intra-articular appearance (7.65), instrumentation (7.21) and was significantly (p<0.001) more realistic than ARTHRO Mentor for all metrics. 61% of participants gave scores ≥7.0 for questions pertaining to haptic feedback realism from intra-articular structures such as menisci and ACL/PCL for the ArthroS vs. 12% for ARTHRO Mentor. 
There was no difference in face-validity perception between intermediate and expert groups for either simulator (p>0.05).

Conclusion: Current active haptic technology which employs motors to simulate tactile feedback fails to demonstrate sufficient face-validity or match the sophistication of passive haptic systems in high fidelity arthroscopy simulators. Textured rubber phantoms that mirror the anatomy and haptic properties of the knee joint provide a significantly more realistic training experience for both intermediate and expert arthroscopists.

There is NO Conflict of Interest: Yes

1319 - Moving past Procedure Based Assessments: The O-SCORE - generic, empowering, valid and twice as fast

K. Logishetty1, J. Oluku1, T. Edwards1, W. Gofton2, J. Cobb1

1Imperial College London, MSk Lab, London, United Kingdom, 2The Ottawa Hospital, Ottawa, Canada

Background: The Ottawa-Surgical Competency Operating Room Evaluation (O-SCORE) is a short 9-item procedure-generic tool that employs entrustment anchors to describe competency through increasing autonomy. Due to its validity across a wide range of procedures, learner-centric focus, and simplicity, it has been incorporated into Canada’s new orthopaedic competency-based curriculum, while similar entrustment scales are now used in general surgical programs in USA and Holland. We aimed to ascertain whether the O-SCORE is a valid method to assess orthopaedic trainees performing a complex index procedure – total hip arthroplasty (THA), by comparing to the current gold-standard – THA-PBA – and a 30-point task-specific checklist (TSC) of THA.

Methods: Twenty-four surgical trainees (CT2-ST5) with variable experience performing THA completed a comprehensive assessment in the management of end-stage hip arthrosis. Trainees consented a simulated patient, performed a cadaveric THA in a simulated theatre with standardised assistance, and completed a post-operative note. Outcome measures were the THA-PBA, THA-TSC, and O-SCORE; assessed independently by two consultant orthopaedic surgeons.

Results: There was high interobserver correlation between the two raters using O-SCORE (mean Cohen’s kappa 0.82 ± 0.09). The eight domains’ internal consistency was excellent (Cronbach’s alpha 0.95). Component and global THA-PBA scores and TSC scores were positively associated with higher O-SCORE entrustment levels (Kruskal’s gamma 0.971, Kruskal’s gamma 0.965, and Spearman 0.81, p<0.005, respectively). TSC scores > 27/30 were consistently associated with O-SCORE independent competence. O-SCORE was sensitive to trainees of differing experience (0-10 THAs vs. 11-30 vs. >30 (p<0.005).

Conclusions: The O-SCORE can reliably and validly assess orthopaedic trainees’ surgical management of a patient with end-stage hip arthrosis. Scores correlated with performance on technical skills, non-technical skills and global rating scores; and discriminated between trainees of differing experience. We recommend its use as an alternative to PBAs in the new T&O curriculum to support progression.

There is NO Conflict of Interest: Yes

1333 - Strategies to improve undergraduate education in Trauma and Orthopaedics: The student perspective

K. Malik-Tabassum1, J. Lamb2, H. Pandit2, J. Aderinto3

1Conquest Hospital, East Sussex Healthcare NHS Trust, Hastings, United Kingdom, 2Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, United Kingdom, 3Leeds General Infirmary, Leeds, United Kingdom

Background: Deficiency in the undergraduate Trauma and Orthopaedics (T&O) education and training is well recognised. Previous studies have shown that a significant proportion of medical graduates feel inadequately prepared to manage T&O patients in their future clinical practice. This study aimed to explore students’ views on how to improve the quality of undergraduate T&O education.

Methods: A census of 204 final-year students from 8 UK medical schools was conducted using an online questionnaire. Students were invited to rank the strength of 5 recommendations on a 3-point Likert scale; “extremely effective”, “moderately effective”, and “not effective”.

Results: 54.4% felt that the introduction of a nationally validated online T&O resource would be “extremely effective” (“moderately effective”=31%, “not effective”=15%). 35% stated that a focused 1-2 days course during the final-year of medical school would be “extremely effective” (“moderately effective”=50%, “not effective”=15%). Increasing the frequency of formative assessments in T&O was deemed as “extremely effective” by 36%, “moderately effective” by 45%, and “not effective” by 19%. Increasing the provision of didactic lecture-based teaching (“extremely effective”=25%, “moderately effective”=54%, “not effective”=21%) and prolonging the duration of the undergraduate T&O rotations (“extremely effective”=12%, “moderately effective”=58%, “not effective”=30%) were perceived to have the least educational value by the students.

Conclusion: In the past, there has been a significant emphasis on increasing the length of undergraduate rotations to help improve students’ knowledge and competence in T&O. Interestingly, this study shows that this opinion is not shared by many medical students. Although there is no substitute for clinical experience, e-learning can be utilised to foster self-directed learning, which allows greater flexibility over content and pace. Medical educators should engage with e-learning to devise innovative approaches to train students in T&O. 

There is NO Conflict of Interest: No

1474 - Barriers to participation in randomised clinical trials: A junior doctor perspective

A. Kulkarni1, H. Daud1, P. D’Sa1, C. Carpenter1

1University Hospital of Wales, Trauma and Orthopaedics, Cardiff, United Kingdom

Background: Clinical trials are the cornerstone upon which modern evidence-based medicine has been built. Recruitment into randomised controlled trials (RCT) is known to be challenging. Clinician-related factors have been cited as one of the main reasons for low rates of recruitment in trials across different care settings. 
Aim: To identify the perceived barriers to participation in RCTs amongst junior doctors, and to find interventions that could improve their engagement.
Methodology: A Google form survey with 15 questions with 5-point Likert scale responses, pertaining to barriers to participation and what would encourage them to take part in RCT’s was sent out to junior doctors in trauma & orthopaedic department across hospitals in Wales.
Results: A total of 53 responses were recorded 38 of which were from specialty registrars and 15 were from senior house officers. Almost 50% of participants were not aware of any ongoing trials. Majority acknowledged they have time constraints (70%) and there is too much paperwork involved (70%). However, they agree taking part in trials is worth the effort (60%), and are still interested in research work (83%). Majority of junior doctors responded that they would more likely take part in RCTs if there was formal training sessions (85%), more dedicated research sessions scheduled into their rota (85%), more rewards/incentives for recruiting subjects (80%), and if there was a peer in-charge who could motivate and guide them (75%). Most participants (92%) believe that taking part in RCTs was relevant for training.
Conclusion: Taking part in RCTs is both essential and relevant to junior doctors in training, with the potential to become the largest recruiting force to aid in trials reaching their planned targets in time. There are multiple barriers that are faced, however, these could be mitigated by implementing some simple interventions as suggested by junior clinicians.

There is NO Conflict of Interest: Yes

1685 - The impact of the COVID-19 pandemic on Trauma and Orthopaedic Surgery subspecialty fellowships in the United Kingdom

U.B.J. Yousuf1, S.P. White1

1Cardiff and Vale University Health Board, University Hospital Llandough, Cardiff and Vale Orthopaedic Centre, Penarth, United Kingdom

Subspecialty fellowships are undertaken near to or at Certificate of Completion of Training (CCT) in the United Kingdom (UK). There is limited work looking at this group of surgeons during the pandemic. We aimed to investigate the impact of COVID-19 on subspecialty fellows (SSFs) qualitatively. We explored their experiences hypothesising SSFs may be affected by deskilling and delayed career progression.
 There is no single register of SSFs making this group challenging to identify. The BOA Future Leaders Programme (FLP) is completed by many SSFs and new consultants. We invited members of the FLP to complete an anonymised electronic questionnaire in July 2020. Criteria for inclusion were SSF during the pandemic with consultants excluded. 
 Of the 26 FLP members, 6 consultants were excluded. 15 of the remaining 20 responded (75.0%) representing 6 subspecialties across England and Wales. 66.7% were post-CCT; 66.7% were redeployed; 20.0% in non-orthopaedic roles. All respondents said their fellowship was negatively affected and felt operating opportunities reduced during the pandemic. There was a mean 83.9% reduction in forecasted logbook numbers with 53.4% surgeons performing five or less operations during the crisis. 33.3% were concerned about deskilling and only 13.3% had access to simulation training. 40.0% said the crisis impacted their next posting; both fellowships and consultant posts equally affected. The crisis offered 46.7% of SSFs an opportunity to be involved in service re-design. 
Limitations include small sample size; both the excellent response rate and purposive design mitigate against this somewhat and may increase the generalisability of these findings. The sample was non-randomised thus bias cannot be excluded.
The pandemic has impacted SSFs adversely in both deskilling and delayed future career progression within a representative national cohort. This has training, workforce-planning and recruitment implications for orthopaedics in the NHS. Further studies should validate these findings in a larger sample.

There is NO Conflict of Interest: Yes

1913 - Complex technical skills in revision total knee arthroplasty learnt in a virtual reality curriculum transfer to the real world

T. Edwards1, A. Patel1, B. Szyszka1, A. Coombs1, R. Kucheria2, J. Cobb1, K. Logishetty1

1Imperial College London, MSk Lab, London, United Kingdom, 2Department of Trauma & Orthopaedics, Wexham Park Hospital, Frimley Health NHS Foundation Trust, Slough, United Kingdom

Background: Revision knee arthroplasty is a high stakes procedure with complex equipment and multiple steps. Scrub nurses may not encounter these operations frequently and often rely heavily on company representatives to guide them which may cause unnecessary delays. This study investigates the impact of a fully immersive virtual reality (VR) curriculum on training scrub nurses in performing a complex revision total knee arthroplasty operation using the ATTUNE revision knee system.

Method: Ten orthopaedic scrub nurses were recruited and trained in four VR sessions over a 4-week period. Each VR session involved a guided mode, where participants were taught the steps of surgery in a simulated operating theatre. The latter 3 sessions involved a guided mode followed by an unguided VR assessment. Outcome measures in the unguided assessment were related to procedural sequence, duration of surgery and efficiency of movement. Transfer of skills was assessed during a pre-training and post-training assessment, where participants completed a set of tasks using the real equipment. A pre and post-training questionnaire assessed the participants knowledge, confidence and anxiety.

Results: All participants reported orthopaedics as their primary speciality with mean of 6-years experience. 80% reported they are ‘sometimes’ required to scrub for operations which they do not feel comfortable with the equipment. All participants improved across the 3 unguided sessions reducing their operative time by 47%, assistive prompts by 75%, dominant hand motion by 28% and head motion by 36%. This transferred into the real-world assessment with assessment scores improving from 11.3% pre-training to 83.5% correct post-training. All participants reported increased confidence and reduced anxiety after the training.

Conclusion: Unfamiliarity with orthopaedic procedures or equipment is not uncommon for scrub nurses. VR training improves their understanding, technical skills and efficiency in complex knee arthroplasty surgery. These VR-learnt skills appear to translate into the physical environment.

There is NO Conflict of Interest: Yes

Foot and Ankle

Virtual Podium Presentations

561 - DVT and Achilles tendon rupture – a better pill to swallow?

G. Scott1, A. Biggs1, A. Carne2, M. Rogers3, M. Solan1

1The Royal Surrey Hospital, Trauma & Orthopaedics, Guildford, United Kingdom, 2The Royal Surrey Hospital, Radiology, Guildford, United Kingdom, 3The Royal Surrey Hospital, Haematology, Guildford, United Kingdom

Background: The BOFAS Guidance regards Achilles rupture patients as high risk for VTE. Many hospitals use 6-weeks of low molecular weight heparin (LMWH) injections which can be unpleasant for patients and result in reduced compliance.
Elective hip and knee arthroplasty patients are also recommended extended prophylaxis. Some oral anticoagulants are licensed and have been offered to our Achilles patients as an alternative. Since this is “off-license”, we developed an information sheet and consent form. In this study we compared VTE outcomes in patients treated before and after Rivaroxaban introduction.

Methods: We retrospectively reviewed Achilles rupture patients diagnosed during three different periods between 2010 and 2019. During the first patients were treated in fracture clinic. Chemical prophylaxis was not always prescribed. In the second period patients were triaged to a Foot & Ankle clinic. VTE prophylaxis was universal but not standardised. The third period saw patients managed by one foot and ankle surgeon using the Rivaroxaban protocol. DVT, pulmonary emboli or significant bleeding within 3 months of treatment were the recorded outcome measures.

Results: Two hundred and thirty patients with Achilles tendon rupture were identified. Thirty-one were excluded either because they took anticoagulants already or presence of a DVT on initial USS requiring treatment. There were no secondary bleeding episodes or fatal PEs. Forty patients had no prophylaxis and three (7.5%) of these developed a symptomatic DVT or PE. Of the 80 patients managed with LMWH, 5 (6.25%) suffered a thromboembolic event. A total of 79 patients were given Rivaroxaban and none suffered a DVT or PE.

Conclusion: Our data suggests Rivaroxaban is an appropriate alternative and may lead to reduced thrombotic episodes. This may be due to reduced compliance with LMWH injections.
Discussion with the hospital therapeutics committee, coagulation clinic and pharmacy helped facilitate implementation and improve VTE rates.

There is NO Conflict of Interest: Yes

611 - Bilateral Versus Unilateral Minimally Invasive Hallux Valgus Surgery: A Propensity Matched Case-Control Study With 2 Year Clinical Outcomes

S. Crooks1, T. Lewis1, R. Ray2, D. Gordon3

1Queen Elizabeth Hospital, Woolwich, Trauma & Orthopaedics, London, United Kingdom, 2Princess Royal University Hospital, Trauma & Orthopaedics, London, United Kingdom, 3The London Clinic, Trauma & Orthopaedics, London, United Kingdom

Background: Hallux valgus deformity correction using a third-generation Minimally Invasive Chevron Akin osteotomy technique (MICA) is becoming increasingly popular. There are limited patient-reported outcome measure (PROM) outcomes for patients undergoing bilateral hallux valgus corrective MICA surgery during a single operative case.

Methods: Between July 2014 and May 2018, 59 consecutive patients comprising 118 feet underwent bilateral MICA in a single operative case. 1:1 propensity score matching based on preoperative PROM assessment, age, and radiographic deformity data was carried out to match each foot in the bilateral cohort with 118 feet who had undergone unilateral MICA. The primary outcome measure was the Manchester-Oxford Foot Questionnaire (MOXFQ) score which was prospectively measured pre-operatively and at 6 months and 2 years post-operatively. Secondary outcomes included complication rates and radiographic deformity correction with regards to the hallux valgus angle (HVA) and inter-metatarsal angle (IMA).

Results: At minimum 2 year follow up, the MOXFQ post-operative scores had significantly improved for every domain (p =<0.001) in both unilateral and bilateral cohorts compared to pre-operative assessment. For all domains of the MOXFQ, there was no statistically significant difference in 6 month or 2 year outcomes between patients undergoing bilateral and unilateral MICA surgery (p =>0.05 for all outcome measures). There was no statistically significant difference between the two cohorts in complication rate (p =>0.05) or post-operative IMA or HVA (p =>0.05).

Conclusion: This study demonstrates that there is no significant difference in patient-reported outcome measures at 2 year follow-up between patients who underwent bilateral versus unilateral MICA. This study should reassure surgeons who perform bilateral hallux valgus surgery in a single case that, in the medium-term, there is no difference in clinical or radiographic PROMs compared to unilateral surgery. There are potentially positive health economic benefits of performing bilateral surgery in a single sitting if clinically indicated.

There is NO Conflict of Interest: Yes

795 - Charcot Neuro-arthropathy Precipitated by First or Fifth ray Amputation: A Cohort Study

W. Zahra1, A. Fontalis2, A. Doorgakant3, C. Blundell4

1Royal Berkshire Hospital, Trauma and Orthopaedics, Reading, United Kingdom, 2Academic Unit of Bone Metabolism, The University of Sheffield, Sheffield, United Kingdom, 3Warrington and Halton Hospitals NHS Foundation Trust, Trauma and Orthopaedics, Warrington, United Kingdom, 4Northern General Hospital, Foot and Ankle Surgery, Sheffield, United Kingdom

Background: Charcot Neuro-arthropathy (CN) can occur spontaneously in a neuropathic foot but is often precipitated by an insult to the foot, such as trauma. Another pattern emerged in our diabetic clinics which led us to hypothesise that a medial or lateral ray amputation could destabilise the foot into CN. We set out to analyse our patients over a 5-year period to explore that link.

Results: We identified 92 patients (98 surgical episodes) who had previous 1st or 5th ray amputations [77 male (83.7%), 15 female (16.3%), mean age 61.5 ± 13.5]. CN developed in 16 cases (17.4%; 9 following 1st ray and 7 following 5th ray amputation). This represented 30.9% of all our new CN cases. CN was diagnosed within 6 months in 6 cases and up to 3 years in the remaining 12. Five of the 1st ray amputations were conducted with a stump length of ≤10mm from the tarsometatarsal joint and a further 1 had resorbed down to it before the Charcot process. 3 of the 5th ray amputations were carried out with a stump length ≤25mm. Receiver Operator Curve (ROC) analysis showed no obvious diagnostic value of stump length in predicting CN (area under the curve 0.42 (95% CI 0.26 – 0.59)). Following a logistic regression analysis into effect of age, gender and peripheral vascular disease, only age was found to significantly affect the risk of developing CN (Nagelkerke R2=0.122, p=0.013).

Conclusion: This is the first report of CN developing after 1st or 5th ray amputations. We theorise that the foot tripod is de-stabilised following these procedures, leading to increased pressures across the midfoot. Our small sample was unable to demonstrate a significant correlation between stump length and CN risk. More work is needed to ascertain this. Meanwhile, we recommend increased foot protection following 1st and 5th ray amputations.

There is NO Conflict of Interest: Yes

907 - Two Year Follow-Up of Clinical and Radiological Outcomes Following Third-Generation Minimally Invasive Chevron Akin Osteotomies (MICA) in Hallux Valgus Surgery

T.L. Lewis1, R. Ray2, D. Gordon3

1Lewisham and Greenwich NHS Trust, Trauma and Orthopaedic Surgery, London, United Kingdom, 2Kings College Hospital NHS Foundation Trust, Trauma and Orthopaedic Surgery, London, United Kingdom, 3The London Clinic, Trauma and Orthopaedic Surgery, London, United Kingdom

Background: There is increasing interest in hallux valgus deformity correction using the third-generation minimally invasive chevron akin osteotomy (MICA) technique.

Objective: To assess the mid-term clinical and radiographic outcomes of third- generation MICA using validated outcome measures.

Methods: This is a prospective single-surgeon case series of 333 consecutive feet undergoing third-generation MICA surgery between July 2014 and April 2018. Primary clinical outcome measures included Manchester-Oxford Foot Questionnaire (MOXFQ), EQ-5D-5L, EQ-VAS, and the Visual Analogue Pain Scale. Secondary outcome measures included radiographic parameters, complications and recurrence rates.

Results: Pre-operative and 2 year post-operative patient reported outcomes were collected for 292 feet (87.7%). At minimum 2 year follow up, the MOXFQ scores (mean ± standard deviation (SD)) had improved for each domain: pain; pre-operative 44.5±21.5 reduced to 9.4±15.8 post-operatively (p<0.001), walking and standing; pre- operative 38.7±23.4 reduced to 6.5±14.6 post-operatively (p<0.001) and social interaction; pre-operative 48.0±22.3, reduced to 6.6±13.5 post-operatively (p<0.001).
At 2 year follow up, the VAS Pain score (mean ± SD) improved from a pre-operative of 31.4±22.7 to 8.4±16.4 post-operatively (p<0.001). 1-2 intermetatarsal angle (mean ± SD) reduced from 15.3°±3.6° to 5.7°±3.2°) (p<0.001) and hallux valgus angle reduced from 32.9°±10.2° to 8.7°±5.2° post-operatively (p<0.001). The screw removal rate was 6.3%. Hallux valgus recurrence rate was 0.9%.

Conclusion: This study demonstrates third-generation MICA is a safe and effective procedure with excellent clinical outcomes at 2 year follow up. Third-generation MICA can be successfully used for correction of a wide range of hallux valgus deformities with a low rate of recurrence.

There is NO Conflict of Interest: Yes

912 - Patient reported outcomes following non-operatively managed Weber Type A distal fibula fractures

C. Lee1, O. Chan1, R. Titheradge1, F. Auld1, E. Iliopoulos1

1Royal Sussex County Hospital, Trauma and Orthopaedics, Brighton, United Kingdom

Introduction: Fibula fractures distal to the syndesmosis “Weber A” type fractures may have been perceived to be relatively benign injuries; however, its outcome following non-operative treatment remains unknown. The aims of this study were to investigate patient reported outcomes following the non-operative management of closed Weber A type distal fibula fractures, and investigate for any correlation with radiological features or other patient factors such as diabetes and smoking.

Methods: Patient reported outcomes (PROMs) were collected from patients with Weber A type fractures treated non-operatively, with a minimum period of 11 months post injury. PROMs included the use of the Chertsey Outcome Score for Trauma (COST) as well as the time to return to work, physical activity and time to become symptom free. The radiographs of the injuries were also reviewed and the effect of fracture height, displacement, comminution and intra-articular extension on such PROMs was analysed.

Results: Data was collected from 72 patients. The mean COST scores were 83 (range 30-100). Patients reported on average 3.1 weeks and 5.7 weeks to return to work for office-based and manual type work respectively. An average of 10.8 weeks to return to physical activity and 14.8 weeks to become symptom free with 21% of patients still symptomatic at follow-up. Fracture height and fractures with comminution, displacement, intra-articular extension did not appear to be associated with poorer PROMs.

Conclusion: The results show that the outcomes are generally very good. The majority of patients however did not return to their baseline prior to the injury with a significant proportion of patients remaining symptomatic. The reported times to return to work, physical activity, and symptom free are useful and can be used to manage patient expectations. Our results dispel any assumption that Weber A type distal fibula fractures are totally benign.

There is NO Conflict of Interest: Yes

951 - Lateral Transligamentous Approach to the Talar Dome

L. Lambert1, A. Molloy1, M. Davies2, J. Mangwani3, L. Mason1

1Liverpool University Hospital NHS Foundation Trust, Trauma and Orthopaedic Department, Liverpool, United Kingdom, 2Sheffield University Hospital, Trauma and Orthopaedic Department, Sheffield, United Kingdom, 3Leicester Royal Infirmary, Trauma and Orthopaedic Department, Leicester, United Kingdom

Background: Anatomic reduction of talar body fractures is critical in restoring congruency to the talocrural joint. Previous studies have indicated a maximum of 25% talar body exposure without malleolar osteotomy. The aim of this study was investigate the percentage talar body exposure when using the lateral transligamentous approach

Methods: The lateral transligamentous approach to the talus was undertaken in 10 fresh frozen cadaveric specimens by surgeons inexperienced in the approach, following demonstration of the technique. An incision was made on the anterolateral aspect of the ankle augmented by the removal of the anterior talofibular ligament (ATFL) and the calcaneofibular ligament (CFL) from their fibular insertions. A bone lever was then placed behind the lateral aspect of the talus and levered forward with the foot in equinus and inversion.
The talus was disarticulated and high resolution images were taken of the talar dome surface. The images were overlain with a reproducible nine-grid division. Accessibility to each zone within the grid with a perpendicular surgical blade was documented. ImageJ software was used to calculate the surface area exposed with each approach.

Results: The mean percentage area of talar dome available through the transligamentous approach was 77.3 % (95% confidence interval 73.3, 81.3). In all specimens the complete lateral talar process was accessible, along with the lateral and dorsomedial aspect of the talar neck. This approach gives complete access to Zones 1,2, 3,5 & 6 with partial access to Zones 4,8 &9.

Conclusion: The lateral transligamentous approach to the talus provides significantly greater access to the talar dome as compared to standard approaches. The residual surface area that is inaccessible with this approach is predominantly within Zone 4 and Zone 7, the posteromedial corner.

There is NO Conflict of Interest: Yes

1060 - Are We Following BOAST Guidelines On Management Of Ankle Fracture? Results From A Prospective All Wales Trainee Led Collaborative Audit

R. Agarwal1

1University hospital Wales, T&O, Cardiff, United Kingdom

Introduction: Purpose of this all Wales national audit was to compare compliance against BOAST guidelines on management of ankle fractures.

Methods: A multi-centre prospective audit of the management adult ankle fractures was conducted between 2ndFeb 2020 and 17thFeb 2020 via Welsh Orthopaedic Research Collaborative (WORC). Regional leads were recruited in 9 NHS hospitals across 6 University Health Boards who recruited collaborators in their hospitals. Questionnaires for data collection on both surgical and conservative management were made available via password protected website (walesortho.co.uk). We defined early weight bearing (EWB) as unrestricted weight bearing on affected leg within 3 weeks of injury or surgery and delayed weight bearing (DWB) as unrestricted weight bearing after 3 weeks of injury or surgery.

Results: 28 collaborators contributed data for 238 ankle fractures. Poor documentation at time of injury was noted. Less than 50 % of patients with posterior malleolus fracture had a CT scan for further evaluation. 84 % of the non-operatively treated patients did not have a weight bearing X-ray (WBXR). Patients who had a WBXR were more likely to be allowed EWB but this was not statistically significant. EWB was allowed in 59.43 % and 10 % of the non-operatively and operatively treated patients respectively. DWB was higher in patients who had fixation of the posterior malleolus or syndesmosis.

Conclusion: There is poor compliance with BOAST guidelines on management of ankle fractures across Wales. We need to improve documentation and also to consider performing a CT scan when the posterior malleolus is fractured. A weight bearing X ray should be performed more often to ascertain the stability of an ankle fracture, and those that are deemed stable should be treated with early weight bearing. The guidelines need to be clearer regarding weight bearing after fixation especially when posterior malleolus and/or syndesmosis are fixed.

There is NO Conflict of Interest: Yes

1686 - High Incidence of spring ligament laxity in ankle fractures with complete deltoid ruptures and secondary first ray instability

V.B. Kiliyanpilakkil1, C. Pasapula2

1Queen Elizabeth Hospital Kings Lynn, Orthopaedics, Kings Lynn, United Kingdom, 2Queen Elizabeth Hospital, Orthopaedics, Kings Lynn, United Kingdom

Aims: To assess the incidence of spring ligament failure in patients who have complete deltoid ruptures

Patients and methods: We retrospectively analysed ankle fractures in our trauma database from January 2015 to January 2019. 61 patients who sustained ankle fractures with complete deltoid ligament ruptures based on an AP ankle radiographs with increased medial joint space were identified. 25 patients attended clinic for assessment. Of these, 5 were found to have gross planovalgus with pre-existing spring ligament laxity in the uninjured control foot and these were excluded from the analysis. 20 patients were assessed for spring ligament failure /laxity. For each patient, the uninjured foot was used as the control.

Results: The TMT instability score and the lateral translation score showed statistically significant increases in the injured compared to the uninjured foot. The ratio of increase in both TMT instability and lateral translation scores (strain) in the injured versus the uninjured foot was assessed. We found a strong correlation (+0.62 pearson correlation coefficient) between the two ratios.

Conclusion: All 20 patients showed increased spring ligament laxity and 19 patients showed increased TMT instability. Our results show that with complete deltoid rupture, there is likely greater disruption of the medial ligamentous structures of the foot than previously recognised. The degree of increase in the spring ligament strain also correlates with the degree of strain at the plantar TMT joint ligaments, and thus first ray instability. This finding has significant implications for the long-term assessment and management of ankle fractures involving complete deltoid disruption. Early intervention with orthotics in this cohort may prevent progressive destabilisation of the midfoot and the first ray. This evolving understanding may lead to the prospect of earlier surgical intervention to reconstitute the integrity of the spring ligament and protect the foot progressing to stage 2 AAFD.

There is NO Conflict of Interest: Yes

1695 - Arthroscopic triple arthrodesis: An effective technique to correct the hind-foot deformity and achieve florid union

V. Kandhari1, S. Guillo2, A. Perera1

1Cardiff and Vale University Health Board, Trauma and Orthopaedics, Cardiff, United Kingdom, 2Clinique du Sport, Foot and ankle, Bordeaux-Mérignac, Bordeaux-Mérignac, France

Objective: This study aims to evaluate the radiological results including rates of union and correction of hind-foot deformity of patients who underwent arthroscopic triple fusion by a single surgeon. We hypothesize that arthroscopic triple fusion will achieve adequate union of subtalar, talo-calcaneal and calcaneo-cuboid joints and restore the normal anatomic alignment of the hind-foot.  

Methods: Consecutive patients of rigid plano-valgus deformity who were realigned using primary arthroscopic triple fusion by the senior surgeon formed the study cohort. Patients who also had arthritis of ankle and/ or mid-tarsal joints, who had previous surgery in the hind-foot region and who had associated bone loss which would require bone graft after realignment were excluded from the study. Pre-operative and post-operative weight bearing radiographs were used to assess the hind-foot alignment. Post-operative CT scan done at 8 – 12 weeks was used to assess fusion of the talo-calcaneal, talo-navicular and calcaneo-cuboid joints.

Results: Arthroscopic triple fusion was performed in 21 consecutive patients with rigid flat foot deformity. The mean post-operative hind-foot alignment was significantly different from the pre-operative value (p<0.001) and they were corrected to the normal physiological range. There was significant improvement in the post-operative talo-navicular coverage compared to pre-op (p<0.001). Complete union was observed in the posterior and middle facets of the subtalar joint, talo-navicular and calcaneo-cuboid joints of the all the included patients.

Conclusions: Arthroscopic triple arthrodesis anatomically aligns the deformed hind-foot and achieves bony union across the talo-calcaneal, talo-navicular and calcaneo-cuboid joints.

There is NO Conflict of Interest: Yes

1719 - Total Ankle Arthroplasty versus Arthroscopic Ankle Arthrodesis: A comparison of clinical outcomes

L. Kurar1, R. Castelhano1, M. Faulkner1, H. Kowitz Arroyo1, J. Omiawele1, V. Kakkar1, I. Aslandis1, J. Grice1

1Great Western Hospital, Swindon, United Kingdom

Background: Traditionally, ankle arthrodesis (AA) has been implemented as a reliable and reproducible surgical intervention for treating end stage ankle osteoarthritis. With the advent of custom made modular implants, low profile design, and improved fluoroscopic navigation, total ankle arthroplasty (TAR) has attracted renewed interest. There remains a lack of high quality retrospective data assessing patient reported functional outcomes, complication rate, and cost effectiveness across both surgical groups.
Methods: We evaluated the results of arthroscopic ankle arthrodesis versus total ankle replacement in a standardised retrospective patient cohort. Inclusion criterion included all patients with primary or secondary degenerative ankle osteoarthritis admitted for either treatment arm over 1 year at a single centre district general hospital. Primary outcome measure included the Manchester-Oxford Questionnaire (MOxFQ), and secondary outcome measures evaluated patient demographic and postoperative complication. A cost benefit analysis was also conducted with incremental cost effectiveness (ICER) calculated for both index procedures.
Results: Two continuous series of n=22 (TAR) and n=20 (AA) were evaluated retrospectively over one year with mean age 74.7 and 64.4 respectively. Smoking status, BMI, and ASA grade were equivocal across both groups. MOxFQ scores at 6 weeks (TAR 43.6+/-6.6; AA 46.05+/-2.95) and at 1 year (TAR 27.58+/-9.08; AA 39.43+/-3.57) reported better functional and pain scores following TAR. Postoperative complications were also notably higher in the AA group (n=7) with the majority attributed to non-union. Cost-benefit analysis using the Markov model had demonstrated an ICER (£/QALY) saving of £5025.92 per TAR performed compared to AA.
Conclusion: Our results have demonstrated TAR remains a useful alternative for end stage osteoarthritis correlating well with patient reported outcomes with an improved side-effect profile. Cost benefit analysis has also demonstrated that although cost of implant is high, reduced follow up appointments and inpatient stay can equalise costing across both index procedures.

There is NO Conflict of Interest: Yes

1759 - Optimal Screw Placement Configuration in Calcaneal Fractures: A Biomechanical Study

I. Liew1, E. Gil Monzo2, P. Tadikonda3, S. Cutt4, C. Pasapula1

1Queen Elizabeth Hospital King's Lynn, King's Lynn, United Kingdom, 2Universitario Dr Peset, Valencia, Spain, 3Queen Elizabeth Hospital, King's Lynn, United Kingdom, 4James Paget Unviersity Hospital, Great Yarmouth, United Kingdom

Background: Calcaneal fractures can be high energy intra-articular injuries associated with joint depression.  Challenges to fracture reduction include lateral wall blow out, medial wall overlap, comminution and central bone loss. Secondary deformity such as hindfoot varus alters foot biomechanics. Use of posterior screws with indirect reduction can be used to maintain the reduction of the calcaneal tuberosity. Optimum screw numbers and position is not known. This study aims to determine the optimum screw configuration in calcaneal fractures.
Methods: Sawbone models were prepared to replicate Sanders type 2-B fracture, with central bone loss and comminution. 0.5cm medial wedge of the calcaneal tuberosity was removed to create varus instability. 7mm cannulated partially threaded Charlotte™ Headless Multi-use compression screws inserted over a wire under image guidance were used. Sagittal plane displacement of the dissociated tuberosity fragment compared to the body when applying  5N, 10N and 20N force was measured in millimeters (mm). 
Results: 2 screws inserted (one medial screw into the sustentaculum talus from inferior to superior and, one lateral screw into the long axis anterior process) provides the least displacement (0.84mm ± 0.114 at 5N and 2.16mm ± 0.385) and the most stable construct (p<0.0001) when compared to other configurations. 2 parallel midline screws from inferior to superior resulted in the least stable construct and most displacement (3.78mm ± 0.709 at 5N and 9.76mm± 1.115 at 20N). 
Conclusion: This is the first study that demonstrates optimal screw configuration in calcaneal fractures in resisting varus deformity when using minimally invasive techniques. 

There is NO Conflict of Interest: No

Disclosure: This work had non-financial support by Wright Medical group and Orthosolutions.

General Orthopaedics

Virtual Podium Presentations

181 - A Novel Antimicrobial Coating to Prevent Prosthetic Joint Infection

R Brown1, R Ramalhete1, M Coathup1, G Blunn1, A Sanghani-Kerai1

1University College London, Institute of Orthopaedics and Musculoskeletal Science, London, United Kingdom

Aim: Prosthetic joint infection (PJI) is a debilitating condition with a significant socioeconomic burden. Biofilm formation is key to its development. A novel autologous blood glue (ABG) has been developed, which can be prepared intra-operatively and sprayed onto prostheses upon implantation. This study aims to assess the antimicrobial potential of ABG when impregnated with gentamicin (Gent-ABG).

Methods: Gentamicin elution from the ABG matrix was quantified in a time-dependent manner. The efficacy of ABG-gentamicin as an anti-biofilm coating was investigated on titanium discs.

Results: ABG-gentamicin was bactericidal from 10μg/ml and released bactericidal concentrations over 7 days. A concentration of 75μg/ml of gentamicin in ABG showed the highest bactericidal effect. On titanium discs, a significant bacterial reduction on ABG-gentamicin coated discs was observed when compared to both uncoated (mean 2-log reduction) and ABG-coated (mean 3-log reduction) discs, at days 3 and 7.

Conclusions: ABG alone exhibited no antimicrobial or anti-biofilm properties. However, a concentration of 75μg/ml gentamicin in ABG sustains release over 7 days and significantly reduced biofilm formation. An ABG-gentamicin implant coating may prevent bacterial adhesion peri-operatively and in the early post-operative period. In vivo studies of ABG-gentamicin are justified, as is in vitro investigation of its potential to co-deliver cells, drugs, and growth factors.

There is NO Conflict of Interest: Yes

187 - Efficacy of Vitamin-D supplementation in patients with chronic low back pain

RR Akhtar1

1Benazir Bhutto Hospital, Rawalpindi Medical University, Rawalpindi, Pakistan

Objective: To determine the clinical efficacy of vitamin-D supplementation on pain intensity and functional disability in patients with chronic low back pain.

Study Design & Methods: This prospective cohort study was conducted from 20th March 2015 to 19th March 2017.The inclusion criteria were patients of CLBP aged between 15 to 55 years. Exclusion criteria included all the patients with Disc prolapse, Spinal stenosis, Any signs of neurological involvement, Metabolic bone disease (Hypo- or Hyperparathyroidism) and Chronic kidney disease/Chronic liver disease. Patients were supplemented with 50,000 IU of oral vitamin-D3 every week for 8 weeks (induction phase) and 50,000 IU of oral vitamin-D3 once monthly for 6 months (maintenance phase). Efficacy parameters included pain intensity and functional disability measured by VAS and modified Oswestry disability questionnaire (MODQ) scores at baseline,2, 3 and 6 months post-supplementation. Vitamin-D3 levels were measured at baseline,2,3 and 6 months.

Results: A total of 600 patients were included in the study. Mean age of patients was 44.21±11.92 years.337(56.17%) were male and 263 (43.83%) were females.454 (75.66%) patients have deficient vitamin-D3 levels. Baseline mean vitamin-D3 levels were 13.32±6.10 ng/mL and increased to 37.18±11.72 post supplementation (P<0.01). 299 (66%) patients attained normal levels (>29 ng/mL) post supplementation. Significant reduction in VAS was observed at 2, 3, and 6 months (61, 45, 36) as compared to 81 at baseline (P = 0.001).A significant improvement in the functional ability was also observed at 2, 3, and 6 months (35,30 and 25) as compared to baseline 46 (P = 0.001).

Conclusion: Vitamin-D supplementation in CLBP patients may lead to improvement in pain intensity and functional ability.

There is NO Conflict of Interest: Yes

827 - Supra-human orthopaedic implant identification in radiographs using deep learning

R. Patel1,2, E. Thong1, V. Batta3, A. Anthony Bharath2, D. Francis1, J. Howard1

1Imperial College Healthcare NHS Trust, Faculty of Medicine, London, United Kingdom, 2Imperial College London, Department of Bioengineering, London, United Kingdom, 3Luton and Dunstable University Hospital, Department of Orthopaedic Surgery, Luton, United Kingdom

Background: Accurate identification of orthopaedic implant model is essential to planning of revision arthroplasty and verification of magnetic resonance imaging conditionality. Current systems are inadequate, associated with poorer patient surgical outcomes, significant time burdens on clinical staff, and increased healthcare costs. This study aimed to develop and evaluate a convolutional neural network classifier for identifying the model of orthopaedic implants in radiographs, with network performance compared to human expert performance.

Methods: 537 knee and 1191 hip unilateral anterior-posterior radiographs including 12 implant models, were collated retrospectively from a tertiary orthaopedic centre between March 2015 and November 2019, to develop a range of neural network classifiers. A subset of 315 images paired with auto-generated image masks were used to develop a U-Net segmentation network to automatically crop implants from radiographs for subsequent classification. Networks taking original radiographs and cropped implants as inputs were ensembled to provide a consensus prediction. Accuracies of five experts assisted by a reference radiographic image gallery were evaluated. Performance was compared using McNemar’s test with continuity correction.

Results: A consensus prediction from a combination of neural networks performed best, by processing U-Net-cropped implants as well as the full radiographs. Evaluated on a balanced unseen test dataset of 180 radiographs, the network achieved a 99.4% accuracy and 100% top 3 accuracy, and performed superiorly to all five human experts (76.1% median accuracy, 85.6% best accuracy; both p<0.0001). The network is robust to scan quality variation and difficult to distinguish implants, and identifies implants in under 20 seconds.

Conclusion: This is the first demonstration of supra-human expert performance of a neural network at identifying orthopaedic implant models in radiographs. Real-world application can now be readily realized through training on a broader range of implants and joints. To support this endeavor, all code and radiographs are being made available.

There is NO Conflict of Interest: Yes

1199 - Pulmonary embolism in lower limb arthroplasty: A retrospective review of 7858 patients over 8 years

J. Cruickshank1, E. Bagouri1, A. Wignall2, N. Muthukumar1, A. Mohsen1

1Hull Royal Infirmary, Trauma and Orthopaedics, Hull, United Kingdom, 2Leeds General Infirmary, Trauma and Orthopaedics, Leeds, United Kingdom

Background: Aspirin has been proposed as an alternative to direct thrombin inhibitors for thromboprophylaxis in lower limb arthroplasty and has been recommended by NICE, but published rates of PE are higher than those observed in our patients receiving Dabigatran.
This study aimed to determine the number of CTPA scans performed and the number of positive results for PE after elective lower limb arthroplasty. We also assessed whether there were differences between THR and TKR and the 120-day mortality from PE.

Design and Methods: We retrospectively analysed the use of CTPA as an inpatient and up to 120 days post operatively over an 8 year period. All patients received Dabigatran on discharge for 42 days for THR and 28 days for TKR. Medical records and imaging were reviewed for each patient undergoing CTPA.

Results: From 7858 patients, 143 scans were performed of which 27 were positive. The rate of PE was 0.41% for THR and 0.29% for TKR. The percentage of CTPA requests were similar but were less likely to be positive for TKR (15.2%) compared to THR (23.4%).
The overall 120-day mortality was 0.48% and in the group who underwent CTPA this was 4.2%. No patient who had a CTPA died from PE within 120 days of surgery.

Conclusion: Our rates of PE are comparable to large series in patients treated with Dabigatran but are lower than those recently published on Aspirin for TKR and slightly higher for THR. Patients who underwent a CTPA were at greater risk of mortality but this was not attributable to PE. This may represent a subset who are medically co-morbid and in whom there was lower threshold for suspecting a PE

Implications: Aspirin implementation as thromboprophylaxis in TKR needs consideration and patients should be counselled regarding the higher risk of PE compared to Dabigatran.

There is NO Conflict of Interest: Yes

1337 - Investigating the role of shear by defining the mean angle of non-union in long bone multi-fragmentary fractures

E. Allen1, J. Houston2, A. Trompeter2

1St. George's, University of London, London, United Kingdom, 2St. George's Hospital, London, United Kingdom

Background: Both mechanical and biological theories have been proposed in the development of non-union. With respect to mechanical theory, it is specifically the strain environment of a fracture which may predispose it to non-union. In multi-fragmentary fractures a non-union may form along any of the original fracture lines, however the plane which experiences the highest strain is at 45O – the shear plane. We hypothesise that in multi-fragmentary fractures the initial fracture line that most often fails to unite will tend towards 45O.

Methods: A retrospective cohort study of patients requiring treatment for diaphyseal or metadiaphyseal non-unions in the tibia or femur was performed. Those with multi-fragmentary fractures were included. A standardised technique was developed and utilised to measure fracture angles. The initial fracture and non-union x-rays were compared to determine which initial fracture plane matched the plane of the non-union. The resultant angle of established non-unions were recorded from AP and lateral X-rays. The means of both the initial fracture plane resulting in a non-union and the mean angle of non-union were calculated.

Results: Of the 108 non-unions screened, 61 formed within multi-fragmentary fractures. 3 were excluded due to inadequate imaging. 58 patients (mean age 48, range 20-84, M:F 43:15) were included. 36% of the fractures had 4 or more fragments. 33% of the fractures were femoral and 67% tibial. The mean angles of initial multi-fragmentary fracture planes resulting in non-union on AP & lateral x-rays were 50O(SD 19) and 48O(SD 17), while the mean angles of non-union were 41O(SD 20) and 49O(SD 18).

Conclusions: In patients with multi-fragmentary fractures that go on to non-union, the non-union angle tends towards 45O. This supports the hypothesis that biomechanical strain and the mechanical shear plane are important factors in the formation of non-unions.

There is NO Conflict of Interest: Yes

1355 - Outcome Following Percutaneous Lower Limb Fasciotomy for Chronic Exertional Compartment Syndrome

W. Oliver1, D. Rhatigan1, S. Mackenzie1, T. White1, A. Duckworth1, S. Molyneux1

1Royal Infirmary of Edinburgh, Edinburgh, United Kingdom

Background: The aim was to report the short- and long-term outcomes following percutaneous lower limb fasciotomy (PLLF) for chronic exertional compartment syndrome (CECS).
Methods: From 2013-2018, 38 patients (mean age 31 years [range 16-60], 71% [n=27/38] male) underwent PLLF. Patient background and surgical details were recorded. There were 21 (55%) unilateral procedures, 10 (26%) simultaneous bilateral and 7 (18%) staged bilateral. There were 22 (58%) anterior fasciotomies, five (13%) posterior and 11 (29%) four-compartment. Short-term outcomes were determined from medical records. The primary short-term outcome was complication rate. Long-term outcomes were obtained via postal survey. The primary long-term outcome was symptomatic improvement.
Results: Short-term follow-up was available for 37 patients (97%) at a mean of four months (range 1-19). Complications occurred in six patients (16%), including superficial infection (11%, n=4/37), deep infection (3%, n=1/37) and wound dehiscence (3%, n=1/37). Three patients (8%) required revision fasciotomy for recurrent leg pain.  Long-term follow-up was available for 27 patients (71%) at a mean of 3.7 years (range 0.3-6.4). Most patients (74%, n=20/27) were satisfied with the outcome of surgery and 81% (n=22/27) were likely to recommend the procedure. Eight patients (30%) were asymptomatic, with another 15 (56%) reporting improved symptoms. The mean pain score improved from 6.1 to 2.5 during normal activity and 9.1 to 4.7 during sport (both p<0.001). The mean EuroQol Five-Dimension Health Outcome score was 0.781 (range 0.130-1) and Visual Analogue Scale was 77 (range 33 to 95). Sixteen patients (64%) returned to sport, 75% of these (n=12/16) reporting improved exercise tolerance.
Conclusions: PLLF is a safe and effective procedure for patients with CECS, with a majority of patients satisfied and reporting good health-related quality of life. The revision rate is low, and most patients achieve symptomatic improvement, with reduced activity-related leg pain and high levels of return to sport.

There is NO Conflict of Interest: Yes

1373 - 5 year review of all ligation claims against orthopaedic trauma in England from 2013/14 to 2017/18

J. Machin1, J. Hardman2, C. Deacon1, D. Ferguson3, R. Handley4, T. Briggs5

1Nottingham University Hospitals NHS Trust, Trauma & Orthopaedic Surgery, Nottingham, United Kingdom, 2Whittington Health NHS Trust, London, United Kingdom, 3Barts Health NHS Trust, London, United Kingdom, 4Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom, 5Royal National Orthopaedic Hospital NHS Trust, London, United Kingdom

Introduction: Orthopaedics has historically had the highest volume of claims compared to other specialties. No paper in the literature has fully evaluated the contribution of trauma to the orthopaedic claims burden at a national level. In this paper we aim to provide the most accurate evaluation of volume and cost of claims brought against orthopaedic trauma. 

Methods: A data sharing agreement was set up between GIRFT and NHS Resolution to access data regarding all claims involving orthopaedic surgery between April 2013 and April 2018. This included claim status, clinical details, and cost breakdown. A predetermined protocol was used to classify claims by orthopaedic surgeons through a claim by claim review to provide a clinical analysis. 

Results: From 7012 claims brought against orthopaedic surgery during this period 2415 claims (34.44%) related to orthopaedic trauma. Of the claims identified as relating to orthopaedic trauma the following themes were found: 1301 claims (53.86%) related to diagnosis of which 473 claims (19.56%) were due to missed fracture and 117 claims (4.83%) due to missed ligament/tendon injury. A further 845 claims (35.02%) were due to unsatisfactory outcome to surgery with 163 claims (6.76%) related to accidental injury, 111 claims (4.59%) related to application of plaster or splint, 76 claims (3.14%) related  to consent, 70 claims (2.80%) related to deep vein thrombosis or pulmonary embolism and 58 claims (2.42%) related to surgical site infections. 

Conclusions: This study has provided the most detailed review in the literature of claims against orthopaedic trauma. Litigation is without doubt a serious concern for the sustainability of the specialty. Claims data must be used as a resource to improve patient care as well as reduce claim volume and cost. The data in this study will be used by 'GIRFT' to create specific clinical guidance for the profession. 

There is NO Conflict of Interest: Yes

1586 - Program for delivery of selective day case hip and knee replacement surgery in an elective orthopaedic centre is safe and confers a positive effect on length of stay full or joint replacement patients

G. Lovasz1, J. Va Faye2, A. Aros3, M. La Malfa4

1Barlborough NHS TC, Orthopedics, Chesterfield, United Kingdom, 2The Royal Orthopaedic Hospital NHS FT, Arthroplasty, Birmingham, United Kingdom, 3Barlborough NHS TC, Anaesthetics, Chesterfield, United Kingdom, 4Barlborough NHS TC, anaesthetic, Chesterfield, United Kingdom

Background: Day case hip and knee arthroplasty is gaining popularity worldwide. We investigated the safety of primary hip and knee arthroplasty with same day discharge (SDD) and their effect on length of stay (LOS) of traditional inpatient arthroplasties at our elective surgical centre.

Methods: Total of 150 patients underwent elective, primary day-case total hip (THA, n=71), total knee (TKA, n=43) and unicondylar knee replacements (UKA, n=36) over a 24-month period. SDD rate, reasons for failure to discharge, readmission, complication and satisfaction rates were recorded at 6-week follow up. Changes in LOS of all inpatient hip and knee arthroplasties treated totalling 3200 patients over this period and complications, readmissions were tracked.

Results: Of the 150 patients enrolled into the programme 130 patients (87%) had a successful SDD while 20 needed overnight stay. Main reasons for failure to discharge were due to single vasovagal episode, lack of confidence and urine retention. 4 patients (3%) had readmission within 6 weeks, including 1 with a partial pulmonary embolism. Patient satisfaction rate was 98%.
Importantly, with the introduction of day case arthroplasty (DCA) program, the ratio of standard pathway patients staying only one night at the centre increased from 12% to 50% over the same time period with no change to complication and readmission rates.

Conclusion: Introduction of routine SDD programme for hip & knee arthroplasty at an elective orthopaedic surgical centre is safe and confers a positive general effect, leading to safe and shorter hospital stay for all inpatient joint replacements. This has a beneficial impact on opportunity costs.

There is NO Conflict of Interest: No

Hands and Tumours

Virtual Podium Presentations

68 - Long-term outcome of complex intraarticular phalangeal fracture fixation using the Ligamentotaxor® device

A. Abouelela1, i. Mubark1, N. Ashwood1, K. Christos1

1University Hospital of Derby and Burton, Queens Hospital Burton, Trauma and Orthopaedics, Burton on Trent, United Kingdom

To evaluate long-term outcomes of using Ligamentotaxor® in treating complex fractures involving the PIP & DIP joints and to determine whether this technique is easy to perform, reliable and reproducible.

Methods: Retrospective study of all patients treated with Ligamentotaxor® for unstable Intra-articular phalangeal fractures in our institution between 2009 and 2018. 29 patients were included and evaluated using both objective (range of motion, and regular X-rays) and subjective QuickDASH score for global function. Out of the 29 Patients, 68% were males and 7% were open injuries. Fractures were classified according to Pélissier’s classification based on the initial radiographs. A gentle active motion was permitted on the day following surgery. The device was removed on average 33 days after surgery.

Results: An average of 27.5 months (70-12) follow up; Radiological union was achieved in all patients at mean 33 days. The mean QuickDASH score was 8.7. 85% of the patients had no limitation of their daily activities and 35 % experience pain on exertion. The mean flexion of the affected digit was 66 degrees and the mean extension deficit was 6 degrees. Neither secondary subluxation nor complex regional pain syndrome was reported in any of the cases. Only one case of superficial pin tract infection was reported and responded well to one week of oral antibiotics. Cold intolerance and persistent swelling were reported in four cases. Neither of the cases needed revision by fusion nor replacement.

Conclusion: Ligamentotaxor® is easy and quick to apply by surgeons and well tolerated by patients, and therefore this reliable technique could be relevant for the management of complex PIP and DIP joint fractures. The device allowed adequate fracture reduction, early mobilization with minimal soft tissue complications.

There is NO Conflict of Interest: Yes

135 - Management of scaphoid fractures using a computerised tomography scan and virtual fracture clinic pathway reduces requirement for clinic follow-up and is cost-effective

A Dutta1, G Crate2, N Bakti3, J Nicholl1

1Tunbridge Wells Hospital, Trauma & Orthopaedics, Royal Tunbridge Wells, United Kingdom, 2St. George's Hospital, Trauma & Orthopaedics, London, United Kingdom, 3William Harvey Hospital, Ashford, United Kingdom

Aims: This study introduced a computerised tomography (CT) pathway in conjunction with the virtual fracture clinic (VFC) in order to reduce the number of unnecessary clinic appointments for patients with a suspected scaphoid fracture.

Methods: The study was conducted at a busy District General Hospital. Pre-pathway data was collected from February to May 2017, with 176 patients presenting to the Emergency Department (ED) with a suspected scaphoid fracture. The pathway began in February 2018: patients presenting to the ED with a clinically suspected scaphoid fracture, but an indeterminate radiograph would have a CT scan, the results of which would be reviewed in the VFC. Those with a confirmed fracture would be seen in face-to-face clinic, and those without discharged. Post-pathway data was collected from May to July 2018, with 111 patients included. Patient pathway outcome measures were analysed, and a cost analysis performed.

Results: 164 of the pre-pathway patients were given a face-to -face fracture clinic appointment and of these 76 were discharged after their first visit. 9 patients presented to fracture clinic, had a CT scan, and were discharged with no fracture. If these patients had been referred to the VFC, had CT scans, and directly discharged, it would have saved £1,629.
41 patients from the post-pathway group had a CT scan and were discharged from the VFC. Avoiding fracture clinic appointments saved £7,421. Extrapolating, the annual savings would be £29,687.

Conclusions: This study shows that a pathway that uses the VFC to review patients presenting with a suspected scaphoid fracture, and arranges CT scans for those in whom the diagnosis is unclear with plain radiography alone, is a safe and cost-effective pathway to manage patients, reducing unnecessary face-to-face follow up.

There is NO Conflict of Interest: Yes

633 - How long does it take for a day case hand surgery procedure?

P. Kodumuri1, D. Samson2, M. Elmajee3, M. Brewster4

1Wrexham Maelor Hospital, Trauma and Orthopaedics, Wrexham, United Kingdom, 2University Hospitals Coventry and Warwickshire, Trauma and Orthopaedics, Coventry, United Kingdom, 3University Hospitals Birmingham, Trauma and Orthopaedics, Birmingham, United Kingdom, 4University Hospitals Birmingham, Hand Surgery, Birmingham, United Kingdom

Introduction: Surgeons are often criticised for under-estimating the time necessary to perform a surgical procedure. The primary aim of this study was to calculate the whole operation time (from entry into anaesthetic room to leaving theatre), theatre time (from entry into theatre to leaving theatre) and surgical time (from start of operation to finish) for day case hand surgery procedures performed at four hospitals in one year between 1 January and 31 December 2018.

Methods: Retrospective anonymised data was cross-checked with theatre records to ensure no cases were missed. This was analysed using Excel spreadsheet.

Results: We evaluated 766 procedures over one year. There were 448 carpal tunnel decompressions (CTD), 59 cubital tunnel decompressions (CuTD), 76 trigger finger releases, 62 trapeziectomies and 116 dupuytren’s fasciectomies. The mean whole operation time for CTD was 48 minutes (range 19-59 min), CuTD was 110 minutes (range 34-257 min), trigger finger release was 50 min (Range 21 – 156 min), trapeziectomy was 142 minutes (Range 64-280 min) and dupuytren’s single digit fasciectomy was 136 minutes (range 24-206 min).
The grade of the primary operation surgeon (consultant versus junior trainee), type of hospital (elective versus trauma) had no statistically significant impact on the surgical time for a day case hand surgical procedure.

Conclusion: Our study provides accurate information on the time required for several day case hand surgery procedures. We found that the wide variations in ranges denote several factors such as admission process, type of anaesthetic and location of administration of anaesthetic play an important role in the theatre turnaround. Close attention to these details will help surgeons to accurately determine whole operation time and maximise theatre efficiency.

There is NO Conflict of Interest: No

915 - Effectiveness of pharmacological adjuncts for the prevention of adhesions in hand flexor tendon surgery: a systematic review and meta-analysis of randomised studies

E. Murray1, D. Challoumas2,3, A. Putti4, N. Millar2

1University Hospital Wishaw, Department of Trauma & Orthopaedics, Wishaw, United Kingdom, 2University of Glasgow, Institute of Infection, Immunity and Inflammation, College of Medicine, Veterinary and Life Sciences, Glasgow, United Kingdom, 3University Hospital Ayr, Department of Trauma & Orthopaedics, Ayr, United Kingdom, 4Forth Valley Royal Hospital, Department of Trauma & Orthopaedics, Larbert, United Kingdom

Background: The aim of the present systematic review and meta-analysis was to summarise all the available evidence deriving from randomised controlled trials (RCTs) assessing the effectiveness of pharmacological interventions for the prevention of adhesions after hand flexor tendon repair.

Methods: A thorough literature search was conducted via Medline, EMBASE, Scopus and Cochrane database in June 2020. Our primary outcome was measures of finger range of motion and the secondary outcomes included ruptures and other complications. Follow up was defined as short-term (<12 weeks), mid-term (12 weeks to 6 months) and long-term (>6 months). Risk of bias was assessed with the Cochrane Collaboration tool and the certainty of evidence with the GRADE tool.

Results: The 8 eligible RCTs assessed locally-administered ADCON-T/N (n=3), sodium hyaluronate (n=3), PXL-01 (n=1) and mannose-6-phosphate (n=1) versus placebo or no treatment after primary flexor tendon repair (n=7) or after tenolysis for adhesions secondary to flexor tendon repair (n=1). For ADCON-T/N, no benefits were detected for total active motion (TAM) of the interphalangeal joints [IPJs; MD 1.71 (-21.54, 24.96), P=0.74] or active motion of the IPJs separately in the short-/mid-term. Similarly, no mid-term differences were found in TAM between sodium hyaluronate and placebo [SMD 0.19 (-0.18, 0.56), P=0.31]. These results are based on low certainty of evidence due to imprecision and high overall risk of bias. Based on limited evidence deriving from single studies, PXL-01 and mannose-6-phosphate do not appear effective compared to standard care alone. All assessed pharmacological interventions appear safe in terms of tendon ruptures.

Conclusion: Despite their safety, ADCON/T-N, sodium hyaluronate, PXL-01 and mannose-6-phosphate administered locally at the time of surgery do not appear more effective than standard care for the prevention of post-operative adhesions after flexor tendon repair. Large, well-designed RCTs are needed to confirm or dispute our results.

There is NO Conflict of Interest: Yes

47 - Osseointegrated Reconstruction for Lower Limb Amputees Following Treatment of Tumours

MA Akhtar1,2, W Lu2, C Roberts2, K Tetsworth2, M Al-Muderis2

1Victoria Hospital, Kirkcaldy, United Kingdom, 2Macquaire University Hospital, Trauma and Orthopaedics, Sydney, Australia

Introduction: Amputation is a treatment option for lower limb tumours when limb salvage surgery is not possible. Our aim was to study the outcomes following osseointegrated reconstruction in these patients.

Methods: Data was collected prospectively for 36 patients including demographics details, type of tumour, amputation level, time between amputation and osseointegrated reconstruction, length of follow-up, mortality, and post-operative complications. Outcomes were recorded using SF-36 Health Survey, Questionnaire for Persons with a Transfemoral Amputation(Q-TFA), Timed Up and Go (TUG), and the 6 Minute Walk Test.

Results: The mean age was 48 years (22-73). The level of amputation was transfemoral in 33 and transtibial in 3 patients. The average length of follow up was 4 years. The tumours included osteosarcoma in 21, chondrosarcoma in 3, Ewing’s sarcoma and myxoid liposarcoma in 2 patients each, and assorted other tumours. The mean time between amputation and osseointegration was 20 years. There was no mortality, although 2 patients each had infection, fracture, and aseptic loosening post-operatively. There was improvement in SF-36 physical component score (41to47), Q-TFA global score (44 to72), TUG test in mobile patients (11.4 to 9.8 seconds), and 6 Minute Walk Test (307 to 375 meters). 3 wheelchair bound patients were able to walk independently with a mean TUG of 10 seconds and mean 6 Minute Walk Test of 373 meters.

Conclusions: We identified 36 osseointegrated lower limb reconstructions following amputation for lower limb tumors. The most common tumour was osteosarcoma in 21 patients (58%). There were 6 complications (2 infections, 2 fractures, and 2 aseptic loosening). There was an improvement in the SF 36, Q-TFA, and 6 Minute Walk Test. We recommend the use of this novel technology in lower limb amputees following treatment of tumours to improve their quality of life.

There is NO Conflict of Interest: No

Disclosure: Munjed Al-Muderis has shares in Osseointegration International Pty Ltd
William Lu has attended meetings with the sponsorship of Osseointegration International Pty Ltd
Claudia Roberts is the Clinical Coordinator and Rehabilitation Manager of Osseointegration Group of Australia

138 - Predictors of survival local recurrence and metastases of Leiomyosarcomas of trunk wall and extremities: a retrospective study

S. Kannan1,2, J.D. Ferguson3, K.S. Rankin2, R.U. Ashford4

1Health Education England - North East, Newcastle, United Kingdom, 2Newcastle University, NICR, Newcastle, United Kingdom, 3Newcastle University, Newcastle, United Kingdom, 4University Hospitals of Leicester, Leicester, United Kingdom

Introduction: The Leiomyosarcomas are aggressive neoplasms with poorly understood, accurate prediction of their behavior have proven to be difficult, and, there are no universally accepted prognostic factors.
Our aim was to identify the risk factors for early recurrence, metastases and poor survival.

Methods: We included 97 patients who had Leiomyosarcomas involving trunk wall and extremities, identified from pathology records from Newcastle upon Tyne Hospitals Foundation Trust.
All tumours showing characteristic, pure smooth muscle differentiation were included.Purely cutaneous tumours with no subcutaneous extension, RP, major vessel and uterine LMS were excluded. We collected demographic, clinical, histopathologic and imaging data. Overall survival, local recurrence and metastasis were the outcome measures. We have used Kaplan Mier plot, Uni and multivariate analysis for prognostication.

Results: The mean survival was 60.8 months (SD 49.3). 51 (57.3%) of the tumors where high-grade. Besides, 41 (62.1%) of the tumors were more than 5 cm.38 (58.4%) of these tumors were located deep to deep facia.
The most common site of origin was thigh accounting for 38% of patients (24/ 63). 14% patients had local
recurrence.56% of patients developed metastases. Most of the patients were at stage 2 during the time of diagnosis (42.8%: 18/41).
The multivariate analysis suggested that age > 60 years (p value 0.02) was an independent predictor of poor survival. Whereas, induction treatment (p value 0.04) independently predicted better survival.
The univariate analysis suggested that size > 5 cms (p value 0.029) and higher grade (p value 0.02) as possible prognostic factors predicting metastases. Similarly, induction treatment was associated with lower risk of metastases (p value 0.003).

Conclusion: Age > 60 years is an independent factor predicting death. Whereas Induction treatment is associated with better survival and probably lower metastasis.
Besides, >5 cm and high-grade tumors could potentially predict of higher risk of metastases.

There is NO Conflict of Interest: Yes

470 - The efficacy of adjunctive topical tranexamic acid for blood salvage in patient undergoing palliative decompressive spinal metastasis surgery. A Randomized double blinded controlled trial

R Maethungkul1, A Sangsin1

1Faculty of Medicine, Chiangmai University, Orthopaedic, Meaung, Chiangmai, Thailand

Background: Palliative decompressive spinal metastasis surgery is associated with massive postoperative blood loss and transfusion rate. Topical tranexamic acid (TXA) are shown to reduce blood loss in traumatic or degenerative spinal surgeries but there is no evidence in decompressive spinal metastasis surgery. Thus, this randomized trial was conducted to evaluate the efficacy of adjunctive topical TXA in palliative decompressive thoracolumbar spinal metastasis surgery 
Method: A total of 65 patients underwent palliative decompressive thoracolumbar spinal metastasis surgery. In 33 patients, 1 g of TXA (20 ml) were soaked in absorbable gelatin sponge and placed lateral to decompressive site. The 32 patients in control group received the same procedures but normal saline at the same volume was used instead of TXA. All of the patients received standard 1 g intravenous TXA just before starting the operation. Primary outcome was postoperative blood loss and secondary outcome were postoperative transfusion rate and complication
Result: No differences were found in postoperative blood loss (p=0.24) and postoperative packed red cell transfusion (p=0.59) between topical TXA and control group. In topical TXA group postoperative blood loss was 790±493 ml while that of the control group was 670±526.5 ml. Packed red cell transfusion was 0.58±0.75 and 0.75±0.95 unit in topical TXA group and control group respectively. No complication related to tranexamic acid and absorbable gelatin sponge was observed. 
Conclusions: Adjunctive topical TXA does not provide additional benefit to prophylactic intravenous TXA in terms of postoperative blood loss and transfusion rate in patient undergoing palliative decompressive thoracolumbar spinal metastasis surgery
Trial registration: TCTR20190831001

There is NO Conflict of Interest: Yes


K Hoban1, S Downie1, A Jariwala2

1NHS Tayside, Trauma and Orthopaedics, Dundee, United Kingdom, 2NHS Tayside and University of Dundee, Trauma and Orthopaedics, Dundee, United Kingdom

The most common cause of destructive bone lesions in the adult population is metastatic bone disease, the humerus being the second most frequently affected long bone.  There are few large cohort studies but small numbers of patients included with upper limb metastases makes pathological fracture prediction difficult.  Mirels’ score predicts the likelihood of sustaining a pathological fracture using pain, lesion site, size and morphology. In femoral fracture prediction, the score has a sensitivity of 91% and specificity of 33% but its reproducibility, reliability and validity are questioned in the upper limb.
We aimed to investigate the accuracy of Mirels’ score in predicting metastatic upper limb fractures and attempt validation in a single-centre cohort study.
It was a retrospective cohort study of 45 patients with upper limb metastases referred to a UK Trauma & Orthopaedic department over 6-years (2013-18). Minimum follow-up =1 year.
The fracture rate of metastatic lesions was 50% and did not significantly increase at 6-months; the highest risk of pathological fracture was within the first 3 months of diagnosis. Overall rate of progression to surgery was 57% (in the same centre, rate for femoral metastases =71%). In patients with a calculated Mirels’ score, data suggested it was a poor discriminator at predicting upper limb pathological fractures, perhaps due to variable weight-bearing status compared to lower limbs.
The current study is the first to note Mirels’ score was insufficient to accurately predict impending fractures. Alternative parameters will need to be identified to provide a better tool for clinical practice.

There is NO Conflict of Interest: Yes

1003 - Accuracy of Computerised Tomography (CT) as guide for the resection margins in endoprosthetic replacement for femoral metastatic bone disease.

N. Dalal1, E. Debuka1, M. Kiran1, B. Kapoor1, G. Kumar1

1Liverpool University Foundation NHS Trust, Orthopaedics, Liverpool, United Kingdom

Background: Endoprosthetic replacement (EPR) is considered in femoral neck/head large lesions and/or longer expected survival in metastatic bone disease (MBD). Magnetic Resonance Imaging (MRI) or Computerised Tomography (CT) is used to assess lesion details. CT may not show subtle medullary involvement. There is a risk of disease positive margin when resection length is based on CT. 
Aim: Purpose was to assess CT in determining femoral resection length to achieve disease free margin in EPR for MBD.
Methods: Between May 2011 and May 2019, we identified patients with femoral MBD who underwent EPR. Inclusion criteria: whole femur CT, histopathological examination (HPE) of resected specimen. Exclusion criteria: EPR for non-pathological fracture or infection and no whole femur CT. Data collected: patient demographics, primary cancer, presence/absence of pathological fracture, femoral resection length - CT templating and surgical, and HPE report for margin status.
Results: There were 49 patients (27 males/ 22 females) with average age of 68 years (33 to 84). Common primary cancers were breast (13), renal (10), lung (8) and prostate (6). Lesion were lytic (45), sclerotic (3) or mixed (1). There were 43 proximal and 6 distal femoral cemented EPRs. CT templating and surgical resection lengths were the same. HPE reports showed 2 patients had positive margins (breast and prostate [both lytic lesions]). Retrospective assessment of CT and MRI of breast MBD and CT of prostate MBD with positive margins showed the planned resection length was appropriate.
Three patients with medullary or permeative lesions had MRI of the femur too. Calculated resection lengths using MRI and CT were similar and HPE reports showed clear margins. None of the EPRs required revision surgery.

Conclusion: CT can be used with caution to determine resection length in femoral MBD. There is a risk of tumour positive resection margins, especially in aggressive lytic lesions.

There is NO Conflict of Interest: Yes

1022 - Disease recurrence in giant cell tumour of bone treated with neo-adjuvant denosumab: a systematic review.

F. Power1, C. McDonald1, L. Mellon2, A. Molloy1, G. O'Toole1

1National Orthopaedic Hospital Cappagh, Department of Orthopaedic Surgery, Dublin, Ireland, 2Royal College of Surgeons in Ireland, Division of Population Health Sciences, Dublin, Ireland

Background: Denosumab is currently being used as a neo-adjuvant systemic therapy in an effort to reduce local disease recurrence and facilitate intra-lesional curettage of giant cell tumour of bone (GCTB) despite limited and conflicting evidence to support such use.

Methods: A comprehensive search strategy incorporating the Methodological Expectations for Cochrane Intervention Reviews (MECIR) was implemented which included database and citation searches, hand searching of selected journals and screening of key study references lists. Randomised controlled trials (RCT) or non-randomised studies (NRS) with control groups that evaluated the effect of neo-adjuvant denosumab on disease recurrence in skeletally mature individuals with GCTB treated with curettage were included for analysis.

Results: No RCTs were identified. Five NRS (n= 370) met the review inclusion/exclusion criteria for the primary outcome measure of local disease recurrence and all five suggested that the use of neo-adjuvant denosumab was associated with an increased risk of local disease recurrence (RR 2.14 to 14.14). A meta-analysis was deemed inappropriate given the degree of methodological heterogeneity between studies and a narrative synthesis was provided.

Conclusions: The presence of significant risk of bias and methodological heterogeneity means that strong conclusions cannot be drawn from the available evidence. Given the consistency in direction and magnitude of effect seen across the included studies however there is a suggestion that the use of neo-adjuvant denosumab may be associated with an increased risk of local disease recurrence in GCTB.

Implications: The findings raise concerns regarding the use of neo-adjuvant denosumab in GCTB treated with curettage and RCTs are urgently required to provide better quality data.

There is NO Conflict of Interest: Yes

1777 - 3D printed custom resection jigs reduce intra-operative complications and decrease surgical time in patients with primary malignant bone tumours

M.A. Williams1, M. Richard2, H. Branford-White1, D. Whitwell1, C.L.M.H. Gibbons1, T.D.A. Cosker1

1Nuffield Orthopaedic Centre, Oxford, United Kingdom, 23D LifePrints, Oxford, United Kingdom

Background: Tumour and Revision Surgery represent some of the most challenging aspects of Orthopaedics. Complex osteotomy around a tumour represents a fundamental technique in orthopaedic oncology, and is often the most crucial step in a procedure. Understanding the 3d anatomy of a difficult primary bone tumour remains challenging. Placement and direction of osteotomy is therefore an important factor considered during peri-operative planning, relying on interpretation of CT and MRI imaging. We present a method of generating custom tailored cutting guides designed from patient CT data and MRI as applied to resection of primary malignant bone tumours.

Methods: Pre-operative high resolution CT and MRI images were acquired in DICOM format and semi-automatically segmented by Hounsfield Units using Simpleware IP to create a preliminary mesh. An expert anatomical artist was then employed to refine the 3D model, under the supervision of a consultant orthopaedic oncology surgeon, manually adding any missing data, before designing the cutting guide around the patients anatomy with millimetre precision. This cutting guide was then imported into GrabCAD and printed on a Connex3 object 260 3D printer.

Results: 8 cases were included in the study group including 3 high grade chondrosarcomas, 3 osteosarcomas and 2 isolated metastatic deposits. The mean age was 56. There were 5 females and 3 males. All cases had custom made patient specific jigs constructed which were deployed intra-operatively. All patients had adequate histological margins (>5mm) and operative time was reduced by use of the jigs. There were no significant complications.

Conclusions: 3D printing offers the potential to provide custom, patient specific, tools to augment the practice of the Orthopaedic Oncology surgeon in a new era of patient centred care. Moreover, the techniques utilised here are readily commercially available and reasonably priced. They show promise in reducing intra-operative risk and surgical time.

There is NO Conflict of Interest: Yes

1828 - Tumours of The Biceps Brachii Muscle – Popeye and its mimics

A. Saad1, C. Azzopardi2, G. Almeer1, G. Sharma1, H. Gupta1, R. Botchu2

1Royal Orthopaedic Hospital, Orthopaedics, Birmingham, United Kingdom, 2Royal Orthopaedic Hospital, Radiology, Birmingham, United Kingdom

Introduction: Soft tissue tumours of the upper extremity are uncommon. Moreover, tumours of the biceps brachii muscle (BBM) are extremely rare and their prevalence is unknown, presenting with non specific symptoms closely mimicking that of biceps tendon rupture. We performed this study and report the largest series of bicep brachii lesions, highlighting tumours simulating the Popeye sign to ensure adequate diagnosis and early management is initiated.

Material and methods: We performed a retrospective study of our radiology and oncology databases of a tertiary orthopedic oncology centre to identify all lesions of the muscle belly of biceps brachii over the last 12 years

Results: We identified a total of 18 cases of tumours involving the BBM. There was a male predominance with a male-to-female ratio of 1.6:1 (11 males and 7 females). The mean age of our cohort was 67 years (47 – 89 years.) Majority (n = 11) of BBM lesions were benign with intramuscular lipomas being the most common constituting 50% of all cases (n = 6). (Figure 2) Other benign tumours were comprised of two hematomas, two vascular malformations, one myxoma.
There were 7 malignant tumours identified within our cohort, of which two were pleomorphic sarcomas. The remaining 5 cases constituted of a spindle cell sarcoma, a leiomyosarcoma, myxoid liposarcoma, a high-grade B cell lymphoma and a metastatic clear cell carcinoma

Conclusion: BBM tumours are rare, and we report the largest case series of BBM tumours. These can mimic a popeye sign ( rupture of long head of biceps tendon with distal retraction of muscle belly).

There is NO Conflict of Interest: Yes


Virtual Podium Presentations

253 - A non-inferiority RCT comparing the effectiveness and safety of aspirin vs rivaroxaban in post-operative thromboprophylaxis in primary hip arthroplasty with the Intention-to-treat

M Tahir1, AR Jamali1, G Mahboob1, FuK Zimri2, S Khan3

1Jinnah Postgraduate Medical Centre, Orthopaedics, Karachi, Pakistan, 2National Institute Rehabilitation of Medicine, Orthopaedics, Islamabad, Pakistan, 3Whiston Hospital NHS Trust, Orthopaedics, Prescott, United Kingdom

Introduction: To evaluate the effectiveness and safety of Aspirin with Rivaroxaban in preventing symptomatic Deep Venous Thrombosis and Pulmonary Embolism after primary and revision hip replacements.

Methods: A randomized controlled trial on 3208 patients who underwent primary and revision hip replacement for various causes were randomized by a computer-generated algorithm stratified by age, sex and type of arthroplasty. The group which was allocated to treatment with rivaroxaban received -10 mg of Rivaroxaban daily for 30 days of treatment and the other group received 81 mg dose aspirin for 30 days.

Results: The incidence of Deep Venous Thrombosis and Pulmonary Embolism at 30 days in primary hip replacement patients was 1.15% and 0.90%, and 1.32% and 0.30% and in Rivaroxaban and Aspirin group respectively.
Summing the results of primary and revision hip replacement patients, there was no significant difference in 30-day, 90-day, and 1-year Deep Venous Thrombosis and 30 and 90 day bleeding episodes between Aspirin and Rivaroxaban group under 0.05 significant level.
Compared with Rivaroxaban users, patients treated with Aspirin in primary surgery had a lower probability of developing Pulmonary Embolism at 30 days, at 90 days, and at 1-year follow-up (ORs, 0.18 (0.04 – 0.82), 0.21 (0.06 – 0.75), and 0.21 (0.06 – 0.75), respectively).
Similarly, patients treated with Aspirin had a lower probability of developing wound hematoma under 30 days and mortality within 30 days and under one year (ORs, 0.38 (0.18 – 0.78), 0.07 (0.01 – 0.55), and 0.53 (0.32 – 0.87), respectively) in comparison to Rivaroxaban.

Conclusions: Aspirin may be an effective and safe option for Venous thromboembolism prophylaxis in patients receiving primary hip replacements and can be considered as an alternative to Rivaroxaban.

There is NO Conflict of Interest: Yes

297 - The National Hip Fracture Database is only as good as the data we feed it - significant inaccuracy demonstrated and how to improve it

L Maling1, C Gray-Stephens2, K Malik-Tabassum3, O Weiner2, M Marples2, G Faria1, R Middleton2

1East Kent Hospitals University Foundation NHS Trust, Margate, United Kingdom, 2Royal Cornwall Hospitals NHS Trust, Truro, United Kingdom, 3East Sussex Healthcare NHS Trust, Hastings, United Kingdom

Purpose: The National Hip Fracture Database of England, Wales and Northern Ireland (NHFD) is the largest such database in the world. Data errors in within the NHFD lead to spurious evidence which ultimately informs Orthopaedic, Anaesthetic and Orthogeriatric clinical practice.

Methods: This multi-centre quality improvement study investigated, and sought to improve data inaccuracy within the NHFD. Hip arthroplasty episodes recorded between 2011-2020 were analysed for errors in operation, implant type and cementation.

Results: Inaccuracies were observed in 20.5% of 3972 data entries. Following the introduction of a hip fracture clinical data administrator in each centre, inaccuracies reduced four-fold (5.2% of 559 data entries).

Conclusions: We advise caution when utilising NHFD data for research and audit purposes. In order to build a robust, accurate database for future research, we recommend the incorporation of specialist data administrators into the hip fracture multidisciplinary team.

There is NO Conflict of Interest: No

378 - Incidence of peri-prosthetic fracture with the cemented collarless polished taper stem: the Nottingham experience

M Higgins1, S Hudson1, R Gnap1, J Harvey1, A Manktelow1

1Nottingham University Hospitals HS Trust, Orthopaedics, Nottingham, United Kingdom

Introduction: Peri-prosthetic fractures (PPF) are a serious complication of total hip replacement (THR). Recent publications have suggested a higher prevalence of PPF with the CPT® stem compared to other polished taper stem designs and a higher revision rate for PPF in the UK National Joint Registry (NJR). The incidence of PPF was assessed in a consecutive series of patients undergoing elective THR in an NHS teaching hospital.

Methods and materials: NJR records were obtained for consecutive patients receiving a CPT® stem since its introduction with a minimum 4 year follow up. Data were cross-checked against a prospective local trauma database. All available imaging carried out after primary surgery was reviewed on a regional digital x-ray platform and details of any fractures recorded. Canal morphology was assessed using cortical thickness index (CTI)and Dorr classification and technical performance was calculated by measuring stem alignment and barrack cement grade.

Results: 550 stems were reviewed in 505 patients with a mean age 66 years (SD 14), 14% 80+ years and 69% females. 91% of femurs were Dorr B and the mean CTI was 0.55 (SD 0.08). There were no revisions for fracture at a mean of 71 months (range 50 – 127). We observed 2 PPF at intervals of 22 and 25 months, treated with open reduction internal fixation. The incidence of PPF was 0.36%.

Discussion: Results of this series demonstrate no evidence of an increased incidence of revision for PPF when using the CPT® stem. Registry data has the potential to underestimate PPF incidence in fractures that do not lead to revision.

Conclusions: The incidence of fracture compares favourably with published results of other cemented polished taper stems and there was 100% survivorship of stems at a mean of 6 years follow-up when taking revision for PPF as the end-point.

There is NO Conflict of Interest: Yes

512 - Evidence-based follow-up recommendations following Primary Hip and Knee replacement (UK SAFE)

M Stone1,2,3, L Smith4, S Kingsbury5,2,3, C Czoski-Murray,6, A Judge7,8, R Pinedo-Villanueva9, R West6, J Wright6, C Smith6, N Arden9, P Conaghan5,3,10

1Chapel Allerton Hospital, Leeds,, Orthopaedic Surgery, Leeds, United Kingdom, 2LMBRC, Leeds, United Kingdom, 3NIHR, Leeds, United Kingdom, 4Weston Area Health Authority, Weston-Suoer-Mare / Bristol, United Kingdom, 5LIRMM, Leeds, United Kingdom, 6Leeds Institute of Health Sciences, Leeds, United Kingdom, 7Bristol University, MSK Research Unit, Bristol, United Kingdom, 8Medical Research Council, Southampton, United Kingdom, 9Nuffield Orthopaedic and Rheumatological Sciences, Oxford, United Kingdom, 10Biomedical Research Centre, Leeds, United Kingdom

Background: Follow-up of arthroplasty varies widely across the UK. The aim of this NIHR-funded study was to employ a mixed-methods approach to examine the requirements for arthroplasty follow-up and produce evidence-based and consensus-based recommendations. It has been supported by BHS, BASK, BOA, ODEP and NJR.
Methods: Four interconnected work packages were undertaken: (1) a systematic literature review; (2a) analysis of routinely-collected National Health Service data from four national datasets to understand when and which patients present for revision surgery; (2b) prospective data regarding how patients currently present for revision surgery; (3) economic modelling to simulate long-term costs and quality-adjusted life years associated with different follow-up care models and (4) a Delphi- consensus process, involving all stakeholders, to develop a policy document to guide appropriate follow-up care after primary hip and knee arthroplasty.
Results: The following Recommendations were agreed:

  • For ODEP10A* minimum implants, it is safe to disinvest in routine follow-up from 1 to 10 years post non-complex hip and knee replacement provided there is rapid access to orthopaedic review 
  • For ODEP10A* minimum implants in complex cases, or non-ODEP10A* minimum implants, periodic follow-up post hip and knee replacement may be required from 1 to 10 years
  • At 10 years post hip and knee replacement, we recommend clinical, which may be virtual, and radiographic evaluation. 
  • After 10 years post hip and knee replacement, frequency of further follow-up should be based on the 10 year assessment; ongoing rapid access to orthopaedic review is still required.

Conclusions and Implications: These recommendations apply to post primary hip and knee replacement follow-up.
The 10-year time point in these recommendations is based on a lack of robust evidence beyond ten years. The term complex cases refer to individual patient and surgical factors that may increase the risk for replacement failure.
Disclosures: Funded by NIHR HS&DR.

There is NO Conflict of Interest: Yes


K.K. Dash1, A. Saad1, I. Wilson1, I. Malek1

1Wrexham Maelor Hospital, Trauma and Orthopaedics, Wrexham, United Kingdom

Background: Hip abductor tendon (HAT) failure following anterolateral total hip replacements (THR) is uncommon but extremely difficult to treat, with no reliable procedures. Results of HAT reconstruction augmented by Ligament Augmentation and Reconstruction System (LARS) in native hips is encouraging. However, evidence is scarce for LARS as a salvage procedure for HAT failure following THR. We report early results of utilisation of this technique.

Methods: Multi-surgeon, single-centre, consecutive series of all HAT tear reconstructions with LARS augmentation in the period from Sep-2018 to Nov-2019. Ten reconstructions performed in 9 patients (one bilateral) (7 females, 2 males) (average age 73.4 years). Surgical technique involved mobilisation of abductors from pelvis, reattachment using suture anchors, augmented with LARS. Clinical outcomes were assessed in Feb-2020 (mean follow-up duration – 364 days) independently by a doctor not previously involved in care.

Results: Mean time-gap between THR and LARS procedure was 23 months (range 11 – 35). Oxford Hip Score improved from prior surgery (mean 17, median 11.5) to post-surgery (mean 29.1, median 33) (statistically significant, Wilcoxon-signed-rank-test). Lateral hip pain improved from an average of 6/10 on visual analogue scale pre-surgery to 2/10 after surgery. Antigravity abductor power (MRC grade 3 or more) was achieved in 6 out of 10 cases after surgery. Trendelenburg test remained positive in 6 cases; however mobility (walking distance and need for assistive devices) improved in 6 out of 10 cases. In 8 out of 10 cases, patients were either ‘satisfied’ or ‘very satisfied’ with the outcome.

Conclusion: Allowing for limitations of this study (small sample size, no control arm), LARS augmented hip abductor reconstruction appears to improve pain, function and patient satisfaction in most patients presenting with hip abductor tears following THR. Authors believe patients should be involved pragmatic discussion that some amount of weakness in abductors and gait issues may persist.

There is NO Conflict of Interest: Yes


L. Farrow1,2, A. Hall3, A. Ablett4, L. Aucott5, P. Myint4

1University of Aberdeen, Aberdeen Centre for Health Data Science, Aberdeen, United Kingdom, 2Aberdeen Royal Infirmary, Trauma & Orthopaedics, Aberdeen, United Kingdom, 3Royal Infirmary Edinburgh, Trauma & Orthopaedics, Edinburgh, United Kingdom, 4University of Aberdeen, School of medicine medical sciences and nutrition, Aberdeen, United Kingdom, 5University of Aberdeen, Health Services Research Unit, Aberdeen, United Kingdom

Introduction: Despite widespread acknowledgement that the determinants of hip fracture outcomes are complex and multifactorial, there is surprisingly little evidence regarding the influence of hospital level service characteristics on hip fracture care. 

Methods: We set out to address this knowledge gap through a retrospective cohort study utilising publically available national audit registry data from the National Hip Fracture Database (NHFD). Analysis included details of hospital level variables and outcomes for 176 participating hospitals treating over 66,000 hip fracture patients.

Results: The primary outcome was 30 day mortality. Univariable outcome analysis for hospital level service provision factors revealed that the only predictor of 30 mortality was hip fracture trial involvement (no trial involvement: median 6.3, trial involvement:  median 5.7; W = 4009.5; p-value = 0.0392). The number of cases per year, hospital type, MTC status, orthogeriatric care model, bed number, ward HDU area, theatre sessions per week, and presence of dedicated hip fracture sessions (HFS) were not significantly associated with 30 day mortality. 
Presence of HFS was however associated with a higher proportion of patients achieving prompt surgery. Shorter acute length of stay, shorter overall stay, and the percentage of patients achieving the best practice tariff were all positively associated with a greater number of hip fracture cases per year. 

Conclusions: Hospital participation in clinical trials is associated with an improvement in hip fracture mortality. This is likely related to a concomitant drive within these centres to produce high-level research and quality improvement. The association of greater hospital hip fracture caseload and dedicated theatre sessions with process of care outcome improvement provides evidence for centralisation of hip fracture services to increase care efficiency.

Implications: This evidence provides vital knowledge of important benchmarking factors when considering hip fracture service configuration.

There is NO Conflict of Interest: Yes

1659 - Total Hip Replacement versus Hemiarthroplasty for Hip Fractures: A Systematic Review and Meta-analysis of Randomised Controlled Trials

C. Wek1, R. Foley1, R. Ahluwalia1, I. Reichert1, V. Kavarthapu1

1King's College Hospital, Trauma & Orthopaedics,, London, United Kingdom

Background: NICE guidance recommends that patients with displaced intracapsular hip fractures should be offered THR if they were independently mobile, not cognitively impaired and medically fit for surgery. However, despite this guidance, just 33% of patients eligible for a THR receive this. Evidence for these guidelines is largely based on a 2010 Cochrane review by Parker et al. However, emerging evidence from recent randomised controlled trials (RCTs) suggest no difference in outcomes between THR or HA. We performed a systematic review and meta-analysis of RCTs to evaluate if there truly was no difference between these interventions.

Methods: A systematic review and meta-analysis of RCTs was performed and reported in accordance with the PRISMA statement. We analysed functional outcome scores; re-operation rates; complications and mortality. Meta-analysis was performed using a random effects model to derive estimated relative risk (RR) ratios as per DerSimonian & Laird’s method.

Results: 13 RCTs met the eligibility criteria and the overall pooled sample size was 3,050. Of these, 1,386 patients received THR and 1,425 received HA. There was no significant difference in Harris Hip Scores (HHS), re-operation rate (I2 = 12.6%, p=0.25) and mortality between groups (I2 = 0.0%, p=0.08). Dislocation rates were higher in the THR group. A subgroup analysis was performed comparing outcomes in patients <80 to those >80. There was a 20-25% increase in the RR of dislocation in patients >80 in the THR group.

Conclusion: In contrast to previous studies, there is no difference between re-operation and mortality between THR and HA. There is a statistically significant but clinically unimportant difference in functional outcomes between the two interventions. We found a significantly higher risk of dislocation in patients undergoing THR, particularly in those >80. Hemiarthroplasty implant choices have a bearing on clinical outcome and should be recorded in the NJR.

There is NO Conflict of Interest: Yes

1731 - 2 year follow up of 111 un-displaced intracapsular neck of femur fractures, treated with internal fixation, in patients over 65 years old, in the Northern General Hospital (NGH) Sheffield

S. Salih1, E. Mills2

1Northern General Hospital Sheffield, Trauma and Orthopaedics, Sheffield, United Kingdom, 2Northern General Hospital Sheffield, Sheffield, United Kingdom

Introduction: In undisplaced and valgus impacted intracapsular NOF fractures fixation in situ is generally accepted.
However post-operative avascular necrosis (AVN), non-union, or soft tissue irritation may require further surgery. The alternative is arthroplasty which has been shown to have higher surgical morbidity and slower mobilisation and longer length of admission. This project examines how many patients treated with fixation required further surgery.

Methods: A patient list was gathered from the National Hip Fracture Database (NHFD) for all intracapsular fractures treated with internal fixation for a 2 year period between 01/01/2015 to 31/12/2016. XRAYs, clinic and operation notes were trawled to find patients that had further surgery. Mean follow up was 742 days. National comparison data over the same period was collected from the NHFD.

Results: Of the 111 patients identified 13 went on to have a further procedure which gives a reoperation rate of 11.7%. Of the 13 patients requiring re-operation 5 patients had failure of fixation (treated with hemiarthroplasty or THR), 2 had a screw into hip joint (treated with change or removal of screw), 3 developed AVN (treated with THR), 2 had soft tissue irritation (treated with removal of screws), and 1 suffered subtrochanteric fracture (treated with IM nail).
There was no statistical difference in age or ASA grade between reoperation and no-reoperation group. For all intracapsular fractures NGH fixes 16.7% with cannulated screws (national average 4.9%) and 2.8% with sliding hip screw (national average 7.7%)

Conclusion: NGH performs over 3 times the national average cannulated screw fixation with a reoperation rate of 11.7%. Careful surgical technique, and further work to predict which patients are at higher risk of further surgery, could reduce the re-operation rate. A randomised control trial is needed to decide whether fixation or arthroplasty is the best treatment.

There is NO Conflict of Interest: Yes

1775 - Minimum Ten Year Follow up of a Randomised Trial Comparing Acetabular Component Fixation of Two Porous Ingrowth Surfaces Using Radiosteriometric Analysis

L. Rahman1,2, M. Ibrahim2, M. Teeter2, D. Naudie2, R. McCalden2

1Chelsea and Westminster Hospital NHS Trust, Orthopaedics, London, United Kingdom, 2London Health Sciences Centre, London, Canada

Aim: To compare the in-vivo long-term fixation achieved by two acetabular components with different porous ingrowth surfaces using Radiostereometric Analysis (RSA).  

Patients and methods: This was a minimum ten-year follow-up of a prospective randomised trial of 62 hips with two different porous ingrowth acetabular components. RSA exams had previously been acquired through two years of follow-up. Patients returned for RSA examination at a minimum of ten years. In addition, radiological appearance of these acetabular components was analysed, and patient reported outcome measures (PROMS) obtained.

Results: Fifteen hips were available at ten years. There was no statistically significant difference in PROMS between the two groups; PROMS were improved at 10 years compared to preoperative scores. Conventional radiographic assessment revealed well-fixed cups. There was minimal movement for both porous surfaces in translation (X, Y, Z, 3D translation in mm (Median+IQR), (StikTite 0.03 (1.08), 0.12 (0.7), 0.003 (2.3), 0.37 (0.30) and Roughcoat -0.6 (0.59), -0.1 (0.49), 0.1 (1.12), 0.48 (0.38)), and rotation (X, Y, Z rotation in degrees (Median+IQR),  (Stiktite -0.4 (3), 0.28 (2), -0.2 (1) and Roughcoat - 0.4 (1), -0.1 (1), 0.2 (2)). There was no statistically significant difference between the two cohorts (p value for X, Y, Z, 3D translation - 0.54, 0.46, 0.87, 0.55 and for X, Y, Z rotation - 0.41, 0.23, 0.23 respectively) at 10 years. There was significant correlation between 2 years and 10 years 3D translation for all components (r=0.81(p=<0.001)). 

Conclusion: Both porous ingrowth surfaces demonstrated excellent fixation on plain radiographs and with RSA at ten years. Short-term RSA data are good predictors for long-term migration data. Take Home Message:

  • This study reinforces the predictive power of early RSA data for long term migration.
  • Both porous ingrowth surfaces demonstrated excellent fixation on plain radiographs and with RSA at ten years follow-up.

There is NO Conflict of Interest: Yes

1881 - Prospective study comparing Acetabular Bone Resection in Hip Resurfacing and Total Hip Arthroplasty

S. O'Sullivan1, T. O'Sullivan2, P. Carton2, D. Filan2

1University Hospital Waterford, Trauma and Orthopaedics, Waterford, Ireland, 2UPMC Whitfield Hospital, Department of Orthopaedics, Waterford, Ireland

Background: Acetabular bone loss is a major concern in hip resurfacing arthroplasty (HRA) as treatment of acetabular bone deficiency during revision arthroplasty is demanding and associated with worse outcomes. Despite this, there have been conflicting results from studies regarding amount of acetabular bone removed when comparing HRA and total hip arthroplasty (THA). Aim is to determine whether HRA or THA is more invasive on acetabular bone.

Methods: We prospectively evaluated the femoral neck size of 509 consecutive hips at the time of primary THA between 2014 to 2018 in an identical manner to when carrying out a HRA. From the femoral neck measurement, we determined the minimum cup size that would be used if the same hip was undergoing a resurfacing and compared it to the actual cup size implanted.

Results: Overall, we found a significantly larger acetabular cup would have been implanted if the patient underwent a HRA rather than a THA with an overall cup size difference of 4.89 mm (56.62 ± 4.7 mm versus 51.73 ± 4.2 mm; p <0.001). 89.98% (n=458) of patients would have had a larger HRA cup size. We also found that the biggest difference in cup size was in those patients with larger femoral necks.

Conclusion/ findings: This study shows that HRA removes more bone from the acetabulum than THA for the same patient. As revision surgery becomes more prevalent with an aging population and particularly as the optimal resurfacing patient has been shown to be young, active, predominantly male patients who will likely require revision, this loss of acetabular bone stock becomes hugely significant and compromises future revision surgery.

Implications: HRA in young patients will lead to revision and re-revision difficulties due to deficient acetabular bone stock.

There is NO Conflict of Interest: Yes

1926 - Improved pelvic loading of a monoblock polyethylene acetabular component

O. Farhan-Alanie1, P. Young2, D. Teixeira1, R. Silverwood1, A. Mohammed1, K. Periasamy3, A. Nicol1, R.M.D. Meek1

1Queen Elizabeth University Hospital, Glasgow, United Kingdom, 2Ayr Hospital, Ayr, United Kingdom, 3Hairmyres Hospital, East Kilbride, United Kingdom

Introduction: Uncemented metal acetabular components show good osseointegration, but are limited by peripheral loading leading to retroacetabular osteolysis. Cemented monoblock polyethylene components load the pelvis more physiologically, however the cement bone interface often suffers fibrous encapsulation and loosening. An uncemented titanium sintered monoblock polyethylene component may offer the optimum combination of osseointegration and anatomical loading. We aim to establish whether this monoblock polyethylene uncemented cup loads the pelvis physiologically by comparison with cemented monoblock polyethylene and trabecular metal cup.

Methods: 38 patients were prospectively enrolled and received an uncemented monoblock polyethylene acetabular component. Periprosthetic bone density (BMD) was measured using dual-energy x-ray absorptiometry over 2 years, as well as radiographic and clinical analysis. This was compared with randomised control cohorts of cemented monoblock and trabecular metal acetabular implants.

Results: In the inferior acetabulum, a significant fall (p<0.01) in BMD was seen at 6 weeks, continuing to 2 years post-operatively. In the pubis and ischium a significant (p<0.01) fall was seen at 6 weeks, which recovered towards baseline by 2 years. This is similar to the trabecular group initially, however the trabecular cup showed no recovery over time in the ischiopubic regions. The cemented cup showed no fall in BMD in inferior acetabulum, but similar initial fall in ischiopubic region with no recovery over time. This would suggest that inferior and medial to the centre of rotation the pressfit cup initially behaves similarly to the trabecular cup. However, the pressfit cup loads the pelvis differently over time, with some improvement in bone density medially.

Conclusion: The uncemented monoblock cup initially behaves similarly to the rigid trabecular metal cup with lateral rim loading, however over time this changes to more closely resemble that of a cemented polyethylene cup with increasing medial pelvic loading. We believe this may give optimised fixation and preservation of retroacetabular bone stock.

There is NO Conflict of Interest: Yes

Accepted Abstracts - Part 1

15 - Incidence of venous thromboembolism in elective hip arthroplasty surgery: a review of 8,891 patients receiving post-operative Aspirin VTE prophylaxis

C Hutton1, N Patel1, S Whitehouse1, M Wilson1, M Hubble1, A-A Kassam1

1Royal Devon & Exeter NHS Foundation Trust, Princess Elizabeth Orthopaedic Department, Exeter, United Kingdom

Background: Venous thromboembolism (VTE) is a preventable cause of morbidity and mortality in patients undergoing elective hip arthroplasty surgery. The balance of post-operative VTE prophylaxis and risk of post-operative haemorrhage remains at the forefront of surgeons mind. The National Institute for Health and Care Excellence (NICE) published updated guidelines in 2018 which recommend the use of both mechanical and pharmacological methods in patients undergoing elective hip arthroplasty surgery.

Objectives: The aim of this study was to present the venous VTE incidence in 8,891 patients who underwent total hip arthroplasty (THA) between January 1997 and March 2018 with aspirin as the primary agent for pharmacological thromboprophylaxis.

Methods: We performed an analysis of prospectively collected data of the incidence of deep vein thrombosis (DVT) and pulmonary embolism (PE) occurring with 6 months of the index operation. We also investigated the 90-day mortality of this cohort of patients.

Results: 8,891 patients were reviewed. This included 6,973 primary, 224 complex primary and 1694 revision cases. The incidence of DVT was 0.64% after elective hip arthroplasty, the incidence of PE was 0.54%. There was no difference in the incidence between primary and revision cases. The 90-day mortality was 0.88%. Cardiovascular and respiratory disease were the main causes of death following surgery. Only 0.03% of deaths (n= 3) within 90 days of index surgery were due to VTE.

Conclusion: Our results support the use of aspirin as an effective and safe form of prophylaxis against VTE following THA in accordance to NICE and recommendation. It is not associated with an increased incidence in symptomatic DVT, PE or death compared to other published studies. The fact that it is inexpensive, readily available, requires no monitoring and does not pose a risk of bleeding are other advantages.

There is NO Conflict of Interest: No


V. Garg1, I. Malek1

1Wrexham Maelor Hospital, Wrexham, United Kingdom

Introduction: Unplanned re-admissions following Total Hip Arthroplasty (THA) are undesirable as it poses inconvenience to patients as well as increases the burden on health-care institutions. The reported re-admission rates are as high as 11% following Enhanced Recovery After Surgery (ERAS) protocol after THA. The aim of this study was to assess the influence of ERAS on 28 days re-admission rates following THA in our unit.

Material and Methods: Consecutive series of 28 days readmission data following THA performed between 2011 and 2018. All primary procedures except for trauma were included in this series. Revision THA procedures were excluded. All in-patient, hospital re-admissions for any cause within 28 days following the index procedures were analysed. The medical records were used to identify the reason of re-admission and investigations were reviewed to confirm the diagnosis.

Results: There were 53 (2.85%) readmissions within 28 days of discharge after 1855 index procedures over 8 years period. Out of these, 28 (1.51%) re-admissions were due to underlying orthopaedic causes, whereas 24 (1.35%) were non-orthopaedic reasons (including medical and general surgical). Leg swelling with suspicion of DVT (n=9) and dislocation (n=9) were the two most common orthopaedic reasons for readmission, making up 64.28% of total orthopaedic re-admissions.
Yearly assessment confirms steady decline in readmissions which is currently 1.99% compared to 5.20% at the start of the ERAS process in our institution.
Our results suggest that, a matured ERAS protocol does substantially reduces 28 days re-admission for any reasons after index THA procedures. Most common reasons were leg swelling and dislocation of hip but with introduction of new implant ,effective rehabilitation and patient education during in-patient stay and easy access to arthroplasty team for further assessment in timely manner will avoid re-admission to the hospital.

There is NO Conflict of Interest: No

167 - Arthroplasty in the developing world: Our experience of 256 hip replacements at The Children's Surgical Centre Phnom Penh

J Shelton1, S Dorman1, H Oy1, K Long1, O Ngiep1, N Popovici1, J Gollogly1

1The Children's Surgical Centre Phnom Penh, T&O, Phnom Penh, Cambodia

Background: Arthroplasty has consistently shown 'beneficial and often dramatic improvements in quality of life' and in the UK we have minimised infection through the recommendations of papers such as Lidwell's. The CSC has performed 256 THRs since 2008, our primary outcome was all cause of re-operation and our secondary outcomes was assessment of complications.

Methods: All patientes coded as having received a THR in the CSC databases their medical notes and radiographs reviewed. Basic demographics, indication for THR, risk factors for complications, implant combinations and complications were recorded. Statistical analysis was performed using MedCalc.

Results: The mean age was 43, with a M2:1F ratio. The most common pathologies were AVN (44%), OA (11%) and DDH (11%). The revision was 13%, the most common reasons for revision were stem fracture (5.8%), aseptic loosening (4.8% and infection (2.7%). The mean time from implantation to revision was 2.8 years (0-9). A variety of stems have been use over the time period with the best surviving being the Zimmer ML Taper and the UMA Muller stems and the worst performing being the UMA C-Stem which suffered 100% stem fracture. A Kaplan Meier chart was created to demonstrate survivorship. 109 complications were demonstrated in 85 patients (33.2%) the three most common being aseptic loosening (10.5%) stem fracture (5.8%) and dislocation 5.8%) 44 patients had previous surgery which was found to be a significant risk for complications but not infection. OHS initially improved but peaked at year 3 indicating early failure.

Conclusion: There is a clear need for arthroplasty in this working age population with neglected hip pathology with significant pre-operative deformity. Complication rates are declining  suggesting CSC is over the learning curve but cheap poorly manufactured implants cause catastrophic failure which begs the question of how to fund high quality implants to developing countries.

There is NO Conflict of Interest: Yes

172 - Acetabular Fractures in older patients Intervention Trial (AceFIT: ISRCTN16739011)

A Carrothers1, D Chou1, J Rawal1, J Queally1, P Hull1

1Cambridge Uni Hos NHS FT Addenbrookes, Orthopaedics, Cambridge, United Kingdom

Purpose: Displaced acetabular fractures in the older patient present significant treatment challenges. There is evidence that the morbidity and mortality associated with these injuries is similar to the fractured neck of femur cohort. There remains controversy regarding treatment algorithms; varying between conservative management, to fracture fixation and finally ‘fix and replace’ surgical strategies to allow immediate full weight bearing.

Methods: £250,000 NHS funding was secured from NIHR, Research for Patient Benefit (Ref: PB-PG-0815-20054) East of England Research Ethics Committee (Ref: 17/EE/0271). After national consultation, 3 trial arms were included; conservative management, fracture fixation and simultaneous fracture fixation with THA. Inclusion criteria included patients >60 years with displaced acetabular fracture with the following exclusion criteria: open fracture, THA, pre-injury immobility, polytrauma. Primary outcome measure was ability to recruit with EQ-5D-5L at 6 months. Secondary outcome measures at 9 months included OHS, Disability Rating Index, radiographs, perioperative physiological variables including surgery duration, blood loss, complications and health economics.

Results: 11 UK level 1 major trauma centres were enrolled into the trial from December 2017. Full trial recruitment of 60 patients was achieved in December 2019. 496 patients were screened; 379 not eligible and 57 declining participation. 66% of patients recruited were male, median age 76 (range 63-93 years), median BMI 25 (range 18-37), 87% of patients had full mental capacity and 77% were admitted from own home. 75% of injuries were due to a fall from standing height and 60% of fractures were classified as anterior column posterior hemi-transverse. Full data acquisition September 2020.

Conclusion: This unique RCT feasibility study represents the first opportunity to understand the intricacies of each of these agreed treatment modalities, including patient reported outcomes and health economics. The primary outcome measure is likely to show feasibility for a fully powered RCT which will need multinational input.

There is NO Conflict of Interest: Yes

514 - A comparative study of patients presenting for revision of hip or knee replacements, based on whether they were or were not under long term follow-up

S Kingsbury1,2,3, L Smith4, F Shuweildhi5, R West6, C Czoski-Murray6, L Vernon1, P Conaghan7,2,1, M Stone8,3,3,8

1LIRMM, Leeds, United Kingdom, 2NIHR, Leeds, United Kingdom, 3LMBRC, Leeds, United Kingdom, 4Weston Area Health Authority, Weston-Suoer-Mare / Bristol, United Kingdom, 5University of Leeds, School of Medicine, Leeds, United Kingdom, 6Leeds Institute of Health Sciences, Leeds, United Kingdom, 7Biomedical Research Centre, Leeds, United Kingdom, 8Chapel Allerton Hospital, Leeds,, Orthopaedic Surgery, Leeds, United Kingdom

Background: This prospective cohort study explored differences in symptoms, healthcare use, reason for revision, and the revision surgery (surgical time, components, length-of-stay) between patients having regular follow-up and those without.

Methods: Data were collected from participants and medical records for the 12 months prior to revision.   Patients with previous revision, metal-on-metal or hip hemi-arthroplasty were excluded. Participants were retrospectively classified to a ‘follow-up’ or ‘no follow-up’ group. Multi-level regression and propensity score matching compared the 2 groups.

Results: 568 patients were enrolled at 35 UK secondary care sites between October 2017 and October 2018 (43.5% male; mean (SD) age 71.86 (9.93) years; 305 hips, 263 knees). No significant inclusion differences were identified between the Follow-up and No Follow-up groups.
For hip revision, male gender (OR 1.975, 95%CI[1.083-3.602], p=0.026) and time-to-revision>10 years (OR 3.804, 95%CI[1.353-10.694], p=0.011) were associated with Follow-up. Periprosthetic fracture (OR 20.309, 95%CI[4.574-90.179], p<0.001) and dislocation (OR 12.953, 95%CI[4.014-41.794], p=0.000) were associated with No Follow-up.
For knee revision, time-to-revision>10 years (OR 2.337, 95% CI[1.007-5.419], p=0.048) and infection (OR 2.946, 95%CI[1.046-8.298], p=0.041) were associated with No Follow-up.
No other significant differences in cost outcomes, length of surgery time and access to a health professional in the 12 months prior to revision were found between the two groups for either hip or knee patients. However, there was a trend for increased length-of-stay and increased surgery time for hip revisions in the No Follow-up group, which was retained when periprosthetic fractures were excluded.

Conclusion: There are differences between patients presenting for revision through follow-up and no follow-up routes. Possible reasons for these differences will be presented.

Implications: This study formed part of the evidence used to inform the development of recommendations for follow-up of hip and knee surgery patients as part of the UKSAFE programme (HS&DR 14/170/96).

There is NO Conflict of Interest: No

538 - Calcar-collar contact during simulated periprosthetic fractures of the femur increases construct stiffness and resistance to fracture but is dependent on the degree of initial separation on implantation: A biomechanical study

J. Lamb1, O. Coltart2, I. Adekanmbi3, T. Stewart2, H. Pandit1

1University of Leeds, LIRMM, Leeds, United Kingdom, 2University of Leeds, Mechanical Engineering, Leeds, United Kingdom, 3DePuy Johnson and Johnson, Leeds, United Kingdom

Introduction: A calcar collar is associated with a reduced risk of periprosthetic fracture of the femur (PFF) possibly by increasing cortical loading during rotational injuries through calcar-collar contact (CCC). We estimated the effect of calcar collar contact on periprosthetic fracture mechanics and the effect of initial calcar-collar gap on the likelihood of CCC using a cementless femoral stem.

Methods: Three groups of six composite femurs were implanted with a collared cementless femoral stem. Neck resection increased between groups (group 1 = no additional resection, group 2 = 3mm additional resection, group 3 = 6mm additional resection). Distance between collar and the calcar (PCC) were measured and PFF were simulated using an established technique. Fracture torque and displacement were measured. High speed video recording identified when CCC occurred. Logistic regression estimated the odds (OR) of failing to achieve CCC for a given PCC.

Results: Where CCC occurred fracture torque was greater (47.33 [41.03 to 50.45] Nm versus 38.26 [33.70 to 43.60] Nm , p= 0.05), Rotational displacement was less (0.29 [0.27 to 0.39] rad versus 0.37 [0.33 to 0.49] rad, p= 0.07), torsional stiffness was greater (151.38 [123.04 to 160.42] rad.Nm‑1 versus 96.86 [84.65 to 112.98] rad.Nm‑1, p <0.01) and rotational work was similar (5.88 [4.67, 6.90] J versus 5.31 [4.40, 6.56] J, p= 0.6). The median (range) PCC for those trials where CCC was achieved was 0.85 (0.00 to 3.71) mm versus 5.97 (2.23 to 7.46) mm, where CCC was not achieved (p <0.01). Binomial logistic regression estimated OR of failure to obtain CCC increased 3.8 fold (95% Confidence interval 1.6 to 30.2, p <0.05) for each millimetre of PCC.

Conclusions: Calcar collar contact, not just a collar, is crucial to reducing the risk of PFF. Surgeons should achieve a gap of less than 1mm to ensure contact.

There is NO Conflict of Interest: No

Disclosure: Education research grant awarded by DePuy Johnson and Johnson: Implants and equipment for implantation supplied at no cost. Author IA is a DePuy Synthese Johnson and Johnson employee.

558 - Reducing Delays for Surgical Intervention in Patients with Fractured Neck of Femur on Direct Oral Anticoagulants

D. Menon1, R. Irons1, S. Ralhan1

1Oxford University Hospitals NHS Foundation Trust, Department of Geratology,, Oxford, United Kingdom

Background: Outcomes for neck of femur fracture patients are optimised by early surgical intervention. Current National Institute for Health and Care Excellence (NICE) guidance recommends direct oral anticoagulants (DOACs) should be suspended for 48 hours following the last dose prior to intervention in major orthopaedic surgery. Current practice for proximal femoral fractures in our centre is to proceed with intervention 24 hours following the last DOAC dose. 

Aim: To determine whether a protocol facilitating early surgical intervention in neck of femur fracture patients admitted on a DOAC agent affects post-operative morbidity.

Method: In this single-centre retrospective case-control study, all patients admitted on a DOAC in a 1 year period (December 2017 to November 2018) were identified and matched to non-DOAC controls. Time to surgery, post-operative blood transfusion rate, post-operative haematoma and deep wound infection rate, and estimated peri-operative blood volume (EBV) loss were calculated. 

Results: 456 fractured neck of femur patients were identified. 48 DOAC patients were included in data analysis. 24 DOAC patients (50%) and 107 non-DOAC patient (62%) underwent surgical intervention within 48 hours. In those operated within 48 hours of admission, there was no significant difference in EBV loss between the DOAC and non-DOAC group (881 ± 638ml vs 762 ± 515ml, p=0.40), blood transfusion rate between the DOAC and non-DOAC group (19.2% vs 18.7%, p=0.95), or post-operative complication (haematoma and wound infection) rate (p=0.23).

Conclusion: Peri-operative blood loss, post-operative transfusion rate, and post-operative wound-related complication rate are not significantly increased by early intervention (within 48 hours) in proximal femoral fracture patients admitted on a DOAC relative to a non-DOAC control cohort. This data is based on local guidelines advocating surgical intervention within 24 hours of last DOAC dose. However, further work is needed to establish a specific time to surgery in this patient cohort.

There is NO Conflict of Interest: Yes

684 - A multicentre observational cohort study describing fracture classification and treatment strategies in 575 postoperative periprosthetic femoral fractures around cemented polished taper slip stems in total hip arthroplasty

J. Lamb1, O. Townsend2, S. Jones3, C. Scott4, R. Middleton5, T. Board6, S. Jain1, H. Pandit1

1University of Leeds, Leeds, United Kingdom, 2University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom, 3Cardiff and Vale University Health Board, Cardiff, United Kingdom, 4Royal Edinburgh Hospital, Edinburgh, United Kingdom, 5Royal Bournemouth Hospital, Bournemouth, United Kingdom, 6Wrightington Hospital, Wigan, United Kingdom

Background: The incidence of periprosthetic femoral fracture (PFF) following total hip arthroplasty (THA) is rising. This study investigates factors associated with classification and treatment methods for PFF around PTS stems.
Methods: We investigated 575 PFFs around PTS stems: Exeter (48.5%), CPT (40%), C-stem classic (7.7%) and C-stem AMT (3.8%). Continuous variables were compared with unpaired t-tests and Mann-Whitney U tests and categorical variables with Chi-squared tests. Multinomial logistic regression estimated the odds ratio (OR) of Vancouver grade. 
Results: Mean (SD) age was 77.79 (11.35) years and 54.3% cases were female. Median (IQR) time to fracture was 3.65 (1.05-7.02) years. Vancouver grade was A (2.6%), B1 (53%), B2 (24.9%), B3 (6.6%) and C (12.9%). Treatment included fixation (48.2%), revision (46.3%), nonoperative (3.0%), excision arthroplasty (0.5%), amputation (0.3%) and unrecorded (1.8%). 
Median (IQR) years to fracture differed with age (years): 1.96 (0.89-4.84) under 60, 2.51 (0.71-6.20) between 60-80 and 5.16 (1.92-8.20) over 80 (p < 0.001). Median (IQR) years to fracture differed by stem brand: C-stem AMT 0.63 (0.24-1.65), CPT 2.83 (0.92-6.49), C-stem classic 3.13 (0.34-5.24) and Exeter 4.24 (1.24-8.40, p<0.001).
Increasing age gave an OR of 1.03 per year (95% CI 1.01-1.06, p=0.02) for type C versus type B fractures. Males were four times less likely than females to get type C versus type B fractures (OR 0.25, 95% CI 0.14-0.45, p<0.001). Similar numbers of B1 and B2 fractures underwent revision (44.0% versus 42.5 %, p>0.05). Treatment strategies were not influenced by age, gender or interprosthetic fracture (p>0.05).
Conclusions: A shorter time to fracture was seen with younger patients and specific stem brands. Fracture classification was influenced by age and gender. Similar numbers of B1 and B2 fractures underwent revision highlighting a lack of treatment consensus.
Implications: Further study is required to determine the optimal treatment for type B fractures.

There is NO Conflict of Interest: Yes

690 - Predictors of Mid-late Term Revision of Total Hip Replacement: a Nation-wide Retrospective Cohort Study (UK SAFE)

A. Judge1, C. Garriga-Fuentes2, S. Kingsbury3, L. Smith4, M. Porter5, R. Pinedo-Villaneuva2, N. Arden2, P. Conaghan3

1University of Bristol, Musculoskeletal Research Unit, Bristol, United Kingdom, 2Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), University of Oxford, Oxford, United Kingdom, 3Leeds Institute of Rheumatic and Musculoskeletal Medicine University of Leeds, Leeds, United Kingdom, 4Health & Applied Sciences, University of the West of England, Bristol, United Kingdom, 5Centre for Hip Surgery, Wrightington Hospital, Wrightington, United Kingdom

Objective: Identify which patients are most likely to require mid-late revision surgery to inform targeted follow-up.

Methods: Setting: Primary care using Clinical Practice Research Datalink (CPRD) data and secondary care using National Joint Registry data linked to English Hospital Episode Statistics (HES) and Patient Reported Outcome Measures (PROMs). Patients: Primary elective total hip replacements (THR) aged ≥18. Event of interest: Revision surgery ≥5 years after primary THR. Statistical methods: Cox regression modelling to ascertain influential factors of mid-late term revision. Hazard ratios (HR) and 95% confidence intervals (CI) assessed the association of sociodemographic factors, comorbidities, medication, surgical variables and PROMs with mid-late term revision.

Results: NJR-HES-PROMs data was available from 2008-2011 on 142,275 THR. The CPRD-HES data covered a longer period from 1995-2011 on 22,312 THR. Patients had a minimum 5-years post primary surgery to end 2016. Age and gender distribution were similar across both datasets; mean age 70 years, 62% female. In the NJR there were 3,582 (2.5%) revision procedures over a median time-to-revision 1.9 years (range 0.01-8.7 years), of which 598 (0.4%) were mid-late term revisions. In CPRD 982 (5.8%) revisions over median time-to-revision 5.3 years (range 0 -20 years), with 520 (3.1%) mid-late term revisions. Older age was related to significantly lower revision after 5 years (HR: 0.97; 95% CI: 0.96-0.98). Ceramic-on-ceramic bearings (0.70; 0.54-0.91) and ceramic-on-polyethene (0.75; 0.57-0.98) were protective for mid-late revision compared to metal-on-polyethylene bearings. Femoral head size >28mm diameter had higher mid-late term revision risk (≥44 mm: 2.74, 1.17-6.40). Pre-operative hypertension (0.77; 0.61-0.96) conferred a lower risk, whilst hyperlipidaemia (1.46; 1.09-1.95), antidepressant medication (1.38; 1.14-1.67) and steroid injections (1.32; 1.05-1.66) increased mid-late revision risk.

Conclusion: Younger age, metal-on-polyethylene bearings and larger femoral head sizes may be relevant factors in deciding which patients require extended follow-up based on their mid-late term revision risk.

There is NO Conflict of Interest: Yes

718 - Femoral heads for histology in neck of femur fracture: a proposed protocol for guiding investigation

z. sadozai1, M. Al-Ashqar1, H. Clarke1, N. Pennington1

1Huddersfield Royal Infirmary, Huddersfield, United Kingdom

Background: Low-energy neck of femur (NOF) fractures commonly afflict the elderly. In some cases the underlying pathology is sinister, such as malignancy, and can be further investigated by histological examination. There is little or no guidance on the indications for sending these samples for histology either at a local-hospital level or in the current literature. Our study has set out to review the indications for sending samples to histology and the management outcomes, and to propose a protocol guiding histological investigation.

Method: We performed a retrospective single-centre study of all femoral heads sent for histology for NOF fractures between January2017 until September2019. All patients who sustained an acute fracture and had their femoral head sent for histology were included. Case-notes from electronic patient records and local histology results were reviewed. Patient demographics,indications for sending, histology results, time taken for results and management outcomes were recorded. We designed a local protocol guiding which samples to send to histology.

Results: A total of 90 samples of femoral head were sent for histology in 3 years. 11 out of the 90 femoral heads were positive for malignancy. The mean number of days until final results were available was 41 (10-86). The most common indication for sending a sample was history of previous or current cancer (71%). No positive malignancy results were seen in any samples sent that did not fit our proposed protocol. 3 out of the 11 positive results were subsequently managed by discussion in the cancer multidisciplinary team, whereas the remaining 8 did not lead to any change in management.

Conclusion: We recommend a protocol as cost-effective screening criteria for deciding when to send femoral heads for histology. History of previous malignancy alone is a poor indicator for a positive result. Results can be time consuming to process however can lead to further appropriate oncological management.

There is NO Conflict of Interest: Yes

788 - Perioperative Administration of Tranexamic acid in Hip fracture Surgery (The PATHS Study): National Audit of Current Practice

T. Naylor1, A. Berg2, D. Johnson3, P.S.C. PATHS Study Collaborators4

1Manchester University NHS Foundation Trust, Department of Trauma and Orthopaedics, Manchester, United Kingdom, 2Health Education England (Northwest), Manchester, United Kingdom, 3Stockport NHS Foundation Trust, Department of Trauma and Orthopaedics, Stockport, United Kingdom, 4PATHS Study Collaborators, Manchester, United Kingdom

Introduction: Neck of femur (NOF) fractures are associated with significant morbidity and mortality. Concomitant anaemia is also associated with morbidity and is often targeted by national quality improvement strategies. Evidence indicates tranexamic acid (TXA) administration in NOF fracture surgery reduces blood loss and need for transfusion, with no increase in complications. The aim of this study was to establish current TXA administration practice in patients undergoing surgery for NOF fractures in the United Kingdom.

Materials and Methods: A multicentre prospective study was conducted over a two-week period from 4th–18th March 2019. Pre-operative, intra-operative and post-operative data was collected locally and submitted via an online platform for central analysis.

Results: Data for 917 patients was submitted by 239 collaborators from 66 institutions. 98.4% were treated surgically. 48.04% of those eligible received TXA peri-operatively. Administration rates varied from 0-100% between centres. 13.6% of institutions had a protocol for TXA in NOF surgery. 57.4% undergoing arthroplasty received TXA and 38.2% for internal fixation (p<0.01). 92.9% of those receiving TXA had 1-gram IV at time of anaesthesia.

Discussion: Wide variation in the administration of TXA between hospitals and procedures has been demonstrated. Administration rate was higher in arthroplasty than fixation procedures. Most centres do not have a protocol for TXA administration in NOF patients.

Conclusion: There exists wide variability in TXA administration rates despite supportive evidence. Recommendations of 1-gram IV TXA peri-operatively for patients undergoing NOF fracture surgery are made but further randomised controlled trials may be required to support a national policy.

There is NO Conflict of Interest: Yes

930 - A comparative study of hip fracture care and outcomes in major trauma centres versus trauma units

J. Lukic1, A. Rajeev1, B. Tyas1, K. Singisetti1

1Queen Elizabeth Hospital, Orthopaedics, Gateshead, United Kingdom

Introduction: Hip fractures in elderly patients are managed at both major trauma centers (MTC) and trauma units (TU). Previous evidence has demonstrated the importance of early surgery to reduce the morbidity and mortality related to the injury. The aim of this study is to compare the ‘time to theatre’ and ‘30 day mortality’ in TUs versus MTC in UK.

Methods: A retrospective review of prospectively collected data on NHFD was performed. The average ‘time to theatre’ in hours and ‘30 day mortality’ of all hospitals were analysed between January and December 2018. Further subgroup analysis was done to check for any regional variations; in each instance a Shapiro-Wilk test was used to check for normal distribution, followed by a one-way ANOVA with a Tukey’s post hoc test.

Results: Data from 158 hospitals in England (ENG), Wales (WAL) and Northern Ireland (NI) were used; 18 of which were MTC. There were 57,936 operative cases in TUs and 8606 in MTC’s. The mean time (hours) to surgery from presentation was 32.51 and 32.64 for TUs and MTC respectively (p=0.513).

There was no significant difference in ‘30 day mortality’ (p=0.635) between TUs (6%) and 5.7% MTC’s (5.7%), MTC’s and TUs in ENG, WAL and NI (p=0.555), and MTC and WAL, NI and the different regions of ENG (p=0.209).

A significant difference was observed, between the regional practice for TUs versus MTC’s in ENG, WAL and NI (p=0.001) and between MTC’s and TUs in WAL, NI and the different regions of ENG (p=0.001), with patients waiting significantly longer in NI for their procedure (mean=60.25 hours, p=0.001)

Conclusion: There was no significant difference in time to surgery or 30 day mortality between TUs and MTC’s, demonstrating comparable hip fracture care, despite MTCs need to prioritise more serious injuries.

There is NO Conflict of Interest: No

1023 - Sacro-Femoro-Pubic Angle used in predicting high-risk cases of THR dislocations

K. Thakre1, A. Kanitkar1, A. Razak1, A. Malik1, R. Mohan1, A. Ahmed1, S. Sharma1

1Pennine Acute NHS Trust, Trauma & Orthopaedics, Manchester, United Kingdom

Background: The sagittal spinopelvic balance plays an important role in the surgeries around the pelvis. The parameters like pelvic tilt and sacral slope are calculated on lateral radiographs of the lumbosacral spine and are helpful to differentiate balanced and unbalanced pelvis. Recently, a few studies have found a correlation between the pelvic tilt and Sacro-Femoro-Pubic angle (SFP angle) which is measured on AP radiograph of the pelvis. The objective of this study was to evaluate the Sacro-Femoro-Pubic angle (SFP angle), which is a direct reflection of the pelvic tilt, in patients who had total hip replacements (THR).

Methods: This is a retrospective study of 80 patients who had THR. They were divided into two subgroups, one with dislocations (n-40) and other without any dislocations (n-40). We evaluated the SFP angles on AP radiographs of the pelvis and compared them in both the groups. The Pelvic Tilt (PT) which is a predictor of an unbalanced and balanced pelvis, can be calculated by the formula: PT= 75- SFP angle.

Results: The average SFP angle was 60.95 in dislocated THR compared to 65.78 in non-dislocated THR.   The PT thus calculated in dislocated vs non-dislocated groups was 14.05 vs 9.22. There was no significant difference between the left and right SFP. The relationship between SFP angle and PT was analysed by Pearson’s correlation analysis and linear regression analysis.

Conclusion: The SFP angle gives an advantage of predicting the PT on AP radiograph of the pelvis which can predict the risk of dislocations after THR. To the best of our knowledge, this is the first study in the available English literature assessing the PT and SFP angles in dislocated THR and non-dislocated THR.

There is NO Conflict of Interest: Yes

1055 - Hemiarthroplasty Hip Dislocation- An Overview of Management and Outcomes

P.K. Shanthi Ashokkumar1, S. Khan2, J. Carter3, J. Dsouza4, P. Chandran5, R. Sanger1

1Warrington and Halton Hospital NHS Foundation Trust, Trauma and Orthopaedics, Warrington, United Kingdom, 2Whiston Hospital, Prescot, United Kingdom, 3Warrington and Halton Hopsital NHS Foundation trust, Warrington, United Kingdom, 4Warrington and Halton Hospital NHS Foundation Trust, Warrington, United Kingdom, 5Warrington and Halton Hospital NHS Foundation trust, Trauma and Orthopaedics, Warrington, United Kingdom

Background: Hip hemiarthroplasty is a recognised method of managing intra-capsular fracture neck of femur. Dislocation of hip hemiarthroplasty management can be complex and leads to increase in morbidity and mortality.
Method: Aim: To evaluate the incidence of prosthetic hip dislocation following hip hemiarthroplasty for displaced fracture neck of femur and to evaluate their outcomes.
Between 2016-2019, 444 patients were treated with hip hemiarthroplasty for displaced intra-capsular fracture neck of femur. Twelve patients (2.5%) developed dislocation of the hip hemiarthroplasty post-operatively, 9(66.6%) were females; mean age was 79(61-92) years.
Results: Ten dislocations (83.3%) occurred within 6 weeks of primary surgery. The initial management was MUA for 10 patients, 1 had Open reduction and 1 had primary revision surgery.
In the 10 patients who had MUA, 4 (40%) failed, of these two proceeded to have excision arthroplasty, one had constrained total hip arthroplasty.
Of six (60%) patients who had successful closed manipulation, 5 had further dislocation and re-surgery; 3 converted to total hip arthroplasty and 2 to excision arthroplasty.
All patients with revision arthroplasty were fully weight bearing while those with excision arthroplasty had limited mobility with hoist transfer at the time of discharge.


  1. Incidence of dislocation following hip hemiarthroplasty was 2.5% of which 83% dislocated within six weeks of primary surgery.
  2. One patient had MUA, 5 patients had Revision arthroplasty and 6 patients had excision arthroplasty as the definitive procedure.
  3. Hemiarthroplasty hip dislocation had a 25% 90 day mortality.
  4. Relocation of hip including closed and open relocation is generally unsuccessful (90%) resulting in further dislocations. For patients with dislocated hip hemiarthroplasty, it is recommended to consider a definitive surgery at the first instance to prevent revisits to theatres.
  5. Revision arthroplasty results in better mobility and function and has lower mortality than excision arthroplasty in patients considered fit for major surgery.

There is NO Conflict of Interest: Yes

1057 - Prevalence of Femeroacetabular Impingement Syndrome in Elite Gaelic Games Players: A Cross-sectional Study Utilising Magnetic Resonance Imaging

C. Mc Donald1, J. Moore1, S. Flynn1, E. Murphy1, S. Gilmartin1, P. O'Neill1, J. O'Byrne1, S. Eustace1

1National Orthopaedic Hospital, Cappagh, T&O, Dublin, Ireland

Background: Femeroacetabular impingement (FAI) is said to effect 15% of the general population, and has been increasingly recognised as a cause of hip pain in athletes. Hip impingement can lead to early onset osteoarthritic and degeneration of the hip joint itself. Identification of the prevalence of impingement in elite Gaelic games players has never been reported in the scientific literature. Impingement can be thought of as a triad of symptoms, signs and radiographic findings. Identification can thereby be assessed by combination of imaging (MRI) and clinical history and examination.

Aim: We aim to identify the prevalence of FAI syndrome in elite Gaelic Games players via clinical examination and MR imaging.

Methods: All existing senior intercounty games players were invited to partake in an anonymous sports medicine study. Subjective functional hip scores were collected for all participants (HAGOS and the IHOT33 questionnaire). Hip examination and impingement tests were subsequently performed. Finally all participants underwent an MRI pelvis. Radiographic evidence of cam impingement was defined as an alpha angle greater then 56*, with pincer impingement identified as lateral centre edge angle > 36*. Impingement syndrome was defined as the presence of hip symptoms, impingement sign positive and evidence of impingement on higher modality imaging (MR).

Results: Fifty one participants were included in this study. The prevalence of FAI syndrome was 24%. The prevalence of radiographic impingement was 39%. Of the asymptomatic population, 43% had evidence of radiographic impingement. The mean IHOT 33 score calculated for all participants was 89.0. Forty participants (78.4%) examined were FADIR positive. Ten of 51 participants (19.6%) had normal pelvis MRIs.

Conclusion: This is the first descriptive study to investigate the prevalence of FAI in a Gaelic athletic population. It provides new information on this study group. This information can be used to inform practice in the future.

There is NO Conflict of Interest: Yes


1074 - Long-Term Results of Revision Total Hip Arthroplasty Using a Modern Extensively Porous Coated Femoral Stem

C. Wallace1, J. Chang1, B. Kayani1, P. Moriarty1, F. Haddad1

1UCLH, London, United Kingdom

Background: The use of an extensively porous coated monoblock femoral stem for revision total hip arthroplasty is well established. The aim of this study is to report the long-term survivorship and functional outcomes of these implants. 
Method: This is a prospective study of femoral stem revisions using a contemporary, uncemented extensively porous coated cobalt-chrome monoblock stem with minimum 10-year follow-up. All patients between 2001-2006 who underwent femoral stem revision with the study implant were included. Fifty-six patients were included with a mean age of 66.4 ± 9.3 years at the time of surgery. The mean time interval from index procedure was 9.8 ± 2.9 years. 37 females (66.1%) and 19 males (33.9%) were included in the study. Harris Hip Score (HHS), Western Ontario and McMaster Universities Index (WOMAC), and University of California Los Angeles (UCLA) activity scores were recorded pre-operatively and at latest follow-up. Radiographs were analysed for evidence of loosening, subsidence, and osteolysis and bony union. 
Results: Fifty-six patients with 56 femoral stem revisions were identified. Indications for revision included aseptic loosening (33), prosthetic joint infection (13), and periprosthetic fracture (10). Mean follow-up was 13.2 ± 2.17 years. Significant improvement in HHS (85.1 ± 1.77 vs. 51.8 ± 2.3, p<0.001), WOMAC (17.6 ± 0.77 vs. 33.3 ± 0.8, p<0.001), and UCLA activity (5.25 ± 0.2 vs. 2.7 ± 0.36, p<0.001) scores were found at latest follow-up compared to pre-operative.  Fifty-four patients (98%) achieved stable bony ingrowth on radiographic analysis and all patients treated for periprosthetic fracture (13) achieved bony union of the fracture. There were no mechanical failures and no femoral stem re-revisions. 
Revision of the femoral component with a contemporary extensively porous coated cobalt chrome femoral stem has excellent functional outcomes, radiographic outcomes, and long-term survivorship with minimal complications.

There is NO Conflict of Interest: No

Disclosure: Prof FS. Haddad reports consultancies and royalties from Smith & Nephew, Corin, MatOrtho, and Stryker, and payments for lectures (including service on speakers bureaus) from Smith & Nephew and Stryker. None of the authors have any conflicts of interest related to this paper. No funding was received for this paper.

1146 - Relationship Between the Transverse Acetabular Ligament & The Psoas Fossa. Implications for iliopsoas Impingement Against the Acetabular Component. A Cadaver study

K.H. Sunil Kumar1, S. Kutty2

1Addenbrookes Hospital, Trauma and Orthopaedics, Cambridge, United Kingdom, 2Princess Alexandra Hospital, Trauma and Orthopaedics, Harlow, United Kingdom

Background: Optimal acetabular component position in Total Hip Arthroplasty is vital for avoiding complications such as dislocation, impingement, abductor muscle strength and range of motion. Transverse acetabular ligament (TAL) and posterior labrum have been shown to be a reliable landmark to guide optimum acetabular cup position. There have been reports of iliopsoas impingement caused by both cemented and uncemented acetabular components. Acetabular component mal-positioning and oversizing of acetabular component are associated with iliopsoas impingement. The Psoas fossa (PF) is not a well-regarded landmark to help with Acetabular Component positioning. Our aim was to assess the relationship of the TAL and PF in relation to Acetabular Component positioning.

Methods: A total of 12 cadavers were implanted with the an uncemented acetabular component, their position was initially aligned to TAL. Following optimal seating of the acetabular component the distance of the rim of the shell from the PF was noted. The Acetabular component was then repositioned inside the PF to prevent exposure of the rim of the Acetabular component. This study was performed at Smith & Nephew wet lab in Watford.

Results: Out of the twelve acetabular components that were implanted parallel to the TAL, all had the acetabular rim very close or outside to the PF with a potential to cause iliopsoas impingement. Alteration of the acetabular component position was necessary in all cadavers to inside the PF to prevent iliopsoas impingement. It was evident that the edge of PF was not aligned with TAL.

Conclusion: Optimal acetabular component position is vital to the longevity and outcome following THA. TAL provides a landmark to guide acetabular component position. We feel the PF is a better landmark to allow appropriate positioning of the acetabular component inside bone without exposure of the component rim and thus preventing iliopsoas impingement at the PF.

There is NO Conflict of Interest: Yes

1150 - The ceiling effect after hip arthroplasty: important differences in return to higher level activity are missed by the Oxford Hip Score

T. Edwards1, B. Keane1, A. Garner1, K. Logishetty1, J. Cobb1

1Imperial College London, MSk Lab, London, United Kingdom

Background: The Oxford Hip Score (OHS) is widely used as the primary outcome measure, by the NHS and for trials, including randomised trials of different forms of hip arthroplasty. The ceiling effect of the OHS may limit its ability to discriminate between postoperative hip arthroplasty patients as the modal score is 48/48. This study investigates the use of the Metabolic Equivalent of Task (MET) score and its ability to distinguish patients scoring maximally on the OHS.
Method: OHS, EuroQol-5D index (EQ-5D), and the MET were prospectively recorded in 98 primary hip resurfacing arthroplasty (HRA) and 105 primary total hip arthroplasty (THA) procedures pre-operatively and at 1-year follow up. A sub-cohort of 50 patients scoring 48/48 on the OHS postoperatively were matched in a 1:1 ratio HRA:THA for age, BMI, preoperative OHS score & preoperative MET. The distribution of each metric was described alongside differences between the two groups using the three scores before surgery and at 1-year follow-up.
Results: As preoperative scores, both OHS and EQ-5D are normally distributed without significant skew, and satisfactory kurtosis. Postoperatively, both scores exhibit significant negative skew, high kurtosis, and large ceiling effects: OHS (40.4%) & EQ5D (52.7%). The MET had a small floor effect pre-operatively (27%) but was normally distributed postoperatively. In the sub-cohort analysis of patients scoring 48/48 on the OHS, using the MET, HRA patients scored 12.7 while THA patients scored 10.5. This 20% difference was both clinically and statistically significant (p=0.01).  
Conclusion: The MET score is normally distributed in patients following hip arthroplasty, recording levels of activity which are undetectable using the OHS. As a simple valid patient-centred activity measure, it should be considered in addition to conventional PROMs scores for patients, clinicians, and health economists who wish to capture the entire benefit experienced following hip arthroplasty.

There is NO Conflict of Interest: Yes

1151 - Multi-Planar Reconstruction As A Novel Method of Measuring Femoral Neck Anteversion on CT Rotational Profile Scan

R. Mansouri1, Z. Nawaz1, H. Chissell1, T. Amies2

1Frimley Health Foundation Trust, Trauma & Orthopaedics, Frimley, United Kingdom, 2Frimley Health Foundation Trust, Radiology, Frimley, United Kingdom

Background: The current gold standard to measure the version values of femur is CT rotational profile scan at the level of hip and knee. However, determining the axis of femoral neck is challenging as the CT cuts do not show femoral neck in its entire length and therefore neck relationship with femoral head and greater trochanter is not clear.

Objectives: Multiplanar reconstruction is a function available in some digital radiology software platforms. It will allow the proximal femoral CT cuts to be reformatted in the plane of femoral neck and head. We hypothesised that using a multiplanar reconstruction will allow better accuracy of femoral neck anteversion measurement and therefore better inter- and intra-observer reliability

Design and Methods: CT rotation profiles of 10 patients with different femoral anteversion values was used in this study. A group of orthopaedic trainees and consultants were asked to measure the femoral neck anteversion using traditional method. They were then given a tutorial on how to use multiplanar reconstruction function and were asked to perform the measurements again. The measurements were repeated using both methods in 4 weeks interval. All observers were blinded to their own prior measurements and to those of other observers.

Results: Intraclass correlation coefficients (ICC) were used to determine the inter-observer and intra-observer reliabilities. 95% prediction limits for the errors in measurements were calculated. For the femoral neck anteversion measurement using the traditional method a mean ICC value of 0.86 was determined for inter-observer reliability and a mean ICC value of 0.90 for intra-observer reliability. For the multiplanar reconstruction method a mean ICC value of 0.93 was determined for inter-observer reliability and a mean ICC value of 0.95 for intra-observer reliability.

Conclusion: Using multiplanar reconstruction reformatting improves the inter- and intra-observer reliability of measuring femoral neck anteversion.

There is NO Conflict of Interest: Yes

1203 - Dual Mobility Cups: Long term Outcome in Complex Primary and Revision Hip Arthroplasty

K. Abdelhakim Edres1, S. Mirza1, N. Shah1

1Worthing Hospital, Western Sussex Hospitals Trust, T&O, Worthing, United Kingdom

Background: The risk of instability and dislocation following complex Primary or Revision Total Hip Arthroplasty (THA) is higher than average; this impacts the future re-revision surgery and patients’ quality of life and satisfaction. Dual mobility socket is considered an alternative to avoid this complication. We therefore carried out this study to evaluate whether dual mobility socket fulfils these aims at long-term.

Methods: We carried out a retrospective analysis of prospectively collected data of patients who had cemented dual mobility (SERF) sockets. Records were evaluated for demographics, comorbidities and body mass index. The Oxford Hip Score (OHS) and the EQ5D were obtained for functional outcomes including satisfaction. The primary outcome measure was dislocation with secondary outcomes including infection, aseptic loosening and other complications. Recent x-rays were evaluated for loosening.

Results: There were 108 complex primary and 133 revision THAs using the cemented SERF cup in 237 patients. 35 patients were deceased, leaving 202 patients with 206 hips for final evaluation at 3 to 11 years follow up. 98 were complex primary with average age of 85 years and 108 were revision THA with average age of 81 years. There were 171 female and 35 male patients. The average OHS was 37 and EQ5D was 77. There were no dislocations or intra-prosthetic complications. There were two deep infections. Radiological analysis using Kaplan-Meirr method showed 100% survival at 11 years.

Conclusion: This is the largest series of exclusive cemented dual mobility socket used for complex primary and revision THAs. Our results show excellent outcomes in this challenging group of patients, achieving satisfactory stability with low complication rates. This exclusive study also looks at patient reported outcome measures, indicating satisfactory outcomes and satisfaction for dual mobility sockets in at medium to long term.

There is NO Conflict of Interest: Yes

1237 - Can hip precautions prevent early hip dislocation? A systematic review and meta-analysis of the literature examining hip precautions in the anterolateral and posterior approach in THA

Y.H. Mirza1, V. Kandhari1, K. Mohanty1

1University Hospital Wales, Cardiff, Trauma and Orthopaedics, Cardiff, United Kingdom

Aim: To evaluate the influence of hip precautions on the incidence of early hip dislocation after total hip arthroplasty performed either using an anterolateral or posterior approach.

Methods: Pubmed, EMBASE (1974-2020) and OVID (1946-2020) databases were searched using the terms total hip arthroplasty as well as MeSH terms. Included studies provided details of the use of hip precautions after primary THA and reported early incidence of hip dislocation. Studies omitting details of hip precautions, the rates of hip dislocation, or those performed for revision THA and non-English language studies were excluded. The systematic review was registered with the PROSPERO database

Results: 18 studies were included, comprising 17,286 THAs. In 10,160 THA patients, either reduced or no hip precautions were used.
Four studies reported primary THAs performed exclusively via the anterolateral approach, whilst 9 described a posterior approach.
The remaining 5 studies described a multitude of approaches including 2 incision anterior to a posterior mini-incision amongst others.
In the posterior approach group, there were 9007 patients, of whom 4492 were not subject to hip precautions. 81 dislocations were observed in those without hip precautions, a risk ratio of 1.80%, whilst 89 were observed in those subject to hip precautions, a risk ratio of 1.72%. A pooled analysis of studies from the posterior approach demonstrated an odds ratio of 0.90, 95% confidence interval of 0.66-1.22, p= 0.50. From the anterolateral approach cohort, there were 4148 patients, of whom 2354 were not subject to hip precautions. 43 dislocations were observed in those without hip precautions, a risk ratio of 1.82%. An adjusted pooled analysis of studies demonstrated an odds ratio of 1.14, 95% confidence interval of 0.356-3.66, p= 0.82.

Conclusion: We conclude that the early hip dislocation incidence after anterolateral or posterior primary THA is not influenced by the practice of hip precautions.

There is NO Conflict of Interest: Yes

1283 - Dislocation of total hip replacement in the fracture neck of femur – Does surgical approach or dual mobility implant matters?

P. Goru1, S. Haque1, M. Hamed1, S. Shah1

1Manchester Royal Infirmary NHS Foudation Trust, Trauma and Orthopaedics, Manchester, United Kingdom

Introduction: Total hip replacement in the neck of femur fracture Is always surgically challenging for the hip surgeons. NICE Hip fracture management clinical guidelines defined clear criteria for patients who need a total hip replacement for the neck of femur fracture. It also recommended the anterolateral approach over the posterior approach.

Aim: To see the dislocation rate in patients with the fracture neck of femur who underwent total hip replacement with Standard bearing compared to Dual mobility bearing surface. Also compare with national dislocation rate.

Methods: Initial audit data collected retrospectively from Feb 2017 till April 2019 in Manchester Royal Infirmary from the electronic records database and clinical documentation. Patients included were the neck of femur fracture who underwent a total hip replacement. Loop audit data collected prospectively from April 2019 till now which followed the recommendation of Dual mobility cup for total hip replacement.

Results: Out of 53 Patients included in the initial audit, 7(13.2 %) THR dislocations recorded. 6(20%) out of 30 patients underwent a posterior surgical approach and 1 (4.34%) of 23 underwent a Lateral approach were dislocated. 6 (13.95%) out of 43 traditional cemented hip replacement and 1(10%) of 10 dual mobility cups were dislocated. 2(20%) of 10 femoral head size 28mm, 5(21.7%) of 23 femoral head size 32mm were dislocated. No dislocations with 36 mm head. Subsequent audit data of 20 hip replacements following neck of femur fracture with no dislocations by using dual mobility cup.

Conclusion: Our series demonstrates a significant reduction of dislocation with the use of Dual mobility cup in the neck of femur fractures who underwent THR. We recommend dual mobility cup for posterior approach THR and Anterolateral approach with standard hip with size 36 head. The surgical approach using posterior or lateral didn’t show any effect on results.

There is NO Conflict of Interest: Yes

1311 - If it is expensive, is it any better? Comparison of Palacos R+G with Copal C+G sensitivities in infected hip hemiarthroplasties between 2017-2020 at a tertiary centre.

M. Kumar1, C. Lodge2, G. Mohrir2, G. Whitwell2

1Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom, 2Leeds Teaching Hospitals NHS Trust, Trauma & Orthopaedics, Leeds, United Kingdom

Background: Hip fractures are one of the commonest encountered fragility fractures in the UK with more than 85% of patients receiving cemented arthroplasty where eligible. Copal C+G had shown to reduce post arthroplasty infection rates from 5.6% to 1.7% (Sprowson et al).  Our standard cement is Palacos R+G. The study aims to review the potential financial impact and healthcare benefits of a cement switch to Copal C+G.

Method: Hip fracture patients who underwent hemiarthroplasty between Jan’2017 & Apr’2020 and had a subsequent deep wound infection were retrospectively identified. Electronic records of these patients were reviewed for microbiological growth and antibiotic sensitivities from intra-operative samples. The sensitivities were then compared with the constituents of both cements. 

Results: A total of 1017 hip hemiarthroplasties were performed during the period. Amongst them, 14 patients (1.4%) were identified to have a deep infection requiring operative intervention and long term antibiotics. Mean age of patients in the infected cohort was 86.2 years. Single organism were isolated in only 6 samples (43%). The remainder of the samples had more than one microbial growth (57%). Staphylococcal species were most commonly isolated (10/14) followed by Proteus species (4/14), and E.coli (4/14). Most isolates were sensitive to Ciprofloxacin (42.8%) & Teicoplanin (35.7%). None of the isolates was sensitive to Clindamycin. Mean duration of antibiotic therapy was 6 weeks (IV+PO). Excision arthroplasty was performed in 5 patients (35.7)%. The total estimated additional financial burden of infective hemiarthroplasties during the period was over £100,000 for the Trust.

Conclusion: Infected hip hemiarthroplasties are a massive economic burden for the Trust. As Copal C+G carries an additional premium of £100 per patient over Palacos, its introduction would have added an additional £101,700 to the cost of hemiarthroplasties without any significant improvement in infection rates.

There is NO Conflict of Interest: Yes

Accepted Abstracts - Part 2

1324 - What Are The Correct Indications For Sending A Femoral Head For Histology? A Retrospective Analysis Of Two Centres In West Yorkshire, UK

M. Kumar1, M. Al-Ashqar2, M. Abdelrahim2, S. Nisar2, C. MacEachern2

1Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom, 2Leeds Teaching Hospitals NHS Trust, Trauma & Orthopaedics, Leeds, United Kingdom

Background: Femoral heads are sent for histological analysis following trauma hip arthroplasty to exclude malignant bone metastasis. The paucity of evidence on the indications for sending a femoral head for histology has led to a discrepancy in practice across centres in the UK. Femoral head histology (FHH) is a time, cost and labour intensive procedure, often requiring multiple cycles of decalcification. This study aims to establish a correlation between FHH indications and outcomes, produce a robust cost analysis and develop further guidance on the correct indications.

Method: Femoral heads from trauma arthroplasties sent for histology during 2016-2018 in a district general hospital and a major trauma centre were retrospectively identified. The electronic records of the patients were reviewed for indications for the test, changes in patient management, cost estimations and labour time.
Results: We identified 120 patients that met the inclusion criteria. 75 patients (62.5%) had known previous or current cancer. The commonest indication was exclusion of malignancy in suspected pathological neck of femur fracture (NOF). Eighty seven patients (72.5%) had a low energy and 33 patients (27.5%) had atraumatic NOF. The mean age was 76.9 years. Twenty patients (16.7%) were positive for malignancy, of whom 16 patients (80%) had active cancer with no alteration in management. The remainder had additional indications as atraumatic fracture, pre-injury pain or abnormal bone intra-operatively. Three patients (2.5%) had a maiden diagnosis of cancer based on FHH and underwent subsequent staging and treatment. The minimum estimated cost was £20,000 and a minimum 300 manhours of labour.

Conclusions: Femoral head histopathological studies based on a history of previous/active cancer is not cost-effective and does not lead to a change in clinical management. Patients with a new diagnosis of cancer based on FHH leading to a clinically relevant change in management had other more sensitive indicators as atraumatic fractures & pre-injury pain.

There is NO Conflict of Interest: Yes

1339 - The Value of Routine Femoral Head Histology in Neck of Femur Fractures

K. Mazur1, S. Bonczek1, A. Ng1

1Pinderfields General Hospital, Trauma and Orthopaedics, Wakefield, United Kingdom

Hip fractures are very common injuries among the elderly population. Many of these patients often have complex medical backgrounds including malignancy. Suspicious radiographic findings, no history of preceding trauma, pre-existing pain and history of cancer may imply a pathological nature of fracture warranting further investigation. In 2016, The Royal College of Pathologists recommended that all fractures below articular surfaces should be examined histologically to identify the underlying pathology. However, there is still much debate amongst clinicians regarding routine histological analysis of femoral heads following surgery for neck of femur fractures. Our aim was to ascertain if the histological findings correlate with diagnosis and influence patient treatment. 
We have conducted a retrospective study of all femoral head samples sent for histology over a 4-year period in patients who underwent hip hemiarthroplasty for neck of femur fracture at a District General Hospital. We investigated the indications for sending histology samples, the results of the investigations, duration of sample processing and patient outcomes. 
Out of 59 femoral heads sent for analysis, 7 were positive for malignancy. All positive samples had previous radiological confirmation of malignancy and patients received oncology input prior to histology results. In none of these cases has the histology contributed to or altered patient care. The most common indication for sending specimens was previous history of cancer or current cancer treatment. The average time to process samples was 16 days.

In conclusion, routine femoral head histology in patients with neck of femur fractures is a costly and time-consuming investigation, which may not directly contribute to patient’s treatment and is, therefore, of limited value. Furthermore, we would advocate creating clear guidelines for hip fracture patients specifying cases in which femoral head histology would be warranted.

There is NO Conflict of Interest: Yes

1353 - Day case THR - 18 months experience in the NHS

G. Snowden1, E. Dunstan1, N. Clement2

1Victoria Hospital Kirkcaldy, Trauma and Orthopaedics, Kirkcaldy, United Kingdom, 2University of Edinburgh/ Edinburgh Royal Infirmary, Trauma and Orthopaedics, Edinburgh, United Kingdom

Background: Since the advent of joint arthroplasty inpatient length of stays (LoS) have been steadily dropping. According to the Scottish arthroplasty project the mean inpatient LoS following a Total Hip Replacement (THR) has fallen from 10.3 days in 2001 to only 3.9 days. This reduction in patient LoS has lead units in the UK to follow the example of centres around the world and offer THR as a day case procedure. In this study we examine data gathered from the first 18 months of day case THR within a district general hospital elective orthopaedics unit.

Methods: Data was collected prospectively from all patients undergoing THR within our district general hospital elective orthopaedic unit. Patients were selected to day case THR group via consultant review at outpatient clinic and anaesthetic assessment at pre-assessment clinics. Oxford hip scores were gathered prior to surgery and again at 6 and 12 months post op. SF36 scores were collected at 6 months and 1 year post surgery.

Results: Between August 2018 and February 2020 (18 months) 40 patients successfully underwent day case THR. None of the patients discharged home where readmitted within the next 30 days. The average age of successful day case THRs was 60 years old. The at 6 months post-op mean OHS was 45.1 and at 1 year post-op the mean score was 47.2. The average improvement in OHS was 21.1 at 6 months and 26.9 at 1 year post-op. All of the patients successfully discharged as day cases where satisfied with their care and all but one would recommend it to their friends and family.

Conclusion/Implications: We have shown that day case THR is not only possible within an NHS district general hospital but gives exceptional patient outcomes with excellent patient satisfaction.

There is NO Conflict of Interest: Yes

1532 - Clinical outcomes following management of hip and knee periprosthetic joint infections in a District General Hospital

G. Kleftouris1, A. Ng1, S. Jones1

1The Mid Yorkshire Hospitals NHS Trust, Trauma and Orthopaedics, Wakefield, United Kingdom

Background: Periprosthetic joint infection (PJI) remains a challenging complication following hip and knee arthroplasty surgery. The aim of this study was to report on the outcomes of periprosthetic joint infections treated in a District General Hospital.

Methods: Between January 2015 and December 2018, all patients treated for periprosthetic joint infection in our institution were included retrospectively in the study. Periprosthetic joint infection was defined according to the criteria set by the Musculoskeletal Infection Society. The primary outcome of the study was to report on the 1-year infection free rate of this cohort. Secondary parameters included patient demographics, timing of infection since the index procedure, length of antibiotic course, operating surgeon, and the pathogen isolated.    

Results: Forty-seven patients met the inclusion criteria. The overall 1-year infection free rate was 80% (37/46 patients). Thirteen patients had debridement, antibiotics and implant retention; 8/13 (61.5%) patients were free of infection at 1 year. Six patients had single stage revision; all of them were infection-free at one year (100%). Twenty-seven patients had 2-stage revision; 23/27 (85.2%) were infection-free at 1 year. The median time of developing PJI following total hip replacement and total knee replacement was 25.3 months. Twelve of the 33 patients (36.4%) who had either a single or a 2-stage revision had low grade infection. There was no association between 1-year re-infection and operating surgeon or the isolated pathogen.

Conclusion: Periprosthetic joint infections can be treated successfully in a General District Hospital. Re-infection rates in our institution were comparable to rates reported in literature. Single stage revision can lead to excellent results; careful patient selection and a dedicated multidiscipline team are prerequisites for good clinical outcomes. Even following a two-stage approach, periprosthetic joint infections can be a challenging condition to treat.

There is NO Conflict of Interest: Yes

1565 - A comparison of acute vs inpatient hip fractures [A study conducted using data from the Scottish Hip Fracture Audit]

A.G.C. Hay-David1, A. Stewart2, R. Houson2, G. Holt2

1Queen Elizabeth University Hospital, Trauma & Orthopaedics, Glasgow, United Kingdom, 2University Hospital Crosshouse, Trauma & Orthopaedics, Crosshouse, United Kingdom

Background: This study sets out to identify if there is a difference in patient populations and outcomes for those admitted acutely (from their own home, care homes or non-NHS residences) compared to those who fracture their hip as an inpatient (in hospital, in rehabilitation or in NHS Continuing Care).

Method: Retrospective data collection from the Scottish MSK audit. Eighteen months were analysed (01/2017-06/2018) to identify patient demographics and outcomes.

Results: 10,140 patients. 92% (9320/10,140) admitted acutely: 81% (7535/9320) own homes, 19% (1755/9320) care homes, <1% (31/9320) from other non-NHS origins. Inpatients accounted for 8% (820/10,140): 70% (578/820) were on acute wards, 20% (167/820) rehab, 9% (76/820) NHS Continuing Care. No difference in ages: 80.1 years acutes vs 80.2 years inpatients, p=0.73. Gender was significant amongst inpatients: males 11% (317/3009) vs females 7% (504/7133), p<0.001. The inpatient hip fractures had longer inpatient stays than the acutely admitted hip fractures (40 vs 17 days, p<0.001) and spent a longer time in rehabilitation (32 vs 25 days, p<0.001). They were less likely to return to their own, or care, home in 30 days (23% vs 60%, p<0.001), or, at 60 days post-admission (41% vs 74%, p<0.001). Mortality rate was higher at 30 days (13% vs 6%, p<0.001) as well as at 60 days post admission (21% vs 10%, p<0.001). There was no difference in readmission rates within 14 days.

Conclusions/Findings: Inpatient hip fractures constitute a much smaller proportion compared with acute admissions yet they have significantly worse outcomes. This may be because patients with acute fractures have been admitted following the recommended standards of care. Meanwhile, inpatients have already been admitted medically unwell and may have more co-morbidities. Further work is required to identify why such a disparity in outcomes should arise and, thereby, aim to improve the care that these patients receive.

There is NO Conflict of Interest: No

Disclosure: There is no conflict of interest for the 1st author. The 4th author is Chairman of the Scottish Hip Fracture Audit and Advisory Group. The 2nd / 3rd authors are Advanced Nurse Practitioners and are members of the Group. There was no financial interest sought nor received by the authors.

1583 - Should we be prepping the foot? Stockinette use and drape contamination during hip arthroplasty

S. Abbott1, A. Naraen1, D. Rawaf1, J. Craik1

1Epsom and St Helier University Hospitals NHS Trust, Trauma and Orthopaedics, Sutton, United Kingdom

Background:  A frequent technique of preparing the operative field during hip arthroplasty utilises a sterile stockinette over an unprepped foot. There is potential for particle contamination from the foot to the surgical site with this technique. This study aims to assess surgical site contamination when draping for hip arthroplasty without disinfecting the foot.  

Methods: UV fluorescent powder was used as a surrogate for microbial presence on the foot. Powder was applied to a volunteer’s foot to a level where antibacterial prep would stop. The leg was then draped according to three methods; directly with stockinette only, wrapping the foot without using a sticky seal followed by stockinette, and wrapping the foot with use of the sticky seal followed by stockinette. UV light was used to assess the proximal spread of powder after draping.

Results: Contamination of the sterile field was found with all methods of draping. Spread was particularly noted in the groin, posterior to the thigh and distal to mid-thigh. Wrapping the foot in a small drape without using the sticky seal prior to stockinette application was associated with significantly greater contamination when compared with use of the sticky seal (p=0.004).

Conclusion: Routine formal prepping of the foot during hip arthroplasty is recommended to reduce the risk of surgical site contamination. Surgeons who select not to prep the foot should make use of a small drape with a sticky seal prior to stockinette application and consider applying a further U drape to the hip.

There is NO Conflict of Interest: Yes

1590 - Heterotopic Ossification Following Acetabular Fracture Fixation, a Retrospective Cohort Study

T. Barker1, F. Khatun1, D. Gill1, B. Davis1

1Norfolk and Norwich University Hospital, Trauma and Orthopaedics, Norwich, United Kingdom

Background: Heterotopic Ossification (HO) is a complication commonly seen following operative fixation of acetabular fractures. The pathological process is not fully understood, and the rates of HO show great variability depending on the study, however a meta-analysis showed the rate to be 25.6% for HO overall, and 5.7% for clinically significant HO (Brooker Grades III-IV), and it did not find a statistically significant reduction in HO in papers advocating the use of Radiotherapy or Indomethacin for prophylaxis. This case series looks at patients following acetabular fracture fixation, performed by a single surgeon at a tertiary centre in the UK. His technique involves minimal dissection of devitalised soft-tissue and minimal fixation required, with an emphasis on reducing surgical time. Neither Indomethacin or Radiotherapy are used.

Methods: This is a retrospective cohort study, of consecutive patients presenting to Norfolk and Norwich University Hospital between 2010 and 2020, and managed by a single surgeon (author BD). Follow up radiographs were assessed for the presence of HO. Patients with insufficient follow up (<10 weeks) were excluded. Other reasons for exclusion were age <18, primary surgery elsewhere, or chronic fracture at presentation.

Results: 68 patients met the inclusion criteria. The male:female ratio was 54:14, mean age was 47 (range 19-87). Kocher-Langenbeck was the primary approach in 84% of cases (n=57). Mean follow up was 381 days (range 78-2776). No patients received prophylactic radiotherapy or indomethacin. The incidence of HO was 10.3% overall, and was 2.9% for Brooker grade III-IV. HO was clinically significant in 1.5% (n=1). When comparing with the results of a 2005 meta-analysis, the reduction in total HO was clinically significant (p<0.05) however the lower rate of clinically significant HO was not.

Conclusions: We propose that the risk of HO following acetabular fracture fixation can be successfully mitigated by using the techniques outlined.

There is NO Conflict of Interest: Yes

1666 - Treatment of Acute Periprosthetic Joint Infection in Total Hip Arthroplasty: The single-stage approach

J. Robinson1, P. Moriarty2, C. Wallace2, S. Konan2, F. Haddad2

1Bronx Lebanon Hospital, New York, United States, 2University College London Hospitals, Orthopaedics, London, United Kingdom

Background: Prosthetic joint infection (PJI) after total hip arthroplasty (THA) can be a difficult and costly complication to treat.  In the acute setting (6-8 weeks post-operatively) debridement and exchange of all modular components with retention of stable implants is the popular treatment option.  While this option is easier on both the patient and the surgeon it does limit the amount of debridement that can be performed.  The aim of this study is to present the outcomes and methodology of single-stage exchange to treat acute PJI in THA.

Methods: We retrospectively reviewed patients undergoing single-stage exchange for the treatment of acute PJI from 2002-2014 at our institution.  Inclusion criteria required patients to be culture positive for a deep infection after cementless primary or revision THA and have a minimum 5-year follow up.

Results: 39 patients were included in the study.  There were 21 males and 18 females with a mean age of 64years.  All patients had minimum 5-year follow-up. There were 33 primary THA’s and 6 revision THA’s. Average time from index operation to development of symptoms was 18days.  The most common organism cultured was coagulase negative Staph 25%.   35 out of 39 patients were infection free at most recent follow up with only 4 re-infections.  All re-infections resolved after two-stage revision. 

Discussion: Our study shows that single-stage exchange is a viable and successful treatment option for PJI in the acute setting. We believe that the removal of implants gives us access to perform a thorough debridement aiding in the eradication of the infection. In the acute setting cementless implants can be removed with relative ease and little to no bone loss. Our study shows 90% success rate and retention of implants at most recent follow up.

There is NO Conflict of Interest: No

Disclosure: Senior authors report board membership of the Bone and Joint Journal and the Annals of the Royal College of Surgeons; consultancy for Smith & Nephew, Corin, MatOrtho and Stryker; service on speakers’ bureaus for Smith & Nephew and Stryker; all outside the submitted work.

1725 - Should we change our follow-up of total hip arthroplasty?

M. Ammori1, M. Haynes2, M. Girgis1, M. Lovell1

1Wythenshawe Hospital, Orthopaedics, Wythenshawe, United Kingdom, 2University of Manchester, Manchester Medical School, Manchester, United Kingdom

Background: A self-referral system has been proposed as a safe alternative to routine follow-up for patients undergoing primary uncemented ODEP 10A* total hip arthroplasty and there are calls for a similar study using cemented implants. Self-referral depends on the patient being symptomatic. Silent osteolysis is the major indication for revision in asymptomatic patients but is less prevalent with modern implants. The objective of this study was to establish the method of referral of patients who undergo revision after primary cemented total hip arthroplasty to determine if long-term follow-up is necessary.

Methods: Out of a single surgeon series of 1,996 primary total hip arthroplasties between September 1998 and June 2019, 23 patients underwent a subsequent revision. The primary implants included Charnley/Opera (n=9), Exeter/Opera (n=2), Exeter/Contemporary (n=9), Exeter/Trident (n=2) and Corail/Ogee (n=1). Data were retrospectively collected and included patient demographics, dates of primary and revision arthroplasty and method of referral.

Results: Five patients (21.7%) underwent a revision total hip arthroplasty within the first year and 12 (52.2%) within seven years. Seven patients (30.4%) attended Accident & Emergency, six (26.1%) were referred by General Practitioners, two (8.7%) were inpatient referrals and one (4.3%) self-referred. Seven patients (30.4%) were identified at routine follow-up [aseptic loosening (n=3), infection (n=3) and leg length discrepancy (n=1)].

Conclusions: We found long term follow-up to be unnecessary. Of those identified at follow-up, we felt they would have otherwise  presented with symptoms. Studies using a system of self-referral should be conducted to determine the safety and efficacy of this method.

There is NO Conflict of Interest: Yes

1763 - Incidental improvements to fragility fracture service with the arrival of the COVID-19 pandemic

M. O'Hare1, G. McAlinden1, A. Mayne1, D. Shirley1

1Ulster Hospital Dundonald, Trauma & Orthopaedics, Belfast, United Kingdom

Background: We describe the changes that occurred to our fracture service during the first three months of COVID-19. Our fracture unit is within an acute hospital with approximately 400 hip fractures per annum in one theatre with three additional sessions and competes with adult and paediatric fracture services. Our elective practice is separately sited and during the pandemic ambulatory patients had surgery on the elective site; this included two THRs for fracture. In NI we do not receive payment for results and local government sets a 48 hour target to surgery. We aimed to analyse how the pandemic impacted hip fracture care.

Methods: Evaluation of a prospectively-collected Fracture Outcomes Research Database between 01/03/2020 and 31/05/2020; this was compared with data submitted to the NHFD in 2019.

Results: The number of hip fractures diagnosed remained constant with 109 hip fractures during the 3 months. Our proportion of patients getting surgery within 36 hours improved from 33.0% in 2019 to 66.5%. Our length of acute stay (LOS) reduced from 15.7 days to 10.2 days. Our 30-day mortality reduced from 6.75% to 5.5%. 7 patients in 2020 were diagnosed with COVID-19 in the peri-operative period; there were no swab positive COVID-19 deaths.

Conclusions: Ambulatory patients displaced from our primary theatre ensured faster theatre access for hip fracture patients; we doubled the number of hip fractures operated on within 36 hours. LOS reduced by a third and the 30-day mortality reduced from 6.75% to 5.5%.

Implications: The additional theatre space free for allocation to hip fractures reduces time to theatre and LOS and 30-day mortality. Future comparison with NHFD 2020 figures will identify if the local trends were observed nationally.

There is NO Conflict of Interest: Yes

1794 - Does preoperative digital templating help restore leg length discrepancy and femoral offset in patients undergoing Total Hip Arthroplasty for primary osteoarthritis

D. Parmar1, J. Wong2, M. Gibson1, P. Subramanian1, P. Jaiswal1

1Royal Free Hospital Foundation Trust, T&O, London, United Kingdom, 2Royal Free Hospital Foundation Trust, London, United Kingdom

The aim of this study was to compare the accuracy in correction of leg length discrepancy (LLD) and restoring femoral offset in patients undergoing total hip arthroplasty (THA) with preoperative digital templating versus without. Secondary objectives were the accuracy of implant sizes (templated versus actual), cup inclination and the femoral neck cut.
This retrospective cohort study compared consecutive patients who underwent THA for primary osteoarthritis. In a 12 month period 56 patients underwent arthroplasty surgery with pre-operative digital templating using Traumacad (Brainlab AG Germany) and 50 patients without templating.
The templated and non-templated cohorts were matched for variables including age (mean = 71.8 years (sd 11) vs 70.9 years sd (10.4), pre op LLD (– 4.9mm (sd 7.4) vs – 5.2mm (sd 7.9) and pre op offset (41.2 sd (6.7) vs 43.7 (sd5.9). Two independent blinded observers recorded all radiological data.
Preoperative digital templating resulted in correction of LLD to <5mm in 76.8% of cases, 5-10mm in 21.4% and >10mm in 1 case only (1.8%). The non-templated cohort had a LLD <5mm in 50% of cases, 5-10mm in 28% and >10mm in 22% (11 patients). Chi square testing demonstrated this to be statistically significant (p = 0.002).
The mean pre-operative offset in templated group was 40mm (sd 4.6) and 46mm (sd 5.1) postoperatively . The non-templated cohort had a mean pre-operative offset off 42 (sd 8.2) and 36mm (sd 6.2) post-operatively. Independent t testing revealed statistical significance at a p value of 0.05.
Preoperative digital templating leads to an increased likelihood of restoring LLD to <5mm and a significantly increased likelihood of preventing lengthening > 10mm.
Templating significantly increases the chance of restoring femoral offset to match the native hip and a negative (decreased) offset is seen in the non-templated group of patients.

There is NO Conflict of Interest: Yes

1808 - Direct contact between the acetabular component and bone reduces the ability to maintain cement pressure during the middle stages of cement curing: An in vitro study of the effects of Polymethyl Methacrylate spacers in total hip arthroplasty

S. Salih1, A. Gordon1, S. Salih1

1Northern General Hospital Sheffield, Sheffield, United Kingdom

Background: Failure of the bone-cement interface of the acetabular component is implicated in up to 8% of cemented total hip replacements at 14 years. A good cement mantle is generally accepted to mean uniform cement thickness with good penetration into trabecular bone. Acetabular components with spacers ensure that the component does not ‘bottom out’ and there is a uniform cement mantle. Their effect on cement pressure however, critical for creating good penetration of the cement into trabecular bone, has not previously been studied.

Methods: Sawbone acetabulums were prepared with pressure monitors. A ball pusher was fitted with a forcemeter. Vacuum mixed bone cement was prepared and introduced at 1m:30s, cups were introduced at 3m:30s. Data was collected until 6 minutes post mix.
Cups with spacers (‘Bobble’ group) were introduced with a target force of 60N so that the spacers contacted the sawbone. Cups without spacers were placed ‘bottomed out’ (‘bottom’ group) on the sawbone with a target force of 60N, or in an ‘ideal’ position without contacting the sawbone (‘ideal’ group).

Results: The bobble group produced mean pressures 5.25kPa (mean force 58.7N). The bottom group produced 10.5kPa (mean force 68.2N). The ‘ideal’ group produced 12.85kPa peripherally (mean force 12.7N). The Cement pressures in the ‘ideal’  group were significantly higher (P<0.001) than both other groups despite the much lower force used.

Conclusions: Contact between the cup and sawbone, either directly or via spacers, reduces the ability to maintain cement pressure. Maintaining cement pressure at a higher level than capillary blood pressure throughout cement curing may be beneficial to prevent blood ‘pushing back’ into the bone cement interface. The authors suggest cups with spacers should not be intentionally pushed against bone, but used as a safety net, and the placement of the cup should be based on intra-operative landmarks.

There is NO Conflict of Interest: No

DisclosureAcknowledgements, Declarations, and disclosures: Thanks to JRI for providing saw bones and acetabular components (Avanteon), Ivan Green from Fruition designs for providing the pressure sensors and transducers, Rebecca Malton and Jacklyn Ellis (Stryker) for providing acetabular components (Rimfit) and Ian Duffy (Hereaus) for providing cement (Palacos) and mixing equipment.

1837 - Management of greater trochanteric pain syndrome: a systematic review of randomised controlled trials

E.L. Goh1,2, S. Chidambaram2, J. Lambert3

1University of Oxford, Oxford Trauma, Oxford, United Kingdom, 2University of Oxford, Oxford University Clinical Academic Graduate School, Oxford, United Kingdom, 3University of Oxford, Oxford, United Kingdom

Background: Greater trochanteric pain syndrome (GTPS) is a condition characterised by gluteus medius and/or minimus tendinopathy, with or without co-existing bursal pathology. A wide range of treatment modalities have been implicated yet there remains a paucity of high quality evidence for the treatment of this condition. The present systematic review aims to evaluate the evidence for the management of GTPS.

Methods: Medline, Embase, Scopus and Cochrane Central Register of Controlled Trials (CENTRAL) were searched from the date of inception to 23rd December 2019. Randomised controlled trials (RCTs) evaluating treatment for GTPS in individuals aged 16 years and older, with no previous surgical procedures of the hip joint, and history of inflammatory joint disease. Non-English, non-human, and unpublished studies were excluded.

Results: A total of 13 RCTs enrolling 864 patients to treatment arms including education, physiotherapy/exercise therapy, corticosteroid injections, platelet-rich plasma (PRP) injections, hyaluronic acid injections, and shockwave therapy were included. There is moderate quality evidence supporting the role of combined education and physiotherapy, and the limited benefit of corticosteroids in the management of GTPS. Limited evidence is available regarding the effects of alternative treatments including PRP injections, hyaluronic acid injections, and shockwave therapy in treating this condition.

Conclusions: There is an increasing number of high quality research into the treatment of GTPS. However, there is a lack of high quality evidence supporting the use of PRP injections, hyaluronic acid injections, and shockwave therapy as part of the treatment algorithm. Combination therapy with education and physiotherapy should be the mainstay of treatment, with no role for corticosteroids injections.

There is NO Conflict of Interest: Yes

1843 - Changing Trends implant usage in Total Hip Replacement

A. Bashir1, N. Nibhani1, K. Gunasekaran1

1Royal Liverpool University Hospital, Orthopaedics, Liverpool, United Kingdom

Background: There is continued debate as to whether cemented or un-cemented implants should be used in primary Total Hip Replacement (THR).The Getting It Right First Time (GIRFT) publication in 2015 and NHS England consultation document 2019/20 highlighted areas of excellence and areas for focus and improvement.

Aim: Purpose of this study was to identify trends in implants used in primary THR.

Methods: During the period 2013-2018, we identified patients who underwent primary THR in our unit. Data collected included type of implants (cemented or uncemented) and their Orthopaedic Data Evaluation Panel (ODEP) rating. Regression analysis of annual trend of implant type, volume and ODEP ratings of THR was undertaken.

Results: Data of 1753 THR were analysed from 2013 to 2018. Of these 583(33%) were un-cemented, 568 (32%) were cemented, 275(15%) were hybrid and 327(18%) reverse hybrid. Uncemented THR declined from 60% in 2013 to 24% in 2018 (p<0.05%). Cemented THRs increased from 11% to 57% (p<0.05) while hybrid and reverse hybrid did not show a significant trend. Annual volumes of THR also showed a gradual downward trend from 343 in 2013 to 256 in 2018 (p<0.05). Implants with ODEP rating of >10A were used as follows: 97% of cemented and 99% of un-cemented cups, 99% of cemented and 94% of un-cemented femoral stems. There was no significant change in ODEP ratings of implants during the study period.

Conclusion: There was a significant shift to cemented THRs over the study period. This was associated with a reduction in volumes of THRs performed. Further detailed analysis is required to identify any causality in this association.
There was no overall significant change in ODEP ratings of implants used.

There is NO Conflict of Interest: No
1850 - Long-term follow up of porous tantalum uncemented acetabular components in complex revision hip arthroplasty

M. Ibrahim1, L. Rahman1, L. Somerville1, J. Howard1, D. Naudie1, S. MacDonald1, R. McCalden1

1London Health Sciences Centre - University Hospital - Western University, Adult Lower Limb Arthroplasty, London, Canada

Introduction: The use of Porous Tantalum cementless component in complex revision total hip arthroplasty (THA) has gained popularity in the last 2 decades with small number of studies reporting on long-term outcomes. The aim of this study is to analyse long-term clinical outcomes, radiological appearance and survivorship of this implant.

Methods: We reviewed our database for patients with tantalum cementless acetabular component with a minimum 7 years follow-up. This study was approved by our research ethics board. We reviewed the Patients’ PROMS including SF12 and WOMAC. We reviewed their latest radiographs to look for any evidence of loosening. We analysed the data using SPSS Statistics and survivorship using Kaplan-Meier survival analysis with revision as an end point.

Results: 101 patients (102 hips) had revision THA between 2003 and 2009 using porous tantalum cup. 26 patients (27 hips) died before the 7 years follow up for reasons unrelated to their surgery and 10 patients lost to FU, this leaves 65 patients with mean FU of 10.1 (7-15.7). Ten-year Survival analysis revealed 95.3% (95%CI 90.1 to 100.0). The total WOMAC scores were improved significantly from 48.9 ± 19.2 preoperatively to 67.5 ± 22.6 postoperatively (p value < 0.001). The SF 12 physical component (PCS) was improved significantly (P = 0.008) with 29.3 ±7.3 preoperatively to 33.4 ± 9 postoperatively. Radiological analysis revealed well-fixed implants with no loosening or migration. There were few complications in this cohort. 5 patients had DAIR with no revision required, 2 patients with periprosthetic femoral fractures required revision of the stem only and one with dislocation that didn’t require cup revision.

Conclusion: At seven to fifteen-year follow up, a porous tantalum cup has shown a stable fixation with improved PROMS and survivorship of 95.3%. This indicates that this acetabular component remains a great option for complex revision THA.

There is NO Conflict of Interest: No

Disclosure: Dr Howard, Naudie, McCalden and MacDonald are paid consultants for Smith and Nephew (S&N), DePuy and Stryker and they receive institutional support from S&N, Stryker and Depuy. The rest of the Coauthors have nothing to declare. The presenting author (Mazin Ibrahim) Has nothing to declare.

1873 - Comparison of the Incidence of pulmonary embolism after total hip replacement among trauma and elective patients. Retrospective analysis of a single centre eight years experience

E. Bagouri1, J.C. Cruickshank1, A. Daoub1, A. Wignal1, M. Kumar1, A. Mohsen1

1Hull University Teaching Hospitals NHS Trust, Trauma and Orthopaedics, Hull, United Kingdom

Introduction: Venous thrombo-thromboembolism remains a major concern after total hip arthroplasty (THR) & pulmonary embolism (PE) can be life-threatening; CT pulmonary angiogram (CTPA) remains the golden standard in diagnosing PE.
In this study, we are comparing the indications outcomes of CTPA & the incidence of PE among trauma & elective THR patients.

Methodology: Prospective analysis of retrospectively collected data from a single trauma center electronic database, coding department records, and National hip fracture database.
The data included the patients’ demographics, indications, and outcomes of CTPAs &chest X-rays-, admission, and discharge dates. Furthermore, the mortality within 120 days and causes of death among patients who had CTPAs were collected.

Results: Between 2010 and 2018 there were 7858 patients who had a lower limb arthroplasty, 3965 were THR including 3700 elective THR, and 265 trauma. The mean age for the patients was 72 and 76 for elective &trauma THR respectively. 64 CTPAs were requested for the elective THR group Vs 13 for the trauma THRs. 15 of the elective group CTPAs had PEs (23%) compared to 5 (38.5%) among trauma patients (overall rate PE of 0.41% for THR). There was no mortality among patients with PE identified on CTPA. Shortness of breath (SB) and low saturations were the commonest indications for CTPA among both groups. SB occurred in 10 of 13 (77%) trauma cases and 4 of the 5 (80%) positive for PE. While in the 64 elective patients 45 (70%) had SB, of those 10 of the 15 (67%) who were positive for PE.

Results: Patients who underwent THR for trauma in our sample had a higher incidence of PEs. That can be due to the different protocols of chemical prophylaxis or the added physiological stresses associated with trauma. That should be considered when consenting patients and in their post-operative management.

There is NO Conflict of Interest: Yes

1878 - Elective Total Hip Arthroplasty in patients with neurodegenerative disorders and epilepsy: A report of 2,860 cases from the Swedish Hip Arthroplasty Register

A. Bhattacharjee1, A. Wojtowicz2, J. Nåtman2, E. Bülow2, O. Rolfson2, P. Cnudde1,2

1Prince Phillip Hospital, Wales Deanery, Cardiff, United Kingdom, 2Swedish Arthroplasty Registry, Sweden, Sweden

Introduction: Few studies report the outcome of total hip arthroplasty (THA) with neurodegenerative disorders and epilepsy. This longitudinal study reports mortality, adverse events, dislocation, reoperation, revision and patient-reported outcomes (PROMs) in this cohort from the Swedish Hip Arthroplasty Register (SHAR).

Methods: The SHAR and the linked national patient register used to identify elective THA patients with the pre-existing neurodegenerative and epileptiform disorder from 2005-2014. Patients matched on demographics, Charlson comorbidity index, diagnosis, surgical approach, head size and bearing. PROMs, Health-Related Quality of Life (HRQoL) and adverse events ( 30 & 90 days), dislocation at one year, reoperation, revision (exchange or removal of components) and mortality reported. Patients were followed-up until death or end of the study. P- values < 0.05 considered significant.

Results: Study period had 132,349 elective THA’s - 2,860 patients had neurodegenerative or epileptiform disorder. Broad categories were dementia (37.6%), epilepsy (35.3%), Parkinson’s and Parkinson’s like diseases,(18.8%) and others (8.3%).
These patients had significantly higher mortality, dislocation rate, reoperation rate and revision rate (p <.0.05).
More patients encountered adverse events at both 30 & 90-days in comparison to the matched cohort (15.6% versus 11.9% and 18.9% versus 14.4% respectively). Despite a lower starting level, there was no difference in EQ-5D-3L at one year in the study group. In total, 83.8% of the patients were satisfied with outcome, and 89.7% of patients reported reduction in pain after surgery.

Conclusion: While few patients report being satisfied or very satisfied with the outcome of the surgery, there is no difference in improvement in the HRQoL between the study and the matched cohort. However, these patients have higher postoperative adverse events. Nevertheless, the change in HRQoL and patient satisfaction in this group indicate the requirement for developing surgical strategies to reduce the risk of dislocation, reoperation and revision.

There is NO Conflict of Interest: No

1884 - A comparison of the outcomes of short versus long cephalomedullary nail fixation over a 10 year period

K. Cheema1, E. Cornish1, M. Chawda1

1Ysbyty Gwynedd, Bangor, Trauma & Orthopaedics, Bangor, United Kingdom

Background: The choice of short versus long cephalomedullary nail (CMN) fixation is one that is frequently discussed at trauma meetings. The aim of this retrospective study was to analyse the outcomes of these procedures, performed at our unit over the last 10 years.

Method: Data was retrospectively collected using the National Hip Fracture Database records at our unit pertaining to all patients who had received a short or long CMN between 01/01/2010-31/12/2019.

Results: 262 patients received long CMNs whilst 42 received short CMNs over this period. Of these patients, there were 4 implant failures (4/42 = 9.5%) amongst the short nails and 8 amongst the long nails (8/262 = 3%, p=0.03). The most common reason for failure was femoral head collapse causing eventual protrusion of the tip of the blade (3 for long nails and 2 for short nails, p=0.07). Cut out was more frequent in long nails (2 versus 1 for short nails, p=0.34). In two of these three cases the tip-apex distance was less than 25mm (12mm and 23mm) however in 1 case it was 39mm. There were 2 periprosthetic fractures, one in each group at the distal aspect of the nail (p=0.14). 2 patients in the long nail group required re-operation for distal migration of the nail.

Conclusion: This study identified a significantly higher rate of implant failures amongst short nails compared to long nails, in our unit over the last 10 years. However, the rate of periprosthetic fractures was comparable amongst both groups.

There is NO Conflict of Interest: Yes

Medical Student

Virtual Podium

394 - The variable anatomy of the medial cutaneous nerve of the forearm - potential medicolegal implications
A. Bonshahi , G. Biyani , A. Sardesai , C. Brassett , K. Sherman
University of Cambridge, Human Anatomy Centre, Department of Physiology, Development and Neuroscience, Cambridge, United Kingdom, Cambridge University Hospitals NHS Foundation Trust, Anaesthesiology, Cambridge, United Kingdom

Background: A recognised complication of operations on the medial aspect of the elbow, such as cubital tunnel surgery, is damage to the medial cutaneous nerve of the forearm (MCNF). Injury can lead to sensory loss around the elbow and medial forearm or, more severely, neuroma formation, which can result in chronic postoperative pain. We aimed to determine if there are any ‘safe-zones’ for surgical incision and dissection that would reduce the risk of damage to the MCNF and its branches.

Methods: Ultrasound using a 22MHz probe on a GE LOGIQ e R7 in healthy volunteers (n=36) and cadaveric dissection (n=6) was used to map the MCNF from 16cm proximal to 12cm distal to the medial epicondyle (ME). Data consisted of coordinates, which were plotted on Excel to provide graphical models of the nerve. Locations where MCNF branches crossed a hypothetical surgical incision were extracted, and vectors from the ME to the nearest MCNF branch were also measured.

Results: Preliminary dissection and ultrasound scanning revealed significant variation in the course of the MCNF. Two variant innervations were observed, including a newly described ulnar cutaneous nerve supplying the skin over the ME. Three common incision crossing locations were identified, at 0.1cm proximal, and 2.3cm and 4.1cm distal to the ME (±0.2cm), but these only accounted for 50.4% of all MCNF crossing branches. The distribution of vectors from the ME to closest MCNF branch was non-normal and widely spread. 16.7% of specimens had an MCNF branch passing over the ME, meaning no ‘safe-radius’ around the ME exists.

Conclusion: There are no consistent patterns in either MCNF incision crossing locations or vectors. Thus, the MCNF cannot reliably be avoided during medial elbow operations by the use of anatomical ‘safezones’. This has important medicolegal implications when obtaining informed consent. 

956 - Clinical Orthopaedic Teaching Programme for Students (COTS)
P.R. Kumar , T. Stubley , Y. Hashmi , U. Ahmed
University of Birmingham, College of Medical and Dental Sciences,, Birmingham, United Kingdom, Princess Royal Hospital, Telford, United Kingdom  

The lack of national undergraduate curriculum for orthopaedic examinations results in a huge variation in depth and breadth of content taught. Undergraduate students are often left confused by variability in examination techniques, thereby increasing concerns for upcoming OSCEs. Doctors, despite being expected to teach, rarely receive formal preparation, with only a handful of institutions providing medical students with necessary training and experience. A teaching programme is therefore required to equip medical students with the knowledge of how to perform clinical orthopaedic examinations and to synergistically provide senior medical students with the necessary experience for the future teaching required of them as a doctor.
Six fortnightly sessions were delivered, each focusing on a specific joint examination with content quality assured. Senior medical student recruitment to teach as tutors and student enrolment was on a voluntary basis from a local UK university. Pre- and post-session MCQs were provided to students to assess improvement in knowledge. Anonymous feedback forms were provided to both students and tutors. 
From 61 student responses, 98.4% of students stated that COTS met the learning outcomes, with content relevant for their medical curriculum and upcoming OSCEs. 96.7% supported COTS’ nearpeer teaching style for OSCE preparation. Based on 5-point Likert scale, students displayed a mean improvement in confidence (1.7±1.2, p<0.001) and MCQ scores (1.3±1.2, p<0.001) before and after the sessions. All 10 tutors perceived an improvement of their teaching skills and confidence to teach (1.0±0.9, p=0.016).
COTS shows that a near-peer teaching style can be used to effectively teach orthopaedic examinations, with benefits for both students and tutors. With our aim to refine and upscale this programme, we publish our pilot study findings to encourage similar teaching programmes to be adopted at other universities to further benefit medical students, doctors and ultimately, patients, on a larger scale.

890 - Use of virtual reality relaxation videos in wide awake hand and wrist surgery improves patient experience and reduces patient’s pain and anxiety, a cohort study
S. Michail , Z. Haj Ali , S. Umarji , C. Hing
St George's University of London, London, United Kingdom 

There has been a 34% increase in hand surgery over the last decade from 149-199 operations/ 100,000 population/year with a potential saving of £750,000 over 1000 cases of wide awake surgery compared to sedation. Relaxing virtual reality (RVR) involves a 3D computer-generated simulation that transports the user to another place using goggles and headphones. RVR has been shown to reduce pre-operative anxiety in studies of burns dressings changes and phlebotomy.

Aims: To establish whether using RVR reduced stress and anxiety in wide awake day case hand surgery. 

Methods: Patients were recruited from elective and trauma lists in a day surgery hand and wrist unit. Patients received regional anaesthesia or local infiltration. Patients completed the Pain Catastrophising Score (PCS) and the Amsterdam Pre-operative Anxiety and Information Scale (APAIS) both pre-operatively and post-operatively. Serial blood pressure and heart rate measurements were recorded as physiological markers of stress. Side effects were recorded and patients were asked to complete a patient experience questionnaire. The data was analysed using a paired t test.

Results: 30 patients took part in the study, with a mean operation time of 36.9 (range 10 – 75) minutes. There was a significant decrease in PCS from 16.8 (SD 13.9) pre-operatively to 3.1 (SD 4.3) postoperatively, P=0.000. The APAIS decreased significantly from 13.7 (SD 5.7) to 9.5 (SD3.5), P=0.000. Systolic blood pressure decreased significantly from 130.6 (SD11.1) to 120.7 (SD10.4), P=0.000, and heart rate decreased from 84.2 (SD16.1) to 73.7 (SD11.2), P=0.001. All patients felt it improved their overall hospital experience, would choose to receive RVR in a future operation, and would recommend it to friends. Over 90% of patients said it helped them feel relaxed or sleepy. No side effects were reported. 

Conclusion: VR is a new and innovative approach to significantly reducing anxiety and improving patient experience in hand surgery.

340 - The Biomechanical Characteristics of The Hybrid Sutures Using Three Arthroscopic Suture-Knot Configurations
M Scotcher , A Kheiran , P Raval , K Boksh , LD Sanders , JJ Dias , HP Singh
University of Leicester, Leicester, United Kingdom, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom  

Purpose: To determine the most secure suture-knot configuration by investigating the biomechanical characteristics of seven different types of hybrid sutures using three different knot-tying techniques; Surgeon’s, the Dines, and the Seoul Medical Centre knots.  

Methods: Seven different No. 2 braided hybrid sutures were first compared using the Surgeon’s knot to analyse the force to failure, knot and loop security, and mode of failure. All knots were tied, using arthroscopic instruments, into standardised loops, subjected to 1,000 cycles, between 10 and 80N, using a model 5965 Instron® hydraulic machine (Instron, Canton, MA). The sutures found to have the best properties, in phase-1, were then used to investigate the tensile strength of three different arthroscopic suture-knot configurations (phase-2).  

Results: In phase 1, the load-to-failure was significantly higher in MagnumWire (270.1 ± 30.3), Ultrabraid (254.1 ± 27.9), and MaxBraid (244.9 ± 26.7) showed significantly higher load-to-failure compared to the other suture types (p=0.015), and no significant difference between each other (p=0.134). Orthocord, Hi-Fi and ForceFiber were more likely to slip at the lowest load to failure and demonstrated lower loop and knot security (p=0.002). In phase 2, the combination of any suture material with the SMC or the Surgeon’s suture-knot configurations demonstrated significantly higher tensile strength when compared to the Dines knot (p<0.05). The Dines suture-knot configuration was more likely to slip at the lowest load, (p<0.05).  

Conclusions: Loop and knot security varied depending on the type of knot tied and suture material used. MagnumWire, Ultrabraid, and MaxBraid sutures provide overall higher Load-to-failure (tensile strength), and resistance to clinical failure (elongation > 3mm). The SMC knot configuration provided the strongest, and most consistent construct. We would therefore advocate the use of the SMC knot configuration with a hybrid suture material for best overall results. 

766 - Availability of Hand Sanitization in a District General Hospital
S. Sirikonda , N. Emms
Newcastle University, Medical School, Newcastle, United Kingdom, St.Helens and Knowsley NHS Trust, Department of Orthopaedics, Whiston.

Background The most serious infections in healthcare are spread by peoples actions. Hospital acquired infections are one of the most common complications of healthcare. Hand hygiene is an important way to prevent the spread of infection. Greater hand hygiene creates a safer working environment for staff and patients. The audit was performed to assess the functionality of hand sanitizers, soap dispensers and towel availability at a District General Hospital.

Method: 264 different data points were collected at different Wards, Outside Theatres, Investigative areas and non-clinical areas of the Whiston hospital. The ward staff and Medirest (hand sanitiser supplier) were informed, then re-audited after 4 weeks.

Results For all areas overall, availability of hand sanitsers improved from 77.5% to 85%, soap dispersers functionality improved from 67% to 96% and hand towels availability improved from 97.5% to 100%. All areas of the hospital improved availability for all parameters tested on re-audit.

Conclusion: The availability of hand gel and the soap dispenser is variable in the areas checked in the initial audit. The increased awareness of the non-functioning hand gel and soap dispensers led to responsible action from the staff. Our results showed that the hand sanitisation facilities could be improved with better information.

Implications: No National or Local Hospital Standards are available for the parameters that were audited. It is generally accepted that there should be 90% functional soap and hand sanitizer dispensers and availability of towels. After the introduction of mandatory hand sanitization in NHS, there was a significant reduction of hospital acquired C.difficile and MRSA infections. This is particularly relevant with the current COVID-19 pandemic. 

1046- Rate and Severity of Disc Degeneration in Preoperative Adolescent Idiopathic Scoliosis
C. Boylan , R. Thimmaiah , C. Baird , M. Jones
University of Birmingham, Birmingham, United Kingdom, The Royal Orthopaedic Hospital, Birmingham, United Kingdom

Background: Adolescent idiopathic scoliosis (AIS) affects between 1-3% of children aged 10-16 years and can cause significant disability if left untreated. Therefore, large or progressive curvatures usually undergo spinal arthrodesis. One consequence of this procedure is a perceived increase in the rate of disc degeneration in the lower, unfused, spinal segments. However, no data currently exists to quantify the rates of disc degeneration prior to the procedure. This study aims to ascertain the rate and severity of disc degeneration in the preoperative AIS population.

Methods: A retrospective chart and MRI review was undertaken. All consecutive patients between September 2007 and January 2019 who had surgical intervention for AIS at a large tertiary orthopaedic hospital were included. MRI reports were analysed to exclude non AIS patients. The severity of disc degeneration on preoperative MRI was assessed using the Pfirrmann grading system.

Results: 1024 preoperative MRI scan reports were collated and analysed. Mean age was 14 years. 93 (9.1%) showed evidence of disc degeneration. 55 (5.4%) had single level disease and 38 (3.7%) involved ≥2 levels (range 1-12). The most commonly affected level was L5/S1 (59.1% of cases), followed by L4/L5 (25.8%), T11/12 and T10/11 (both 15.0%). The majority of damaged discs were Pfirrmann grade 2 (63.1%), followed by grade 3 (31.3%). Only 1 disc was graded Pfirrmann 5. 35 patients (3.4%) had grade 1 L5/S1 spondylolisthesis and 15 (1.5%) had bilateral L5 pars defects.

Conclusion: This is one of the largest reported case series to investigate preoperative disc degeneration in the AIS cohort. A significant proportion of patients showed some degree of disc degeneration, although the Pfirrmann grade was usually low. When present, degeneration was typically in the lower two intervertebral discs.

Implications: This study provides a baseline rate of disc abnormalities against which postoperative fusion cases can be compared.

357 - The Association of Anterior Cruciate Ligament Injury with Knee Osteoarthritis and Total Knee Arthroplasy

O Krahelski, O Keenan, C Scott, JF Keating
University of Edinburgh, Edinburgh, United Kingdom, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom.

Background: There is evidence that anterior cruciate ligament (ACL) deficiency is associated with an increased risk of knee osteoarthritis (OA). However, there has been a lack of studies with long term follow up investigating the association of ACL deficiency with severe OA and the need for subsequent total knee arthroplasty (TKA).

Objectives: 1. To define the incidence of ACL tears in patients undergoing TKA. 2. Investigate demographic differences between patients with ACL deficient knees and those with ACL intact knees undergoing TKA. 3. Assess the different patterns and severity of OA in the knee between patients with ACL deficiency ACL intact knees undergoing TKA.

Study Design & Methods: A retrospective comparison between ACL deficient knees and ACL intact knees in a consecutive series of patients undergoing primary TKA.

Results: There were 298 knees, of which 44 (14.77%) were ACL deficient. Comparing ACL deficient with ACL intact knees there no differences in age (69 vs 72; p=0.053) or BMI (31.48 vs 29.76; p=0.059). The knees that were ACL deficient were more likely to have a deficient or absent medial and/or lateral meniscus (p=0.017, p<0.0005). They were more likely to have a valgus deformity (p=0.002), have a larger area of the knee affected by OA (p=0.001) and exhibit more severe hallmarks of OA using the Ahlback score(p<0.0005).

Conclusions: The incidence of ACL deficiency in the TKA population is 214 times higher than the general population and is associated with more severe and extensive arthritis in the knee. However the age at the time of surgery between the two groups was not significantly different nor was there any gender difference. Patients who sustain ACL tears can be advised that their long term risk of requiring TKA is increased but their age at the time of surgery is similar to the general TKA population. 

377- When do people return to work and hobbies after a Traumatic Rotator Cuff Tear?
O Kooseenlin, L Pitt, M Bateman, DI Clark, A Tambe
University of Nottingham, Nottingham, United Kingdom, University Hospitals of Derby and Burton NHS Foundation Trust, Derby, United Kingdom

Background: Large studies have demonstrated increasing prevalence and therefore increased economic burden that rotator cuff tears (RCT) have on the population. The purpose of this study was to evaluate the impact of traumatic RCTs on the population, an area with little published literature.

Methods: Prospectively collected data was obtained using the soft tissue shoulder injury database maintained in the unit. A consecutive series of patients attending the acute shoulder injury clinic in a University Teaching Hospital over a 24-month period, who were diagnosed as having a traumatic RCT and subsequent repair (arthroscopic or open) were included. Oxford shoulder scores (OSS) and Constant scores were measured pre- and post-operatively. These assessments were undertaken by an independent physiotherapist. Complications were recorded. A patient questionnaire regarding time-off work, return to work and hobbies was completed.

Results: Data was collected from 24 patients. Mean age was 54 years (range- 36-79). Mean time from listing to operation was 76 days. Of those with full OSS pre- and post-operation, median improvement was 38. Mean improvement in Constant score in patients with pre- and post-operative data was 46. Mean time to return to work was 12.8 weeks. Of those that returned to work (18), 6 (33.3%) returned with lighter duties. 29.2% of patients (7/24) suffered complications post-operatively, and 6.7% of patients (4/24) went on to suffer subsequent re-tear of their primary injury.

Discussion: Traumatic RCTs have a significant impact on the population. Collecting OSS and Constant scores allows surveillance of progress and recovery. Most patients required considerable time before returning to work and full activity levels, with some returning to work with altered duties, reflecting the current literature. The perioperative morbidity associated with traumatic RCT repair and the lifestyle changes involved post-operation and consequent psychological impact needs to be further research with in-depth psychosocial questioning. 

764 - Assessing an undergraduate low back pain teaching programme: medical student understanding of Deyo’s low back pain myths
M. Karim , M. McCarthy
Cardiff University, Caerdydd, United Kingdom, University Hospital Wales, Cardiff, United Kingdom 

Introduction: Low back pain (LBP) is recognised as a leading cause of disability worldwide, with significant financial implications. Deyo’s “7 Myths of Back Pain” were formulated to address the most commonly held incorrect beliefs surrounding LBP. This study looked to evaluate medical student understanding of LBP after a 2-week structured case on spinal conditions.      

Objectives: To evaluate the undergraduate medical second-year curriculum at Cardiff University with regard to LBP and assess medical students understanding of the “Myths of Back Pain”.

Methods: A pre and post-case questionnaire was designed and distributed in paper format prior to the start of the 2-week module and at the close of formal teaching. The teaching module did not contain any explicit reference to Deyo’s “7 Myths of Back Pain”.

Results: 109 second-year medical students completed both the pre and post-case questionnaire. A general trend of improvement was seen in recognition of the myths in the questionnaire postteaching, with 3/7 myths being successfully identified by over 95% of the participants. A history of back pain was associated with higher correct responses.

Conclusion: There are commonly held misconceptions within medical students surrounding the topic of LBP. It is important to address these beliefs and dispel these myths within medical schools across the UK. 

D.S. Rye, H. Merchant, K.S. Eyres, J.R. Phillips, H.B. Waterson, A.D. Toms
University of Exeter Medical School, Exeter, United Kingdom, Royal Devon and Exeter Hospital: Princess Elizabeth Orthopaedic Centre, Exeter Knee Reconstruction Unit, Exeter, United Kingdom 

Background: Stemmed revision components have been accepted as a viable option to improve mechanical stability of a revision construct; thereby enhancing ultimate component survival. However, the tibial fixation method in revision knee arthroplasty remains controversial. We review the survivorship, failure mechanisms and presence of radio-lucent lines in a consecutive cohort of 125 revision tibial cemented stems.

Methods: Review of 118 patients (125 knees) with fixation of the revision tibial component with short-medium cemented stem extensions. A fully cemented technique with a cement plug and pressurisation was used in all. Indications for using a stemmed prosthesis were: The need for a varus-valgus constrained implant Or proximal bone loss requiring a metal augment with an intact diaphysis.

Results: Minimum 5 year follow up (range 5–13). 39 patients deceased; 8 were lost to follow-up. The AORI tibial defect was: Grade 1 in 77 knees 2A in 26 2B in 20 3 in 2 Of 125 tibial revision stems, using aseptic loosening as the end-point there was only 1 failure representing a 0.8% failure rate. There were 4 failures for infection, (2 of whom had infection as the primary indication for revision surgery), 2 for peri-prosthetic fracture and 1 for instability secondary to a traumatic MCL rupture. Overall survivorship with re-revision for any reason as the end point was 94%. 12 patients had radiolucent lines in 4 or more zones but have not required re-revision surgery.

Conclusions: Cemented tibial stems provided excellent fixation in revision arthroplasty, even with metaphyseal defects and hinged prostheses. Infection was the highest cause of failure.

Implications: A plug and pressurisation cementation technique is recommended for stemmed revision total knee arthroplasty. Patients with infection as the primary indication for revision should be counselled appropriately. Longer follow-up for patients with evidence of radiolucent lines is required to confirm fixation durability. 

1380 - Poor outcomes following primary total knee replacements (TKR) – an investigation into the reason behind why some perform poorly 1-1.5 years post-TKR
A. Mohomed, A. Bilal, E. Campion, P. Lewis
Cardiff University, School of Medicine, Cardiff, United Kingdom, Prince Charles Hospital, Department of Trauma and Orthopaedic, Merthyr Tydfil, United Kingdom  

Objective: To explore why some patients are left dissatisfied following a primary total knee replacement (TKR) and to investigate any factors that may contribute to this poor outcome.

Methods: All data on TKRs performed by a single surgeon between May 2010 - Jan 2019 was accessed. 1 or 1.5 year post-operative OKS was subtracted from the pre-operative OKS and a bottom 10% group of patients was established. Comparison of patients in bottom 10% group to rest of cohort was done using SPSS for statistical analysis. Patient notes in the poor outcome group were then accessed and studied.     
Results: There is no statistical difference between the poor performers and the rest of the cohort in regards to BMI, age, gender, pre-operative OKS and laterality (p values=0.539, 0.065, 0.557, 0.46, 0.854 respectively). 11/35 (31.0%) of poor outcome cohort have depression/anxiety, 23/35 (66.0%) had three or more joint pains, 25/35 (71.4%) had pre-operative pain at rest and 14/35 (40.0%) had neuropathic pain post-operatively, 12/35 (34%) of patients had preserved joint space (PJS) on plain film with 5 of these having well preserved in all three compartments (, 8/35 (22.8%) had MRI following insignificant plain film. 20/35 (57.1%) had arthroscopies performed. 9/35 (25%) of patients went on to have contralateral TKR despite poor outcomes.

Conclusions: Demographics and pre-operative OKS are not reliable in determining which patients will have a good TKR outcome. Having preserved joint space(s) on plain film, multiple different joint pains and depression/anxiety are risk factors for a poor outcome following a TKR. Caution and due counselling in proceeding with such surgery is required for those with preserved joint spaces on plain film, and those requiring further investigations such as arthroscopies or MRIs, for overall better informed patient care. 

1469 - Repeating lumbosacral MRI scan – when is it necessary?
M.A. Noor, M. Al-Ashqar, S. Azhar, P. Loughenbury, G. Radcliffe, S. Nisar
University of Leeds, Department of Health Sciences, Leeds, United Kingdom, University of Leeds, Academic Department of Trauma & Orthopaedics, Leeds, United Kingdom, Leeds Teaching Hospitals, Leeds, United Kingdom, Bradford Teaching Hospitals, Bradford, United Kingdom

Background: Lumbosacral MRI scans are useful in investigating spinal pathologies such as infection, tumour and degenerative disc disease. When the clinical presentation changes, a repeat MRI may be indicated.  However, MRI scans take time and resources, and the value of repeated MRI scans is unclear.   

Aim: Audit the outcomes of all lumbosacral MRI scans repeated within 12-months in a local teaching hospital. Assess the rates of change in MRI findings and management.

Methods: Data was obtained for all patients over a 10-year period who underwent a repeat lumbosacral MRI within a 12-month window. 787 patients were identified. 290 patients were excluded either due to missing MRI reports, or whose repeat MRIs were part of the same clinical episode. The remaining 497 patients were grouped by pathology for analysis.

Results: In the degenerative group, 416 repeat MRIs were performed, of which 89 demonstrated changes compared to the original scan (21.4%). Changes were frequently reported as ‘minor progression’ or ‘improved appearance’. Three patients demonstrated cauda equina compression in the repeat scan (0.72%). These patients presented on average 5 months after the initial MRI.   In the tumour/infection group, 43 of the 54 repeat MRIs performed demonstrated changes (79.6%). Of these, three showed progression to cauda equina compression secondary to tumour/infection (5.6%). They presented after 15, 299 and 329 days respectively.

Conclusion: For patients with degenerative disc disease, repeating MRI within 12-months is unlikely to show radiological change of clinical value. Likelihood of clinically relevant change in MRI findings is higher in the infection/tumour group. We, therefore, propose repeating a lumbosacral MRI scan within 12 months only in patients with suspected Cauda Equina Syndrome, or patients being managed for spine tumours or infections who have changes in their clinical presentation. 

A.W. Coombs , T.C. Edwards , B. Szyszka , K. Logishetty , J.P. Cobb
Imperial College London, School of Medicine, London, United Kingdom, MSk Lab, Imperial College London, London, United Kingdom

Intra-operative decision-making skills are a key component of surgical competency. Working-hour limits, litigation, and a sharp focus on patient safety and outcomes has reduced the opportunities for trainees to learn these skills during surgery. Cognitive task analysis-based training (CTA-based training), a technique widely adopted in aviation and the military, has been explored as a method to transfer cognitive skills to surgical trainees outside the operating room. This systematic review is the first to evaluate if CTA-based training is effective at teaching surgical procedures to novices.

We followed PRISMA guidelines and implemented a pre-agreed protocol to search MEDLINE, EMBASE, Web of Science and Cochrane (CENTRAL) database for prospective studies investigating the impact of CTA-based surgical training. Identified studies were screened for eligibility by two independent reviewers. The studies meeting full inclusion were assessed for risk of bias using Cochrane’s RoB 2 and ROBINS-I tools, with methodological quality being assessed using the Medical Education Research Study Quality Instrument (MERSQI).

The search yielded 2049 articles, of which 12 met the full inclusion criteria. A total of 327 participants were analysed including 162 surgical trainees, 139 medical students and one 26-participant study using a combination. Surgical trainees that were taught using CTA-based interventions had improved procedural knowledge (standardised mean difference [SMD] 1.36, 95% confidence intervals [CI] 0.67-2.05, p < 0.001) and superior technical performance (SMD 2.06, 95% CI 1.17-2.96, p < 0.001) in comparison to conventionally taught trainees. Medical students displayed no additional benefit from using CTA-based training to improve their surgical technical performance over conventional training methods, though CTA-based training was superior in developing their procedural knowledge.

CTA-based training is effective in teaching the cognitive skills of surgery outside the operating theatre and its implementation into the surgical curriculum is recommended to enhance the training of surgeons.

1210 - #OrthoTwitter: Social Media as an Educational Tool
M.A. Sahu, Z. Goolam-Mahomed, Y. Hashmi, P.R. Kumar, R. Morad, S. Fleming, U. Ahmed
University of Birmingham, College of Medical and Dental Sciences, Birmingham, United Kingdom, Barts and The London School of Medicine and Dentistry, London, United Kingdom, Princess Royal Hospital, Shrewsbury & Telford Hospital NHS Trust, Trauma and Orthopaedics, Telford, United Kingdom

Background and aims: The increased use of social media creates opportunity for new, effective methods of delivering medical and clinical education. Twitter is a popular social media platform where users can post frequent updates and create threads containing related content using hashtags. This study aims to investigate and analyse the type of content relating to orthopaedic surgery that is being posted on the platform of Twitter.

Methods: A retrospective search was performed for tweets containing the words “orthopaedic surgery” or “orthopedic surgery” or the use of the hashtag “#OrthoTwitter” between November 2018 to November 2019. A total of 5243 tweets were included.

Results: Tweets containing “orthopaedic surgery” or “orthopedic surgery” most frequently contained promotional or marketing content (30% promotional, 21% marketing), and private organisations were the category of author to which the greatest number of tweets belonged (30%). Tweets containing educational or research content were the least common amongst all tweets containing “orthopaedic surgery” or “orthopedic surgery” (11%). In contrast, of the tweets containing the hashtag “#OrthoTwitter”, 44% contained educational or research content, 15% contained promotional content and no tweets containing marketing content. Furthermore, 87% of all tweets using the hashtag “#OrthoTwitter” were from orthopaedic surgeons, and the least number of tweets were from private organisations (2%).

Conclusion: Twitter is a widely used social media platform regarding orthopaedic surgery. We propose that the hashtag “#OrthoTwitter” can be used to create an online community of orthopaedic surgeons where members can assist one another through sharing reliable and educational content.

Implications: Twitter provides an easily accessible platform to share content relating to orthopaedic surgery. “#OrthoTwitter” can be used to create a “virtual area” which helps separate the high-quality educational tweets from the large volumes of promotional and marketing tweets.


Quality Improvement

Virtual Podium Presentations

157 - Application of E3 method (educate, engange and empathesize) enhances the patient satisfaction after TKR

A. Doshi1, S. Londhe2

1Meril Life Sciences, Orthopaedics, Mumbai, India, 2Holy Spirit Hospital, Orthopaedics, Mumbai, India

Introduction: TKR is the most successful operation in modern day orthopedics. Still about 20-30% remain dissatisfied with the operation. Various factors like sex, BMI have been studied for their effect on the patient satisfaction. In this study we employed a counsellor to educate,engage and provide empathy to the patient undergoing TKR. The counselling started preoperatively and continued throughout the perioperative period upto six months post operatively. We started the study with null hypothesis.

Material and Methods: 100 patients were divided into group A and group B. Both the groups were matched for age, sex, BMI, coexistent co-morbidities. Group B received preoperative counselling by the surgeon whilst group A received counselling by the counsellor in the preoperative, perioperative and post operative period (at 1 week, 2 week, 4 week, 8 week, 16 week and 24 weeks post operatively). The counsellor educated the patient about the TKR procedure, the modalities of pain management and the post operative ambulation programme. The counsellor was trained to alleviate the the patient fears and reassure the patient on the course of recovery. At 24 weeks after the operation patient satisfaction and consumer gap was recorded by an independent observer.

Results: The patient satisfaction with the TKR procedure was significantly better with group A than group B (88% with group A versus 74% with group B). Consumer gap was present only in 6 % of patients in group A as against 16% of patients in group B. This difference is statistically significant. P value 0.005

Conclusion: This study clearly demonstrates that the use of counsellor for the patient undergoing TKR in the preoperative, peri operative and post operative period significantlly improves the patient satisfaction scores and reduces the consumer gap. Hence we strongly advocate the employment of a trained counsellor for the patients undergoing TKR procedure in the pre operative, peri operative and post operative period.

There is NO Conflict of Interest: Yes

204 - Peri-operative administration of tranexamic acid in lower limb arthroplasty: a multicentre, prospective cohort study

T. Lloyd1,2,3, G. Neal-Smith2, J. Fennelly2, H. Claireaux2,1, C. Bretherton2,1, A. Carr1, M. Murphy3, B. Kendrick4,1, A.J.R. Palmer1

1University of Oxford, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Science, Oxford, United Kingdom, 2Oxord Surgical Collaborative for Audit and Research (OxSCAR), Oxford, United Kingdom, 3NHS Blood and Transplant, Oxford, United Kingdom, 4Oxford University Hospitals NHS Trust, Department of Orthopaedics, Oxford, United Kingdom

Introduction: Tranexamic acid is recommended for all surgery where expected blood loss exceeds 500mls. However, the optimal dose, route and timing of administration is not known. This study aimed to evaluate current practice of peri-operative tranexamic acid administration in patients undergoing primary hip and knee arthroplasty in the UK.

Methods: Patients undergoing primary total hip arthroplasty, total knee arthroplasty or unicompartmental knee arthroplasty during a two-week period were eligible for inclusion in this prospective study. The primary outcome was the proportion of patients receiving tranexamic acid in the peri-operative period. Secondary outcomes included: dose, route, and timing of tranexamic acid administration, prevalence of pre- and postoperative anaemia, estimated blood loss and red blood cell transfusion rates. Regional variation in practice was explored by country, with England sub-divided into Public Health England regions.

Results: 1701 patients were recruited from 56 NHS hospitals. 1523/1701 (89.5%) patients received tranexamic acid, of these 1052/1523 (69.1%) received a single dose of 1g intravenously either pre- or intra-operatively. 571/1701 (33.6%) and 1386/1701 (81.5%) patients were anaemic (Hb<130g.l-1) in the pre- and postoperative period, respectively. Mean (SD) estimated blood loss for all included patients was 792(453) ml and 54 patients (3.1%) received a red blood cell transfusion postoperatively. The lowest rate of preoperative anaemia was in North East England (22.0%) and the highest rate was recorded in Yorkshire and Humber (49.5%). Blood transfusion rates were lowest in Northern Ireland (0%) and highest in Yorkshire and Humber (7.6%).

Conclusions/Findings: Current standard of care in the UK is to administer 1g of tranexamic intravenously either pre- or intra-operatively. Approximately one-third of patients present for surgery with anaemia, although the overall red blood cell transfusion rate is low.

Implications: These data provide useful comparators when assessing the efficacy of tranexamic acid and other patient blood management interventions in future studies.

There is NO Conflict of Interest: Yes

381 - Can introducing a hyponatremia protocol with a direct endoctine pathway help reduce hyponatremia in elective knee and hip replacement patients? A closed loop audit and service evaluation study

M Waller1, M Hampton1, T Harrison1, J Stoddard1

1Sheffield Teaching Hospitals Trust, Orthopaedics, Sheffield, United Kingdom

Background: Hyponatremia has a prevalence of up to 30% after orthopaedic surgery(1) and is associated with poor outcomes postoperatively, including mortality of up to 20%(2) and longer stay(1).
This study assessed the prevalence of hyponatremia following total hip & knee replacement (THR & TKR), the causes identified, further tests and management, effect on length of stay, ICU admission and the impact of an endocrinology agreed hyponatremia protocol.
Methods: Post-op U&E's for patients undergoing elective TKR/THR replacement were reviewed. Retrospective data was gathered through ICE. Parameters included demographics, procedure, sodium pre and post op, Endocrine input, HDU admissions and length of stay.
A hyponatremia protocol based on NICE guidance was then developed and agreed with STHT's endocrinology department and a second audit cycle was initiated. SPSS software was used for data analysis.
Results: Hyponatraemia was found in 12% of patients, resulted in a significantly longer stay (7.7 days vs 4.6t=-4.6p=<0.00001) and multiple critical care admissions (8 ICU days). It was more common in TKR (X2=5.5194P=0.018807) and older age (t=-2.81083p=0.002619). Prior to implementation of the endocrine pathway it was under investigated(38%), and in both cycles the precipitating factors such as age and use of diuretics corroborated with prior research(3,1).
Conclusion/Findings: Implementation of the hyponatremia protocol resulted in quicker referrals to Endocrinology (2.3vs3.6 days), reduced the length of stay by almost a day(t=-2.40973p=0.008144) and reduced the number of ICU days to 0(X2=4.6189p=0.031622).
Implications: This endocrine pathway is easily reproducible should other departments also wish to trial it. It may help reduce waiting times and improve outcomes for TKR/THR’s within the NHS.

Disclosure: This study was based within one unit in STHT limiting its relevance to the wider population and audit cycles only assessed patients over four-month periods limiting reliability.

There is NO Conflict of Interest: Yes

593 - The right thing to do: “Showing Acts of Kindness”. The Torbay experience of improving departmental morale

A. Roberton1, R. Ramesh1

1Torbay Hospital, Trauma and Orthopaedics, Torquay, United Kingdom

Background: Progressing from Medical Student to Junior Doctor can be overwhelming and stressful.  Burnout can affect 1 in 3 Junior Doctors and has significant implications for their quality of life, workforce retention and patient care.  The GMC National Trainee Survey (NTS) identified “lack of support” as a reason for low morale in our hospital.  The Boorman review recognises that an organisational culture is required for effective change to improve staff wellbeing. This is our strategy.
Methods: We have introduced the philosophy of “Showing Acts of Kindness”.  This started as a process where Junior Doctors were enabled to “buddy-up” with colleagues and had prescribed Acts of Kindness such as coffee rounds, checking-in phone calls and regular meetings.  The philosophy has grown to encompass many of the common features of a positive work environment identified by Health Education England. Specifically, good rota management, regular teaching including daily “Pearls-of-Wisdom”, a 4pm on-call meeting, feedback meetings and creation of a WhatsApp group. 
Results: Successive GMC NTS suggest Junior Doctors in our department feel valued, supported and enjoy their placement.  Significant improvement was demonstrated in; Supportive Environment (67.69% to 81.11%), Adequacy of Experience(71.21% to 90.00%), Local Teaching (46.81% to 84.78%) and Overall Satisfaction (70.63% to 88.83%).  Junior colleagues feel confident to bring up concerns and there is a stronger sense of “team”, which has been eroded since moving away from “Firm” structures.
Conclusion: A departmental philosophy of kindness is a powerful tool to improve Junior Doctor morale. Since introduction the Registrar feedback has also demonstrated the placement to be well regarded and popular. The Covid crisis further highlights the stress Junior Doctors face and the importance of support measures. Campaigns such as “Showing Acts of Kindness” are critical for this and have a positive impact on retention, recruitment and patient care.

There is NO Conflict of Interest: Yes

792 - Multi-Disciplinary Service Improvement to Improve Imaging Access for Suspected Cauda Equina

P. Mahapatra1, P. Beak1, E. Chew1, M. Hindawi1, I. Gill1

1Kingston Hospital NHS Foundation Trust, Trauma and Orthopaedics, London, United Kingdom

Background: The GIRFT Spinal services report and SBNS/BASS Standards of care set out a clear path for investigation of suspected cauda equina syndrome (CES). The ENTICE Audit demonstrated a significant burden of out-of-hours referrals to specialist centres, substantial costs of transferring patients, and staffing difficulty within MRI departments. Working together, we agreed a local protocol for MRI investigation of suspected CES in conjunction with radiology and radiography departments to allow rapid early scanning of suspected CES patients, including out-of-hours facilities.

Methods: Retrospective collection of data from pre- and post-implementation of new suspected CES MRI protocol. We included all patients over 18 presenting with atraumatic back pain who underwent an MRI for investigation of CES. Data collected over a 2-month period included timings of presentation, scanning, transfer and/or discharge.

Results: Thirty-five patients were eligible for inclusion across the 2-month period. We observed an average reduction of over 5 hours (pre 14.1, post 8.4) from orthopaedic review to MRI performed. We also observed a significant reduction (pre 41.1, post 25.6, p=0.06) in hours between MRI performed and discharge. Of those patients who were transferred for scans post-implementation, 60% required subsequent surgical intervention.

Conclusion/Findings: Information available from GIRFT, SBNS/BASS and ENTICE can be used to justify development of local pathways for MRI investigation of suspected CES within district general hospital (DGH) settings. The new protocol enabled earlier scanning and discharge. This has positive implications both clinically for the patient and financially for the hospital.

Implications: DGHs should review their current practice for investigation suspected CES and if required design/revise protocol to ensure clear pathway for 24-hour MRI is available. Ideally with local adjustment to enable provision of appropriately trained radiographers out-of-hours.

There is NO Conflict of Interest: Yes

986 - Has the Getting It Right First Time (GIRFT) programme made an impact in litigation? A review of clinical negligence claims against orthopaedic surgery in England 2007/2008 to 2011/12 and 2013/14 to 2017/18

J. Machin1, J. Hardman2, C. Deacon1, D. Ferguson3, D. Foward1, T. Briggs4

1Nottingham University Hospitals NHS Trust, Trauma & Orthopaedic Surgery, Nottingham, United Kingdom, 2Whittington Health NHS Trust, London, United Kingdom, 3Barts Health NHS Trust, London, United Kingdom, 4Royal National Orthopaedic Hospital NHS Trust, London, United Kingdom

Introduction: Orthopaedics has historically had the highest annual volume of claims compared to other specialties. In response to this the GIRFT litigation workstream was set up in 2012 to review claims and provide guidance on how to learn from claims to improve patient care and reduce claim volume.
Methods: A data sharing agreement was set up between GIRFT and NHS Resolution to access data regarding all claims involving orthopaedic surgery between April 2007 and April 2018. This included claim status, clinical details, and cost breakdown. A predetermined protocol was used to classify claims by orthopaedic surgeons through a claim by claim review to provide a clinical analysis.

Results: After the initial orthopaedic GIRFT visits in 2013/14 a fall in claim volume was observed over a four year period with claim numbers starting at 1617 in 2013/14 and falling to 1202 in 2017/18. The year on year fall in claims volume during this period was 6.06%, 8.76%, 9.02% and 4.68% respectively. There were an estimated 264 fewer orthopaedic claims than would have been expected.

Conclusions: In the context of the national clinical negligence bill increasing significantly orthopaedics has bucked the trend with annual costs remaining below 2013/14 levels for the years reviewed. The positive change in orthopaedics in comparison to other specialties has resulted in the specialty falling from its historical top ranking in claims volume to second behind emergency medicine with a respective fall in its share of clinical negligence costs from 10% in 2013/14 to 4% in 2017/18. Correlation between any one factor and litigation trends is not directly possible however it seems apparent that notifying clinicians of claims to facilitate and ensure learning from the incidents behind them must contribute to the improvement of patient care and limits the risk of future litigation.

There is NO Conflict of Interest: Yes

1145 - Reducing the duration of post-operative antibiotics in surgical prophylaxis for lower limb arthroplasty is safe; results of a quality improvement project

T. Okoro1, M. Wan2, T. Mukabeta3, E. Malev4, C. Williams4, M. Gross4, P. Craig4, J. Murnaghan4

1Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust, Arthroplasty, Oswestry, United Kingdom, 2Unity Health Toronto, Pharmacy, Toronto, Canada, 3Royal Devon and Exeter Hospital, Exeter Hip Unit, Exeter, United Kingdom, 4Sunnybrook Holland Orthopaedic and Arthritic Center, Toronto, Canada

Background: This quality improvement (QI) study assessed the impact of a reduction in the number of doses administered in the prophylactic antibiotic regimen for lower limb arthroplasty (primary total hip and knee arthroplasty (THA/TKA)) at a tertiary referral centre.

Methods: Following Ethical approval, a QI project was undertaken at the busiest arthroplasty unit in Canada (~ 2400 operations/year). Multidisciplinary meetings were held with various stakeholders prior to the change. The previous regime ((PR); September 2018 - December 2018) of a single pre-operative dose (cefazolin 2g intravenously (IV)), and two subsequent antibiotic doses (cefazolin 2g IV at 2 hours and cefazolin 1g IV at 8 hours), was compared to the new regime ((NR); January to April 2019) i.e. a weight-based pre-operative dose (cefazolin 2g IV for patients <120kg; cefazolin 3g IV for patients >120kg) and a single subsequent dose (cefazolin 2g IV at 2 hours). The primary outcome was surgical site infection (SSI) incidence at 12-month follow-up. 

Results: A total of n=1273 operations (THA n=534, TKA n= 739) were performed over the study period in n=1264 patients (males n=493, females n= 771).  For the PR group (n=669;) the mean age was 69.3 ±11.9 years, whilst for the NR group (n= 595) the mean age was 68.8 ±10.5 years. There was no statistically significant difference in deep incisional infection rate between the PR and NR groups (0.74% (5/675) vs. 0.66% (4/598); fishers exact test p=1.00), nor in the superficial incisional infection rate (PR 2.07% (14/675) vs. NR 1.50% (9/598); fishers exact test p= 0.53) at 12 months following surgery. 

Conclusions: Reducing the number of post-operative antibiotic doses had no adverse impact on SSI incidence, at 12 months following surgery, in this patient population. 

Implications: Use of a weight-based regime, with reduced duration, for antibiotic prophylaxis is safe in lower limb arthroplasty.

There is NO Conflict of Interest: Yes

1197 - The importance of early MRI in the diagnosis of acute occult scaphoid fractures: an audit of MRI waiting times and diagnostic results in a Major Trauma Centre

R.L. Donovan1, E. Lostis1, A. Bott1, N. Blewitt1, M.B. Kelly1

1North Bristol NHS Trust, Trauma & Orthopaedic Surgery, Bristol, United Kingdom

Introduction: Magnetic Resonance Imaging (MRI) is considered the ‘gold standard’ for the investigation of suspected occult scaphoid fractures. In May 2018, 68% of surgeons attending the British Society for Surgery of the Hand (BSSH) Conference reported that an ‘MRI Scaphoid’ could be completed within 2 weeks of request at their institutions. Our study aimed to audit MRI waiting times for the investigation of acute occult scaphoid fractures at our institution against a BSSH members consensus timeframe, and to evaluate the clinical importance of early scanning in patients with wrist trauma and persistent symptoms despite normal radiographs.

Methods: We conducted a retrospective audit of all MRI requests investigating suspected occult scaphoid between February and August 2019 at our regional Major Trauma Centre. Waiting times, from request to scan, and their results were reviewed to assess the pickup rate of occult fracture and other significant diagnoses. MRI requests for atraumatic causes or chronic conditions were excluded.

Results: We analysed 200 MRI Wrist requests over six months. 134 patients met the inclusion criteria. The mean time-to-MRI was 20.8 days. Four patients (3%) underwent same-day MRIs, 26 patients (19%) had an MRI within 7 days, and 84 patients (63%) achieved MRI within 14 days. Early imaging with MRI detected acute occult scaphoid fractures in 16 patients (12%) and high rates other non-scaphoid related injuries.

Conclusions: We confirm in our trust, the value of MRI as an early diagnostic tool in occult scaphoid fractures. However, a third of patients wait longer than 2 weeks for their investigation. We, therefore, suggest that national standards of care in regard to scaphoid fractures may help hospitals develop efficient MDT pathways for these potentially complex injuries.

There is NO Conflict of Interest: Yes

1330 - Torbay Charts as an efficient Patient Decision Aid (PDA) in the management of hip and knee arthritis

R. Ramesh1

1Torbay Hospital, Department of Trauma & Orthopaedics, Paignton, United Kingdom

Background: To make an informed decision in collaboration (Shared Decision Making - SDM), one requires enthusiastic clinicians, willing patients, and a good information repository like Patient Decision Aids (PDA). Surgical rates decrease by a minimum of 11.5% (Sepucha et al, 2017) when PDA are used. Current PDA have unattractive, cumbersome layouts and can be impractical during consultations. NICE recognises the limitations of the current PDA (June 2020). Torbay Charts (TC) PDA has a novel infographic overview of disease progression where treatment options are listed to the stage of the disease and provide a focal point during SDM conversation. Web-version allows the users to have a side-by-side comparison of risks, benefits, burden, and costs with links to a video library.

Methods: Our objective was to evaluate TC to enable SDM. Pilot testing was conducted over an 8-week period and was focused on the management of hip and knee arthritis (107 patients). Additional testing was conducted at a different hospital (14 patients). Thus, 121 patients used TC to reach a collaborative decision. The outcome was evaluated with a questionnaire.

Result: 92% strongly agreed that TC helped their SDM process. 91% strongly agreed they understood various treatment options. Healthcare practitioners felt they had an engaging consultation with TC’s focused approach. 13.2% chose non-operative treatment. 7.4% of patients who came expecting surgery opted for conservative treatments.

Conclusion: TC multi-layer, multi-formatted approach addresses many of the limitations of current PDAs. In 8w of its trial a potential cost avoidance of a minimum £45,000 was achieved with 7.4% choosing non-operative methods. Using NJR data, with a conservative 2% surgery avoidance, over £26 million per year could be potentially saved.

Implications: TC revolutionary approach enhances SDM, saves money, and allows a “Montgomery compliant” choice exercise for patients before choosing the most appropriate personalised cost-effective treatment.

There is NO Conflict of Interest: Yes

1357 - Poor quality of referrals to an elective arthroplasty service: An audit against the GIRFT guidelines of May 2020

K. Baryeh1, A. Sagi1, V. Asopa1, D. Sochart1

1South West London Elective Orthopaedic Centre, Academic Surgical Unit, Epsom, United Kingdom

Background: In May 2020 GIRFT released a set of standard for referrals to orthopaedic services for hip and knee replacements. Anecdotally, the quality of referrals has been of variable quality.

Methods: A cohort of patients undergoing either hip or knee replacement were identified using electronic theatre records. These patients then had their referral letters reviewed and assessed against the GIRFT standards for referral:

  • Any referral to An Orthopaedic Department should include:
    1. Medical History
    2. Details of failed attempts at conservative treatment
    3. Details of pain or functional disability and impact on QoL
    4. Confirmation that the patient would want surgery if offered
    5. X-ray within 6 months (WB AP, lateral and skyline for knees, non-WB AP pelvis for hips)
  • In addition:
    1. Weight loss advice given in patients with BMI > 30 or abdominal girth>4cm over chest
    2. Information and support for smoking cessation
    3. Recommendation of achieving a minimum aerobic exercise of 150 minutes per week

Results: 100 patients undergoing hip or knee replacement with an average age of 69.8 (33 – 88 years) and an average BMI of 29.4 (21.8 – 45.9) were included. 71% of referrals were from a GP setting. Only 28% of patients had an appropriate x-ray available, 47% documented patient willingness for surgery and 55% included details of attempts at conservative management. 91% of referrals met less than five of the eight standards.

Conclusions: The quality of referrals is of demonstrably low quality when compared to GIRFT standards. In view of the need to prioritise and rationalise services, it is important that pertinent information is readily available to aid in the decision making process.

Implications: A lack of, or poor quality information, can lead to unnecessary delays in management.

There is NO Conflict of Interest: Yes

1442 - The results of tranexamic acid use in over 10,000 hip and knee arthroplasty patients in North-West England from 2017 to 2019

O. O'Malley1, J. McEvoy1, T. Donnelly1, P. Thorpe1

1Aintree University Hospitals Foundation Trust, Orthopaedics, Liverpool, United Kingdom

The Advancing Quality Alliance (AQuA) was the first hospital-based ‘payment for performance’ scheme in the UK and was introduced in the North-West of England to cover a population group of 6.8 million people. Hip and knee arthoplasty care is just one area where AQuA has supported the use of evidence to set standards which promote quality improvement.  
One target which was reviewed and implemented by the AQuA Hip and Knee Arthroplasty Expert Group was a recommendation for the use of tranexamic acid to be administered pre-operatively in the anaesthetic room for individuals undergoing arthroplasty (as long as there were no contra-indications). We looked at those patients who were discharged following their surgery from 2017 to 2019.
There were 10,999 patients in total in the AQuA dataset who were eligible for the administration of tranexamic acid of which 10,483 (95.3%) received it. There was no difference in length of stay for patients who did and didn't receive tranexamic acid, with a median of 3 days for each. Mortality is always very low for arthroplasty and there were only 8 deaths, all in the group receiving tranexamic acid. This was not statistically significant.
There were small differences seen in readmissions: 8.1% of patients who didn't receive tranexamic acid came back within 30 days compared to 6.6% who did, but again there was no significant statistical difference (p-value = 0.091).
There are many reasons to support the use of tranexamic acid, not merely due to the well-documented significant reduction in blood loss but also due to the dampening of the inflammatory response. However, this does not seem to result in improvement of other parameters surrounding admission for arthroplasty surgery, nor readmission. The main benefits may still lie in the reduction of blood loss thereby reducing transfusion risk and cost.

There is NO Conflict of Interest: Yes

1589 - Reliability and accuracy of the Hand-held Electronic Blood Lactate meter (Lactate Pro 2) for point of care testing in the Clinical Setting

G.R. Ganapathy1, F. Raheman1, G.J.S. Taylor1

1University Hospitals of Leicester, Trauma and Orthopaedics, Leicester, United Kingdom

Introduction: Lactate Pro 2 is a device that was developed for measuring Lactate in athletes. It is a hand held device, simple to use, gives results in 15 seconds and only requires 0.05 microlitre of blood. The device was developed for athletes but has the potential to be used in the medical setting. Athletes tolerate very high Lactate levels whereas in levels in patients are generally lower. 
Objectives: The purpose of this study was to determine if the Lactate Pro 2 could be used for point of care testing in patients compared to the presently used benchtop analyzers in the Emergency Department. Could the Lactate Pro 2 provide accurate data at lower lactate levels seen clinically.
Methodology: We performed a method comparison study using forearm venous blood in a cohort of 51 patients comparing Lactate Pro-2 with two Cobas b 221 benchtop blood gas analyzers in our Emergency Department. Statistical analysis involved group comparison (Kruskal-Wallis), correlation(Spearmans), level of agreement(bland-altman), fixed and proportional bias using ordinary least products (OLP) regression.  
Results: There was no difference in group comparison (p = 0.6). Strong correlation (r value 0.916 to 0.950) between the three analyzers. There was a variable level of agreement between the three devices. The agreement between the benchtop analyzers was 0.20 and between the benchtop anallzers and lactate Pro 2 was 0.2 and 0.02.  There was no fixed bias between any of the devices but there was proportional bias between all the devices at higher levels approximately above 4mmol/L. The frequency distribution when plotted showed the smoothest curves was using the Lactate-Pro 2 analyzer.
Conclusions: Lactate Pro 2 was accurate in the majority of the levels tested and hence making it an appropriate device for clinical use.

There is NO Conflict of Interest: Yes

Accepted Abstracts - Part 1

103 - Development and testing of a novel set of quality indicators (QIs) of care for patients with metastatic bone disease (MBD)

S. Downie1, A. Stillie2, M. Moran2, C. Sudlow3, H. Simpson3

1University of Edinburgh, Trauma & Orthopaedics, Edinburgh, United Kingdom, 2NHS Lothian, Edinburgh, United Kingdom, 3University of Edinburgh, Edinburgh, United Kingdom

Background: Patients with metastatic bone disease (MBD) should all receive the same standard of care on presentation. We aimed to develop and test a set of quality indicators (QIs) to evaluate basic care for patients with MBD referred to orthopaedics.

Methods: We adapted QIs from the literature and ranked them on feasibility, necessity and practicality during a modified RAND/UCLA expert consensus process. We validated and tested each indicator in the final QI set in a retrospective cohort of 133 patients, using indicator-specific targets set by consensus.

Results: We reviewed 2568 articles, including three guidelines, and extracted 43 quality objectives. Following review by the authors, 40 proceeded to RAND/UCLA consensus. Through two rounds we generated 19 quality indicators of MBD care, with the following generating the highest consensus:

  • Patients with high fracture risk should receive urgent assessment (mean 6.7/7)
  • Patients with a possible solitary metastasis should have full work-up pre-operatively (mean 6.5/7)
  • Dying patients should have ceiling of treatment/resuscitation status documented (mean 7/7)
  • Surgical patients should have a documented follow-up plan (mean 7/7)

Targets ranged from 50-85%.
In our validation cohort, targets were met for 6/19 QIs (mean 50% STD 33.6), while a further 4/19 were within 15% of target. The median deviation from projected target was -15% (IQR 0 to -44%, range -100% to 20%). The highest and lowest scoring QIs were: “Patients with fractures should have surgery within 7 days” (target 80%:actual 100%) and “Surgical patients should have rehabilitation within 72 hours” (target 75%:actual 4%), respectively.

Conclusion: We adapted published evidence and guidelines into a set of validated QIs for MBD care, which can be used to evaluate improvements in treatment for these patients.  These QIs should be correlated with markers of good outcome (e.g. outcome scores) to determine whether they can act as surrogate outcome markers after surgery.

There is NO Conflict of Interest: Yes

438 - A Novel Caldicott Compliant Hospital Imaging Protocol (C-CHIP) for Open Fracture Photography

J Houston1, E Ben-David1, J Ogidi1, S Lewis1, S Marsden1, M Arnander1, D Lui1, A Trompeter1

1St Georges University Hospitals NHS Foundation Trust, London, United Kingdom

Background: Photography of open fractures is an essential component of documentation in the treatment of open fractures as per BOAST and NICE guidelines. Smartphones have made photography easily accessible to the clinician, but serious concerns exist regarding data security and the consent process around the use of sensitive clinical images.
Standards: BOAST (4) and NICE (NG37) guidelines:

  • Photographs should be stored within the patients permanent medical record
  • A robust protocol should be in place for ensure the photography of open fractures 24 hours a day 

Methods: Retrospective analysis of trauma database for six weeks from 15/9/2018 to 31/10/2018 and then for six weeks following implementation of the protocol from 15/9/2019 to 31/10/2019. The number of open fractures photographed and stored on PACS was recorded in each time period.
Intervention: A Caldicott-compliant hospital imaging protocol for taking and storing photos of open fracture wounds as a permanent part of a patient’s record was designed. Clinicians can take secure pictures on their mobile phone using a compliant messaging application, which can be instantly distributed to relevant members of the multi-disciplinary team involved in the patients care. 

Results: Prior to introduction of the protocol, the rate of open fracture photographic documentation on PACS was 0%. A re-audit performed six weeks following implementation of the protocol demonstrated 70% of open fractures were documented on PACS.  
Conclusions: The establishment of this protocol has led to the simple, safe and secure of clinical images from clinician’s smartphones to the hospital medical record. The protocol is is adherent to Caldicott, General Medical Council and NHS guidelines and has improved the documentation of open fracture photography as per BOAST guidelines in a major trauma centre. The authors suggest this C-CHIP would be transferrable to other trusts and could be adopted across trauma networks.

There is NO Conflict of Interest: Yes


M. Raza1, R. Geleit2, J. Houston1, R. Williams3, A. Trompeter1

1St George's University Hospitals NHS Foundation Trust, Trauma & Orthopaedics, London, United Kingdom, 2Epsom & St Helier NHS Trust, Trauma & Orthopaedics, London, United Kingdom, 3St George's University Hospitals NHS Foundation Trust, Radiology, London, United Kingdom

Background: Ionising radiation (IR) is extensively used in both trauma and elective orthopaedic surgery. However, its use can be dangerous and potential harmful cumulative effects on living tissue are widely documented. The UK government produces legislation known as IR(ME)R (Ionising Radiation Medical Exposure Regulations) 2018 and IRR (Ionising Radiations Regulations) 2017 which governs the safe use of IR for patients and staff respectively. Orthopaedic surgeons have a responsibility to utilise IR safely to minimise exposure to themselves, theatre staff and patients. This project aims to assess current orthopaedic doctors’ understanding of IR safety training, guidelines, knowledge and practicalities of utilising IR in the operating theatre.

Methods: A twenty question online survey was distributed to all doctors (juniors, registrars, fellows and consultants) working within the Trauma & Orthopaedic departments of four acute NHS trusts in southwest London between September and October 2019.

Results: A total of 55 responses were collected. 73% of respondents used IR at least once per week. Nearly half had received no training in radiation safety. 80% were not familiar with their radiation department’s local rules or IRR 2017 employee duties. 25% correctly identified the annual recommended employee ‘effective dose’ limit and 33% were familiar with equivalent dosages of background radiation for common radiographs. Over half understood the relationship between distance and radiation dose exposure. Use of radiation protective equipment was limited. There was clear agreement on current inadequate training in radiation safety/guidelines and in radiation equipment use/principles for orthopaedic surgeons.

Conclusions: This study has identified wide variability in orthopaedic doctors’ understanding of important radiation safety principles, knowledge and practicalities in the operating room. Current understanding and safe use of IR is limited. We argue for improved awareness and standardised radiation safety training for all orthopaedic doctors to improve safety for surgeons, theatre staff and patients.

There is NO Conflict of Interest: Yes

587 - The adoption of Virtual Trauma Meetings in response to COVID-19: A positive result

D. Burchette1, C. To1, H. Willmott1

1Conquest Hospital, Trauma and Orthopaedics, Hastings, United Kingdom

Introduction: The COVID-19 pandemic has undoubtedly led to changes in our day-to-day clinical practice. In many ways, this has been a catalyst for change, renewing interest in utilising modern-day technologies to improve service delivery. In response to Public Health England guidance on limiting the size of social gatherings, our conventional trauma meetings have been moved to an online platform- the Virtual Trauma Meeting (VTM). In this study, we report early service evaluation results with particular interest to patient safety, staff satisfaction, and trainee educational opportunities.

Materials and Methods: Microsoft Teams was used for our online VTM platform.  This was operated by the Trauma and Orthopaedic on-call team, with other members of staff logging-in from a device of their choosing.
One week following the introduction of the VTM, users were surveyed using an online questionnaire. Qualitative statements regarding the VTM experience were assessed using a five-point Likert scale. The option for free-text feedback was also included.

Results: There were 27 respondents, predominantly Registrars (42%) and Consultants (26%). There were no concerns regarding the maintenance of patient safety through the use of VTM. At 74%, the majority of respondents were satisfied or very satisfied with VTM. Audio quality and background chatter were highlighted as the main reasons for dissatisfaction. Opportunities for training was felt to be possible via VTM by 62% of respondents. Free-text responses revealed that benefits of the VTM include; the ability to participate even when not at work, cross-site communication, contemporaneous subspecialty input, and its role in maintaining team spirit when social interactions have otherwise been limited.

Conclusion: This service evaluation concludes that the VTM has been a safe and desirable change from the conventional trauma meeting, with opportunities for education maintained. Adapting to conference-call etiquette and investment in conference-call specific audio equipment will likely further improve the experience.

There is NO Conflict of Interest: Yes

598 - The use of Change Management Models to Guide Introduction of a Novel Technique into an Orthopaedic Department

E. Burden1, R. Walker1, A. Atkinson1, M. Quantick1, A.-A. Kassam1

1Royal Devon and Exeter Foundation Trust, Exeter, United Kingdom

Background: Models for change management are routinely used in business and economics but are under-utilised within healthcare organisations. We demonstrate the use of change management models in an orthopaedic department to create meaningful and sustainable change. Our driver was the need to deliver fascia iliaca compartment blocks (FICB) within the orthopaedic department for patients presenting with hip fractures, as a result of service reorganisation due to Covid-19.

Methods: Combined methodologies from Kotter’s 8-Step change model and Tuckman’s team development model were used to guide the implementation of FICB delivery within the orthopaedic department. A training programme including an educational seminar, online resources and one-to-one training was organised. Effects of training interventions were monitored through surveys assessing individuals' confidence to perform FICBs. Data were collected on the number of patients receiving FICB, and morphine requirements of patients receiving FICB compared to those without FICB. Following completion of training selected doctors became FICB trainers to maintain institutional expertise and service sustainability.

Results: Twenty-one doctors responded to each of three surveys; before any training no-one reported being fully confident to perform FIB unsupervised, compared to 71% after training. After completion of all interventions, 88% of hip-fracture patients had FICB performed by a member of the orthopaedic team, an increase from 0% before these interventions. Patients not receiving FICB (12%) had acceptable and documented contraindications to the procedure. Patients who received FICB required 22mg less morphine preoperatively than those without FICB.

Conclusion: Combining the change management models of Kotter and Tuckman helped to maximise the benefit of a FICB implementation programme by working on process development (Kotter's) in parallel with team development (Tuckman's). All patients in whom it was clinically appropriate received FICB by the end of the implementation period, demonstrating the ability of change management models to implement change effectively.

There is NO Conflict of Interest: No

677 - Improving the quality of trauma meetings by implementation of a modern trauma management platform

B.M. Sephton1, O. Vernon1, K. Kimber1, M. Shenouda2, P. Mahapatra3

1University Hospitals of South Manchester NHS Foundation Trust, Orthopaedics, Manchester, United Kingdom, 2Hillingdon Hospital NHS Foundation Trust, Orthopaedics, London, United Kingdom, 3Imperial College Healthcare NHS Foundation Trust, London, United Kingdom

Trauma meetings constitute the majority of clinical decision making for new referrals and also act as a crucial tool to co-ordinate the trauma theatre list. Incorporation of electronic technology has been shown to improve the quality of patient handover. eTrauma is a recently developed cloud-based patient management platform which we planned to implement at our hospital. The aim of our project was to evaluate the quality of our current trauma meeting and subsequently the effect of implementing a modern trauma management platform.

In order to identify the key concerns of staff members with the trauma meeting handover, a questionnaire was given to 20 members of the team. A review of effective handover guidelines published from the Royal College of Surgeons and the Royal College of Physicians was undertaken. We combined information from these guidelines to identify two key sets of data points for an effective trauma referral; patient demographics and referral details.

Questionnaires were distributed at three separate time periods providing assessment of implementation of changes. The questionnaire results indicated progressive improvement in the morning trauma trauma meeting with increased clarity for the anaesthetic team, better communication of operation to be performed, better documentation and clarity of management plans. A total of 150 referrals using the existing system (TIGER) were compared to 100 eTrauma referrals at two separate time intervals. Our analysis showed significant improvements in 12 of the 21 key data points (57%) indicating improved data entry for referrals using the new platform. A total of 3 PDSA cycles were completed within this process.

Introduction of a new cloud-based trauma management platform has had a positive impact overall within our trust. Modern electronic trauma systems have the ability to improve our trauma management, this must go hand in hand, however, with a structured and effectively communicated trauma meeting.

There is NO Conflict of Interest: No

Disclosure: Senior authors MS and PM declare a competing interest in their role as directors by Open Medical Ltd. PM and MS did not have any role in data collection or analysis, being involved initially in the design and planning for the quality improvement project with review of the finalised manuscript.

747 - Patient Activation in Lower Limb Arthroplasty: can we improve it pre-operatively and is disease severity predictive of a patient’s level of activation?

L. Hoggett1, H. Robinson1, J. Blong1, A. Bokhari1, A. Sloan1

1East Lancashire Hospitals NHS Trust, Trauma and Orthopaedics, Blackburn, United Kingdom

Introduction: It is recognised that patients with ownership and understanding of their health needs have better outcomes. Patient Activation Measure (PAM) is a validated tool licensed to NHS England that measures a patient’s level of health confidence ranging from 1 (low level) to 4 (high level). It is thought that higher PAM scores correlate with better health outcomes. This is the first study using PAM scores in patients undergoing lower limb arthroplasty.

Aim: To determine whether the use of a pre-operative patient-focussed education session (Joint School) improves patient activation and to see if the scores correlate to disease severity.

Method: Prospective case series. Patients awaiting arthroplasty surgery were recruited at the Joint School and PAM and oxford hip (OHS) or knee (OKS) scores collected. Patients were contacted two weeks following the session to reassess PAM.

Results: 114 patients recruited, 5 uncontactable at follow up, leaving 109 patients: 48 hip and 61 knee replacements. PAM1 patients [n=7] 71% improved by one or more level from a mean score of 43 (41.6-44.4 95%CI) to 48 (44.6-51.4 95% CI), statistically significant on t-testing (p=0.026). PAM2 patients [n=32] 38% improved by one or more level from a mean score of 51 (50.6-51.4 95%CI) to 57 (52.8-61.2 95% CI) (p=0.009). PAM3 patients [n=33] 12% improved from a mean score of 62 (60.4-53.6 95%CI) to 59 (55.1-62.9 95% CI) this change was not significant (p=0.175). PAM4 patients could not improve, therefore no analysis performed. Relationship testing between PAM and OHS/OKS revealed no correlation (r=-0.08).

Conclusion: A pre-operative joint school confers objective evidence of improved patient activation. Patients who are highly activated as a baseline see less benefit. Given budget constraints, this easy tool may be used to focus resources on patients most in need. There is no correlation between disease severity (OKS/OHS) and PAM scoring.

There is NO Conflict of Interest: Yes

777 - An acute Trauma and Orthopaedic ward round pro-forma: optimising efficiency and improving documentation

D. Hill1, T. Ball1

1Torbay and South Devon NHS Foundation Trust, T+O, Torquay, United Kingdom

Introduction: Concerns existed around ward round documentation of medical reviews, observations and examinations, acknowledging abnormal results, and recognition of deteriorating patients.  Our aim was to produce a daily medical entry that synthesised important parameters encompassing trauma meeting discussions, a bedside review, and a plan. 
Methods: We retrospectively reviewed a random sample of ward round entries over a 12 month period.  A ward round proforma was subsequently introduced highlighting pertinent parameters including: a pre-ward round assessment completed during the morning trauma meeting, a bedside assessment, and a plan.  Refinements were made and alternate monthly audits were performed during a 12 month period.  
Results: Documentation of consultant ward rounds was often missing completely, and where present was poor, but improved dramatically following the introduction of the proforma.  The presence of a consultant ward round entry improved from 72% (n=73/102) to 100% (n=100/100).  Reference to the pre-ward round assessment criteria including trauma meeting discussion improved from 0% (0/102) to 100% (102/102).  Mention to most recent bloods improved from 7% (5/102) to 100% (102/102).  Documentation of observations and a bedside assessment improved from 40% (29/102) to 100%  (102/102).  Details of an onward plan and medical fitness for discharge improved from 53% (n=38) to 100% (102/102).  
Conclusions: A dramatic and measurable improvement has been sustained over a 12-month period. 
Implications: This quality improvement project has increased efficiency of ward rounds through utilising junior doctors time during the morning trauma meeting, with the valuable addition of contemporaneous documentation of daily morning trauma meeting discussions.  The enhanced record synthesising all pertinent information has a potential to improve patient safety through a systematic approach and has the added benefit of being more medico-legally robust.  

There is NO Conflict of Interest: Yes

801 - A Study on the effectiveness of foot school in facilitating early and safe hospital discharges after foot and ankle surgery

T. Thomas1, S. Khan1, S. Morgan1

1Whiston Hospital, Orthopaedics, Prescot, United Kingdom

Introduction: Research has shown that poor patient education is associated with adverse outcomes in foot and ankle surgery. Foot school aims at preparing the patient prior to surgery which involves addressing patient’s queries regarding surgical procedure; measuring patients for any equipment they might need postoperatively and organising any help they might require once discharged home. 

Materials and methods: This is a retrospective study of 100 patients who had foot surgeries performed from January 2019 to March 2020 at Whiston Hospital. They were divided into two groups based on their foot school attendance. Hospital database was used to determine any delay in hospital discharges postoperatively and the difficulties faced by both patients and the physiotherapy department. All Post-operative complications were also recorded. A patient satisfaction survey was also done at the time of this study.

Results: 95% of patients who attended foot school were discharged home within 23 hours of their admission, 2 cases of delayed discharge were due to increased post-operative bleeding, while only 60% patients in the Non-foot school group achieved this. This was due to the delay in rehabilitating the patient postoperatively and also arranging adequate care at home on discharge. 3 patients in the Non-foot school group started weight-bearing a week after surgery in spite of being advised against it which may have caused early failure after surgical intervention. 

Conclusion: Foot school has facilitated early and safe discharges post-surgery as patients are educated preoperatively and adequate time is available preoperatively for making patient-specific equipment and arranging safe home discharges. The higher early discharge rate and better patient satisfaction on the survey give proof of this.

There is NO Conflict of Interest: Yes

869 - What is the impact and consequences of Montgomery on surgical practice?

G. Mundy1,2

1Northampton General Hospital, Department of Trauma and Orthopaedics, Northampton, United Kingdom, 2De Montfort University, Faculty of Law, Leicester, United Kingdom

Background: Montgomery has been criticised for creating uncertainty for clinicians seeking to avoid legal liability and creating unrealistic disclosure obligations given increasing time constraints and limitation of NHS resources as the NHS strives to become “leaner”. Montgomery however simply reaffirms longstanding established professional guidance. The aim of this piece of research is to  analyse Montgomery's impact on surgical practice.

Methods: A regional survey was performed of UK surgical trainees and consultants ascertaining whether the regulatory and legal requirements were now part of established surgical practice. Cases post Montgomery were identified using Westlaw and subsequently analysed.

Results: 101 respondents (78% consultants) 10% of consultants are unaware of Montgomery. Only 44% have read RCS consent guidance. Less than 1/3 have undergone consent training. Over 2/3 believe a 10 minute appointment is sufficient to undertake consent. 70% perceive they now spend longer discussing consent. 41% consent at the first appointment with 11% consenting immediately prior to the operative procedure. Less than 50% tailor their advice for each patient. Lack of understanding of materiality and risk disclosure is evident, with paucity of use of easily accessible resources to aid the consent process. Case law analysis reveals important lessons for consideration. These include centrality of dialogue, tailored discussions, use of non numeric descriptors, changes in treatment plans, new/alternative treatments, guideline departures, unclear prognosis and methods of patient communication.

Conclusions: Changes to consent law implemented by Montgomery are not completely understood or appreciated. Strategies improving the consent process are needed including training, consent pathways, greater use of patient decision aids, and use of consent tools to enhance patient satisfaction and document the patient-clinician dialogue. Implementing these requires input from those who manage surgical services with the ultimate aim of improved patient and surgeon partnerships and a reduction in the burden of legal costs to the NHS.

There is NO Conflict of Interest: No

901 - Making Arthroscopic Orthopaedics Procedures More Sustainable

A. Azhar1, F. Ali1, S. Shahane1, J. Garcia1

1Chesterfield Royal Hospital, Trauma & Orthpaedics, Chesterfield, United Kingdom

As orthopaedic surgeons, we also want to contribute to make our planet sustainable by reducing the “carbon foot print”.
The purpose of this study was to quantify the amount of waste produced during “Arthroscopic Rotator Cuff Repairs” and “Arthroscopic Anterior Cruciate Ligament (ACL) Reconstructions” in our hospital and compare it with household waste in Chesterfield Borough.
This was a prospective study and we were lucky that we were able to finish this project just before COVID-19 crisis started.
All clinical waste created by our anaesthetic colleagues were excluded in this study. 
All procedures were performed by two senior arthroscopic surgeons. All data was analyzed on Microsoft Excel 2010®.
From the start of the procedure, the bags were labelled as clean & contaminated paper, clean & contaminated plastic. 
At the end of each procedure, we weighed them using a theatre scale DIGI® (DS-502). We found that the average plastic waste created during one standard rotator cuff repair was 3.6 kilograms & paper waste was 1.3 kilograms with a total of 4.9 Kilograms. In ACL reconstruction, average plastic waste per case was 1.7 kilograms & paper waste was 1.3 kilograms with a total of 3 kilograms. Per year we perform an average of 92 rotator cuff repairs and 64 ACL reconstructions, with a total of 642.80 kilograms of waste. The average waste per year per house hold in Chesterfield was 198.05 kilograms which means we are producing 3 times more waste. 
The carbon foot print is 3 times the average house hold waste. This is the time to act together to make our planet greener and safer for next generation.

There is NO Conflict of Interest: No

957 - Improving ward round documentation for post-surgical elective Orthopaedic patients: A closed loop audit

J.Z. Shah1, K.M. Feroze1, N. Khan1

1Hull University and Teaching Hospital, Trauma and Orthopaedics, Hull, United Kingdom

Background: Orthopedic ward rounds are generally fast paced. With a quick patient turn over, key information regarding pre/postoperative care e.g postop bloods, xrays, DVT and wound check often gets missed. Documentation is routinely done by ward based doctors who have had little involvement in management. If seniors are unavailable, omissions in documentation can lead to detrimental outcomes for the patients. The patients’ notes provide a record of on-going clinical issues and serve as a medico-legal document. Therefore, the need for notes to be thorough and legible with a clear indication to all MDT members regarding future care is paramount.

Method: In first cycle the last ward round entry in the patient’s notes was analyzed against 4 parameters chosen by clinical lead. This included important post operative variables like: post op wound check, postop bloods, DVT status and post op x-rays review. A preprinted sticker enumerating these variables was introduced to the nurses and the doctors. The sticker was made the part of doctors notes and it was mandatory to fill the sticker. The data was then again calculated after the implementation of the sticker.

Results: A total of 20 entries were analyzed in first cycle. 9/20(45%) had no post op ward documentation. 5/20(25%) had more than 2 variables documented. In the second cycle 20 patients were analyzed and there was 100% documentation except for 2 patients who didn’t require post op bloods and wound check respectively.

Conclusion: Lack of clear documentation can lead to poor patient outcomes and difficulty for other team members to provide care. The introduction of a new sticker prompting daily review of the key areas has shown a vast improvement in documentation and communication between staff and patients. Questioning and reviewing these areas has also provided a learning opportunity with positive feedback from junior doctors.

There is NO Conflict of Interest: Yes

963 - Digital Tools Lead to Improved Multidisciplinary Working and Documentation in the Plaster Room

R. de Sá1, C. Khoza1, K. Matwala1, P. Mahapatra2

1Imperial College London, London, United Kingdom, 2Kingston Hospital NHS Foundation Trust, London, United Kingdom

Background: Effective communication between the clinician and plaster room (PR) staff remains vital in the running of increasingly busy fracture clinics. Clinician-generated referral forms for the PR are core in establishing this communication, providing safe care to patients and ensuring documentation is adequate for medico-legal purposes. With increasing integration of digital innovation across NHS hospitals, use of paper forms is on the decline. This quality improvement project aimed to assess the benefit of electronic forms over paper referral forms in fracture clinics.

Methods: We retrospectively analysed paper and electronic referral forms over 5-week periods from December 2019 to January 2020, and February 2020 to March 2020 respectively. Data collection was based on domains outlined by the British Orthopaedic Association (BOA) Casting Standards which include: referring clinician details; patient injury details and procedure requested; post-procedure documentation. Adherence of paper and digital referrals to these standards was compared.

Results: 1227 forms were analysed (580 paper; 647 electronic). 100% of electronic referrals had diagnosis, laterality, name/signature, and date/time; compared to 25%, 40%, 82% and 74% respectively on paper forms. Type of cast or procedure was recorded 46% more on electronic referrals than on paper. Over 90% of electronic forms documented post-procedural information e.g. neurovascular status (92%), skin integrity (96%) and verbal advice (95%); 28% of forms stated that written advice was provided. Neither post-procedural information nor written advice provision was recorded on paper forms. 26% of paper forms were ‘illegible’ or ‘legible with effort’; comparatively 0% on electronic forms.
Electronic PR referral forms demonstrated better compliance to BOA Casting audit standards compared to paper forms. They enable accurate and effective communication between clinical teams in the fracture clinic in addition to providing robust documentation vital for medico-legal purposes. Future work should assess the impact of similar platforms on patient outcomes.

There is NO Conflict of Interest: No

Disclosure: PM is a director of Open Medical, who supplied the electronic platform. PM did not have any role in data collection or analysis.

968 - Using virtual telephone clinic as a screening tool for elective foot and ankle follow-up waiting list

H. Mohamed1, M. Butt1K.H. Teoh1

1Princess Alexandra Hospital, Department of Trauma and Orthopaedics, Harlow, United Kingdom

Background: Virtual clinics have been shown to be safe and cost-effective in many specialties. Its use in foot and ankle(F&A) elective follow ups is not well documented. Most newly appointed consultant would inevitably be inheriting an outpatient waiting list as part of their practice. The aim of this study is to evaluate its use as a screening tool for unnecessary follow-up when inheriting a practice as a new consultant.

Methods: Using the hospital’s patient electronic record system, we collected data containing patient demographics, previous management plan and investigations and reviewed the outcome of the virtual clinic for each patient. Each virtual follow up slot was 10 min.

Results: 292 patients (167 females, 125 males) seen in 16 PA-sessions were included. Their mean age was 57 (range:16-90) years old. They were reviewed by mobile phone (184 patients, 63%) or landline( 41 patients, 14%). 67 patients (23%) did not picked their phone despite trying multiple attempts and were discharged, of which one requested to be seen face to face. The reason listed for follow-up at previous review were: post-surgery (28%), Post injection (15%), following investigations (5%), wait-and-see (52%).
In total, 232 patients (79.5%) were discharged from that virtual clinic. 40 patients (13.7%) were listed for a review clinic, 12 patients (4.1%) were listed for surgery with premise of being reviewed at pre-admission clinic first. 8 patients (2.7%) were listed for steroid injection.

Conclusion: A large number of patients did not require follow-up appointment. Virtual telephone clinics for elective F&A follow-up is an effective, cost-savings and safe way for management of long outpatient waiting lists when inheriting a busy practice.

Implication: Our study shows that virtual telephone clinic is useful as a screening tool for a new consultant’s practice. We have come up with recommendations/algorithm on how to run it based on our experience and highlight the benefits and drawbacks.

There is NO Conflict of Interest: Yes

1054 - Patient satisfaction in virtual elective orthopaedic clinics

A.-R. Rabiu1, R. Ahluwalia1, J. Sinha1, A. Arya1

1King's College Hospital, Orthopaedics Department, London, United Kingdom

Background: The COVID-19 pandemic has been a catalyst for change in healthcare delivery worldwide. It has forced healthcare providers to adopt new methods of delivering patient care including wider use of virtual clinics. Whilst they were routine at many hospitals prior to the pandemic, to our knowledge, the use of virtual clinics for elective orthopaedic patients was limited.
Virtual clinics may become a norm for suitable patients in future. Therefore, we decided to assess patient satisfaction with virtual elective orthopaedic clinics at a major teaching hospital.

Methods: All elective orthopaedic clinics were screened by Consultants who used a locally agreed protocol to assign suitable patients to a virtual telephone clinic. Following the consultation, patients were consented to give feedback on their experience. A different doctor telephoned patients within 1 week to collect feedback using a patient satisfaction questionnaire.

Results: Over a 7-week period, 122 (68%) out of 179 consented patients were available for feedback. Using a linear scale of 1 to 10 (Terrible to Excellent) 86% of patients rated their overall experience as 8 and above. The main reasons for patient dissatisfaction were: inability to explain clearly or show the affected part to the doctor; a desire to see their imaging; and talking to a faceless person. One in three patients would have preferred a video consultation.

Conclusion/Findings: Virtual clinics for suitable elective orthopaedic patients are a viable option. Video clinics may be better than telephone clinics.

Implications: Hospitals would need to invest initially to create the set up for virtual clinics. In the long run, we believe they would save resources. Virtual clinics would be a boon for patients with mobility problems, those who have to travel long distances or have difficulty taking time off work, and for routine follow ups.

There is NO Conflict of Interest: Yes

1184 - One-stop management of Simple fractures. The Lincoln experience (Phase 1 of QSIR Trauma)

M. Elmeligy1, T. Southorn1, C. Corbin1, D. Hewish1, K. Weerasinghe1

1United Lincolnshire Hospitals NHS Trust, Trauma and Othopaedics, Lincoln, United Kingdom

Background: United Lincolnshire Hospitals NHS Trust is one of the largest NHS Trusts in the United Kingdom. Despite the geography location of acute services which meant that patients often have to travel over 30 miles, the fracture clinic referrals pathway has been of the traditional type for many years.
While other trusts have implemented changes to the way they manage simple fractures, such as a virtual clinic, this out-dated model has remained at ULHT until recently. Covid-19 highlighted the importance of such pathways.

Aim: Plan and implement a pathway for one-stop management of six common fractures at initial assessment. (Mallet finger, Radial head, Boxer’s, base 5th MT fractures, and Buckle, Clavicle fractures in children)

Method: SWOT analysis of the proposed pathway including an in-depth review of current practice showed that they represent 13.7% of total fracture clinics new referrals. We Identified stake-holders, training needs, radiology reporting standardization, and safety checking measures for one of our Acute Hospitals. During the initial PDSA cycle training A&E nurse practitioners on 6 fractures was not suitable so for cycle 2 they were trained on 3 fractures only (Boxer’s fracture, Buckle and clavicle fracture in children). We also produced patient discharge advice leaflets for those fractures.

Results after PDSA 2: 50 patients with injuries suitable for the above management over a period of 3 months. 35 patients were discharged using the new protocol.13 patients were incorrectly referred to new patient fracture clinic (Likely due to learning curve) but were discharged after a single visit. 2 patients were incorrectly discharged but were recalled to fracture clinic.

Conclusion and Recommendations: It is safe and cost-effective to use this model for simple fracture management as long as training of A&E staff continues with staff changes and adherence to the agreed pathways is monitored.

There is NO Conflict of Interest: Yes

1279 - Assessing the need for a dedicated nerve block room to improve upper limb theatre efficiency

K. Vimalanathan1, I. Hussain1, A. Vusirikala1, D. Tsekes1

1Basildon University Hospital, Basildon, United Kingdom

Background: The use of a dedicated block room has been entertained for many years across the globe to increase the efficiency of theatre usage with success. Currently regional anaesthesia is delivered in the theatre anaesthetic room at our busy district general hospital for shoulder and elbow orthopaedic surgeries. The purpose of this study is to assess the need for a dedicated nerve block room to increase theatre efficiency and enhance patient experience.

Methods: Retrospective study over a 6-month period using ORMIS (theatre management software) and electronic medical records to measure time from entry into anaesthetic room to entry into the operating theatre for elective patients who received general anaesthesia (GA) and regional anaesthesia (RA) versus GA only. To compare the start time of theatre lists where the first patient received either GA & RA or GA only.

Results: 186 patients (54 trauma and 132 elective) were operated on during the 6 month period. On average, 3 cases were performed per full day theatre list with 1.8 cases receiving a regional nerve block. Time taken from entry into anaesthetic room to entry into operating theatre for elective cases had a median of 30 minutes for GA & RA versus 18 minutes for GA only. Knife to skin for the first patient was delayed when patient received both GA & RA (mean= 22minutes) in comparison to GA alone (mean= 11minutes). Both these findings reached statistical significance (p<0.05).

Conclusion: Our study has shown that the administration of RA with GA increases anaesthetic time and leads to late theatre starts. We aim to introduce a dedicated nerve block room in our hospital so as to increase theatre efficiency and proficiency, avoid late starts, improve patient experience and also provide training opportunities.

There is NO Conflict of Interest: Yes

1287 - Outcomes for Innovative Same Day Discharge for Elective Total Hip Arthroplasty during COVID-19 pandemic

C. Ng1, A. Taylor1, B. Kendrick1, S. Glyn -Jones1, R. Afinowi-Luitz1, K. Vaz1, B. Ahmed1, T. Hamilton1, L. Holman2, S. Newman1

1Nuffield Orthopaedic Centre, Orthopaedics, Oxford, United Kingdom, 2Nuffield Orthopaedic Centre, Anaesthesia, Oxford, United Kingdom

Background: COVID-19 presents a significant risk to patients and has had a serious impact on elective surgical capacity. To minimise the risk of COVID-19 whilst simultaneously delivering elective surgery, were structured our elective hip operations into a day-case pathway. The aim of this study was to report on the success of instituting primary THA as a day-case procedure, short term outcomes, patient satisfaction and incidence of COVID-19.
Methods: A prospective single centre observational cohort study of the first 10 patients between May 2020 until June 2020 was conducted. Waiting list patients were stratified using the BOA COVID-19 Stratification tool with only low risk patients selected. Patients were consented for day-case surgery two weeks prior and requested to shield with a COVID-19 swab taken at 72 hours prior. Modifications to our usual anaesthetic protocol consisted of short acting prilocaine spinal anaesthesia along with high dose Dexamethasone 16mg, intravenous lidocaine infusion and MgSO4 2.5mg. VAS pain scores pre and post-operatively and serum haemoglobin were collected prior to discharge. Patients were followed up by telephone the following day regarding pain control at home.
Results: Low risk patients comprised 14.7% of the primary THA waiting list. All patients contacted were happy to proceed with day-case surgery. There were 72.7% men, mean age 55.5 (range 31 to 70) and BMI 26.7 (range 21.1 to 31.1). 72.7% were successful same day discharge with the remaining patients discharged day 1. Mean pain score at discharge was 2.2 (range 0 to 4). No morbidity or mortality was reported. No patients contracted COVID-19. There was a 100% satisfaction. 
Conclusions: Our initial cohort is encouraging in the current climate surrounding the pandemic. The majority of patients achieved a safe same day discharge with no evidence of morbidity or mortality. Moreover there was high patient satisfaction.
There is NO Conflict of Interest: No


M.G. Matthews1, R. Misra2

1BMI Chiltern Hospital, Orthopaedics, Great Missenden, United Kingdom, 2BMI Chiltern Hospital, Radiology, Great Missenden, United Kingdom

Background: Sitting lateral Budin x-ray views of the hip have been reported previously in the Bone & Joint Journal by Lee et al. 2013. These views can provide a simple and reliable method of measuring femoral stem version following total hip replacement (THR).
Version of the femoral stem is known to be an important factor both with regard to the risk of dislocation and early loosening of cemented femoral stems.
We therefore undertook this study to assess the usefulness of this technique in everyday UK practice.
Methods: Sitting lateral Budin views were used to assess a consecutive series of patients following THR surgery carried out by MGM at two surgical centres.
Our radiographers had difficulty in including the full view of the knee in the views using standard cassettes in our typical UK patients, who we suspect were physically taller than the typical South Korean patients who were the subjects of the earlier paper.
Our protocol did however insure that all of our patients were positioned with their lower legs vertical. The resulting views therefore still provided a consistent assessment of stem version.
The x-ray doses were recorded automatically by the x-ray machine. A contemporary series of patients who were assessed post operatively using conventional horizontal beam lateral (HBL) x-ray views were used as controls.
Results: Radiation doses for the Budin views were Mean 303 cGycm2 Std.Dev. 165, compared with 398 cGycm2 Std.Dev.192 for conventional HBL in one centre and Mean 394 cGycm2 Std.Dev.288, compared with Mean 700 cGycm2 Std.Dev. 232 at the second.
Conclusion: Sitting lateral Budin x-ray views of the hip provide useful assessment of femoral stem anteversion as well as a reduced x-ray dose when compared with conventional HBL views. We recommend that the Budin sitting lateral view is more widely adopted following THR surgery.

There is NO Conflict of Interest: Yes

1428  - The Impact of Intravenous Drug Users on an Orthopaedic Unit in the UK

S.S.J. Wunnava1, R.Y. Liow1, A. Bradbury1, A. Milne1, L. Weatherall1, R.P. Jeavons1

1North Tees and Hartlepool NHS Trust, Stockton-on-Tees, United Kingdom

Background: The North East has a significant intravenous drug use (IVDU) burden. This study aims to quantify the economic service cost and resource consumption of an acute orthopaedic service treating IVDU sequalae.
Methods: Retrospective review of IVDU admissions January 2018-March 2019. Patient level information and costing system (PLICS) was used to estimate costs associated with theatre time, inpatient/ITU stay and radiological intervention. 
Results: 86 patients were admitted - 67 for infection management, 15 for trauma/fracture and 4 for hip/back pain. 36 patients required surgery for infection with 6 requiring return to theatre. 3 trauma patients underwent local operative fixations. The majority of patients had at least one X-ray however, significant numbers underwent further ultrasound, CT or MRI imaging.
Total theatre time was 3975 minutes. 63 patients required intravenous antibiotics and 22 patients required long line insertion. 10 patients required critical care admission necessitating 22 critical care bed days in total. 3 patients died of sepsis and associated complications during the collection period.
Average inpatient duration was 9.7 days (range 0-56). 11 patients self-discharged and 8 were transferred to tertiary care. The total IVDU admission cost was £325,529 – averaging £767.8 per day. Mean admission cost was £3785 per patient.
Conclusion/Findings: IVDU admissions consume significant nursing, radiological and surgical resources, with a huge yearly cost implication. Optimum IVDU care would incorporate a multidisciplinary approach with a specific cohorted ward, run by a medical team with an interest in drug misuse. Surgical teams would undertake technical debridement procedures and offer support as required with Drug and Alcohol teams co-ordinating hospital and community services.
Blood test, antibiotic, central line insertion and administration costs were unable to be collected, leading to an underestimated total cost.
Implications: Due to the large economic burden associated with admission, refining IVDU pathways offers significant benefits to orthopaedic units.

There is NO Conflict of Interest: Yes

1540 - Post-Operative Evaluation of Technical Error following Conventional Primary Knee Arthroplasty using a Standardised Roentgenographic Assessment Tool

L. Kurar1, M. Gawad1, I. Lowdon1, S. Deo1

1Great Western Hospital, Swindon, United Kingdom

Background: The number of total knee arthroplasty (TKA) procedures are common and numbers are increasing worldwide. Radiographic evaluation is a simple marker of quality assurance in terms of implantation. There is currently no simple standardised assessment approach for post-operative TKA. We describe a peer-reviewed algorithm to screen for technical errors at implantation.
Objectives: The key aims were to quantify and define technical errors at implementation using the standardised screening tool.
Study Design & Methods: All primary post-operative TKA radiographs were evaluated by a blinded specialist consultant panel, the arthroplasty patients having been entered onto a specific database.  We analysed information from reviews over a seven year period (2006 to 2012). After exclusions for unicompartment knee replacement, revision procedure, or poor quality post-operative radiographs, 1,702 patients comprised the main study cohort. Radiographs that demonstrated technical errors such as overhang, notching, or implant malalignment were noted. 
Results: There were 79 technical errors (5%), over the study period. The most common error, was placement of the tibial component in either excessive varus (more common n=36) or valgus (n=13), which accounted for 62% (n=49). Anterior tibial slope, femoral or tibial overhang were least frequently observed, in 1%, 1% and 4% respectively. There were a total of 11 different types of technical error overall. There was a reduction in technical errors of 19% in total across the study period. 
Conclusions: The use of this simple assessment tool results in improvements in radiographic outcomes for patients undergoing TKA procedures, with a reduction in the common errors associated with TKA implantation.. This system can be used to inform on departmental quality assurance, trainee progression, delivering a consistent level of high quality care.

There is NO Conflict of Interest: Yes

1595 - Improving intravenous fluid therapy to reduce the incidence of acute kidney injury in hip fracture patients

C. McCann1, A. Hall1, J.M. Leow1, A. Harris1, N. Hafiz1, K. Myers1, A. Amin1, A. MacLullich1

1Royal Infirmary of Edinburgh, Deparment of Trauma and Orthopaedics, Edinburgh, United Kingdom

Background: Acute kidney injury (AKI) in hip fracture patients is associated with morbidity, mortality, and increased length of stay. To avoid this our unit policy recommends maintenance crystalloid IV fluids of >62.5mL/Hr for hip fracture patients. However, audits have shown that many patients still receive inadequate IV fluids.
Methods: Three prospective audits, each including 100 consecutive acute hip fracture patients aged >55, were completed with interventional measures employed between each cycle. Data collection points included details of IV fluid administration and pre/post-operative presence of AKI. Interventions between cycles included a revised checklist for admissions with a structured ward round tool for post-take ward round and various educational measures for Emergency Department, nursing and admitting team staff with dissemination of infographic posters, respectively.
Results: Cycle 1: 64/100 (64%) patients received adequate fluids. No significant difference in developing AKI post operatively was seen in patients given adequate fluids (2/64, 3.1%) compared to inadequate fluids (4/36, 11.1%; p=0.107). More patients with pre-operative AKI demonstrated resolution of AKI with appropriate fluid prescription (5/6, 83.3%, vs 0/4, 0%, p<0.05) 
Cycle 2: Fewer patients were prescribed adequate fluids (54/100, 54%). There was no significant difference in terms of developing AKI post operatively between patients with adequate fluids (4/54, 7.4%) or inadequate fluids (2/46, 4.3%; p=0.52). Resolution of pre-operative AKI was similar in patients with adequate or inadequate fluid administration (4/6, 67% vs 2/2, 100%). 
Cycle 3:  More patients received adequate fluids (79/100, 79%, p<0.05). Patients prescribed adequate fluids were less likely to develop post-operative AKI than those receiving inadequate fluids (2/79, 2.5% vs 3/21, 14.3%; p<0.05).
Discussion: This audit demonstrates the importance of administering appropriate IV fluid in hip fracture patients to avoid AKI. Improving coordination with Emergency Department and ward nursing/medical ward staff was a critical step in improving our unit’s adherence to policy.

There is NO Conflict of Interest: Yes

Accepted Abstracts - Part 2

1697 - The Influence of Senior Staff on a Virtual Fracture Clinic

P. Mahapatra1, R. Bhattacharya1, M. Pearse1

1Imperial College Healthcare NHS Foundation Trust, Trauma and Orthopaedics, London, United Kingdom

Background: We reorganised the virtual fracture clinic (VFC) service at our major trauma centre in response to the COVID-19 pandemic. A fully consultant-led service was introduced decrease subsequent face-to-face episodes. All VFC referrals were triaged by a senior consultant and a personalised care plan was formulated and communicated directly to the patient by telephone consultation. Detailed rehabilitation advice was also distributed.

Method: A retrospective analysis of digital records of the new consultant-led VFC from 19th of March 2020 to 30 June 2020 was compared to the results for a similar period in 2019 and the results were subjected to Chi squared analysis.

Results: In total 803 patients were assessed virtually during the 2020 period compared to 1778 in 2019, a reduction of 55%. During 2020, 578 (72%) of patients were discharged directly with advice at the initial virtual consultation. 124 (15.4%) were referred direct to therapy and 101 (12.9%) were seen in a clinic. 2 patients required urgent (same-day review). 93.1% of referrals were assessed within 72 hours.
In the same time period in 2019, 201 (11%) patients were discharged, 110 (6%) were referred to physio and1467 (80%) were seen in a clinic.
There was a 67.1% reduction in face-to-face clinic appointments with the new consultant-led model of VFC, which was a highly statistically significant difference  (p<0.0001). The financial implications and patient reported outcome data will be presented.

Conclusion: Patient attendances during the 2020 period were dramatically reduced as expected. The VFC discharge rate of over 70% is the highest in the literature. Our results suggest that a consultant-led VFC involving direct patient communication with instantaneous delivery of personalised care plans is highly efficient and cost-effective.

There is NO Conflict of Interest: No

Disclosure: PM is a director of Open Medical Ltd, which supplies the electronic virtual fracture clinic software utilised in this project. All clinical decisions made by MP, who has no involvement with Open Medical.

1723 - Prolonged waiting times for fracture clinic attendance with the Orthopaedic trauma service- An unintended fall-out of moving to a Virtual Fracture Clinic model

A. Mishra1, R. Gopireddy1, H. Gosal1

1Gloucestershire Hospitals NHS Trust, Gloucester, United Kingdom

Introduction: A ‘virtual’ fracture clinic (VFC) is a system for electronic review of imaging and clinical notes of patients with proven or suspected skeletal injury, who have received primary evaluation and care, and are suitable for management on an ambulatory basis. A plan for further investigations, management and follow-up is made, patients are appraised by telephone and followed up as necessary. This replaces an appointment in a ‘real’ fracture clinic, the goal being to cut down on unnecessary clinic visits and improve efficiency.
Aims: To investigate (1)the impact of implementation of this model on the waiting time to be seen in a ‘real’ clinic (2)number of referrals which are judged inappropriate as the model stipulates these simple injuries to be discharged directly from ED.

Methods: Electronic records of 635 first-time fracture clinic attendances in the same calendar fortnights before and after implementation were checked for the diagnosis, waiting times (from primary point of care to clinic), and management plan (continued non-operative treatment, manipulation, further imaging or surgery) and figures compared. 
Results: The median delay increased from 4 to 10 days for all patients, which was significant using the unpaired ‘t’ test (p=0.0001), 4 to 13 days for those who had further imaging (not radiographs), 4 to 6 days for those who required surgery and 5 to 10 days for hand fractures. 60% waited more than a week to be seen compared to 7% previously. The number of inappropriate referrals at 17% was only slightly reduced from 20% in the year before implementation.

Conclusion:  An unintended, early fallout of implementing the VFC model is an inappropriate increase in waiting times which can affect satisfaction with the service and has potential to be unsafe. This has not been reported previously in literature.

There is NO Conflict of Interest: Yes

1740 - COMPASS surgical risk prediction score; a safe adjunct to Cardiopulmonary Exercise Testing

A. Paterson1, R. Ramesh1, J. Kim1, K. Anderson1

1Torbay Hospital, Department of Trauma & Orthopaedics, Torquay, United Kingdom

Background: Cardiopulmonary Exercise Testing (CPET) is an established surgical risk prediction tool. Patients being considered for high-risk surgery have their risk of complications and death calculated through VO2 max, ECG monitoring and cardiopulmonary observations while performing controlled exercise tests. COMPASS is an algorithmic score for the same outcomes, which does not require the expense of specialist involvement of a CPET test. Both are calibrated to predict 30 d mortality.

Methods: COMPASS scores were compared to CPET in a retrospective cohort study on 305 patients who attended CPET clinics for proposed elective Orthopaedic surgery in our Institute. The primary outcome measures were postoperative morbidity and mortality within 1 year.

Results: Our preliminary results are presented here. Of the 305, only 135 (44%) managed exercise testing. CPET mortality calculation was available for 206 and morbidity calculation for 65. Rest did not have numerical figures but were classed as high or low risk. We had full data for COMPASS. The mortality negative predictive rate was 1.0 when COMPASS <1.5% risk (n=120). COMPASS and CPET Hosmer-Lemeshow and AUC c-indexes of 0.034, 0.71 and 0.78 (+-0.01), 0.89 (+-0.02) for mortality at 1 year showed significant but inferior calibration and discrimination, respectively. The correlation coefficient was 0.728 (p<0.01) and 0.37 (p<0.01) for the total population (n=305) and the COMPASS mortality <1.5% cohort (n=155), respectively. It was 0.17 (p<0.05) and 0.62 (p<0.05) for total population morbidity (n=305) and “non-exercise” CPET, respectively. 9 patients died and their risks were comparably predicted by the scores.

Conclusions: COMPASS is a safe substitute for CPET mortality risk prediction for low-risk patients (<1.5%) and can be used as a screening tool. At this cut-off, 120 (46%) patients would have avoided risk assessment in a more resource-intensive CPEX clinic. A paired regression analysis is indicated to confirm the non-inferiority in this sub-analyses.

There is NO Conflict of Interest: Yes

1892 - Acute Kidney Injury following Elective Total Knee and Total Hip Arthroplasty: A clinical outcome study

F. Raheman1,2, J. Campion1, R. Ashford3

1Northampton General Hospital, Department of Trauma and Orthopaedics, Northampton, United Kingdom, 2University of Edinburgh, Clinical and Divisional Sciences, Edinburgh, United Kingdom, 3University of Leicester, Leicester Cancer Research Centre, Leicester, United Kingdom

Background: Acute Kidney Injury (AKI) following major surgery is a challenging complication. Evidence suggests AKI in the post-operative period increases risk for progression to chronic kidney disease (CKD) and long-term mortality. The aim of this study was to evaluate incidence of post-operative AKI following elective total hip and total knee arthroplasty and its clinical outcomes.

Methods: Data was collected retrospectively between January 2019 – November 2019 through clinical coding with all cases cross referenced with electronic patient records. Patients were audited over 1 year to approximate acuity of elective hip and knee service at a district general hospital. NICE NG148 was the audit standard used to define the quantitative and qualitative varialbles measured. Patient demographics, ASA score, Body Mass Index (BMI), pre-operative blood tests, known risk factors of AKI defined the pre-operative variables measured. Peri-operative variables were estimated blood loss (ESBL), post-operative baseline bloods, length of stay (LOS) and duration of AKI. AKI was defined as at least a 50% increase in serum creatinine (SCr) from baseline and severity was classified according to Acute kidney injury network (AKIN) criteria.

Results: 550-patients were identified; 258 Total Hip Arthroplasties; 292 Total Knee Arthroplasties. Mean age= 70 Years (range 40-94), LOS= 4.24 days (SD 3.28). 53% of all patients had a BMI ≥25. Prevalence of diabetics was 17%. Mean ASA grade= 2.55 (SD 1.03) and average Preoperative eGFR was 74ml/min/1.73m2. Prevalence of pre-existing CKD was 8% (n=44).
60 patients (11%) were found to have developed Acute Kidney Injury in the post-operative period. 18 had persistent AKI (> 5 days); 42 had transient AKI (<5 days). Sub-group analysis of AKI-group revealed 50% of all patients with BMI<25 had a SCr peak day 4 post-operatively.

Conculsion: We note the significance of managing post-operative AKI promptly and diagnosis may be missed in patients with a low BMI

There is NO Conflict of Interest: Yes

1893 - Trauma Hip Arthroplasty Templating: Radiographic and Patient Factors Affecting Accuracy

T. Hodkinson1, O. Musbahi1, A. Wiik1, S. Nathan1, C. Huber1

1West Middlesex Hospital, London, United Kingdom

Background: Pre-operative planning is an essential component of the hip arthroplasty pathway. It facilitates the surgical procedure, helps to provide the correct implant size and allows for greater biomechnical functional outcomes. Indeed, templating for hip arthroplasty is becoming a routine standard of care. However, there is limited data on its usefulness in the trauma patients undergoing arthroplasty. In particular, the benefits of a King's Mark as a standard is not known. We present a study addressing the various radiographic and patient factors affecting accuracy in hip arthroplasty templating. We also present a novel templating methodology for use in trauma centres without a King's Mark.

Methods: All neck of femur radiographs of patients that underwent hemiarthroplasty between the period of December 2018 and December 2019 were analysed. Baseline demographics were recorded. Three different radiographic soft tissue measurements were analysed. Implant and operative data was recorded. Statistical tests were undertaken using STATATM. A logistic regression model was created to address the effects of patient and radiographic variables on templating accuracy.

Results: 95 neck of femur patients radiographs were analysed. Mean age was 81(Range 58 to 100). The mean soft tissue width to the lesser trochanter(STLT) was 107.3 mm and the mean soft tissue width to the greater trochanter was 107.3mm. For every 1mm increase in STLT there is 6% decrease in accuracy (p value = 0.048, 95% CI 0.942 to 0.999). A Bland-Altman plot illustrates the correlation between our templated measurements and the actual implant used in the operation.

Conclusion: Soft tissue width measured from the lesser trochanter was a significant influence on templating accuracy for patients undergoing hemiarthroplasty.

There is NO Conflict of Interest: Yes


Virtual Podium Presentations


M McMullan1

1Northumbria NHS Foundation Trust, Newcastle, United Kingdom

Background: Recent publications in the media have shone a negative light on knee arthroscopy. Despite this it is still a procedure that can benefit patients greatly when clinically appropriate. In Northumbria, we set out to create an internal soft tissue knee registry with the aim of collecting data, analysing outcomes and providing evidence for continuing to perform knee arthroscopies in suitable patients.

Methods: Set up in 2017, all patients undergoing an arthroscopic knee operation, not including ligament reconstructions, were submitted to the registry. Along with clinical and imaging information, KOOS and EQ-5D scores were collected pre-operatively, then at 6 months and 12 months post-operatively. All consultants performing elective knee arthroscopies were required to submit data.

Results: 800 patients are registered currently, 65% of these being male with a mean age of 48. All have pre-op PROMS whilst currently 42% have scores at all stages collected. Eleven consultants contributed to the registry with only three consultants making up 74% of the patients. Four consultants performed less than 10 arthroscopies during this time frame.
A clinically significant change was seen in average pre and post op KOOS scores at one year (229.04 to 328.02). Average EQ-5D index improved by 0.11 at one year yet the EQ-5D VAS showed no change.

Conclusions: Data from an internal registry is a powerful tool and going forward our registry can be used to evidence that we are giving correct patients the correct treatment and furthermore provide commissioners with this information. We were able to set this up with minimal resources and are keen to share its benefit with others.

There is NO Conflict of Interest: Yes

317 - Pain and Function in Cemented and Cementless Unicompartmental Knee Replacements: A 5-year Comparative Study

A. Rahman1, C. Jenkins2, A. Price2, W. Jackson2, C. Dodd2, S. Mellon1, K. Barker2, D. Murray1,2

1Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Oxford, United Kingdom, 2Nuffield Orthopaedic Centre, Oxford, United Kingdom

Introduction: Unicompartmental Knee Replacements (UKRs) offer improved outcomes and reduced healthcare costs compared to Total Knee Replacements. However, UKRs have higher revision rates, primarily due implant loosening. Cementless UKRs have been shown to reduce the risk of such loosening compared to cemented variants. However, the overall mid-to-long-term clinical benefits of cementless UKRs remain unclear.

Objectives: To compare pain-related and function-related outcomes of cementless and cemented medial UKR at 5 years after surgery.

Methods: 262 cemented and 262 cementless UKR were implanted by 4 high-volume surgeons, and assessed at 5 years postoperatively by independent physiotherapists. Implants, instrumentation used, and pre/peri/post-operative management were identical, with the exception of method of fixation. The assessment included Oxford Knee Score (OKS), American Knee Society Score (AKSS), Charnley Grade, EQ-5D-5L and two pain scores, the Intermittent and Constant Osteoarthritis Pain (ICOAP) and PainDetect (PD) scores.

Results: There were no significant differences in pre-operative characteristics and postoperative revision, reoperation, and complication rates (0.8%, 2.2%, 4% respectively).
Patients with the cementless UKR had significantly better pain-related scores with OKS, AKSS, and EQ-5D, and the differences were proportionally much greater than differences in the overall scores. 45% more cementless UKR patients experienced no pain at all (ICOAP=0/100, 61%v43%, p<0.0001), and 75% less experienced ≥moderate pain (ICOAP>40/100, 1.6%v6.6%, p=0.0433). No cementless patients experienced severe/extreme pain (ICOAP>60/100); 2.9% of cemented patients did.
97% of all patients who experienced constant pain also experienced intermittent pain. When split into 2 pain groups, the high-pain group (ICOAP 21-100v0-20) were more likely to have out-of-knee pathology (Charnley-C OR 1.37-1.48) and neuropathic pain (PD-Q OR 3.14-6.29).

Conclusion: Cementless UKR is associated with better patient reported outcomes than cemented. The biggest difference was in pain, which may explain differences in function and general health. We do not understand why this is, and further study is necessary.

There is NO Conflict of Interest: No

Disclosure: Some authors have received personal fees for consultancy for Zimmer Biomet, Johnson and Johnson, and Medacta, outside the submitted work. Some authors have various patents related to knee replacement with royalties paid.

406 - A prospective randomised controlled trial comparing biochemical, thermal, and macroscopic soft tissue injury outcomes in conventional jig-based versus robotic total knee arthroplasty

B Kayani1, J Tahmassebi1, A Ayuob1, S Oussedik1, S Konan1, FS Haddad1

1University College London Hospital, London, United Kingdom

Introduction: The objectives of this study were to compare the serum inflammatory reaction, localised thermal response and macroscopic soft tissue injury outcomes in conventional jig-based total knee arthroplasty (conventional TKA) versus robotic total knee arthroplasty (robotic TKA).

Methods: This prospective randomised single-blinded controlled trial included 15 patients undergoing conventional TKA versus 15 patients receiving robotic TKA. Predefined serum markers of inflammation and topical knee temperature were collected preoperatively and postoperatively at 6 hours, day 1, day 2, day 7, and day 28 following TKA. Blinded observers used the Macroscopic Soft Tissue Injury (MASTI) classification system to grade intraoperative periarticular soft tissue injury and bone trauma. Plain radiographs were used to assess the accuracy of achieving the planned limb alignment and implant positioning in both treatment groups.

Results: Conventional TKA and robotic TKA had comparable increases in the postoperative serum inflammatory cytokines and localised thermal responses at 6 hours, day 1, day 2 and day 28 after surgery. Robotic TKA had reduced levels of interleukin-6 (p<0.001),tumour necrosis factor-alpha (p=0.021), erythrocyte sedimentation rate (p=0.001), C-reactive protein (p=0.004), and creatine kinase (p=0.004) at day 7 after surgery compared to conventional TKA. Robotic TKA was associated with improved intraoperative preservation of the periarticular soft tissue envelope (p<0.001) and reduced bone trauma (p=0.015) compared to conventional TKA. Robotic TKA improved accuracy of achieving the planned limb alignment (p<0.001), femoral component positioning (<0.001), and tibial component positioning (<0.001) compared to conventional TKA.

Conclusion: Robotic TKA was associated with a transient reduction in the early (day 7) postoperative inflammatory response but there was no difference in the immediate (<48 hours) or late (day 28) postoperative serum inflammatory responses compared to conventional TKA. Robotic TKA was associated with decreased iatrogenic periarticular soft tissue injury, reduced bone trauma and improved accuracy of implant positioning compared to conventional TKA.

There is NO Conflict of Interest: No

509 - Return to work following total knee and hip arthroplasty: the effect of patient intent and preoperative work status

K Al-Hourani1, D MacDonald1, G Turnbull1, S Breusch1, C Scott1

1Royal Infirmary of Edinburgh, Trauma & Orthopaedics, Edinburgh, United Kingdom

Introduction: The ability of total knee and hip arthroplasty (TKA/THA) to facilitate return to work (RTW) when it is the patient’s preoperative intent to do so remains unclear. We aimed to determine whether TKA/THA facilitated RTW in patients of working age who intended to return. 

Materials and Methods: Prospective cohort study of 173 consecutive patients <65 years of age, undergoing unilateral  TKA (n=82: median age 58, range 39-65; 36 (43.9%) male) or THA (n=91: median age 59 , range 34-65; 42 (46.2%) male) during 2018. Oxford knee/hip scores (OKS/OHS), Oxford-APQ and EuroQol-5 dimension (EQ-5D) scores were measured preoperatively and at one year when an employment questionnaire was also completed. 

Results: Of patients who intended to RTW, 44/52 (84.6%) RTW by one year following TKA (at mean 14.8±8.4 weeks) and 53/60 (88.3%) following THA (at mean 13.6±7.5 weeks). Failure to RTW despite intent was associated with job physicality for TKA (p=0.004) and negative preoperative EQ-5D for THA (p=0.01). In patients unable to work prior to surgery due to joint disease, fewer RTW:  4/21 (19.0%) after TKA; and 6/17 (35.3%) after THA. Preoperative OKS >18.5 predicted RTW with 74% sensitivity (p<0.001); preoperative OHS >19.5 predicted RTW with 75% sensitivity (p<0.001). Preoperative EQ-5D indices were similarly predictive (p<0.001) 

Conclusion: Where patients intend to RTW following TKA/THA, 85% RTW following TKA and 88% following THA. Patients of working age should not be left to the point where they are unable to work due to joint symptoms, as RTW becomes the exception not the rule.

There is NO Conflict of Interest: Yes


V. Kandhari1, S. Grasso1, D. Myat1, J. Twiggs2, B. Fritsch1, D. Parker,1

1Sydney Orthopaedic Research Institute, Orthopaedic Knee Surgery, Chatswood, Australia, 2360 Knee Systems, Research, Sydney, Australia

Objective: To assess the patellar resurfacing techniques in total knee arthroplasty (TKA) using CT scan and 3D modelling and evaluate their influence on clinical outcomes.

Methods: This retrospective study included all TKAs between 2013 and 2018. All patients underwent preoperative and postoperative CT scans. Patellae with significant anatomical distortion secondary to advanced arthritis were excluded. Accurately landmarked 3D models of patellae were created from CT data in ScanIP software. Patellar resection plane tilts, button positioning and volumetric articular restoration were evaluated using Solidworks design software. Correlation analyses were performed between measured variables and 1-year follow-up KOOS scores.

Results: 229 of 291 TKAs satisfied the inclusion criteria. Clinical follow-up data was available for 158 TKAs. Wide variations were observed in the patellar resection plane tilts to supero-inferior and medio-lateral patellar axes and in patellar button positioning. Resection plane was tilted laterally and inferiorly and patellar button positioned posteriorly, inferiorly and laterally in more number of patellae. Though total post-op patellar volume was comparable to pre-op, polyethylene volume build-up was found in the superior-third zone. Superior tilting of resection plane [R (-0.6)] and polyethylene volume build-up in medial part of superior-third zone [R (-0.4)] negatively correlated with 1-year KOOS sub-scores. Superiorization of patellar button had significant positive correlation with volume of polyethylene in superior-third zone (R-0.36).

Conclusions: There is a need to devise better and reproducible patellar resurfacing techniques toachieve more consistent optimal patellar resection planes. Superior tilting of patellar resection plane and supero-medial positioning of the patellar button should be avoided.

There is NO Conflict of Interest: No

Disclosure: Vikram Kandhari, Samuel Grasso, Darli Myat - None. Joshua Twiggs - employee 360 Knee Systems. Brett Fritsch, David Parker - Share holder 360 Knee System, Trium and Optimised ortho; Consulting work 360 Knee Systems, Global Orthopaedics, Omni; Institutional support Zimmer, Smith and Nephew, Global Orthopaedics and Arthrex.

1011 - Regional Five-year clinical outcomes of 289 cementless Oxford unicompartmental knee replacements at a non-inventor centre

H. Rajgor1, R. Nandra1, C. Winkworth1, N. Aslam1

1Worcestershire Acute Hospitals NHS Trust, Birmingham, United Kingdom

Uncemented unicompartmental knee replacement offers a minimally invasive approach, faster rehabilitation and good levels of function, supported by evidence reporting low intra-operative fracture rate and mid-term stability with no implant migration at 5-years. Our aim was to examine the clinical outcomes in 289 consecutive Oxford unicompartmental knee arthroplasties (257 patients), five years post-operatively. Performing a retrospective study of patients treated between 2008 and 2014 in a non-inventor centre by a single surgeon. Patients with anteromedial bone on bone unicompartmental arthritis included. Oxford Knee Scores (OKSs) at last follow-up were recorded, intra-operative complications reported with commentary on revision cases. 
Mean age of patients 66 years (SD 9.6, 45 to 88 years). 122 female patients (42%) predominantly ASA 1 (36%), ASA 2 (62%) and ASA 3 (01%). There were no intra-operative complications, particularly tibia fractures during impaction. The average oxford knee score was 40.1 (n=232, Range 06 to 48, SD 8.46) at an average 6 years and 3 months from surgery, including revised patients. Six patients had their prosthesis revised within five years of the index surgery. Five-year cumulative implant survival rate was 97.8% (95% CI 97.62 to 97.98, SE 0.09). Indication for revision were: lateral side wear (n=1); dislocated spacer (n=4); instability and spacer subluxation (n=1). Thirteen patients died within five years of surgery Five-year cumulative survival rate was 94.9% (95% CI 94.87 to 94.925, SE 0.013).

Conclusion:  The proportion of patients requiring revision at five years is lower than that generally reported for UKA. These findings add support for the use of the cementless OUKA outside the design centre.

There is NO Conflict of Interest: Yes

1075 - Failures and Complications with MPFL reconstruction:Our experience in 215 patients.

P. Setia1, S. Dalal1, A. Debnath1, R. Kotwal1, A. Chandratreya1

1Princess of Wales Hospital, Trauma and Orthopaedics, Bridgend, United Kingdom

Background: Chronic lateral patellar instability is one of the most commonly seen clinical conditions encountered by knee surgeons.Medial patellofemoral ligament (MPFL) reconstruction has become increasingly popular over the last three decades. Upto 26% complication rates have been reported in literature with MPFL reconstruction.The purpose of this study is to analyse failure rates,complications of surgery for PF instability and to identify the predictive factors for failure.

Methods: A retrospective analysis of prospectively collected data was performed for all 215 (234 knees) patients who had undergone MPFL reconstruction between October 2007 and August  2018. All the cases with any postoperative complications or failures were included. A failure was defined by a postoperative patellar dislocation or surgical revision for recurrent patellar instability or anterior knee pain not resolving with conservative methods. Other complications such as stiffness,infection,neurological deficit and deep vein thrombosis were also included. Lysholm,Kujala,Tegner and radiographic features, such as trochlear dysplasia according to Dejour classification,patellar height with the Caton-Deschamps index (CDI), tibial tubercle-trochlear groove distance were analysed pre and post operatively.

Results: Six patients (2.56%) had a revision of their MPFL reconstruction, six patients (2.56%) had removal of their metal work while only three patients (1.28%) had stiffness postoperatively and required manipulation under anesthesia.Five patients (2.17%)had patellofemoral replacement over time while four patients(1.70%) had arthroscopic debridement for cartilage related pathology. There was also one case each of femoral nerve palsy, post operative infection, deep vein thrombosis, nonunion of tibial tuberosity osteotomy.

Conclusions: To our knowledge, this is the only study recording the failures and complications of MPFL reconstruction on a large patient database. Age above 30,obesity, cartilage lesions, hyperlaxity and female gender are predictors of a poor subjective outcome. Identifying the potential risk factors preoperatively can prevent future complications.

There is NO Conflict of Interest: Yes

1209 - Long-Term Results of Revision Total Knee Arthroplasty Using a Rotating Hinge Implant

W. Wignadasan1, J. Chang1, B. Kayani2, C. Kontoghiorghe2, F.S. Haddad1

1University College London Hospital, Trauma and Orthopaedics, London, United Kingdom, 2University College London Hospital, London, United Kingdom

Background: Rotating hinge implants are commonly used in revision total knee arthroplasty (TKA) in the setting of significant ligamentous instability or bone deficiency. These highly constrained implants have been associated with variable clinical outcomes and uncertain long-term survivorship. The aim of this study is to establish long-term functional outcomes, radiographic results, and survivorship after revision TKA with a rotating hinge implant.

Method: 41 consecutive patients undergoing revision TKA with rotating hinge components were included in the study. Indications for revision TKA included: aseptic loosening with bone and soft tissue loss in 23 cases (56.1%), fractures in 4 cases (9.8%), infection in 10 cases (24.2%), ligamentous instability in 3 cases (7.3%), and pain and malalignment in 3 cases (7.3%). Clinical outcomes recorded included the Oxford Knee Score (OKS) preoperatively and postoperatively at latest follow-up. Range of motion, implant survivorship, and complications were recorded. Mean time from date of revision TKA to last follow-up was 14 years (range, 10.7 years to 17.1. years)

Results: There was a significant improvement in OKS after revision TKA with a rotating hinge implant compared to preoperative scores (40.7 ± 4.2 vs. 21.4 ± 4.9 respectively, p<0.001). At latest follow-up, mean range of motion was 111.5° ± 9.3° and mean overall limb alignment of 0.2° ± 2.0° varus. Implant survivorship at minimum 10-year follow-up was 90.2%. Radiographic lucent lines were observed in 14 patients (34.1%); however only two of these patients (4.9%) required further revision TKA. A further two patients (4.9%) underwent revision TKA for periprosthetic fracture.

Conclusion: Revision TKA with a rotating hinge implant leads to satisfactory clinical outcomes and very good implant survivorship at long-term follow-up. Despite the relatively high complication rates where did the high complication rate come from, surgeons should have a low threshold to use these versatile implants in complex revision knee arthroplasty.

There is NO Conflict of Interest: Yes


D.S. Rye1,2, R. Walker2, A. Yoong1,2, H.B. Waterson2,1, J.R. Phillips2, A.D. Toms2

1University of Exeter Medical School, Exeter, United Kingdom, 2Royal Devon and Exeter Hospital: Princess Elizabeth Orthopaedic Centre, Exeter Knee Reconstruction Unit, Exeter, United Kingdom

Background: Lower limb mechanical axis has long been seen as a key to successful in lower limb surgery, including knee arthroplasty. Traditionally, coronal alignment has been assessed with weight-bearing lower limb radiographs (LLR) allowing assessment of hip-knee-ankle alignment. More recently CT scanograms (CTS) have been advocated as a possible alternative, having the potential benefits of being quicker, cheaper, requiring less specialist equipment and being non-weightbearing.

Objectives: To evaluate the accuracy and comparability of lower limb alignment values derived from LLR versus CTS.

Methods: We prospectively investigated patients undergoing knee arthroplasty with preoperative and postoperative LLR and CTS, analysing both preoperative and postoperative LLRs & CTS giving 140 imaging tests for direct comparison. We used two independent observers to calculate on each of imaging modalities, on both pre- and post-operative images, the: hip-knee-ankle alignment (HKA), lateral distal femoral angle (LDFA) and medial proximal tibial angle (MPTA).

Results: 840 data points were captured from pre- and post-operative LLRs and CTSs. Analysis demonstrated very strong correlation in pre-operative HKA (LLR vs CTS, r = 0.917), post-operative HKAs (LLR vs CTS, r = 0.850) and postoperative LDFAs (LLR vs CTS, r = 0.850). Strong correlation was observed in pre-operative LDFAs (r = 0.732), MPTAs (r = 0.604), and post-operative MPTAs (r = 0.690).

Conclusion: Both pre- and post-operative LLR and CTS imaging display very strong correlation for HKA coronal alignment correlation, with strong correlation for other associated angles around the knee. Our results demonstrate that both LLR and CTS can be used interchangeably with similar results.

There is NO Conflict of Interest: Yes

1379 - Staged or Simultaneous Bilateral Total Knee Arthroplasty; When is the most clinically effective time interval to operate on your patients’ undergoing Bilateral Total Knee Replacement?

S. Radha1, I. Afzal1, D. Kader1, R. Field1

1SWLEOC, London, United Kingdom

The question, which remains unanswered, is should bilateral Total Knee Replacements (TKRs), be performed simultaneously or staged. If staged, what should the time interval be? To date, there is no peer reviewed evidence in the orthopaedic literature investigating whether the improvement in patient satisfaction and Patient Reported Outcome Scores (PROMs) is influenced by the duration of the interval between first and second TKR when different surgical strategies are used.
We conducted a prospective, multi-surgeon, study on 1308 patients (2616 TKRs) who underwent bilateral TKRs between 2004 and 2015. The aim of this study was to identify whether there was any significant difference in patient satisfaction and PROMs improvement when performing bilateral TKRs. In this study, we used the 12-question validated Oxford Knee Score (OKS) and a visual analogue Patient Outcome Satisfaction score (0:Bad outcome – 100:Great outcome). PROMs were collected pre-operatively, one- year post-operatively and two-year post operatively. Timing interval between first and second TKR were divided as: Zero (simultaneous), day 1 to 3 months, 3-6, 6-9, 9-12, 12-15, 15-18, 18-21, 21-24 months and > 24 months.
Results from this study showed the greatest change in both knees for the OKS was those patients who had their TKRs day 1-3 months apart. This result was also statistically significant with a p-value of 0.001. The lowest OKS change was those patient who their knee operated on >24 months apart. Patient satisfaction also correlated with these results. Those patients operated on with day 1-3 months had the highest satisfaction of 93.12 and those patients operated on >24 months had the lowest satisfaction of 91.65.
Awareness of the reported outcomes following TKR can be a useful tool for surgeons when suggesting when undertake a bilateral TKR.

There is NO Conflict of Interest: Yes

1423 - An MRI analysis of 500 patients to assess variations in popliteal artery anatomy as predictors for significant intra-operative vascular complications during knee surgery

N. Vetharajan1, A. Dodds1, G. Silk1

1Gloucestershire Hospitals NHS Foundation Trust, Trauma and Orthopaedics department, Cheltenham General Hospital, Cheltenham, United Kingdom

Background: Although vascular complications associated with knee surgery are rare, with a reported incidence of 0.03-0.12%, they can cause significant morbidity. Variations in the anatomy of the popliteal artery may mean structures are at risk during high tibial osteotomy or arthroplasty surgery.
Aims: The aim of this study was to quantify the proportion of patients with an aberrant popliteal artery, and to describe the variation in location of this aberrant vessels in relation to the posterior cortex of the tibia.
Materials and methods: In our study three independent observers (two orthopaedic surgeons and MSK radiologist) performed an analysis of 500 consecutive MRI scans (with axial, coronal and sagittal sequences) of knees who had not had prior surgery.
Results: 7% (35 patients) were confirmed to have an aberrant high popliteal artery variant. Of these 23 patients show a high separate anterior tibial artery variant that is present anterior to the popliteus muscle adjacent to the posterior tibial cortex. These are found to be largely in the midline posteriorly, at risk of vascular injury during osteotomy or tibial preparation during arthroplasty surgery.The remaining 12 patients had an aberrant artery variation separately with smaller-calibre vessels also anterior to the popliteus muscle which may increase the risk of intra-operative injury.
Conclusion: This study aims to highlight a variation in arterial anatomy that was readily identifiable on MRI knee scans. These variations should be identified during pre-operative surgical planning.

There is NO Conflict of Interest: Yes

1718 - Combined Supracondylar Nailing And Lateral Femoral Locking Plate In Complex Distal Femur Fractures: A New Technique And Outcome

K. Natarajan1, M. Bari1, R. Swaminathan1

1Tameside and Glossop Integrated Care NHS Foundation Trust, Trauma and Orthopedics, Ashton-under-Lyne, United Kingdom

Background: Complex fractures of distal femur are a challenge to treat. The fracture morphology, quality of bone and the size of the distal fragment plays a role in the choice of treatment options. Mechanical studies have shown better axial, torsional loading properties with higher load to failure with the combined nailing and plating of distal femur. We believe that this is the first report of the use of combination of the methods in treating these complex distal femoral fractures.

Objectives: To review the outcomes of combined supracondylar nailing and anatomical lateral femoral locking plate in complex distal femur fractures.

Study Design & Methods: All patients with complex distal femur fractures who underwent combined supracondylar nailing and lateral femoral locking plate fixation were included in this retrospective study. The electronic records and imaging from database were analysed.

Results: A total of 11 patients were identified from the records. 100 % of patients showed evidence of clinical and radiological union at a mean follow up of 3.8 months (range 3 to 5 months). One patient developed infection which needed removal of metal work and subsequently underwent total knee replacement for symptomatic osteoarthritis of knee. Another patient developed a bursitis over the locking plate and the plate had to be removed.

Conclusions: This new technique uses the intramedullary nail to achieve gross reduction of the distal femoral fracture with lateral locking plate, fine tuning the reduction in mediolateral/anteroposterior plane. The use of blocking screw/ pushing screw through the plate achieves anatomical reduction with correction of translation, minor valgus, varus, procurvatum and recurvatum malalignment. We believe that this technique provides stability for immediate weight bearing with higher potential for healing especially in those with osteoporotic distal femoral fractures.The results show maintenance of alignment with 100% of fractures healed.

There is NO Conflict of Interest: Yes

1911 - Early surgery for Medial Meniscal Posterior Root tear results in good clinical and radiological outcomes

H. Singh1

1Royal Derby Hospital, Trauma and Orthopaedics, Derby, United Kingdom

Background: Medial meniscus posterior root tear (MMPRT) defunctions the meniscus leading to Medial meniscus extrusion(MME) which can cause progression of arthritis. Early Root repair may improve biomechanics and clinical outcomes.

Methods: 17 patients (7 male,10 female) with MMPRT on MRI were operated with a trans-tibial pull- out repair between 2017-2019. Average age was 41.5 years (range:26-62 years) with mean BMI of 24.71. Patients were classified as type 2 (11 patients), type 4 (4 patients) and type 1 (2 patients) acccording to La Prade Classification. Hip-Knee-Ankle (HKA) xrays were taken to assess limb alignment and Kellgren-lawrence classification used to grade Osteoarthritis. Patients were followed up at 6,12 weeks and 6 monthly thereafter for an average of 20 months (range:14-26 months) with MRI at 6 weeks to assess MME post-op. Range of motion (ROM) and Lysholm scores were used to assess functional outcomes. SPSSTM v26 was used for statistical analysis and p value <0.05 considered significant.

Results: Mean pre-op score was 41.94 (range: 33-55) which improved to a statistically significant mean post op score of 70.24 (range: 60-82) (p<0.05). The mean pre-op Medial Meniscal extrusion (MME)of 3.38 ± 1.11mm reduced to 2.77 ± 0.93 post-op (p<0.05). Weak negative correlation was observed between post op MME and post-op Lysholm scores (r= -0.51, r2= 0.26). Time since symptoms {average:7.6 months (range: 2weeks to 24 months)} showed a negative correlation with post-op scores (r = -0.87; r2=0.65) and weak correlation with post- op MME(r=0.64, r2= 0.41). HKA angle (mean 178.30) and BMI bore no correlation with MME or post op scores. OA grades did not worsen over the follow-up period. Improvements in ROM were clinically beneficial but not significant statistically.

Conclusion: Early operative treatment of MMPRT results in better functional outcomes with improvements in MME and prevents progression of OA over short follow ups.

There is NO Conflict of Interest: Yes

Accepted Abstracts

127 - Orientating the tibial component along the Anatomical Tibial Axis may result in patellofemoral problems following total knee replacement

PA Mac Suibhne1, M Ganapathi1

1Ysbyty Gwynedd, Trauma & Orthopaedics, Bangor, United Kingdom

Introduction: Optimal rotational alignment of the tibial component is important for good functional outcome following total knee replacement. Internal rotation of the tibial component has been associated with patella-femoral problems. A commonly used rotational reference is a line drawn from the deepest point of the posterior tibial sulcus to a point dividing the tibial tuberosity into its medial 1/3 and lateral 2/3 (MTA). Another commonly used axis is the Anatomical Tibial Axis (ATA) where a line connecting tibial condylar centres is transected by a perpendicular line through the tibial tuberosity.

Aim: To analyse the degree of variability in inter-axis angular relationships between the ATA and MTA.

Methods: MRI imaging from 350 knees obtained for the purpose of patient specific instrumented TKRs were analysed. The MTA and ATA were identified as described above and the variation in angular relationship between them were measured.

Results: The median angular difference was found to be 6.41o. The minimum value was -11.950 and the maximum value was 17.69o with an overall range of 29.64o.

Conclusion: There is considerable variability in the angular relationships between the two axes of rotation of the proximal tibia. If rotation of the tibial component is based on the ATA, significant internal rotation of the tibial component (in relation to the patellar tendon insertion) will occur in some patients with resultant patellofemoral problems and poor outcome. However, in those patients with large variation between the two axes, tibiofemoral incongruency may occur if more constrained tibial inserts are used and consideration should be given in those cases to use a less constrained insert or mobile bearing insert to avoid the conflict between patellofemoral dysfunction and tibiofemoral incongruency.

There is NO Conflict of Interest: Yes

358 - Soft tissue landmarks for tibial baseplate rotational alignment in total knee arthroplasty. A cadaveric study

O Eseonu1, M Mactier1, E Ferguson2, F Quondamatteo2, B Jones1

1Glagow Royal Infirmary, Department of Trauma and Orthopaedics, Glasgow, United Kingdom, 2University of Glasgow, Thomson Building, Glasgow, United Kingdom

Background: The bony landmark of the highest point of the tibial tubercle (HPTT) is used to assess tibial baseplate rotation on post-operative CT scans in total knee arthroplasty (TKA), however this landmark can be difficult to palpate and visualise intra-operatively. Several more easily accessible soft-tissue landmarks have been proposed, including the medial border of the patellar tendon (MBPT) and the junction of the medial third of the patellar tendon (mt-PT). This study aimed to determine the relationship between the HPTT and these soft tissue landmarks, and simulate tibial baseplate rotational alignment if these landmarks were used during TKA.

Methods: Measurements of the patellar tendon borders relative to the HPTT were made on both knees from twenty-eight cadavers (14 male). A simulation of tibial baseplate rotation was subsequently carried out on ten post-TKA knee CT scans using the measurements obtained from the cadaveric study.
Results: Using the mean measurements of the MBPT, in its anatomical position, resulted in 12.68o of excessive tibial baseplate internal rotation on the CT simulation. The subluxed MBPT (sMBPT) resulted in 6.23o of external rotation; and the mt-PTresulted in 8.29 o of tibial baseplate external rotation.
Conclusion: Use of the anatomical MBPT may predispose to internal rotation of the tibial baseplate. However use of sMBPT or mt-PT minimise the risk of internal rotation of the tibial baseplate, which may influence TKA kinematics and development of post-operative pain.

There is NO Conflict of Interest: Yes

387 - Financial analysis of revision knee surgery at a tertiary referral centre as classified according to the Revision Knee Complexity Classification (RKCC)

M Petrie1, S Salih1, T Harrison1, A Gordon1, A Hamer1, S Buckley1, R Kerry1

1Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom

Background: Revision TKA (rTKA) can be complex; with greater complication risk and cost to the treating hospital than primary TKA. A rTKA regional network has been proposed with a hierarchy of case complexity appropriate to each unit. The revision knee complexity classification (RKCC) is a system proposed to triage cases to the most appropriate centre. The aim of this work was to accurately quantify costs and reimbursement for the rTKA service, classified according to the RKCC, at a tertiary referral centre.
Patients and Methods: A retrospective review of two consecutive financial years 2017 - 2019 was performed of all rTKA performed at our institution. Cases were classified according to the RKCC system and also by mode of failure; “infected” and “non-infected”. Financial data was acquired through PLICS.
159 patients underwent 188 rTKA procedures. 60 (32%) R1 revisions, 46 (24%) R2 revisions and 82 (44%) R3 revisions. Length of stay (LoS) significantly increased between complexity groups (p<0.0001) and for infected revisions (p<0.0001). Cost per inpatient episode increased significantly between complexity groups (p<0.0001) and for infected revisions (p<0.0001). The mean difference between costs and reimbursement resulted in a deficit for all groups but significantly increased with revision complexity and for infected revisions. A mean deficit of £1,903 was seen for the R1 group, £3,260 for the R2 group and £5,269 for the R3 group (p<0.0001). The total deficit to the Trust for the two-year rTKA service was £667,091. 
Discussion: The current levels of NHS reimbursement are inadequate for centres which offer a rTKA service. The RKCC correlates well with the increasing costs associated with the more complex cases. An increase in the most complex rTKA at major revision centres will undoubtedly place an even greater strain on the finances of these units without a significant uplift in tariff.

There is NO Conflict of Interest: Yes

448 - Revision anterior cruciate ligament reconstruction with Bone Patellar Tendon Bone Graft- 3 to 16 year result

M Kiran1, S Roy1, O Javed1, N Atwal1, H Gosal1

1Gloucestershire Hospitals NHS Foundation Trust, Cheltenham, United Kingdom

Background: Revision anterior cruciate ligament reconstruction(ACLR) may be influenced by previous tunnel position, tunnel widening, bone loss, graft used during primary surgery, presence of additional joint injury and infection. We present the medium term results of a cohort of patients undergoing single and two-stage revision ACLR with bone patellar tendon bone graft (BPTB).

Methods: All patients who underwent revision ACLR with BPTB between January 2004 and June 2017 were included in this study. Demographic details and symptoms were prospectively in the hospital database. Single or two stage revision was performed based on pre-operative planning. Iliac crest bone graft was used. Pre-operative and follow-up Lysholm and Tegner activity scores and return to sport(RTS) were recorded. Paired t-test was used to analyze improvement in functional score with p<=0.05 considered significant.

Results: Eighty patients with a mean age was 30.6 years were included in this study. Single stage revision ACLR was performed in 68 patients. In 12 patients (15%), revision ACLR was performed in two stages. Additional ALL reconstruction was performed in 7 patients using the iliotibial band. There was a significant improvement in Lysholm score from mean 52.4 to 85.1 (p<0.001). The incidence of re-rupture in our cohort was 0%. The median Tegner score 6, RTS at any level was 66.1% and pre-injury level was 36.9%. ALL reconstruction was performed in 7 patients. The mean follow-up was 8.75 years (range 3.25-16 years).

Discussion and Conclusion: Revision ACLR is complicated by the presence of tunnel malposition and widening and additional chondral and meniscal injuries. Thorough pre-operative planning, appropriate staging of procedures, correct tunnel positioning and additional procedures to ensure rotatory stability results in low graft re-rupture rates, good functional scores and return to sport.

Implications: BPTB graft results in low rerupture rates after revision ACLR with careful planning and appropriate staging of surgery.

There is NO Conflict of Interest: Yes

652 - Arthroscopic Menisectomy in Patients Over 55: Does it Work?

M. Walker1, P. Gallacher1

1The Robert Jones and Agnes Hunt Orthopaedic Hospital, Department of Sports Knee Surgery, Oswestry, United Kingdom

Background: Arthroscopic menisectomy for degenerate meniscal tears in older adults is a commonly performed procedure. We examined a cohort of patients over 55 years old at RJAH undergoing arthroscopic meniscectomy, aiming to determine their risk of needing arthroplasty surgery within 5 years, and the efficacy of the procedure.
Methods: We Prospectively collected data between 2012 and 2013 on patients over 55 years of age undergoing arthroscopic menisectomy alone or menisectomy and chondroplasty. The patient records were reviewed in 2019 to determine if the patient’s symptoms had resolved, and whether they had required subsequent arthroplasty surgery. Data collected included:

  • Patient demographics such as age, sex, employment status, symptoms, and which meniscus was injured.
  • Whether patients subsequently had any form of knee arthroplasty.
  • Whether the patient’s symptoms settled.

Results: 63 patients were included in the study: 28 in the menisectomy group and 35 in the menisectomy and chondroplasty group.

  • Mean age was 63.9 in menisectomy group and 64.1 in the menisectomy and chondroplasty group (no significant difference P=0.85).
  • There was no significant difference in the patient demographics other than employment status.
  • There was a significantly higher rate of patients requiring arthroplasty in the menisectomy and chondroplasty group compared to menisectomy alone, 42.9% and 17.9% respectively P=0.034).
  • There was no difference between the two groups in rates of symptoms settling (71.4% for menisectomy alone, 65.7% for menisectomy and chondroplasty P=0.63).


  • Symptoms will settle in most patients undergoing arthroscopic menisectomy with or without chondroplasty.
  • Patients who also undergo additional chondroplasty surgery have a significantly higher risk of requiring subsequent arthroplasty surgery within 5 years.

Implications: When considering menisectomy in older patients, caution should be used in patients with articular surface damage, however those who do not have chondral lesions have a 82% chance of not requiring joint replacement at 5 years.

There is NO Conflict of Interest: Yes

689 - Long term outcomes of a fixed all-polyethylene bearing unicompartmental knee arthroplasty in older patients

D. Bruce1, M. Hassaballa1, J. Robinson1, A. Porteous1, J. Murray1, J. Newman1

1Avon Orthopaedic Centre, Southmead Hospital, Bristol, United Kingdom

Background: Medial compartment osteoarthritis can be successfully treated with a unicompartmental knee arthroplasty (UKA). An all-polyethylene fixed-bearing UKA can reduce backside wear, preserve tibial bone stock, eliminate the risk of bearing dislocation and is a lower cost implant (Koskinen et al., 2008). However, some studies suggest there may be poorer clinical outcomes and survivorship (Gladnick et al., 2015).
Methods: Prospective data was collected for consecutive patients undergoing implantation of an all-polyethylene fixed-bearing Uniglide UKA (Corin Ltd., Cirencester, UK) at a single tertiary hospital between November 2002 and December 2007. Patients met standard criteria for UKA implantation and the mean patient age was 70 (range 41-87). The Oxford Knee Score (OKS), American Knee Society Score (AKSS) and Western Ontario and McMaster Universities Arthritis Index (WOMAC) were collected at one, two, five, eight, 10 and 12 years postoperatively. Data were analysed with SAS University Edition (SAS Institute Inc, NC, USA).

Results: 214 fixed all-polyethylene tibia UKAs were implanted in 184 patients. Overall, Kaplan-Meier survivorship was 89.1% at 10 years. 122 UKAs were implanted in 104 patients who were at least 70 years old at the time of operation and Kaplan-Meier analysis demonstrated 10 year survivorship of 92.4%. Outcome data at 10 years or longer was available for 28 UKAs in this age group. This demonstrated that a significant improvement (p<0.001) was maintained at 10 year follow up with mean scores of: OKS 32.2 (95% CI: 27.6-36.8), AKSS 160.7 (95% CI: 142.5 – 178.9) and WOMAC 27.2 (95% CI: 22.3-32.0).

Conclusions: This fixed all-polyethylene tibia UKA has demonstrated encouraging survivorship in patients over 70 years old and appears to maintain a functional benefit at 10 year follow up. For the treatment of medial compartment osteoarthritis, it remains a reliable and relatively low-cost option and may be particularly suitable for the older patient.

There is NO Conflict of Interest: No

Disclosure: JH Newman was the design surgeon for this implant.

697 - Predictors of Mid-late Term Revision of Knee Replacement: a Nation-wide Retrospective Cohort Study (UK SAFE)

A. Judge1, C. Garriga-Fuentes2, S. Kingsbury3, L. Smith4, M. Porter5, R. Pinedo-Villaneuva2, N. Arden2, P. Conaghan3

1University of Bristol, Musculoskeletal Research Unit, Bristol, United Kingdom, 2Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), University of Oxford, Oxford, United Kingdom, 3Leeds Institute of Rheumatic and Musculoskeletal Medicine University of Leeds, Leeds, United Kingdom, 4Health & Applied Sciences, University of the West of England, Bristol, United Kingdom, 5Centre for Hip Surgery, Wrightington Hospital, Wrightington, United Kingdom

Objective: Identify patients likely to require mid-late revision of knee replacement (KR) to inform targeted follow-up.

Methods: Setting: Primary care using Clinical Practice Research Datalink (CPRD) data and secondary care using National Joint Registry (NJR) data linked to English Hospital Episode Statistics (HES) and Patient Reported Outcome Measures (PROMs). Patients: Primary elective KRs aged ≥18. Event of interest: Revision surgery ≥5 years after primary. Statistical methods: Cox regression modelling to ascertain influential factors of mid-late term revision. Hazard ratios (HR) and 95% confidence intervals (CI) assessed association of sociodemographic factors, comorbidities, medication, surgical variables and PROMs with mid-late term revision.    

Results: NJR-HES-PROMs data was available from 2008-2011 on 188,509 KR. CPRD-HES data covered 1995-2011 on 17,378 KR. Patients had minimum 5-years post primary surgery to end 2016. Age and gender distribution were similar across datasets; mean age 70 years, 57% female. In NJR there were 8607 (4.6%) revisions, median time-to-revision 1.8 years (range 0-8.8), with 1,055 (0.6%) mid-late term revisions. In CPRD 877 (5.1%) revisions, median time-to-revision 4.2 years (range 0.02-18.3), with 352 (2.0%) mid-late term revisions. Older age was related to significantly lower revision after 5 years (HR: 0.95; 95% CI: 0.95-0.96); male gender increased risk of revision (1.32; 1.04-1.67). Obesity (0.78; 0.64- 0.96), living in deprived areas (0.76; 0.62-0.93), and non-white ethnicity (0.63; 0.47-0.84) were associated with reduced mid-late revision. No implant factors were identified. Patients with less pain and functional limitation at primary surgery (0.29; 0.23-0.36), or moderate anxiety/depression (0.80; 0.70-0.92) had reduced risk for mid-late term revision. Risk was increased when anticonvulsants (gabapentin, pregabalin) (1.58; 1.01-2.47) and opioids (1.36; 1.08-1.71) were required prior to primary surgery.

Conclusion: There appears to be evidence of sociodemographic inequality in mid-late revision KR. Patient case-mix factors for increased risk of revision surgery indicate those requiring closer monitoring for extended follow-up.

There is NO Conflict of Interest: Yes

699 - Does high BMI predict outcomes of patients with ACL reconstruction?

M. Elnaggar1, O. Riaz1, B. Patel1, A. Siddiqui1

1Calderdale and Huddersfield Foundation Trust, Huddersfield, United Kingdom

Objectives: Identifying risk factors for inferior outcomes after anterior cruciate ligament reconstruction (ACLR) is important for prognosis and patient information. This study aimed to ascertain if BMI, pre-operative scores, demographic data and concomitant injuries in patients undergoing ACLR affected patient-reported functional outcomes.

Methods: A prospective review collected data from a single surgeon series of 278 patients who underwent arthroscopic ACLR. BMI, age, gender, graft choice, pre-op Lysholm score, meniscal and chondral injuries were recorded. The Lysholm score, hop test and KT1000 were used to measure post-op functional outcome at one year. Multiple regression analysis was used to determine factors that predicted Lysholm scores at one year.  

Results: The mean age was 29 years, with 58 female and 220 male patients. The mean pre-op Lysholm score was 53.8. 179 patients had meniscal injuries, of which 81 were medial, 60 lateral, and 38 bilateral. 18 patients also had chondral injury and 106 patients had no other associated injury. 
Age, gender, graft type and presence of meniscal or chondral injuries did not affect one-year post-operative Lysholm scores. A BMI greater than 30, physio compliance and preoperative Lysholm scores helped predict one-year post-operative Lysholm scores (p=0.02). Pearson’s correlation found a direct link between BMI and post-operative Lysholm (p=0.03).

Conclusions: BMI, physio compliance and pre-operative Lysholm scores are the most significant determinants of short-term functional outcome after ACLR. However, the effects of associated injuries may be apparent in the long-term as degenerative changes set in or the continued detriment resulting from the concomitant injury affect outcome.

There is NO Conflict of Interest: Yes


S. Arya1, M. Nagy1, S. Yatham1, C.Y. Ng1

1Wrightington Hospital, Trauma and Orthopaedics, Wigan, United Kingdom

Objective: We report the aetiology and outcome of common peroneal nerve (CPN) palsy. 
Methods: This was a retrospective study of patients who had undergone exploration of CPNs.
Demographics, clinical, electrophysiological, radiological and surgical findings were reviewed. The main outcome measures were Medical Research Council (MRC) grading of ankle power, and dorsal sensation (0-10) of the foot. MRC4-5 was considered a good outcome. 
Results: Between 2014-2020, 44 patients (45 knees) underwent CPN exploration. There were 31 males and 13 females, with a mean age of 45 years (range 19-87). 31 patients presented with complete foot drop, 7 had partial palsy, 7 had sensory only symptoms. Aetiologies included trauma (n=13), iatrogenic (n=5), primary entrapment (n=8), secondary entrapment (n=14), intraneural ganglion (n=4) and schwannoma (n=1). The traumatic group consisted of knee dislocation (n=6), tibial plateau (n=1), fibular avulsion (n=2), laceration (n=2), direct contusion (n=1) and twisting injury (n=1). 
For the traumatic and iatrogenic groups, the mean time from the index incident to surgery was 167 days. Procedures performed included neurolysis (n=35), nerve transfer (n=4), allograft (n=2), direct repair (n=1), schwannoma excision (n=1) and sural nerve graft (n=2). 
Mean follow-up duration was 12.2 months (range=1 to 18). At final review, 16 patients (42%) had recovered MRC4-5 of ankle dorsiflexion. Dorsal foot sensation improved from a mean of 4.6 to 7.5. Six patients required tibialis posterior tendon transfer. Postoperative complications included a superficial wound infection and a seroma. 
Conclusions: There is a spectrum of pathologies causing CPN palsy. Neurolysis can help improve function, even in delayed cases. The results of nerve transfer and grafting remain mixed. Tendon transfer is a salvage option.

There is NO Conflict of Interest: No

1194 - Brace before you replace? Our clinical experience of 540 consecutive knees

L. Oliver-Welsh1, N. Patel1, M. A. Imam1, D. Elliott1, P. Trikha1

1Ashford and St Peters Hospital, Trauma and Orthopaedics, Surrey, United Kingdom
Objectives: To investigate the clinical and cost effectiveness of an unloader brace for managing unicompartmental knee osteoarthritis.

Design: A retrospective cohort study of 540 consecutive patients managed with an unloader brace over 5 years at our unit.

Setting: District general hospital in Surrey, UK.

Participants: Of 540 patients, we excluded 31 patients, based on our eligibility criteria. 
We have included 509 consecutive participants (212 females and 297 males), aged 32 to 91 (mean of 59) years old, who were managed with an unloader brace for unicompartmental arthritis. 

Intervention: Each patient was prescribed an unloader brace, and followed up for a minimum of one year. Main outcome measures: Failure of the brace was the end point; this was defined by listing those patients for surgery.

Results: 447 (87.82%) participants had medial compartment knee OA, and 62 (12.18%) had lateral compartment OA. 409 (80.4%) patients managed with an unloader brace did not require surgery for their knee OA; the mean follow-up was 3 years with a minimum follow-up of 1 year. 100 participants went on to have knee surgery; 96 had a total knee replacement (TKR), and 4 underwent a high tibial osteotomy. Those with lateral OA wore their brace for a mean of 8.3 months prior to surgery, whilst those with medial OA wore the brace for 7.1 months prior to surgery. In our unit, we performed 141 fewer TKR’s than expected, in 2019, with an annual saving of £864,820.

There is NO Conflict of Interest: Yes

1195 - Effect of robotics on clinical outcomes in patients following TKA: 850 consecutive patient cohort

K. Marchand1, L. Scholl2, K. Taylor1, D. Erwin1, M. Bhowmik-Stoker2, E. Hampp2, R. Marchand1

1Ortho Rhode Island, Wakefield, United States, 2Stryker, Mahwah, United States

Introduction: Optimizing surgical technique in conventional total knee arthroplasty (CTKA) takes years to master. Learning curve with the adoption of new surgical technologies, such as robotic assistance, is often reported by case time efficiency. The purpose of this study was to assess the patient focused effects of new technology adoption in a large case controlled, cohort study.  We specifically investigated adverse events (AEs) and patient reported outcomes (PROs) in the first 6 months of a single surgeons’ robotic adoption.

Methods: Total knee arthroplasty was performed by a single surgeon on 850 patients. This study considered the last 150 CTKAs prior to adopting (Robotic Assisted Total Knee Arthroplasty) RATKA and first 700 RATKAs after transitioning. All patients received the same implant design, and demographics were similar between groups. AEs and PROs were collected through 6-months postoperatively. PRO was collected through the reduced-WOMAC survey (r-WOMAC). Statistical analysis was performed using a one-way ANOVA (alpha = 0.05).
Results: Patients in the RATKA cohort had significantly improved mean 6-month postoperative r-WOMAC physical function (4±5 vs. 5±4 points, p=0.010), and total scores (7±8 vs. 8±7 points, p=0.023) compared to the CTKA group. Although not statistically significant, RATKA had less r-WOMAC pain (3±3 vs. 3±3 points, p=0.101). At 6-months, there were no reported aseptic failures for the RAKTA and CTKA groups and equivalent rate of manipulations under anesthesia (MUA).
Discussion: This study demonstrated improved clinical outcomes, no revisions, and equivalent rate of MUA during the adoption phase of a new operative technology. PROs and AEs reported in this study corroborate literature from other centers on clinical performance on RATKA. Longitudinal follow-up is needed to support the initial impressions from this analysis.

There is NO Conflict of Interest: No

Disclosure: Laura Scholl, Emily Hampp, and Manoshi Bhowmik-Stoker are paid employees of Stryker. Dr. Robert Marchand is a paid consultant of Stryker. 

1273 - Analysis of the relationship between surgeon procedure volume and the risks of revision and deep infection after total knee arthroplasty using a propensity matched cohort study

T. Okoro1, S. Tomescu2, J.M. Paterson3, B. Ravi2

1Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust, Arthroplasty, Oswestry, United Kingdom, 2Sunnybrook Holland Orthopaedic and Arthritic Center, Toronto, Canada, 3Institute for Clinical Evaluative Sciences (ICES), Toronto, Canada

Background: To identify a threshold in annual surgeon volume associated with increased risk of revision (for any cause) and deep infection requiring surgery following primary elective total knee arthroplasty (TKA), and to quantify this risk, if any.

Methods: A propensity score matched cohort study was undertaken in Ontario, Canada. The participants were 169,713 persons who received their first primary TKA between 2002-2016, and were followed for three years post-operatively. The outcome measures assessed were revision arthroplasty (for any cause), and the occurrence of deep surgical infection requiring surgery at three years follow-up.

Results: Based on restricted cubic spline analysis, the threshold for increased probability of revision (for any cause) and deep infection requiring surgery was <70 cases per year. After matching of 51,658 TKA recipients from surgeons performing <70 cases/year to TKA recipients from surgeons with greater than 70 cases/year, patients in the former group had a higher rate of revision (for any cause) within three years (2.23% (95% CI 1.39 - 3.07) versus 1.70% (95% CI 0.85 – 2.55) ; HR 1.33, 95% CI 1.21-1.47, p<0.0001) and deep infection requiring surgery within three years (1.29% (95% CI 0.44 - 2.14) versus 1.09% (95% CI 0.24 – 1.94) ; HR 1.33, 95% CI 1.17-1.51, p<0.0001).

Conclusions: In a cohort of primary TKA recipients, we found that cases performed by surgeons who had performed fewer than 70 TKA procedures in the year prior to the index TKA were at 31% increased relative risk of revision (for any cause), and 18% increased relative risk for deep surgical infection requiring surgery, at 3 years follow up.

Implications: Three years following primary TKA, the risks for revision (for any cause) or infection requiring surgery is higher in patients whose surgeons have carried out less than 70 procedures in the preceding year.

There is NO Conflict of Interest: No

Disclosure: This study was supported by a grant from the Canadian Institutes of Health Research and by the Institute for Clinical Evaluative Sciences, a non-profit research institute funded by the Ontario Ministry of Health and Long-Term Care.


V. Kandhari1, D. Angadi1, D. Myat1, B. Fritsch1, D. Parker1, M. Coolican1

1Sydney Orthopaedic Research Institute, Orthopaedic Knee surgery, Chatswood, Australia

Objectives: To determine the outcomes and survivorship of navigated lateral opening wedge distal femoral osteotomy (DFO) for valgus knees with lateral compartment arthrosis.

Methods: Navigated lateral opening wedge DFOs operated between 2006 and 2012 were included. Patients were contacted to get information on patient reported outcomes and complications. Data on conversion to arthroplasty was verified with the Australian National Joint Replacement Registry. Prospectively collected data including demographics, limb alignment, and cartilage and meniscal status were analyzed to evaluate their influence on outcomes and survivorship.

Results: Nineteen DFOs in 17 patients (11 males) with mean age 46.6 years were included. The mean pre-operative mechanical alignment 7.1° valgus was corrected to 2.1° varus and mean preop flexion contracture 6.8° was corrected to 1°. Survivorship at mean of 9.1 years follow-up was 78.9%; 4 DFOs were converted to TKA at mean follow-up of 5.5 years. Additional procedures (except conversion to
TKA) occurred in 10 knees (52.6%) including arthrolysis, hardware removal, bone grafting and revision fixation. Patients with ICRS grade 2 or more cartilage wear in medial compartment and higher pre-op valgus had significantly higher likelihood of conversion to TKA (PCC – 0.72). At long-term follow-up the mean IKDC score was 55.35 and KOOS scores were symptoms-57.93, pain-72.71, daily living-83.5, sports related-60.36 and quality of life-43.93.

Conclusions: The long-term survivorship of navigated lateral opening wedge DFOs is 78.9%. Patients with early stages of cartilage wear in the medial compartment and more higher pre-op valgus have significantly higher chance of conversion to TKA.

There is NO Conflict of Interest: No

Disclosure: *Vikram Kandhari, Darshan Angadi, Darli Myat - None.
Brett Fritsch, David Parker, Myles Coolican - Consulting work for 360 Knee Systems, Global Orthopaedics, Omni, Smith and Nephew; Institutional support Zimmer, Smith and Nephew, Global Orthopaedics, Corin, Arthrex; Paid presentations Smith and Nephew, J&J DePuy, Medacta.

1476 - "Can we ignore the patello-femoral joint?" Severe medial patello-femoral osteoarthritis does not diminish the excellent outcomes of isolated fixed-bearing partial knee arthroplasty

N. London1, A. Mannan2, C. Bennett3, K. Mason2, E. London4, T. Idrees5, W. Manning2, J. Ansari2, D. Duffy2

1Harrogate District Hospital, Department of Trauma & Orthopaedics, Harrogate, United Kingdom, 2Harrogate, Department of Trauma & Orthopaedics, Harrogate, United Kingdom, 3Harrogate, Harrogate District Hospital, Harrogate, United Kingdom, 4West Middlesex Hospital, Middlesex, United Kingdom, 5Harrogate District Hospital, Harrogate, United Kingdom

Introduction: Patello-femoral osteoarthritis (PFJOA) is still viewed by many surgeons as a contraindication to isolated medial partial knee arthroplasty (PKA), despite published outcomes from mobile-bearing advocates. This study, supported by The European Knee Society, prospectively examined clinical outcomes from a large series of fixed-bearing medial PKA.
Methods: We prospectively studied 240 consecutive, fixed-bearing PKA cases. Broad selection criteria included patients with PFJOA providing it was not significantly symptomatic. Patients diagnosed with extensive lateral PFJOA were excluded. Pre and post-operative (1 and 2-year) data documenting OKS, KOOS PS, UCLA and FJS-12 was collected. Intra-operative examination was made of each compartment with regards to severity and location of arthritic disease.  
Results: From February 2017, 240 fixed-bearing PKA were performed in 229 consecutive patients. Mean age at time of surgery was 68yrs (range 41-89), mean BMI 29.1 (range 20 – 47). Mean OKS increased from 24.9 (pre-op) to 43.7 and 44.4 at one and two years respectively. Mean KOOS PS, UCLA (1-10) and FJS-12 all showed improvement to 83.1, 6.6 and 76.6 (one year) and 84.9, 6.5 and 79.8 (two years post-op). Grade III and IV osteoarthritis of the medial, central and lateral PFJOA was observed in 99, 86 and 28 cases respectively. No significant difference was demonstrated in 1 or 2-year post-operative outcomes with comparison of cases demonstrating nil PFJOA vs those with grade III / IV PFJOA involving medial, central or lateral facets. 95.9% patients declared they were satisfied (one-year) and only one patient has required a revision procedure (tibial loosening).

Discussion and Conclusion: Excellent functional outcomes are confirmed with fixed-bearing PKA for the treatment of severe medial compartmental arthritis. Our study supports the use of isolated fixed-bearing PKA in patients with co-existing PFJOA and such patients should be included in the selection criteria although severe lateral PFJOA remains a relative contraindication.

There is NO Conflict of Interest: No

Disclosure: Nick London / David Duffy: Zimmer Biomet

1613 - Patients have a wider stance following valgus high tibial osteotomy

A. Kinghorn1,2, J. Bowd1, G. Whatling1, C. Wilson2, D. Mason1, C. Holt1

1Cardiff University, The Biomechanics and Bioengineering Research Centre Versus Arthritis, Cardiff, United Kingdom, 2Cardiff and Vale University Health Board, Department of Trauma and Orthopaedics, Cardiff, United Kingdom

Objectives: Valgus high tibial osteotomy (HTO) represents an effective treatment for patients with medial compartment osteoarthritis (OA) in a varus knee. However, the mechanisms which cause this clinical improvement are unclear. Previous studies suggest a wider stance gait can reduce medial compartment loading via reduction in the external knee adduction moment (KAM); a measure implicated in progression of medial compartment OA. This study aimed to measure whether valgus HTO is associated with a postoperative increase in static stance width. 
Methods: 32 patients, recruited in the Biomechanics and Bioengineering Centre Versus Arthritis HTO study, underwent valgus (medial opening wedge) HTO. Weightbearing pre- and post- operative radiographs were taken showing both lower limbs. The horizontal distance, measured from a fixed point on the right talus to the corresponding point on the left, was divided by the talus width to give a standardised “stance width” for each radiograph. The difference between pre- and post- operative stance width was compared for each patient using a paired sample t-test. 
Results: Preoperatively, mean stance was 4.00 talar-widths but postoperatively this increased to 5.41. This mean increase of 1.42 talar-widths was statistically significant (p=0.001) and represents a mean proportional increase in stance width of 35.5% following HTO. Of the 32 patients, 23 showed increased stance width and 9 decreased (range -4.64 to 6.00 talar-widths). 
Conclusions: These findings indicate an association of frontal plane surgical realignment at the proximal tibia via a medial opening wedge HTO with an increased stance width on postoperative radiographs. Considering both wider stance gait and HTO have been shown to affect the progression of medial compartment OA, these results may explain one mechanism contributing to the efficacy of HTO surgery. However, the range of changes in stance width suggests significant variability in how patients adapt at a whole-limb and whole-body level following HTO.

There is NO Conflict of Interest: Yes

1724 - The impact of ethnicity on knee joint laxity in the osteoarthritic population

C. Thomson1, J. Setsoafia1, S. Deshpande1

1New Cross Hospital, Trauma and Orthopaedics, Wolverhampton, United Kingdom

Introduction: Current understanding suggests that soft tissue balancing has a crucial role to play in the outcome of total knee arthroplasty (TKA), but appropriate balancing is often based on subjective assessment and experience. There appears to be considerable variation between individuals, genders, and ethnic groups when it comes to “normal” varus/valgus knee laxity. However, much of the existing data relates to healthy young volunteers, and it is not clear how this information should map against the elderly osteoarthritic population who require TKA. Computer navigated TKA procedures routinely generate precise data about varus/valgus laxity as an immediate prelude to the arthroplasty procedure. We wished to use a database of such measurements to understand “normal” pre-operative varus/valgus laxity, and how this was influenced by both gender and ethnicity.

Method: The Precision Navigation System (Stryker, Kalamazoo, Michigan, USA) is used by a single surgeon at our institution to perform all TKA procedures. Dynamic varus/valgus laxity measurements (typically between 0-50degrees of extension/flexion) are recorded using infrared sensors attached to pins in both femur and tibia at the start of the procedure. We retrospectively analysed data collected between 2015-2019, comparing maximum varus/valgus laxity between genders and ethnic groups. The demographic data was cross checked with the clinical record.

Results: We obtained complete data for 146 TKA procedures, including 87 ethnic south asian patients and 59 caucasian patients. M:F split was 1:1.47. The median maximum varus/valgus laxity was 13.06 degrees in the asian knees and 10.14 degrees in the caucasian knees (Mann-Whitney U= 4007.5, p<0.001, two tailed). The median maximum varus/valgus laxity was 12.00 degrees in the female and 11.96 degrees in the male knees (Mann-Whitney U= 2625.5, p<0.816, two tailed).

Conclusion: Ethnicity has a significant impact on pre-operative varus/valgus laxity and should be considered when making subjective judgements about appropriate soft tissue balancing in TKA.

There is NO Conflict of Interest: Yes

1789 - Multi-ligament knee injury: Staged management with Posterior Cruciate Ligament (PCL) bracing is a viable treatment option

C. Goodland1, M. Arneill1, L. O'Connor1, P. Archbold1, R. Napier1, C. Stevenson1

1Royal Victoria Hospital, Trauma and Orthopaedics, Belfast, United Kingdom

Background: The ideal management of PCL injuries in Multi-ligament Knee injury (MLKI) remains uncertain and controversial. The Royal Victoria Hospital, Belfast, is the tertiary referral center for multi-ligament knee trauma in Northern Ireland. The aim of this study was to review the management and clinical outcome of PCL injuries.

Methods: Patients were identified from the Trauma Research Database from 2011-2019. Data were obtained from patient’s clinical notes, telephone consultations and clinical review.

Results: In total 84 patients (87 knees) had a MLKI, 61 of which involved the PCL. 5 patients were excluded from analysis (one had less than 12-month follow-up, one primary amputation and three patients had grade 1 injuries managed conservatively). Of the remaining 56 PCL grade 2-3 injuries: 40 were treated conservatively in a dynamic PCL brace for 3 months. The remaining 16 patients underwent surgical management consisting of; early fixation of PCL tibial avulsion fracture (3), definitive management in an external-fixator (5), and early total reconstruction (8). At 12-month minimum follow-up, only 3 patients treated conservatively had symptomatic instability requiring delayed PCL reconstruction (7.5%). There were no complications in the bracing group.

Conclusion: The management of multi-ligament knee injury should be individualized to the patient and injury pattern. Our data highlights that the use of dynamic PCL bracing is not only safe and effective but also reduces the requirement and unnecessary risk associated with PCL reconstruction.

There is NO Conflict of Interest: Yes


D. Cooper1, P. McQuail1, E.P. Murphy1, F.J. Shannon1,2

1University Hospital Galway, Dept. of Orthopaedics, Galway, Ireland, 2Bon Secours Hospital, Dept. of Orthopaedics, Galway, Ireland

Introduction: The anterior cruciate ligament (ACL) is one of the most commonly injured ligaments of the knee. Patients who undergo ACL reconstruction (ACLR) often express concern with regards to the likelihood of graft rupture. Rates of graft rupture vary throughout the literature, (1.4%-25%). This wide range suggests a multifactorial cause for graft rupture.
Our primary objective was to determine the rate of graft rupture in a younger patient cohort (<20 years old) who have had ACLR performed by a single surgeon. Secondary objectives included ascertaining patient and surgical characteristics associated with re-rupture, and establishing correlations between risk factors for rupture and return to play (RTP).

Methods: All cases of primary ACLR for patients under 20 performed by a single surgeon between 2010 and 2018 inclusive with a minimum of 12 months follow-up were included. We retrospectively collected data on RTP rates, patient factors and surgical factors. A telephone survey was used to further these data sets.

Results: 104 patients met our inclusion criteria. The graft rupture rate was 8.65%. 83.81% of patients had a successful RTP following ACLR. Of the 16.19% who did not return to play, 52.9% had a hamstring graft while 47% had a BPTB reconstruction. 14% reported a drop in their level of sport/activity while 83% returned to their pre-injury levels or better. 41.9% of patients reported a repeat injury to their ipsilateral knee on follow-up. 79.5% of these (33% of total), required/sought medical attention, with 45% of the re-injured cohort undergoing some form of surgical management. 16% of patients throughout the entire cohort suffered a contralateral ACL injury following their ALCR.

Conclusions: This retrospective study provides us with an overview of the rates of graft rupture, contralateral injury, RTP rates, the level of RTP, and patient satisfaction across a range of varying patient and surgical factors.

There is NO Conflict of Interest: Yes

Trauma and Limb Reconstruction

Virtual Podium Presentations

36 - Open reduction and internal fixation versus non-operative treatment for closed, displaced, intra-articular fractures of the calcaneus: Long term follow up from the UK Heel Fracture randomised controlled trial

E Dickenson1,2, N Parsons1, D Griffin1,2

1University of Warwick, Coventry, United Kingdom, 2University Hospitals Coventry and Warwickshire, Coventry, United Kingdom

The UK Heel Fracutre Trial (HeFT) was randomised controlled trial conducted to compare the clinical effectiveness of open reduction and internal fixation (ORIF) with non-operative treatment. We report the long-term outcomes of UK HeFT.
UK HeFT was a pragmatic, multi-centre, two arm, assessor-blinded, RCT in patients with displaced intra-articular fractures of the calcaneus. Participants were randomly allocated to ORIF or non-operative treatment. Randomisation was by a computer generated algorithm in a 1:1.
The primary outcome measure was the Kerr Atkins score at 24 months. We report Kerr Atkins scores, self-reported difficulty walking, fitting shoes and additional surgical procedures at 36, 48 and 60 months.
UK HeFT recruited 151 participants. 60 month outcome data was available for 118 participants (78%; 52 ORIF, 66 non operative). After 60months mean Kerr Atkins scores were 79.2 for ORIF and 86.4 for non-operative. Mixed effects regression analysis with baseline score, age, sex, smoking status, employment status, Sanders classification and compensation status as covariates (fixed effects) and recruiting centre as a random effect, gave an estimated effect size of -0.14 points (95% CI -8.87 to 8.59; p-value = 0.975) in favour of ORIF. There were no between group differences in difficulty walking (p=0.175) or on the type of shoes worn (p=0.432) at 60 months. Additional surgical procedures were conducted on 10 participants allocated ORIF, compared to 4 in the non-operative group (p=0.043).
ORIF of displaced intra articular calcaneal fractures showed no difference in outcomes at 60 months compared to non operative care, but with an increased risk of additional surgery.

There is NO Conflict of Interest: No

69 - Retaining adjunctive plate fixation does not increase complications following "plate assisted nailing" of open IIIB tibia fractures

M Stoddart1, K Al-Hourani1, T Fowler1, U Khan1, M Kelly1

1Southmead Hospital, Bristol, United Kingdom

Introduction: Open tibial fractures can present both bony and soft tissue challenges. A two stage orthoplastic approach, using a small fragment plate as temporary internal fixation, encourages adequate exposure of the zone of injury at first debridement. If replaced with a fresh implant at the second stage, the plate can also be used for “Plate assisting nailing” and retained as part of the definitive fixation. We aimed to determine if this retained adjunct plate fixation (RAP) was associated with an increase in infection and non-union rates.

Patients and Methods: One hundred and thirty-seven consecutive patients with a Gustilo–Anderson type IIIB open diaphyseal tibia fracture (OTA/AO 42) treated between May 2014 and January 2018. Ninety-eight patients (RAP 67; non-RAP 31) met the inclusion criteria and underwent 2-stage reconstruction. All had a small fragment plate to hold the reduction before intramedullary nailing, this was then either retained as part of the definitive construct or not. The main outcome measures were reoperation rate, deep infection, nonunion, and flap-related complication. A binary logistic model was utilised for all outcomes.

Results: Six patients (6/98, 6.1%) proceeded to nonunion (RAP 5/67, non-RAP 1/31). This was not significant (P = 0.416). Two hundred twelve operations were undertaken, and the median was 2. Sixteen (16/212, 7.5%) complication-related reoperations were undertaken, affecting 8 patients (8/67, 11.9%) in the RAP group. Eight patients (8/98, 8.2%) developed a deep infection (RAP 6/67, non-RAP 2/31). This was not significant (P = 0.674). The odds ratio of patients treated with RAP developing a complication compared to non-RAP was 1.266 (95% CI, 0.312–5.137).

Conclusions: In the context of an orthoplastic approach, the use of a RAP with definitive intramedullary nailing does not seem to significantly increase the rate of deep infection or nonunion in patients with type IIIB open tibial shaft fractures.

There is NO Conflict of Interest: Yes

124 - Percutaneous Screw Fixation of Pubic Symphysis Diastasis: It’s Safe and Effective

J Eakin1, I Grewal1, E Fene1, A Sathy1, A Starr1

1University of Texas Southwestern Medical Center, Dallas, United States

Background: Percutaneous techniques are commonly used to treat pelvic ring injuries but are not mainstream for fixation of pubic symphysis diastasis in North America or Europe. Potential advantages include less blood loss and lower risk of surgical site infection, especially in the morbidly obese or multiply injured patient.

Methods: A retrospective review was performed to identify all patients who underwent percutaneous fixation of pubic symphysis diastasis by 2 surgeons at an academic level I trauma center over a 3-year period. Symphyseal injuries were fixed with 1 or 2 partially- or fully-threaded 6.5 or 7.3 mm cannulated screws in a transverse or oblique configuration. Associated posterior ring injuries were fixed percutaneously with trans-sacral and/or sacroiliac screws. The primary outcome of interest was loss of reduction, defined as symphyseal diastasis greater than 15 mm on final anterior-posterior pelvis x-ray. Secondary outcomes included blood loss, infection, vascular injury, and sexual or urologic dysfunction related to surgery.

Results: Twenty-nine patients met inclusion criteria. One patient died from a pulmonary embolus 8 days after fixation and 2 were lost prior to first radiographic follow-up, leaving 26 patients (90%) available for analysis. Three patients (12%) lost reduction. Mean final symphyseal displacement was 9.0 mm. Mean radiographic follow-up was 10 months. Mean operative time and blood loss were 126 minutes and 43cc, respectively. One patient (4%) had an infection, which presented after union and resolved after hardware removal. No identifiable vascular or urologic injuries occurred. Two patients (8%) reported sexual dysfunction, which were both suspected results of initial trauma.

Conclusion: Initial study findings support that percutaneous reduction and fixation of pubic symphysis diastasis is a safe and effective method of treatment which warrants further investigation.

There is NO Conflict of Interest: Yes

544 - The Introduction of the Trauma Triage Clinic at a District General Hospital: Safety Issues During the First Year of Implementation

J. Hardie1, N. Madhusudan1, T. Lewis1, A. Kunicki1, I. Macleod1, D. Marsland1

1Royal Hampshire County Hospital, Trauma & Orthopaedics, Winchester, United Kingdom

Background: Previously published work has shown that there are no missed injuries following the introduction of a trauma triage clinic (TTC). The aims of this study were to assess both safety and efficacy of the Trauma Triage Clinic (TTC) model in a district general hospital in the United Kingdom. In particular we aimed to assess the rate of missed ‘high risk’ injuries, including posterior shoulder dislocations, talar injuries, Lisfranc injuries and complex carpal instability. 
Methods: Data were retrospectively collected between November 2017 and October 2018 (inclusive), in the first 12 months following the introduction of TTC. During this time, 3721 patients were reviewed (mean age 38 years, SD 25.5, range 1-103 years). Case notes and radiographs were reviewed for all patients. We assessed compliance with British Orthopaedic Association Standards for Trauma (BOAST 7) guidelines on fracture clinic services, and the standard for adherence to guidelines was 100%. Efficacy was calculated as the percentage of patients discharged from TTC, in comparison with previously published data.
Results: Thirty two out of 3721 patients had a missed injury during the study period, and 66% of these were high risk. The TTC was effective in reducing the number of patients seen in fracture clinic, with 23% of patients discharged directly from the TTC. 89% of patients were reviewed in clinic within 72 hours of presentation, with a median time to review of 2 days. 
Conclusion and Implications: The current study has shown that whilst the TTC is efficient in reducing the burden of patients seen in the fracture clinic, it is not as safe as previously reported. Such information on the screening of high risk injuries is important for other hospitals considering the introduction of a TTC model.

There is NO Conflict of Interest: Yes

546 - Intravenous tranexamic acid given at femoral fragility fracture surgery reduces blood transfusion requirements four-fold

M. Powell-Bowns1, R.K. Olley1, C. McCann1, J. Balfour1, C. Brennan1, J. Peh1, A. Duckworth1, C. Scott1

1Royal Infirmary of Edinburgh, Trauma and Orthopaedics, Edinburgh, United Kingdom

Background: Tranexamic acid (TXA) is an inexpensive antifibrinolytic. Its use in major trauma and arthroplasty is promoted through national guidelines. Currently there are no national guidelines in the UK that promote the use of TXA in femoral fragility fracture (FFF) management.

Aim: The aim of the study was to determine whether intra-operative intravenous TXA affects blood loss and transfusion requirements following the surgical management of FFF. 

Methods: A prospective non-randomized case-control study of consecutive FFF admitted to the study centre over a 4-month period was performed. 361 patients were included in the study (mean age 81.4, mean BMI 23.5, 73.7% were female). TXA was given at the discretion of the operating surgical team, 49% of patients received TXA. Patient demographics, surgical management, blood results, intravenous TXA use, and requirement for blood transfusion were recorded prospectively. Percentage fall in haemoglobin (HB) from preoperative level was calculated at postoperative day one. Calculated-blood-loss (CBL) was determined using the Nadler and Gross formulae. 

Results: The requirement for postoperative blood transfusion was significantly reduced in the TXA group: 15/178 (8.4%) compared to 58/163 (31.7%) (p<0.001, Chi square). TXA significantly reduced both the percentage fall in HB (mean difference 4.3% (-6.3 to -2.3, 95%CI), p<0.001) and the CBL (Mean difference -222ml (-337 to -106, 95%CI), p<0.001). The difference in CBL was greatest in patients treated with intramedullary nail (n=49: mean difference -394ml (-751 to 36 95%CI), p=0.030) and DHS (n=101, mean difference -216ml, (-411 to -21 95%CI), p=0.032). There was no difference in the rate of venous-thrombo-embolism between TXA and control groups. 

Conclusion: Intra-operative intravenous TXA during the surgical management of FFF significantly reduced calculated blood loss, percentage drop in HB and blood transfusion requirements. This data suggests that TXA should be routinely given at the time of femoral fragility fracture surgery.

There is NO Conflict of Interest: No


G. Chan1, K. Hughes2, A. Barakat2, K. Edres3, R. da Assuncao3, P. Page1, E. Dawe1

1St Richard's Hospital, Chichester, United Kingdom, 2Royal Sussex County Hospital, Brighton, United Kingdom, 3Worthing Hospital, Worthing, United Kingdom

Introduction: NICE guidance on the management of intertrochanteric fractures (ITF) is based on AO/OTA classification of fractures.
The previous AO/OTA classification of ITF has been shown to have poor interobserver reliability at both group (e.g. 31-A1) and subgroup classifications (e.g. 31-A2.2). The revised classification was released in 2018 and redefined the 31-A1 fractures as having a competent lateral wall, with 31-A2 fractures having an incompetent lateral wall.
This study assesses the inter- and intra-observer reliability of the 2018 AO/OTA classification.

Methods: A multicentre observational study involving three hospitals. The first 50 patients treated with DHS or CMN for AO/OTA 31-A1, 31-A2 or 31-A3 fractures after 1st-January-2018 at each hospital were identified from NHFD records. Anteroposterior and lateral radiographs were obtained for all 150 patients.
Images were reviewed by six Orthopaedic surgeons; 2 SHOs, 2 Registrars and 2 Consultants, all blinded to the intra- and post-operative imaging. Fractures were classified independently using the 2018 AO/OTA classification and once again after a minimum of 3-months.
Cohen’s kappa (k) was calculated for inter- and intraobserver reliability. First-round classifications were used for calculation of inter-observer correlation

Results: The mean k value for group (31A1, 31A2 or 31A3) interobserver classifications was 0.479 (0.335 – 0.771), interobserver reliability reduced when sub group classifications were assessed with a mean k of 0.376 (0.223-0.613).
Mean intra-observer reliability was similar for both group and sub-group classifications at 0.661 and 0.587 respectively.

Discussion: Our results suggest that the revised AO/OTA classification of ITF remains unreliable despite efforts to further define the 31-A1 and 31-A2 groups and is more unreliable at group level compared to the preceding classification. Using the revised classification to determine stability and therefore guide surgical treatment may be difficult to apply consistently in practice and has the potential to deleteriously affect clinical decisions.

There is NO Conflict of Interest: Yes

878 - Predictors of Humeral Diaphyseal Nonunion

W. Oliver1, H. Searle1, Z.H. Ng1, S. Molyneux1, T. White1, N. Clement1, A. Duckworth1

1Royal Infirmary of Edinburgh, Edinburgh, United Kingdom

Background: The primary aim was to identify patient and injury factors independently associated with humeral diaphyseal fracture nonunion after non-operative management. The secondary aim was to determine the effect of management (operative/non-operative) upon nonunion.

Methods: From 2008-2017 there were 732 consecutive patients (734 humeral shaft fractures) retrospectively identified from a trauma database. Follow-up was available for 662 patients (663 fractures, 90%) that formed the study cohort. Patient and injury characteristics were recorded. There were 523 patients (79%) managed non-operatively and 139 (21%) managed operatively. Outcome (union/nonunion) was determined from medical records and radiographic review.

Results: The median age at injury was 57 (range 16-96) years and 54% (n=359/662) were female. Median follow-up was five (1.2-74) months. Nonunion occurred in 22.7% (n=119/524) of non-operatively managed injuries. Multivariate analysis demonstrated pre-injury NSAIDs (non-steroidal anti-inflammatory drugs; adjusted OR 40.8, 95% CI 2.6-632; p=0.008) being underweight (body mass index [BMI] <18.5kg/m2; adjusted OR 7.3, 95% CI 1.3 to 40.2; p=0.022), overweight (BMI 25-29.9kg/m2; adjusted OR 2.5, 95% CI 1.1 to 5.9; p=0.034) and class II obesity (BMI 35-39.9kg/m2; adjusted OR 4.5, 95% CI 1.4 to 15.5; p=0.014) were independently associated with an increased risk of nonunion. Operative fixation was independently associated with a lower risk of nonunion (2.9%, n=4/139) compared with non-operative management (adjusted OR for non-operative/operative management 11.0, 95% CI 2.8 to 43.6; p=0.001). Based upon these results, five patients would need to undergo primary operative fixation in order to avoid one nonunion.

Conclusions: Pre-injury NSAIDs and abnormal BMI were independently associated with nonunion following non-operative management of a humeral diaphyseal fracture.  Operative fixation was the independent factor most strongly associated with a lower risk of nonunion.  Targeting operative fixation to high risk patients may reduce the rate of nonunion and the morbidity associated with delayed definitive management.

There is NO Conflict of Interest: Yes

1095 - Talar Fracture Outcomes: A Multicentre Retrospective Review

G. Crate1, A. Robertson2, A. Martin3, N. Marlow3, E. Guryel2, A. Trompeter1

1St George's Hospital, London, United Kingdom, 2Royal Sussex County Hospital, Brighton, United Kingdom, 3Oxford University Hospitals NHS Trust, Oxford, United Kingdom

Background: Talar fractures are uncommon injuries that are well recognised as challenging to manage with high complication rates such as post-traumatic arthritis and avascular necrosis; patients often have poor functional outcomes.  Definitive management usually involves surgical fixation with open reduction and internal fixation, however percutaneous fixation can be considered for undisplaced fractures.

Methods: The aim of this study was to retrospectively assess the complication rates for patients with talus fractures across three major trauma centres. This was a tri-centre study involving hospitals in London, Brighton and Oxford. Patients with talar neck and/or body fractures sustained between August 2015-August2019 were identified and their clinical course reviewed from notes and imaging.

Results: 85 patients with talar neck and/or body fractures were included. 75 patients received operative management, 10 non-operative. The overall AVN rate was 5.9% (five patients), overall post-traumatic arthritis rate was 18.8% (16 patients), deep infection rate 1.2% (patient patient), non-union rate 4.7% (four patients). Removal of metalwork rate was 9.4% (eight patients).

Conclusion: Although limited by the follow up period for many patients (who may have received local follow up) the complication rates reported are generally lower than those in the literature. This may be due to the higher frequency of performing open reduction with direct visualisation of the fractures, or by the surgery being performed by specialist consultants. More work will be done looking at comorbidities, complication rate by Hawkins Classification and duration of follow up.

There is NO Conflict of Interest: Yes

1180 - Percutaneous Strain Reduction Screws are an effective, minimally invasive treatment for long bone non-union

M. Bence1, A. Kothari2, R. Handley2, A. Trompeter3

1Epsom and St Helier University Hospitals, London, United Kingdom, 2Oxford University Hospitals, Oxford, United Kingdom, 3St George's University Hospitals, London, United Kingdom

Introduction: Fracture non-union complicates the treatment of around 2% of long bone fractures. Traditional treatment involving revision fixation, bone grafting and biologic treatments can be expensive and invasive. The majority of fractures develop non-union because of a high strain environment which is not conducive to fracture healing. Percutaneous strain reduction screws (PSRS) can be inserted as a day case surgical procedure to supplement primary fixation at a fraction of the cost of traditional treatments. When inserted perpendicular to the plane of a non-union they can resist shear forces and achieve union by modifying the strain environment. We undertook a multicentre retrospective study to confirm the results of the initial published case series.
Methods: We performed retrospective analysis of all PSRS cases for treatment of un-united long bone fractures in two level 1 trauma centres from 2016 to 2020. All patients were followed up until fracture union was achieved or further management was required. Demographic data was collected on patients, as were data about their injuries, initial management and timings of all treatments received. Clinical notes and radiology were reviewed, to determine whether patients had reached clinical and/or radiographic union.
Results: 44 patients were treated with the PSRS technique. Mean follow up was for 7.5 months (range 1 – 40). Fracture union was achieved in 40 patients at a mean time of 6.4 months (range 1 – 26). One patient was lost to follow up, three underwent further surgical procedures to treat fracture non-union and one patient has not yet had face-to-face follow-up due to the ongoing COVID pandemic.
Conclusions: PSRS is a safe, cost-effective treatment for long bone non-union. Results of the initial case series have now been confirmed outside of the parent institution.

There is NO Conflict of Interest: Yes

1225 - Anatomy of the Sural Nerve in the Posterolateral Approach to the Ankle: A Cadaveric Study

Y. Ghani1, A.-A. Najefi2, Y. Al-Jabi3, K. Vemulapalli4

1Buckinghamshire NHS Trust, Stoke Mandeville Hospital, Trauma & Orthopaedic Surgery, Aylesbury, United Kingdom, 2East & North Hertfordshire NHS Trust, Lister Hospital, Trauma & Orthopaedic Surgery, Stevenage, United Kingdom, 3Royal Free Hospital NHS Foundation Trust, Barnet Hospital, Trauma & Orthopaedic Surgery, London, United Kingdom, 4Barking Havering and Redbridge NHS Trust, Queens Hospital, Trauma & Orthopaedic Surgery, Romford, United Kingdom

Background: Sural nerve injury may occur during the posterolateral approach to the ankle. The aim of this study was to map the sural nerve location in a posterolateral ankle approach in cadaveric specimens and allow surgeons to be aware of the anatomy and variations, thereby reducing the risk of sural nerve injuries.

Methods: A posterolateral approach was used in 28 cadaver legs with the incision made half-way between the medial border of the fibula and the lateral border of Achilles tendon, extending proximally from the tip of the lateral malleolus. The sural nerve was identified and the distance from the distal tip of the incision to where it crossed the incision proximally was measured.

Results: Out of the 28 specimens, there were 2 specimens in which the sural nerve did not cross the incision. Therefore, for the distance calculations we analysed the remaining 26 specimens. The mean distance was 3.4 ± 1.2cm. Twenty-two cases (76%) crossed between 2.7cm and 4.5cm. In 16 patients (55%), the distance from the lowest part of the incision to the nerve was 3.1-4cm. There were 3 cases between 0.1-1cm, and 1 between 6.1-7cm. Three cases were between 2.1-3.0cm, and 3 cases were between 4.1-5.0cm. Measurements between all three authors demonstrated excellent intra- and inter-observer reliability (intraclass correlation coefficient 0.80 and 0.78 respectively; Pearson correlation 0.80 and 0.88 respectively (p<0.001).

Conclusion: We have demonstrated that the sural nerve crossed the posterolateral incision between 2.7cm and 4.5cm proximal to the tip of the fibula in 76% of cases. However, there remains individual anatomical variation, and we would recommend that care should be taken to look for the nerve closer to the achilles tendon proximally and nearer the fibula distally. We hope that this information can help surgeons plan their approach and minimise iatrogenic injury to the sural nerve.

There is NO Conflict of Interest: No

1363 - Are routine post-operative radiographs following hip hemiarthroplasty really necessary? Our preliminary experience during the COVID-19 pandemic in a District General Hospital

H. Phillips1, C. Lewis1, S. Ankarath1

1Calderdale and Huddersfield NHS Foundation Trust, Department of Trauma and Orthopaedics, Huddersfield, United Kingdom

Background: Routine practice following hip hemiarthroplasty for neck of femur (NOF) fractures is to obtain post-operative radiographs. However, during the COVID-19 pandemic our department stopped this, to minimise risk, exposure and spread of COVID-19. 
The study aimed to assess patient outcomes who underwent hip hemiarthroplasty 1 year before the COVID-19 pandemic and after this change in practice.

Methods: We audited all patients who underwent hip hemiarthroplasty for NOF fractures in our hospital, between March 1st 2019 and June 30th 2020. Data was collected on grade of surgeons, intra-operative stability and whether check radiographs were performed.

Results: Between March 1st 2019 and 2nd April 2020, 238 patients had post-operative radiographs and 1 patient had intra-operative radiographs. No dislocations or fractures were identified. 32 patients had further radiographs following further trauma, confirming 4 dislocations and 1 peri-prosthetic fracture. Between April 3rd and June 30th 2020, 42 patients underwent hemiarthroplasty, of which 2 patients had post-op radiographs, 1 for intra-operative wiring of a fracture and 1 patient fell immediately post-operatively resulting in dislocation, requiring closed reduction the same day. Senior operating or scrubbed supervising surgeon was Consultant (n=33), Specialist Trainee Registrar (n=6) and Specialty Doctor (n=3). Satisfactory intra–operative stability was documented in 37 patients. 1 patient had a fall and had normal radiographs. 1 patient had radiographs due to clinical suspicion of dislocation, confirming dislocation and the patient underwent a girdlestones procedure.

Conclusions: In the year prior to the COVID pandemic, there were no dislocations or fractures on routine post-operative radiographs. Changing our practice does not appear to have been detrimental to patient safety. Documenting intra-operative stability is imperative. Senior grade of surgeon may be an influencing factor.

Implications: As we consider whether to restart routine post-operative radiographs, would this be for patient safety or for our training and for medicolegal purposes?

There is NO Conflict of Interest: Yes

1395 - Patient outcomes for open fractures managed in a major trauma centre without an on-site plastics service

L. Abdeh1, J. McNamara1, R. Davies1

1Manchester Royal Infirmary, Trauma & Orthopaedics, Manchester, United Kingdom

Background: As per the BOAST guidelines (2017), open fractures should be managed in centres that can provide orthoplastic care. This study aims to evaluate how the absence of an on-site plastics service, at a major trauma centre (MTC) in the UK, can influence patient outcomes for open fracture management.
Methods: A retrospective audit was conducted to assess our department’s compliance with the BOAST Guidelines for open fractures. Data was collected for patients managed at our centre over a 15-month period. Outcomes of patients with open fractures requiring plastic surgery intervention were compared to those who did not require plastics input.
Results: 57 patients were included in this study. All patients were initially managed solely by Trauma & Orthopaedic surgeons.  Following initial surgical debridement, 10 patients required plastics input for wound closure. This was sought via an agreed referral system to another hospital in the same Trust. The results of the study demonstrated that definitive wound closure within 72 hours, as advised by BOAST guidelines, was achieved in more than 75% of cases where plastics involvement was not required, compared to only 10% of cases that required plastics intervention. Definitive fracture management within 72 hours was also achieved in more than 80% of cases not requiring plastics, compared to 40% of cases that required plastics input. In addition, infection was recorded in 42 % of cases where wound closure was delayed beyond 72 hours, compared to less than 3% of cases where the wound was closed in a timely manner.
Conclusion: Absence of an on-site orthoplastics service delays definitive soft tissue and fracture management and correlates with high infection rates. We recommend that all MTCs have an on-site orthoplastic service or rapid access to relevant expertise to improve the management of open fractures.

There is NO Conflict of Interest: Yes

366 - Paediatric Femoral Lengthening Using Precice Intramedullary Nail Versus External Fixator Devices: A Single Surgeon Matched Cohort Study

L Tillotson1, C Maddock1, C Bradley1, S Kelley1

1The Hospital for Sick Children, Orthopaedics, Toronto, Canada

Background: Femoral lengthening in the paediatric population is used in many circumstances, from congenital limb deficiency to post traumatic growth arrest.   Traditionally, external fixation devices have been the predominant methods used to achieve lengthening, but are associated with high complication rates. Recently intra-medullary devices such as the Precice nail have grown in popularity. We compared outcomes of both femoral lengthening methods in children using matched cohorts. 
Methods: All children who had undergone femoral lengthening by the senior author, using a Precice nail or with either TSF or MRS, were reviewed. Data was collected on each patient group including femoral length achieved, consolidation index, length of inpatient stay, post-operative complications, and follow up, and the statistical analysis used to review results.
Results: 27 patients were included. 13 underwent femoral lengthening with Precice nail, 14 with external fixation. Groups were well matched by age, gender and pathology. Significant differences were found in length of stay (Precice mean 2.2 days, TSF/MRS mean 4.1 days, p 0.02). The external fixator group had high rates of complications, including pin site infections (50%) and return to OR (28.6%). There were no post-operative complications in the Precice group. There was no statistically significant difference between the two groups with regard to overall femoral length achieved (Precice group mean 43.16mm, external fixator group mean 42.43mm, p-value 0.98) or consolidation index (Precice mean 24.05days/cm, and TSF/MRS group mean 28.47days/cm, p-value 0.275).
Conclusion: Both the Precice intra-medullary nail system and external fixation devices are adequate methods of achieving femoral lengthening in the paediatric population. The Precice nail however has advantage of significantly reduced length of inpatient stay, unplanned return to the OR and rate of complications — none in our study. We would recommend use of the Precice intra-medullary nail system for femoral lengthening in this patient population.

There is NO Conflict of Interest: Yes

898 - Russian Tensioning Angle and the Impact of an Orthogonal Wire in Ilizarov Frames: A Biomechanical Study

P. Nicholas1, D. Shields2, B. Jamal2

1Univeristy Hospital Ayr, Dept. of Surgery, Ayr, United Kingdom, 2Queen Elizabeth University Hospital, Division of Limb Reconstruction Surgery, Department of Trauma and Orthopaedics, Glasgow, United Kingdom

Background and Aims: During its conception, Ilizarov advocated a fine wire tension of between 900N and 1200N for circular frame construction. Wire tension can be achieved via a tensioning device or ‘Russian tensioning’ (a fixed wire lengthening around a bolt). There is limited information on the latter technique. This study aimed to explore the tensions achieved via Russian tensioning and report the impact of a second wire on construct tension.

Methods: A single 160mm stainless-steel ring was constructed, then 1.8mm stainless steel wires were secured using a Russian fixation bolt and Russian tensioned with a 2nd bolt. The angle subtended by tensioning using the 2nd bolt was measured using a goniometer. Angles of 45°, 70° and 90° were repeated in triplicates, with wire tension measured using a calibrated tensiometer. A 2nd orthogonal wire was placed on the opposite side and tensioned to the same angle. Tensions of both wires were remeasured and recorded. Statistical comparison using unpaired t-tests was used to compare mean tensions. A value of p<0.05 was considered significant.

Results: Russian wire tensioning at all angles was insufficient to achieve the target range of 900-1200N (range 99-110N). The addition of a second orthogonal wire changed frame dynamics such that a 90° angle resulted in both wires achieving adequate tension (mean 1143N, SD 307N). Increases were significant across all tensioning angles (p=<0.002) however only biomechanically relevant for 90°. 

Conclusions: Russian tensioning is insufficient with a single wire, however the addition of an orthogonal wire increases tension in both rings, which reaches the target range at 90° deflection. This phenomenon is explained by force transmission initially into ring deflection, which is then balanced out by the second wire. Further study of this phenomenon using wire tensioners is warranted, and also the impact of non-orthogonal wire constructs.

There is NO Conflict of Interest: Yes

1896 - Circular frames without x-ray – lessons learns regarding deformity correction in Low & Middle Income Countries?

J. Shelton1, H. Oy1, K. Long1, K. Yinna1, P. Thorpe2, B. Narayan2, J. Gollogly1

1The Children's Surgical Centre Phnom Penh, T&O, Phnom Penh, Cambodia, 2Liverpool University Teaching Hospitals, Liverpool, United Kingdom

Background: Circular frames are a successful way of treating difficult fractures and non-unions. At our institution in Cambodia our method differs from developed healthcare systems in that we do not use x-ray to site the frames.

Method: A retrospective case control study was performed using all tibial fractures treated with a ring fixator from The Children’s Surgical Centre in Phnom Penh (70 cases) and a control group of randomly selected cases from The Royal Liverpool Hospital limb reconstruction service. Cases were assessed for diagnosis, frame type (TSF or Ilizerov) pre-op deformity, proximal and distal construct alignment comparative to the tibia, residual deformity and time to union/failure

Results: 70 patients total were identified having had a circular frame and CSC and 70 patients were randomly selected using an online random number generator from RLUTH. Demographics & deformity were similar, pre-op varus 9.4° vs 9.8°, valgus 9.4° vs 9.2°, procurvatum 14.5° vs 12.7° and recurvatum 6.7° vs 10.4°. Proximal ring alignment varus 1.6° vs 2.5°, valgus 1.8° vs 2.1°, procurvatum 3.1° vs 3.8°, recurvatum 1.9° vs 3.5°. Distal ring alignment varus 1.6° vs 3.6°, valgus 2.8° vs 5.9°, procurvatum 2.4° vs 5.9° recurvatum 4.3° vs 4.3°. Residual deformity varys 1.1° vs 2.3°, valgus 2.4° vs 2.1°, procurvatum 2.5° vs 2.6° recurvatum 2.7° vs 1.4°. Union rate 70% vs 82%, time to union 9.8 months vs 8.5 months. Radiation exposure mean 0 vs 74 cGy/cm2 (range 6.4 – 326.7)

Conclusion: This is a startlingly homogenous group considering the difference in settings. We believe that ring fixators are a viable treatment method in austere environments where image intensifiers are not available. We also suggest that for diaphyseal fractures x-ray is not always required however in short metaphyseal segments x-ray is useful to prevent significant frame misalignment.

There is NO Conflict of Interest: No

Accepted Abstracts

88 - Defining the ideal distal ‘exit point’ of a tibial intramedullary nail – a computed tomography analysis of 860 tibiae

M Williamson1, P Bates2, M Kelly3, A Petersik4, A Trompeter1

1St George's University Hospitals NHS Foundation Trust, London, United Kingdom, 2The Royal London Hospital - Barts Health NHS Trust, London, United Kingdom, 3North Bristol NHS Trust, Bristol, United Kingdom, 4Stryker Trauma Gmbh, Kiel, Germany

Background: Fractures of the tibial shaft are routinely managed with intramedullary nailing. The accuracy of the position of the nail in the distal metaphyseal block – the ‘exit point’ – can significantly affect reduction and alignment of distal tibia fractures. The aim of this study is to identify the ideal nail position in the distal tibia - the so called ‘exit point’ for the nail, using computed tomography (CT) analysis.

Methods: 3D models of 860 left tibiae were analysed using the Stryker Orthopaedic Modelling and Analytics software (SOMA, Stryker, Kiel, Germany). The nail axis was defined by seven centre points at the middle of the the inner cortical boundary. The centre point at the isthmus and three centre points above and three centre points below were determined. A best fit line was calculated through the seven points. This best fit line defines the nail axis and thus the exit point in the tibial metaphysis. Where this line fell relative to the centre of the tibial plafond in both the anteroposterior and mediolateral planes were calculated.

Results: The mean mediolateral offset of the tibial exit point was 4.4 ± 0.2mm and 4.4 ± 0.2mm lateral to the centre of the tibial plafond using the absolute and relative technique accordingly. The mean anteroposterior offset of the tibial exit point was 0.6 ± 0.1mm anterior to the centre of the tibial plafond for both relative and absolute techniques. 95% confidence intervals were calculated.

Conclusions: We have presented the largest reported series analysing the ideal nail position using CT scans of 860 tibiae. We have defined the ideal ‘exit point’ of a tibial nail is lateral with respect to the centre of the tibial plafond. This has significant implications for treating distal tibial fractures using intramedullary nailing and preventing mal alignment.

There is NO Conflict of Interest: No

Disclosure: A. Trompeter, M. Kelly and P. Bates have an Education consultancy and / or R+D contract with Stryker. A. Petersik is an employee of Stryker. However, no payment or work is related to this project and there are no other conflicts of interest that could inappropriately influence this work.


A Trompeter1, R Knight2, N Parsons3, M Costa2

1St Georges University Hospital, London, United Kingdom, 2NDORMS, Oxford, United Kingdom, 3Warwick Trials Unit, Warwick, United Kingdom

Aims: To describe a new objective classification for open fractures of the lower limb and to correlate the classification with patient-centred outcomes.

Methods: The proposed classification was investigated within a cohort of adults with open fractures of the lower limb who were recruited as part of two large clinical trials within the UK Major Trauma Network. The classification was correlated with patient-reported Disability Rating Index (DRI) and health-related quality of life (EQ-5D) in the year after injury, and with deep infection at 30 days according to the Center for Disease Control and Prevention definition of a deep surgical site infection.

Results: 748 participants were included in the analysis, 288 (38.5%) had a simple open fracture, and 460 (61.5%) had a complex fracture as defined by the new classification system. At 12 months the mean disability (DRI) in the simple fracture group was 32.5 (SD=26.8) versus 43.9 (SD=26.1) in the complex fracture group (OR 8.19, 95% CI 3.69, 12.69). At 12 months the mean health-related quality of life (EQ-5D utility) in the simple fracture group was 0.59 (SD=0.29) versus 0.56 (SD=0.32) in the complex fracture group (OR -0.03, 95%CI -0.09, 0.02). The differences in the rate of deep infection at 30 days was not statistically significant.

Conclusion: The OTS open fracture classification is based upon objective descriptors of the injury and correlates with patient-centred outcomes in a large cohort of open fractures of the lower limb.

There is NO Conflict of Interest: No

344 - Hip hemiarthroplasty dislocation: a multi-centre risk factor analysis

G Chan1, R Aladwan1, S Hook1, B Rogers2, D Ricketts2, P Stott2

1St Richard's Hospital, Chichester, United Kingdom, 2Royal Sussex County Hospital, Brighton, United Kingdom

Introduction: Dislocated hemiarthroplasties (HAs) are associated with a 45% revision rate and 40% mortality rate. Implant selection for HA operations vary between hospitals and surgeons with no universally accepted implant choice.
We present a large contemporaneous multi-centre consecutive series of NOFs treated with HA, assessing the impact of surgical and patient factors on dislocation.

Methods: Medical and radiographic records for NOFs treated between 01-January-2009 and 30-September-2017 with a HA at three acute hospitals were retrospectively reviewed.
Prosthesis type and subsequent dislocation data were recorded. Demographics, co-morbidities and operation details were extracted from the medical records.

Results: We identified 4305 consecutive patients. The mean age at initial operation was 85-years with a 1:2.6 male to female ratio. There was no difference in patient characteristics between the three hospitals or five implant groups (p>0.05). Four HA implants were used during the study period; Thompson, Austin-Moore, Furlong and Exeter V40 + Unitrax.
63 dislocations were identified (1.5%), median time to dislocation was 24 days. Dislocation rates for Thompson HAs were significantly higher (p=0.004) at 3.7%. There was no difference in median time to dislocation between implant types (p>0.05).
No association was demonstrated with cemented versus uncemented implants, monoblock versus modular prostheses, operating surgeon grade, patient characteristics and dislocation rates (p>0.05).

Discussion: Our study demonstrates that Thompson implants for HA after NOFs have a significantly higher dislocation rate than other common prostheses. This effect has not been demonstrated in previous studies.
We postulate that due the Thompson prosthesis, being a medial calcar bearing implant requiring resection of the femoral neck , fails to adequately restore patients’ native anatomical biomechanics, compared against implants such as the Exeter V40 and Furlong which allow for varying degrees of patient customisability.
Patient, implant construct and surgeon factors had little bearing on the subsequent dislocation rate.

There is NO Conflict of Interest: Yes

437 - Gravity Assisted Reduction of Ankle (GARA) in fracture dislocations – Simple and successful technique in the acute management

R Rangan1, R Mohammed, P Andrew Fenton2, D Bose2

1University Hospitals Birmingham NHS Foundation Trust, Trauma and Orthopaedics, Birmingham, United Kingdom, 2University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom

Background: Reduction of displaced/dislocated ankle fractures need acute timely reduction to address pain and soft tissue compromise. These techniques could be technically challenging, requiring more personnel for sedation, monitoring, traction, counter-traction and plaster application. We describe a technique which utilises gravity to reduce the displacement, following which, plaster applied with less utilisation of personnel or equipment.

Method: From 2017 to 2020, in our Trauma Hospital, 20 patients were treated with the Gravity Assisted Reduction of Ankle (GARA) technique by a single practitioner. This technique was offered to Isolated closed ankle fracture patients with increased medial clear space. Adequate pre-reduction analgesia (Morphine) along with inhalational anaesthetic (Entonox or Penthrox) are provided. Patients were requested to turn to the unaffected side, with the affected side up. Prone position preferred for posterior dislocations. Stable support provided under the lower leg of the affected side with the ankle hanging out for 5 to 10 minutes. Depending on clinical situation, gentle internal rotation +/- manipulation can be applied if necessary.

Results: Age range 18 to 85 yrs. All but one patient were seen in less than 24 hrs of injury. All 20 patients had improvement of ankle position. Medial clear space has improved from a mean of 11 mm to 5 mm. One patient with less optimal improvement was noted, who has presented to us after 4 days of injury. All procedures were done with the need of up to 2 personnel only.

Conclusion: Unstable ankle fractures can be reduced satisfactorily with GARA technique, with less need of personnel

Implications: With the demonstrated simplicity of the procedure and the drugs needed, this technique can potentially be implemented by the ambulance crew while transferring the patient – to have the ankle reduced and then to be splinted.

There is NO Conflict of Interest: Yes

463 - Single Stage “Fix and Flap” Approach for Complex Lower Limbs Gustilo-Anderson IIIB Open Fractures. A Prospective Review of 102 Patients at 2 Years

A Aljawadi1, A Islam1, N Jahangir2, N Niazi2, M Elmajee3, A Reid1, J Wong1, A Pillai2

1Wythenshawe Hospital, Manchester, United Kingdom, 2Wythenshawe Hospital, Trauma and Orthopaedics, Manchester, United Kingdom, 3Royal Orthopaedics Hospital, Birmingham, United Kingdom

Background: Management of open fractures is challenging and requires a multidisciplinary team approach. This study aims to evaluate outcomes of Open Gustilo-Anderson IIIB fractures managed at a single Ortho-Plastic centre following a single-stage “Fix and Flap” approach.
Methods: A prospective data review was conducted for patients presented with Gustilo Anderson Type IIIB Open Fractures to our centre and were managed with single-stage “Fix and Flap” approach. Postoperative outcomes are presented only for the patients who had a minimum of 12 months postoperative follow-up.
Results: 120 patients were included in our study (83 males and 37 females). Mean age was 43 years (10-96).   Tibia diaphysis was the most common site of injury, and open tibial fractures were reported in 60% patients. 55.9% of injuries were caused by Road Traffic Accidents (RTA). 102 patients had a minimum of 12 months follow-up. The mean follow-up time was 25 months. The mean time from injury until definitive surgery was 7.71 days (1-30 days). Primary union achieved in 86.73%, the mean time to union was 32 weeks. Delayed union was reported in 10.20% of patients. Three patients (3.06%) had non-union. Limb salvage rate was 97.05% and deep infection rate was only 0.98%.
Conclusion: Our results showed that low infection rates, high limb salvage rates and high union rates can be achieved in these complex injuries with meticulous technique, a combined Ortho-Plastic (Fix and Flap) approach, and MDT input.

There is NO Conflict of Interest: Yes


E Jones1, G Chan1,2, A Robertson3, E Iliopoulos4, E Guryel4

1Brighton & Sussex Medical School, Brighton, United Kingdom, 2St Richard's Hospital, Chichester, United Kingdom, 3Conquest Hospital, Hastings, United Kingdom, 4Royal Sussex County Hospital, Brighton, United Kingdom

Introduction: Ankle fractures account for 10% of all inpatient trauma hospital bed days and is the most common fracture treated in working age adults. Unstable ankle fractures are, in the majority of patients treated with open reduction internal fixation (ORIF). However, post-operative regimes vary greatly between surgeons, with some preferring early weight-bearing and mobilisation, those preferring non weight-bearing regimes to protect the fracture fixation and those opting for a regime between the two. All options are associated with potential complications including metalwork failure, wound dehiscence, infection and venous thromboembolic events. This study aims to assess for differences in post-operative complications in various weight-bearing regimes.
Method: A retrospective cohort study of 165 consecutive patients undergoing ankle fracture ORIF at two centres between July 2017 and January 2019 was performed. Medical records were reviewed to assess for demographic data, past medical history, injury features and post-operative complications in addition to post-operative weight-bearing. Radiographic images taken at 6 and 12-weeks after ORIF were analysed for evidence of radiographic union. Weight-bearing regimes were classified as non-weight-bearing (n=75), partially weight-bearing (n=26) and full weight-bearing (n=64). 
Results: Patients treated with any post-operative plan that allowed a form of weight-bearing compared against a non-weight-bearing regime, had no significant increase in complication rates (p>0.05). There was no significant difference of fracture union at 6 and 12-weeks after ORIF in any weight-bearing regime (p>0.05).
Conclusions: Post-operative weight-bearing regimes after ankle ORIF are associated with biological and physiological benefits, the results of this study also demonstrate that they are not associated with increased risk of complications compared against non-weight-bearing regimes. We therefore advocate post-operative regimes after ankle fracture ORIF should incorporate a degree of weight-bearing, preferably fully weight-bearing.

There is NO Conflict of Interest: Yes

547 - Familiarity breeds contempt: Incidence and Associations of the Floating Pubic Symphysis

R. Clegg1, H. Taki1, W. Kitchen2, A. Carrothers1, P. Hull1, J. Rawal1, D. Chou1

1Addenbrooke's Hospital, Cambridge University Hospitals NHS Trust, Trauma and Orthopaedics, Cambridge, United Kingdom, 2University of Cambridge, Cambridge, United Kingdom

Introduction: The floating pubic symphysis (FPS) refers to bilateral superior and inferior pubic rami fractures resulting in an unstable anterior pelvic ring. Despite being a familiar concept, this fracture pattern does not feature in either of the commonly used pelvic fracture classification systems and to our knowledge, the incidence and implications of this fracture pattern are not well published in the literature. We aim to describe the incidence and associations of this fracture pattern presenting to a tertiary referral major trauma centre.

Methods: Our tertiary referral unit database of pelvic and acetabular fractures was interrogated to identify patients with a FPS. Medical notes, radiographs and computer tomography scans were reviewed to determine the incidence, demographics, injury mechanisms and associated fracture patterns.

Results: We identified 57 patients over a five year period (incidence of 5%). The median age was 32 (IQR 22-57) with a range of 6-86 years. 29 (51%) patients were male. All sustained a high energy injury, with 40 (70%) of these involving road traffic accidents, specifically 16 (28%) were motorbike accidents. The majority of pelvic fractures in this cohort of patients were classified as Lateral Compression type 1 (N=28, 49%). Only twopatients had no associated injuries, other orthopaedic injuries were present in 48 (84%) and urological injuries in 13 (23%).

Conclusion: The FPS is a significant and under-recognised fracture pattern, occurring in 5% of our pelvic and acetabular fracture patients. It is associated with high energy trauma and a high percentage (96%) of associated polytrauma injuries including a urological injury rate of 23%. We hypothesise that this fracture pattern is biomechanically significant and should be treated aggressively. Further work is ongoing to assess the management and outcomes of these patients.

There is NO Conflict of Interest: Yes

592 - Clinical Frailty Score independently predicts mortality and length of stay in trauma patients

R. Brown1, S. Stanger1, M. Rogers2, M. Peakman2, N. Peter1

1Gloucestershire Royal Hospital, Trauma and Orthopaedics, Gloucester, United Kingdom, 2University of Bristol, Bristol Medical School, Bristol, United Kingdom

Introduction: Frailty is a health state in which body systems gradually lose their in-built reserves, linked to greater hospitalisation, morbidity, and mortality. British Orthopaedic Association Standards for Trauma (BOAST) guidelines currently state that trauma patients with a Clinical Frailty Score (CFS) of 5 or more should receive multidisciplinary care. The 2017 Trauma and Research Network (TARN) report identified that further research was needed to determine the effect of frailty on outcomes in trauma patients. This retrospective cohort study sought to investigate the effect of frailty on mortality and length of stay in hospitalised patients with fragility fractures.

Methods: Notes from all patients aged over 60 admitted to Gloucestershire Royal Hospital in 2019 with any fragility fracture were reviewed retrospectively. A CFS was assigned retrospectively using the Rockwood Clinical Frailty Scale.

Results: 886 patients were reviewed (male:female 266:620, mean age 82.75). There was no significant effect of gender or fracture type (hip vs non-hip fracture) on length of stay or mortality. For every one step up in CFS, age-adjusted odds of death increased by 55% at 30 days (OR 1.545, 95% CI 1.272-1.876, p<0.001) and by 54% at 1 year (OR 1.538, 95% CI 1.348-1.754, p<0.001). 826/886 (93.2%) patients who survived to discharge. For every once step up in CFS, age-adjusted increase in length of stay per was 10.4% (OR 0.104, 95% CI 0.660-0.143).

Conclusion: CFS independently predicts adverse outcome in hospitalised trauma patients. CFS should be used routinely to identify patients at risk of poorer outcomes and may assist in allocation of limited orthogeriatric resources and shaping future BOAST guidelines. Future research should investigate how additional resources affect outcomes for patients at each level of CFS.

There is NO Conflict of Interest: Yes

623 - Results of Primary Arthrodesis Versus Internal Fixation for Complex Plafond Fractures

A. Barakat1, C. Manafa1, E. Guryel1

1Brighton and Sussex University Hospitals, Trauma & Orthopaedics, Brighton, United Kingdom

Background: The aim of this study is to evaluate different risk factors for complications and compare the results of primary arthrodesis to internal fixation for the highly comminuted subset.

Methods: We retrospectively identified pilon fractures treated at our institute (Brighton and Sussex University Hospitals – UK) over a 5-year period (2014-2018). Patient demographics and fracture characteristics were noted. Prevalence of ankle osteoarthritis was assessed at latest follow-up using Kellgren-Lawrence criteria. Logistic regression was employed to assess the correlation between occurrence of complications and various pre-operative factors as well as number of surgical approaches. Matched groups of patients who had primary ankle arthrodesis (n=6) versus internal fixation (n=6) were compared in terms of duration of hospital stay, complication rates, return to work (RTW) and self-reported foot and ankle score (SEFAS) using Chi-square test.

Results: Excluding pathological fractures and skeletally immature patients, 110 patients were identified with mean age 43 years and mean follow-up 29 months. Open injuries constituted 23.6%. Overall complication rate was 31% with post-operative infection being most common (12.8%). Open injury the highest predictor for complications (OR=5.88, P=0.008) followed by increasing fracture severity (OR=3.68, P=0.036) and presence of two or more co-morbidities (OR=2.61, P=0.046) but no correlation found to number of surgical approaches utilised during internal fixation (OR=1.06, P=0.628). Prevalence of ankle osteoarthritis at latest follow-up was 78% with 7.8% conversion rate to secondary arthrodesis. Primary arthrodesis group compared to internal fixation had fewer complications (0% vs 33%), shorter hospital stay (mean 9 days vs 23 days) and quicker RTW (mean 3 months vs 11 months) with significantly better SEFAS scores (mean 46 vs 32, P=0.02). 

Conclusion: Occurrence of complications in Pilon fractures is mainly related to initial soft tissue injury. Due to high incidence of post-traumatic osteoarthritis, primary arthrodesis is a better option than internal fixation for such fractures.

There is NO Conflict of Interest: Yes

658 - An proposed extension to the Bado classification system for paediatric Monteggia equivalent injuries

M. Chamberlain1, A. Afsharpad1

1Guy's and St Thomas' NHS Foundation Trust, Department of Trauma & Orthopaedics, London, United Kingdom

The Monteggia lesion of elbow injuries was first described in 1814, and classified into four types in 1967 by Bado’s now widely-used system.  This has been validated for the paediatric population, and several modifications for paediatric injuries have been proposed.  Given the special considerations of the immature skeleton, a heterogenous group of Monteggia equivalent injuries also exist, which currently do not fit into any classification system.  We report a case series of eight of these injures over three years at two London paediatric trauma units, detailing the operative technique, management and outcomes, and propose a paediatric extension to Bado’s system, specifically for ulnar fractures proximal to the coronoid process, not covered in his original description of type III or IV injuries or more recent systems.

All eight injuries described occurred after a fall from standing or higher onto an outstretched arm, with fractures of the olecranon process of the ulna. These included avulsion fractures of the tip, plastic deformation and displaced bicortical injuries, which we propose fall into a fifth category. Radio-capitellar disruption was in the form of either lateral joint subluxation, or displaced fractures of the radial neck, allowing further subclassification. The subluxation seen in our type Va injuries is often subtle, and care needs to be taken to assess the congruency of the joint at the time of operation, so it is not missed and the cause of poor functional outcomes. Four cases form our sixth category, which is defined by an associated fracture of the lateral humeral condyl. This severe paediatric injury triad has been reported sparsely in the literature, but to our knowledge has never before been formally described.

There is NO Conflict of Interest: Yes

873 - Fixation of intertrochanteric hip fractures with intramedullary and extramedullary devices: is there any difference?

A. Lindh1, C. Lewis2, A. Mahmood1, M. Macrae1, S. Niculescu1, L. Koch1

1Midyorkshire Hospitals Trust, Trauma and Orthopaedics, Wakefield, United Kingdom, 2Calderdale and Huddersfield Foundation Trust, Trauma & Orthopaedics, Huddersfield, United Kingdom

Introduction: Quality Standard 16 statement 4 recommends that extramedullary devices are the treatment of choice for trochanteric fractures, based on equivocal outcomes, the possibility of a lower reoperation rate and lower cost. Our unit has examined the outcomes for patients with intertrochanteric fractures treated with intramedullary and extramedullary devices to assess for differences between groups.

Methods: The National Hip Fracture Database was used to identify 691 patients who had sustained an AO classification 31.A1 or A2 fracture between 2016 – 2019, treated with either a long Gamma nail, a short Gamma nail or a dynamic hip screw. Outcomes compared included age, change in pre- and post-operative haemoglobin, length of stay, operation duration, incidence of transfusion, reoperation within 12 months, Nottingham Hip Fracture Score, 30-day and 120-day mortality. Data were compared using one-way ANOVA and Pearsons X2 tests. Unit costs per device were accessed from the supplier.

Results: No differences were identified between the different device groups for age, length of stay, Nottingham Hip Fracture Score, 30-day and 120-day mortality or reoperation rate. Significant differences were identified between short Gamma vs long Gamma groups for operation duration (00:48:32 vs 00:59:13, p = 0.004) and change in haemoglobin levels (17.8g/dL vs 21.9g/dL, p = 0.02). Incidence of transfusion was greater in the long Gamma group as compared to the short Gamma and DHS groups (58.7% vs 42.3% and 34.2%, p = 0.000). Device costs were: DHS = £110, short Gamma = £310, long Gamma = £480.

Conclusions: We found no difference in the reoperation rate between intra and extramedullary devices. For all outcomes, DHS and short Gamma nails were equivocal. The increased operation duration and transfusion burden for long Gamma nails did not translate into increased length of stay or increased mortality risk, but may increase the cost of opting for this implant.

There is NO Conflict of Interest: Yes

971 - Functional and Radiological outcomes of 3- & 4-part fracture proximal Humerus in elderly (>65 years) treated by MULTILOC nail

A. Adapa1, M.S. Shetty2, M.A. Kumar2, S. Pai2

1Akshath Adapa, Orthopaedics, Oldham, United Kingdom, 2Tejasvini Hospital & SSIOT, Orthopaedics, Mangalore, India

Background: Fractures Proximal humerus account for nearly 10 % of geriatric fractures. The treatment options varies. There is no consensus regarding the optimal treatment, with almost all modalities giving functionally poor outcomes. Hence literature recommends conservative management over surgical options. MULTILOC nail with its straight design seems to be a promising tool in treating these fractures. We hereby report our early experience in the treatment of 37 elderly patients
Objectives: To evaluate the radiological outcome with regards to union, collapse, screw back out/cut through, implant failures, Greater tuberosity migration. To evaluate the functional outcome at the end of 6 months using Constant score. 
Methods: All patients aged >65 years who underwent surgery for 3,4-part fracture proximal humerus using the MULTILOC nail were included in the study after consent. Pre –existing rotator cuff disease were excluded. Within the time frame, a total of 39 patients underwent the said surgery. 2 patients were lost to follow up. All the measurements were taken at the end of 6 months and results tabulated and analysed. 
Results: Union was achieved in all the 37 (100%) patients. There were no varus collapse or screw backout/cut through seen in any of the patients. There was Greater tuberosity migration in 1 patient who underwent revision surgery at 6 weeks. All the patients got a minimum of 70° abduction and forward flexion. We had 29 excellent,6 good,2 fair and none poor results as per Constant scoring system. 
Conclusion: MULTILOC nail is a versatile tool in the armamentarium of trauma surgeons and the early results seem to be favourable in achieving an excellent functional and radiological outcome in treatment of 3,4part fracture proximal humerus in elderly patients. Further long term, multicentric studies with larger cohort is required to label this as gold standard for the treatment of these injuries

There is NO Conflict of Interest: Yes

990 - The impact of the introduction of best practice tariff for femoral fragility fractures – a network perspective

P. Page1, R. Richardson2, M. Karbowiak3, B. Barkham4, J. Craik5, W. Keiffer6, A. Dinneen3, Z. Nawaz1

1Frimley Health Foundation Trust, Camberley, United Kingdom, 2Ashford & St. Peter's Hospitals NHS Foundation Trust, Chertsey, United Kingdom, 3Royal Surrey NHS Foundation Trust, Guildford, United Kingdom, 4Croydon Health Services NHS Trust, Croydon, United Kingdom, 5Epsom & St. Helier University Hospitals NHS Trust, Epsom, United Kingdom, 6Surrey and Sussex Healthcare NHS Trust, Redhill, United Kingdom

Introduction: In the UK, more than 65,000 hip fractures occur annually at an estimated cost in excess of £1 bn. Their treatment has been revolutionised by the introduction of the best practice tariff, an uplift payment for achievement of a number of targets, including surgery within 48 hours. There is increasing recognition that fragility fractures occurring throughout the entire femur confer much the same risk and that in this elderly population, a high proportion of them are periprosthetic in nature. A phased introduction of BPT for all these injuries is therefore being undertaken. In this study we set out to quantify the incidence of these injuries within our regional trauma network and ascertain the resource implications for their treatment.
Methods: We identified all femoral fractures, except hip fractures, occurring over a two year period in patients aged 60 years or over. We recorded dates of admission, surgery and discharge as well as any procedures performed. We also recorded how many surgeons were able to provide arthroplasty and fixation surgery at each centre, the frequency of multidisciplinary meetings and current achievement of hip fracture BPT.
Results: Over 2 years, 454 patients were eligible for inclusion. Mean age was 82 years. A total of 329 patients underwent some form of surgical intervention, waiting 9 days. Achievement of BPT ranged from 59.2% to 88.8%. All centres had more surgeons performing fixation than arthroplasty, and none had sufficient meetings to ensure all patients could be discussed by the MDT prior to surgery within 48 hours.
Our study clearly demonstrates that the introduction of BPT for all femoral fragility fractures will have substantial resource implications and that centres are already struggling to meet the targets for hip fracture. We advocate realistic and innovative planning for a challenging emerging target.

There is NO Conflict of Interest: Yes

991 - A Prospective Study Assessing Weight Loss in the Peri-operative Period for Neck of Femur (NOF) Fracture Patients

S. Naseem1, S. Sambhwani1, F. Rayan1, R. Smith1

1Kettering General Hospital, Trauma and Orthopaedics, Kettering, United Kingdom

Background: Patients admitted with NOF fractures tend to have multiple debilitating geriatric co-morbidities. Hip fracture trauma and subsequent surgery induces a catabolic response. In the peri-operative period patients are therefore at risk of weight loss. This combined with a failure to meet increased nutritional needs can result in longer hospital stays and post-operative complications. The aim of this project was to assess body weight changes in the peri-operative period with a view to starting future oral nutritional supplementation for all NOF fracture patients.

Methods: Prospective data was collected for 50 patients admitted with NOF fractures. Admission weight, MUST (a malnutrition score) and AMTS were noted and compared to their respective post-op values at week 1 and week 2.

Results: Average change of weight was found to be a loss of 5.4kg ( +6.8kg to -16.9kg) with an average loss of 3.4% at Week 1 post op. Average change of MUST score changed from 0 at admission to 1 at the end of week 2 (range 0 to 4). Older Patients had a lower weight on admission (r=-0.275) and were likely to lose more weight at 1 week post-op (r=0.320). A greater increase in MUST score at 2 weeks was associated with longer length of stay (r=0.531).

Conclusion: In this study following trauma and surgery, NOF patients lose weight in the peri-operative period. The biggest effect being visible during the first week post operation. Patients with a higher MUST score at the end of week 2 demonstrated a longer length of stay. There is a need to optimise the nutrition of patients sustaining NOF fractures from the time of admission. We aim to introduce routine oral nutritional supplementation on admission for all NOF fracture patients.

There is NO Conflict of Interest: Yes

993 - 1-year mortality rates are not affected by delay to stabilisation in the elderly pelvic or acetabular fracture

A. Harrison1, A. Ordas2, M. Chimutengwende-Gordon2, M. Fortune1, D. Chou2, P. Hull2, A. Carrothers2, J. Rawal2

1University of Cambridge, School of Clinical Medicine, Cambridge, United Kingdom, 2Cambridge University Hospital NHS Foundation Trust, Department of Trauma & Orthopaedics, Cambridge, United Kingdom

Aims: The aim of this study was to investigate factors affecting the mortality in elderly patients sustaining pelvic or acetabular (PA) fractures.

Patients and Methods: A retrospective review of the Trauma Audit and Research Network (TARN) database was performed to identify elderly patients (aged 65 and over) sustaining PA fractures surgically treated in a UK Major Trauma Centre (MTC) between 2015 and 2019. Chi-squared and Fisher tests were used to compare 1-year mortality rates following operative intervention between patients treated within 72 hours and after 72 hours. Kaplan-Meier curves were used to visualise survival probability; significant predictors of survival were found using Cox proportional hazard models.

Results: 70 patients met the inclusion criteria. The mean age was 76.1 years. The overall 1-year mortality rate was 20% (17% for acetabular and 29% for pelvic fractures). When patients were grouped by time to surgery (fracture fixation within or greater than 72 hours), there was no statistically significant difference in 1-year mortality. Patients whose surgery was delayed more than 72 hours were more likely to have longer hospital stays (p = 0.002) or to have suffered from polytrauma (p = 0.025). Age, Charlson Co-morbidities Index (CCI) and pre-op mobility status were associated with statistically significant differences in overall mortality. The same factors were found to be associated with a significant increased hazard of death in the multivariate Cox proportional hazards model. Patient gender, mechanism of injury, Injury Severity Score (ISS) > 15 and head injury were not significant predictors of mortality.

Conclusion: Surgical intervention within 72 hours of injury did not result in decreased mortality in elderly patients with PA fractures. The 1–year mortality rate between elderly PA fractures and hip fractures was comparable. Consideration should be given to a combined multidisciplinary approach between orthogeriatric and expert PA surgeons for these patients.

There is NO Conflict of Interest: Yes

1070 - 10 years of Interprosthetic Femoral Fractures managed with modern techniques at a Major Trauma Centre

A. Mittal1, W. Poole1, D. Crone1

1Brighton and Sussex University Hospitals NHS Trust, Trauma and Orthopaedics, Brighton, United Kingdom

Background: Interprosthetic femoral fractures (IFF) are rare but increasing with an ageing population. Operative management is challenging and there is currently a paucity of outcome data in the literature. The purpose of this study was to evaluate outcomes of IFFs managed with modern distal femoral locking plates, in a greater sample size than previously published. 
Methods: Retrospective study reviewed 41 closed IFFs in 40 patients at a major trauma centre from 2009 to 2019 occurring between previous total (n=38), or hemi (n=3), hip arthroplasty and total knee arthroplasty. Fractures were classified using OTA/AO and Pires. They were managed with Minimally Invasive Plate Osteosynthesis (MIPO) employing modern biological fixation techniques and stabilised with either VA-LCP Condylar (Synthes; n=23) or Peri-Loc (S&N; n=18) plate. Most were performed by orthopaedic trauma consultants (85%); the others with trauma consultant supervision. Clinical and radiographic outcomes were measured.
Results: The majority were female (78%), elderly (average 78 years), and comorbid (ASA grade 3 or 4 - 53%). Most fractures were type IIA (n=30) by Pires classification and type 33A (1, 2 or 3) according to OTA/AO. The average plate spanning the femur was 16 holes, with an average working length of 6 holes. 83% had unrestricted weight bearing immediately post operatively. 26 fractures reached radiological (n=22) or clinical (n=4) union. 10 died with 2 lost to follow up before union, giving a union rate of 90% (n=26/29). There were 3 non-unions, with all 3 implants failing before 4 months. 
IFFs are occurring with increasing frequency in a frail elderly population. In patients with IFFs, MIPO and biological fixation techniques using modern distal femoral locking plates can achieve a high rate of union when combined with unrestricted weight bearing post operatively.

There is NO Conflict of Interest: Yes

1154 - Pilon fractures treated with acute tibiotalar fusion with antegrade nail – a new approach to a significant injury

A. Robertson1, R. Freeman2, E. Guryel1

1Brighton and Sussex University Hospitals, Trauma and Orthopaedics, Brighton, United Kingdom, 2Maidstone and Tunbridge Wells NHS Trust, Tunbridge Wells, United Kingdom

Background: Pilon fractures are complex, potentially limb changing injuries. The high energy nature, comminuted fracture patterns and associated soft tissue injuries pose significant challenges to the surgeon treating these injuries. As a result, historically the treatment of pilon fractures has been associated with high rates of complications including wound complications, infection, union delays and amputation
Methods: A retrospective outcome review was completed of all pilon fractures treated with acute tibiotalar fusion with antegrade nail in our UK major trauma centre
Results: All pilon fractures treated over a 7 year period were reviewed and a total of 117 identified. 42 patients had Ruedi and Allgower type 3 injuries. Of these 42 patietns, 6 patients treated with acute tibiotalar fusion with antegrade nail were identified. There were 5 males and 1 females with an average age of 41.5 years. 5 patients have achieved have successfully achieved infection free fusion. One patient is partially fused however full fusion cannot be confirmed yet due to the time from surgery. 
Conclusion: Managing these injuries by acute tibiotalar fusion with antegrade nail has its advantages. The entry point for the nail is outside of the zone of injury, patients can fully weight bear post operatively, the incisions within the zone of injury are small and the necessity for second surgery for complications such as post-traumatic ankle arthritis are removed. In a study of 42 patients with type 3 Ruedi and Allgower pilon fractures treated with classical open reduction and internal fixation techniques , 26 patients developed symptomatic post traumatic arthritis. This novel, safe and reproducible technique permits early return to function, has the potential to shorten total treatment time and therefore we believe it is a key option in managing these complex injuries.

There is NO Conflict of Interest: Yes

1204 - Admission bloodwork can aid prediction of inpatient mortality following hip fracture surgery

R. Geleit1, M. Bence1, P. Samouel2, J. Craik1

1Epsom and St Helier University Hospitals, London, United Kingdom, 2Kingston University Business School, London, United Kingdom

Introduction: Hip fracture is a serious injury affecting around 65,000 people per year in the UK. Around 7% of people die within 30 days of surgery necessitating accurate prognostication for the purposes of consent, ceilings of care and managing expectations. There is mounting evidence that common haematological and biochemical blood tests may give prognostic data about post-operative mortality. The Nottingham hip fracture score (NHFS) is a commonly used pre-operative mortality calculator which factors pre-operative haemoglobin into the calculation of expected death rate. We performed a study to investigate the role of other commonly available pre-operative blood tests in prognosticating for peri-operative death.
Methods: We retrospectively analysed the records of 2,158 patients treated for hip fracture in our institution between April 2014 and August 2019. We collected data for analysis on age, type of fracture, pre-injury residence, AMTS, ASA, operation performed, discharge destination and admission blood work. We ascertained which patients died in hospital and performed multivariate logistic regression to ascertain which factors accurately predicted mortality.
Results: Age > 90, male gender and ASA 4/5 were all predictive of increased mortality. Pre-operative lymphopenia and hypoalbuminaemia were statistically highly significant in predicting increased mortality. Significantly, a number of factors found in the NHFS including pre-operative anaemia, pre-morbid institutionalisation and pre-operative AMTS were not predictive of increased death rates.
Discussion: This study adds to the increasing body of evidence that pre-operative blood tests may predict peri-operative hip fracture deaths. Hypoalbuminaemia and lymphopenia are recognised consequences of malnutrition and may signify need for further pre-operative optimisation.

There is NO Conflict of Interest: Yes

1303 - The Impact of Virtual Fracture Clinic and The Use of Weight Bearing Radiographs on SER 2/4 Ankle Fractures of Undetermined Stability

G. Wilson1, F. Cowell1, P. Houghton1, A. Singh1

1Liverpool University Foundation Trust, Liverpool, United Kingdom

Background: Weight bearing radiographs (WBRs) are a reliable method for predicting stability in SER 2/4 ankle fractures, and therefore need for surgical intervention. Our first audit cycle revealed that patients receive an average of 2.9 radiographs across 3.7 clinic visits.

Methods: Following the introduction of a protocol based on obtaining early, single WBRs to guide management, this prospective audit reviewed all new SER 2/4 ankle fractures of undetermined stability presenting to virtual fracture clinic over a two month period.

Results: 18 patients were identified. Mean age was 35 years (16-70).
All patients were streamlined to a subspecialty fracture clinic and assessed for weight bearing ability, and 16 had WBRs, 1 was unable due to pain (CT at week 2 confirmed stability), and 1 was able to but did not have a WBR. Following WBRs, 15/16 (94%) were deemed to have stable injuries, and were given a walking boot. 1 had an unstable injury and was listed for fixation. 11/15 (73%) patients were followed up at 6 weeks post injury, with 4 returning at 1 week for a ‘check X-Ray’. At 6 weeks, 9/15 (64%) were discharged, and 6/15 (40%) were followed up further, with no strong evidence for extended follow up. 0/15 underwent a change of plan based on subsequent radiographs or suffered any early complication of conservative management.
The number of radiographs and clinic visits reduced from 2.9 to 1.9, and 3.7 to 2.4, respectively, saving £186 per patient.

Conclusion: Implementation of a new protocol reduced both the number of radiographs and fracture clinic appointments, and lead to no early complications. 13/18 patients (72%) had management in accordance with the protocol, and improved compliance will result in further savings. Recommendations include further education to increase compliance, and encouragement of a safe 6 week discharge to physiotherapy.

There is NO Conflict of Interest: Yes

1349 - Fractures of the Proximal- and Middle-Thirds of the Humeral Diaphysis Should Be Considered as Fragility Fractures: An Epidemiological Study of 900 Consecutive Injuries

W. Oliver1, H. Searle1, Z.H. Ng1, N. Wickramasinghe1, S. Molyneux1, T. White1, N. Clement1, A. Duckworth1

1Royal Infirmary of Edinburgh, Edinburgh, United Kingdom

Background:  The primary aim was to determine the current incidence and epidemiology of humeral diaphyseal fractures.  The secondary aim was to explore variation in patient and injury factors by fracture location within the humeral diaphysis.
Methods: Over a ten-year period (2008-2017), all adult patients (aged ≥16 years) sustaining an acute fracture of the humeral diaphysis managed at the study centre were retrospectively identified from a trauma database. Patient age, gender, medical/social background, injury mechanism, fracture classification and associated injuries were recorded and analysed.
Results:  Nine hundred fractures (typical 88.9%, n=800/900; pathological 8.3%, n=75/900; periprosthetic n=25/900, 2.8%) were identified in 898 patients (mean age 57 years [range 16-97, 55.5% [n=498/898] female). Overall fracture incidence was 12.6/100,000/year. For patients with a typical fracture (n=798, mean age 56 years [range 16-96], 55.1% [n=440/798] female), there was a bimodal distribution in men and unimodal distribution in older women (Type G). A fall from standing was the most common injury mechanism (72.6%, n=581/800). The majority of fractures involved the middle-third of the diaphysis (47.6%, n=381/800) followed by the proximal- (30.5%, n=244/800) and distal-thirds (n=175/800, 21.9%). Eighteen injuries (2.3%) were open and a radial nerve palsy occurred in 6.7% (n=53/795). Fractures involving the proximal- and middle-thirds were more likely to occur in older (p<0.001), female patients (p<0.001) with comorbidities (p<0.001) after a fall from standing (p<0.001). Proximal-third fractures were also more likely to occur in patients with alcohol excess (p=0.003) and to be classified as AO-OTA type B or C injuries (p<0.001).
Conclusions: This study updates the incidence and epidemiology of humeral diaphyseal fractures. Important differences in patient and injury characteristics were observed based upon fracture location. Injuries involving the proximal- and middle-thirds of the humeral diaphysis should be considered as fragility fractures.

There is NO Conflict of Interest: Yes

1470 - The growing burden of Mental Health on Trauma and Orthopaedic Services at a Major Trauma Centre

C. Jump1, K. Higham-Deakin2, W. Payne3, H. Goldup4, J. Rawal1

1Salford Royal NHS Foundation Trust, Trauma & Orthopaedics, Salford, United Kingdom, 2Salford Royal NHS Foundation Trust, Major Trauma Team, Salford, United Kingdom, 3Salford Royal NHS Foundation Trust, Major trauma team, Salford, United Kingdom, 4Salford Royal NHS Foundation Trust, Mental Health, Salford, United Kingdom

Introduction: One of the leading causes of death and disability in young adults is trauma. Thus far there has not been a quantification of deliberate self-harm associated trauma with an Injury severity score(ISS) above 15.
We sought to assess and quantify the demand over time on the trauma service at a level 1 major trauma centre as a result of deliberate self-harm and attempted suicide(DSH).

Methods: The Trauma Audit Research Network(TARN) database was used to identify adult patients with an ISS >15 who were admitted to this major trauma centre as a result of DSH over a 4 year period(1/1/2015 - 31/12/2018). The incidence was then established per year and associations with demographic parameters, lead speciality providers, return to theatre and number of procedures performed.
The incidence of patients admitted with an ISS>15 as a result of DSH increased by 70% over the study period. Identified risk factors included age <40 years, unemployment, previous self-harm/overdose and pre-existing mental health disorder.
This patient population are presenting with a greater number of injuries (increased 176%), which are more severe (average ISS increased 47%), requiring more surgical procedures (increased 217%) and as a result occupying more time on theatre lists (increased by 258%). The Trauma and Orthopaedic service perform 81% of operations. Despite increased demand, 1-year mortality rate remains at 13%. Average length of stay has increased from 19 days to 26 days due to patients’ complex needs and lack of appropriate discharge destination.

Conclusion: There is a growing demand on this major trauma centre as a result of DSH. On discharge this patient population require a facility that can address their unique needs, which are frequently unavailable. Specialist mental health rehabilitation beds in the community and a change in the organisation of services is required to prevent further impact on major trauma centres.

There is NO Conflict of Interest: Yes

1606 - The Efficacy of Intravenous Tranexamic Acid administration at induction in definitive hip fracture surgery: Is there a role?

S. Kanthasamy1, B. Guhan1, D. Chakravarty2, M.J. Parker1

1Peterborough City Hospital, Hip Fracture Unit, Department of Trauma and Orthopaedics, Peterborough, United Kingdom, 2Fortis Hospitals Kolkata, Department of Trauma and Orthopaedics, Kolkata, India

Tranexamic acid (TXA) is a cheap and powerful drug that has several uses in surgery and is well established in elective orthopaedic surgery. At present, limited small studies have looked into its role in the acute hip fracture. Transfusion in the geriatric population presents risks and increased costs to the National Health Service. Our retrospective study looks at the role of TXA administration at induction for both intracapsular fracture requiring hemiarthroplasty and our preferred method of fixation of extracapsular fracture by intramedullary nail (IM nail). We show a statistically significant reduction in the number of patients requiring transfusion as well as mean haemoglobin (Hb) drop in those undergoing hemiarthroplasty. This was not replicated in those undergoing IM nail fixation. Both groups showed no increase in 1-year mortality or thromboembolic events following TXA administration. These results support the use of TXA for hemiarthroplasty for intracapsular hip fractures.  

There is NO Conflict of Interest: No

Disclosure: Martyn Parker has received expenses and honorarium from a number of commercial companies and organisations for giving lectures on different aspects of hip fracture treatment. In addition,he has received royalties from BBrawn Ltd related to the design and development of an implant used for internal fixation of intracapsular hip fractures.



Virtual Podium Presentations

19 - Long term surgical management of symptomatic osteonecrosis and utility of core decompression of the femoral head in young people with acute lymphoblastic leukaemia recruited into UKALL 2003

A. Fishlock1, N. Amin1, J. Kraft1, C. Holton1, A. White1, B. James1, S. Kinsey2, R. Feltbower

1Leeds General Infirmary, Leeds, United Kingdom, 2Leeds Children’s Hospital, University of Leeds, Leeds, United Kingdom

Aims: It has been recognised that osteonecrosis can cause considerable morbidity in young people being treated for acute lymphoblastic leukaemia (ALL). The purpose of this work was to determine surgical procedures used for osteonecrosis in this population in the UK, timing of procedures and sequential procedures used in different joints. We also aimed to ascertain if core decompression (CD) is warranted as a method of preventing joint collapse.

Patients and methods: UK treatment centres were contacted to obtain details regarding surgical interventions and long term outcomes for patients who were treated for ALL and developed osteonecrosis in UKALL 2003. Radiographic imaging for patients with osteonecrosis affecting the femoral head was requested. Diagnostic imaging was used to score all lesions, with subsequent imaging used to determine final grade. Kaplan-Meier failure time plots were used to compare use of CD with no joint preserving surgical intervention.

Results: Detailed information was received for 85 patients who had developed osteonecrosis during the course of their ALL treatment. A total of 206 joints were affected by osteonecrosis. Of all joints affected by osteonecrosis, 21% required arthroplasty, and 43% of all hips affected went on to be replaced. CD was performed in 30% of hips affected by osteonecrosis. The majority of hips were grade 4 or 5 at initial diagnosis of osteonecrosis. There was no significant difference in time to joint collapse between those joints in which CD was performed, compared with no joint preserving surgical intervention.

Conclusion: There is a high burden of surgery in young people who have received treatment for ALL and have developed osteonecrosis. These results suggest that CD of the femoral head in this patient group does not delay or improve rates of hip survival.

There is NO Conflict of Interest: Yes

24 - The cuneiform osteotomy for patients with slipped capital femoral epiphysis (SCFE): A 14-year experience from a tertiary paediatric referral unit

J Craven1, A Truss1, V Bucknall1, R Walton1, C Bruce1, C Talbot1

1Alder Hey Children's Hospital, Orthopaedics, Liverpool, United Kingdom

Background: To report the outcomes of the cuneiform osteotomy through an anterior approach in the treatment of slipped capital femoral epiphysis from a tertiary paediatric referral unit over a 14 year period.

Methods: A single centre retrospective study was undertaken. All patients presenting with SCFE between 2004 and 2018 treated with cuneiform osteotomy through the anterior approach were included. Patient demographics, type of SCFE and outcomes were recorded.

Results: 37 cuneiform osteotomies [24 left;13 right] were performed in 35 patients [22 females;13 males]. The mean age at surgery was 12.2 years. The mean pre op slip angle was 53 degrees [range 88-25] with a mean correction of 43 degrees [range 18-81], and a residual slip angle of 10 degrees [2-29]. There were 32 unstable and 5 stable SCFE, of which 20 had an ‘acute’,13 ‘acute on chronic’ and 4 ‘chronic’ presentation. The mean number of days from symptom onset to surgery was 39.1 days (1- 180). Minimum follow up was 14 months. The overall rate of avascular necrosis (AVN) was 35.1%, developing in 13 of the 37 hips [11 unstable, 2 stable]. The mean presentation of AVN was 5.3 months following surgery. Other complications included chondrolysis (n=1), implant failure (n=2), hip dislocation (n=1), meralgia paraesthetica (n=2), delayed union (n=1), heterotrophic ossification (n=3), contractures (n=2) and wound infection (n=1). 14 patients required further surgery, 13 as a result of AVN including; removal of metalwork, hip distraction, pelvic support osteotomy, soft tissue releases, epiphysiodesis. 4 patients had a residual leg length discrepancy > 2.0cm.

Conclusion: Our experience of the cuneiform osteotomy highlights the effectiveness in correcting deformity of the slipped capital epiphysis. However, the risk profile including AVN described is significant and must be considered when counselling patients undergoing this procedure.

There is NO Conflict of Interest: Yes

29 - The unstable slipped capital femoral epiphysis: Does timing and type of surgery really matter?

J Craven1, A Truss1, V Bucknall1, R Walton1, C Bruce1, C Talbot1

1Alder Hey Children's Hospital, Orthopaedics, Liverpool, United Kingdom

Background: We undertook this retrospective cohort study to determine the outcomes of surgical management of the unstable slipped capital femoral epiphysis (SCFE)

Methods: All patients diagnosed and treated at Alder Hey Children’s Hospital with a Loder classified unstable SCFE over 20 years were identified. Patient demographics, timing to theatre, surgical procedure, avascular necrosis (AVN) and outcomes were reviewed. Follow up was taken a time to last clinic review or time to discharge.

Results: There were 67 unstable SCFE in 65 patients [37 Left: 30 Right]. Mean age was 13 years [7 to 16]. Thirty-two cuneiform osteotomies, 30 closed reduction and percutaneous pinning (CRPP), 3 ‘Parsch’ reduction and pinning, and 2 surgical hip dislocations with modified Dunn osteotomy were performed. 5 patients (4 CRPP and 1 ‘Parsch’) lost to follow up. The overall AVN rate was 34.3% [n=23]; cuneiform [34%; n=11/32], CRPP [42%; n=11/26], ‘Parsch’ [50%; n=1/2], Modified Dunn [0%; n=0/2]. No difference was found between cuneiform and CRPP (p=0.268). Median follow up 31 months [6-71]. Mean time to AVN following surgery was 5.5 months [6 weeks – 14 months]. The relative risk for AVN rates in CRPP when treated <24 hours and >24 hours was 0.86, p=0.371. The relative risk for AVN rates in cuneiform when treated <7 days and >7 days was 0.95, p=0.472. Further surgery and leg length discrepancy were more frequent in the cuneiform group compared to CRPP group (40% vs. 23% and 31% vs 17% respectively).

Conclusion: Our experience highlights the AVN and complication rates are similar in both cuneiform osteotomy and CRPP groups for the unstable SCFE. Despite previous work, timing may not have a significant effect on AVN rates. An adequately powered multicenter national trial is required to determine the gold standard treatment for the ‘unstable’ SCFE.

There is NO Conflict of Interest: Yes


R. Lanzetti1, V. Pace2, A. Ciompi3, D. Perugia4, M. Spoliti1, F. Falez3, C. Park5, A. Caraffa2

1San Camillo - Forlanini Hospital, T&O, Rome, Italy, 2University of Perugia, T&O, Perugia, Italy, 3Santo Spirito Hospital, T&O, Rome, Italy, 4La Sapienza University, T&O, Rome, Italy, 5North West Thames, T&O, London, United Kingdom

Anterior Cruciate Ligament (ACL) rupture in skeletally immature athletes is becoming an injury with increasing incidence. Choices of treatments are still debated, including conservative management vs various surgical techniques. Lack of long-term reports has been highlighted in the literature. Our aim was to evaluate long-term results of ACL reconstructions performed in skeletally immature patients using the Over the Top technique with lateral extra-articular tenodesis.
Retrospective study. All surgeries performed by same team. 42 patients included. All patients had preoperative and postoperative radiological studies. 30 males-12 females. Average age: 12.5 years (range 11-14 years). Average follow-up: 96.1 months. Clinical evaluation: Pedi-IKDC, Tegner-Lysholm, KT-1000, plain radiographs. Standardized rehabilitation protocol.
No instability nor leg length discrepancy recorded. Time from injury to surgery: 3.2 months (range 0.5-5). Average pre-op Tegner-Lysholm and Pedi-IKDC: 55 and 40; 94.8 (p<0.05) and 94.78 at final follow-up (p<0.05). Average post-op (1 month) Tegner-Lysholm: 75 (range: 62-79). Median post-op Tegner: 8. Mean side-to-side (KT-1000): 1,2mm. 22 patients could go back to pre-injury sport activity. Average rehabilitation: 7.3 months. The most common sports were soccer (35.1%), skiing
(21.7%), and rugby (22.4%).
A significant amount of cases was included in our structured standardised study and follow up. Functional scores were overall excellent. Excellent results are testified by final achievement of 22 patients to go back to pre-injury sport activity in keeping with literature. Our experience exhibited a low complication rate and no metalwork failure. We correlate our results to the use of the over the top technique with lateral extra-articular tenodesis. The studied procedure seems to be an excellent option strategy and an effective, feasible and safe technique when treating ruptured ACLs in skeletally immature patients. Studies with higher level of evidence are needed in order to further validate our results.

There is NO Conflict of Interest: Yes

348 - Day-case pelvic osteotomy for Developmental Dysplasia of the Hip (DDH)

D Moore1, G Sheridan2, DP Moore2

1Children's Health Ireland at Crumlin, Orthopaedics, Dublin 12, Ireland, 2Childrens Health Ireland at Crumlin, Orthopaedics, Dublin 12, Ireland

Background: We report the results of a pilot study analysing the feasibility and financial implications of performing pelvic osteotomies for DDH as day-case's. This is a novel process that hasn't been described to date in the literature.

Methods: This was a prospective study analysing Salter and Pemberton osteotomies for DDH over a 3 year period from 2017 to 2019. Anaesthetic involvement with a dedicated analgesic protocol on discharge was provided along with parental instruction and phone call the following day. Clinical review was as per standard practice. Economic costings were sourced from the official ‘HSE specialty costing report 2018’.

Results: Eighty-four osteotomies were performed from 2017 to 2019. Thirty-five were performed as day-cases. Considering the standard number of in-patient days for the same procedure is 2 days, a reduction in 70 in-patient bed-days were reported. Discharge costs for a single inpatient were €5,752. For 35 in-patient osteotomies, this would have amounted to €201,320. The total discharge cost of a day case was €2,670. Calculating the difference, a total saving of €102,696 was made by the hospital. Only 7 patients re-attended due to inadequate analgesic control, and all were discharged without issue the following day. The savings made per patient amounted to €3,082 for every osteotomy performed as a day-case.

Conclusion: Day case pelvic osteotomies can significantly reduce the number of inpatient bed days in an elective paediatric setting. Economic gains made by treating only 35 patients in this manner amounted to €102,696. There was no adverse impact on the standard of clinical care. We propose that the introduction of day case pelvic osteotomy procedures can significantly improve the cost-effectiveness of managing DDH in a paediatric population. Provided there is a stringent analgesic protocol provided on discharge with close clinical follow-up, this is a safe and effective innovation in this field.

There is NO Conflict of Interest: Yes

362 - Litigation costs in paediatric trauma and orthopaedics: a 15 year trend comparison to paediatric surgery

G Hodhody1, S Afzal1

1Manchester Childrens Hospital, Paediatric Orthopaedics, Manchester, United Kingdom

Background: The surgical management of the paediatric patient is challenging and complex. There are many factors to consider in the diagnosis and treatment of a paediatric patient, in particular the inclusion of an adult with parental responsibilities with whom the legal right of consent lies.
This study looks at litigation trends in the paediatric population. Much work has been published looking at litigation in the adult patient, however we believe this to be the first study to scrutinise the litigation figures in the UK for the paediatric patient.

Methods: We focused on a 15 year time frame, the financial years of 2003-2018. Data was obtained from NHS Resolution, via the Freedom of Information Act 2000. All claims pertaining to children aged 16 and under who had received care under these subspecialties, were collated.

Results: A total of 1435 closed claims were found resulting in £162 million of costs across both specialties. 1119 claims (79%)  were for T&O with 728 claims (65%) paying out for damages. 44% of total claims (n=318) were due to delay in treatment or diagnosis and 10% (n=44) were due to intraoperative complications. A total of £45million was paid out for delayed diagnosis and delayed treatment with a grand total of £112million paid out over 15 years in T&O alone.

Conclusion: Litigation is a growing burden on the NHS budget with increasing demands every year.
Delays in diagnosis and treatment were identified as the biggest cause for litigation in the paediatric orthopaedic population which is in keeping with previous studies in the adult population.

Implications: A large proportion of the claims from their cause data can be recognised as potentially avoidable. The results point to the need for further education and reflection within this aspect of trauma and orthopaedics.

There is NO Conflict of Interest: No

866 - Can Virtual Reality headsets be used safely as a distraction method for Paediatric Orthopaedic patients? A feasibility study.

K. Shepherd1, Y. Shanmugharaj2, M. Kokkinakis1, O. Kattan2

1Evelina Children's Hospital, Paediatric Orthopaedics, London, United Kingdom, 2Kings College London, London, United Kingdom

Background: Virtual Reality (VR) has been shown to decrease pain and anxiety in clinical areas. Venepuncture, Plaster Room procedures and the Operating Theatre environment can provoke anxiety in Paediatric Orthopaedic patients. The purpose of this study was to assess the feasibility of the ‘Rescape DR:VR’ headset as a distraction method within these Paediatric Orthopaedic settings.

Methods: An internal risk assessment by medical engineers was carried out to determine the safety of the VR-Headset in the three clinical areas. The device was deemed safe to be used only in the Venepuncture and Plaster Rooms, while further investigation is needed to establish its safety in the operating theatre/anaesthetic room. Thirty-three children (age range:2 -15 years) were given the option to use a VR-headset while they underwent venepuncture or a cast procedure. Anxiety scores, measured on a Likert scale, were collected pre and post-procedure. Participants were asked if they would use the device again. Subjective feedback was also collated from the supervising clinical staff.

Results: 64% (21) showed a reduction in anxiety scores, 27% (9) had no change in score; all scores being mild, 1-3 on the Likert scale. 6% (2) showed an increase in post procedure score. All participants stated they would use the device again. One patient declined the headset. Health professionals also gave positive subjective feedback and they would all use it again with their paediatric patients. No adverse events were recorded.

Conclusion/Findings: The ‘Rescape DR:VR’ headset has been found to be safe and a feasible distraction method for use within the Venepuncture and Plaster Room. Further research is required to assess its use safety and effectiveness in other clinical areas including the Paediatric Orthopaedic operating theatre.

Disclosure: The Virtual Reality Headset and kit was loaned to the Evelina Children's Hospital by Rescape Innovation Ltd for a trial period and returned after the designated period.

There is NO Conflict of Interest: No

1067 - 128 consecutive ACL reconstructions at a Children's Hospital: Low revision rates with a delayed return to sports at 5 years mean follow up.

H. Mills1,2, P. Jose3, D. O'Dowd3, G. Davies3, F. Ali3,4, N. Nicolaou3

1University of Sheffield, Sheffield, United Kingdom, 2Kingston Hospital, London, United Kingdom, 3Sheffield Children's Hospital, Sheffield, United Kingdom, 4Chesterfield Royal Hospital, United Kingdom

Background: Isolated studies of Paediatric ACL reconstruction are limited. Re-operation rates are high with little mid-term data on functional outcomes. This study reports on the functional outcomes and reoperation rates for a young cohort treated at one institution with a delay in return to contact sports of minimum 1 year from the time of surgery.

Methods: Ethical approval for the study was granted. All patients with >1 year of follow up post-surgery were contacted and asked to complete functional scores including Pedi-IKDC, Pedi-KOOS, Tegner, IKDC, KOOS and EQ-5D depending on age. Data on surgical technique, bone age, post-op growth disturbance/ mechanical axis deviation, re-operation or revision was collected.

Results: 138 cases of primary ACL reconstruction with at least one year follow up were identified. 10 cases were excluded as congenital ACL. Mean follow up was 5 years (range 1-14) for the 128 patients treated for traumatic ACL rupture at a mean age of 15 (6-17). None were treated within 6 weeks of injury. 86% underwent transphyseal reconstruction with hamstring graft. Re-ruptures occurred in 11% of patients, 64% requiring revision. Contralateral rupture occurred in 5%. 63% had a meniscal tear at the time of surgery, treated with medial menisectomy (12%), medial repair (16%), lateral menisectomy (16%) and lateral repair (19%). Further meniscal surgery was required in 18% of which 43% had revision fixation, 61% meniscectomy and 4% meniscal transplant. There were 2 radiological valgus deformities not requiring treatment and 4 further arthroscopies. 1 case of failure was due to tunnel malposition. There were statistically significant improvements in functional scores from pre-operative values with improvement over time.

Conclusions: Meniscal injury rates are high in this cohort due in part to delay in presentation and treatment. Reinjury rates are low, possibly due to a determined effort to delay return to pivoting sports.

There is NO Conflict of Interest: No

1124 - A prediction model for treatment decisions in distal radial physeal injuries. A multicentre retrospective study

S. Kannan1,2, H. Hong Chong3, A. Fadulelmola1, H. Lennox-Warburton1, G. Mcconaghie4, B. Emmerson5, S. Venkatachalam6, A. Abraham7, P. Henman6

1Health Education England- North East, Newcastle, United Kingdom, 2Newcastle University, Newcastle, United Kingdom, 3Health Education England- East Midlands, Leicester, United Kingdom, 4Health Education England- West Midlands, Oswestry, United Kingdom, 5Northumbria Hospitals NHS Foundation Trust, Newcastle, United Kingdom, 6Newcastle Upon Tyne Hospitals NHS Foundation trust, Newcastle, United Kingdom, 7University Hospitals of Leicester, Leicester, United Kingdom

Background: Distal radius fractures are the most frequent fractures seen in the pediatric  population and they constitute approximately 1/6 of fractures treated in the emergency department. About 15% of these fractures involve physis. Despite being common there are no clearly defined treatment guidelines for the management of distal radial physeal injuries(DRP). To support shared decision-making, we developed the first prediction model for patients with DRP. The personalised model, predicts the risk of deformity, physeal damage and remanipulation. Our aim was to identify patients who have a high risk of poor radiological outcome the following injury and develop a prediction model. To our knowledge, this is the single the largest study on DRP injuries.

Methods: The study was conducted across multiple centers in the UK. We included all patients under 16 years with isolated DRP injuries. Data were analysed using SPSS. Nomogram was developed using R. The predictive accuracy of the validated model was assessed using sensitivity, specificity, PPV, and NPV.

Results: Our study included 479 patients. 6.6%(32/479) patients had a second procedure. The rate of physeal closure was 10.2%(49/479). 6%(28/479) of patients had a distal radius deformity at the end of follow-up. The occurrence of distal radius deformity had a strong correlation with age (p 0.04) and immobilization duration (p 0.003). ROC analysis showed that age >12.5 years (p 0.006) and sagittal angulation of >21.7° (p 0.002) had a higher odds of distal radius deformity. Immobilisation < 4.5 weeks (p 0.01) had a higher revision rate. The nomograms showed good calibration, with a sensitivity of 70% and specificity of 75%.

Conclusion: The prediction model is the first of it’s kind for prognosticating the outcomes for distal radial physeal injuries. The developed model shows good sensitivity and specificity to provide a reliable prediction of poor outcomes.

There is NO Conflict of Interest: Yes


J. Barrow1, A. Foster2, M. Kenawey2, T. Board1

1Wrightington, Centre for Hip Surgery, Wigan, United Kingdom, 2Royal Manchester Children's Hospital, Trauma and Orthopaedics, Manchester, United Kingdom

Background:  The decision to undertake THA in a child is complex and surgery challenging. Pre-operatively patients’ typically have significant pain and mobility restriction. Little is published on the functional gains after THA in this group. The aim of this study was therefore to measure the impact THA had on the PROMS in our young patients undergoing THA, to determine QoL improvement.
Methods: This was a prospective, consecutive cohort study of patients under the age of 17 years undergoing THA by a single surgeon in a tertiary referral centre. Patient electronic notes, radiographs and PROMS (EQ5D-Y, Oxford Hip Score (OHS) and modified Harris Hip Score (mHHS)) were reviewed.
Results: 12 children (8 females and 4 males) underwent THA before their 17th birthday, with 5 undergoing bilateral operations (17 THA total). The mean age was 14.6 years (10.75-16.9) and mean follow-up 1.7 years. Nine of the THA were undertaken for congenital syndromes, 4 for AVN, 2 for Perthe’s disease and 1 for dysplasia and idiopathic chondrolysis. The mean pre-operative OHS was 15 (1-33) improving to 31 (19-39) at 6-weeks, 44 (42-46) at a year and 48 (47-48) at 3 years. mHHS improved from a pre-operative mean of 25 (0-56) to 60 (37-92) at 6-weeks, 65 (38-84) at a year and 91 (91) at 3 years. The EQ-VAS mean score pre-operatively was 35 (8-100) improving at 6-weeks to 73 (55-96), 84 (76-96) at a year and 92 (76-100) at 3 years. All patients achieved MCID or higher for OHS. 6 patients were wheelchair users preop. All patients were independent walkers at follow-up. There were no complications.
Discussion: THA in children is safe and leads to a significant positive impact on QoL as measured with validated PROMS scores. Wheelchair users can reliably gain independent walking. Further follow-up is required understand the long-term outcomes.

Disclosure: J. Barrow: None Declared, A. Foster: None Declared, M. Kenawey: None Declared, T. Board received grant/research support from: DePuy Synthes, is consultant for: DePuy Synthes, is a paid instructor for: DePuy Synthes, has a conflict with: Royalties from Springer, Associate Editor of Hip International, Research Committee Member for BOA

There is NO Conflict of Interest: No


A. Gabr1, S. Williams1, S. Dodd1, N. Barton-Hanson1

1Alder Hey Children's NHS Foundation Trust, Trauma and orthopaedics, Liverpool, United Kingdom

Background: Meniscal sparing surgery is a widely utilised treatment option for unstable meniscal tears. The aim of this study was to assess the re-operation rate and functional outcomes of meniscal repairs in children and adolescence.

Methods: We performed a retrospective review of all patients who underwent arthroscopic meniscal repair surgery between January 2007 and January 2018. All patients were under the age of 18 at the time of surgery. Procedures were all performed by a single surgeon. Information was gathered from our hospital Electronic Patient Records (EPR) system. The primary outcome measure was re-operation rate (need for further surgery on the same meniscus).

Results: We identified 59 patients who underwent 66 All-inside meniscal repairs (32 medial meniscus and 34 lateral meniscus). There were 37 males and 22 females with an average age of 14 years (range 6-16). The average follow-up time was 53 months (range 16-140). Six patients had concomitant ACL reconstruction surgery along with the meniscal repair. There were no intra-operative complications. The re-operation rate for meniscal repairs was 16.6% (11 cases) with 2 patients requiring further meniscal repairs and 9 patients underwent partial meniscectomies. The mean postoperative IKDC score was 88 (44-100), Tegner score was 7(2-10) and Lysholm score was 94 (57-100).

Conclusion: Our results showed that arthroscopic repair of meniscal tears in the paediatric population is an effective treatment option that has a low failure rate and good postoperative clinical outcomes with the advantage of preserving meniscal tissues.

There is NO Conflict of Interest: Yes

1910 - Predicting paediatric anterior cruciate ligament injury: The influence of steep lateral posterior tibial slope & its relationship to the lateral meniscus

T. Edwards1, A.Z. Naqvi1, N. Dela Cruz1, C. Gupte1

1Imperial College London, MSk Lab, London, United Kingdom

Background: This study examines the relationship between posterior tibial slope & lateral meniscal bone angle (LMBA) on anterior cruciate ligament (ACL) tear risk in a pediatric population.

Methods: In this case-control study, non-contact, ACL-injured, pediatric patients with no significant lateral meniscal lesions were age and gender matched in a 1:1 ratio to a group of radiologically normal controls. Knee magnetic resonance imaging (MRI) studies were analysed by 2 independent, blinded observers measuring the medial posterior tibial slope (MTS), lateral posterior tibial slope (LTS) and LMBA. Sagittal slope asymmetry was calculated as the absolute difference in ° between slopes & the relationship between LMBA & LTS was calculated as a ratio. Binary logistic regressions identified independent predictors of ACL injury. Receiver operator characteristics were performed to determine predictive accuracy.

Results: 20 study patients (mean age 14.8 ± 2.42 years) were compared with 20 gender & age-matched controls (mean age 14.55 ± 2.04). LTS was significantly higher in the ACL-injured group (11.35±3.79° vs 7.04±2.65°, p =0.0002) as were the absolute slope difference (7.09±3.02° vs 3.06± 2.77°, p=0.0001) and LTS:LMBA ratio (0.47±0.18 vs 0.27±0.12, p=0.0001). No significant differences were observed for MTS or LMBA. Independent predictors were LTS (OR: 1.56 [95% CI:1.16-2.10], p=0.003), LTS:LMBA ratio (OR: 3.07 [95% CI: 1.43-6.62], p=0.004) and absolute slope difference (OR: 1.72 [95% CI: 1.20-2.46], p=0.003). Absolute slope difference and LTS:LMBA ratio were the strongest predictors (area under the curve: 0.85 & 0.87 respectively).

Conclusion: This study suggests LTS, absolute slope difference & LTS:LMBA ratio are significant pediatric ACL-injury risk factors. All three demonstrate good predictive accuracy, however sagittal slope asymmetry & the relationship between steep LTS & shallow LMBA were stronger predictors than LTS in isolation. These criteria could be used to risk-assess athletes with a view to developing injury prevention strategies.

There is NO Conflict of Interest: Yes

Accepted Abstracts

62 - Outcome Analysis Of Ender Nail In Paediatric Femoral Shaft Fracture

RR Akhtar1

1Benazir Bhutto Hospital,Rawalpindi Medical University, Rawalpindi, Pakistan

Background: Usage of spica casting as the treatment for children with femoral shaft fractures is a controversy. Operative approach is the main stand for the management of femoral shaft fractures in children presently. The advantages of flexible intramedullary nails as a fixation device are closed insertion of the device, with preservation of fracture hematoma and minimal risk of fracture site infection, no reaming is required and as such the endosteal blood supply is essentially preserved.

Objectives: To assess the treatment outcome of ender nail in paediatric femoral shaft fractures in terms of union,function and limb length discrepancy.

Study Design & Methods: This case series was done using non-probability purposive sampling technique at department of orthopedic surgery from March 2015 to October 2017. We enrolled 83 children 6 -13 years of age with fracture shaft of femur and children with skeletal dysplasia, malignancy, pathological fracture were excluded from the study. We recorded time of surgery, infection, implant failure, union, limb length discrepancy and functional outcome. Time of surgery, infection, implant failure, limb length discrepancy was recorded clinically while union and functional outcome was observed using radiographic and Flynn criteria.

Results: There were 49 (59.03%) male and 34 (40.96%) female children. Mean age was 7.89 ± 3.43 years. The mean duration of surgery was 20 ± 6.12 mins.There were 04 (4.8%) superficial and no case of deep infection. There was no implant failure. The time duration from clinical & radiographic union to full weight bearing was 7.2 weeks (5-12weeks). On Flynn criteria 57 (68.7%) has excellent and 26 (31.3%) had satisfactory functional outcome. There was no limb length discrepancy in 7 (85.8%) children with mean of 5.23mm discrepancy in 10 (14.2%) children.

Conclusions: Ender nail is a good treatment option for paediatric femoral shaft fracture in terms of union and functional outcome with low rate of infection, implant failure and limb length discrepancy.

There is NO Conflict of Interest: Yes

202 - The Inpatient Cost of Developmental Dysplasia of the Hip: Is delayed presentation more expensive?

T Walton1, K Hughes1, S Maripuri1, T Crompton1

1Brighton and Sussex University Hospitals NHS Trust, Trauma and Orthopaedics, Brighton, United Kingdom

Background: Developmental dysplasia of the hip (DDH) can be treated using conservative management, provided diagnosis is made early. In the UK, selective screening is used to guide the need for definitive imaging and subsequent treatment. The aim of this study was to determine the total cost of inpatient admissions for DDH at a large NHS trust, and identify any association with newborn screening status on the total cost of treatment.

Methods: All inpatient episodes between 01/01/2014 to 30/06/2019 with an ICD-10 code stem of Q65 ‘congenital deformities of hip’ were retrospectively screened. Data was obtained from electronic and paper records. Patients were divided into ‘screening-positive’ (diagnosed through selective screening) and ‘screening-negative’ (not diagnosed through screening). The tariff paid for each inpatient episode was identified, and the number of individual clinic attendances, surgical procedures and radiological examinations performed (USS, XR, CT, MRI) were recorded.

Results: 41 patients were admitted for inpatient management. 44% (n=18) were screening-positive, diagnosed at mean age 6.7 weeks. 56% (n = 23) were screening-negative, diagnosed at mean age 26 months. During the study period, the total cost of inpatient care in the screening-positive group was £171,471 (£9,526.18 per-patient) compared to £306,615 (£13,331.10 per-patient) for screening-negative cases. In the screening-positive group, there were 99 clinic attendances, 47 surgical procedures and 160 radiological examinations performed (36 USS, 107 XR, 17 CT). This compared to 148 clinic attendances, 56 surgical procedures and 215 radiological examinations (187 XR, 26 CT, 2 MRI) in the screening-negative group.

Conclusion: This study demonstrates that ‘screening-negative’ patients account for a greater proportion of inpatient admissions related to DDH. They incur a higher cost from inpatient treatment per patient, and necessitate more resources. This study adds to the ongoing conversation around the cost-effectiveness of selective screening for DDH in the UK.

There is NO Conflict of Interest: Yes

263 - A retrospective review of patients treated surgically for developmental dysplasia of the hip

M Sharrock1, C Whelton1, Q Choudhry2, R Paton2

1School of Surgery, North West Deanery, Manchester, United Kingdom, 2Royal Blackburn Teaching Hospital, East Lancashire Hospitals NHS Trust, Blackburn, United Kingdom

Purpose: The aim of this retrospective study is to identify trends in presentation, surgical treatment and outcomes of patients with developmental dysplasia of the hip in a single centre cohort, over a 22 year period.

Methods: The available clinical records and imaging were reviewed of 106 children (117 hips) treated surgically. Demographic data, age and mode of presentation, and surgical treatments were reviewed, as well as outcomes, re-operation rate and AVN incidence. Early presentation was defined as less than 4 months to include those patients identified during the six week check.

Results: 106 children (16 male, 90 female) underwent surgery from 1997 to 2017, (79.3% Caucasian). 85 children presented with dislocation, 24 with dysplasia (3 had both dislocation and dysplasia in different hips), and 13 patients had bilateral dislocations. The mean age at presentation was 12.1 months, with 45 patients (42.5%) diagnosed early (younger than four months of age), and 61 patients presenting late (subgroup mean age for late presentation 20.9 months). After accounting for variations in birth-rate within the trust’s catchment area, there was an increasing trend in late presentation, but constant rate of early presentation. This has also been associated with an increasing trend in the operative rate per 1000 births. Of the patients requiring surgery for dislocation (n=85), 25 were reduced closed, 55 required open reduction, with 20 femoral osteotomies and 40 pelvic osteotomies. 33 (39%) patients underwent further surgery for dislocation, and 4 (4.7%) patients were diagnosed with AVN.

Conclusion: This study demonstrates an increasing trend in late presentation (> 4 months age) and surgical management, over time. This suggests that screening is failing to identify these children within a reasonable time, and therefore, increasingly aggressive surgical management is indicated.

There is NO Conflict of Interest: Yes

848 - The treatment of DDH using a Pavlik Harness – The Alder Hey Experience over >20 years

I. Jaly1, G. Laing1, I. Shah1, S. Saville1, R. Davies1, C. Bruce1, N. Garg1, D. Perry1, C. Talbot1

1Alder Hey Children's Hospital NHS Foundation Trust, Trauma & Orthopaedics, Liverpool, United Kingdom

Background: Use of the Pavlik harness has become the accepted first line option of initial treatment in neonates/young infants for the treatment of developmental dysplasia of the hip (DDH). We aim to describe the Alder Hey method in treating DDH in a Pavlik Harness and to present our outcomes over the last 20 years.

Method: This was a retrospective cohort study. All patients who underwent Pavlik Harness treatment for DDH using our standard treatment protocol at Alder Hey were identified. Our treatment protocol dictates immediate discontinuation of the harness on achievement of a Graf I hip, with no weaning. Following achievement of a stable Graf I hip, patients are followed up in clinic up until the age of 5 years. Those who failed treatment and required surgery were followed up until skeletal maturity. Demographics, time in harness, success rates are described. All data was collated and analysed on Excel.

Results: A total of 1392 patients were included. 18 % male, 82% female. Mean age at harness application was 52 days. Mean duration of treatment in Harness was 8.9 weeks. A total of 315 Graf IIA, 475 Graf IIB, 513 Graf IIC, 487 Graf III, 3 Graf IV were treated. 86% of our cohort were successfully treated in a Pavlik Harness.

Conclusions: Our experience of non-weaning Pavlik Harness treatment for DDH is consistent with quoted literature of success rates. It remains a safe and valuable 1st line treatment method for DDH.

There is NO Conflict of Interest: Yes

913 - The safety and efficacy of ring splints in the management of the dysplastic hip in older infants

S. McMahon1, R. McKenna1, A. Cosgrove1

1Royal Belfast Hospital for Sick Children, Belfast, United Kingdom

Introduction: We aim to assess the effectiveness and safety of ring splints in the management of the dysplastic hip in patients between 6 and 12 months of age.

Method: All infants who had full-time application of ring splints for hip dysplasia initiated between 6 and 12 months of age, with no prior treatment, between 2012 and 2016 were included. Acetabular index (AI) was measured on radiographs at the start and the end of treatment. A comparator group who had two interval radiographs, but no treatment, was identified.

Results: 186 hips (133 patients) were included. The mean age at initiation of treatment was 221 (185-347) days. The mean duration was 85.6 (55-112) days. The mean starting AI was 32.5° (30-40°) and the mean final AI was 25.3° (16-32°), with a mean change in AI of 7.2° (1-17°). Three hips (1.6%) did not tolerate treatment and four hips (2.2%) were lost to follow-up. There was one (0.5%) femoral nerve palsy leading to abandonment. No patients had AVN and three (1.6%) underwent arthrogram. One (0.5%) has persistent dysplasia requiring surveillance for a future corrective procedure. The comparator group comprised of 85 hips (52 patients). The mean age at first radiograph was 216 (184-299) days, with a mean AI of 29.4° (27-33°). The mean interval between radiographs was 91.3 (77-113) days and the mean change in AI was 2.0° (-3-12°). This was significantly less than the treated group (p=0.0001). No secondary procedures were required in this cohort.

Conclusion: Treated hips showed a greater magnitude of AI change than the comparator group. There was a high compliance rate, low complication rate and only one patient requiring a future corrective procedure.

Implications: This data suggests that ring splints are both safe and effective in treating dysplastic hips in this older cohort.

There is NO Conflict of Interest: Yes

1268 - Distal Tibial Fractures in Children: Management Remains Unclear

L. Render1, A. Rammohun1, D. Bodansky1, J. Himsworth1, N. Giannakakis1, V. Parnami2, N. Nicolaou3, V. Muthukumar2, A. Christou3, D. Perry1

1Alder Hey Children's Hospital, Liverpool, United Kingdom, 2Royal Manchester Children's Hospital, Manchester, United Kingdom, 3Sheffield Children's Hospital, Sheffield, United Kingdom

Background: Paediatric distal tibial fracture management is diverse and optimal treatment is controversial. We present the management and outcomes in three large UK tertiary centres.
Method: We undertook a retrospective review of all patients with distal tibial physeal fractures, presenting to three UK paediatric trauma centres (2017-19).  

Results: Of 129 patients, median age was 12 (IQR2), with 85 males. Fractures were grouped according to Salter-Harris classification: 3 SH1;  78 SH2; 19 SH3; 29 SH4. Nine fractures were open (3 SH1, 6 SH2). 24 were excluded through inaccessible follow-up data.
All SH 1 fractures were treated with K-wires with one physeal arrest. Of 78 SH2 fractures, 33 were stable and treated conservatively with a cast, 22 with screws, 9 external fixator and 14 with K-wires. One patient with screw fixation had physeal arrest. SH2 patients treated by cast were followed-up for a median of 39 days (IQR28); K-wires 173 days (IQR87); screws 357 days (IQR199) and 622 days (IQR325) for external-fixation. Twelve SH3 patients received screws and 7 received casts.
7 of 29 SH4 patients received casts, 2 plate fixation, 18 screws and two K-wires. SH4 follow-up for casts was a median 141 days (IQR179); plate fixation 115 days; screws 309 days (IQR266) and K-wires 138 days.

Conclusion/Findings: All treatment options had low complication rates. Within unstable fractures, particularly SH2 and SH4, there is variation in treatment for similar injuries. There was no association between complications and any particular fixation method. Conservative management in stable fractures had a shorter hospital stay. K-wire fixation had a low complication rate but required later removal. Treatment choice should be influenced by cost-effectiveness, burden of total procedures and total time under orthopaedic care.

Implications: Different treatments are currently utilised in treating unstable physeal injuries, with similar complication rates. Cost-effectiveness and efficacy should be considered.

There is NO Conflict of Interest: Yes

1555 - Will it get worse? Predicting which immature hips will develop into developmental dysplasia of the hip

B. Marson1, J. Hunter2, K. Price2

1University of Nottingham, Trauma and orthopaedics, Nottingham, United Kingdom, 2Nottingham University Hospitals, Trauma and Orthopaedics, Nottingham, United Kingdom

Background: It is unclear which children with physiologically immature hips will develop dysplasia requiring treatment, so most will be monitored with the accompanying anxiety and inconvenience for new families. The aim of this project is to identify if there are predictive features to identify which hips will develop dysplasia to help target investigations and interventions for those most at risk.

Methods: Children with risk factors or concerns from GP assessments were all assessed in a single one-stop hip clinic. Outcomes from all patients presenting to the paediatric hip clinic between 1/9/2014 and 1/10/2019 were prospectively collected. Children with immature (Graf IIa) hips were included.
Parents were advised to use double nappies, avoid swaddling and to return for a repeat scan to confirm normal development. Potential predictive covariates were analysed through logistic regression.

Results: 9,119 children were reviewed in the clinic of which 532 (5.8% of referrals) had immature hips. The mean age at first scan was 36.8 days (SD 23.7).
Thirty-nine (7.3%) of children with immature hips subsequently developed dysplasia including four children with Graf III and 2 children with Graf IV hips. All children that developed dysplasia were successfully treated using a Pavlik harness.
Breech presentation, family history, clicky hip, CETV, limited abduction or leg length discrepancy and time of first scan (within 28 or 42 days) were not significant predictors of dysplasia. Half of the children who developed Graf III of IV hips were referred with a dislocatable hip (HR for all DDH 7.6 95% CI 3.2-18.7).

Conclusions: Immature hips are a common finding during hip screening and can be treated in the majority with minimal intervention. Children with dislocatable hips at birth should be observed closely, though the sensitivity of 23% is low. We therefore recommend repeat ultrasound to confirm hip stability and avoidance of dysplasia.

There is NO Conflict of Interest: Yes

1766 - Ultrasound follow-up after successful treatment in Pavlik harness for Developmental Dysplasia of the Hip. Seven years’ experience from a paediatric tertiary referral centre

K. Studnicka1, E. Spink1, C. Talbot1

1Alder Hey Children's Hospital, Liverpool, United Kingdom

Introduction: A national newborn screening aims to recognise Developmental Dysplasia of the Hip (DDH) at the earliest possible stage where treatment with Pavlik harness is most successful. Apart from ultrasound (USS) monitoring of hip development in harness, we perform USS four weeks after successfully completed treatment.

Aims: To verify if the 4 week USS follow-up has influence on treatment.

Methods: Patients with DDH hips IIc-IV according to Graf, successfully treated with Pavlik harness between 2012 and 2019 identified. Babies who failed harness treatment were excluded. Details of referral, surgical treatment, and follow-up obtained from electronic notes. USS reports and radiological follow-up images reviewed on PACS.

Results: Majority of 342 babies referred from Maternity Unit with dislocatable hip. The average waiting time for the first appointment was 35 days (0-67).
USS performed on the day of Pavlik harness application identified 161 right and 273 left Graf IIc-IV hips. Treatment lasted on average for 60 days (29-149). On removal of the harness, the average alpha angle in either hip was 64°. 76 % of babies had USS follow-up showing average left and right hip’s alpha angle of 63° (57-75; 54-72). The average age on the most recent follow up was 44 months (2-86) with an acetabular index of 20° and 22°.
Despite Graf I hip at the time of removal of the harness, two hips regressed to IIb on follow-up scan. Both were followed up radiologically and didn’t require surgical treatment. Four hips with normal parameters on follow-up scan were found subluxed on subsequent radiographs and required surgical treatment.

Conclusion: USS surveillance during the period in Pavlik harness is an excellent adjunct in monitoring the treatment and filtering the cases requiring surgical intervention. The 4 weeks follow-up hasn’t influenced the surgical management of monitored hips and will be discontinued.

There is NO Conflict of Interest: No

Shoulder and Elbow

Virtual Podium Presentations


S Raja1, S Jassim1, D Butt1, W Rudge1, M Falworth1, D Higgs1, A Majed1

1Royal National Orthopaedic Hospital, Shoulder & Elbow Unit, London, United Kingdom

Aim: To assess the rate of recurrent instability after arthroscopic inferior capsular shift for atraumatic shoulder instability at minimum two-year follow up.

Methods: From April 2013 to January 2017, 72 patients with atraumatic instability underwent arthroscopic inferior capsular shift. Patient-reported outcome scores were prospectively collected during routine outpatient follow up. These included Oxford Shoulder (OSS), Oxford Shoulder Instability (OSI), pain using a numerical rating system (NRS) and Stanmore Percentage of Normal Shoulder Assessment (SPONSA).

Results: Mean age was 27.4 years with a large female preponderance (46F:26M). Median Beighton score was 5. Mean follow up was 2.7 years (range 2 to 5.8 years). As of January 2019, 59 patients have attended two year follow up. Significant improvements in pain and functional outcomes were seen. Mean pain score improved from 7.3(SE ±0.34) to 2.7(SE±0.35) and mean SPONSA increased from 43.8% (SE±3.31) to 71.6% (SE±2.92). Mean OSS increased from 29.6(SE±1.81) to 39.1(SE ±1.34), while mean post-operative OSI was good at 34.6(SE ±1.47). Twenty-three patients (39%) reported instability symptoms, with 5 requiring further stabilisation surgery (8.5%). Subgroup analysis of our recurrent instability group demonstrated age less than 30 (<30 vs >30, p=0.007) and female gender (male vs female, p=0.007) as significant predictors of recurrence. Beighton score (<5 vs ≥5, p=0.297) or direction of instability (anterior vs inferior vs posterior vs multidirectional, p=0.307) were not predictive of recurrent instability. Nor was pre-existing Hill-Sachs or glenoid bone loss.

Conclusions: Arthroscopic inferior capsular shift surgery is an appropriate treatment option for those with atraumatic shoulder instability recalcitrant to conservative measures. Although improvements in stability and functional outcomes can be anticipated it is our obligation to inform patients of the high rates of recurrent instability. Female patients under the age of 30 should be made especially aware.

There is NO Conflict of Interest: No

178 - Motor Unit Number Estimation following nerve transfer to reanimate elbow flexion

M Wilcox1,2, T Tidswell3, S Laranjeira1, J Phillips1, T Quick1,2

1University College London, London, United Kingdom, 2Royal National Orthopaedic Hospital, London, United Kingdom, 3Royal Free Hospital, Clinical Neurophysiology, London, United Kingdom

Background: Peripheral nerve injuries are common following blunt and penetrating trauma. A substantial barrier to the trial of new therapies for the treatment of nerve injuries is the absence of responsive outcome measures that correlate with functional assessments of recovery. Motor Unit Number Estimation (MUNE) is a neurophysiological test that quantifies the number of functional motor units (MUs) innervating a muscle. Therefore, this study aimed to measure MUNE at a range of acute and time points following nerve transfer to reanimate elbow flexion. Furthermore, the relationship of MUNE with objective and subjective measures of functional recovery was investigated.

Methods: Fifteen patients, 14 men and 1 female, with a mean age of 36.7 years (23 to 59 years) were recruited into the study. All patients sustained C5/6 avulsions following road traffic accidents. The patients were followed up for Spike Triggered Averaging (STA) MUNE assessment at a median follow-up time of 543 days (90 to 1698 days). STA MUNE was performed in the injured and uninjured arm of each participant allowing the percentage of recovered MUs to be quantified.

Results: MUNE demonstrated a statistically significant positive correlation (r2=0.71, p<0.01) with time following surgery. Second, MUNE demonstrated statistically significant and positive correlations with objective measures of muscle fatigue improvement (r2=0.86, p<0.01) and subjective measures of elbow flexion (Stanmore Percentage of Normal Elbow Assessment) (r2=0.94, p<0.01). A recovery of approximately 29% of MUs was predictive of the recovery of Medical Research Council grade 3 or greater.

Conclusion: The findings of this study suggest that MUNE is a responsive outcome measure that is related to objective and subjective measures of muscular function. This has the potential to aid the clinical translation of new treatments and to act as a prognostic marker for peripheral nerve injuries.

There is NO Conflict of Interest: Yes


P Raval1, R Pandey1

1University Hospitals of Leicester NHS Trust, Leicester, United Kingdom

Background: A stemless humeral implant in total shoulder arthroplasty preserves bone, reduces blood loss, lowers risk of intra and postoperative fractures and provides good access for glenoid replacement. The use of stemless humeral component is increasing. However, most literature report outcomes over short periods.

Aim: Our objective was to determine the medium-term outcome of a stemless arthroplasty with a ceramic head.

Methods: Patients undergoing a stemless shoulder arthroplasty between 2011-2014 were included. All underwent uncemented stemless modular humeral implant with a ceramic head and a cemented pegged glenoid component. Patients were assessed with pre- and post-operative Oxford Shoulder Score and range of movement. AP and Axillary radiographs were performed for evidence of loosening and glenoid radiolucencies were graded using Lazarus score.

Results: 51 patients (M21:F30), with a mean age 70.2 (56-88) years, were included. Mean follow-up was 5.5 years (range 5.1-7.7 years). Significant improvements in pain, range of movement, were reported in all cases. Final follow-up post-operative Oxford Shoulder scores were 44 (30-48) with minimum 14 points improvement (p=0.001). External rotation (40° vs 20°; P = 0.001), forward flexion(140° vs 80°; P = 0.015), abduction (45° vs 90°; P = 0.016) and internal rotation (to the sacrum) also improved. Lucencies has been observed in 12 glenoids. Grade 1-11, grade 2-2 & none with grade 3. There were no cases of loosening or failure. One patient was revised for cuff failure; one patient had washout for infection.

Conclusion: This is one of the largest patient series following a stemless shoulder arthroplasty with a ceramic head. We demonstrate good humeral component fixation and no loosening. Although radiological lucencies are seen in glenoid prostheses, these are asymptomatic and have not required revision. Stemless humeral implant has good 5-year outcomes, comparable to stemmed implants without the complications associated with stemmed implants.

There is NO Conflict of Interest: Yes

430 - Does Partial Glenohumeral Degenerative Change In Patients Undergoing Arthroscopic Rotator Cuff Repair Influence Clinical Outcomes?

K Al-Tawil1, P Thayaparan1, J Sinha1, T Colegate-Stone1

1Kings College Hospital, T&O, London, United Kingdom

Background: Accepted prognostic surgical repair factors for patients with full-thickness rotator cuff tears include tear size, muscle atrophy and fatty infiltration. However, influence of partial co-existing cartilaginous degenerative change on RCT repair is unappreciated. The aim of this study was to calculate the impact of co-existing glenohumeral cartilaginous changes on patients undergoing arthroscopic repair of full-thickness rotator cuff tears.
Methods: A study of 54 patients (male n=20;female n=34;average age 61 years) undergoing arthroscopic RCT repair was undertaken. Tear size and glenohumeral degenerative change, as per Outerbridge classification, were recorded. Pre and post-operative outcomes were assessed using traditional scores (OSS;EQ5D5L;EQ-VAS) and patient centric re-formatted prisms. The latter prism was calculated by stripping and translating the questions from traditional scores into 3 domains: pain, function and psychological well-being. Outcomes were assessed as an entire dataset and sub-group analysis by grade of co-existing arthritis and tear size. Exclusion criteria were obvious bone-on-bone changes on radiographs and traumatic tears. 
Results: Variations of tear sizes (0-2cm n=20; 2-4cm n=20; >4cm n=13) and cartilaginous changes (G0-n=12; G1-n=11, G2-n=19, G3-n=9, G4-n=3) were noted. Significant improvement (p<0.05) in clinical outcomes were recognised when assessed from either traditional or re-formatted prisms (average % improvement OSS, EQ5D5L, EQ-VAS:47%, 33%, 43% respectively; average improvement pain, function, psychological:48%, 33%, 29% respectively). Positive gain was noted in all sub-groups of arthritic grading and tear size.
Conclusion: Good clinical outcomes can be achieved following rotator cuff tear repair even in the presence of local partial degenerative cartilage change and advancing tear size. These benefits are patient-centred but require RCT repairability. Such a strategy represents high value care.
Implications: Rotator cuff tear repair even in the presence of local partial degenerative cartilage change and advancing tear size is beneficial and represents high value care.

There is NO Conflict of Interest: Yes

536 - Post operative results in acromioclavicular joint dislocation using the LockDown synthetic implant: A retrospective case series

G. Saraglis1, G. Mamarelis2

1Queen Elizabeth Hospital, Orthopaedics, london, United Kingdom, 2Southend Hospital, Orthopaedics, Southend, United Kingdom

Background: Dislocation of the acromioclavicular joint is a common injury with a number of surgical interventions being described for its treatment. Operative treatment is usually indicated for complete dislocation (Rockwood type 3 or more) in order to restore the joint stability. Among the different techniques developed, the LockDown synthetic implant (previously called the Nottingham Surgilig) is a synthetic ligament which has been increasingly used in the ACJ reconstruction with encouraging results. The aim of this study is to assess the post operative results in patients who underwent acromioclavicular joint reconstruction using the LockDown system, comparing the pre and post operative results, using the VAS and Oxford Shoulder score as well as measuring the radiographic appearance in the post operative radiograph. Patients with a minimum 2 year follow up were included in the study.

Methods: A case series evaluating 30 patients undergoing ACJ reconstruction with the LockDown system with at least two years of follow up. The clinical assessment was conducted before and after the operation using the Oxford shoulder score and the visual analogue pain score. Types of complications as well as the radiographic appearance were also noted.

Results: The patients who underwent a Lockdown synthetic implant reconstruction for an acromioclavicular joint dislocation, improved from 
24.67±2.35 to 46.8±2.35, p<0.001 in the 2 year follow up appointment. According to the VAS score, the pain was reduced significantly from 6.87±0.33 to 1.11±0.22, p<0.001. Complications occurred in 6.6% of the patients, with 2 cases of superficial wound infections.

Conclusion: Patients who underwent a LockDown synthetic implant reconstruction had a significant improvement in their quality of life as seen from the comparison of the Oxford Shoulder and Vas scores. Complication rate was 6.6% and included 2 cases of superficial wound infections. From our case series, its widely use is totally justified, making the Lockdown system a valuable tool in the management of acromioclavicular joint dislocations.

There is NO Conflict of Interest: Yes

694 - Survivorship and intermediate to long-term clinical and radiological results of reverse shoulder arthroplasty with a cementless stemless metaphyseal humeral prosthesis

S. Virani1, N. Holmes1, M. Al-Janabi1, C. Watts1, C. Brooks1, J. Relwani1

1East Kent Hospitals University NHS Foundation Trust, Trauma and Orthopaedics, Ashford, United Kingdom

Introduction: The incidence of shoulder arthroplasty is increasing as is the volume of revision surgeries. Revision surgery is easier if humeral bone stock is preserved and with minimal bone defects and osteolysis. This has led to increased focus on development of various short stemmed and stemless implants which provides stable fixation whilst preserving humeral bone stock. We present the medium to long term clinical and radiological outcomes, complications and survival of a stemless reverse shoulder prosthesis.
Methods: Patients with a minimum follow-up of 60 months were eligible for the study. Clinical and radiological data on twenty one patients undergoing the stemless reverse shoulder arthroplasty between 2009 and 2014 was prospectively recorded. Survivorship with the end point of revision surgery was recorded.
Results: The mean follow-up was 78 months (60 to 114 months). The range of active elevation at final follow-up was 136 degrees (80-170 degrees). The range of active abduction and active external rotation was 122 (70 to 170 degrees) degrees and 47 degrees (10 to 75 degrees) respectively. The mean Oxford score improved from 12 pre-operatively to 44 at final follow up (p<0.0001). The mean Constant Murley Score improved from 18 to 72 (p<0.0001). The mean ADLEIR score pre-operatively was 13 and post-operatively was 32 (p<0.0001). Notching was seen 23.5% of cases and no radiolucencies were observed around the glenoid component. There were two cases of post traumatic peri-prosthetic fractures that were managed conservatively and one case of deep seated infection that needed a washout. The survivorship at the most recent follow-up was 100%.
Conclusions: The advantages of bone preservation with a stemless metaphyseal prosthesis combined with encouraging medium to long term clinical and radiological results, make this prosthesis a good option for elective reverse shoulder arthroplasty.

There is NO Conflict of Interest: Yes

927 - Management Of Glenoid Bone Loss With Impaction And Structural Bone Grafting In Reverse Shoulder Arthroplasty

S. Virani1,2, A. Leonidou1,2, G. Sforza2, O. Levy2

1East Kent Hospitals University NHS Foundation Trust, Trauma and Orthopaedics, Ashford, United Kingdom, 2Reading Shoulder Unit, Trauma and Orthopaedics, Reading, United Kingdom

Introduction: Glenoid bone loss is a commonly encountered problem in complex primary and revision reverse shoulder arthroplasty. Addressing glenoid bone loss is critical to avoid complications like early loosening, impingement, notching and instability. We present medium term results of stemless reverse shoulder replacement in cases of glenoid bone loss.
Materials and Methods: Prospective data of all patients with glenoid defects undergoing reverse shoulder replacement between 2004 and 2017 was collected. A pre-operative CT scan was done to plan the surgery and calculate the glenoid version. At each follow-up the clinical function and shoulder scores were assessed. The radiographs were assessed for graft incorporation, evidence of lysis and calculation of glenoid version. 
Results: From 2004-2017, 34 patients underwent glenoid bone grafting during reverse shoulder arthroplasty. Average age was 72 years(range 46 – 88). Indications for surgery were cuff tear arthropathy(6 patients); revision of failed prosthesis(20); osteoarthritis(4); rheumatoid arthritis(3) and second stage revision for infection(1). The glenoid defect was contained in 24 patients and impaction graft with a combination of bone graft substitute and/or humeral head autograft was performed. In 10 patients the glenoid defect was severe and uncontainable and a graft-implant composite glenoid was implanted using humeral head autograft or allograft. Average follow up was 3.6 years(range 1 – 10).  Mean Constant score improved from 34 pre-operatively to 63(p<0.001). Subjective Shoulder Value improved from 0.9/10 to 8.3/10. Active forward elevation improved from 54°to 123°; abduction from 48°to 123°; external rotation from 24°to 38°; internal rotation from 57°to 70°. Final follow-up radiographs showed no lucencies around the glenoid component or loosening. Survivorship was 100% at the last follow-up.

Conclusion: Impaction bone grafting along with structural grafting when required is an effective and reproducible way of managing severe eccentric glenoid bone loss. This technique gives consistent clinical and radiological results.

There is NO Conflict of Interest: Yes

1191 - Clinical results and 9-year survivorship of the Mathys Affinis Short, Short Stemmed Total Shoulder Arthroplasty

T. Karssiens1, J. Gill1, K.H. Sunil Kumar2, S. Sjolin1

1West Suffolk Hospital NHSFT, Trauma & Orthopaedics, Bury St Edmunds, United Kingdom, 2Cambridge University Hospitals NHS Trust, Trauma & Orthopaedics, Cambridge, United Kingdom

Aims: The Mathys Affinis Short is the most frequently used stemless total shoulder prosthesis in the United Kingdom. The purpose of this prospective cohort study is to report the survivorship, clinical and radiographic outcomes of the first independent series of the Affinis Short prosthesis.
Patients and Methods: From 2011 to 2019 a total of 141 Affinis Short prostheses were implanted in 127 patients by a single surgeon. Mean age at time of surgery was 68 (range 44–89). Minimum one year and maximum eight year follow up (mean 3.7 years) was analysed using the Oxford Shoulder Score (OSS) at latest follow up. Kaplan Meier survivorship analysis was performed with implant revision as the end point. Most recently performed radiographs were reviewed for component radiolucent lines (RLLs) and proximal humeral migration.
Results: Five shoulders underwent revision surgery (3.5%); three for rotator cuff failure, one for infection and one for component malposition. Survivorship of the implant was 95.4% (95% confidence intervals, 90.1-97.9%) at five and nine years. Mean OSS improved significantly compared to pre-operative values from 19.0 (range 1–35) to 43.3 (range 7–48) (p=0.0001). Radiographic analysis was undertaken for 95 shoulders. This revealed humeral RLLs in one case (1.1%), glenoid RLLs in 15 cases (15.8%) and radiographic rotator cuff failure in 19 cases (20%).
Conclusion: This prospective cohort study shows encouraging short to mid-term survivorship, clinical and radiographic results and for the Mathys Affinis Short, Short Stemmed Shoulder Prosthesis.

There is NO Conflict of Interest: Yes

1668 - Pectoralis Minor Syndrome: diagnosis with Botulinum injection and treatment with tenotomy - a prospective case series

M. Howard1, M. Jones1, O. Donaldson1

1Yeovil District Hospital, Trauma & Orthopaedics, Yeovil, United Kingdom

Background: Pectoralis Minor Syndrome (PMS) is a collection of symptoms including pain, paraesthesia and weakness in the arm due to compression of the brachial plexus as it passes beneath pectoralis minor; diagnosis is a clinical challenge, and often overlooked. This study reports the results of a single centre’s treatment pathway in patients with symptoms of PMS, using Botulinum injection as a diagnostic tool, and subsequent pectoralis minor tenotomy in patients with a positive response.

Methods: During a 3 year period, patients exhibiting symptoms of PMS who failed to see significant improvement following an initial course of physiotherapy went on to have Botulinum injection. Those with good response to injection but subsequent recurrence of symptoms were offered pectoralis minor tenotomy. Oxford Shoulder Scores (OSS) were collected at baseline and after interventions.

Results: 21 patients received Botulinum injection; mean baseline OSS prior to injection was 20.7 (range 9-32). At 6 weeks following injection, mean OSS was 33.0 (range 14-46); mean change in OSS was +12.4 (range -18-+30), with only 1 patient reporting a worsening of symptoms. Of the 17 patients with a clinically significant response to the injection, 14 were listed for pectoralis minor tenotomy following recurrence of symptoms at 4 month review. 12 patients so far have undergone tenotomy; 3 months following the procedure, mean OSS was 38.8 (range 31-48); mean change in OSS from baseline was +21.6 (range +10 - +38).

Conclusions: This pathway has shown to be extremely effective in patients not responding to first-line treatment for PMS, with 85% of patients post-injection and 100% of patients post-tenotomy showing significant (greater than published MCID value of 6 points) improvements in OSS.

Implications: Although further research with larger numbers and longer follow-up is required, these are promising results in treatment of an underdiagnosed condition.

There is NO Conflict of Interest: Yes

1689 - Clinical Predictors of Poor Outcomes of Hydrodistention in Idiopathic Adhesive Capsulitis

P. Akhbari1, C. Martin2, L. Hallam2, M. Walton3, P. Monga3, A. Watts3, L. Funk3

1Imperial College, London, London, United Kingdom, 2The Arm Clinic, Wigan, United Kingdom, 3Wrightington Upper Limb Unit, Wigan, United Kingdom

Background: Hydrodistension (HD) is a recognised treatment for Adhesive Capsulitis (AC) of the shoulder. However, it is not successful in all cases. The aim of this study was to investigate the factors predictive of poor outcomes following arthrographic HD for idiopathic AC, in order to facilitate future decision making for this procedure.

Methods: A retrospective cohort study of 220 patients with idiopathic AC undergoing HD was undertaken from 2012 to 2017. HD was performed in all patients with 40mg Triamcinolone, 10mls of 0.25% levo-bupivoccaine and 0.9% normal saline until the point of tolerable discomfort or capsular rupture under ultrasound or radiographic guidance. All patients underwent a standardised physiotherapy protocol. Data was fit to a normal distribution. Unpaired t-tests were conducted to compare groups with “successful” and “unsuccessful” HD procedures. Relative risks were calculated. False discovery rate (FDR) adjusted p-values were calculated to account for multiple testing. A p<0.05 was deemed to be statistically significant.

Results: This series consisted of 100 males and 120 females with a mean age of 53.1 years ±7.4 (range 35-82 years). Thirty-six patients (16.4%) reported poor outcomes and underwent an arthroscopic capsular release (ACR). Factors associated with an increased relative risk of failure following HD and progression to ACR were female gender, contralateral AC, a pain score from the Constant score greater than 10/15 and reduced external rotation less than zero degrees. The relative risks were 2.9, 2.9, 2.5 and 2.25 respectively. No statistically significant difference was demonstrated in age, diabetes, arm dominance, forward flexion, abduction or internal rotation.

Conclusion: Clinical predictors of poor outcomes for HD include female gender, high pain scores, previous contralateral AC and external rotation less than zero degrees.

Implications: This information is useful in the treatment decision making process for idiopathic AC.

There is NO Conflict of Interest: Yes

1785 - Complications and survivorship associated with operatively treated olecranon fractures in the elderly

J. Parkes1, R. Limb1, S.T. Quadri2, J. Lamb3, G. Mohrir2, A. Yousef2, P. Cowling1

1Leeds Teaching Hospitals NHS Trust, Leeds Upper Limb Unit, Department of Trauma and Orthopaedics, Leeds, United Kingdom, 2Leeds Teaching Hospitals NHS Trust, Department of Trauma and Orthopaedics, Leeds, United Kingdom, 3University of Leeds, Leeds, United Kingdom

Background: Olecranon fractures in the elderly have an increasing incidence, and often present as fragility fractures secondary to low energy trauma such as a fall from standing height. Our aim is to investigate the complications and patient survivorship of treating elderly patients with olecranon fractures.

Method: Using our trauma database, we identified patients >70 years old with olecranon fractures, and retrospectively reviewed radiographs and medical records.

Results: 195 patients were identified (mean age 81.5 years, 73% female). 31 patients presented with concomitant fractures (16%), of which 17 were hip fractures. Overall, 19.6% of patients suffered a failure of fixation, and of these, 59% returned to surgery. Most complications were related to fixation failure, metal work problems and non-union: wound healing problems and SSI were low. The largest treatment group underwent tension band wiring (TBW) (n=95, 49%, mean age 81.4yrs). 18 patients suffered a surgical complication (19%), 13 of whom required return to surgery. The second largest treatment group underwent plating (ORIF) (n=53 27%, mean age 79.9yrs). 11 patients suffered a surgical complication (21%), 4 of whom required return to surgery. 47 patients had non-operative treatment (24%). This group was the oldest (mean age 83.6 years). 2 patients suffered a complication (4.7%), none requiring return to surgery. Overall patient survivorship calculated by Kaplan-Meier was 0.82 at 1 year. The worst survivorship occurred in patients treated non-operatively (0.62 at 1 year).

Conclusions: Olecranon fractures in the elderly have reasonably high mortality rates at a year following injury, and carry high rates of complications, including return to surgery, when operatively managed. Significant thought should be given to the management options of a patient presenting with this injury, with non-operative management providing fewer complications than surgery.

There is NO Conflict of Interest: Yes

1864  - Systematic Review of The Treatment of Periprosthetic Fractures of The Humerus

H. Mourkus1, N. Phillips1, C. Peach1

1Manchester University Foundation Trust, Shoulder and Elbow Unit, Manchester, United Kingdom

Background: The UK National Joint Registry data reported a rise in the number of revision procedures performed for periprosthetic fractures around the shoulder and the elbow between 2012 and 2018. The number of revision arthroplasties has more than doubled for both the shoulder and the elbow during this period. Guidelines for treatment of these increasingly frequent fractures patterns are not well defined.

Methods: A systematic search was performed on PubMed, Medline and Embase. Hand searching abstracts from selected papers was also used. For inclusion, studies were required to include outcomes of treatment of post-operative periprosthetic humeral fractures, ability to identify fracture pattern and prosthetic stability.

Results: The search returned 402papers. Abstracts were reviewed and 5 more papers were included. 40 papers met the inclusion criteria. Average MINORS score was 10. A total of 210 patients were included. Non-surgical treatment was used in 60 patients predominantly having stable prostheses. 30 (50%) fractures healed, however the remaining patients required further surgical treatment. Overall complication rate, excluding revision, was 31%. Surgical fixation of fractures with or without bone grafting was used in 99 fractures. The majority (94 fractures) were associated with stable prostheses and no further intervention was needed. There were 17 reported complications in this group. Revision arthroplasty was used to treat 57 patients, predominantly with unstable implants (84%). No further intervention was needed in 87%. Endo-prosthetic replacement was used to treat 22 patients. No further intervention was needed in 16 fractures (72%). There were 25 complications reported in this group.

Conclusion: Surgical management of periprosthetic fractures of the humerus appears to be more effective than non-surgical treatment with similar rates of complications between groups. Treatment methods tended to be selected based on implant stability. This study highlights that there is a lack of high-quality evidence in this evolving field.

There is NO Conflict of Interest: Yes

Accepted Abstracts

67 - Distal Humeral Arthroplasty for Revision Elbow Surgery: a retrospective review of implant survival

M Stoddart1, B Gabbott1, D Butt1, W Rudge1, A Majed1, D Higgs1, M Falworth1

1Royal National Orthopaedic Hospital, London, United Kingdom

Introduction: Distal humeral arthroplasty is an uncommon procedure, reserved as a last resort for patients with poor bone stock following trauma or revision elbow arthroplasty. The majority of reported literature concentrates on outcomes following tumour resection requiring endoprosthesis. We present our consecutive cohort of 29 patients with non-malignant disease treated in a tertiary upper limb referral centre.

Methods: Database review identified 39 patients treated in a single centre over a ten-year period. We report on 29 patients who were followed up for a minimum of one year. Data were retrieved from electronic patient records, clinic letters and operative logbooks. The primary outcome measure was complication rate. Secondary outcomes included infection, loosening, periprosthetic fracture, and overall revision rates. A binary logistic model was utilised for primary and secondary outcomes. Significance was set at p <0.05.

Results: Mean age was 60 years (range 29 – 87). Twenty replacements were performed in female patients and median follow up was 3.7 years (IQR 1.4 to 6.4). Thirteen were performed for aseptic loosening of previous total elbow arthroplasty, 9 for infected metalwork, 5 for periprosthetic fracture and 2 following failed fracture fixation. The overall complication rate was 34.5% including 3 cases of infection (10%), 4 aseptic loosening (14%) and 3 periprosthetic fractures (10%) by final follow up. Two patients had radial nerve neuropraxia post operatively which resolved without intervention. Median time to complication was 11.7 months (IQR 11.0-13.8). Five patients (17.2%) progressed to revision distal humerus surgery. No independent variable was found to be associated with complication rate.

Conclusions: We report on the largest cohort of distal humeral arthroplasty in the literature, with a complication rate reflecting the complexity of surgery. Distal humeral arthroplasty appears to be a reliable method of reconstruction in patients with poor bone stock following trauma or previous total elbow arthroplasty.

There is NO Conflict of Interest: Yes


D Thurston1, N Green1, S Elashry1, S Gella1, T Singh1, S Deshmukh1, K Theivendran1

1Sandwell & West Birmingham Hospitals NHS Trust, Birmingham, United Kingdom

Background: Rupture of the distal biceps tendon is an uncommon injury, typically occurring in the dominant elbow of male patients, with steroid-users and smokers being at increased risk. In younger, high-demand patients, surgical repair is usually advisable and should ideally be performed within a couple of weeks of injury. The aim of our review was to determine patient satisfaction following distal biceps tendon repair.

Methods: We performed a single-centre, multi-surgeon retrospective review of all distal biceps tendon repairs performed between March 2014 and April 2018. Data were collected on mechanism and side of injury, hand dominance and timing of surgery. We then conducted telephone interviews with identified patients to determine satisfaction with treatment, utilising the Oxford Elbow Score (OES) and Quick Disabilities of Arm, Shoulder and Hand (Q-DASH) outcome measures.

Results: Twenty-nine patients identified (100% male), average age 41, 36% of injuries occurred on the dominant side. Fifteen patients (52%) were operated on within 2 weeks of injury. Surgical repair was performed using endobutton in most cases (72%). Nineteen patients (66%) were able to be contacted for telephone follow-up. Average follow-up period to time of telephone interview was 41 months (Range: 15 – 64 months). Two post-operative complications were reported (one superficial infection, one incidence of lysis around endobutton). Average OES was 46 (range: 42 – 48), and average Q-DASH was 1.6 (range: 0 – 9.1). There was no significant difference in either OES or Q-DASH when comparing patients who were operated on within two weeks and those whose surgery was delayed beyond two weeks.

Conclusion: Our results suggest that patient-reported outcome measures following distal biceps tendon repair remain satisfactory in the short to medium term, irrespective of time to surgery.

There is NO Conflict of Interest: Yes


K. Gokaraju1, I. Drummond1, P. O'Hagan1, S. Khor1, H. Okewole1, A. Carlos1, L. Di Mascio1

1Royal London Hospital, Trauma and Orthopaedics, London, United Kingdom

Background: We present findings from the largest available UK series of scapula fractures. We aim to provide a review of these injuries in order to provide a greater understanding of the management of such injuries.
Methods: We performed a retrospective cohort study reviewing scapula fractures admitted to our level 1 trauma centre from 2012-2018. Imaging and electronic notes were reviewed to identify demographics, injury patterns, assessment modalities and management.
Results: We identified 370 patients (391 scapula fractures) of mean age 43yrs (3-93), 82% being male. 91% of patients had high energy injuries, 92% ATLS management, 29% haemodynamically unstable, 11% had central nervous system (CNS) deficit and 3 died. RTA was the most common mechanism (59%) followed by a fall from height (25%) and 92% were polytraumas. 16 fractures were open, 6 associated with GHJ dislocation, 11 brachial plexus injuries, 7 vascular injuries and 1 traumatic amputation. 38% of fractures were assessed with x-ray compared to 96% with CT. 51 (13.3%) fractures were intra-articular (classified according to Ideberg). 67 (17.5%) fractures demonstrated relative indications for surgery but only 72% (48) of these underwent surgery, largely due to the severity of other injuries and comorbidities. 92% of the fractures followed-up united.
Conclusion: Our experience is comparable to that of the international literature. Scapula fractures are often complex, high-energy injuries demanding ATLS management in a level 1 trauma centre due to the high incidence of polytrauma, haemodynamic instability and CNS injury. Despite this, mortality rates remain low in comparison. Thorough and timely evaluation with Identification of associated upper limb injuries and CT to delineate fracture configuration and displacement is essential for appropriate management and reduction in morbidity.
Implications: A greater awareness of the complexity of these injuries by the treating clinician is required for appropriate assessment and management

There is NO Conflict of Interest: Yes

929 - Minimally Invasive Percutaneous Fixation with modified Palm Tree Technique for fractures of the proximal humerus: Clinical and radiological outcomes in a series of one hundred and thirty-two patients

S. Virani1,2, A. Leonidou1,2, G. Panagopoulos2, G. Sforza2, E. Atoun2, O. Levy2

1East Kent Hospitals University NHS Foundation Trust, Trauma and Orthopaedics, Ashford, United Kingdom, 2Reading Shoulder Unit, Trauma and Orthopaedics, Reading, United Kingdom

Introduction: The optimal treatment of displaced proximal humeral fractures remains controversial. We describe a minimally invasive technique using  3 curved wires, inserted in a retrograde fashion into the humeral head. These are aimed to diverge within the humeral head to provide three separate 3-point fixations to achieve good stability. We present the results of proximal humerus fractures managed with the modified palm tree technique.

Methods: A retrospective analysis of data collected prospectively including demographics, radiographs, clinical outcomes, complications and revision surgery for patients treated with the palm tree technique was performed. 

Results: Between 1998-2017, 132 patients underwent fixation with this technique. Average age was 61.8 years. Fifty-Eight fractures were 2 part, 46 were three part and 28 were four part. Average follow up was 26 months. In three to four part fractures, a bone graft substitute block was used behind the humeral head fragment for structural support. There were 11 early revisions (8.3%). In 7 cases the fixation failed early and was revised to other implants like angular & locking plates (4), hemiarthroplasties (2) and reverse arthroplasty (1). In 4 cases the construct was revised to achieve better positioning of the wires. From the 125 remaining patients, 120 achieved union (96.8%). There were 3 painless fibrous non-unions and 2 painful non-unions requiring revision. The mean final Constant score was 75.5 and subjective shoulder value was 7.8/10. Nine patients (6.8%) developed avascular necrosis of the humeral head of which three patients were revised later to an arthroplasty.
Conclusion: This technique is a simple, minimally invasive technique which can be used for two, three and four part fractures with good functional outcomes and high union rates. No metalwork remains in the proximal humerus should another procedure like arthroplasty be required in case of avascular necrosis of the humeral head or fracture sequela.

There is NO Conflict of Interest: Yes


R. Rampal1, M. Al-uzri1, P. Cowling1

1Leeds Teaching Hospitals NHS Trust, Department of Trauma and orthopaedics, Leeds, United Kingdom

Background: The humerus is the second commonest bone involved in skeleton metastasis, and presents late in the course of metastatic disease. These fractures can lead to severe functional impairment for the patient and often require surgical intervention with intramedullary nail fixation (IMN). This study was conducted to determine the incidence of humeral metastatic tumours requiring surgery at our institution, identify the involved primary tumour, and quantify complications, further interventions and survivorship following surgery.

Methods: We retrospectively analysed medical records and radiographic images of 54 consecutive patients undergoing 61 IMNs for humeral metastasis at our institution between 2004–2017.

Results: Mean age at surgery was 68 years (M=F). Multiple myeloma was the most common primary tumour (26%) followed by breast carcinoma (18%), renal cell carcinoma (15%) and prostate carcinoma (15%). 67% presented having already sustained a pathological fracture through a humeral deposit. 54% of bone lesions were in the proximal third of the humeral shaft. Mean overall survivorship was 15 months (range 1 week - 68 months), with a cumulative survival after surgery of 45% (95% CI 32-60) at 1 year. IMNs for multiple myeloma demonstrated the best survivorship (mean 27 months) followed by breast carcinoma (mean 16 months). The worst survivorship was seen with a presentation of pathological fracture, presence of visceral metastasis and >2 other bony metastases. We found no documentation of wound infection, metalwork failure, or revision of implant.

Conclusions: Our survival of 15 months demonstrates this procedure can provide symptomatic relief for an acceptable portion of the latter stages of this cohort’s lives. Our series also demonstrated that survivorship is worse if metastatic disease is more advanced or fracture is already sustained. Therefore, regular surveillance of common tumours with high chance of bony metastasis and early recognition of local symptoms is required to prevent this.

There is NO Conflict of Interest: Yes

1609 - Treatment of Irreparable Rotator Cuff Tear Without Glenohumeral Arthritis with Reverse Shoulder Arthroplasty

D. Neogi1, S. Venkatachalam1, D. Cloke1, C. Gibbons1, R. Pratt1, J. Candal-Couto1

1Northumbria Healthcare NHS Foundation Trust, Trauma and Orthopaedics, Newcastle, United Kingdom

Background: The purpose of the present study was to evaluate the outcomes of reverse shoulder arthroplasty (RSA) in patients with massive rotator cuff tears but without glenohumeral arthritis.

Methods: From July 2015 to June 2018, we prospectively collected PROMS on 221 Reverse Shoulder Replacements. In 67 cases RSA was used for the treatment of irreparable rotator cuff tears without glenohumeral arthritis. The indications were persistent pain and dysfunction despite adequate non-arthroplasty treatment, in the presence of at least a two-tendon tear with retraction and muscle degeneration. Patients were retrospectively classified according to cuff tear arthropathy (CTA) Hamada stage-1, 2, or 3. 66 patients had a minimum of two years of follow-up with completion of Oxford Shoulder Score.

Results: There were 11, 34 and 21 patients in CTA 1, CTA 2 & CTA 3 respectively with an average age of 74 years. Forty-six shoulders had no previous surgery, and 20 shoulders had at least one previous operation. The average duration of follow-up was 37 months (range, 24 to 60 months). On average the OSS improved from 17 to 35 (p < 0.05). The post op OSS was 37 in CTA1, 36 in CTA2 and 33 in CTA3. Patients with previous surgery had a lower OSS than those without, but this difference was statistically insignificant 32 vs 36 (P >.05). There were a total of 4 revisions and 5 other complications. Overall 92% of patients experienced an improvement in the OSS and in 82% this improvement was more than 10 points. 6% of patients has a OSS worse than the preoperative one. Overall, 70%of patients achieved a good or excellent result.

Conclusions: RSA provides reliable pain relief and return of shoulder function in most patients with massive rotator cuff tears without arthritis at 2 years follow-up with a modest complication rate.

There is NO Conflict of Interest: Yes

1869 - The Glenoid Convergence Angle - A simple method to assess glenoid inclination on plain radiographs

R. Whitham1, A. Assaf1, H. Akehurst1,2, O. Donaldson1

1Yeovil District Hospital, Department of Trauma and Orthopaedics, Yeovil, United Kingdom, 2Gloucester Hospitals NHS Foundation Trust, Department of Trauma and Orthopaedics, Gloucester, United Kingdom

Purpose of study: Superior glenoid inclination is known to increase shear stress when performing reverse total shoulder arthroplasty (RTSA); the aim of this study was to evaluate a new measurement of glenoid inclination for pre-operative planning in RTSA.

Methods: Pre-operative plain AP radiographs and CT scans of thirty-eight patients undergoing RTSA over 2 years were independently assessed by three reviewers to measure glenoid inclination. Two methods for measuring inclination were compared: the commonly used Beta angle, measured as an angle between a line drawn along the floor of the supraspinatus fossa intersecting a line connecting the superior and inferior glenoid tubercles (glenoid fossa); and a novel angle measured between a glenoid fossa line and a line drawn up the medial border of the scapula (named ‘convergence angle’). A positive angle was attributed when lines converged superiorly, denoting superior glenoid inclination. Pearson’s Correlation Coefficient was assessed between the 2 angles as well as between imaging modalities.

Results: Average age of patients was 76.8-years-old and 82% were female. Mean time between pre-operative radiographs and CT was 25 weeks. There was a strong correlation between beta and convergence angles (-0.77). Mean beta angle measured on radiographs and CT was 75.6 and 82.1 degrees respectively, with a correlation coefficient of 0.42. Mean convergence angle on radiographs and CT was -1.19 and +3.37 degrees respectively, with a correlation coefficient of 0.85. Correlation between CT and radiographic methods was significantly greater for the convergence angle compared to beta angle.

Conclusion: The convergence angle described is a simple method to measure glenoid inclination pre-operatively with improved correlation compared to the current gold standard. This should aid in pre-operative planning for patients in whom superior metaglene augmentation may be beneficial to reduce the risk of a superiorly inclined baseplate and subsequent excessive bone-implant interface stresses.

There is NO Conflict of Interest: No

Disclosure: Mr Whitham, Mr Assaf, and Mr Akehurst have no conflicts of interest to declare. Mr Donaldson reports personal fees for consulting services for Exactech, outside the submitted work.


Virtual Podium Presentations

Virtual Podium Presentations

25 - Risk Factors for Failure in the Management of Traumatic Cervical Fractures with Single-Stage Anterior Cervical Discectomy and Fusion (ACDF)

J. McDonnell1, T.D. Ross1, D. Ahern2, T. O Doinn3, D. Gibbons3, J.S. Butler3

1Royal College of Surgeons, School of Medicine, Dublin, Ireland, 2Trinity College, School of Medicine, Dublin, Ireland, 3The Mater Misericordiae University Hospital, National Spinal Injuries Unit, Dublin, Ireland

Background: Diagnosis and appropriate management of traumatic cervical fractures is important due to secondary neurological sequelae and permanent disability that can arise. For fractures requiring surgical fixation 1-stage surgery is appealing in favour of 2-stage surgery due to reduced intraoperative time and potential subsequent complications. However certain patients fail a 1-stage anterior approach. The purpose of this study is to identify patient- and injury-specific factors associated with failure in 1-stage anterior fixation to optimise the treatment of traumatic cervical fractures.

Methods: A retrospective study was performed at our institution from June 22nd 2016 to August 14th 2019 to identify patients that suffered traumatic cervical fractures and were managed surgically with a 1-stage anterior cervical discectomy and fusion (ACDF). Data collated included demographic parameters, fracture characteristics, associated injuries, and characteristics of fusion surgeries. Statistical analysis involved t-test of independent means, and z-test of proportions where applicable.

Results: Twenty-two patients were identified. Five patients (22.7%) failed the 1-stage ACDF approach and required subsequent second-stage posterior instrumentation. Statistically significant parameters that influenced 1-stage ACDF failure were age discrepancy between cohorts (65.2 vs 50.2, p<0.04) and injuries requiring cervico-thoracic junctional stabilization due to instability (60% vs. 11.7%, p<0.01).

Conclusion: The definitive management of traumatic cervical fractures remains a surgical challenge. The results of our study indicate that older patients and injuries at the cervicothoracic junction have a higher risk of failure with 1-stage ACDF. Thus, the authors recommend considering 2-stage anterior-posterior fusion in elderly patients and in injuries at the cervicothoracic junction.

There is NO Conflict of Interest: No

156 - Sex steroids therapy in Spinal Cord Injury using MRI as biomarker

M Fataki Likale1, S Lévy1

1Hopital Riviera Chablais, Orthopaedic Surgery, Rennaz, Switzerland

Background: Spinal Cord Injury (SCI) can be defined as an insult to the spine which can cause partial or complete interruption of its function. MethylPrednisolone is a long-timed use molecule in SCI acute phase management. But, there has been a controversy related to harmful side effects. Estrogen and Progesterone are known for their gynecological purposes. Nevertheless, proofs of their neuroprotective properties are accumulating, with encouraging results related to powerful anti-inflammatory effects and reduction of apoptosis. MRI remains a cornerstone in diagnosis and management, allowing the acquisition of data leading to prognostic and therapeutic outcomes. The purpose of this research is to demonstrate that the use of sex steroids in SCI with MRI as a biomarker, could be a valuable step in the management of the disease.

Methods: A literature research was performed on PubMed. Inclusions criteria were studies describing molecular mechanisms of Estrogen/Progesterone efficiency in SCI and those focusing on MRI as a biomarker in SCI, especially Diffusion Tensor Imaging (DTI).

Results: Our research has identified 64 articles matching our inclusion criteria, showing solid evidences of sex steroids efficiency in SCI, with promising neuroprotective effects. Concerning MRI, 61 articles discussing about DTI as biomarker in SCI were included, demonstrating its great potential.

Conclusion: Estrogen promotes neuritis outgrowth, neurons sprouting, synaptogenesis and enhances the up-regulation of anti-apoptotic genes. Progesterone stimulates oligodendrocytes precursors maturation and thus, myelination. DTI provides priceless informations by being sensitive to microstructural changes in the spinal cord. Therefore, we can conclude that the use of sex steroids would be an efficient neuroprotective therapy during the acute phase management of SCI. As far as we know, no clinical trial worldwide have investigated this. To demonstrate it, we suggest the conduct of a multi-centered, prospective, randomized and double-blinded study.

There is NO Conflict of Interest: Yes


J Boktor1, A Al-Shahwani2, M Simons3, R Smith4, P Banerjee4

1Royal Gwent Hospital, Orthopaedic Department, Newport, United Kingdom, 2Kettering General Hospital, Orthopaedics, Kettering, United Kingdom, 3Morriston Hospital, Trauma & Orthopaedics, Cardiff, United Kingdom, 4Kettering General Hospital, Trauma & Orthopaedics, Kettering, United Kingdom

Background: Cauda equina syndrome (CES) is a rare but serious condition that, if missed at initial presentation, can lead to serious morbidity and dysfunction. Early diagnosis is crucial for favourable outcome. Urodynamic assessment using bladder scan can gives an accurate impression about the bladder emptying abilities. Few studies included measurement of post-void residual urine (PVR) as a predictor for acute CES before proceeding to MRI scan, yet there are differences in the numerical cut-off point as a threshold volume predicting the diagnosis amongst these studies.

Objectives: Meta-analysis and systematic review of literature focusing on PVR as a predictor CES to identify the reliability of PVR and the optimal numerical volume to predict CES.

Material & Methods: A comprehensive literature search was undertaken in PubMed, Medline, and Embase databases using our search strategy. Meta-analysis of collated data was done.

Results: A total of six articles from 1954 studies fit with our inclusions and exclusions criteria. These articles included 3274 patients with 454 suitable for meta-analysis. CES was confirmed in 73. Bladder scan diagnosed 52 and excluded 275. The sensitivity of PVR> 100ml was 64% (CI 97.5%: 0.44-0.80), specificity 59.2% (CI 97.5%: 0.46 - 0.711), while PVR >200 showed more predictive figures, with sensitivity improved to 76.9% (CI 97.5%: 0.52-0.91) and specificity to 97.5% (CI 97.5%: 0.38-1.00).

Conclusions: Post-void bladder scan is an essential tool in CES assessment. Authors recommend PVR > 200 ml as the numerical cut-off point might be the used along with other clinical red flags to recommend urgent MRI in suspected acute CES.

There is NO Conflict of Interest: Yes

388 - The effect of isolated sacral fracture morphology on length of inpatient stay

T Heaton1, D Evans1, V Kumar1, C Jordan1, J Daurka1

1Imperial College Healthcare NHS Trust, Orthopaedics, London, United Kingdom

Aim: Sacral fractures are complex injuries with varied morphology and outcomes. It is unclear how sacral fracture morphology affects outcomes. In 2018, AO Spine published the first validated system for classification of isolated sacral fractures. So far, this classification system has not been correlated with any outcomes. This study aims to determine whether sacral fracture morphology predicts length of inpatient stay. 
Patients and methods: This retrospective case series describes isolated sacral fractures admitted to a major trauma centre over a 7 year time period. The computerised tomography scans of the fractures were retrospectively classified according to the AO Spine system, which is based on increasing levels of posterior pelvic and spinopelvic instability. Length of inpatient stay was compared with AO Spine classification, patient age, sex, injury severity score and whether management was surgical or conservative. 
Results: 76 patients were included, comprising 42 males and 34 females. Mean age at time of injury was 47 (15-95). Of the 76 fractures, 32 fractures were type A, 20 were type B and 24 were type C. Average length of stay was 22 days (2-111). Linear regression analyses revealed that a type C fracture and high injury severity score predict an increased length of stay. Length of stay increased 11.1 days when a patient had a type C fracture (p<0.05) and increased 0.6 days for each unit of ISS (p<0.05). Patient age, sex and management did not affect length of stay. 
Conclusion: These data show for the first time that a validated sacral fracture classification system predicts short term outcomes. Type C sacral fractures have the highest level of instability and predict a longer inpatient stay. 
Implication: These findings suggest that sacral fracture morphology, particularly the AO Spine classification system, could contribute to the first validated treatment algorithm.

There is NO Conflict of Interest: Yes

653 - Does short segment reduction and fusion (TLIF) of spondylolytic spondylolisthesis normalise lumbar lordosis and improve spino-pelvic alignment?

T. Boddice1, T. Robinson1, H. Fitzjohn2, R. Shah1

1Hull Royal Infirmary, Trauma and Orthopaedics, Hull, United Kingdom, 2Hull York Medical School, Hull, United Kingdom

Background: Spondylolytic spondylolisthesis is commonly associated with back pain and neurological symptoms. The primary localised kyphotic deformity at the level of the spondylolisthesis is compensated by increased lordosis across the remaining lumbar spine giving rise to a hyperlordotic lumbar spine. There is usually an associated increase in sacral slope and a corresponding decrease in pelvic tilt.

Patient Sample: 37 consecutive patients from a single surgeon series of spondylolytic spondylolisthesis undergoing reduction and fusion (TLIF) performed between 2013 and 2019.

Methods: Two independent observers, blinded of each other, reviewed the pre and post-operative standing radiographs. Using PACS software they measured the lumbar lordosis across the lumbar spine as a whole and individual motion segments, and sacral slope. The lumber lordosis was measured from the superior border of S1 to superior border of L1.

Results: 27 fusions were performed at L5/S1, 9 at L4/5 and one at L3/4. Normalisation of lordosis was noted at all spinal levels, including distant from the surgical site. Overall mean lumbar lordosis reduced from 63.43 degrees to 48.89 degrees (p <0.0001) and sacral slope from 45.78 degrees to 39.12 degrees (p=0.0001). The lumbar lordosis was also mapped level-by-level with the greatest proportional change seen at L1/2, where a 27% reduction in the lordosis angle was noted. The greatest angular correction was consistently at L5/S1 with a mean reduction of 3.55 degrees (p=0.009). The decrease in sacral slope following reduction of the spondylolisthesis is likely to be a contributory factor for this reduction.

Conclusions: This study shows that short segment reduction and fusion for spondylolytic spondylolisthesis can normalise lumbar lordosis at all levels of the lumbar spine and this occurs level-by-level. There is also an associated spontaneous reduction in the sacral slope and therefore a corresponding improvement in the pelvic tilt leading to improved spino-pelvic alignment.

There is NO Conflict of Interest: Yes

673 - A study of relationship between vitamin b12 levels and neurological function in patients with cervical spondylotic myelopathy

S. Rawat1, S. Arya1, S. Ghumare2, P. Jadhav2, S. Sankar1

1Wrightington Hospital, Trauma & Orthopaedics, Wigan, United Kingdom, 2B.J. Govt. Medical College & Sassoon General Hospital, Orthopaedics, Pune, India

Background: Cervical spondylotic myelopathy refers to a clinical syndrome of long tract signs in the upper and lower extremities arising from a combination of static and dynamic compression. Vitamin B 12 deficiency leads to the development of degenerative disease of the peripheral and central nervous systems. There have been studies on subacute combined degeneration of the spinal cord resulting from VB12 deficiency, but, no studies to confirm the role of Vitamin B12 in the pathogenesis of CSM. The present study is to find out a co-relation between VB12 deficiency and CSM.

Methods: Our study includes 100 patients with CSM to evaluate for co-relation with VB12 deficiency. Demographic data, clinical, radiological and laboratory investigations were done to find a co-relation between VB12 deficiency and severity of symptoms.

Result: The level of involvement was maximum at C5-C6 level (42%) followed by C4-C5 level (28%) and C6-C7 levels (20%). Sensory abnormalities were seen in 61% cases, while motor weakness was reported in 50% cases. Prevalence of VB12 deficiency was noted in 47% of cases. VB12 deficiency was seen in 40% cases of level 1 compression and 54.1% and 53.8% cases of level 2 and 3 cord compression respectively. No significant association was observed between level of cord compression and VB12 deficiency (p- 0.37). Significant association was seen between VB12 deficiency and sensory abnormalities (p<0.05). A higher prevalence of VB12 deficiency was seen in cases with motor weakness in all four limbs (48.6%) as compared to isolated involvement of upper or lower limbs (33.3% and 14.3%).

Conclusion: The results in the present study suggested that the incidence of CSM may be correlated with Vitamin B 12 deficiency, particularly for cases in which the clinical manifestations and the MR imaging do not fully match.

There is NO Conflict of Interest: Yes

756 - Clinical and Radiological Outcomes of Surgical Management of Severe Spinal Deformity in Osteogenesis Imperfecta (OI) Children

J. Yeats1, S. Lakkol1, C. DeVile2, B. Crowe2, R. Nadarajah2

1Great Ormond Street Hospital, Department of Spinal Surgery, London, United Kingdom, 2Great Ormond Street Hospital, Department of Neurology, London, United Kingdom

Background: Osteogenesis Imperfecta (OI) is commonly associated with spinal deformity, mainly in moderate and severe forms. We report clinical and radiological outcomes of surgical intervention in children with severe spinal deformity associated with OI.

Methods: This is a retrospective study of all children with OI receiving surgical intervention for scoliosis at our tertiary referral centre from April 2011 to October 2019. All children had multidisciplinary team assessment prior to surgery. Children who underwent surgical intervention were monitored for clinical and radiological outcomes including complications.

Results: At our tertiary paediatric referral centre there are 106 patients designated as Severe, Complex and Atypical (SCA) OI. Out of 106 SCA type children 12 (11.3%) had scoliosis with Cobb angle >30°; 5 (4.72%) had Cobb angle >45° at the time of presentation. All children treated with bisphosphonates. Surgical intervention was performed on 11 children during study period. Nine had posterior spinal surgery and two had magnetic growing rod construct. Average age range at the time of surgery 4-16 years (mean 12.3). There were 5 patients with double curve scoliosis (proximal thoracic and lumbar), four patients with single thoracolumbar scoliosis and two patients with single proximal thoracic scoliosis. The mean Cobb angle prior to surgery was 85.6° (range 68.5 to 109.8°). Following surgical intervention the mean post-operative Cobb angle was 63.8° (range 33 to 94°).

Three patients had metalwork complications requiring revision surgery (1 metalwork failure, 2 prominent metalwork causing pain). One patient developed a deep wound infection requiring surgical exploration and debridement. Two patients developed superficial wound infections which resolved with conservative management.

Conclusions: Spinal surgery can be a successful intervention for children with OI. Multidisciplinary assessment to inform decision-making around surgery is paramount. Our experience will facilitate the development of a standardised national spinal pathway for children with complex OI.

There is NO Conflict of Interest: Yes

886 - Back pain outcomes in single level lumbar spine surgery – a registry study of 1,937 patients

R. Jeyapalan1, M. Athanassacopoulos2, A. Cole2, M. Ivanov2, A. Michael2, N. Chiverton2, L. Breakwell2, J. Tomlinson2

1Northern General Hospital, Trauma and Orthopaedics, Sheffield, United Kingdom, 2Northern General Hospital, Sheffield, United Kingdom

Methods: All patients undergoing single level lumbar discectomy (D) and single level decompression (SLD) in our unit between June 2012 and July 2018 were identified using the British Spine Registry. Patients with pre and post op VAS scores were included. There were 1,353 patients in the lumbar discectomy group and 914 patients in the single level decompression group.  Primary outcome was change in VAS back pain score (VAS back) at six months.
Results: There were 1159 discectomy patients (mean age 44 years, 51.5% male) and 778 decompression patients (mean age 61 years, 49.5% male). Mean pre-operative VAS back was 6.2 in both groups.  86.6% of discectomy patients had an improvement in back pain at 6 weeks and 79.3% at 6 months. 55.6% of patients achieved MCID (minimum clinically important difference) in VAS back at 6 weeks, and 43.7% at 6 months. 83.5% of decompression patients had an improvement in VAS back at 6 weeks and 75.8% at 6 months. 55.5% of patients had a MCID in VAS back pain score at 6 weeks and 42.3% at 6 months.
Conclusion: Less than 50% of patients undergoing lumbar discectomy or decompression achieve the VAS back MCID at six months after surgery. This data is potentially useful when counselling patients about treatment options.

There is NO Conflict of Interest: Yes

1032 - Is it necessary to cross match blood for Posterior Correction of Adolescent Idiopathic Scoliosis?

R. Thimmaiah1, N. Nagrath2, D. Gowda1, C. Bhimarasetty1, J. Mehta1

1The Royal Orthopaedic Hospital, Birmingham, United Kingdom, 2University Hospital Hradec Kralove, Hradec Kralove, Czech Republic

Background: Routine grouping and cross matching 2 units of blood is an accepted practice for posterior correction of Adolescent Idiopathic Scoliosis (AIS). We reviewed this in light of the current anaesthetic practices and explored the economic implications of not ordering blood for uncomplicated posterior AIS corrections.

Methods: In this prospective case series, 84 patients (17 males, 67 females) with a mean age of 14.6 years (range 10-18 years) and a mean BMI of 20.71, underwent a posterior correction for AIS between September 2016 and March 2018. We excluded revision and anterior procedures. The anaesthesia protocol was identical in all the patients with regards to the mean arterial pressure, maintenance of the temperature and haemoglobin status. Intra-operative cell salvage, Tranexamic acid and routine multi modal spinal cord monitoring was used. We documented patient demographics, surgical and blood transfusion related parameters.

Results: A mean of 11.7 levels were instrumented with forty-four patients requiring additional Ponte osteotomies at the apex (mean 3.61 levels). The mean pre-operative Cobb angle was 57.2 degrees and was corrected to 17.4 degrees (Correction Index 1.5). The mean blood loss was 1073.2 ml (20.09 ml / kg). The cell salvage resulted in an intra-operative replacement of 422.8 ml (mean). The mean pre-operative haemoglobin (Hb) was 138.7 and the mean lowest post-operative Hb was 97.68. None of the patients required intra-operative homologous blood transfusion. Five patients required postoperative blood transfusion on day 2 or 3. The handling fee per blood product is approximately £90.13. We had ordered 195 units at a cost of £17, 665 and only 5 patients were transfused.

Conclusion: Our results indicate that cross matching blood is not essential on the day of the operation for a posterior correction of AIS. Our modern day anaesthetic practices allow for a safe operation. Additionally, this reduces the financial burden.

There is NO Conflict of Interest: Yes

1076 - Triangular Titanium Dowel IS Better Than Cannulated HA Coated Screw For Sacroiliac Joint Stabilisation: Results From A Prospective Non Randomised Study

R. Agarwal1, K. Mohanty1

1University Hospital Wales, T&O, Cardiff, United Kingdom

Introduction: Minimally invasive sacroiliac joint (SIJ) stabilisation is a NICE recommended treatment option for refractory SIJ pain. The purpose of this study was to compare patient reported clinical outcomes of minimally invasive SIJ fusion between triangular titanium dowels (TTD) and hydroxyapatite coated screw (HACS).
Methods: 40 patients underwent SIJ fusion using HACS between 2013 to 2015 and 73 patients underwent SIJ fusion using TTD between 2016 and 2018. Patients were followed up closely and patient report outcome measures (PROM) were collected preoperative and 12 months after surgery. Pre- and postoperative outcomes were evaluated using Short Form (SF)-36, Oswestry Disability Index (ODI), EuroQol-5D-5L (EQ-5D-5L) and Majeed Pelvic Scores (MPS). All PROMs were collected prospectively. 
Results: 33 patients in HACS group and 61 patients in TTD group completed follow-up. Both groups were comparable as there was no significant difference in preoperative age and all PROMs. All postoperative PROMs were significantly better in the TTD group. 21 patients (63%) had lysis around the screw in the HACS group compared to 6 patients (9.83 %) in the TTD group. There was a 6.5 times higher risk of developing lysis around the screw in the HACS group (p=<0.001). Patients with lysis around the screw had significantly worse PROMs compared to those without lysis.  
Conclusion: SIJ stabilisation using triangular titanium dowel resulted in better improvement in PROMs as compared to cannulated HA screws. HA coated screws resulted in higher risk of developing lysis around the screw which results in poor outcome following SIJ stabilisation.

There is NO Conflict of Interest: Yes

 1490 - Ogilvie’s Syndrome (OS) Following Paediatric Posterior Scoliosis Correction

S. Singh1, A. Ragab1, M. McCarthy1

1University Hospital of Wales, Spinal Surgery, Cardiff, United Kingdom

Introduction: Ogilvie’s syndrome (large bowel pseudo-obstruction) is a recognized cause of post-operative diffuse abdominal pain and distension. Few cases have been described following spinal surgery in the pediatric population.

Aim: To assess the incidence and management of Ogilvie Syndrome following paediatric posterior scoliosis correction.

Methods: Single center retrospective analysis of patients below 18 years undergoing posterior scoliosis correction from September 2013 to July 2019. Post-operative X-Rays and case notes were reviewed.

Results: Two hundred patients underwent posterior scoliosis correction in the period of the study. Twelve patients (6%) had signs of large bowel pseudo-obstruction on abdominal x-rays performed post operatively. The average age was 14.5 years. Four patients were operated for neuromuscular scoliosis. Only one patient was diagnosed as large bowel pseudo obstruction and managed appropriately according to literature guidelines. All cases settled spontaneously without complication.

Conclusion: Ogilvie’s Syndrome should be taken into consideration as a sequalae following paediatric posterior scoliosis correction. Clinicians looking after these patients need to be aware of this condition so that it can be identified and managed appropriately.

There is NO Conflict of Interest: Yes

Accepted Abstracts

102 - Early post-operative complications with a return to theatre – the experience of a single regional spinal surgery unit over a 5 year period

M Baker1, M Athanassacopoulos1, E Bayley1, L Breakwell1, A Cole1, M Ivanov1, R Michael1, J Tomlinson1, N Chiverton1

1Sheffield Teaching Hospitals, Sheffield, United Kingdom

Background: There is a paucity of literature on the overall incidence of early post-operative complications requiring a return to theatre after spinal surgery. We wished to determine our experiences and identify any potential areas upon which we could improve.

Methods: We undertook a retrospective review of 1709 consecutive elective and emergency operated cases (excluding injections) carried out in a regional Spinal Surgery Service over a 5 year period. All cases requiring a return to theatre within 30 days of the index procedure were identified via a variety of hospital information sources including the central theatre database. These were then analysed for type of complication, individual complication rate, associated risk factors, operating surgeon and outcome.

Results: 37 (2.17%) patients were identified to have returned to theatre within 30 days of their index operation. There was a range of complication types which included; wound dehiscence/infection (11), haematoma (7), recurrent disc herniation (7), failed anterior cervical fusion (4), failed posterior fixation (1), failed metalwork (2), progressive cervical myelopathy (3), dural tear (1), recurrent spinal abscess (1).

Discussion: For each complication we looked at common demographics that could be identified as potential risk factors. We also analysed our management of these complications and compared this to current literature to identify where we could change our practice.


  • We recommend that within the pre-operative consenting process, patients should be informed of a 2% overall risk of an early return to theatre due to all potential complications.
  • We have found our rates for individual types of complications to be in line with those typically quoted in the literature but have put measures in place with the aim to reduce future risk.   

There is NO Conflict of Interest: Yes

503 - Is there evidence of functional iron deficiency in adolescents and young adults undergoing spinal correction surgery?

T Barker1, P Barker2, A Cook1

1Norfolk and Norwich University Hospital, Trauma and Orthopaedics, Norwich, United Kingdom, 2Norfolk and Norwich University Hospital, Anaesthetics, Norwich, United Kingdom

Background: Spinal corrective surgery in adolescents can be associated with significant blood loss, which despite cell salvage and the use of tranexamic acid, may result in anaemia postoperatively.  Functional Iron Deficiency (FID) is a relatively new concept whereby otherwise well individuals have low iron stores but are not anaemic.  FID reduces a person’s ability to generate new red blood cells, and has been linked to poor outcomes for some other surgical procedures. This quality improvement project reviewed routine pre-operative blood tests to see if there was evidence of iron deficiency.
Methods: After gaining institutional approval, we retrospectively audited the haemoglobin concentration and blood indices in a sample of adolescents who had undergone spinal corrective surgery at Norfolk and Norwich University Hospital. These results were cross-referenced with the departmental database to identify extent of surgery and any complications.
Results: In our sample of 64 patients, the mean preoperative haemoglobin concentration was normal in both males (155.1g/L) and females (134.9g/L) (p<.005), however the Mean Corpuscular Haemoglobin (MCH) and Mean Cell Volume (MCV) tended to cluster towards and below the lower limits of normal, and were significantly lower than the population means (MCH p<.05 and MCV p<.001).  We also found that those with a low MCV preoperatively were more likely to be moderately to severely anaemic postoperatively (p<0.05).
Conclusions: These findings may suggest a prevalence of FID in this cohort, as the haemoglobin is the last index to fall. The degree of anaemia seen postoperatively can be associated with delayed wound healing, wound infection, and a longer recovery, although we did not demonstrate that in this cohort. Our next step will be to measure the serum ferritin concentration when patients are listed for surgery and if this is less than 100mcg/L supplement with oral iron for at least a month before surgery.

There is NO Conflict of Interest: No


570 - Does the cage prototype matter in Anterior Cervical Decompression and Fusion (ACDF)? A short-term single centre retrospective comparative review of complication profile between standalone cages and self-locking cage screw constructs

B. Balakumar1, F. Hassan1, S. Raju2, S. David Marconi3

1Royal Orthopaedic Hospital, Spinal surgery unit, Birmingham, United Kingdom, 2SSM Health Cardinal Glennon Children's Hospital-St. Louis University, Department of Orthopaedic surgery, St- Louis, United States, 3Christian Medical College, Community Health, Vellore, India

Background: This study aims to look at early complications following Anterior decompression and fusion (ACDF) performed using standalone cages versus cages-crew (Zero-P) construct for patients with cervical degenerative disc disease.

Methods: A total of 162 patients had undergone ACDF in between Aug 2016 to July 2018. There were 83 patients (111 levels) with standalone cage (SA) and 79 (111 levels) with cage-screw (CS) fixation. There was no difference between the groups in terms of age, gender, and levels of surgery. The follow-up ranged from 2 months to 24 months. We looked at the complications encountered between the groups in relation to the various clinical and radiological parameters assessed.

Results: The groups SA and CS were subdivided into single Vs multilevel surgery. The univariate analysis between the groups did not show any difference in the improvement of cervical sagittal balance, fusion rate, subsidence and complications encountered. Multivariate logistic regression analysis for complications showed no difference between the groups when assessed for smoking, gender, age, Charlson comorbidity index, levels of surgery, fusion status, Odom score, or the type of implant. Complications encountered in the SA group were temporary swallowing problems 10, Hoarseness of voice 3, cage migration 1, delayed union 1, Horner's syndrome 1. In the CS group swallowing problems in 4, hoarseness of voice 4, CSF leak 1, recurrent symptoms 1. The observed difference in the incidence of complications between the groups did not reach statistical significance.

Conclusion: In this short-term study the standalone cages showed no difference in their complication profile in comparison to a cage-crew construct for both single and multilevel ACDF. Standalone cages might be a more economical option without raising the complication risks. Nevertheless, we propose a longer-term follow up for further evaluation of this finding.

There is NO Conflict of Interest: Yes

724 - A Major Trauma Centre's experience of its novel Virtual Thoraco-Lumbar Fracture Clinic – an Evaluation of Injuries and Outcomes

M. Al-Ashqar1, A. Faraz1, A. Murtaza2, P. Loughenbury3

1Leeds Teaching Hospitals, Leeds, United Kingdom, 2Bradford Royal Infirmary, Bradford, United Kingdom, 3Leeds Teaching Hospitals, Neurosciences and Spinal Surgery, Leeds, United Kingdom

Background: Leeds Major Trauma Centre is among the first in the UK to launch a Virtual Thoraco-Lumbar Fracture Clinic (VTLFC). The importance of virtual and remote management of patients has only increased since the COVID-19 pandemic.

Aim: Audit the throughput of the Leeds VTLFC during the first 7 months of its inception.

Methods: A retrospective review of all patients booked into the Leeds VTLFC between 01/06/2019 and 31/12/2019. Patient demographics, injury classifications, and treatment outcomes were analysed.

Results: A total of 340 patients were processed through the clinic; mean age 61, 165 males and 175 females. 26.5% had fractures of L1, 14.7% of T12, 9.1% of L2, and the rest with fewer frequencies. 68.2% had A1 fractures, 8.2% had A2 fractures, 11.5% had A3 fractures, 5% had A4 fractures, and 2.1% had A0 fractures.
73% of patients were discharged directly after remote management. 25.6% patients were invited to a face-to-face fracture clinic for further management, usually for organisation of weightbearing spine X-rays or other clinical assessments.
Only 2 patients discharged from VTLFC (0.6%) contacted the service and requested to be seen due to ongoing concerns. Out of all 340 patients processed through the VTLFC, 2 (0.6%) went on to have surgery.

Conclusions: Our experience in Leeds suggests that a majority of stable thoracolumbar vertebral fractures can be managed virtually and remotely safely. Less than 1% of discharged patients called back to request to be seen, suggesting a high degree of satisfaction with and understanding of self-management of these injuries with the letters and resources provided by the VTLFC. Less than 1% of patients ultimately required surgery, and both were among the patients invited to face-to-face clinics for further assessments and radiographs.

There is NO Conflict of Interest: Yes

731 - Implementation of a cauda equina service in a medium size district general hospital in the United Kingdom

S. Graham1, P. Madhavan2, P. Thorpe2, Y. Leung2, A. Subramanian2, D. Thavarajah2, P. Burn2, D. Fox2, G. Karnati2

1Severn deanery, Trauma and Orthopaedics, Bristol, United Kingdom, 2Musgrove Park Hospital, Spinal Surgery, Taunton, United Kingdom

Background: This study aims to explore the impact on service provision at a district general hospital following the implementation of national guidance for investigation and management of patients with suspected Cauda Equina Syndrome (CES).

Methods: The local policy for the management of patients with suspected CES was updated in May 2017. Retrospective data analysis of patients who were admitted with suspected CES during the 12 months prior to the implementation of the new guidelines were compared with data from patients during the 21 months following the implementation of the guidelines. Data collected were number of referrals, number of magnetic resonance imaging (MRI) scans performed and time to surgery for both groups. Comparison statistics were performed between the two groups. The impact on service provision was also analysed.

Results: Monthly mean numbers of referrals for suspected CES increased from 10.1 prior to the new local policy, to 18.9 afterwards (p<0.001). Statistically significant increases were also seen in the total numbers of MRI scans for suspected CES, and the amount of out of hours MRI scanning. The mean time interval, from MRI scan confirming CES to starting emergency decompressive surgery, reduced from 14.87 hours to 9.57 hours. The data showed an increase in the percentage of emergency decompression operations being performed out of hours from 22.2% to 64.0% (p=0.018).

Conclusions: Compliance with the national guidance for suspected CES is imperative for our patients to receive optimal treatment. However, we have demonstrated challenges related to increased pressure on resources.


  • This study supports previous evidence that MRI imaging should be available at all times in all acute care hospitals with Emergency Departments. 
  • This paper supports the other literature calling for calling for MRI for suspected CES to be performed at the local referring hospital, prior to any transfer to a specialist centre.

There is NO Conflict of Interest: Yes

859 - CT-guided vs. Fluoroscopically-guided Transforaminal Epidural Steroid Injections for Lumbar Radiculopathy – A Comparison of Efficacy, Safety and Cost

J. Bartlett1, J. Kamp2, A. Fahmy2, M. Akula2

1Rotorua Hospital, Lakes District Health Board, Trauma and Orthopaedics, Rotorua, New Zealand, 2Basildon and Thurrock University Hospital, Trauma and Orthopaedics, Basildon, United Kingdom

Background: Transforaminal epidural steroid injection (TFESI) of the lumbar spine of patients is an increasingly common procedure that can be performed using either computerised tomography (CT) or fluoroscopic guidance technologies. The aim of this study was to compare the clinical outcomes, radiation dose and cost of these procedures for patients with unilateral single-level lumbar spine radiculopathy.

Methods: All patients who underwent CT or fluoroscopically guided lumbar TFESI at our institution between June 2016 and June 2018 were identified. Patients’ electronic records were reviewed for complications and clinical outcomes at 6-week follow-up records were categorised. The radiation doses were retrieved from automatically generated reports for each patient’s procedure and the associated cost was retrieved from our institution’s costing system.

Results: 116 patients met the inclusion criteria (CT – 50; Fluoroscopy – 56). There were no documented complications. Significantly more patients were discharged from clinic 6-weeks after CT-guided lumbar TFESI as compared with fluoroscopically guided TFESI (CT – 23, Fluoroscopy – 14 (P=0.027)). There was no difference in the number of patients who were referred to surgery (P=0.18), for further pain management (P=0.45), or for further TFESI (P=0.43). The median effective radiation dose was significantly higher for CT-guided TFESI (CT - 5.73 mSv (3.87 to 7.76); Fluoroscopy - 0.55 mSv (0.11 to 1.4) (P<0.01)). The median total cost for CT-guided lumbar TFESI was £237.5 (£235 to £337), over £800 less than under fluoroscopic guidance (£1052 (£892.8 to £1298), P<0.01)).

Conclusions: At our institution, CT-guided TFESI was associated with a higher 6-week discharge rate, a lower cost, but a ten-times higher radiation dose as compared with fluoroscopically guided TFESI. Prospective randomised studies are required to effectively compare the clinical efficacy of these procedures and to investigate how the radiation dose associated with CT-guided TFESI can be reduced without jeopardising efficacy or safety.

There is NO Conflict of Interet: Yes

902 - Does country of origin influence research outcomes in operative interventions for lumbar spinal stenosis?

F.J. McCabe1, D.M. Dalton1, J.P. McCabe1

1Galway University Hospitals, Spine Service, Department of Trauma and Orthopaedics, Galway, Ireland

Background: Bias undermines evidence-based decision making. To counter this, surgeons must be aware of biases that may influence studies’ reported outcomes. Lumbar spinal stenosis is a common surgical problem due to an aging society, with multiple published surgical strategies. Our aim was to assess the role that country of origin plays in published surgical outcomes for lumbar spinal stenosis.
Methods: We performed a search strategy of MEDLINE and EMBASE for all English language primary research papers evaluating operative interventions for lumbar spinal stenosis during the years 2010-2019 inclusive. Small case series and metanalyses were excluded. Papers were assessed for self-reported outcome positivity and country of origin. Data analysis was conducted using GraphPad Prism statistical software.
Results: 487 papers met the inclusion criteria. Of these, 419 (86%) reported positive outcomes. Asian studies were the most likely to report positive outcomes, at 93% (220 of 236), followed by US studies at 89% (98 of 110). European studies had the lowest positive publication rate at 69% (84 of 121). The difference in positive outcome rate reached statistical significance, Pearson chi square test P<0.001. This effect was seen across different levels of evidence. Healthcare system played a role, with National Health Service-type systems publishing more negative research than more privatised systems.  
Conclusion: There is an association between country of origin and positive reported outcome in studies evaluating operative interventions for lumbar spinal stenosis. Clinicians should consider this when making clinical decisions based on published evidence.

There is NO Conflict of Interest: Yes

920 - Enhanced recovery protocol for multi-level decompression surgery - an Oswestry experience

S. Aranganathan1, A. Ghodke1, H. Jayanna1, R. Dhawan1, F. Kader1, R. Trivedi2, M. Ockendon1, B. Balain1, J. Trivedi1, J. Hohn1, S. Dheerendra1, S. Munigangaiah1, S. Ahmad1, J. Kuiper3

1Robert Jones and Agnes Hunt Hospital, Spinal Disorders Unit, Oswestry, United Kingdom, 2University of Bristol, Bristol Medical School, Bristol, United Kingdom, 3Keele University, Faculty of Medicine and Health Sciences, Oswestry, United Kingdom

Background: Multi-level lumbar decompression is a painful procedure requiring strong opioids. This has significant side effects for the patient and a domino-effect on theatre flow-through and hospital discharge. We hypothesise that adjuvant spinal anaesthetic could reduce morphine requirement, length of recovery and inpatient stay as well as operative-day mobility. Reduction in opioid use by implementing regional anaesthesia techniques is a core principle of enhanced recovery in surgery.

Method: A 7-year, prospective case-control study of age, ASA and number of decompression level matched patients were undertaken. Eighty-two patients had adjuvant spinal anaesthetic (treatment-group) and 226 patients received standard anaesthetic care (control-group) between 2013 and 2019. For the treatment group, a lumbar spinal anaesthetic with 1 to 4 ml 0.25% Bupivacaine was used prior to induction depending on expected duration of surgery. The control group received a standard opioid based GA. Both groups received multimodal analgesia and surgical local infiltration with 60ml 0.25% Bupivacaine. Statistical analysis was performed using “Matching” package of R. Outcome measures were total perioperative morphine consumption, 48-hr morphine consumption, recovery time, time to mobilisation and length of stay.

Results: In the treatment group, the mean perioperative morphine requirement was 6.7-6.9 grams less and the mean 48hr post-operative Oxycodone use was 22 grams less. This equated to a 11-minute early discharge from recovery, one-day less of inpatient stay with 80% patients mobilising within 12-hrs, all of which were statistically significant.

Conclusion: Our study clearly demonstrates a significant advantage of adjuvant spinal anaesthetic in early outcomes of lumbar decompression surgery.

There is NO Conflict of Interest: Yes

972 - The impact of spinal best practice tariff on compliance with the British Spine registry: A review of 3250 patients at a tertiary spinal centre

A. Habeebullah1, H. Rajgor1, M. Jones1

1Royal Orthopaedic Hospital, Birmingham, United Kingdom

Background: The British Spine Registry (BSR) was introduced in May 2012 to be used as a web-based database for spinal surgeries carried out across the UK. Use of this database has been encouraged but not compulsory which has led to a variable level of engagement in the UK. In 2019, NHS England and NHS Improvement introduced a new Best Practice Tariff (BPT) to encourage input of spinal surgical data on the BSR. The aim of our study was to assess the impact of the spinal BPT on compliance with the recording of surgical data on the BSR.

Method: A retrospective review of data was performed at a tertiary spinal centre. Royal Orthopaedic Hospital Birmingham, between 2018-2020. Data was collated from electronic patient records, theatre operating lists and trust specific BSR data. Information from the BSR included operative procedures, patient consent, email and demographic details. We also identified Health Resource Groups (HRGs) which qualified for BPT.

Results: 3250 patients were included in our study. 1684 patients were eligible for BPT. In 2018-19 269/974 (28%) records were complete on the BSR for those that would be eligible for BPT. Following introduction of BPT in 2019, 671/710 (95%) records were complete (P<0.05). Operative details input into BSR increased from 28% to 94% (P<0.05). Patient consent to data collection also improved from 62% to 95%. Email details were present in 43% of patients compared with 69% following BPT introduction.

Conclusion: Our study found that following the introduction of a BPT, there was a statistically significant improvement in BSR record completion compliance in our unit. The BPT offers a financial incentive which can help generate further income for trusts. National data input into the BSR is vitally important to assess patient outcome following spinal surgery. The BSR can also aid future research in spinal surgery.

There is NO Conflict of Interest: Yes

1103 - Current practice of management of Discitis at a District general hospital compared to recommended guidelines

A. Sobti1, A. Sriramanarayanan2, A. Unnithan1, S. Dey1, R. Gadde1

1Ashford & St Peters Hospitals NHS Trust, Trauma & Orthopaedics, Chertsey, United Kingdom, 2Ashford & St Peters Hospitals NHS Trust, Chertsey, United Kingdom

Background: Discitis classically presents with fever and back pain. However, varied presentation and lack of adherence to definite guidelines leads to great variation in management causing a rise in inadequately resolved disease.

Objective: To assess current management protocol for Discitis at a District General Hospital and to compare it against recommended guidelines. Also planed to formulate a management protocol to improve quality of care.

Methodology: A retrospective study was conducted. The study finally included patients who had magnetic resonance imaging (MRI) of the spine reported as discitis with some clinical relevance, performed between January 2017 - September 2019. 

Results: Out of the 305 spine MRI’s included, 152(35%) were reported to have discitis purely based on imaging. However, only 38(55%) of them had clinical correlation and were managed for the same. Back pain (47.3%) was the most common presenting complaint followed by fever. The commonest site of involvement was the lumbar vertebrae (70.4%) and 87% of patients had, only a single site involved. All patients had a baseline C-reactive protein (CRP) and 34(92.11%) had blood cultures tested for. Out of the patient with negative blood cultures 70.5% further had a computer tomography (CT) guided biopsy to aid diagnosis. Staphylococcus Aureus was the most common causative organism isolated on microbiology. Treatment was commonly with intravenous Flucloxacillin with 63% of the patients being treated for six weeks or more.

Conclusion: Compared to the recommended guidelines we should aim to reach a 100 % target in the number of blood cultures prior to starting antibiotics and CT guided biopsies if blood cultures remain negative. Additionally, we need to work towards a minimum of 6 weeks of treatment and follow a structured follow up protocol. Following a checklist based on guidelines can be a step towards achieving higher success rate in outcome of discitis.

There is NO Conflict of Interest: Yes

1152 - Does surgery offer benefits in Metastatic Spinal Cord Compression? A case matched study

S. Aziz1, G. Taylor1

1University Hospitals of Leicester, Trauma and Orthopaedics, Leicester, United Kingdom

Background: Patients with MSCC present with pain and/or neurological loss. NICE guidance recommends surgery to prevent paralysis or manage pain in paralysed patients. There are no RCTs and paucity of literature comparing surgery with no surgery. 
Aim: To compare surgery with no surgery for neurological change, survival, length of stay and re-admissions.
Methods: A case matched cohort study comparing patients managed surgically with those declining surgery when offered. Cases declining surgery were matched with surgical cases. Match criteria were by primary tumour, presentation neurological grade (ambulatory, weight bearing, bed bound and paralysed), co-morbidities (ASA grade), age and gender. Data collected from MSCC database, clinical letters and coding. Statistical analysis was performed using GraphPad prism 8.2.
Results: Statistical analysis of the match criteria confirmed no difference between the groups. Twenty-seven patients declining surgery were matched to 54 receiving surgery. 
Out of the no surgery group (n=27), 3 patients improved by 1 grade and 3 deteriorated by 1 grade. In the surgery group (n=54), 1 improved by 2 grades, 5 improved by 1 grade, 9 deteriorated by 1 grade and 3 deteriorated by 2 grades. Net effect of no surgery was 0; surgery resulted in a net neurological loss of 8 grades (p=0.07). 
At 3 months, survival rates were 83% in the surgery group and 61% in the no surgery group (p=0.05). Average initial length of stay in the surgery group was 21 vs. 10 days in the no surgery group (p<0.001). There were more re-admissions in the surgery group than the no surgery group, 45% vs. 36% (p=0.05). 
Conclusion: In this study, albeit underpowered, surgery resulted in significantly more neurological deterioration than improvement; longer initial hospital stay, and higher re-admission rates. Surgical patients did, however, live longer.

There is NO Conflict of Interest: No

1207 - Mortality Rate Following Conservative Management Of Type II Odontoid Peg Fractures In Comparison To Neck Of Femur Fractures

H. Lewis1, R. Brown1, A. Dodds1, A. Torrie1

1Gloucestershire Royal Hospital, Trauma and Orthopaedics, Gloucester, United Kingdom

Background: Fragility fractures encompass a range of injuries of which hip fractures receive the most attention due to high morbidity and mortality. Odontoid peg fractures account for 10-15% of all c-spine injuries, with an ageing population an increase in incidence has been reported. These fragility fractures also occur in patients who are co-morbid and are similarly associated with high rates of morbidity and mortality.
The aim of this study was to assess the mortality rate of low velocity, Type II odontoid peg fractures in over 65s treated conservatively within our trust. In addition, compare the 30-day mortality with the neck of femur (NOF) fracture cohort. Identifying avenues in which patient care can be improved.
Methods: A retrospective audit of all c-spine injuries admitted to the trust between 06/01/2018 – 15/01/2019 was conducted. Patient imaging was reviewed to identify all low velocity Type II odontoid peg fractures in patients aged over 65. Only those patients treated conservatively were included. Charlson co-morbidity index was calculated and mortality was recorded from electronic patient records.
Results: A total of 32 low velocity, type II odontoid peg fractures were identified, all of which were treated conservatively. The average age was 84.6 (range 74-96). The mean Charlson comorbidity index was 6.09 compared to 5.44 in the NOF fracture cohort. The average 30 day mortality rate for odontoid peg fractures was 12.5% in comparison to 6.7% in the NOF fracture patient group.
Conclusion: This study identifies that the patient cohort experiencing type II odontoid peg fractures are as frail as the neck of femur cohort and at high risk of early mortality. With this in mind a patient pathway has been suggested and recommendations have been made to provide orthogeriatrician review within 72 hours as per the BOAST guidelines for fragility fractures.

There is NO Conflict of Interest: Yes

1216 - Audit on Compliance of NICE Guidelines for the use of Caudal Epidural Injections

M. Woodmass1, R. Thimmaiah2, B. Balakumar2, F. Hassan2

1University of Birmingham, Birmingham, United Kingdom, 2Royal Orthopaedic Hospital, Birmingham, United Kingdom

Background: The guidelines at the time of this audit states that caudal epidural steroid injection should be considered for acute and severe sciatica and not for neurogenic claudication from spinal canal stenosis. We evaluated the compliance with the NICE guidelines (NG59) at our hospital.

Methods: All consecutive patients who underwent caudal epidural injection between March and April 2019 were identified, and included in this audit. Between March and April 2019, data was collected using an audit proforma using electronic case notes, MRI findings and information request from the hospital. Baseline patient demographics along with indication for injection and post injection pain assessment was recorded.

Results: A total of 29 patients were included. There were 2 exclusions, one due to cervical injection and the other being abandoned due to non-patent sacral canal. The mean age was 64 years (range 33-88yrs). Five patients have had previous spinal surgery. Twenty-five patients had reported radiculopathy. However, 4 cases had epidural steroid injection for non-radiculopathy symptoms. Of these 25 cases, there was mixed response to the injection. Fifty six percent (14/25) reported beneficial outcome, 12 percent (4/25) reported no improvement and 8 percent (2/25) had worsening of pain. Five patients (24 percent) were lost to follow up. In those who were outside the guideline 50 percent expressed benefit.

Conclusion: This audit demonstrates that our compliance with the NICE guidelines was 86%. Furthermore, more than 50% of the patients benefitted from the injection. We feel that this can be further improved by taking the NICE guidance into consideration and recommend circulating the guidance in the outpatient clinics where these patients are listed.

There is NO Conflict of Interest: Yes

1425 - Size Doesn’t Matter: Correlating disc size with disability and leg pain

R. Dunsmuir1, S. Nisar1,2, J. Cruikshank1, P. Loughenbury1

1Leeds Teaching Hospitals, Leeds, United Kingdom, 2Academic Department of Trauma and Orthopaedics, Leeds General Infirmary, Leeds, United Kingdom

Background: The size of the herniated disc is commonly mentioned as a factor when deciding if a patient requires surgical intervention. However, to our knowledge, there are no published studies correlating the size of the herniated disc with severity of symptoms using VAS or ODI scores.

Methods: Data was collected prospectively. Patients were asked to complete VAS and ODI scores on the day of their MRI scan. All patients with primary disc herniation were included. Exclusion criteria included recurrent disc herniation or any other associated spinal pathology.
T2 weighted MRI scans were reviewed on PACS software.  The T2 axial image showing the disc protrusion with the largest cross sectional area was used for measurements.  The area of the disc and canal were measured.
The VAS Leg score and ODI score were correlated with the size of the disc using the Pearson Correlation Coefficient. Intra-observer reliability was assessed using the Interclass Correlation Co-efficient (ICC).

Results: Fifty six patients were included in the study. Ages ranged from 22.8 to 70.3 years, with an average age of 41.1 years.
A high degree of intra-observer reliability was observed. The single measure ICC was 0.99 (95% CI from 0.97- 0.99. (alpha = 0.05). 
The Pearson Correlation Coefficient comparing VAS Leg scores with percentage canal occupied by the herniated disc was 0.056. When comparing ODI scores with percentage of the canal occupied by the herniated disc the Pearson Correlation Coefficient was 0.0698.

Conclusion: The results of the statistical analysis show that there is no direct correlation between the size of the disc and a patient’s symptoms.
This study highlights the importance of clinical assessment. Management decisions should not be made on the basis of radiological imaging but rather a clinician must consider a patient’s symptoms and the impact on their lifestyle.

There is NO Conflict of Interest: Yes

1430 - Percutaneous vertebroplasty only improves pain when treating one or two-level vertebral body compression fractures: 10-year experience at a large teaching hospital

G. Abbas1, G. Metcalf1, A. Highland1

1Sheffield Teaching Hospitals, Spinal Surgery, Sheffield, United Kingdom

Background: Percutaneous vertebroplasty (PVP) has been successfully used to treat pain in patients with vertebral body compression fractures (VBCFs). Recently published data does not clearly support benefit of PVP over non-operative management for VBCFS.

Methods: We review our 10- year experience of PVP in a large teaching hospital to compare results in patients having single-level, two-level or multiple level PVP
We performed 231 PVP procedures in 214 patients over 10-year period. All patients undergoing vertebroplasty procedures were provided with outcome measures using visual analogue scale (VAS), Oswestry disability index (ODI) and analgesia use scores. The outcome measures were done preoperatively and post-operatively at 1, 3 and 12-months intervals. We compared the mean reduction in VAS, ODI and analgesia scores in single-level, two-level and multi-level PVP.

Results: A statistically significant reduction in pain measured on the VAS is only present in single-level and two-level vertebroplasty procedures. A mean reduction in pain scores was 2.58 (95% confidence interval: 1.69-3.48) and 1.93 (95% confidence interval: 0.93-2.93) at 12-months respectively. We found that the minimum clinically important difference (MCID) for pain and ODI reduction was only exceeded when a single level was treated. The overall complication rate was 22.5% with the majority of complications being asymptomatic radiological cement leakage outside the vertebral body.

Conclusion: Our study indicates that vertebroplasty is effective in treating pain caused by VBCFs when performed at one or two levels. The reduction in pain and reduction in analgesic use is only clinically significant when performed on one level. We therefore recommend that vertebroplasty only be considered as a treatment for VBCFs when a single level is affected

There is NO Conflict of Interest: Yes

1822 - Distal Junctional Failure in patients with long construct fusions: surgical and radiographic risk factors

S. Evans1, D.P. Ahern2,3, J. McDonnell4, A.S. Sebastian5, S.C. Wagner5, P.B. Morrissey5, I.D. Kaye5, C.K. Kepler5, A.R. Vaccaro5, J.S. Butler3,1

1University College Dublin, School of Medicine, Dublin, Ireland, 2Trinity College Dublin, School of Medicine, Dublin, Ireland, 3Mater Misericordiae University Hospital, National Spinal Injuries Unit, Department of Trauma & Orthopaedic Surgery, Dublin, Ireland, 4Royal College of Surgeons in Ireland, School of Medcine, Dublin, Ireland, 5Rothman Instititute at Thomas Jefferson University, Department of Orthopaedic Surgery, Philadelphia, PA, United States

Background: Distal junctional failure (DJF) is a complication of long instrumented posterior fusion for correction of adult spinal deformity resulting in structural failure at the distal end of the construct. The aim of this study was to identify presumed risk factors for DJF through the use radiographic and surgical risk factors.

Methods: A retrospective case study including 102 patients that underwent corrective surgery using Long Construct Lumbar Fusions with fixation to Pelvis. DJF occurred in 41 patients while 61 patients experienced normal outcomes. The parameters included were the pelvic tilt (PT), the lumbar lordosis (LL), sacral slope (SS), the pelvic index (PI), thoracic kyphosis, sagittal vertical axis (SVA) and pelvic index – lumbar lordosis miss match. Comparative analysis was carried out using an ANOVA on presumed risk factors. Following this presumed risk factors were analysed for association with DJF using multivariate cox regression analysis.

Results: DJF participants experienced a greater change in LLo 25.7 ± 2.16 vs 9.90 ±1.87 (P= 1.23e-06). In the DJF cohort larger pre and post-operative changes were observed in the SVA 5.55 ± 0.58 vs -3.1 ± 0.489 (P= 0.00359), PT - 4.70 ± 1.38 vs 0.9 ± 1.05 (P = 0.0461), PI/LL mismatch -25.7 ± 2.16 vs -9.90 ± 1.87 (P= 5.05e-07) and SS 4.7 ± 1.38 vs 0.89 ± 1.05 (P=0.0461). The most significant risk factors associated with DJF were postoperative lumbar lordosis (HR = 1.1202; P = 0.000161), Postoperative sagittal vertebral angle (HR = 1.0713; P=0.002235 ) and the change in PI/LL mismatch (HR = 1.0765; P=1.48e-07).

Conclusion: Patients that experienced DJF had significantly less correction in both comparative analysis and multivariate analysis. Under correction can therefore be seen to place patients at greater risk of DJF.

There is NO Conflict of Interest: Yes

1852 - Changing Demographic Trends in Spine Trauma: The Presentation and Outcome of Major Spine Trauma in the Elderly

K. Nagassima Rodrigues dos Reis1, D.P. Ahern2, S. Evans3, J. McDonnell4, D. Gibbons2, J.S. Butler2

1Trinity College Dublin, DUBLIN, Ireland, 2Mater Misericordiae University Hospital, National Spinal Injuries Unit, Dublin, Ireland, 3University College Dublin, Dublin, Ireland, 4Royal College of Surgeons in Ireland, Dublin, Ireland

Introduction: Traumatic injuries are among the leading cause of death and disability worldwide. Major trauma has seen a demographic shift in recent years from the young to the elderly. However, whether a similar trend exists in those undergoing operative intervention for major spinal trauma remains to be elucidated.

Aims: To compare the presentation and outcomes of patients >65 years of age sustaining major spine trauma to those <65 years at a national tertiary referral spine centre.

Methods: The local Trauma Audit Research Network (TARN) database was analysed to select patients admitted between November 2015 and May 2019. Variables analysed included patient demographics, injury severity, mortality, interventions, mechanism of injury and length of hospital stay.

Results: A total of 669 patients were admitted of which 471 patients underwent operative intervention for spinal trauma. Within the elderly cohort, this represented 73.7% of cases. Among the younger population, road traffic collisions were the most common mechanism of injury (37.1%) followed by high falls (>2m) (31.7%), while low falls (<2m) (63.3%) was the most common mechanism among the older population. Patients >65 years old had significantly longer length of stay (21 days [1-194] v 14 days [1-183]) and suffered higher 30-day mortality rates (1.8% [0-12] v 0.6% [0-4]).

Conclusion: Major orthopaedic spinal trauma in older people is associated with a significantly higher mortality rate as well as a longer duration of hospitalization. Even though severity of injury is similar for both young and old patients, the mechanism of injury for the older population is of typically much lower energy compared to the high energy trauma affecting younger patients.

There is NO Conflict of Interest: No

Sports Trauma

Virtual Podium Presentations

6 - Minimally invasive lower leg fasciotomy for chronic exertional compartment syndrome- how safe is it?

P Grechenig1, EM Valsamis2, T Muller1, A Gansslen3, G Hohenberger1

1Institute of Anatomy, Medical University of Graz, Graz, Austria, 2Oxford Univeristy Hospitals NHS Trust, Oxford, United Kingdom, 3Klinikum Wolfsburg, Wolfsburg, Germany

Background: Chronic exertional compartment syndrome (CECS) is a recognised clinical diagnosis in running athletes and military recruits. Minimally invasive fasciotomy techniques have become increasingly popular but with varied results and small case numbers. While decompression of the anterior and peroneal compartments has demonstrated a low rate of iatrogenic injury, little is known about the safety of decompressing the deep posterior compartment. The aim of this study was to evaluate the risk of iatrogenic injury when using a minimally invasive technique to decompress the anterior, peroneal and deep posterior compartments of the lower leg.

Methods: Sixty lower extremities from 30 adult cadavers were subject to fasciotomy of the anterior, peroneal and deep posterior compartments using a minimally invasive technique. Two common variations in surgical technique were employed to decompress each compartment. Subsequent anatomical dissection was carried out to identify incomplete division of the fascia, muscle injury, neurovascular injury and the anatomical relationship of key neurovascular structures to the incisions.

Results: Release of the anterior and peroneal compartments was successful in all but two specimens. There was no injury to the superficial peroneal nerve (SPN) or any vessel in any specimen. A horizontal incision crossing the anterior intermuscular septum resulted in muscle injury in 21% of cases.
Release of the deep posterior compartment was successful in all but one specimen when a longitudinal skin incision was used, without injury to neurovascular structures. A horizontal skin incision resulted in fewer complete releases and in a high rate of injury to the saphenous nerve (16.7%) and long saphenous vein (23.3%).

Conclusion: Minimally invasive fasciotomy of the anterior, peroneal and deep posterior compartments has a low rate of iatrogenic injury in the cadaveric model.

There is NO Conflict of Interest: Yes

146 - The Impact of Exercise on the Development of Varus Knee Morphology during Adolescence: A Cross-sectional Cohort of Elite Footballers and Controls

S Fernquest1, T Lloyd1, M Gimpel2, R Birchall2, A Carr1, S Glyn-Jones1, A Palmer1

1University of Oxford, NDORMS, Oxford, United Kingdom, 2Southampton Football Club, Southampton, United Kingdom

Introduction: Varus leg alignment predisposes to soft tissue and cartilage injury and is more common in elite footballers. An improved understanding of abnormal leg alignment development during adolescence is required to determine whether the process is predictable or modifiable. The aim of this study was to characterise the risk factors, timing, and pathogenesis of varus leg alignment.

Methods: Cross sectional observational cohort study of individuals from football club academies and an age-matched control population, aged 11-21 years. Assessments included questionnaires, clinical examination. Primary imaging outcome measures were Hip Knee Angle (HKA), Medial Proximal Tibial Physeal Angle (MPTPhyA), and Alpha Angle measured from full leg length MRI scans.

Results: Cohort comprised 58 elite male footballers, 34 male and 34 female controls. HKA decreased with age, with the greatest decrease occurring between 13-16 years (HKA 1.11° (SD 2.10°)), with no significant change after 16 years. Skeletally mature elite male footballers had a HKA 2.28° less than male controls and 3.73° less than female controls. A negative correlation existed between HKA and Physical Activity Questionnaire Score (coefficient -0.24, p=0.029). A negative correlation existed between HKA and alpha angle (coefficient -0.75, p = 0.003). A positive correlation existed between HKA and MPTPhyA (coefficient 0.32, p = 0.008). Physical Activity Questionnaire Score at baseline showed some capability of predicting the development of varus leg alignment at 3 years with an area under the curve of 0.69.

Conclusions: The development of varus leg alignment is greatest age 13-16 years in male footballers and male controls. Females remained in valgus alignment throughout adolescence. There is no significant change in leg alignment after 16 years. High physical activity during adolescence is strongly associated with the development of varus alignment. A low MPTPhyA likely represents physiological adaptation to load and be the mechanism by which varus alignment develops.

There is NO Conflict of Interest: No

211 - A survey of over 700 patients with proximal hamstring rupture. Patient experiences, complications and outcomes

R. Hackney1, R. Hackney2

1Royal Infirmary Edinburgh, Trauma and Orthopaedics, Edinburgh, United Kingdom, 2Spire Hospital Leeds, Orthopaedics, Leeds, United Kingdom

Proximal hamstring tears are uncommon and poorly understood. A survey was conducted via SurveyMonkey of a Facebook group, Proximal hamstring ruptures and surgery.
The aim is to report patient's experiences, difficulties and reported outcomes order to guide future practice and patient care, with 723 responses.
Commonest sufferer is a middle aged female, the mechanism was sport in over 50%, tripping 34%. There was no pain preceding the injury in 73%. 41% of tears were retracted between 1-4 cm, 26% 5-8cm and 12% over 8cm.
Nerve pain was reported by 68% of patients at some stage during their treatment, but worryingly 18% reported pain after surgery, but not before.
Although 54% of injuries were diagnosed within 2 weeks, diagnosis is frequently delayed, 20% took over 3 months for their diagnosis to be made. 47% of people saw 2-3 healthcare practitioners prior to getting a diagnosis, 18% saw more than 3. Once the diagnosis was made, 39% of patients consulted 2-3 practitioners before deciding upon treatment.
41% of respondents did not attempt conservative treatment prior to surgery, 70% had surgery. Of those treated conservatively 42% had treatment for longer than 6 months. 54% waited less than a month for surgery, 16% over 6 months.
Most surgeons used a buttock crease incision and suture anchors. 35% had NO thromboprophylaxis, and 28% no antibiotics.
29% were unbraced after surgery, both hip and knee braces were used, 15% at 90 degrees knee flexion, 35% non-weight bearing. Return to sport took 6 months, 34%, 12 months 28%.
35% reported no complications. 28% buttock pain, hamstring pain 19%, nerve pain 24%, knee pain 22%. Re-tear was 8%, 2% thrombosis.
Proximal hamstring rupture patients report a 65% complication rate, with many seeking several opinions before obtaining surgery. Iatrogenic nerve injury, persisting pain and delayed recovery are major concerns.

There is NO Conflict of Interest: No

238 - The Oswestry-Bristol Classification (OBC): A New Assessment Tool to Grade Trochlear Dysplasia

N Sharma1, A Brown1, T Bouras1, J Herman Kuiper1, J Eldridge2, A Barnett1

1Robert Jones and Agnes Hunt Orthopedic Hospital NHS Foundation Trusts, Trauma & Orthopedics, Oswestry, United Kingdom, 2Bristol Royal Infirmary, Bristol, United Kingdom

Background: Trochlear dysplasia is a significant risk factor for patellofemoral instability. The Dejour classification is currently considered the gold standard for classifying trochlear dysplasia, but numerous studies have reported poor results of reliability on both plain radiography and MRI. The severity of trochlear dysplasia is important to establish in order to guide surgical management. We have developed an MRI specific classification system to assess the severity of trochlear dysplasia - The Oswestry-Bristol Classification (OBC). This is a 4-grade classification comprising of Normal, Mild, Moderate and Severe to represent a normal, shallow, flat and convex trochlear respectively.
The purpose of this study is to assess the inter- and intraobserver reliability of the OBC and compare it with that of the Dejour classification. 

Methods: Four observers (2 senior and 2 junior orthopedic surgeons) independently assessed 32 CT and MR axial imaging for trochlear dysplasia and classified each according to the Oswestry-Bristol and the Dejour classification systems. Assessments were repeated following a 4-week interval. The inter- and intraobserver agreement was determined by using Fleiss’ generalization of Cohen’s kappa statistic and S-statistic nominal and linear weights using R vs 3.3.3 (R Foundation for Statistical Computing, Vienna, Austria).

Results: The Oswestry-Bristol Classification showed fair to good interobserver agreement and good to excellent intraobserver agreement (mean kappa 0.68). The Dejour classification showed poor interobserver agreement and fair to good intraobserver agreement (mean kappa 0.52).

Conclusion(s): The Oswestry-Bristol Classification is a validated classification system to assess the severity of trochlear dysplasia. It can be utilized in clinical practice to simplify and standardize surgical decision-making in patients with trochlear dysplasia and recurrent patella instability.

Implications: The Oswestry-Bristol Classification is more reliable than the Dejour classification and can be introduced into clinical practice to guide the surgical management of patellofemoral instability.

There is NO Conflict of Interest: Yes

240 - Decellularised Porcine Xenograft for Anterior Cruciate Ligament Reconstruction: A Histological Study in Sheep Comparing Cross Pin and Cortical Suspensory Femoral Fixation

A Hexter1, F Haddad2, G Blunn3

1UCL Institute of Orthopaedics and Musculoskeletal Sciences, Stanmore, United Kingdom, 2University College London Hospitals, London, United Kingdom, 3University of Portsmouth, Portsmouth, United Kingdom

Background: There is a wealth of preclinical research reporting the in vitro biomechanical properties of decellularised porcine superflexor tendon (pSFT) xenograft. However the in vivo performance and graft healing has not been reported. We aimed to evaluate graft healing of pSFT in an ovine ACL reconstruction model using two femoral fixation devices. Also, to determine if pSFT allows functional recovery of gait as compared to pre-operative measurements.

Methods: Twelve sheep underwent unilateral single-bundle ACL reconstruction using pSFT. Two femoral fixation devices were investigated: Group 1 (n=6) used cortical suspensory fixation (Endobutton CL) and Group 2 (n=6) used cross-pin fixation (Stratis ST). A soft screw was used for tibial fixation. Functional recovery was quantified using force plate analysis at weeks 5, 8 and 11. The sheep were euthanised after 12 weeks and comprehensive histological analysis characterised graft healing at the graft-bone interface and the intra-articular graft (ligamentisation).

Results: The pSFT remodelled into a ligament-like structure and no adverse inflammatory reaction was seen. An indirect insertion was seen at the graft-bone interface characterised by Sharpey-like fibres. Qualitative differences in tendon remodelling were seen between the two groups, with greater crimp-like organisation and more aligned collagen fibres seen with Endobutton fixation. One graft rupture occurred in the cross-pin group, which histologically showed low collagen organisation. The ground reaction force in the operated leg of the Endobutton group was higher at 11 weeks (p<0.05).

Conclusion: decellularised pSFT xenograft remodels into a ligament-like structure after 12 weeks and regenerates an indirect-type insertion with Sharpey-like fibres. No adverse inflammatory reaction was observed. Cortical suspensory femoral fixation was associated with more enhanced graft remodelling and earlier functional recovery when compared to the stiffer cross-pin fixation.

Implications: Femoral fixation influences graft healing in the femoral tunnel, with cortical suspensory fixation associated with superior graft healing than cross-pin fixation.

There is NO Conflict of Interest: No

246 - Do patients return to sport after the Laterjet surgery?

A Gough1, T Batten1, P Guyver1, A Murphy1

1University Hospitals Plymouth NHS Trust, Trauma & Orthopaedics, Plymouth, United Kingdom

The shoulder is the most commonly dislocated joint with recurrent instability twice as high in athletes than the general population. The Latarjet procedure is a commonly performed operation for recurrent traumatic anterior shoulder instability. The standard and type of sport they return to after surgery is not currently known.
This is a 10-year cross-sectional, quantitative, questionnaire study using a single surgeon series of 103 consecutive shoulders (97 patients) with a minimum follow up of 12 months. Completed questionnaires were received from 52 patients. Mean age at surgery was 31 (range 16-63 years) with a mean follow up of 5 years (range 1-10 years). 83% of patients, amateur through to professional athletes, returned to playing sport after their Latarjet procedure. However, only 66% returned to the same sport at the same standard as pre-operatively. Fear of re-injury, pain and time constraints were the reasons given why athletes might not return to sport.
This study demonstrates 3 key new findings. Firstly, individual sports have a higher return to sport rate than team sports. Secondly, the psycho-social factors of fear, time constraints and kinesiophobia might explain why some patients do not return to sport . These are the same reasons athletes delay their return to sport after surgery. Thirdly, returning to sport is an important post-surgery goal for young patients that can help drive their rehabilitation and psychological recovery after surgery.

There is NO Conflict of Interest: Yes


J Sayani1, T Plotkin2, D Burchette1, J Phadnis3

1East Sussex Healthcare NHS Trust, Orthopaedics, Hastings, United Kingdom, 2Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom, 3Brighton and Sussex University Hospitals NHS Trust, Brighton, United Kingdom

Background: There is no clear consensus on optimal treatment for OCD of the elbow in young athletes. This study aims to compare the outcomes of the surgical treatment strategies employed to treat capitellar OCD.

Methods: A systemic review of all treatment studies from January 1975 to January 2018 was performed following the PRISMA guidelines. 41 clinical studies including 1039 patients were suitable for inclusion. Qualitative and quantitative subgroup analysis was performed to compare the functional and radiographic outcomes between non-operative and surgical treatments for capitellar OCD. A unified grading system (Grade 1-4) was developed from the existing validated classification systems to allow comparison of patients with similar grade OCD lesions. Outcome measures of interest were patient reported functional outcome, range of motion, return to sport and radiographic outcome. Each outcome measure was evaluated according to grade of OCD and treatment method which included debridement/microfracture; fragment fixation, OATS and non-operative.

Results: There was no significant difference in outcome according to range of motion (ROM) (p=0.052), Mayo elbow performance score (MEPS) (p=0.34), Timmerman-Andrews score (TAS) (p=0.16) or return to sports (p=0.11) when OATS, fragment fixation and Microfracture were compared for the same OCD grade. Functional outcome scores and ROM were equivalent when comparing non-operative and all types of surgical treatment for low grade lesions. For high grade lesions, there was a significantly higher rate of return to sport and functional outcome following surgical intervention as compared to non-operative treatment (<p=0.001) although there was no difference between the type of surgical treatment performed.

Conclusion: For equivalent grade OCD lesions of the capitellum, Non operative treatment was similar in outcome to surgical treatment for low grade lesions, whereas surgical treatment was superior for higher grade lesions. There was insufficient evidence to support cartilage augmentation (OATS) for high grade lesions as compared to microfracture/debridement alone.

There is NO Conflict of Interest: Yes

424 - Surgical Repair of Distal Musculotendinous T Junction Injuries of the Biceps Femoris

B Kayani1, A Ayoub1, F Begum1, S Singh1, FS Haddad1

1University College London Hospital, London, United Kingdom

Background: Non-operative management of injuries to the distal musculotendinous T junction of biceps femoris is associated with variable periods of rehabilitation and high risk of recurrence. To our knowledge, the efficacy of operative treatment in patients with these acute injuries has not been previously reported.

Methods: This prospective single surgeon study included 34 professional athletes undergoing primary surgical repair of acute injuries to the distal musculotendinous T junction of biceps femoris. Predefined study outcomes relating to time for return to sporting activity, patient satisfaction, range of motion, hamstring muscle strength, passive range of motion, functional progress, and complications were recorded at regular intervals after surgery. Mean follow-up time was 28.4 months (range, 24.0 months to 36.3 months) from date of surgery.

Results: All study patients returned to their preinjury level of sporting activity. Mean time from surgical repair to full sporting activity was 11.7 ± 3.6 weeks. No patients had recurrence of the primary injury. At one-year follow-up, 18 patients (52.9%) were very satisfied and 16 patients (47.1%) were satisfied with the outcomes of their surgery. At 3 months after surgery, patients had improved mean passive straight leg raise (69.7°± 11.7°vs 24.1°± 7.4°, p<0.001); increased mean isometric hamstring muscle strength (93.1% ± 5.4% vs 63.1% ± 7.7%, p<0.001), higher mean lower extremity functional scores (64.5 ± 4.5 vs 27.2 ± 5.4, p<0.001), and improved mean Marx activity rating scores (10.7 ± 2.7 vs 2.2 ± 2.1p<0.001) compared to preoperative values. High patient satisfaction and functional outcome scores were maintained at one- and two-years following surgery.

Conclusion: Surgical repair of acute injuries to the distal musculotendinous T junction of biceps femoris is associated with high patient satisfaction, increased muscle strength, improved functional outcome scores, and high return to preinjury level of sporting activity with low risk of recurrence at short-term follow-up.

There is NO Conflict of Interest: No

638 - Meniscal Repair and Concurrent ACL Reconstruction: Does Autograft Choice Effect Healing of the Meniscus?

M. Walker1, A. Barnett1, P. Gallacher1

1The Robert Jones and Agnes Hunt Orthopaedic Hospital, Department of Sports Knee Surgery, Oswestry, United Kingdom

Background: Anterior cruciate ligament rupture (ACL) is a common soft tissue knee injury. A frequent concurrent finding is a meniscal tear. We aimed to determine if autograft choice for ACL reconstruction influenced the outcome of the meniscal surgery when the two were performed simultaneously.
Methods: We prospectively collected data between 2013 and 2018 of patients undergoing simultaneous hamstring or bone patella tendon bone (BTB) ACL reconstruction with meniscal repair.  Electronic patient records and imaging software were used to retrospectively review this. The data were analysed using R Statistical software. Collected data included:

  • Patient and injury demographics.
  • Patient reported outcomes (Lysholm, Tegner and Visual Analogue Scale) pre and post-op.
  • Failure rates of the meniscal repair.

Results: 129 Patients were identified, 90 of whom had hamstring ACL reconstructions, and 39 with BTB ACL reconstructions with meniscal repair.

  • Median age 23 for the ACL group and 24.5 for the BTB group (P = 0.3, no significant difference).
  • 70% of the hamstring group were male, 97% of the BTB group were male.
  • At 6 months, survival of the meniscal repair was 92% and 91% for the Hamstring group and BTB group, respectively.
  • At 24 months this was 75% and 78% for the hamstring and BTB groups.
  • No significant difference in repair survival found in the two groups (P=0.84).
  • There was no significant different in patient reported outcome data at any time point between the two groups.

Conclusions: There appears to be no statistically significant benefit to the survival of meniscal repairs, or the patient-reported outcomes choosing either hamstring or BTB Autograft ACL reconstruction.
Implications: In this setting, the need to perform a meniscal repair does not need to influence the graft choice of the surgeon, as outcomes appear similar.

There is NO Conflict of Interest: Yes

1192 - The higher rate of injury following the Covid-19 Lockdown period in elite professional footballers highlights the importance of pre-season training

A. Tang1, J. Ranson1, N. Jain1

1Pennine Acute Trust, Trauma & Orthopaedics, Manchester, United Kingdom

Introduction: The ‘preseason’ is an established element of the football season for players to gain fitness and improve performance following the start of the season. Although players are at greater risk of injury in the preseason period, it is questioned whether a preseason subsequently decreases the risk of injury in the season start itself.

Aim: To report the injury rate from post-lockdown professional football games (no preseason programme - NPP) and compare to the start of the season (following a preseason programme - FPP).

Method: We compared the injuries sustained across 4 European Professional Football Leagues (Premier League, Serie A, Bundesliga, La Liga) from the first 2 games for each team at the start of the 2019-20 season (FPP group) and from the first 2 games for each team after the re-start of football following lockdown (NPP group). We recorded the frequency, injuries per game, contact and soft tissue injuries. An injury was recorded if the player was deemed unable to continue play.

Results: In total 156 games were reviewed, 78 per group. Ten injuries were observed in the FPP group, 0.13 per game, compared to 30 injuries in the NPP group, 0.39 per game (p=0.001). The ratio of contact to soft tissue injuries was the same for both groups (1:4). There was no significant difference in the length of downtime between the leagues stopping and restarting (92 -103 days) and no correlation between injury rate and length of downtime.

Conclusion: Injuries in elite professional football were more common in the first 2 games following the restart after lockdown than in the first 2 games of the season. We believe this is due to the beneficial effect of a normal preseason being absent for the restart.

Implications: We highlight the importance of preseason in reducing injury rates amongst professional footballers.

There is NO Conflict of Interest: Yes

1877 - Is a minimum of 20mm of intra-femoral tunnel graft length really needed for successful outcomes after arthroscopic ACL reconstruction? – A myth confuted by a cohort study

V. Khanna1, P. Gupta2, A. Acharya2, A. Mourya2

1Wrightington Wigan and Leigh NHS Foundation Trust, Orthopaedics, Wigan, United Kingdom, 2Sir Ganga Ram Hospital, Sports Medicine and Arthroscopy, New Delhi, India

Background: Increasing demands on skills with mounting pressures from expectations from arthroscopic anterior cruciate ligament (ACL) reconstructions requires precise knowledge of technical details by surgeons. One such element is the minimum length of graft in femoral tunnel to allow for adequate tendon-to-bone healing and early return to activities and sports. This has, however, remained an unanswered question.
This study aimed to compare clinico-radiological outcomes of ACL reconstructions in patients with <20mm of intra-femoral tunnel graft length with those measuring ≥20mm.

Methods: This prospective, single-surgeon, cohort study was conducted at a tertiary-care teaching centre between November 2015-July 2018. Ethical clearances and informed consents were duly obtained. All ACL injuries listed for arthroscopic reconstruction were included except those older than 45, chondral/multi-ligamentous injuries and other systemic pathologies. Patients were sequentially divided into 2 groups based on the intrafemoral tunnel graft lengths (A:<20mm, n=27; and B:≥20mm, n=25).
Thorough pre and postoperative (3, 6 and 12 months) clinical and functional assessment using the Lysholm and modified-Cincinnati knee scores was performed for all patients (primary outcomes). MRI scans were additionally performed preoperatively and at 3 and 12 months postoperatively. Signal intensity was calculated at 6 regions of interest (ROI). Graft revascularization was measured quantitatively by measuring signal intensity and by using signal/noise-quotient formula (SNQ=signal from ROI in graft/background signal).

Results: No significant differences were noted in mean Lysholm and modified Cincinnati scores between the 2 groups at 1 year. There were also no significant differences in graft maturation over time and SNQR at 3 and 12 months in the region of interest (ROI).

Conclusions: Only 2 human studies have, to date, looked at addressing this crucial aspect of ACL reconstruction. Based on clinico-radiological outcomes from this study, intra-femoral tunnel graft lengths <20mm do not compromise early clinical and functional outcomes of ACL reconstructions.

There is NO Conflict of Interest: Yes

Accepted Abstracts

241 - The Effect of Demineralised Bone Matrix and Bone Marrow Mesenchymal Stromal Cells on Bone Tunnel Healing After Anterior Cruciate Ligament Reconstruction in a Sheep Model: A Comparison Using Micro–Computed Tomography

A Hexter1, C Pendegrass2, F Haddad3, G Blunn4

1University College London, Stanmore, United Kingdom, 2UCL Institute of Orthopaedics and Musculoskeletal Sciences, Stanmore, United Kingdom, 3University College London Hospitals, London, United Kingdom, 4University of Portsmouth, Portsmouth, United Kingdom

Background: Bone tunnel widening is common finding after ACL reconstruction of unknown significance. There is a rise in the use of orthobiologics in orthopaedic surgery with the aim of enhancing biological healing. We aimed to determine the effect of Demineralised Bone Matrix (DBM) and Bone Marrow Mesenchymal Stromal Cells (BMSCs) on graft healing in the femoral and tibial bone tunnels after Anterior Cruciate Ligament (ACL) Reconstruction in an ovine model.

Methods: Fifteen sheep underwent unilateral single-bundle ACL reconstruction using Achilles allograft. Femoral and tibial fixation was achieved using peek interference screws (Biosure, Smith & Nephew). Three groups were investigated: Group 1 (n=5) had 10 million allogeneic BMSCs applied to the tunnels in a fibrin glue carrier; Group 2 (n=5) had 5cc allogeneic DBM applied; Group 3 (n=5) had no treatment applied to the ACL reconstruction (control). The sheep were euthanised after 12 weeks and micro–computed tomography performed using Xradia 520 Versa (Zeiss). The outcome measures were Bone tunnel widening, bone mineral density (BMD), bone volume / total volume (BV/TV).

Results: These are provisional results and final p values are not available (full results ready by BOA 2020). DBM led to improvements in BMD and BV/TV in both tunnels compared to BMSC and control group. Regarding tunnel widening, BMSC lead to improvements in the tibial tunnel compared to DBM and control, but no difference was seen in the femur.

Conclusion: Orthobiologics can enhance graft healing in the bone tunnels after ACL reconstruction, with a greater effect seen in the tibia than the femur.

Implications: DBM appears to influence bone morphology and bone mineral density in the bone next to the bone tunnel, whereas BMSCs appear to have a greater effect on bone tunnel diameter itself. Different orthobiologics can have different effects when applied to the tendon-bone junction during ACL reconstruction.

There is NO Conflict of Interest: No

427 - Acute Surgical Repair of Complete, Non-Avulsion Proximal Semimembranosus Injuries in Professional Athletes

B Kayani1, A Ayuob1, F Begum1, FS Haddad1

1University College London Hospital, London, United Kingdom

Background: Non-operative management of proximal semimembranosus injuries is associated with prolonged periods of convalescenceand high risk of recurrence. To our knowledge, the outcomes of acute surgical repair for complete, non-avulsion proximal semimembranosus injuries have not been previously reported. The objectives of this study were to determine the impact of surgical repair for complete, non-avulsion proximal semimembranosus injuries on return to preinjury levels of activity, functional outcomes, and complications at short-term follow-up.

Methods: This prospective single surgeon study included 20 professional athletes undergoing acute primary surgical repair of complete, non-avulsion proximal semimembranosus injuries confirmed on preoperative magnetic resonance imaging. All study patients underwent a standardised postoperative rehabilitation programme. Predefined outcomes were recorded at regular intervals after surgery. Mean follow-up time was 27.6 months (range, 24.0 months to 34.6 months) from date of surgery.
Results: Nineteen of the 20 patients (95%) returned to their preinjury level of sporting activity. Mean time from surgical repair to full sporting activity was 11.9 ± 5.7 weeks. No patients had recurrence of the primary injury. At 3 months after surgery, patients had improved mean passive straight leg raise (71.5°± 5.9°vs 31.1° ± 7.2°, p<0.001); increased mean isometric hamstring muscle strength at 0°(83.8% ± 5.9% vs 48.4% ± 8.3%, p<0.001), 15°(77.6% ± 6.0% vs 52.3% ± 14.7%, p<0.001) and 45°(88.6% ± 5.5% vs 66.7% ± 13.1%, p<0.001), higher mean lower extremity functional scores (64.8 ± 4.6 vs 34.4 ± 5.2, p<0.001), and improved Marx activity rating scores (8.5 ± 2.0 vs 5.5 ± 1.5 p<0.001) compared to preoperative values. High patient satisfaction and functional outcome scores were maintained at one- and two-years following surgery.
Conclusion: Acute surgical repair of complete, non-avulsion proximal semimembranosus injuries was associated with high patient satisfaction, increased muscle strength, improved functional outcome scores, and high return to preinjury level of sporting activity with low risk of recurrence at short-term follow-up.

There is NO Conflict of Interest: No

508 - Anterior cruciate ligament graft rupture: Trans-tibial versus anteromedial portal technique for femoral tunnel placement

K Al-Hourani1, J Sheppard1, K Sri1, Y Zhang1, B Hull1, I Murray1, A Duckworth1, J Keating1, T White1

1Royal Infirmary of Edinburgh, Trauma & Orthopaedics, Edinburgh, United Kingdom

Aims: Correct femoral tunnel position in anterior cruciate ligament reconstruction (ACLR) is critical in obtaining good clinical outcomes. We aimed to delineate whether any difference exists between the anteromedial (AM) and trans-tibial (TT) portal femoral tunnel placement techniques on the primary outcome of ACLR graft rupture.

Methods: Adult patients (>18year old)  who underwent primary ACLR between January 2011 - January 2018 were identified and divided based on portal technique (AM v TT). The primary outcome measure was graft rupture. Univariate analysis was used to delineate association between independent variables and outcome. Binary logistic regression was utilised to delineate odds ratios of significant variables. 

Results: 473 patients were analysed. Median age at surgery was 27 years old (range 18-70). A total of  152/473, (32.1%) patients were AM group compared to 321/473 (67.9%) TT. Twenty-five patients (25/473, 5.3%) sustained graft rupture. Median time to graft rupture was 12 months (IQR 9). A higher odds for graft rupture was associated with the AM group, which trended towards significance (OR 2.03; 95% CI 0.90 - 4.56, p=0.081). Older age at time of surgery was associated with a lower odds of rupture (OR 0.92, 95% CI 0.86 - 0.98, p=0.014). 

Conclusion: There is no statistically significant difference in ACLR graft rupture rates when comparing anteromedial and trans-tibial portal technique for femoral tunnel placement. However, there was a trend towards higher rupture rates in the anteromedial portal group.

There is NO Conflict of Interest: Yes

1358 - Use of the FIFA 11+S as part of post-operative rehabilitation from arthroscopic shoulder stabilisation results in a higher Oxford Shoulder Instability Score and lower dislocation rate

L. Hoggett1, J. Ranson1, N. Jain1

1Pennine Acute Hospitals, Trauma and Orthopaedics, Manchester, United Kingdom

Introduction: Arthroscopic shoulder stabilisation is an established treatment for recurrent instability. The FIFA 11+ has been used to decrease the rate of injury in sport as part of injury prevention. The FIFA11+S is focused on the Upper Limb and in particular the shoulder.

Aim: To report the clinical findings from a series of patients undergoing arthroscopic shoulder stabilisation and the effects of incorporating the FIFA 11+S into their post-operative rehabilitation.

Method: A retrospective series of 30 patients undergoing arthroscopic shoulder stabilisation was reviewed. Two paired groups of 15 patients each were identified, those receiving the FIFA11+S (FIFA) as part of their rehabilitation and those who did not (No FIFA). Each patient underwent arthroscopic shoulder stabilisation in the form of labral (Bankart) repair using knotless anchor fixation and suture tape. Each was assessed for the number of post-operative dislocations and Oxford Shoulder Instability Score (OSIS).

Results: The mean post-op OSIS for the FIFA group was 43.6 and there were no post-operative dislocations. The mean post-op OSIS for the No FIFA group was 39.4 with 2 post-operative dislocations in this group. There was no statistically significant difference observed (p=0.19). A sample size of 39 patients in each group was calculated to be required to observe a statistical difference.

Conclusion: The FIFA 11+S has been introduced as an injury prevention technique, we suggest it should also be used to supplement rehabilitation following shoulder stabilisation surgery as it is suggested that its use provides a beneficial effect on post-operative outcome. We believe that the FIFA 11+S should be used as an adjunct to post-operative shoulder stabilisation rehabilitation. A larger study would confirm the suggested benefit.

There is NO Conflict of Interest: Yes

1597 - Functional outcomes, BMI and length of stay following Medial Patello Femoral Ligament (MPFL) reconstruction: Single surgeons, single-surgeon case series

S. Ismael1, G. Orfanos2, A. Patel2

1The Robert Jones and Agnes Hunt Orthopaedic hospital, Trauma and Orthopaedics, Oswestry, United Kingdom, 2Royal Stoke University Hospital, Trauma and Orthopaedics, Stoke on trent, United Kingdom

Acute patellar dislocation is usually a younger patients injury with a higher occurrence among females. The MPFL is often damaged during patellar dislocation. Repair or reconstruction of the MPFL is recommended to reduce the high incidence of recurrent dislocation, accordingly many surgical techniques describe repairing or reconstruction.

Retrospective evaluation of a single surgeon case series of 48 MPFL reconstruction procedure in 44 patients. We looked at baseline demographics, Length of stay, BMI at time of operation, pre and post-operative outcome scores. We used the latest values of post-op Kujula and KOOS scores. We divided patients in obese (>30) and non-obese (<30).

The mean age was 23 years and the majority were male with 54% (26 knees). The majority of the knees were left side 60% (31). The mean average of the BMI was 28.2 with the highest of 42 and lowest of 16. 37% (18) of our patients were in the high BMI category (>=30) and mainly females. The mean length of stay was 0.7 days and 45% of the patients discharged on the same day. Those patients who had bilateral MPFL-R spent longer between 3 to 4 days. The complication rate was higher in obese (16%) vs non-obese group. Two cases of patella fracture following a mechanical fall reported that required fixation.

T-tests showed statistically significant differences in mean improvement in the latest post-op KOOS (5.8, P<0.02) and Kujala (11.1, P <0.008) scores and LOS (-0.9, P<0.001) between obese and non-obese. The correlation matrix showed statistically significant disproportional relations between postoperative Kujala Score and patient pre-operative BMI (co-ef -0.33, P<0.018) and LOS in the hospital (-0.66, P <0.001).

In conclusion, higher BMI patients reported worse functional outcomes and stay longer in the hospital following MPFL reconstruction. The senior author's recommendation during MPFL reconstruction is careful and meticulous tunneling to prevent subsequent patella fracture.

There is NO Conflict of Interest: No