Abstracts - 2022

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The BOA Abstract submission for Congress 2022 is Now Closed!

Every year, as part of the BOA Annual Congress, healthcare professionals from across the UK and overseas submit abstracts on orthopaedic topics to be judged by experts in the field, with the hope of being able to present their work at Congress. Please see below for more information on the process, as well as the categories available for this year.

Oral presentation
All accepted podium authors will be required to present their abstract in-person at the BOA Annual Congress between 20th - 23rd of September, slots will be allocated in July prior to notification.

E-Poster presentation
All accepted posters will be published on the BOA website, app & displayed on digital screens at Congress. The format of posters must be submitted in PDF, A4 and Portrait. Any Landscape posters will not fit and will not be eligible to be displayed.  

Submitting your E-Poster

An A0 Portrait PDF (841mm wide x 1189mm high) of your poster must be submitted via the Oxford Abstract Platform via this link HERE no later than Tuesday 6th September.  Please note you DO NOT need to present the poster or attend.

Publication of Abstracts 
All selected abstracts will appear in full on the Congress Website and App.  

Should you have any queries please contact the BOA Events Team at [email protected].


Best of the Best 1

The feasibility of achieving Elective Care Framework targets for Total Hip Arthroplasty (THA) and Total Knee Arthroplasty (TKA) in Northern Ireland

Mayne AIW, Cassidy RS, Magill P, Mockford BJ, Acton DA, McAlinden MG

Primary Joint Unit, Musgrave Park Hospital, Stockman’s Lane, Belfast, BT9 7JB, Northern Ireland.

Background: Waiting times for arthroplasty surgery in Northern Ireland are among the longest in the National Health Service, which have been further lengthened by the onset of the SARS-CoV-19 global pandemic in March 2020. The Department of Health in Northern Ireland has announced a new Elective Care Framework (ECF), with the framework proposing that by March 2026 no patient will wait more than 52 weeks for inpatient/day case treatment. We aimed to assess the feasibility of achieving this with reference to Total Hip Arthroplasty (THA) and Total Knee Arthroplasty (TKA).

Methods: Mathematical modelling was undertaken to calculate the time taken to meet the ECF target and also to clear the waiting lists for THA and TKA, using the number of patients currently on the waiting list and percentage operating capacity relative to pre-Covid-19 capacity to determine future projections.

Results: As of May 2021, there were 3,757 patients awaiting primary THA and 4,469 awaiting primary TKA in Northern Ireland. Prior to April 2020, there were a mean 2,346 patients/annum boarded for primary THA and mean 2,514 patients/ annum boarded for primary TKA and there were a mean 1,624 primary THAs and 1,518 primary TKAs performed per annum.

The ECF targets for THA will only be achieved in 2026 if operating capacity is 200% of pre Covid-19 pandemic capacity and in 2030 if capacity is 170%. For TKA, the targets will only be met in 2034 if capacity is 200% of pre Covid-19 capacity.

Conclusions: This modelling demonstrates that, in the absence of major funding and reorganisation of elective orthopaedic care, the targets set out in the ECF will not be achieved with regards to hip and knee arthroplasty.  Waiting times for THA and TKA surgery in Northern Ireland are likely to remain greater than 52 weeks for most of this decade.

Prophylactic pinning in Slipped Upper Femoral Epiphysis – a closed loop audit of 25 years practice

EA Semple, A Bakhiet, D Campbell, JGB MacLean

Introduction: Prophylactic pinning of the contralateral hip in unilateral Slipped Upper Femoral Epiphysis (SUFE) persists as a source of debate with the majority of surgeons selecting this option in a proportion of patients whom they regard as at increased risk of a subsequent slip.

Methods: Universal prophylactic pinning was introduced in our health region in 2005 after an audit of ten years local practice (Cohort 1) identified one in four unilateral cases presented with a subsequent slip. This study compares the initial audit with our experience between 2005 and 2020 (Cohort 2) and as such constitutes a closed loop audit of 25 years practice.

Results: We observed a reduction in the overall incidence of cases. In Cohort 2, 44 patients presented with 52 affected hips compared with 60 patients with 76 affected hips in Cohort 1.

In Cohort 2, eight slips were bilateral, 34 of the 36 unilateral slips underwent simultaneous prophylactic pinning of the contralateral side. At a minimum follow up of 13m there have been no complications subsequent to prophylactic pinning in the form of wound infection, fracture , chondrolysis or avascular necrosis.

53 patients have undergone prophylactic pinning without complication. On the premise that 25% of our unpinned hips presented with subsequent slips before instituting our policy we estimate that we have prevented 9 subsequent slips over 25 years including the consequences which can be significant.

Conclusions: We continue to advocate universal prophylactic pinning as an effective and safe practice in the management of SUFE.

Reverse Total Shoulder Replacement – A Systematic Review and Meta-analysis of Complications and Patient Outcomes Dependant on Prosthesis Design

Ella Burden, Timothy Batten, Christopher Smith, Jonathan P Evans

Royal Devon and Exeter Hospital

Aim: This systematic review asked: In patients undergoing reverse shoulder arthroplasty (RTSA) for the management of cuff tear arthropathy, massive cuff tear, osteoarthritis and rheumatoid arthritis, what patterns of complications are associated with three RTSA prosthesis designs classified by Routman et al. The three implant philosophies investigated were; (1) Medial Glenoid, Medial Humerus (MGMH) (2) Medial Glenoid, Lateral Humerus (MGLH) (3) Lateral Glenoid, Medial Humerus (LGMH).

Methods: A systematic review of the literature was performed via a search of MEDLINE and Embase. Two reviewers extracted data on complication occurrence and Patient-Reported Outcome Measures (PROMs). Meta-analysis was conducted on the reported proportion of complication, weighted by sample size, PROMs were pooled using the reported Standardised Mean Difference (SMD). Quality of methodology was assessed using Wylde’s non-summative four-point system. The study was registered with PROSPERO (CRD42020193041).

Results: 42 studies met the inclusion and exclusion criteria. Rates of scapular notching were found to be significantly higher in MGMH implants (52% (95% CI 40, 3)) compared with MGLH ((18% (95% CI 6, 34)) and LGMH (12% (95% CI 3, 26)). Higher rates of glenoid loosening were seen in MGMH implants (6% (95% CI 3, 10) than MGLH implants (0% (95% CI 0, 2), however strength of evidence for this finding was low. No significant differences were identified in any other complication, and there was no significant difference observed in PROMs between implant philosophies.

Conclusion: This systematic review has found significant improvement in PROMS and low complication rates across the implant philosophies studied. Scapula notching was the only complication found to have significantly higher prevalence within the medialised glenoid, medialised humerus implant design.

Medical students’ perceptions of and experiences in trauma and orthopaedic surgery: A cross-sectional study

R Hackney1,  PG Robinson1, AD Hall1,2, G Brown1,2, AD Duckworth1,3, CEH Scott1

1Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, UK; 2Edinburgh Medical School, University of Edinburgh; 3Usher Institute, University of Edinburgh

Minorities are poorly represented in trauma and orthopaedic surgery (T&O).  Medical students’ perceptions of T&O and career influences are poorly understood. This study aims to assess medical students’ perceptions and experiences of T&O in a single United Kingdom centre, the sources that influenced these and how they could be improved.  

129 medical students completed a web-based survey using SurveyLegend (Malmö, Sweden). All students were scheduled to have rotated through T&O either virtually with web-based teaching only, or with additional face-to-face placements. 

Ninety-eight (76%) students responded: 67 females (68%) with 14 identifying as LGBTQ (14%). 52 students (53%) were White British, 29 (30%) Asian or Asian British, 17 (17%) from other or mixed ethnic groups. Choice of specialty was most influenced by subject matter, followed by positive clinical experiences of that specialty, perceived work-life balance and role models. Gender, LGBTQ status, race and ethnicity did not differ (all p>0.05) between those considering T&O as a career (n=31, 32%) and those who were not (n=67, 68%). Thirty-seven students had been influenced by positive comments regarding T&O, 38 (39%) had received negative comments, with the majority (57%) originating from other medical specialties. Direct exposure to T&O significantly improved negative perceptions of gender (p=0.03) and ethnicity distribution (p=0.02).

Female medical students early in their clinical career are equally likely to consider a career in T&O as males. All specialties should be aware of the impact of negative comments on students’ speciality choices and emphasise and encourage the importance of diversity.


Reducing Radiation Exposure and Cancer Risk for children with Scoliosis: EOS The New Gold Standard

Rose LD, Williams R, Ajayi B, Abdalla M, Bernard J, Bishop T, Papadakos N, Lui DF

Department of Trauma & Orthopaedic Surgery, St George’s University Hospital, London, UK

Purpose: Children are exposed to significant radiation doses during the investigation and treatment phases of scoliosis. EOS is a new form of low-dose radiation scan which also yields great image quality. However, currently its use is discouraged in the UK due to higher costs. We aimed to quantify the additional radiation dose and cancer risk.

Methods: We retrospectively reviewed all paediatric cases who received both standing whole spine roentgenograms and EOS scans as part of their investigations for scoliosis during a six-month period. We compared the radiation doses between the two modalities and estimated the additional mean lifetime cancer risk per study.

Results: We identified 206 children (mean age 14.4) who met the criteria of having both scans. Dose area products (dGycm2) were converted to estimated effective doses (mSv). The total mean doses were 0.68 mSv (AP 0.49 + Lat 0.19) for plain films, and 0.13 mSv (AP 0.08 + Lat 0.04) for EOS scans (p < 0.001).

Additional lifetime cancer risk of a plain film was 543% greater than EOS for both sexes (1/10727 versus 1/5827 in males, 1/34483 versus 1/6350 in females).

Conclusion: Plain film imaging of the whole spine requires in excess of five-times higher doses of radiation compared to dual planar EOS scans. This carries a significant impact when considering the need for repeat imaging on additional lifetime malignancy risk in children.  There is approximately 5.4-fold increase in risk of cancer for both boys and girls with roentgenograms over EOS, with girls being the most impacted. In our opinion, EOS dual planar scanning is the new gold standard when X ray of the whole spine is required.

Are orthopaedic surgeons tough as nails? A regional resilience study

Ghazal Hodhody 

Background: Healthcare professionals require resilience in the workplace to cope with the high demands of the job. Resilience reduces anxiety and distress following an adverse event, which orthopaedic surgeons must be prepared for. This cross-sectional study aims to assess the resilience levels of orthopaedic surgeons in one region to determine whether there are any factors which enhance it.

Methods: Data from one hundred orthopaedic surgeons of varying levels was collected and compared using a validated scoring questionnaire (Connor-Davidson resilience scale 25). Scores were assessed and compared to experience level and participant demographics such as age, sex and subspecialty. Data on extracurricular activities i.e. sport, meditation/prayer and crafts were also collected.

Results: There was no significant difference between the scores between genders (p= 0.74). The highest scores were found in trust grade doctors, SHOs and senior consultants. Higher resilience trends were noted for those who performed regular meditation and participated in regular arts and crafts. Those who participated in daily sports had lower resilience levels than those who participated less frequently.  A concerning 13% reported that they felt pandemic had negatively impacted their resilience.

Summary: This is the only study looking at resilience amongst orthopaedic doctors in the literature. Possible factors which may be protective of a higher resilience score are meditation, arts and crafts.  Lack of resilience is an issue throughout all grades. Orthopaedic trainees and consultants may benefit from external support outside their own extracurricular activities to maintain healthy levels of resilience in order to avoid burnout.

The Management of Gartland Type 1 Supracondylar Humeral Fractures During a Global Pandemic

C Allan, J Pietrzycki, I Smith

Department of Trauma & Orthopaedics, Royal Hospital for Children, 1345 Govan Road, Glasgow, G51 4TF

Introduction: Due to the Covid-19 pandemic, many treatment guidelines were adapted, with the aim of minimising face-to-face patient interactions.  Previously, children presenting with a Gartland Type 1 (undisplaced) supracondylar humeral fracture (SCHF) were placed into an above-elbow backslab and reviewed at a face-to-face fracture clinic.  

During the pandemic, the SCHF treatment guideline was altered and Type 1 SCHFs were treated in either a collar-&-cuff or backslab, as dictated by pain levels.   These were removed at three weeks post-injury by the child’s parent/guardian, followed by gentle mobilisation with no routine follow-up arranged.

This study aimed to ascertain adherence to this new guidance and to determine if any adverse events were associated with this change in practice.

Methods: Data was gathered retrospectively between the months of March to September during both 2019 (pre-pandemic) and 2020 (during pandemic). Electronic sources including Trakcare, Clinical Portal and PACS were utilised.

Results: In 2019, a total of 94 children were diagnosed with a Type 1 SCHF, of which 75 (79.7%) were managed in a backslab and 17 (18.1%) in collar-&-cuff. A total of 89 (94.6%) patients were followed up in a face-to-face fracture clinic within one week.

In 2020, a total of 82 children were diagnosed with a Type 1 SCHF, of which 37 (45.1%) were managed in a backslab and 45 (54.9%) in a collar-&-cuff. A total of 27 (32.9%) patients were followed up in fracture clinic, as a result of either diagnosis dubiety or parental concerns, thereby representing a significant reduction (p<0.001) in clinic visits. The remainder (67.1%) had no follow-up.  No further management was required for any patient and no adverse outcomes were recorded.

Conclusion: The updated guideline for children presenting with a Type 1 SCHF has significantly (p<0.001) reduced face-to-face patient interactions with no adverse events. We suggest this practice continues post-pandemic.

Time to surgery for open hand injuries and the risk of surgical site infection: a prospective multicentre cohort study

Richard Limb1, James Davies2, Daniel Thornton2, Ryckie Wade2, Tobias Robers3, David Mather4

1Liverpool University Foundation Trust, Liverpool, United Kingdom; 2Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom; 3Royal United Hospitals NHS Trust, Bath, United Kingdom; 4The Midyorkshire NHS Trust, Wakefield, United Kingdom

Background: Surgical teaching perpetuates the dogma that traumatic open hand injuries require urgent surgery to reduce the risk of infection. This is important because surgical site infection (SSI) is a common and costly complication, occurring in 1-35% of operations for hand trauma. Whether delaying surgery increases the risk of infection in open hand injuries is an important but unresolved topic as previous studies have implemented arbitrary time cut-offs and have failed to control for confounders. We set out to identify whether time to surgery influences the incidence of SSI in traumatic open hand injuries.

Methods: This prospective multicentre cohort study evaluated 938 consecutive adults (>16 years) with traumatic open unilateral hand injuries distal to the distal wrist crease who underwent surgery. SSI within 28 days was evaluated as the primary outcome along with confounding factors for SSI as per study protocol (patient, injury and management factors). A proxy power calculation based on previous literature was implemented (90% power, 5% significance) to guide recruitment. As the outcome is uncommon and odds approximate risk, the risk ratio (RR) of surgical site infection was estimated by multivariable logistic regression.

Results: The median time from injury to surgery was 20 hours (range 4–90). Forty-one patients (4%) developed an infection. The risk of infection was not affected by the time to surgery (adjusted risk ratio 1.0 [95% CI: 1.0 to 1.0]) or preoperative antibiotics (adjusted risk ratio 1.8 [95% CI: 0.2 to 13]), which were provided to 95% of patients. Skin loss increased the risk of infection (adjusted risk ratio 2.6 [95% CI: 1.3 to 5.0]). Costs - NA

Conclusion: Delaying surgery for open hand injuries by 4 days does not appear to increase the risk of surgical site infection.

Evaluating the Use of Routine Postoperative Laboratory Tests Following Primary Hip and Knee Arthroplasty

Georgios Orfanos, Hannah Meacher, Ashley Brown, Robin Banerjee, David Lowe, Dan Redfern, Geraint Thomas

Introduction: Primary joint arthroplasty is increasing in prevalence and the recovery following such a procedure is becoming more reliable and predictable. Routine postoperative blood tests form a routine practice following this, without substantial evidence of their need. The purpose of this study is to evaluate the incidence of abnormal postoperative laboratory tests following primary THA and TKA, as well as identify specific preoperative risk factors to advise for ordering postoperative blood tests.

Methods: This was a retrospective cohort study for all patients having a THA or TKA between January to December 2019 in our tertiary centre. A case analysis was performed for each patient.

Results: The study included 2721 patients with a mean age of 69 year old (SD ± 10.3, range 27.0-98.0y) and a mean BMI was 29.8 Kg/m2 (SD ± 5.4, range 14.9-50.9 Kg/m2). There were 1266 (46.6%) males and 1455 (53.4%) females, with 1452 (53.4%) having a THA and 1269 (46.6%) a TKA. The median ASA was 2 (range 1.0-4.0). Abnormal postoperative bloods were identified in 444 (16.3%) patients. Significant factors for having an abnormal postoperative result were gender (p<0.001), ASA (p=0.003), preoperative haemoglobin (p<0.001), preoperative haematocrit (<0.001), preoperative platelets (p<0.001), preoperative sodium (p<0.001), preoperative potassium (p<0.001), preoperative sodium (p<0.001), preoperative creatinine (p<0.001), There were 20 (0.7%) patients having an AKI and 67 (2.5%) requiring a transfusion. Preoperative haemoglobin (£ 126 g/dL), haematocrit (£ 0.490L/L), platelets (£ 200 (10*9/L)) and eGFR (£ 75ml/min) were identified as significant predictors for abnormal postoperative blood tests with a high sensitivity and a significant AUC (>0.800).

Conclusion: Patients should be stratified to receive postoperative blood tests targeting patients with abnormal preoperative haemoglobin (£ 126 g/L), haematocrit (£ 0.490L/L), platelets (£ 200 (10*9/L)), and eGFR (£ 75ml/min). Older patients (³65 years), females, ASA ³ 3 appear to be the ones more affected, but clinical judgement should be used to decide if they are required.

Virtual fracture clinic triage and selective use of MRI. A hybrid model for managing suspected scaphoid fractures

N MacDonald, J Heylen, H Moon, E Larsson, A Vaughan, R Owens

Introduction: In current practice in the UK there are three main approaches to investigating suspected scaphoid fractures not seen on initial plain film x-rays.

1. Early MRI of all cases
2. Review all cases in clinic at two weeks with repeat x-rays
3. Hybrid model. Virtual Fracture Clinic (VFC) triage to reduce those who are seen in clinic at two weeks by:
- Organising early MRI for those with high-risk presentation.
- Discharging those with an alternative more likely diagnosis.

Our unit uses the VFC model. We aimed to evaluate its efficiency, safety, clinical outcomes and economic viability.

Method: All patients attending the emergency department with either a confirmed or suspected scaphoid fracture between March and December 2020 were included (n=305). Of these 297 were referred to the VFC: 33 had a confirmed fracture on x-ray and 264 had a suspected fracture.

Results: Of the suspected fractures reviewed in VFC 14% had an MRI organised directly owing to a high-risk presentation, 79% were brought for fracture clinic review and 17% discharged with an alternative diagnosis such as osteoarthritis.

Of those subsequently reviewed in fracture clinic at two weeks: 9% were treated as scaphoid fractures (based on clinical suspicion and repeat x-rays), 17% had MRI or CT imaging organised, 5% did not attend and 69% were discharged.

Overall, 17% of cases initially triaged, had further imaging – 41 MRIs and 5 CTs. MRI detected: 5% scaphoid fracture, 17% other fracture, 24% bone contusion, complete ligament tear 10%, partial ligament tear 39% and normal study 10%. The results of MRI minimally affected management. 3 patients were taken out of plaster early, 1 patient was immobilized who was not previously and no patients underwent operative management.

In the following 12-month period one patient re-presented with a hand or wrist issue.

This approach avoided 218 MRIs, equating to £24000 and 109 hours of scanner time.

Conclusion: VFC triage and selective use of MRI scanning is a safe, efficient and cost-effective method for the management suspected scaphoid fractures. This can be implemented in units without the resource to MRI all suspected scaphoid fractures from the emergency department.

The Joint Specific BACH classification: A Predictor of Outcome in Prosthetic Joint Infection

AJ Hotchen, M Galea Wismayer, E Robertson-Waters, S McDonell, B Kendrick, A Taylor, A Alvand, M McNally

Aim: To assess the ability of the JS-BACH classification of bone infection to predict clinical and patient-reported outcomes in prosthetic joint infection(PJI).

Method: Patients who received surgery for suspected PJI at two tertiary UK centres between 2010 and 2015 were classified into ‘uncomplicated’, ‘complex’ or ‘limited options’ by two clinicians blinded to outcome. Any discrepancies adjudicated by a third reviewer. Patients were assessed for  recurrence since the index operation and  status of the joint. A Cox proportional-hazard model assessed significant predictors of recurrence following the index procedure. Patient-reported outcomes included the EuroQol EQ-5D-3L index score and the EQ-visual analogue score(VAS) at 0, 14, 42, 120 and 365 days following the index operation.

Results: 220 patients were included with a median time to final follow-up of 4.7years. Controlling for type of index procedure and site of infection, Cox proportional-hazards ratio of recurrence when  classified as complex versus uncomplicated was 25.2(95% CI 3.45 – 183.7,p<0.001) and having limited options verses uncomplicated was 59.0 (95% CI 7.93 – 439.1, p<0.001). None of the patients who were classified as ‘uncomplicated’ PJI(0/52) had received either amputation, joint fusion, excision arthroplasty, chronic suppressive anti-biotics, had died from sepsis secondary to PJI or were awaiting treatment for an active infection at final follow-up. This compared to 21.3%(27/127) of patients classified as ‘complex’ PJI and 65.9%(27/41) of patients classified as ‘limited options’. Compared to the age-matched population, patients with ‘uncomplicated’ PJI reported similar EQ-index scores(age-matched population: 0.782, ‘uncomplicated’: 0.730, SD 0.326) and EQ-VAS(age-matched: 77.9, ‘uncomplicated’ PJI: 79.4, SD 20.9). This was significantly higher when compared to patients classified as ‘complex’(EQ-index: 0.515 SD 0.323, p<0.012; EQ-VAS: 68.4 SD 19.4, p=0.042) and ‘limited options’(EQ-index: 0.333 SD 0.383, p<0.001; EQ-VAS: 60.2, SD 23.1, p=0.005, ANOVA with Tukey post-hoc comparison).

Conclusions: JS-BACH classification is a significant predictor of clinical outcome and quality of life following surgery for PJI.

Dynamic (4DCT) Imaging of the DRUJ - a novel method for identifying and describing instability

A Overton, D Williams, G Dean, A Ahluwalia, K Rajesparan, A Hunter

Introduction: Clinical diagnosis of subtle DRUJ instability remains a challenge. Currently available static imaging techniques have low sensitivity, specificity and reproducibility. 4DCT scanning of the DRUJ potentially offers a novel method of investigating this dynamic pathology.The aim of this study was to test this imaging technique, establish a reproducible scanning protocol and describe normal DRUJ kinematics.

Methods: 4 adult patients (8 wrists) presenting to our institution with clinical signs of instability were included in the study. Each of the patients underwent a ‘4DCT’ of both wrists following a pre-agreed protocol aimed at examining the full pronosupination cycle. Following image acquisition, the relationship between the ulna and radius at the sigmoid notch was examined on PACS using the ulna subluxation method and presented graphically. The difference between the pathological and the contralateral (control) wrist kinematics was examined. A measurable difference in ulna subluxation was detectable in pathological vs normal wrists.

Results and Conclusions: This study is the first to examine the sensitivity of 4DCT by including and comparing findings with a control group (the contralateral wrist).The optimal radiological protocol is discussed. The normal kinematics of the DRUJ as seen on axial CT is discussed. This method shows promise in offering an objective assessment of instability in more subtle cases.

Functional change following surgical intervention for ambulant patients with Cerebral Palsy

D MacDonald, L Farrow, S Barker

Royal Aberdeen Children’s Hospital, Aberdeen.

Aim: To assess the short term functional impact of different surgical interventions for ambulant patients with Cerebral Palsy

Methods: A retrospective cohort study was undertaken using the national Cerebral Palsy Integrated Pathway Scotland (CPIPS) database, which includes all patients with CP currently or previously cared for within the Scottish NHS since 2013. We assessed all ambulant patients (Gross Motor Function Classification System [GMFCS] 1-3) who underwent surgical intervention and had both a pre-operative and post-operative Functional Mobility Scale (FMS) score recorded before the end of the data collection period (August 2019). Intervention types were classified as either Botulinum toxin injection (Botox); single site soft tissue or bony surgery, selective dorsal rhizotomy (SDR) or single event multi-level surgery (SEMLS). Age, GMFCS, Sex, CP classification and CP distribution were also recorded. Chi squared analysis was performed to assess whether each surgical intervention was associated with a post-operative improvement in FMS; including adjustment for age, sex and GMFCS.

Results: There was 168 surgery events in 114 children (60.2% male). 31% children were GMFCS 1, 37.5% GMFCS 2 and 30.4% GMFCS 3. The age range was 2-17 with a first peak of intervention at 6 years (12.5%), and a second at 11 years (10.7%). With regards to surgical intervention type we found a statistically higher likelihood of improvement in FMS for those undergoing SDR (5/9; 55.6%) and SEMLS (11/21; 52.4%) compared to Botox (22/119; 18.5%), p<0.002. This remained significant when adjusted for age, sex and GMFCS. Those undergoing single site soft tissue or bony surgery also had a non-significantly lower likelihood of FMS improvement (5/16; 31.3%) compared to SDR or SEMLS.

Conclusion: The overall likelihood of functional improvement following surgical intervention in ambulant patients with CP was relatively low. SDR and SEMLS appear to offer a greater chance of functional improvements than either Botox or single site interventions.

Best of the Best 2

Lateral Hinge Fracture Risk Reduction in Medial Opening Wedge High Tibial Osteotomy: A Finite Element Analysis Study

Stanisław Tomaszczyk1, Rosie Earl1, Humza Osmani2, Michael Sutcliffe1, Joel Melton2 

1Department of Engineering, University of Cambridge, 2Department of Trauma and Orthopaedics, Addenbrooke’s Hospital

Background: Lateral hinge fractures are a significant complication of medial opening wedge high tibial osteotomies. We sought to identify the optimum cut geometry, in order to minimise the risk of intra and post-operative fractures, as well as quantify the trade-off between fracture risk and stability, in order to propose a more precise position for the osteotomy hinge.

Method: A finite element model was studied to investigate the effect of varying the hinge position for a given bone geometry; variables analysed included the shape around the apex of the osteotomy cut and micromotion levels. A further nine finite element  knee models were studied to consider the variability between patients’ bone properties and the feasibility of finding an optimum hinge position using references from a pre-operative x-ray. Screw technique, insertion pressures and hinge compression were also analysed.

Results:  Wide hinges provide improved stability but increased stress and probability of intra-articular fracture. A width: height ratio < 0.85 reduces this likelihood. Furthermore, wider and more rounded saw profiles reduce stress concentrations and fractures. Narrow hinges lead to more micromotion, therefore reducing post-operative stability. This led to us identifying  a proposed cut apex position (width 10.5mm and height 17mm) which was shown to keep stresses low, reduce fracture risk and retain bone at the hinge for stability. Strain was lowest when the apex was 13% of the maximum medial-lateral width and the cut was aimed towards the fibular head tip. Finally, screw techniques (including the use of flexible wires) can possibly reduce hinge tensile strains by 30%.

Discussion: Our study has proposed a position for the apex, which can be located for any patient using references and dimensions taken from the pre-operative x-ray. Further work is required to define the exact location of fracture type transition and corroborate the suggested osteotomy cut geometry.

High rate of tibial debonding and failure in a popular knee replacement: a follow-up review

David Keohane, Gerard A Sheridan, Eric Masterson

Aims: Total knee arthroplasty (TKA) is a common and safe orthopaedic procedure. Zimmer Biomet's NexGen is the second most popular brand of implant used in the UK. The primary cause of revision after the first year is aseptic loosening. We present our experience of using this implant, with significant concerns around its performance with regards early aseptic loosening of the tibial component.

Methods: A retrospective, single-surgeon review was carried out of all of the NexGen Legacy Posterior Stabilized (LPS) TKAs performed in this institute. The specific model used for the index procedures was the NexGen Complete Knee System (Legacy Knee-Posterior Stabilized LPS-Flex Articular Surface, LPS-Flex Femoral Component Option, and Stemmed Nonaugmentable Tibial Component Option).

Results: Between 2013 and 2016, 352 NexGen TKAs were carried out on 331 patients. A total of 62 TKAs have been revised to date, giving an all-cause revision rate of 17.6% at a minimum of five years. Three of these revisions were due to infection. Overall, 59 of the revisions were performed for aseptic loosening (16.7%) of the tibial component. The tibial component was removed intraoperatively without instrumentation due to significant tibial debonding between the implant-cement interface.

Conclusion: While overall, we believe that early aseptic loosening is multi-factorial in nature, the significantly high aseptic revision rate, as seen by an experienced fellowship-trained arthroplasty surgeon, has led us to believe that there is a fundamental issue with this NexGen implant design. Continued implant surveillance and rigorous review across all regions using this particular implant is warranted based on the concerning findings described here. Cite this article: Bone Jt Open 2022;3(6):495-501.

Closing the surgical training gap

Hannnah James

Background: Surgical training has been significantly affected by the Covid pandemic, with trainee logbooks showing a 50% reduction in the number of first-surgeon procedures in 2020/21 compared to 2019/20. We designed an intensive, high anatomical fidelity cadaveric simulation ‘catch-up’ course to be delivered to trainees in several surgical specialities in a single sitting. We aimed to: 1) measure the training gap due to Covid training disruption, and assess (2) feasibility and (3) educational impact of a ‘catch-up’ simulation training course delivered to a wide variety of surgical specialties using a single set of cadavers over 3 days.

Materials and methods: 26 trainees between CT1 and ST6, from 6 surgical specialties (and ITU/anaesthetics) in a large University Teaching Hospital were recruited. Bespoke learning objectives were developed for trainees before the course. The training gap and educational impact was measured using trainee self-assessment of their PBA (Procedure Based Assessment) levels in a web-survey after the course.

Results: 29 different surgical procedures were performed (62% index). A mean learning gap of 1.36 PBA levels was reported across all specialities (range 1.0-3.0, n=64). By sub-group, the gap was greatest for index procedures, vascular surgery trainees, and mid-higher stage (ST3-4). The mean PBA level gain (gap closure) post-course was +1.51 (range 0 to 5.0, n=64), and was highest for index procedures, anaesthetic trainees, and the mid-higher stage group. Trainees were highly satisfied with the course and reported the anatomical fidelity of the simulation was not compromised by sharing cadavers between specialities.

Conclusion: There is a measurable trainee-reported learning gap following Covid disruption to surgical training, and an intensive cadaveric simulation training intervention with bespoke learning objectives appears to go a long way towards closing this.  It is feasible to deliver a time and resource efficient cadaveric course for multiple surgical specialities in one sitting. Catch-up simulation is acceptable to trainees who report it should be centrally funded and embedded in regular training provision.

A new look at the tidemark: understanding the cellular and molecular changes at the osteochondral interface

Adam Esa

Subchondral bone is at the interface between non-calcified cartilage and the trabecular bone of the skeletal system. It is separated from the articular cartilage by a thin basophilic acellular region known as the tidemark.

The purpose of this study was to examine cellular changes occurring in the deeper zones of articular cartilage and particularly at the osteochondral interface. With this in mind, we used osteochondral plugs isolated from healthy tissues donated postmortem and osteoarthritic tissues from patients undergoing total knee replacement. The first part of this study characterised infiltrating cellular phenotypes using markers for endothelial and mesenchymal stromal cells. In addition, the involvement of bone cells in particular osteoclast was also investigated using series of experimental designs. This work suggests that changes affecting the subchondral bone marked by alteration in proteoglycan composition, loss of tidemark integrity and invasion of blood vessels from the subchondral bone is apparent even in early stages of the disease where there is little damage affecting the superficial zone of the articular cartilage. This finding is interesting as it is increasingly becoming more evident than in osteoarthritis, changes in the underlying bone including microfracture which are thought to occur due to abnormal joint loading, might supersede that of articular cartilage.

By examining the association of bone cells particularly osteoclast with endothelial cells at the osteochondral interface, the results showed that osteoclasts play a role in altering articular cartilage integrity. In normal osteochondral tissues, there was no evidence of TRAP positive cells approaching the tidemark of the osteochondral interface. TRAP positive cells appeared to be mainly found in osteoarthritic tissues. Furthermore, there seemed to be a strong association between endothelial cells, bone marrow mesenchymal stem cells and osteoclast cells in an interesting manner where endothelial cells act like a ‘Trojan horse’ by invading articular cartilage eventually leading to cartilage loss. These findings helps one to understand the complex and intricate relationship between different cell types found in the subchondral bone in osteoarthritis .

Understanding these alterations at the osteochondral junction and regulating pathways implicated in their initial occurrence will lead to a greater knowledge of the pathophysiology of osteoarthritis.

Open reduction Capsulorrhaphy & Acetabuloplasty (ORCA): A one stop surgical treatment for infant DDH

Amanda Rhodes, Nic Uren, Alex Aarvold, S Penker, Edward Lindisfarne, Kirsten Elliot, Nicholas Clarke

University Hospital Southampton and Wessex Deanery

Introduction: This study reports the longer-term outcomes of the Open Reduction Capsulorrhaphy Acetabuloplasty (ORCA) procedure, utilising a minimal outer table acetabuloplasty, which aims to stimulates acetabular growth and avoid later pelvic osteotomies.

Methods: The outcomes for 100 infants treated with ORCA, with a minimum of four year follow up, were analysed. Pre-operative patient demographics and radiological measurements were recorded. Radiological outcomes including IHDI classification, Acetabular Index (AI) and Severin grade were recorded at pre-defined post-operative intervals. The % of hips requiring further pelvic surgery was calculated. Operated hips were then compared to normal contralateral hips

Results: The median age at the time of surgery was 15 months. Pre-operative dislocation severity was IHDI grade IV (high dislocation) in sixty cases, grade III in 28 and grade II in twelve cases. Mean pre-operative AI was 40° deg. This showed statistically significant improvements year on year (Repeated measures ANOVA, post hoc Bonferroni correction, p<0.001). 
Mean AI at final follow up (range 4-12 years) was 18°, compared to 15° in the normal contralateral hips. 94% of cases have Severin Grade 1 (excellent) or 2 (good) outcome. Only 2% of patients required later pelvic osteotomy for residual acetabular dysplasia, compared to 60% of cases who do so after surgical reduction without pelvic osteotomy.

Conclusions: This procedure, utilising a minimal acetabuloplasty, appears to be at least as effective as open reduction and any formal pelvic osteotomy. The acetabuloplasty is technically quicker to perform, is far less invasive, and is therefore a simple adjunct for the surgeons.

Cost-effectiveness following osseointegration for transfemoral amputation and the relationship between pre and post-operative EQ5D Health Utility Value

C Handford, L McMenemy, J kendrew, A Mistlin, A Akhtar, M Parry P Hindle

Aim: To assess the effect of osseointegration in transfemoral amputees on health-related quality of life and cost analysis.

Methods: Two centre analysis of patients receiving transcutaneous femoral osseointegration using The Osseointegration Group of Australia Osseointegration Prosthetic Limb (OGAP-OPL) implant. Retrospective health utility and cost analysis of prospectively collected patient reported health outcome data. Osseointegration cost was compared with the yearly cost of a poorly fitting conventional prosthetic determining cost/Quality Adjusted Life Year.

Results: Eighty received osseointegration. Mean age was 39 years (range 20-57) and 66% were male (n=53). The majority of subjects underwent unilateral (n=62, 77.5%) rather than bilateral surgery (n=18, 22.5%). Trauma was the most common indication (n=59, 74%). Maximum follow up was 10.5-years. Mean preoperative EQ5D HUV in pooled data was 0.64 (SEM 0.025) increasing to 0.73 (0.036) at 5-years and 0.78 (0.051) at 6 years with continued improvement up to 10.5-years. In subgroup analysis those with a starting EQ5D HUV <0.60 reached a cost/QALY of <£30,000 at 5-years postoperatively and show statistically significant improvement in EQ5D HUV. The UK military experience was wholly positive with a mean starting EQ5D HUV of 0.48 (0.017) with significant (p<0.05) improvement in EQ5D HUV at each time point and a resultant reducing cost/QALY at each time point being £28616.89 at 5 years.

Conclusion: There is both a quality of life and financial argument in favour of osseointegration in select patients with above knee amputations. In those unable to mobilise satisfactorily with traditional prostheses and a pre-intervention score of <0.60, a consistent cost effectiveness and quality of life benefit can be seen. Such patients should be considered for osseointegration as these patients reap the maximum benefit and cost effectiveness of the device. This evidence lends strongly to the debate advocating the use of osseointegration through centrally funded resources, including the NHS.

The Characteristics, Outcomes and Management of PeriprOsthetic fractures Service Evaluation (COMPOSE): A cohort study

Ashley Scrimshire

Aims: To describe the demographics of UK patients sustaining femoral periprosthetic fractures (PPF), fracture characteristics, predictors, management, and associated outcomes.

Methods: Multicentre retrospective study of patients presenting with a PPF from 01/01/2018-31/12/2018. Descriptive analysis by fracture location was performed and predictors of fracture type, management and outcomes assessed using mixed-effects logistic regression.

Results: 720 femoral PPFs from 27 NHS Trusts were included; 74.9% were hip PPFs, 21.0% knee and 4.2% dividing type. UCPF B type fractures were most common. Patients were typically elderly(mean 79.9 years), female(63.2%), with one or more comorbidity(93.1%), and reduced mobility before admission(61.7%). Female gender was the only significant predictor of fracture type for hip PPFs (OR 0.61;p=0.01).

78% of cases were managed operatively and 22% conservatively. 13.8% required transfer to a different hospital for treatment. Median time from admission to surgery was 4 days (IQR:2-7). Of those undergoing surgery, 53% underwent revision+/-fixation and 47% fixation alone. Cemented stem(OR=2.66;p<0.01) and B2/B3 fracture type(OR=7.56;p<0.01) were predictors of operative management.

Median LOS was 15 days(IQR:9-24), 12-month reoperation rate 5.6%, and 30-day readmission rate 7.5%. 30-day and 12-month mortality rates were 6.0% and 21.4%. Non-operative treatment, older age, male gender, admission from residential/nursing care and fracture around a revision prosthesis were statistically significant predictors of increased 12-month mortality.

Conclusions: Femoral PPFs patients are generally elderly and comorbid, with mortality, re-operation and readmission rates comparable to hip fractures. However, they have longer waits for surgery and treatment is more complex. This data can be useful in planning future services and trials.

A review of distal third clavicle fracture management in the United Kingdom – How many are out there and what do we do? A multicentre national collaborative study

Parag Raval, Abbas See, Harvinder Singh, DTC Collaborative

Background: Distal third clavicle(DTC) fractures represent about 2-4% of all adult fractures. Due to their instability and non-union risk, they can prove difficult to treat. There are several different operative options for DTC fixation reported. The primary outcomes of this study were to determine the frequency of DTC fractures and their management. Secondary outcomes included complications, further procedures, fracture union and the breakdown of treatment by modified Neer classification.

Methods: A multicentre cohort study was conducted with patients included between 1st January 2019- 31st December 2019. All patients, over the age of 18, with an isolated DTC fracture were included. Demographic variables were recorded: age; sex; side of injury; mechanism of injury; modified Neer classification grading; operative technique; fracture union; complications and subsequent procedures. Baseline characteristics were described for demographic variables. For all continuous data, means and standard deviations were calculated.

Results: A total of 859 patients were included from 18 NHS trusts(5 MTC, 13 DGH). The mean age was 57 years(18 to 99). 87% were treated conservatively and 54% were Neer type 1 fractures. With regards to operative management, 89% of patients who underwent an operation were under the age of 60. Main selected fixation methods: Hook plate(47), Locking plate(34), Tightrope(5), Locking plate and tight rope(7). 56% of patients had evidence of union at the most recent follow-up. 56% of patients had evidence of bony union at the most recent follow-up and 13 patients with non-union went on to have further surgical intervention. 

Conclusions: Our study is the first to review the epidemiology and practice of DTC management in the UK and analyse the surgical methods practised. We have found that hook plates are the predominantly used fixation method followed by locking plates.  We suggest a pragmatic RCT to see which method of fixation is optimal is required.

Elevated Metal Ion levels Can Be Tolerated by Some Patients

Chinyelu Menakaya, Matthieu Durand-Hill, Christos Hadjikyriacou, Iftikhar Ahmed, Nabi Wahidun, Shiraz Sabah, Robert Mccoulloch, Alister Hart, James Donaldson, Timothy Briggs, John Skinner.

Background: Ten years following withdrawal and revision of large diameter metal on metal hips (MOM), there remains an uncertainty in how best to manage asymptomatic patients with MOM hips who have abnormal imaging and/or raised blood metal ion levels. This study investigates the trajectories of symptoms, serological metal ion tests and cross-sectional imaging in this patient group.

Methods: 523 patients with 707 acceptable functioning MOM hips (defined as Oxford Hip Score (OHS) >30) on active monitoring were identified. Surveillance included: patient-reported pain and function (OHS), blood metal ion measurement (Cobalt and Chromium) and/or cross-sectional imaging with MRI.

Results: 364 patients had serial metal ion levels at two time intervals. Mean serum cobalt and chromium levels in parts per billion (ppb) were Co1 4.5 (S.D. 11.5), Co2 4.7 (S.D. 11.6) and Ch1 3.0 (S.D. 4.8) and Ch2 3.2 (S.D. 4.9). Median Oxford hip score was 42 (IQR 28 – 27). OHS was not significantly correlated to serum metal ion levels (Cobalt Chromium Pearson correlation = -0.105 P = 0.106, Chromium Pearson correlation = -.125 P = 0.054). There was no significant change in cobalt (-0.48, P = 0.414) and chromium levels (-0.25, P = 0.325) between the two time intervals.

45 patients were identified as having metal ion levels >7 ppb, 64.4% had OHS greater than 30 and 13.3% had pseudotumour formation.

6 patients had metal ions level greater than 50 ppb, with no significant deterioration of OHS greater than 30. Only 33.3% had pseudotumour formation. Their MRI did not show worsening pseudotumour or deterioration in gluteal muscle anatomy.

Conclusion: Our results indicate that there are a subset of patients with high metal ion levels, stable imaging and acceptable function who can safely be actively monitored. This study provides more information in assisting joint decision making with this challenging patient group.

Are we deconditioned post COVID?

Alex Witek

We often look back on the past with rather rose tinted glasses and are guilty of occasionally making grand claims regarding the productivity of theatres and how this has deteriorated, regularly laying the blame at the feet of others involved in the patient pathway.

Productivity in theatre can be simplified into the number of operations performed with the least amount of time lost between cases. This study compared two time periods pre and post COVID-19 pandemic and analysed the total number of cases per list, the total operating time, anaesthetic time, and time between cases at a single centre.

When breaking down time for patients to arrive in theatre, anaesthetic time and operating time, the only factor to increase was the overall operating time. On a weekday trauma list, the average operating time increased from 3 hours 55 minutes pre to 4 hours 21 minutes post pandemic. On a weekday elective list the average operating time also increased from 3 hours 33 minutes to 4 hours 33 minutes. The average downtime between cases actually decreased.

Though this increase in operating time may be a reflection of an increasingly complex patient workload, as surgeons, we must not ignore that we are human and just as susceptible to skill decay as anyone else. It is vital that we focus on getting back up to speed post pandemic through maximising training opportunities, engaging with courses and using educational time to refine our skills and maximise theatre list efficiency.

Cementation Techniques in Knee Surgery: A Delphi Consensus Study

Vivek Balachandar1, Matthew Hampton1, Bambos Charalambos2, Paul Sutton1

1Northern General Hospital, 2Blackpool Victoria Hospital, University of Lancashire

Introduction: Aseptic loosening is the most common cause of failure following cemented total knee arthroplasty (TKA) [1]. For Total Hip Arthroplasty there are well established cementation techniques, but by contrast there is no consensuses for cementation of TKA and a paucity of literature guiding this. The aim of our study was to develop a consensus on the optimal technique for component cementation in TKA.

Methods: A three round, modified Delphi consensus study based on surgeons identified on the National Joint Registry of England, Wales and Northern Ireland (NJR) was completed. From a cohort of surgeons with at least 5 years’ NJR data, ‘experts’ were identified by fulfilling any of the following 3 criteria: 1) surgeons recording over 150 TKA per annum, 2) authorship of a TKA related paper in a peer reviewed journal within the previous 5 years, or 3) named trainers offering post-CCT fellowship training positions. Cementation techniques where evidence is poor quality, inconclusive, or absent formed the focus of the study and a threshold of 70% was used to identify consensus.

Results: Eighty-two experts (Round 1), eighty experts (Round 2), and seventy-nine experts (Round 3) participated. Four domains with a total of twenty-four statements were identified. A 100% consensus was reached within the pressurisation, cement curing, and surface preparation domains. A 70% consensus was reached within the cement application domain. Consensus was not reached regarding the method of cement application.

Conclusion: In the absence of high-quality evidence expert opinion is of value. This consensus study provides recommendations on the technique for component cementation in TKA but further high quality research in this area is needed.

[1] Ben-Shlomo Y, Blom A, Boulton C, et al. The National Joint Registry 18th Annual Report 2021. NJR; September 2021.

Instrumented Smart Sensor Technology for Total Knee Replacement

B van Duren, E Kelmers, T Carpenter, D Cowell, S Freear, H Pandit

Background: Although TKR is an established treatment approximately 20% of patients remain unhappy with a 5% risk of failure requiring revision surgery within ten years. Increasing focus has turned to post-operative rehabilitation using sensor technology to help guide and drive progress.  Additionally, treatment the failing implant is difficult with significant consequences for the patient. Smart implant technology has the potential to offer valuable adjuncts to rehabilitation as well monitoring and diagnosing failing implants. This work presents the design and testing of a novel smart module for TKR.

Methods: An instrumented sensor module was designed to be incorporated into the insert of a TKR limited to 10mm x 20mm maximum dimensions. The module included independent rechargeable power supply, processor unit, memory, two-way communication as well as temperature, accelerometer, and strain sensors. Initial modelling and lab tests were undertaken to determine construct safety. Sawbone and cadaveric tests were the undertaken with the device incorporated into a contemporary TKR insert to verify charging & communication functionality as well as force, motion, and temperature measurement capability.

Results: Finite element analysis using forces exerted on the knee for multiple activities including walking, running and stair climbing showed that introducing a space to accommodate the sensor device is unlikely to compromise the insert or change its mechanical functioning. Sawbone and cadaver testing showed that the device was able to detect varying forces exerted on the knee (e.g. vars/valgus), motion of the knee (e.g. flexion/extension), and temperature. Functionality testing showed the device was able to transfer data both to and from an external device with a reliable signal strength. Charging the device was tested and showed that sufficient current could be induced to realise a charge from a battery depleted of charge.

Conclusions: This work has demonstrated that the technology required to achieve smart implants is achievable and capable of monitoring the implant environment in-vivo. This technological advancement opens the path to improvements in rehabilitation, implant monitoring, failure detection, and implant design.


Podium Presentation Abstracts

56 - A study to assess the effectiveness of adapting physiotherapy working patterns on an Orthopaedic Trauma Ward

Peter Eckersley, Jennifer Heneghan

Manchester University NHS Foundation Trust, Manchester, United Kingdom

Background: Elective Orthopaedics has shown effective examples of moving Physiotherapy working hours to later in the day to facilitate mobilisation of patients on the day of surgery following lower limb joint arthroplasty.

Conversely, our Physiotherapy team working within Trauma Orthopaedics felt that an earlier start time may allow our team to routinely engage Hip Fracture patients in functional activity at the start of their first post-operative day; such as sitting out in a chair to eat their breakfast or assisting them to get out of bed for toileting purposes.  This would have the consequent effect of achieving the following National Hip Fracture Database (NHFD) performance measures in a manner which is purposeful for the patient:

  • ‘Assessed by Physiotherapist on day of, or day after, surgery’ (Assessed by Day 1)
  • ‘Mobilised on day of, or day following, surgery’ (Mobilised by Day 1)

Methods: It was decided that two of the six members of our Orthopaedic Physiotherapy Team would move their start times forward to 06.30, with the other four continuing to begin their shift at 08.00.

Assessment of the effectiveness of this change was achieved through measuring our performance against the NHFD measures above over a one year period.

Results: For the six months immediately prior to the change of working hours (145 patients in total):

  • Assessed by Day 1: 144/145 (99.3%)
  • Mobilised by Day 1: 101/145 (69.7%)

 For the six months immediately following the change of working hours (164 patients in total):

  • Assessed by Day 1: 164/164 (100%)
  • Mobilised by Day 1: 148/164 (90.2%)

Conclusions: The project results indicate an uplift in our performance in relation to the NHFD standards since the alteration of the team’s working hours.

Implications: This change has now been adopted as a standard working pattern for the team; with ongoing monitoring of its effectiveness.

118 - How has the Covid-19 pandemic affected the baseline physical ability of patients presenting to hospital with hip fracture?

Peter Eckersley, Jennifer Heneghan, Margaret Carney

Manchester University NHS Foundation Trust, Manchester, United Kingdom

Background: It had been noted anecdotally within our Physiotherapy team that patients with hip fracture have presented with a gradually more dependent level of ability throughout the Covid-19 pandemic.

In 2021, Age UK published findings describing that older people were subjectively reporting increased difficulty in completing basic mobility tasks as a direct effect of the pandemic.

Our study attempted to quantify these subjective feelings through use of the Cumulative Ambulatory Score (CAS) – a valid measure for evaluation of levels of physical independence in patients with hip fracture.

A single CAS can be recorded (scored out of six) to assess patients’ pre-admission baseline mobility level. Furthermore, CAS can be recorded cumulatively for the first three days post-surgery (scored out of eighteen) – whereby a score of equal to/greater than ten indicates a 99% survival rate at one month, and a 93% chance that the patient will achieve discharge home.

Methods: CAS for the first three days post-surgery, and as a pre-admission baseline score, was calculated for two groups of 50 patients admitted with hip fracture to our hospital. The initial group studied was from the pre-pandemic timescale of January/February 2020. The comparison group was from a later phase of the pandemic – January/February 2022.


  • Average pre-admission CAS reduced from 4.7 in 2020, to 4.1 in 2022.
  • Average 3-day post-surgery CAS reduced from 10.4 in 2020, to 7.3 in 2022.

Conclusions: The results above indicate a reduction in physical ability of patients presenting with hip fracture later in the pandemic.

Implications: It is worth noting that the average score for patients in the group from later in the pandemic is now below the threshold of equal to/greater than ten on the three–day post-operative CAS; potentially therefore having an affect upon their survival rates and chance of discharge home.

127 - Randomised controlled trial of a behaviour change physiotherapy intervention to increase physical activity following hip and knee replacement: the PEP-TALK trial

Toby Smith1,2, Scott Parsons1, Alex Ooms1, Susan Dutton1, Beth Fordham1, Angela Garrett1, Caroline Hing3, Sallie Lamb4

1University of Oxford, Oxford, United Kingdom; 2University of East Anglia, Norwich, United Kingdom; 3St George's Hospital, Tooting, London, United Kingdom; 4University of Exeter, Exeter, United Kingdom

Background: We aimed to test the effectiveness of a behaviour change physiotherapy intervention to increase physical activity compared with usual rehabilitation after Total Hip Replacement (THR) or Total Knee Replacement (TKR).

Methods: A multicentre, pragmatic, two-arm, open, randomised controlled, superiority trial was conducted in nine NHS hospital. 224 individuals aged ³18 years, undergoing a primary THR or TKR deemed “moderately inactive” or “inactive” were recruited. Participants received either six, 30-minute, weekly, group-based exercise sessions (usual care), or the same six-weekly, group-based, exercise sessions each preceded by a 30-minute cognitive behaviour discussion group aimed at challenging barriers to physical inactivity following surgery (experimental). Initial 75 participants were randomised 1:1 before changing the allocation ratio to 2:1 (experimental:usual care). Allocation was based on minimisation, stratifying on comorbidities, operation type and hospital. There was no blinding. Primary outcome measure was UCLA Activity Score at 12 months. Secondary outcome measures at six and 12 month assessed function, pain, self-efficacy, kinesiophobia, psychological distress and quality of life. 

Results: Of the 1254 participants assessed for eligibility, 224 were included (139 experimental:85 usual care). Mean age was 68.4 years (standard deviation: 8.7), 63% were female, 52% underwent TKR. There was no between-group difference in UCLA score (mean difference: -0.03 (95% CI: -0.52 to 0.45, p=0.89)). There were no differences observed in any of the secondary outcomes at six or 12 months. There were no important adverse events. The COVID-19 pandemic contributed to the reduced intended sample size (target 260) and reduced intervention compliance.

Conclusions: There is no evidence to suggest attending usual care physiotherapy sessions plus a group-based behaviour change intervention differs to attending usual care physiotherapy alone. As the trial could not reach its intended sample size, nor a proportion of participants receive their intended rehabilitation, this should be interpreted with caution.

184 - Feasibility of a backwards walking programme: A randomised controlled pilot study in patients following Hip and Knee Replacement

Martha Batting, Karen Barker

Oxford University Hospitals NHS Foundation Trust, Oxfordshire, United Kingdom

Background: Patients following hip or knee joint replacement are at increased risk of falls due to strength and proprioception deficits following surgery. Backwards walking as a therapeutic exercise could improve strength and balance however the feasibility and safety of such an intervention needs to be assessed.

Methods: A feasibility pilot Randomised Controlled Trial (RCT) was conducted (Trial Registration number: NCT04247802). Patients in the intervention group were issued a home exercise programme of a backwards walking programme. Feasibility was assessed through recruitment and retention rates, adherence to study protocols and acceptability of the intervention collected through qualitative interviews. The primary outcome measure was the Berg Balance Score (BBS).

Results: 63 participants were recruited (hip 32, knee 31), with a mean age of 73 years (range 65-84), over an 8-month period.  335 patients were screened, of which 18.8% enrolled. Four participants withdrew, leaving 32 intervention and 27 control participants in the final analysis. Only 65.6% of participants received the treatment plan as per the protocol, owing in part to virtual appointments for COVID-19. Furthermore, 15 participants only completed questionnaires at 3 month follow up due to covid restrictions. Patients reported that they found the intervention to be acceptable, but adherence was only 50%. No falls were reported. A small effect size for the BBS was observed (d=0.15). Estimates suggest a future definitive study would require 1,164 participants.

Conclusions: Backwards walking is a safe intervention for patients following hip or knee replacement. However, significant amendments to the design of the study are needed to account for reduced treatment fidelity, recruitment, and adherence for the study to be feasible at full trial.

Implications: Further work should look at adherence, recruitment, and fidelity strategies to improve these outcomes for a backwards walking intervention prior to a future definitive study.

192 - Exploring the factors affecting post-surgical mobilisation for people following hip fracture: A scoping review

Rene Gray

James Paget University Hospital, Gorleston, United Kingdom

Background: Delayed mobilisation following hip fracture surgery is detrimental, causing prolonged hospital stays and increased mortality. There is wide variation across Trusts in the percentage of patients mobilised by day one following surgery. This review aims to identify the factors affecting early mobilisation in order to suggest recommendations for future research.

Method: A systematic search of MEDLINE, AMED, CINAHL, APA PsycINFO, APA PsycArticles databases was completed. Inclusion criteria was: (1) patients received surgery for fragility hip fracture (2) included data on factors which impacted mobilisation within 48 hours post-surgery. 

Critical Appraisal Skills Programme (CASP) and Mixed Methods Appraisal Tool (MMAT) were used to appraise the methodological quality of the papers. Data was synthesised through a narrative analysis approach due to the heterogeneity of included studies.

Results: 2,998 records screened using the PRISMA flow diagram resulting in 16 eligible studies. The average age for patients was 82.3 years, 69.7% were female and 42.7% had dementia or a recognised cognitive impairment.   

Five themes were identified: chronic health factors, system factors, Healthcare worker-related factors, acute modifiable health factors & Patient psychological factors.

Conclusion: The term “early mobilisation” was poorly defined across studies impacting on the ability to compare and generalise results.

There were limited studies exploring early mobilisation in patients with cognitive impairment.

Three, of five, themes identified that could be more amenable to change in both the patient and healthcare workers involved in early mobilisation following hip fracture surgery at the peri- and post-surgical stages.

Education and awareness could help to overcome some barriers to early mobilisation.

Implications: Interventions aimed at changing the attitude and behaviour of patients and healthcare worker could help to overcome some barriers to early mobilisation following hip fracture.

This could have a positive impact nationally and internationally on metrics related to early mobilisation and health outcomes.

282 - Managing Students Placement Preparation

Sarah Harris1, Katrina Mitchell2,3

1University of Winchester, Winchester, United Kingdom; 2AHP Faculty, Hampshire and Isle of Wight, United Kingdom; 3ATOCP, UK, United Kingdom

Allied Health Professional students are required to undertake 1000 hours of practice-based learning over their 2-3 year degree programme. At the University of Winchester (UoW), feedback is collated from students and Practice Educators after each placement to assess the quality of their experience and inform process improvement. A review of the feedback in 2021 identified common themes associated with the changing placement landscape and skills required from physiotherapy students.  A literature search and a mixed methodology quality improvement model around students’ readiness for placement, including a questionnaire from years 1-3 (n=61), focus groups (n=45), and discussions with Practice Educators’ on their perceptions of students’ readiness for placement. 63% of students did not feel prepared for placement (score <4/10). The key themes identified: travel/commuting (n=54%), educator expectations (n=62%) and unfamiliar environment (53%). These were also evidenced in the literature review. The toolkit was developed on the UoW student virtual learning environment, pulling together existing and new resources. Examples of some of the new resources developed include expectations guides from various placement environments (student and educator perspective), travel guides to support students in planning their placement journey, and signposting to university support services. The toolkit has had a focus on the preparation of placement but will include sections on “during” and “after” placement to support all years throughout the whole placement. Topics included within these sections of the toolkit incorporate dealing with sensitive/challenging situations, professional behaviour in the workplace, and reflecting/feeding-back on placement experience.  The toolkit will be piloted April 2022, to year 1 students on placement June 2022. A follow-up survey will be sent to year 1 students post placement to identify if the toolkit supported their preparation for placement. The aim is to launch the toolkit September 2022 to all year groups to support the placement experience.

306 - The Oxford Participation Activity Questionnaire (Oxpaq) in a district hospital setting. A useful adjunct to assessing functional outcomes and patient recovery with implications for delivering rehabilitation

Sunny Deo1, Claire Thelwell1, Simon Lovett1, James Bilzon2

1Great Western Hospital NHS Foundation Trust, Swindon, United Kingdom; 2University of Bath, Bath, United Kingdom

Background: The Oxford Participation & Activity Questionnaire (OKS-APQ), is a patient-based questionnaire that focusses on patients’ own functional level, based on the World Health Organisation’s International Classification of Function, Disability and Health parameters, thereby providing a better indicator of individual patient’s functional restoration.

Introduction: The Key research question was: Does the OxPAQ add additional information about an individual patient and patient cohort recovery?

Method: A consecutive cohort of patients was asked to complete the OxAPQ in addition to the standard Oxford Knee Score (OKS) at 1 year follow-up following primary knee replacement surgery undertaken at a single institution. The cohort was 94 consecutive patients with complete data. Main analysis was of the OKS-APQ scores and OKS, including correlations, comparison of mean scores and score distributions.

Results: There was weak positive correlation between the OxPAQ and OKS scores, r2 of 0.57. When converted to percentage scores, the mean OxPAQ was 59 (95% CI+/-6.1) and OKS was 79 (95% CI +/- 3.1), demonstrating lower patient-specific functional return to normal and wider spread of responses. Diagrammatic representation allows visualisation of sub-groups of patients such as those with excellent return of function with symptoms, those with minimal symptoms but very poor function and the smallest subgroup of patients with significant pain and function.

Conclusions: The OxPAQ is usable in a district hospital setting and confirms that restoration of full function based on patients’ functional expectations and is generally not reached at 1 year. It defines patients into groups for whom specific additional targeted rehabilitation may be better employed, and those for whom there may no added benefit, potentially allowing better targeting of rehabilitation resources.

Implications: If functional restoration is seen as an important marker of joint replacement success, longer follow up using the OxPAQ is required. Larger scale studies are warranted.

342 - The Role of Allied Health Professionals in the Preparation and Delivery of a “Super Saturday” Day Case Waiting List Initiative

Victoria Kennedy

Fairfield General Hospital, Bury, United Kingdom

Background: Bury Care Organisation tested a new way of working within Orthopaedics by holding a “Super Saturday” initiative list. The purpose of this event was to reduce the number of patients on the post Covid waiting list without any adverse effect on the weekday service, whilst maintaining patient safety and positive patient experience.

Method: A dedicated multi-professional task and finish group was established eight weeks prior to the event and the team met on a regular basis. The Therapy Lead Physiotherapists were active members of this group.

Our role involved:

  • Examined usual practise from pre-op assessment through to discharge home with ongoing physiotherapy referrals.
  • Explored safe staffing numbers and staff skill-mix to match the tasks involved throughout the initiative day to predict what physiotherapy and occupational therapy input would be required to facilitate day case discharge.
  • Arranged appropriate staffing for the event.
  • Predicted start and finish times for therapy staff which were staggered from 07:00 until 20:00.
  • Calculated therapy staff costings.
  • Attended the Debrief after the event.
  • Presented findings at the Trust wide Team Brief.


  • We piloted an extra Saturday list without impacting on weekday activity           
  • 10 arthroplasty patients (2 total hip replacements, 5 total knee replacements and 3  uni-compartmental knee replacements)
  • 8 patients were discharged as day case with 2 patients discharged at 23 hours (80% day case rate)
  • Additional therapy time (30 hours in total) was correctly predicted and required to deliver this service – with approximately 5 hours to complete pre-op Occupational therapy telephone assessments.

Conclusion: Careful patient selection, agreed funding and dedicated multi-professional teamwork enabled 10 patients to be removed from the surgical waiting list in one day, without any impact on the weekday admissions.

Implications: If replicated nationally there would be a significant impact on surgical waiting times.

413 - Improving outpatient staff satisfaction and experience on delivering virtual consultations at a tertiary hospital for patients with complex Musculoskeletal conditions following the COVID-19 pandemic: a quality improvement initiative

Stephanie O'Neill, Anju Jaggi, Sarah Rodrigues

RNOH, London, United Kingdom

The rapid implementation of Virtual Consultations (VCs) as a surrogate for face-to-face clinics at the start of the COVID-19 pandemic represented a major challenge for NHS managers and stakeholders across England. The Royal National Orthopaedic Hospital set a standard to transform 80% of all face-to-face outpatient appointments to VCs within two weeks, necessitating the need to promptly improve staff satisfaction and experience in parallel to providing the physical infrastructure. The aim of this quality improvement project was to improve outpatient staff satisfaction/experience when delivering VCs.

Methods: Quality Improvement (QI) methodology was utilised by a group of clinicians and improvement experts. Initial open feedback via email/ Microsoft Teams dialogue were obtained from physiotherapists and occupational therapists to identify key themes for improvement using an inductive approach. Driver diagrams were created to identify ‘change ideas’ from key themes, which were subsequently implemented over six months. Two online surveys evaluating staff satisfaction and experience were distributed to outpatient staff before and after changes were implemented to evaluate their impact.

Results: Several key improvement themes were identified from initial open feedback, namely; communication, robust networks, education and training, supplementary resources (staff and patient), feedback and reliable video consultation platform. Twenty-eight responses were submitted at baseline, while 14 were submitted post implementation. Cumulative baseline response for ‘extremely/moderately satisfied’ according to several domains were 75% (referral information), 35.7% (admin booking process), 42.9% (induction support), 17.9% (available resources). All post implementation responses for ‘extremely/moderately satisfied’ increased to 78.6%, 57.1%, 64.3%, 64.3% respectively.

Conclusion: QI methodology rapidly facilitated the identification of several change ideas that were feasible to implement with limited resources and corresponded with overall improvements in outpatient staff satisfaction and experience when conducting VCs.

Implications: Expanding QI methodology skillset amongst outpatient staff is essential for improving services within the continuously evolving clinical landscape.

565 - SQuaRe score. Qualitative Study of A Novel Patient Related Measure Of The Quality Of Rehabilitation Following Knee Replacement Surgery

Sunny Deo1, Simon Lovett1, James Bilzon2

1Great Western Hospital NHS Foundation Trust, Swindon, United Kingdom; 2University of Bath, Bath, United Kingdom

Background: Post-surgical rehabilitation is a key element of optimal recovery, which is affected by lack of funding.

Introduction: To better evaluate patients’ evaluation of their rehabilitation, a patient-centred Survey on Quality of Rehabilitation Survey (SQuaRe), based on NHS England’s 2014 10 key parameters for patient expectations for good rehabilitation, was devised

Aims were to assess questionnaire usability, whether it could identify areas of good and poor rehabilitation and therefore be used for mapping improvements.

Methods: A pilot cohort of 20 consecutive primary total knee replacement and 6 hip fracture patients was asked to complete the questionnaire at 6 weeks post-surgery. Patients asked to rate each of the 10 key NHSE parameters using a Likert scale, providing an overall score with 40 best and 0 worst. Additional questions on the simplicity of understanding and completing the survey and space for comments were also included. 

Results: The score range was from 3 to 40, with 100% completion. The majority of patients (81%) rating their rehabilitation experience with a score of 21 or more. Over a third (38%), rated expectations very highly, in the top quartile, however 19% rated rehabilitation as 20/40 or less. The mean score for the cohort was 28/40 (SD 9.5). There were differences between individual stems ranging from 2.9 (SD 0.9) to 3.8 (SD 1.1), with overall mean stem score of 2.9. Overall rating of the survey for simplicity of questionnaire was 85%.

Conclusion: This is a novel, simple method for evaluation rehabilitation by patients, based on nationally established rehabilitation goals. It is easy to complete. It identifies patients who may require additional therapy inputs, potentially allowing targeting of therapy resources. 

Implications: This is an easy to use survey, which could be used to measure rehabilitation service quality and improvements and warrants further evaluation.

832 - A systematic review of randomized control trials to assess exercise prescription practice in Tennis Elbow

J Rai1, E Turgut2, E Ivemey3, O Khaiyat4, D Towey3, T Richardson3, C Coulthard5, J Mohammed3

1Kent Community Health NHS Foundation Trust, Ashford, United Kingdom; 2Hacettepe University, Faculty of Physical Therapy and Rehabilitation, Ankara, Turkey; 3Lincolnshire Community Health services NHS Trust, Lincoln, United Kingdom; 4Liverpool Hope University, Liverpool, United Kingdom; 5Ashford and St Peters NHS Hospital Foundation Trust, Ashford, United Kingdom

Aim: To systematically review the exercise prescription practices in the management of Tennis Elbow. 

Method: A comprehensive literature search was conducted using recommended methods using Boolean logic with the following terms: physiotherapy; physical therapy; rehabilitation; exercise; tennis elbow; lateral epicondylitis and lateral elbow tendinopathy. The study was registered under PROSPERO registration number: CRD42021281976.  PICO and PRISMA was used to guide the search and report the process of synthesizing the search results. The quality of the RCTs was assessed using The Physiotherapy Evidence Database (PEDro) scale.

Results: Out of the total of 848 articles that were identified from the initial search 22 RCT’s were shortlisted for the current systematic review. On the PEDro scale, of the 22 RCT’s only 2 scored as excellent, 12 as good, 7 fair and 1 poor. Majority of the studies failed to outline their scientific rationale for choosing exercises and have also not provided science behind exercise progression aimed at achieving optimal benefits. 

Conclusion: There is clearly a paucity of high-quality evidence available to guide physiotherapists in designing and progressing exercise programs for patients with TE. Further research in the field of exercise prescription and related progression is required to provide more robust evidence in prescribing exercise for the management of TE in clinical practice.

Developing World Orthopaedics

Podium Presentation Abstracts

765 - How Can Orthopaedic Surgeons Advocate For A Sustainable And Ethical Cobalt Supply Chain From The Democratic Republic Of Congo?

John Williams1, Elizabeth Tissingh2

1London, London, United Kingdom; 2King's College London, London, United Kingdom

Background: The vast majority of the global cobalt supply is mined in the Democratic Republic of Congo, where there has been longstanding international concern regarding exploitative and unsustainable mining practices. The orthopaedic sector as a whole uses approximately 2,000 tonnes of cobalt a year, mostly in arthroplasty implants. Some large electronics and vehicle manufacturers have taken extensive steps to ensure their cobalt supply chain is fully mapped; what measures we are taking in the orthopaedic sector is less well known.

Objectives: To highlight human rights issues, environmental concerns and ethical challenges raised. We explore how orthopaedic surgeons themselves can advocate for the issue.

Methods: Up-to-date review of relevant reports from governments, industry and NGOs; assessment of current international law and guidelines in place; measures taken by companies both inside and outside of the orthopaedic industry; explore potential strategies for advocacy.

Results: There is a comparative lack of mandatory regulatory compliance requirements for cobalt supply chains in Europe and the USA. Two key international documents are published by the OECD and United Nations. A number of NGOs exist which advocate for improvements in cobalt supply chain due diligence and offer advice to companies. Two companies from the orthopaedic sector are known to be members of one such NGO, the Responsible Minerals Initiative, which is an encouraging sign. An opportunity exists to improve the lives of Congolese miners, which will require a collaborative effort from consumers, industry and regulators.

Conclusions: We believe ethically and environmentally conscious decision making regarding orthopaedic materials should become of increasing importance and focus. Surgeons can help by raising awareness, advocating for this issue in their individual hospitals and clinics and applying pressure upstream to managers, purchasers and implant companies. National orthopaedic organisations can help surgeons by supporting this issue publicly.


Podium Presentation Abstracts

186 - Impact of haptic feedback on surgical training outcomes:  A randomised, controlled, double-blinded trial of haptic versus non-haptic immersive virtual reality training

Abrar Gani1,2, Oliver Pickering3, Caroline Ellis4, Philip Pucher5, Omar Sabri2

1Hillingdon Hospital NHS trust, London, United Kingdom; 2St Georges University NHS Foundation trust, London, United Kingdom; 3Portsmouth University Hospitals NHS trust, Portsmouth, United Kingdom; 4Ashford and St Peters NHS Trust, Chertsey, United Kingdom; 5Portsmouth University Hospitals NHS trust, London, United Kingdom

Objective: This study aimed to evaluate the educational impact of integrated haptic feedback in an immersive VR bone drilling simulation on the performance of a cohort of junior surgeons 

Design: Block randomised, controlled, double-blinded study. 

Setting: St Georges University Hospital, London, United Kingdom.

Participants and methods: 31 junior doctors with limited orthopaedic experience were recruited to participate in this randomised controlled study through e-mail advertising. They were allocated to haptic or non-haptic group through block randomisation . All participants were blinded to the nature of the study as well as its intervention arms. All participants completed an immersive virtual reality training module with either haptic feedback or no haptic feedback in which they had to drill 3 bicortical holes in a VR tibia bone model in preparation for screw insertion followed by an ex vivo equivalent task on a tibial sawbone model drilling 3 holes through both cortices of the tibia.  Outcome measures were plunge gap distance, drilling time and objective structures assessment of technical skills (OSAT) as well as qualitative questionnaire outcomes

Results: Haptic feedback in the VR training module showed significantly less plunge gap distance compared to the non-haptic group (7.6mm ± 4.3 vs 13.6mm ± 7.4 (p = 0.012)). The haptic group also had longer drill times (17.5 seconds ± 4.0 vs 13.8 seconds ± 4.2 (p = 0.027)), higher combined OSAT cores (14 (10,17) vs 8.5 (7.75, 12), p = 0.0006) and greater number of safe drills of <5mm plunge gap in at least 2 out of 3 attempts (6 (40)vs 0(0)), (p = 0.021). 

Conclusions: This study demonstrates better performance for an orthopaedic surgical task when using a VR-based simulation model incorporating haptic feedback, compared to one without haptic feedback supporting the pursuit and implementation of haptics in surgical training simulation models to enhance their educational value.

Foot and Ankle

Podium Presentation Abstracts

602 - Platelet rich plasma injection for acute Achilles tendon rupture: Two-year follow-up of the PATH-2 randomized, placebo-controlled, superiority trial

Joseph Alsousou1, David Keene2, Paul Harrison3, Heather O’Connor4, Susan Wagland5, Susan Dutton6, Philippa Hulley7, Sarah Lamb8,2, Keith Willett2

1Manchester University Hospitals Foundation Tursy, Manchester, United Kingdom; 2Kadoorie Research Centre, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK, Oxford, United Kingdom; 3Institute of Inflammation and Ageing, University of Birmingham, Birmingham, United Kingdom; 4Oxford Clinical Trials Research Unit, Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom; 5Kadoorie Research Centre, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom; 6Oxford Clinical Trials Research Unit, Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom; 7Botnar Research Centre, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom; 8College of Medicine and Health, University of Exeter, Exeter, United Kingdom

Background: The PATH-2 trial found no evidence of a benefit of Platelet Rich Plasma (PRP) injection versus a placebo after Achilles tendon rupture (ATR) at six-months. ATR often leave long-term functional deficiencies beyond six-months. This study aim is to determine if PRP affect tendon functional outcomes at two-years after rupture.

Study Design: Randomised multi-centre two-arm parallel-group, participant- and assessor-blinded, superiority trial.

Methods: Adults with acute ATR managed with non-surgical treatment were recruited in 19 UK hospitals from 2015 to 2019. Exclusions were insertion or musculotendinous injuries, leg injury or deformity, diabetes, haematological disorder, systemic corticosteroids and anticoagulation therapy. Participants were randomised via a central online system 1:1 to PRP or placebo. Primary outcome was Achilles Tendon Rupture Score (ATRS) at two-years. Secondary outcomes were pain, Patient-Specific Functional Scale (PSFS), SF-12 and re-rupture rate. Assessors were blinded. Intention-to-treat and Compliance Average Causal effects (CACE) analyses were carried out. Consistency of effects across subgroups age, BMI, smoking and gender were assessed using Forest plots. Pearson’s correlation was used to explore ATRS correlation with blood and growth factors.

Results: 216/230 (94%) participants completed the 6-months follow-up were contacted. 182/216 (84%) completed the two-year follow-up. Participants were aged mean 46 (SD 13.0), 57 female/159 male. 96% received the allocated intervention. Two-years ATRS scores were 82.2 (SD 18.3) in the PRP group (n=85) and 83.8 (SD 16.0) in the placebo group (n=92). There was no evidence of a difference in the two-years ATRS (adjusted-mean difference -0.752 95%CI -5.523 to 4.020, p=0.757), or in any secondary outcome, and no re-rupture between at two-years. Neither PRP cellular or growth factors correlated with the two-year ATRS. 

Conclusion: PRP did not improve patient-reported function or quality of life two-years after acute Achilles tendon rupture, compared with placebo, indicating that PRP offers no patient benefit in the longer term.

657 - Saving the Foot: Simple Orthopaedic Intervention to Adjust the Mechanics of the Ulcerated Neuropathic Foot Improves Outcomes by Reducing Sepsis, Amputation & Mortality

Jessica Blong1, Andrew Sharpe1, Jess Cairney-Hill1, Andy Gorman1, Matthew Allen1, Samantha Haycocks1, Mike Stedman2, Adam Robinson1, Adrian Heald1, Edward Gee1

1Salford Royal Hospital - Northern Care Alliance, Salford, United Kingdom; 2Res Consortium, Hampshire, United Kingdom

Background: Orthopaedic surgeons have the potential to transform their diabetic foot service, with the introduction of outpatient percutaneous tendon procedures performed under local anaesthetic. These adjustments to the mechanics of the foot help to offload the ulcerated region, expediting healing, and reducing the morbidity and mortality associated with chronic neuropathic ulceration.

Methods: Patients with neuropathic ulceration were offered a percutaneous procedure performed under local anaesthetic by an orthopaedic surgeon within a tertiary centre Diabetic Foot MDT. Percutaneous tenotomies (PT) for toe apex ulcers. Percutaneous tendoachilles lengthening (TAL) for plantar metatarsal head ulcers. Study period April 2019 - October 2021. Primary outcome: ulcer resolution. 12 month follow-up period. 

Results: PT: 12 feet, 10 patients (70.8 years). Pre-intervention ulcer duration 20.8 weeks. 3.3 weeks to ulcer resolution post-procedure. Complete ulcer resolution achieved in 100% of patients. 0% recurrence. 0% admission for foot sepsis. 0% amputations. 0% mortality.

TAL: 10 feet, 9 patients (48.8 years). Pre-intervention ulcer duration 38.2 weeks. 4.5 weeks to ulcer resolution post-procedure. Complete ulcer resolution achieved in 100% of patients. 10% ulcer recurrence. 0% admission for foot sepsis. 10% amputation. 0% mortality.

Conservatively-managed comparison cohort: 15 feet, 14 patients (69.8 years). Complete ulcer resolution achieved in 36% of patients. 66% ulcer recurrence. 46% admitted for foot sepsis. 46% amputation. 40% mortality.

Average cost saving of £8691 per patient undergoing surgery: an 88% reduction in healthcare costs.

Conclusions/ Findings: Surgical intervention outcomes: successful ulcer resolution achieved for all; no admissions for diabetic foot sepsis; reduced recurrence and amputation rates; no mortality within 12 months. 

We have demonstrated significant patient benefit and cost savings for this simple intervention, which merits full evaluation in a clinical trial.

Implications: Simple orthopaedic surgical intervention can prevent progression to diabetic foot sepsis, reducing both financial and logistical burdens on the emergency orthopaedic service.

658 - A cohort study of risk Factors for failure of total ankle replacements: A data linkage study using the National Joint Registry and NHS Digital

Toby Jennison1, Ian Sharpe2, Andy Goldberg3

1Royal Devon and Exeter Hospital, Exeter, United Kingdom; 2Royal Devon and Exeter NHS Trust, Exeter, United Kingdom; 3Wellington Hospital, London, United Kingdom

Introduction: Despite the increasing numbers of ankle replacements that are being performed there are still limited studies on the survival of ankle replacements and which factors influence survivorship.comparisons between different implants

The primary aim of this study is to link NJR data with NHS digital data to determine the true failure rates of ankle replacements and to determine the risk factors for failure of total ankle replacements

Methods: A data linkage study combined National Joint Registry Data and NHS Digital data. The primary outcome of failure is defined as the removal or exchange of any components of the implanted device inserted during ankle replacement surgery. Life tables and Kaplan Meier survival charts demonstrated survivorship. Cox proportional hazards regression models with the Breslow method used for ties were fitted to compare failure rates. 

Results: 5,562 primary ankle replacement were recorded on the NJR between 1st April 2010 and 31st December 2018. The unadjusted 1-year survivorship of ankle replacements was 98.8% (95% CI 98.4%-99.0the 5-year survival in 2725 patients was 90.2% (95% CI 89.2%-91.1) and the 10-year survival in 199 patients was 86.2% (95% CI 84.6%-87.6%).
In univariate cox regression models age, BMI, ASA, Charlson co-morbidity score, indication for surgery were significantly associated with an increased risk of failure. In multivariate cox regression models only age (HR 0.956, 95% CI 0.942-0.970), BMI (HR 1.032, 95% CI 1.006-1.059) and indication (HR 0.880, 95% CI 0.799-0.968) were associated with an increased risk of failure.

Conclusion: Ankle replacements have been demonstrated to have higher failure rates in younger patients, those with an increased BMI, and those with osteoarthritis. These findings should be taken into account when deciding which patients should undergo an ankle replacement and in counselling them on the likely survivorship of there ankle replacement.

General Orthopaedics

Podium Presentation Abstracts

327 - Association between combat-related traumatic injury and skeletal health: bone mineral density loss is localised and correlates with altered loading in amputees - The ADVANCE Study

Louise McMenemy1,2,3,4, Fearghal Behan5, Josh Kaufmann5, David Cain4,6, Alexander Bennett7,8, Christopher Boos9, Nicola Fear10,11, Paul Cullinan12, Andrew Phillips5, Anthony Bull5, Alison McGregor5

1Centre for Blast Injury Studies, London, United Kingdom; 2Imperial College London, London, United Kingdom; 3Academic department for military surgery and trauma, London, United Kingdom; 4Royal Centre for Defence Medicine, Birmingham, United Kingdom; 5Department of Bioengineering, Imperal College, London, United Kingdom; 6Academic Department of Military Trauma and Orthopaedics, London, United Kingdom; 7Academic Department of Military Rehabilitation, London, United Kingdom; 8Defence Medical Rehabilitation Centre, Loughborough, United Kingdom; 9University Hospital Dorset, Dorset, United Kingdom; 10Academic department of Military Mental Health, Kings college London, London, United Kingdom; 11Kings centre for Military Health Research, London, United Kingdom; 12Department of Occupational and Environmental Lung Disease, Imperial college London, London, United Kingdom

Background: A large number of young amputees are disproportionately diagnosed with osteopenia/osteoporosis each year, increasing their life time risk of fragility fractures. Our aim was to investigate if the reduction in bone mineral density (BMD) in amputees was a systemic reduction or secondary to a mechanical phenomenon. 

Methods: Cross-sectional analysis of a cohort study comprising 579 male adult UK military personnel (including 153 lower limb amputees) with combat-related traumatic injury (CRTI) who were frequency-matched to 565 uninjured men by age, service, rank, regiment, deployment period and role-in-theatre. BMD was assessed using DEXA scanning T-scores at three diagnostic sites: lumbar spine and neck of each femur. Discordance of results were assessed to establish whether observed BMD loss was a result of systemic phenomenon or localised. 

Results: Femoral neck BMD was lower in the CRTI than the uninjured group (T-score -0.08 vs -0.42 p=0.000). Subgroup analysis revealed this reduction was only significant at the femoral neck of the amputated limb of the amputees(p=0.000), the reduction was greater for above knee amputees than below knee amputees (p=0.037). There was no statistical difference in the spine BMD. 

Conclusion: Findings suggest that changes in bone health in amputees are mechanically driven, rather than systemic. There was no statistical difference in bone health in the non-amputee groups who suffered CRTI compared to the uninjured group, we believe this is applicable to all amputees regardless of the mechanism which led to their amputation. These changes may arise due to altered joint and muscle loading which results in a reduced mechanical stimulus in the amputated femur. We could potentially eliminate the need for bone preserving medications and prevent or reverse these changes with the implementation of targeted loading regimes or with a change in prosthetic design. We suggest a more suitable diagnosis of unloading osteopenia.


Podium Presentation Abstracts

139 - A qualitative study exploring clinicians’ views on clinical trials in thumb carpometacarpal joint osteoarthritis

Benjamin Dean1, Cynthia Srikesavan1, Robin Horton2, Francine Toye3

1University of Oxford, Oxford, United Kingdom; 2BSSH, London, United Kingdom; 3Oxford University Hospitals, Oxford, United Kingdom

Objectives: Osteoarthritis (OA) affecting the thumb carpometacarpal joint (CMCJ) is a common painful condition.  In this study, we aimed to explore clinicians’ approach to management with a particular focus on the role of specific interventions that will inform the design of future clinical trials.

Design: This is a qualitative study using semi-structured, online interviews. Interviews were audio-recorded, transcribed verbatim and analysed using thematic analysis.

Setting: Hospital and community based centres in the United Kingdom.

Participants: We interviewed a purposive sample of 24 clinicians; consisting of 12 surgeons and 12 therapists (4 occupational therapists and 8 physiotherapists) who managed patients with CMCJ OA.

Results: A total of fourteen themes were developed.  Six themes were developed relating to the clinical management of CMCJ OA: 1) A flexible ‘ladder’ approach starting with conservative treatment first; 2) The malleable role of steroid injection; 3) Surgery as an invasive and risky last resort; 4) A shared and collaborative approach; 5) Treating the whole person; 6) Severity of life impact influences treatment. Eight themes were developed relating to clinical trial barriers and facilitators: 1) We need to embrace uncertainty; 2) You are not losing out by taking part; 3) It is difficult to be neutral about certain treatments 4) It is difficult to recruit to ‘no treatment’ ; 5) Difficult to recruit to a trial comparing no surgery to surgery; 6) Patients are keen to participate in research; 7) Burden on staff and participants; 8) A enthusiasm for a variety of potential trial arms.

Conclusions: Our findings contribute to a better understanding of how clinicians manage thumb CMCJ OA in their practice settings. Our study also provides useful insights informing the design of randomised clinical trials involving steroid injections and surgery in people with thumb CMCJ OA.  

161 - Outcomes of MAIA Dual Mobility CMC Joint Arthroplasty from a UK based Orthopaedic Hospital – with 3 years follow-up

Debashis Dass, Jefin Edakalathur, Srinivasan Cheruvu, Marck Van Liefland, Ibrahim Roushdi

Robert Jones and Agnes Hunt Orthopaedic Hospital, Oswestry, United Kingdom

Objective: CMCJ replacement is a recognised alternative option to Trapeziectomy. This is the first UK study to publish results on the outcome of MAIA dual mobility arthroplasty in patients. The objective of the study was to retrospectively review the outcomes of the MAIA dual mobility CMC joint arthroplasty performed in our specialist unit. 

Methods: This single centre prospective study reviewed 52 MAIA CMC prosthesis implantations from February 2017. Patients were evaluated preoperatively and postoperatively for pain, Kapandji scoring, function, power and pinch strength. Patients were followed up clinically (Brief Michigan Hand Outcome Questionnaire) and radiographically until death or revision surgery. Post-operative complications, radiographic implant failure and indications for revision surgery were all reviewed. 

Results: The mean age at surgery was 67 years (range, 62 - 73). The maximum follow up of 54 months. The Brief Michigan score improved from 42 to 85 (p < 0.005). Pain score improved from 7 to 1 (p < 0.005). Opposition, defined by the Kapandji score, improved from 8 (IQR 6-9) to 9 (IQR 9) post-operatively. Pinch strength improved from 5 to 8 lbs (p = 0.007) while power grip improved from 38 to 47 lbs (p = 0.09). There were two dislocations and one fractured trapezium found on follow-up radiographs. The procedure success, by survival analysis over 4 years, was 96%. 

Conclusion: MAIA dual mobility CMC joint arthroplasty has shown good results in pain relief, strength, and mobility, as well as improvement in patient reported outcomes over the short term. Patients also rehabilitated quicker. Based on the evidence provided it would be worthwhile for the National Institute for Clinical Excellence (NICE) to review the guidelines for use of joint replacements in CMCJ arthritis, as there may be benefit in this type of surgery over traditional Trapeziectomy. 

299 - A qualitative study exploring clinicians’ views on clinical trials in thumb carpometacarpal joint osteoarthritis

Benjamin Dean1, Cynthia Srikesavan2, Francine Toye1, Robin Horton3

1Oxford University Hospitals, Oxford, United Kingdom; 2University of Oxford, Oxford, United Kingdom; 3None, Oxford, United Kingdom

Aims: Osteoarthritis (OA) affecting the thumb carpometacarpal joint (CMCJ) is a common painful condition. In this study, we aimed to explore clinicians’ approach to management with a particular focus on the role of specific interventions that will inform the design of future clinical trials.

Methods: We interviewed a purposive sample of 24 clinicians, consisting of 12 surgeons and 12 therapists (four occupational therapists and eight physiotherapists) who managed patients with CMCJ OA. This is a qualitative study using semi-structured, online interviews. Interviews were audio-recorded, transcribed verbatim, and analyzed using thematic analysis.

Results: A total of 14 themes were developed, six of which were developed relating to the clinical management of CMCJ OA: 1) A flexible ‘ladder’ approach starting with conservative treatment first; 2) The malleable role of steroid injection; 3) Surgery as an invasive and risky last resort; 4) A shared and collaborative approach; 5) Treating the whole person; and 6) Severity of life impact influences treatment. The remaining eight themes were developed relating to clinical trial barriers and facilitators: 1) We need to embrace uncertainty; 2) You are not losing out by taking part; 3) It is difficult to be neutral about certain treatments; 4) Difficult to recruit to ‘no treatment’ ; 5) Difficult to recruit to a trial comparing no surgery to surgery; 6) Patients are keen to participate in research; 7) Burden on staff and participants; and 8) A enthusiasm for a variety of potential trial arms.

Conclusion: Our findings contribute to a better understanding of how clinicians manage thumb CMCJ OA in their practice settings. Our study also provides useful insights informing the design of randomized clinical trials involving steroid injections and surgery in people with thumb CMCJ OA.

624 - Validation of a new, low profile, adherence sensor for monitoring orthosis wear time following surgical repair of flexor tendon injuries

Ellie Flatt1, Dominic Wardell2, Hannah Berntsson3, Joseph Colecchia2, Gill Cottrill2, William Giles2, Cieran McGrory2, Rahul Ravi2, Ellice Wymer2, Ian Shelton3, Anna Selby3, Emma Bamford3, Raveen Jayasuriya1,2

1Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom; 2University of Sheffield, Sheffield, United Kingdom; 3Pulvertaft Hand Centre, University Hospitals Derby and Burton NHS Foundation Trust, Derby, United Kingdom

BACKGROUND: Patient reported orthosis adherence is unreliable. Low-profile adherence sensors have not been validated for upper extremity orthoses. Pragmatic RCTs benefit from validated adherence monitoring to characterise patient wear patterns, and qualify secondary outcome analyses; where functional outcome and re-rupture rate may be orthosis adherence dependent. 

AIMS: To identify:

  • optimal threshold for agreement between sensor-measured & true wear-time
  • orthosis material effect
  • outdoor ambient temperature effect

Outcomes will inform upcoming FIRST study (NIHR133582): an RCT comparing 3 splints following finger flexor tendon repair. 

METHODS: Three custom thermoplastic splints were made for 8 healthy volunteers: Long wrist (San-Splint), Short wrist (X-lite), and Mini finger (Orficast). Each splint was embedded with an Orthotimer® sensor (long splint fitted with 2 sensors - proximal & distal), measuring skin temperature at 1-minute intervals. Seven timed protocols were conducted with fixed donning-doffing times and indoor-outdoor wear synchronised to universal coordinated time. Intraclass correlation coefficient (ICC) assessed measured and true wear-time agreement (poor <0.500, moderate 0.500-0.750, good >0.750) at different temperature thresholds from 10-34°C.

RESULTS: Optimal indoor threshold temperature:

  • Long splint proximal: 25.5°C (ICC 0.689)
  • Long splint distal: 25.0°C (ICC 0.514)
  • Short splint: 25.5°C (ICC 0.447)
  • Mini splint: 24.0°C (ICC 0.479)

Combined indoor & outdoor optimal threshold:

  • Long splint proximal: 24.5°C (ICC 0.541)
  • Long splint distal: 23.0°C (ICC 0.181)
  • Short splint: 23.5°C (ICC 0.220)
  • Mini splint: 21.5°C (ICC 0.149)

CONCLUSION: Adequate peak temperatures were achieved, suggesting successful embedding of sensors and good skin contact. An absolute temperature threshold of 25-25.5°C can be set for indoor wear of long and short orthoses made of San-Splint with moderate agreement of sensor measured wear time. Splints made from X-lite and Orficast will require thermal optimisation with insulation or a rate of change of temperature algorithm to achieve adequate wear-time agreement, rather than a single threshold.


Podium Presentation Abstracts - Part 1

154 - Electronic referral systems improve the documentation of hip arthroplasty MDT outcomes

Lina Chevalier, Shih-Han Chen, David Howard, Toby Briant-Evans, Geoffrey Stranks, Jamies Griffiths

Hampshire Hospitals NHS Foundation Trust, Basingstoke, United Kingdom

Background: Complex hip procedures often require specialist surgeons, pre-operative planning and work-up. There is increasing literature suggesting that a multi-disciplinary approach improves overall patient outcomes.

The GIRFT, BHS and BOA best practice guidelines recommend that the outcome of MDTs should clearly document the surgical indications and decisions.

We studied the impact of implementing an e-referral system to the hip arthroplasty MDT process at a district general hospital.

Methods: Hip MDT outcomes documented on electronic patient records (EPR) were audited against the GIRFT, BHS and BOA standards.

During the first audit (March to June 2021), referrals were facilitated by phone or email to a single MDT coordinator.

An electronic referral system was directly integrated into EPR over Summer 2021.

After allowing time for transition, a subsequent audit (November 2021 to February 2022) was performed to evaluate the impact of the e-referral process.

Results: In the first audit, 45 cases (34 patients) were identified in 6 MDTs. Only 47% (21 cases) had documented MDT outcomes on EPR.

After implementing the e-referral process, the re-audit identified 55 cases (31 patients) in 7 MDTs. 85% (47 cases) had documented outcomes, of which the majority (71%) were auditable directly via the e-referral system.

Conclusion/Findings: The implementation of an e-referral system significantly improved the overall standard of documentation of hip MDT outcomes (χ2=20.2, p<0.001).

We also identified the need for an e-referral system tailored for the MDT process, as our current technical implementation (based on generic inter-departmental referral templates) had areas for improvement.

A working group is currently exploring options for further improvement and expansion, in preparation for the upcoming regional MDT process.


  • Hip arthroplasty MDTs should be supported by an electronic referral system
  • E-referral systems should be tailored for the MDT process
  • Appropriate support and funding for MDTs improve patient outcomes

185 - The Impact of Post-operative Peri-prosthetic Femoral Fracture after Total Hip Replacement: a Qualitative Study

Charlotte Carpenter, Vikki Wylde, Michael Whitehouse, Andrew Moore

University of Bristol, Bristol, United Kingdom

Post-operative peri-prosthetic femoral fracture (PPFF) after total hip replacement (THR) is a rare but serious adverse event. PPFF is associated with increased mortality, reduced mobility, increased care needs and reduced quality of life. This study aimed to develop an in-depth understanding of the unknown psychosocial and physical impact of PPFF to patients.

In-depth semi-structured face-to-face interviews were undertaken with patients who had experienced PPFF treated in one secondary referral centre. Data were audio-recorded, transcribed, anonymised and analysed using an inductive thematic analysis approach, with a proportion of transcripts double coded.

PPFF represents an unexpected and traumatic event that impacts on participants’ recovery after THR. PPFF and its treatment represents a significant disruption in participants biographies. Participants experience lasting fear of falls and loss of confidence in mobility, leading to restrictions in their mobility, particularly during recovery.

Participants mobility may be significantly restricted, with some unable to perform basic activities for daily living. Participants rely on family and social networks during this period and for many into the longer term. Most participants see significant improvements in their mobility and abilities sometime after PPFF but many adapt their life to the psychological and physical restrictions that PPFF imposed in the long term.

Surgeons represent a key source of information regarding the operation, expected recovery and physical challenges that participants should expect, as well as a source of reassurance. Participants associate progress in recovery with adequate and timely provision of physiotherapy which improved participants mobility and confidence.

The impact of PPFF should not be underestimated. There is a cyclical interplay between the physical and psychological manifestations that significantly and negatively impact patients. Patients require access to good communication throughout treatment, minimal limitations to weight bearing, and access to physiotherapy, information and support, including psychological, after discharge in order to optimise recovery.


225 - The risk of mortality in patients undergoing elective primary total hip replacement for osteoarthritis with recent inpatient admission for management of medical conditions, analysis of the National Joint Registry

Jonathan Evans1, Linda Hunt1, Ashley Blom1, Mark Wilkinson2, Andrew Stevenson3, Michael Whitehouse1

1University of Bristol, Bristol, United Kingdom. 2University of Sheffield, Sheffield, United Kingdom. 3Musgrove Park Hospital, Taunton, United Kingdom

Introduction:  Although total hip replacement (THR) is generally safe and effective, pre-existing medical conditions increase the risk of post-operative mortality. Developing a co-morbidity shortly before elective surgery may increase mortality risk and whilst delaying surgery may be of use, it is unclear how long a delay is sufficient. 

Materials/methods: We analysed 958,145 primary THRs performed between 2003 and 2018 in the NJR, linked to Hospital Episodes Statistics to identify new diagnoses of medical co-morbidities before THR. Patients were categorised into groups according to how soon before THR they developed the co-morbidity.

Results: 90-day mortality was 0.34% (95%CI: 0.33-0.35). In the 432 patients who had an acute MI in the three months before THR, this figure increased to 18.1% (95%CI 14.8, 22.0). Cox models observed a 63 times increased hazard of death within 90-days if patients experienced an acute MI in the 3 months before their THR (HR 63.6 (95%CI 50.8, 79.7)). This association reduced as the time between the MI and THR increased. For congestive cardiac failure, the hazard of death was 18 times higher with a similar protective effect of delaying surgery observed.

Discussion/conclusions: Linked NJR and HES data demonstrate an association between inpatient admission due to acute medical co-morbidities and death within 90-days of THR. This association is greatest in MI, congestive cardiac failure and cerebrovascular disease with smaller associations observed in several other conditions including diabetes. The hazard reduces when longer delays are seen between the inpatient admission for acute medical condition and THR in all diagnoses.

237 - Outcomes of Dislocated Hip Hemiarthroplasties

Gareth Chan1,2, Keegan Curlewis2, Rahmeh Aladwan3, Benedict Rogers1,2, David Ricketts2, Philip Stott2

1Brighton & Sussex Medical Scholl, Brighton, United Kingdom; 2University Hospitals Sussex NHS Foundation Trust, Brighton, United Kingdom; 3University Hospitals Sussex NHS Foundation Trust, Chichester, United Kingdom

Introduction: Displaced intracapsular neck of femur (NOF) fractures are treated with hemiarthroplasties in the medically frail and comorbid. Dislocations are rare however, are associated with significant mortality; 40% at 30-days compared to the 28.3% mortality rate with no dislocations. 

This study aims to quantify the outcomes associated with dislocated hip hemiarthroplasties in a contemporaneous cohort of patients reflecting current surgical practice in the U.K.  

Methods: All consecutive hip hemiarthroplasties performed for NOF fractures eligible for BPT payment between January 2009 and September 2017 at three high volume NOF units were included. 

Cases of dislocation were identified through individual review of all patients’ radiology records, medical records were interrogated to determine mortality, definitive treatment and subsequent complication rates. 

Results: 4116 hemiarthroplasties were reviewed during the study period with a total of 63 (1.6%) dislocations identified. Median time to first dislocation was 24 days. 

The success rate of a MUA (no further dislocations) for a first dislocation was 28% (12/43), this reduced sequentially with each subsequent dislocation and MUA; 23% (2/13) for a second dislocation and 0% success for third dislocations with a successful MUA. 

46% (29/63) all cause 1-year post-dislocation mortality rate was recorded. Rates were highest in those whose hips were left dislocation 60% (6/10), with the lowest in those treated with a revision THR; 27.3% (6/22). 

38 patients undergoing open revision procedures, 21 (in keeping with PJI guidelines) had microbiology samples taken. 40% returned evidence of a PJI, Staphylococcus Aureus the most commonly isolated organism. 

Conclusion: This study demonstrates the need for revision procedures after a second dislocation after a successful MUA for the first. A high index of suspicion needs to be maintained for a PJI in cases of dislocation after a hemiarthroplasty for NOF.


373 - Torbay Hip Score Demonstrates the Deterioration of Surgical Complexity of Performing Total Hip Replacements in Patients Waiting for Elective Surgery

Rangaraju Ramesh, Chi Kit Chuen

Torbay Hospital, Torquay, United Kingdom

Background: Many patients are waiting over 52 weeks for their elective total hip replacements (THR) due to the COVID pandemic. This waiting can lead to significant deterioration of hip arthritis and alter the complexity of performing a hip replacement. There is still no reported scoring system to capture this deterioration. The Torbay Hip Score System (THS) has been developed to quantify the surgical complexity. Using THS, this study aims to determine if the surgical complexity of THR deteriorates while patients wait for their operation.

Methods: Analysis of radiological and electronic patient records of 101 patients who were waiting for an elective THR for over 52 weeks was carried out by two independent surgeons. Their surgical complexity of performing THR at the time of listing and after 52 weeks was determined using the THS. The complexity was graded as simple (green), intermediate (amber) or complex primary (red) hip replacement at both time intervals.

Results: Overall, 10.9 % (11/101) of patients’ surgical complexity deteriorated while waiting for the operation (P<0.05).13.2% (7/53) of green hips had statistically significantly deteriorated with 3.8% (2/53) deteriorating from green to red, and 9.4 % (5/53) deteriorating from green to amber hips. 12.5% (4/16) of amber hips deteriorated to red hips. Fliess Kappa coefficient showed an almost perfect degree of agreement between the 2 observers when determining the level of surgical complexity of THR for all cases. (k>0.8)

Conclusion: By using an objective scoring system, we have demonstrated the deterioration of the difficulty of performing THR when the patients wait too long for their operation.

Implications: Application of THS scoring system is likely to help one to prioritise the urgency of performing THR in long waiters, plan for increased allocation of theatre time or the need for using more expensive implants and has the potential to decrease poor outcomes.

428 - A randomized controlled trial of short versus standard Exeter V40 stems in total hip arthroplasty: Can Arthroplasty Stem INfluence Outcome (CASINO)?

Paul Gaston1, Nick Clement1, Nick Ohly2, Gavin Macpherson1, David Hamilton3

1Edinburgh Orthopaedics, Edinburgh, United Kingdom; 2Golden Jubilee National Hospital, Glasgow, United Kingdom; 3Edinburgh Napier University, Edinburgh, United Kingdom

Aims: The primary aim was to assess whether a short (125mm) Exeter V40 stem offered an equivalent hip specific function as the standard (150mm) stem at 1-year when used for total hip arthroplasty (THA). Secondary aims are to evaluate health-related quality of life (HRQoL), patient satisfaction, length and stem alignment, radiographic loosening, and complications between the two stems. 

Methods: A prospective multicentre double-blind randomised control trial was conducted. During 15-month period 220 patients undergoing THA were randomised to either a standard (n=110) or short (n=110) stem Exeter. There were no significant (p≥0.065) differences in gender, age, BMI, ASA grade, Tonnis grade, comorbidities or hip specific function between the groups. Functional outcome and radiographic assessment were undertaken a 1 and 2 years.

Results: There was no significant difference (1.0, 95%CI -1.4 to 3.2, p=0.428) in hip specific function according to the Oxford hip score at 1-year (primary end point) and 2-years (p=0.767) between the groups. The short stem group had a significantly greater varus angulation (0.9 degrees, p=0.003) when compared to the standard group and were more likely (odds ratio 2.42, 95%CI 1.36 to 4.29, p=0.002) to have a varus stem alignment beyond one standard deviation (2.3 degrees) from the mean. There were no significant (p≥0.083) differences in the length of stay, Forgotten joint score, EuroQol-5-Dimension, EuroQol-VAS, Short form 12, patient satisfaction, complications, or radiolucent zones at 1 or 2-years between the groups. 

Conclusion: The Exeter short stem offers equivocal hip specific, HRQoL, patient satisfaction, and limb length as the standard stem. However, the short stem was associated with a greater rate of varus malalignment which may influence future implant survival, but no increased risk of complications was observed at 2-years.

452 - Long-term implant survival following arthroplasty for fractured neck of femur: An analysis of commonly used prosthesis constructs using Australian National Joint Registry Data

Ben Tyas1, Martin Marsh2, Michelle Lorimer3, Richard de Steiger3, Tim Petheram1, Mike Reed1, Simon Jameson4

1Northumbria Healthcare NHS Foundation Trust, Cramlington, United Kingdom; 2Royal Victoria Infirmary, Newcastle Upon Tyne, United Kingdom; 3Epworth Institute, Melbourne, Australia; 4South Tees Hospitals, Middlesbrough, United Kingdom

Background: There remains a wide variety of practice in implant selection to treat intracapsular neck of femur fractures. There is no clinical benefit of a modern, costly modular construct over a traditional, inexpensive mono-block design. Long term data is lacking. This study outlines 10-year survivorship of specific prosthesis concepts for fractured neck of femur.

Methods: Patients recorded by the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR) from 1st September 1999 to 31st December 2020 who had a Stryker Exeter stem (unipolar or bipolar hemiarthroplasty), Exeter Trauma Stem (ETS) or Thompson’s prosthesis for treatment of hip fracture, were included. Overall and age-defined 10-year cumulative revision rates were compared. A sub-analysis of Thompson’s data, by type of material (Cobalt/Chrome or Titanium), was performed.

Results: 41949 hemiarthroplasties were included. Exeter/Unitrax hemiarthroplasty was the most common construct (n=20707, 49.4% of procedures) followed by Exeter bipolar hemiarthroplasty (n=11494, 27.4%). At 10 years, Exeter bipolar hemiarthroplasty had the lowest cumulative revision rate at 5.0% (CIs 4.4, 5.8). There was no difference in revision rates between Cobalt/Chromium Thompson’s (6.3%, CIs 4.7, 8.5) vs ETS (5.1%, CIs 3.6, 7.1) (HR=0.82, p=0.196) or vs Exeter/Unitrax (7.5%, CIs 6.7, 8.4) (HR=1.12, p=0.307).  Titanium Thompson’s had the highest 10-year revision rate at 10.1% (CIs 7.5, 13.6). Excluding Titanium Thompson’s, all constructs had 10-year cumulative revision rates ≤ 3.5% in patients >80 years old. 10-year mortality rates were similar for ETS (88.3%) and Cobalt/Chromium Thompsons (90.9%), contrasting with 77.9% for those receiving a bipolar.

Conclusion: 10-year implant survival of the inexpensive Cobalt/Chromium Thompson’s is similar to the ETS and Exeter/Unitrax. Given the growing amount of evidence in this area, we would advocate NICE to implement the principles of GIRFT and recommend this cost-effective implant for frail hip fracture patients.

468 - The Relative Percentage of Acetabular Cartilage to Cotyloid Fossa Surface Area is Reduced in Acetabular Dysplasia and Correlates Best with Radiographic Fossa Depth

Edward Bray1, Mark Roussot1, Zachary Devries2, Pablo Slullitel2, George Grammatopoulos2, Johan Witt1

1UCLH, London, United Kingdom; 2The Ottawa Hospital, Ottawa, Canada

Standard measurements of acetabular dysplasia, for example lateral centre-edge angle (LCEA) and acetabular index (AI) inadequately characterise acetabular load-bearing morphology, an essential consideration when planning peri-acetabular osteotomy (PAO) to improve femoral head coverage and load distribution.


  • characterize acetabular articular cartilage (AC) area relative to cotyloid fossa (CF) area
  • compare this ratio in dysplastic with asymptomatic hips
  • correlate 3D-CT measurements with reliable radiographic landmarks

This study assessed 221 hips with symptomatic acetabular dysplasia undergoing PAO between 2011 and 2017 comparing them with 195 control hips visualised on CT for non-hip related pathology. Imaging and medical records were reviewed to ensure the absence of hip pathology for controls. The acetabular articular surface index (ASI), defined as the percentage contribution of the surface area of the AC relative to the CF, was evaluated with 3D analysis of CT scans using software. The ASI was then correlated with 2D measurements on supine AP pelvic radiographs and coronal CT images including LCEA, AI, and novel measurements: fossa height (perpendicular distance from the interteardrop line to the medial edge of the acetabular sourcil) and fossa depth (distance from the medial margin of the femoral head to the corresponding margin of the acetabular fossa on X-ray and coronal CT). Inter-observer coefficients for X-ray and CT measurements were 0.97-0.99 (p<0.001) and intra-observer coefficients for segmented measurements were (0.93-0.96 (p<0.001). 

Mean ASI was 66.6% ± 4.7 and was significantly lower for patients with symptomatic acetabular dysplasia in comparison to controls (64.6% vs. 68.6%; p<0.001). Fossa depth was a stronger predictor of ASI (rho = 0.411 and 0.398) than LCEA and AI (rho = 0.383 and 0.333). Fossa height and depth on pelvic radiographs correlated with those on CT images.  

ASI is significantly lower in acetabular dysplasia compared to asymptomatic controls and best estimated by radiographic fossa depth and height.

524 - Surgical interventions for treating intracapsular hip fractures in older adults: a series of Cochrane Reviews

Sharon Lewis1, Richard Macey2, Jamie Stokes3, Jonathon Cook3, William Eardley4, Xavier Griffin1

1Bone and Joint Health, Blizard Institute, Queen Mary University of London, London, United Kingdom; 2c/o Bone and Joint Health, Blizard Institute, Queen Mary University of London, London, United Kingdom; 3Oxford Clinical Trials Research Unit, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), University of Oxford, Oxford, United Kingdom; 4Department of Trauma and Orthopaedics, The James Cook University Hospital, Middlesbrough, United Kingdom

Background: Hip fractures are a major healthcare burden. We assessed the relative benefits and harms of all surgical treatments for intracapsular hip fractures. 

Methods: Using Cochrane methodology, we conducted two systematic reviews and one network meta-analysis (NMA) comparing types of: internal fixation; arthroplasty; all surgical treatments and non-operative treatment. We searched nine databases in July 2020 for randomised controlled trials comparing treatments for fragility intracapsular hip fractures in older adults.  

Results: Overall, we included 119 studies (17,653 participants); 83% of participants had displaced fractures, aged from 60 to 87 years, and 73% were women. For internal fixation (38 studies, 8585 participants), we found no clinically important differences between screws, pins or fixed angle plates. For arthroplasties (58 studies, 10654 participants), cemented hemiarthoplasties (HA) likely improve quality-of-life and mortality, with fewer periprosthetic fractures but increased pulmonary embolism, compared to uncemented HA. In the NMA (including all studies), cemented modern unipolar HA, dynamic fixed angle plates and smooth pins had the greatest likelihood of reducing mortality. Arthroplasties had the greatest likelihood of reducing unplanned return to theatre compared to internal fixation and non-operative treatment. Evidence was limited, and therefore uncertain, for quality-of-life at 12 months.    

Conclusions: There was considerable variability in the ranking of treatments in our NMA, with no one outstanding, or subset of outstanding, superior treatments. However, cemented modern arthroplasties tended to yield better outcomes.  

Clinical implications: Cemented modern arthroplasties may be the most successful surgical option. However, our evidence was mostly derived from displaced intracapsular fractures. THA may be an appropriate treatment for a subset of people with intracapsular fracture, but the characteristics of this subgroup were not explored in this series of reviews.

555 - Efficacy of the Non-Arthroplasty Hip Registry (NAHR)

Maria Dadabhoy, Mark Webb

St. George's Hospital, London, United Kingdom

Background: Orthopaedic clinical registries are used to collect patient reported outcomes for research and improving clinical care. The Non-Arthroplasty Hip Registry (NAHR) went live in 2012 collecting data on non-arthroplasty hip (NAH) procedures. It aims to compare the success rates of different surgical approaches to the hip and which pathology may benefit from which procedure. We aimed to test the efficacy of the NAHR.

Methods: We sent a freedom of information (FOI) request to 147 trusts on 08/03/2022 requesting the number of NAH procedures undertaken in 2021 and 2022 and the number of surgeons this had been coded under. We compared this to the number of procedures reported in the NAHR annual reports.

Results: 67 trusts responded within 8 weeks. 3 declined the request based on time and cost. 5 did not carry out any orthopaedic procedures. 16 did not undertake NAH procedures and 15 did not provide the requested data due to coding difficulties. Across 28 trusts, 3372 NAH procedures were performed in 2020 and 3622 in 2021 by 565 different surgeons. 831 (23%) procedures were recorded in the NAHR in 2020 by 49 (8.7%) different surgeons. In 2021 774 (21%) procedures were input by 46 different surgeons (8.1%)

Conclusions: 21-23% of NAH surgeries undertaken in NHS trusts have been uploaded into the national database over the last 2 years by a small proportion of surgeons (8-9%). This proportion is likely smaller with the addition of trusts who did not respond to the FOI request and procedures undertaken privately. NAHR provides a great potential for data collection  and improvement of patient outcomes, however more work needs to be done to increase uptake of the registry to provide meaningful outcomes. Investment from hospitals and incentivisation such as with the National Joint Registry could increase.

621 - What are the outcomes of hip preservation surgery in patients with a pre-operative quality of life ‘worse than death’?: A study using the NAHR dataset

Karadi H Sunil Kumar1, Richard Holleyman2, Vikas Khanduja3, Ajay Malviya1

1Northumbria Healthcare NHS Foundation Trust, Ashington, United Kingdom; 2Newcastle University, Newcastle, United Kingdom; 3Cambridge University Hosptial NHS Foundation Trust, Cambridge, United Kingdom

Introduction: This study aims to describe the characteristics and outcomes of patients who reported their pre-operative quality of life (QoL) was ‘worse than death’ (‘WTD’) prior to hip arthroscopy (HA) or peri-acetabular osteotomy (PAO).

Methods: Adult patients who underwent HA or PAO between 1/01/2012 and 31/10/2020 were extracted from the UK Non-Arthroplasty Hip Registry. International Hip Outcome Tool 12 (iHOT-12) and EuroQol-5 Dimensions (EQ-5D) index questionnaires were collected pre-operatively and at 6 and 12 months. WTD was defined as an EQ-5D score of less than zero. Chi-squared and t-tests were used to compare categorical and continuous variables respectively.

Results: 8493 procedures (6355 HA, 746 PAO) were identified in whom 7101 (84%) returned pre-operative EQ-5D questionnaires. 283 HA and 52 PAOs declared their pre-operative QoL to be ‘WTD’. Compared to those patients with pre-operative QoL ‘better than death’ (n=6072, control group) patients reporting ‘WTD’ function prior to HA were more likely to be female (66% vs 59%, p = 0.013), of higher body mass index (mean 27.6 kg/m2 (SD 5.9) vs 25.7 kg/m2 (4.5), p < 0.0001). There were no statistically significant differences in demographics or pathology for both HA and PAO.

For HA, iHOT-12 scores in WTD patients were significantly poorer pre- [10.8 vs 33.3] and 12 months post-operatively [34.9 vs 59.3] compared to controls. Whilst the majority of patients saw improvement in their scores (p <0.0001), a significantly smaller proportion achieved the minimum clinically important difference for iHOT-12 by 12 months. (51% in the WTD group vs 65% in the control group). Similar trends were observed for PAO.

Conclusions: Patients with WTD quality of life may benefit less from hip preservation surgery and should be counselled accordingly regarding expectations. Although the scores improve, only 51% achieve scores beyond MCID.

Podium Presentation Abstracts - Part 2

625 - Sexual function before and after hip arthroscopy: A study using the NAHR dataset

Karadi H Sunil Kumar1, Richard Holleyman2, Vikas Khanduja3, Ajay Malviya1

1Northumbria Healthcare NHS Foundation Trust, Ashington, United Kingdom; 2Newcastle University, Newcastle, United Kingdom; 3Cambridge University Hospital NHS Foundation Trust, Cambridge, United Kingdom

Introduction: Young adult hip pathology commonly affects patients of reproductive age. The extent to which hip arthroscopy (HA) treatments influence sexual function is not well described and limited to small cohorts. This study aims to describe trends in self-reported reported sexual function before and after HA.

Methods: Adult (≥18 years) patients who underwent HA between 1st January 2012 and 31st October 2020 were extracted from the UK Non-Arthroplasty Hip Registry. International Hip Outcome Tool 12 (iHOT-12) questionnaires were collected pre-operatively and at 6 and 12 months. Patients are first asked if ‘questions about sexual activity are relevant to them’. The iHOT-12 then asks asking patients to quantify ‘how much trouble they experience with sexual activity because of their hip?’ with responses converted to a continuous scale (0-100) to measure function. Chi-squared and t-tests were used to compare categorical and continuous variables respectively.

Results: Of 7639 procedures (59% female, mean age 36.5 years (SD 11)), 91% (5616 of 6151 respondants) indicated pre-operatively that questions about sexual activity were relevant to them (male 93%, female 90%, p < 0.001). Overall, mean pre-operative sexual function increased from 42.0 (95%CI 41.2 to 42.8, n=5267) to 61.8 (60.6 to 63.1, n=2393) at 6 months, and 62.1 (60.8 to 63.5, n=2246) at 12 months post-operatively.

At 12 months, both sexes saw significant improvement in their pre-operative sexual function scores (p<0.0001). Males started from significantly higher baseline sexual function (53.3 vs 34.2) and achieved higher scores by 12 months (68.8 vs 58.0) compared to female patients. There was no significant difference in pre- or post-operative scores when comparing younger (<40 years) and older (>40 years).

Conclusions: Most patients can expect to experience improvement in their sexual function following hip arthroscopy, regardless of sex or age group.

642 - Are patients’ outcomes of function, pain, and quality of life, the same whether or not, patients followed post-operative precautions after THR?” A randomised controlled trial

Justine Theaker1,2, Michael Callaghan3, Jacqueline Oldham2

1Manchester University NHS Foundation Trust, Manchester, United Kingdom; 2University of Manchester, Manchester, United Kingdom; 3Manchester Metropolitan University, Manchester, United Kingdom

Background: Dislocation rates remain low after THR, and the use of post-operative precautions may not be the only influencing factor in low dislocation incidence. Current research raises questions regarding continuation of this practice, particularly if it contributes to patients’ unnecessary discomfort and inconvenience by enforcing precautions, with no known additional benefit. This study intended to answer the question “Are patients’ outcomes of function, pain, and quality of life (QoL), the same whether patients followed hip post-operative precautions after THR, or not?”  

Methods: A randomised controlled trial comparing quality of life, pain, sleep, function and anxiety outcomes for patients following precautions after hip replacement, compared with patients not following precautions. 

Results: A significant difference in function (OHS) (p=0.03), and pain (VAS) (p=0.04) at 6 weeks was observed although by 12 weeks the difference between groups in OHS was no longer significant (p=0.53).  However, VAS pain remained significantly better in the treatment group (p=0.01). Patients in the treatment group reported higher anxiety than the routine care group at 6 weeks (p=0.001), although by 12 weeks the difference had diminished (p=0.78). Patient satisfaction with walking ability, quality of life and sleep were no different between groups at either 6 or 12 weeks. There were no dislocations in the study group. 

Conclusions: The benefit of precautions following hip replacement remain questionable. In terms of pain and function, patients following precautions report worse outcomes at 6 weeks, than patients not following precautions. 

Implications: Considerable NHS and patient costs are associated with the continued use of precautions, when there are no demonstrable improvements in outcomes, and no difference in dislocation in this study.  This has significant implications for patient experience and NHS resources.  

Disclosure: Funding received from Manchester University Foundation Trust Charitable Trust with no conflicts to disclose. 

655 - Elevated Metal Ion Levels Can Be Tolerated by Some Patients

Chinyelu Menakaya, Matthieu Durrand-Hill, Christos Hadjikyriacou, Iftikhar Ahmed, Nabi Wahidun, Shiraz Sabah, Robert Mcculloch, James Donaldson, Alister Hart, Timothy Briggs, John Skinner

Royal National Orthopaedic Hospital Stanmore, London, United Kingdom

Background: Ten years following withdrawal and revision of large diameter metal on metal hips (MOM), there remains an uncertainty in how best to manage asymptomatic patients who have abnormal imaging and/or raised blood metal ion levels. This study investigates the trajectories of symptoms, serological metal ion tests and cross-sectional imaging in this patient group.

Methods: 523 patients with 707 acceptable functioning MOM hips (defined as Oxford Hip Score (OHS) >30) on active monitoring were identified. Surveillance included: patient-reported pain and function (OHS), blood metal ion measurement (Cobalt and Chromium) and/or cross-sectional imaging with MRI. 

Results: 364 patients had serial metal ion levels at two time intervals. Mean serum cobalt and chromium levels in parts per billion (ppb) were Co1 4.5 (S.D. 11.5), Co2 4.7 (S.D. 11.6) and Ch1 3.0 (S.D. 4.8) and Ch2 3.2 (S.D. 4.9). Median Oxford hip score was 42 (IQR 28 – 27). OHS was not significantly correlated to serum metal ion levels (Cobalt Chromium Pearson correlation = -0.105 P = 0.106, Chromium Pearson correlation = -0.125 P = 0.054). There was no significant change in cobalt (-0.48, P = 0.414) and chromium levels (-0.25, P = 0.325) between the two time intervals.

45 patients were identified as having metal ion levels >7 ppb, 64.4% had OHS greater than 30 and 13.3% had pseudotumour formation.

6 patients had metal ions level greater than 50ppb, with no significant deterioration of OHS greater than 30. Only 33.3% had pseudotumour formation. Their MRI did not show worsening pseudotumour or deterioration in gluteal muscle anatomy. 

Conclusion: Our results indicate that there are a subset of patients with high metal ion levels, stable imaging and acceptable function who can safely be actively monitored. This study provides more information in assisting joint decision making with this challenging patient group. 

672 - Vancouver B Periprosthetic Femur fracture treatment: Subsidence or Dislocation, pick your poison

Ali Assaf1, Khaled Al-Kharouf1, Mohammad Amer1, Douglas Dunlop1, Kashif Abbas1

1University Hospital Southampton, Southampton, United Kingdom

Introduction: Cementer taper slip stems (CTSS) are amongst the most popular designs in the UK. While demonstrating excellent survivorship, they come at an increased risk of Vancouver B periprosthetic femoral fractures (VBPFFs). There seems to be equipoise regarding the surgical management of these injuries. This study aimed to analyze the clinical and radiological differences between osteosynthesis (ORIF) and revision arthroplasty with or without osteosynthesis (R) as the main surgical options. The R group was subdivided into cemented revision (CR) and uncemented revision (UR).      

Methods: The electronic database of a UK MTC was used to extract all PFF. Only VBPFFs around CTSS with a good bone-cement interface were included. The primary outcome was revision rate. There were a variety of secondary outcomes. 

Results: From 2015-2021, 577 PFF were identified, of which 93 VBPFF met the criteria. Of these, 50 (54%) were treated with ORIF, 30 (32%) received an UR and 13 (14%) a CR. Average age at fracture, gender and ASA was comparable in the three groups.

Five cases (10%) were revised in the ORIF group, 7 cases (23%) in the UR and 1 (8%) in CR group. In the ORIF group there were no dislocations recorded, whereas there were 2 (7%) in the UR group and 1 in CR group, all requiring revision. In the ORIF group, there were 24 (48%) stems that subsided, 11 (37%) in the UR group with no subsidence in the CR group. Subsidence was correlated with residual symptoms during follow-up. 

Conclusion: A higher dislocation rate was observed with revisions compared to ORIF, with all of them translating to revisions. A higher subsidence rate was noted with the ORIF group, this did not translate into revisions possibly due to patient and surgeon-related factors. The cemented revision group radiologically achieved the best outcome with low revision rates.

756 - Survivorship of primary total hip replacement using short-stem variants of the Exeter V40 femoral stem: median 5-year follow-up study

Liam Yapp1,2, Leo Baxendale-Smith1,2, Deborah Macdonald2, Colin Howie1, Paul Gaston1, Nick Clement1,2

1Royal Infirmary of Edinburgh, Edinburgh, United Kingdom; 2University of Edinburgh, Edinburgh, United Kingdom

BACKGROUND: Short length femoral stems in total hip replacement (THR) enable greater femoral bone preservation and are useful in technically challenging cases. This study aims to compare the mid-term survivorship of three short-stem variants of the Exeter V40 femoral stem.

METHODS: This is a single-centre retrospective cohort study (2011 to 2020) of patients undergoing primary THR. An Exeter femoral stem length less than 150mm was considered a short-stem variant. Sub-categories were: DDH (offset <= 35.5); Short (37.5, 44 and 50 offset); and the Short Revision Stem (44.00 offset). Outcomes included all-cause and femoral-component-only revision. Survivorship was calculated using Kaplan-Meier estimates with 95% confidence intervals (CI). Cox-proportional hazard modelling was used to assess the influence of patient factors and stem type. A p-value < 0.05 were considered statistically significant.

RESULTS: During the period of follow-up, there were 662 primary THR cases utilising a short-stem variant of the Exeter femoral stem (median age 62.2; 495 (74.8%) females; median ASA 2; median survival was 5.2 years). Overall 5 year survivorship was 96.4% (95%CI 94.8-98.1). There were no differences when comparing the sub-categories of short stem all-cause (DDH (n=226, 97.7% 95%CI 95.8-99.7); Short (n=209, 97.6% 95%CI 95.5-99.7); Short Revision Stem (n=227, 96.9% 95%CI 94.6-99.2), log-rank p =0.83) or femoral-component-only revision (DDH (n=226, 98.2% 95%CI 96.4-1.0); Short (n=209, 98.0% 95%CI 96.1-1.0) and Short Revision Stem (n=227, 97.8% 95%CI 95.8-99.7), log-rank p=0.95) . Age, sex, ASA grade and stem-type were not associated with the risk of revision within five years.

CONCLUSIONS: Short stem variants of the Exeter V40 femoral stem demonstrated satisfactory mid-term survivorship when used in primary THR. Patient factors and stem type did not influence revision risk within 5 years of surgery.

IMPLICATIONS: Based on these estimates, short stem variants of the Exeter V40 would achieve an ODEP 5A, but not 5A*, rating


Podium Presentation Abstracts

129 - Microbiology profile of Fracture Related Infection (FRI): A 6-year series from a UK major trauma centre and bone infection tertiary referral unit

Kavi Patel1, Prabu Balasubramanian1, Athanasios Galanis2, Ioannis Hannadjas3, Alexios Iliadis1, Nima Heidari1, Benny Cherian1, Caryn Rosmarin1, Alex Vris1

1The Royal London Hospital, London, United Kingdom; 2KAT General Hospital, Athens, Greece; 3Barts & The London School of Medicine & Dentistry, London, United Kingdom

Background: Fracture Related Infections (FRI) are being increasingly recognised as one of the biggest challenges for Trauma & Orthopaedic surgery. Our primary aim was to report on the microbiology profile of FRI cases treated at our unit, one of Europe’s busiest trauma centres, over a 6-year period. Secondarily, we sought to identify patterns and correlate with existing anti-microbial protocols.

Method: All eligible adult cases were identified retrospectively through our electronic ortho-microbiology database between 2016 to 2021.  We reported on patient demographics, treatment strategy, causative organisms and sensitivities. Our results were then compared to current literature and correlated with our current microbiology guidelines.

Results: A total of 428 pathological organisms were identified in the 320 patients included in our study of which 52.6% were gram-positive and 32.2% gram-negative. Patients had a mean age of 45.6 and the commonest site of infection was the tibia. The majority of injuries were caused by falls or road traffic accidents. Open fractures accounted for 31.1% of FRI cases and 70.3% were diagnosed within 1 year of surgery. Polymicrobial cultures were found in 29.1% of patients and no causative organism in 11.3%. The most prevalent organisms were Staphylococcus aureus (36.9%), Pseudomonas aeruginosa (10.7%), Escherichia coli (8.4%) and Enterococcus cloacae (8.2%). Resistant organisms were identified in under 5% of cases (namely methicillin-resistant Staphylococcus aureus and extended-spectrum ß-lactamase-producing bacteria). Our empiric antibiotic cover of teicoplanin and meropenem would cover over 86% of organisms isolated in the study. Of note, carbapenem resistant organisms and fungal infections were uncommon in our cohort of patients.

Conclusion: To our knowledge this is the largest reported cohort of FRIs from a UK major trauma centre. Our results demonstrate patterns in microbiology profiles that should serve to inform the decision-making process regarding antimicrobial agent choices for both prophylaxis and management.

250 - The burden of orthopaedic surgical site infection as identified by a national surveillance day - results of the pilot study day

Vedran Curkovic, Andy Jones, Rhidian Morgan - Jones

Cardiff & Vale Orthopaedic Centre, Llandough University Hospital, Cardiff & Vale NHS Trust, Cardiff, United Kingdom

Introduction: Surgical Site Infection (SSI) remains a significant but underestimated problem. In order to assess the burden of in-hospital SSI we organised a nationwide SSI Prevalence Day to capture real-time data on inpatients who had undergone primary/revision knee/hip arthroplasty or hemiarthroplasty for neck of femur (NOF) fractures.

Methods: A multicentre real time cohort study was conducted on a single day across 15 UK hospitals. Surgical site infections (SSI) were divided into three groups: superficial SSI, deep SSI and wound dehiscence. Data was collected on index procedure, gender, BMI, medical/surgical risk factors and length of hospital stay. 

Results: 457 patients were included with 65% of female cases, 35% male. 63% of the patients were post NOF arthroplasty and only 3% had revision knee surgery. 38% of patients had BMI 25-29 and 64% of   patients were ASA >=3. 20% had no risks recorded. 

The overall complication rate was 7.7% (35 patients). Of these, deep SSI was found in 80%, superficial SSI in 6% and wound dehiscence in 23%. Highest complication rate (33%) was seen in revision knee surgery while the lowest rate was in NOF fracture repair patients (6%). High BMI patients (25-34.9) had more complications than other patients (13%). Patients with associated renal failure had more complications than patients with other co-morbidity (23%).

Conclusion:  This single day snapshot cohort study gives a realistic indication of the burden of SSI across the UK and Ireland. SSI we believe remains under diagnosed and can be difficult to treat. We plan to repeat this study in 6 months, expanding across more units incrementally until we have built a true picture of inpatient and outpatient orthopaedic surgical site infection and it’s burden on healthcare.

Innovation in Simulation

Podium Presentation Abstracts

836 - Multidisciplinary surgical team training in virtual reality is superior to individual learning for performing anterior approach total hip arthroplasty: A randomised controlled trial

Thomas Edwards, Shubham Gupta, Daniella Soussi, Arjun Patel, Amogh Patil, Sikandar Khan, Alexander Liddle, Justin Cobb, Kartik Logishetty

Imperial College London, London, United Kingdom

Background: Evidence suggests that superior surgical team performance is linked to fewer intraoperative errors, reduced mortality and improved outcomes. Virtual reality (VR) has demonstrated excellent efficacy in training surgeons and scrub nurses individually, however its impact on training teams is currently unknown. This study aimed to assess if training together (scrub nurse and surgeon) in an innovative multiplayer virtual reality program was superior to single player training for novices learning anterior approach total hip arthroplasty (AA-THA).

Methods: 40 participants (20 novice surgeons (CT1-ST3 level) and 20 novice scrub nurses) were enrolled in this study and randomised to individual or team VR training. Individually-trained participants played with virtual avatar counterparts, whilst teams completed the same VR training, the only difference being they trained live in pairs (surgeon and scrub nurse together). Both groups underwent 5 VR training sessions over 6 weeks. Subsequently, they underwent a real-life assessment in which they performed AA-THA on a high-fidelity model with real equipment in a simulated operating theatre. Teams performed together and individually-trained participants were randomly paired up with a solo player of the opposite role. Videos of the assessment were marked by two blinded expert assessors. The primary outcome was team performance as graded by the validated NOTECHs II score. Secondary outcomes were procedure time and number of technical errors from an expert pre-defined protocol. 

Results: Teams outperformed individually-trained participants for non-technical skills in the real-world assessment (NOTECHS-II score 50.3 ± 6.04 vs 43.90 ± 5.90, p=0.0275). They completed the assessment 28.1% faster (31.22 minutes ±2.02 vs 43.43 ±2.71, p=0.01), and made close to half the number of technical errors when compared to the individual group (12.9 ± 8.3 vs 25.6 ± 6.1, p=0.001). 

Conclusions: Multiplayer, team training led to faster surgery with fewer technical errors and the development of superior non-technical skills.


Podium Presentation Abstracts

21 - How does hip and knee arthroplasty affect golfer performance and what should be expected regarding post-operative return to play?

Lee Hoggett1, John Ranson2, Samuel frankland3, Christopher Nevill4, Peter Hughes5

1Health Education North West, Manchester, United Kingdom; 2Health Education North West, Manchester, United Kingdom; 3University of Manchester, Manchester, United Kingdom; 4Royal and Ancient Golf Club, St Andrews, United Kingdom; 5Lancashire Teaching Hospitals, Preston, United Kingdom

Background: Hip and knee arthroplasty is commonly performed for end-stage arthritis. There is limited information to guide golfers on the impact this procedure will have post-operatively. This study aimed to determine the impact of lower limb arthroplasty on amateur golfer performance and return to play.

Methods: A retrospective, observational study was designed to collect information from golfers following arthroplasty. Data collection occurred: 18/4/19 – 30/4/19 and combined a patient survey with in-app handicap data.

Results: 2198 responses were analysed. 1097 hip and 1101 knee. 1763 (80%) were male. Average age was 70 (26-92). Hip arthroplasty was associated with an average increase in handicap of 1.03 (95%CI0.81-1.25). No difference was seen between isolated leading or trailing leg (p=0.428). Bilateral hip arthroplasty increased handicap (p=0.0009). 1025 (94%) maintained or increased the amount of golf played. 258 (23.5%) returned to iron shots at 6 weeks and 883 (80%) to club competitions at 6 months. 18 (1.6%) had persistent pain. 19 (1.7%) were unable to return to play. Knee arthroplasty was associated with an average increase in handicap of 1.18 (95%CI 0.99-1.38). Trailing leg replacement alone was associated with higher postoperative handicap (p=0.002) as was bilateral surgery (p=0.009). 1009 (92%) maintained or increased the amount of golf played. 270 (25%) returned to iron shots at 6 weeks and 842 (76%) to club competition at 6 months. 66 (6%) had persistent pain. 18 (1.6%) were unable to return to play.

Conclusion: Hip and knee arthroplasty enables most patients to maintain or increase the amount of golf played. Majority return to competitions within 1 year. Return to iron shots occurs from 6 weeks. A small increase in handicap following surgery is expected and is larger in patients undergoing bilateral surgery or those with knee arthroplasty to their trailing leg. Patients may still experience pain when playing golf.

27 - Knee Replacement Bandaging Study (KReBS): a randomised trial evaluating the effectiveness of a two layered compression bandage following total knee replacement

Jonathan Kent1, Liz Cook2, Caroline Fairhurst2, Mike Reed3, Belen Corbacho2, Alexandra Dean2, Alex Mitchell2, Matthew Norgrave2, Sarah Ronaldson2, David Torgerson2

1North Tees University Hospital, Stockton on Tees, United Kingdom; 2University of York, York, United Kingdom; 3Northumbria NHS Foundation Trust, Ashington, United Kingdom

Background: The efficacy of the use of compression bandaging following total knee replacement (TKR) is unclear due to conflicting results in the literature and heterogeneous methodology. There is some evidence from a feasibility randomised trial that short-stretch compression bandaging after a total knee replacement may lead to an improvement in health outcomes relative to usual care.  

Methods: A pragmatic, parallel-group, multicentre, open-label, two-arm, randomised controlled trial in adults undergoing TKR to assess the clinical and cost effectiveness of compression bandaging following TKR. The primary outcome was the Oxford Knee Score (OKS) at 12 months post-randomisation. Because the intervention is relatively inexpensive and easy to implement a small difference of one point in the OKS was sought, which required a sample size of 2600 participants (80% power, 2p=0.05). Secondary outcomes included: health-related quality of life, post-operative pain, length of hospital stay, costs and complications, e.g. return to surgery.  

Findings: 26 surgical sites recruited and randomised 2330 eligible participants.  Data from 1700 participants were included in the primary analysis (73.0%, compression bandaging n=890, 73.4%; usual care n=810, 72.5%).  There was a small, non-statistically significant difference in the OKS at 12 months favouring the intervention (0.29  , 95% confidence interval (CI) -0.60 to 1.20, p=0.52).  There were no differences in any of the secondary outcomes. The economic analysis found that compression bandages were £72 more costly and generated 0.005 fewer quality-adjusted life years (QALYs) than usual care; hence, compression bandages were dominated by usual care.  More non-serious adverse events were observed in the compression bandage arm.  

Interpretation: KReBS is the largest (2334 participants) randomised trial to date comparing the use of compression bandaging with routine care following TKR. Compression bandages do not represent a cost-effective option when compared with usual care.

Implication: The use of compression bandages after total knee replacement is not recommended.

69 - Study of Peri-Articular Anaesthetic for Replacement of the Knee (SPAARK): a multi-centre patient-blinded, randomised controlled superiority trial of liposomal bupivacaine

Thomas Hamilton1, Ruth Knight1, Jamie Stokes1, Ines Rombach1, Cushla Cooper1, Loretta Davies1, Susan Dutton1, Karen Barker1, Jonathan Cook1, Sallie Lamb2, David Murray1, Lisa Poulton1, Ariel Wang1, Louise Strickland1, Bernard Van Duren3, Jose Leal1, David Beard1, Hemant Pandit3

1University of Oxford, Oxford, United Kingdom; 2University of Exeter, Exeter, United Kingdom; 3University of Leeds, Leeds, United Kingdom

Background: This multi-centre randomised controlled superiority trial, evaluated the clinical and cost effectiveness of liposomal bupivacaine, a novel liposome encapsulated local anaesthetic, for pain and recovery following knee replacement. ISRCTN54191675

Methods: 533 patients (11 centres) undergoing primary knee replacement were randomised to receive either liposomal bupivacaine (266mg) plus bupivacaine hydrochloride (100mg) or control (bupivacaine hydrochloride 100mg), administered at the surgical site using a standardised technique. Patients and outcome assessors were blinded to treatment allocation. The co-primary outcomes were pain visual analogue score (VAS) area under the curve (AUC) 6 to 72hours and the Quality of Recovery 40 (QoR-40) score at 72hours. 

Results: Primary analysis found no difference in pain VAS AUC 6 to 72hours between liposomal bupivacaine and control (MD -21.5 (97.5% CI -46.8 to 3.8; p=0.057)), nor the QoR-40 at 72hours (MD 0.54, 97.5% CI -2.05 to 3.13, p=0.643). Analyses of pain VAS and QoR-40 scores on days 0, 1, 2 and 3 demonstrated only one significant difference, with the liposomal bupivacaine arm having lower pain scores the evening of surgery (day 0; MD -0.54, 97.5% CI -1.07 to -0.02; p=0.021). No difference in cumulative opioid consumption, functional outcome at 6weeks, 6months or 1year was detected. Heath economic analysis found liposomal bupivacaine to be less effective in terms of QALYs as well as more costly. No difference in adverse events was found between treatment arms.

Conclusion: This is the largest RCT evaluating the clinical and cost effectiveness of liposomal bupivacaine. It found that compared to bupivacaine hydrochloride local infiltration of liposomal bupivacaine at the surgical site does not provide any clinical or cost benefit for knee replacement and therefore should not be routinely used.

Disclosure: Funding received from NIHR Research for Patient Benefit (PB-PG-0215-36084). Pacira Pharmaceuticals Inc. supplied the investigational medicinal product.

350 - Outcomes of Bereiter Trochleoplasty for Recurrent Patellar Instability with Severe Trochlear Dysplasia

Jimmy Ng, John Broomfield, Francisco Barbosa, Navjot Bhangoo, Guido Geutjens

Royal Derby Hospital, Derby, United Kingdom

Background: Trochlear dysplasia is an independent risk factor for recurrent patellar instability with evidence demonstrating its presence in up to 85% of patients with patellar instability. Severe trochlear dysplasia can be treated with trochleoplasty to improve engagement of the patella in the trochlear groove and prevent future dislocations. The aim of this study was to determine the clinical outcome of Bereiter trochleoplasty in patients with recurrent patellar instability and severe trochlear dysplasia.     

Methods: This was a retrospective case series of all trochleoplasties performed in our institution from 2008-2019. All clinical records and pre-operative MRI scans were reviewed to assess for trochlear dysplasia, tibial tuberosity to trochlear groove distance (TTTG) and patella height using patella trochlear index (PTI). Trochlear dysplasia was classified using Dejour classification. 

Incidence of re-dislocation, infection, arthrofibrosis, chondral necrosis and re-operation were recorded. All patients were invited to complete a post-operative visual analogue score for pain (VAS-P) and Banff Patella Instability Instrument (BPII).

Results: 58 trochleoplasties were performed in 50 patients during this period. All trochleoplasties were combined with additional procedures. 93% had concomitant MPFL reconstructions and 47% had tibial tuberosity transfer. The mean follow up period was 36.8 months. The rate of dislocation and arthrofibrosis were 5% each. There were no chondral necrosis or non-union. The mean post-operative BPII was 58.4 and VAS-P was 30.4.

Conclusion: Bereiter trochleoplasty, often combined with MPFL reconstruction and/or tibial tuberosity transfer provides good clinical outcome for severe trochlear dysplasia.

377 - Primary Knee Arthroplasty for Osteoarthritis Restores Patients’ Health-Related Quality of Life to Normal Population Levels: A Propensity Score Matched Study

Liam Yapp1,2, Chloe Scott1,2, Deborah Macdonald2, Colin Howie1, Hamish Simpson2,1, Nick Clement1,2

1Royal Infirmary of Edinburgh, Edinburgh, United Kingdom; 2University of Edinburgh, Edinburgh, United Kingdom

BACKGROUND: This study investigates whether primary knee arthroplasty (KA) restores health-related quality of life (HRQoL) to levels expected in the General Population.

METHODS: This retrospective case-control study utilises two sources: patients undergoing primary KA from the Edinburgh Orthopaedic Research Database; and individual-level data from the Health Survey for England which was used to represent the General Population. Propensity score matching was used to balance covariates (sex, age and body mass index (BMI)) and facilitate group comparisons. Two matched cohorts with 3029 patients each were obtained for the adjusted analyses (median age 70.3 interquartile range (IQR) 64-77; Female sex 3233 (53.4%); median BMI 29.7 IQR 26.5-33.7). HRQoL was measured using the three-level version of the EuroQol 5-Dimensions’ (EQ-5D-3L) Index and EQ-VAS scores.

RESULTS: Patients awaiting KA had significantly lower EQ-5D-3L Index scores than the General Population (median 0.620 (IQR 0.16-0.69) vs median 0.796 (IQR 0.69-1.00), p<0.001). By one-year post-operation, the median EQ-5D-3L Index score improved significantly in the KA cohort (mean change 0.32 (Standard deviation 0.33), p<0.001), and demonstrated no significant differences when compared to the General Population (0.796 (IQR 0.69-1.00) vs 0.796 (0.69-1.00), p=1.0). Older age-groups had statistically better Index scores than matched peers in the General Population. Compared to the General Population cohort, the post-operative EQ-VAS was significantly higher in the KA cohort (p<0.001).

CONCLUSIONS: Patients awaiting KA for osteoarthritis have significantly poorer HRQoL than the General Population. However, within one year of surgery, primary KA restored HRQoL to levels expected for patient’s age, BMI and sex-matched peers.


455 - Gait Studies of Robotic Total knee Arthroplasty Versus Conventional Jig-Based Outcomes: Results of A Prospective Randomised Controlled Trial

Dia Eldean Giebaly, Shanil Hansjee, Ahmed Magan, Vishal Rajput, Andreas Fontalis, Babar Kayani, Jenni Tahmassebi, Fares Haddad

UCLH, London, United Kingdom

Background: The recent evolution in intraoperative surgical aids, such as computer navigation and robotic technology, have offered the opportunity to assess patient-specific knee kinematics intra-operatively during total knee arthroplasty (TKA) and obtain more physiological limb alignment targets and potentially better markers of gait function post operatively. The aim of this study is to detect differences in gait between robotic assisted and conventional TKA.

Methods: This prospective randomised controlled trial included 30 patients with symptomatic knee osteoarthritis undergoing conventional TKA versus robotic TKA. This study included 13 male patients and 17 female patients. Gait analysis was performed with an instrumented dual-belt treadmill, with force plates underneath both belts to record the kinetics of each step at increasing speed and inclination.

Results: There were no differences in baseline demographics or preoperative radiological deformity between the two groups. Mean age 68.7 in the conventional TKA group and 67.9 in the robotic TKA group. Mean BMI was 27.5 in the conventional TKA group and 27.0 in the robotic TKA group. Mean pre-operative limb alignment was 3.4 degrees in the conventional TKA group and 3.1 degrees in the robotic TKA group.

Gait studies were performed at mean follow up at 27.8 months. No difference was found in the two groups at low walking speed. With increasing walking speed, the robotic TKA group reached a higher speed compared with conventional TKA. Gait analysis revealed significantly better cadence, walking speed, stride length and stance time in the robotic TKA group.

Robotic TKA patients tolerated more weight on the operated side at high walking speed. Fixed walking speed and an increasing incline showed no statistically significant differences were seen between robotic TKA and conventional TKA patients.

Conclusions/Findings: Robotic assisted surgery in total knee arthroplasty improves outcomes of gait performed under increased physical demand.

606 - Intra-articular injection and knee arthroscopy prior to primary knee replacement are each associated with worse outcomes. Analysis of data from CPRD-HES-PROMs

Matthew Strang1,2, Setor Kunutsor1, Micheal Whitehouse1,2, Ashley Blom1,2, Andrew Judge1

1University of Bristol, Bristol, United Kingdom; 2Southmead Hospital, Bristol, United Kingdom

Background: Patients with symptomatic degenerative knee disease will often undergo routine intra-articular interventions such as steroid injections and knee arthroscopy prior to undergoing primary knee replacement. Such interventions may improve symptoms and delay surgery, but their impact on subsequent knee replacements is uncertain. This study aimed to investigate if prior steroid injections and knee arthroscopy each impact on the outcomes of subsequent primary knee replacement.

Methods: We performed an observational retrospective analysis of linked CPRD-HES data of 38,494 patients undergoing primary unilateral and total knee replacements. Patients undergoing intra-articular steroid injections and knee arthroscopy prior to primary knee replacement were identified. Hazard ratios (HRs) with 95% CIs were estimated for the primary outcomes of revision and reoperation. Secondary outcomes included timing to knee replacement, post-operative oxford knee scores (OKS), mortality and post-operative surgical site infection at 3 months. Kaplan-Meier estimates were used to calculate the cumulative probabilities of revision and re-operation. 

Results: Prior steroid injections increased the risk of revision (HR=1.25, p=0.009), re-operation (HR=1.18, p=0.005), and infection in the immediate 3-month post-operative period (HR=3.17, p=0.027) following primary knee replacement and was associated with a lower 15-year implant survival. Timing from diagnosis of degenerative knee disease to knee replacement was 6 months longer in patients receiving steroid injections. Knee arthroscopy was associated with an increased risk of revision (HR=3.14, p<0.001), re-operation (HR=3.25, p<0.001), lower post-operative OKS (14.7 vs 16.4), and a lower 15-year implant survival following primary knee replacement. Both interventions were associated with a reduced risk of mortality following knee replacement. 

Conclusion: Steroid injection and knee arthroscopy prior to primary knee replacement are each associated with significantly worse outcomes. Surgeons should avoid these interventions in the presence of OA where the patient is a candidate for a knee replacement in the foreseeable future.

676 - Early tibial component aseptic loosening in NexGen LPS (non flex) Total Knee Replacement (TKR)

Lokesh Sharoff, Jaison Patel, Gohar Naqvi, Ryan Wood, Mark Bowditch

East Suffolk and North Essex NHS Foundation Trust, Ipswich, United Kingdom

Background: The Ipswich NHS unit’s NJR results for TKR revision have been excellent. Recently there has been a concerning rise of early revision. Though there has been reports of concerns with the NexGen LPS flex component, this has not been used at Ipswich.

Aim: To evaluate the scale and cause of the apparent increase in revision rates.

Methods: A retrospective cohort study of revision TKR numbers in last 4 years.

Inclusion: Revision due to aseptic loosening of NexGen TKR.
Exclusion: Revision for reasons other than aseptic loosening.

Data collection: demographic data, dates of primary and revision surgeries, implants combination used, surgeons and their type of cement used & cementing technique, alignment of implant on pre and post-operative radiographs and zones of the cement lucency.

Results: Implant; Nexgen LPS standard option (non flex) femur with the cemented stemmed tibia and LPS articulating insert. 2002-2013 the unit used the cemented stemmed precoat (augmentable) tibial component. In 2013-21 the unit changed only the tibia to the cemented stemmed non precoat (non augmentable) tibial component. All other factors have remained constant. There has been a significant rise in revisions in last 4 years within 8 years of implantation. The mode of failure is aseptic loosening of the tibial component with debonding at the cement metal interface. It rapidly progresses.

Conclusions/Findings: A real rise in the aseptic loosening rate with a change in the tibial component in this implant combination, with all other factors remaining constant.

Implications: Change back to the stemmed precoat (augmentable) tibia with the Nexgen LPS femur. There are numerous combinations possible under the ‘Nexgen’ banner. Whilst some may have excellent long term outcomes, this may not be the case for all.

681 - Changes in Bone Density below the Cementless Unicompartmental Knee Replacement Tibial Component are not related to Patient-Reported Outcomes

Azmi Rahman, Katerina Dangas, Stephen Mellon, David W Murray

University of Oxford, Oxford, United Kingdom

Introduction: After remodelling, loss of bone density beside the keel of cementless UKR tibial components has been observed as a potential cause of concern. How this affects patient-reported outcomes, and therefore its clinical implications, are unclear. This study aimed to assess the effect of cementless UKR implantation on tibial bone density, and to explore its relationship to patient demographics and outcomes. 

Method: This prospective study assesses 115 anterior-posterior radiographs from cementless UKR postoperatively and five years after surgery. Gray values from nine regions around each keel were collected and standardised to enable inter-radiograph comparison. Change between the post-operative and 5-year radiographs (indicating bone density) was calculated and effect on 5-year patient demographics (age and BMI) and pain and functional outcomes (OKS, ICOAP-A/B, TAS) was assessed. Repeat measurements were performed by two operators to assess reliability.

Results: There was excellent inter-operator correlation. There was increased relative radio-opacity directly below the keel (9.1% vs 3.3%: p<0.0001), and reduced density beside the keel (-5.9% vs -1.0%, p<0.0001); comparisons to adjacent regions. Overall remodelling was significantly greater in smaller tibias (p=0.006), and females (p=0.01). Remodelling was unrelated to outcomes (OKS, ICOAP-A/B, TAS), age, and BMI.

Conclusion: Remodelling patterns suggest increased loading below and decreased loading adjacent to the tibial keel. Remodelling is greater in smaller tibias and females. Remodelling is not related to any patient-reported pain or function five years after surgery, suggesting that remodelling is successful in removing any mechanical source of bone pain. Therefore, clinicians viewing such remodelling patterns can ignore them as they are of no consequence.

712 - Socioeconomic area deprivation negatively impacts patient-reported outcomes following autologous chondrocyte implantation (ACI) in the knee

Salam Ismael1, Helen McCarthy2, Jan Kuiper2, Mike Williams1, Andrew Barnett1, Peter Gallacher1, Paul Jermin1, James Richardson1, Karina Wright2, Sally Roberts2

1Robert Jones and Agnes Hunt Orthopaedic Hospital, Oswestry, United Kingdom; 2School of Medicine - Keele University, Stoke on Trent, United Kingdom

Background & Purpose: Autologous chondrocyte implantation (ACI) is an effective treatment for isolated knee chondral defects. Increasing evidence highlights the impact of socioeconomic deprivation on the outcome of orthopaedic surgery. This study aimed to determine the association between socioeconomic deprivation and short-term patient-reported ACI outcomes.

Methods& Materials: All patients at our institution who underwent knee ACI between 1996-2020 were identified. Socioeconomic deprivation of their residential area was quantified by the Index of Multiple Deprivation (IMD) and employment/income deprivation. One-year Lysholm scores were the primary outcome. After transformation where needed to ensure normal distributions, linear multivariable regression was used to analyse the relation between IMD and 1-year Lysholm score, adjusting for demographic characteristics (age, sex, BMI and smoking) and baseline Lysholm.

Results: We identified 293 patients with mean age 50 years (range 16-84; 266 (68%) male). BMI and deprivation were log-transformed to achieve normal distributions. Median BMI was 27 (17-47): 138 patients (43%) were overweight and 105 (33%) obese. Seventy-seven patients lived in upper and 41 in lower quintile deprivation areas. The mean baseline Lysholm score was 49.8±17.3SD, improving to 66.5±21.3SD at 1 year. Mean one-year Lysholm scores were significantly lower with increasing area deprivation scores, adjusted for demographic factors. Specifically, areas with high unemployment levels were associated with poorer functional outcomes. Being female or having a lower baseline Lysholm was also associated with poorer outcomes, but age, BMI, smoking or higher income deprivation were not.

Conclusion: This study demonstrates poorer functional outcomes following ACI in patients from more deprived areas. Specifically higher unemployment levels were associated with lower mean 1-year Lysholm scores, as were the female gender. Future studies in patients undergoing ACI should consider neighbourhood deprivation as a confounding factor. Targeting patients from areas with higher deprivation with special interventions may improve their outcomes.

803 - Knee replacements done with neutral mechanical alignment technique often results in overstuffing of the distal lateral femoral condyle – an analysis using MRI based 3D modelling

Srinivas Cheruvu1,2,3, Muthu Ganapathi1

1Ysbyty Gwynedd, Bangor, United Kingdom; 2Royal Stoke University Hospital, Stoke-on-Trent, United Kingdom; 3Robert Jones and Agnes Hunt Orthopaedic Hospital, Oswestry, United Kingdom

Background: Conventional TKR aims for neutral mechanical alignment which often results in smaller lateral distal femoral condyle resection than implant size. We aim to explore the mismatch between implant and bone resection using 3D planning software.  

Methods: A retrospective anatomical study of MRI 3D models of patients with PSI TKR under a single surgeon. The cartilage mapping software allowed rebuilding of the native anatomy which enabled us to measure the mismatch between the distal lateral femoral condyle resection and the implant thickness. 

Results: 292 PSI TKR between 2012 and 2015.  225  varus knees  and 67 valgus knees, with mean supine hip-knee-angle of 5.6±3.1 degrees and 3.6±4.6 degrees. The estimated mean overstuffing of the lateral femoral condyle after implantation was 1.9±2.2 mm in varus knees and 4.1±1.9mm in valgus knees.

Discussion: In this anatomical study we have explored a novel concept and a potential factor that maybe contributing towards anterior knee pain following TKRs done using neutral mechanical alignment. The distal femoral cut thickness is based on the medial condyle as reference. Neutral mechanical alignment technique usually results in the distal femoral cut to be in relative varus. This results in a lateral distal femoral condyle resection less than implant thickness and therefore an overstuffing effect. Overstuffing the distal lateral femoral condyle can result in increased pressure at the lateral patella facet in flexion leading to anterior knee pain. It may also cause tight lateral retinaculum which may contribute to anterior knee pain despite patellar resurfacing. 

Conclusions: Neutral alignment TKR results in overstuffing of the distal femoral lateral condyle as shown in our study. This may be a potential factor causing anterior knee pain following knee replacements. A more anatomical alignment technique to resurface the distal femur may minimise this problem resulting in less anterior knee pain.

810 - A Prospective Cohort Study Comparing the Accuracy of Plain Long-Leg Radiographs Versus Computerised Tomography-Based Modelling for Calculating Coronal Plane Alignment of the Knee (Cpak) During Robotic Knee Arthroplasty

Vishal Rajput, Andreas Fontalis, Ricci Plastow, Babar Kayani, Dia Giebaly, Shanil Hansjee, Ahmed Magan, Fares Haddad

University College London Hospitals NHS trust, London, United Kingdom

Introduction: Coronal plane alignment of the knee (CPAK) classification utilises the native arithmetic hip-knee alignment to calculate the constitutional limb alignment and joint line obliquity which is important in pre-operative planning. The objective of this study was to compare the accuracy and reproducibility of measuring the lower limb constitutional alignment with the traditional long leg radiographs versus computed tomography (CT) used for pre-operative planning in robotic-arm assisted TKA.  

Methods: Digital long leg radiographs and pre-operative CT scan plans of 42 patients (46 knees) with osteoarthritis undergoing robotic-arm assisted total knee replacement were analysed. The constitutional alignment was established by measuring the medial proximal tibial angle (mPTA), lateral distal femoral angle (LDFA), weight bearing hip knee alignment (WBHKA), arithmetic hip knee alignment (aHKA) and joint line obliquity (JLO). Furthermore, the Coronal Plane Alignment of the Knee (CPAK) classification was utilised to classify the patients based on their coronal knee alignment phenotype.

Results: Mean age of the patients was 66 years (SD 9) and mean BMI 31.2 (SD 3.9). There were 27 left and 19 right sided surgeries. The Pearson’s corelation coefficient was 0.722 (p=0.008) for WBHKA; 0.729 (p<0.001) for MPTA; 0.618 (p=0.14) for aHKA; 0.502 (p= 0.04) for LDFA and 0.305 (p=0.234) for JLO. CPAK classification was concordant for 53% study participants between the two groups. 

Conclusion: Three-dimensional CT-based modelling with computer software has potential to more accurately predict constitutional limb alignment and JLO as defined by the CPAK classification compared to plain long-leg radiographs in pre-operative planning of total knee arthroplasty and may substitute long- leg radiographs.

Limb Reconstruction

Podium Presentation Abstracts

178 - Do circular fixators have a role in bone tumour management?

Sherif Ahmed Kamel1,2, Mohamed Abdel Rahman1, Salah Abou Seif1

1Faculty of Medicine, Ain Shams University, Cairo, Egypt; 2University Hospitals of Leicester NHS Trust, Leicester, United Kingdom

Background: The advances in chemotherapy have encouraged limb salvage of malignant bone tumours. There are several techniques for limb salvage either conservative or surgical resection with or without reconstruction. Reconstruction could be biological, metallurgic or both. We hypothesised that circular fixators could be used to solve the reconstruction problems by using various modes. 

Methods: A prospective case series of 15 patients with benign or malignant tumours treated by resection followed by bone and soft tissue reconstruction using Ilizarov fixator from June 2012-June 2014 in Ain Shams University hospitals, Cairo, Egypt. The aim of this study was to evaluate the Ilizarov’s fixator either as primary reconstruction, complicated or failed reconstruction. Inclusion criteria were patients who need surgical reconstruction for benign, malignant, or complicated cases of bone tumours that results in shortening or bone defect of 2cm or more. Excluded cases were patient refusal or cases with extremely poor prognosis. The outcomes were overall survival, disease free survival, MSTS score, ASAMI scores, and Paley’s adverse events.

Results: Ages were 7-52 (21.1) years. Seven cases were benign, 8 cases were malignant, and 7 cases had previous surgeries. Follow-up was 14-28 (21.7) months. In malignant tumours, disease-free survival was 12-30 (22.8) months. Two patients developed local recurrence. The overall survival was 13-30 (25.8) months. One patient died from chemotherapy. Overall, MSTS score was 50-100% (84.6). ASAMI-bone score was excellent/good in 10 cases. ASAMI-function score was excellent/good in 13 cases. There were 7 problems, 5 obstacles and 6 complications according to Paley. The most common adverse event was pin tract infection especially with chemotherapy. 

Conclusion: Biological reconstruction using circular fixator could be considered safe and effective in the management of benign and low-grade malignant tumours, and a salvage treatment in case of failure of other methods of limb salvage.

364 - Amputation Versus Reconstruction in Type IV Tibial Hemimelia: Comparing Functional Outcomes and Description of a Reconstructive Surgical Technique

Chun Hong Tang, Abdullah Addar, James A Fernandes

Sheffield Childrens Hospital, Sheffield, United Kingdom

Introduction: Tibial hemimelia is a congenital anomaly with an absent or dysplastic tibia and can be seen in isolation or as part of complex syndromes. The management of tibial hemimelia can be a spirited discussion with patients and their families, and can be either reconstructive or ablative. We report our unit’s experience in managing tibial hemimelia with Jones Type IV. We describe the reconstructive procedure performed. 

Methods: This study is a retrospective case series of 9 cases (8 patients, 1 bilateral) treated over 22 years. The inclusion criteria were patients with a diagnosis of Type IV tibial hemimelia. The primary outcome was functional scores in patients after they had completed their treatment. The Special Interest Group in Amputee Medicine (SIGAM) scores were used in patients with an amputation. The reconstructive arm of the study were analysed according to the Short Form-12 (sf-12) questionnaire.

Results: We report a median age in our cohort of 14 years, with a mean follow up period of 10 years. We had 3 patients in each of the ablative (4 cases) and reconstructive arm (3 cases) of the study. 2 patients did not require any form of surgery. We report SIGAM score of F, D and B within the amputation cohort, and a mean physical and mental sf-12 score of 47.6 and 45.92 within the reconstructive cohort. This was compared to the general population and within our series, with no statistically significant difference. (p=0.69) None of the patients in the either group required walking aids, and only one patient in the amputation group used a wheelchair to mobilise in the community. 

Conclusion: In type IV tibial hemimelia, a staged reconstructive procedure is preferable to correct the deformity and provide the patient with a plantigrade functional foot on which to weight bear.

391 - Outcome of Tibial fractures in elderly treated with circular frame with minimum 12 months follow up

Hussain AL Omar, Oliver Dixon, Arun Watts, Panayiotis Souroullas, Mickhael Langit, Elizabeth Barron, Yvonne Hadland, Ross Muir, Elizabeth Moulder, Hemant Sharma

Hull University Teaching Hospitals, Hull, United Kingdom

Background: Management of tibia fractures in elderly patients with fragile soft tissue and bone quality is a challenge. Circular external fixators (CEF) provide a minimally invasive stable fixation that allows immediate weight-bearing.

Methods: Retrospective review of patients >65 years, with tibial fractures, between 2014 and 2021, treated with a CEF, with at least 1-year follow-up. Outcomes were time to union, complications, ASAMI functional and radiological scores. Data were collected from the hospital electronic system; on sex, comorbidities, smoking, fracture type (open/closed), fracture location (AO41/42/43) frame type (Ilizarov/hexapod), weight-bearing status, and mechanism of injury. Man-Whitney and regression analyses were performed.  

Results: 55 frames were included, median age 70 years. All fractures united in a median time of 23.7 weeks (IQR 20.3 to 30.1). 18% of patients required return to theatre or change in management plan. ASAMI functional scores were excellent or good in 87% of patients. ASAMI Radiological scores were excellent or good in 97% of patients. Ilizarov frames (p=0.001) in comparison with hexapods healed faster. In regression analysis Younger patients (p=0.002) were associated with better functional outcomes. 

Conclusions: CEF for complex tibia fractures showed excellent functional outcomes and no cases of nonunion in the elderly. Time in frame and complications were comparable with other studies for younger adults. Circular should frame should be considered primary fixation mode where immediate weight-bearing is critical.

Implications: When immediate weight bearing is required, circular can be an excellent treatment choice.

Disclosure: Hemant Sharma is paid consultant for Smith & Nephew and Orthofix, Elizabeth Moulder is paid consultant for Orthofix.

499 - Bone formation in Limb Lengthening over nails. A new way of healing in distraction osteogenesis, the ‘Multilayer Concentric’ Healing Pattern.

Jean-Marc Guichet1,2,3, Véronique Sauret-Jackson4, Daniele Clementi3, Barbara Deromedis5

1Princess Grace Hospital, London, United Kingdom; 2Harley Street Specialist Hospital, London, United Kingdom; 3Columbus Clinic Center, Milan, Italy; 4Cavendish Imaging London, London, United Kingdom; 5CTO, Milan, Italy

Introduction: Distraction Osteogenesis shows the bone marrow role in external fixator lengthening with a ‘growth zone’ (GZ) (Ilizarov GA) from where bone formation gradually calcifies. To better understand the 3D Bone regenerate healing during gradual intramedullary lengthening and  the role of periosteum vs bone marrow, we present results of high resolution 3D-Cone-Beam CTScan (CBCT), providing better information than 2D-X-rays.

Material & Method: 30 patients operated on bilaterally with a fully weight bearing nails underwent CBCT evaluation of the regenerate at POD15, 30, 45 & 60. 

Results: Longitudinally, healing is observed as periosteal islands spreading along the lengthening area and gradually increasing in quantity and size over time. The callus is generally hypertrophic. Islands gradually converge to join at time of fusion.

Transversally, a gradient of bone formation is observed from each island of periosteum, spreading and fading concentrically. A multilayer pattern can be observed, with some areas where few gradient layers arrange like onions layers. Density of the bone increases gradually, creating gradually a uniform healing pattern.

Over time, the island layers get thicker and denser and join together, resulting in bone fusion, which is initially ‘soft’. Hardening is observed gradually with whitening of the regenerate areas. A continuous ‘soft’ bone fusion is occasionally observed on X-rays or CBCT, with maintained capacity for the patient to distract.

Conclusion: X-rays do not allow to have a 3D understanding of healing processes, which CBCT allows. Bone formation occurs with islands, initially as ‘dots’, spreading longitudinally and concentrically. Gradual densification occurs. Periosteum healing has capacity of migration in the elevated spaces, which bone marrow healing does not have.

According to mechanical conditions and the balance between endosteum, bone marrow and periosteum, various healing pattern can be observed. In case of lengthening over nail, the multilayer concentric pattern applies.

532 - Is full weight bearing an advantage over partial weight bearing or wheel-chair? A series of 721 lengthening

Daniele Clementi1, Jean-Marc Guichet2,3,1

1Columbus Clinic Center, Milan, Italy; 2Princess Grace Hospital, London, United Kingdom; 3Harley Street Specialist Hospital, London, United Kingdom

Introduction: Full weight bearing (FWB) is the Gold Standard in Orthopaedics preventing muscle loss, with fast return to sports and social activities. Limb lengthening is prone to complications. Weight bearing nails (WBN) may add further risks. For evaluating that, we reviewed a prospective series of 720 femoral lengthening (1991-2022) with WBN.

Material & Method: 352 patients (P) were operated with 336 Albizzia (76P),  367 G-Nail (176P) for 68 discrepancies, 17 dwarfism and 267 cosmetic patients (simultaneous bilateral WBN).

Day Care is standard (cosmetic since 2019). Evaluation included for all patients long-leg X-rays/3D-EOS 3D, Isokinetic testing, DEXA, Psychological evaluation.

Weight bearing with Albizzia was initially partial, lately full from POD1. With G-Nail, FWB and sports were are authorised on POD0 including stairs and bike.

Results: Gain averaged 3.8 cm (discrepancy), 6.2 cm (dwarfism, up to 22 cm) and 6.7 cm (cosmetic; up to 18.6 cm). Obtained/Planned gain variations are 0.25 mm (measured on removed implants), reliability is 99.85%) and precision 99.34%. 

Static weight bearing (hoping) is currently authorised during lengthening), free walking close to end of lengthening, stairs and bike (POD0), elliptical (POD2), stepper (POD6) if density is normal at DEXA. 

Added surgery (13.3%) are for implant fracture (1.8%, WBN or screws), bone grafting (3.8%), bone fracture (5.0%), callotomy (0.6%), other surgeries (2%). GA for clicking were initially 17.7% (Albizzia), currently 3% (G-Nail). X-rays showed strong and fast healing with no bone resorption. Implants retrieval showed no corrosion (even 14 years after insertion). No problem of biocompatibility nor cytotoxicity has been noted.

Conclusion: Weight bearing nails have a low rate of complications, even if they do not suppress them and should be the preferred solution for surgeons and patients.

Questions for improving patient care are: why do not we prefer WBN for patients, and can we decide to switch to them?

Medical Students

Podium Presentation Abstracts

92 - Practical Undergraduate Orthopaedic Education: Lessons Learnt During the COVID-19 Pandemic

Arwel Poacher1, Joseph Froud2, Hari Bhachoo2, Jack Weston2, Kavita Shergill2, Gethin Poacher3, Clare Carpenter4

1University of Wales Hospital, Trauma Department, Cardiff, United Kingdom; 2Cardiff University School of Medicine, Cardiff, United Kingdom; 3Ability Medical Education, Cardiff, United Kingdom; 4Noah’s Ark Children’s Hospital for Wales, Cardiff, United Kingdom

Background: Competition in Trauma and Orthopaedics (T&O) is declining amongst applicants, coinciding with a decline in undergraduate orthopaedic placement length. With over 10% of non-specialist healthcare appointments related to musculoskeletal health, there is a need for comprehensive undergraduate placements to ensure students are well equipped for clinical practice as medical professionals. 

Methods: A multi-centre study of teaching hospitals (n=13) that provide undergraduate orthopaedic education in Wales, in which students (n=91) responded to a survey rating each component of their placement against learning outcomes (LO) provided by the British Orthopaedic Association.

Results: The average orthopaedic placement length was 1.7 weeks, however 19% of students received no formal T&O teaching. Those that did reported teaching was predominantly lecture based (67%). Small group or in person teaching sessions were significantly better at fulfilling LO (p<0.01). When students demonstrated active engagement on placement their LO fulfilment improved across consultant clinics (p<0.01), ward work (p<0.001), and theatre time (p<0.01). 85% of participants felt that COVID-19 had impacted their learning, the greatest impact a lack of theatre time (38.5%), followed by reduced patient contact (34.1%). Students ‘strongly’ believed (Likert mean: 4.61/5) that a uniform e-learning resource would be useful to supplement their learning. Furthermore, active engagement during placement significantly improved the impact of the placement on their desire to pursue a career in orthopaedics (p<0.05).

Conclusion: Orthopaedic teaching was inadequate compared to current guidance. However, a focus on interactivity and practical engagement in clinical areas have a significant impact on learning and career choice. There is a need for a standardised learning resource to reduce the discrepancies between student placements, alongside encouragement of seniors to engage with undergraduate education. This will both provide adequate teaching to students and reignite interest in the field.

108 - Is industry-sponsored research in orthopaedic surgery biased towards positive results? A systematic review

Madeleine Brandon1,2, Munier Hossain3, Hannah Grundy1,2, Jessica Waitling1,2

1Lincoln Medical School, Lincoln, United Kingdom; 2University of Nottingham, Nottingham, United Kingdom; 3ULHT, Lincoln, United Kingdom

Background: Recent studies suggest industry sponsored research is more likely to yield positive results. It is unclear if this is due to bias. Orthopaedic research is often industry sponsored. The aim of this review was to assess if industry sponsored research in orthopaedic surgery was more likely to be biased compared to non-industry sponsored research.

Methods: We conducted a systematic review. We included Randomised controlled trials (RCTs) published in 2020 on Orthopaedics and/ or trauma in the English language. We searched Embase, Medline, Cochrane library and Orthosearch. Studies were excluded that used animal subjects, trialled ‘non-commercial’ products or were follow-ups of previously published trials. The outcomes for each study were recorded. Risk of bias (ROB) was assessed using the Cochrane ROB tool.

Results: 23 studies were included: 14 studies were industry-sponsored (RoB: 2 high, 8 some concerns, 4 low), 4 studies were non-industry sponsored (RoB: 1 high, 3 some concerns), 5 studies had unknown source of funding (RoB: 3 high risk, 1 some concerns, 1 low). 12/14 industry-sponsored studies demonstrated positive results, 10 of these had either some concerns or high RoB. 2/4 non industry sponsored trials showed positive results (one had high ROB and the other had some concerns).

Conclusion/ findings: Our review demonstrated the high prevalence of industry sponsorship in orthopaedic research. Non-industry sponsored trials were few and therefore we could not perform any statistical tests to compare the outcomes. However, industry sponsored trials did not appear more likely to contain methodological limitations compared to non-industry sponsored ones. We observed variable degree of bias which most likely reflects the quality of orthopaedic trials in general rather than its relationship to the source of funding.

Disclosure: This review was a conducted by three medical students for a BMedSci project under the supervision of the senior author.


114 - Operating table height and lumbar spine ergonomics

Ahmed Elsayed, Tim Drew, Graham Arnold

University Department Orthopaedic & Trauma Surgery, Dundee, United Kingdom

BACKGROUND: Back pain is one of the most common injuries in surgeons and previous research has suggested that the most common cause is suboptimal operating table height. The aim of the present study is to investigate the effect of different operating table heights on spinal biomechanics and surgical performance.

METHOD: Three individualised heights of 21 participants were measured. The lumbar segment was tracked using six markers and recorded with 3D-motion cameras. EMG sensors were attached on the erector spinae muscle bulk. Participants completed a simulated surgical task with the table at the three heights. Each trial was timed as a measure of surgical performance. A custom model provided angles of lumbar flexion.  Raw electromyograms were treated with established processing models.

RESULTS: Trial times were fastest at elbow height** (86.87 ± 33.68 s) then ASIS height (98.47 ± 38.20 s) and xiphisternum height (107.49 ± 50.37 s) (mean ± SD). Lumbar flexion (f), estimated compression (C) and shear (S) loading were greater at ASIS height** (f = 38.47 ± 8.20˚, C = 664.69 ± 179.39 N, S = 43.25 ± 27.70 N) than elbow height (f = 21.92 ± 7.88˚, C = 576.67 ± 181.62 N, S = 36.56 ± 20.70 N) and xiphisternum height (f = 19.81 ± 7.33˚, C = 542.10 ± 151.65 N, S = 26.56 ± 16.99 N). No significant trends were identified from the EMG results.

CONCLUSIONS: Elbow height is ergonomically superior as it balances the need for enhanced surgical performance with minimal lumbar spinal loading.

119 - Noise in orthopaedic theatres, is it safe?

Maliha Ayoola1, Catherine Kellett2, Sarah Radcliffe3, Caroline Hing1

1St George's University Hospitals NHS Foundation Trust, London, United Kingdom; 2Mohammed Bin Rashid University of Medicine and Health Sciences, Dubai, UAE; 3Curload Consultants Ltd, Taunton, United Kingdom

Background: Noise-Induced Hearing Loss (NIHL) is a condition caused by repeated exposure to loud noise and affects 26 million adults between 20-69 years with 2 million people in the UK exposed to unacceptable levels of noise at work. Daily personal noise exposure greater than 85 decibels risks NIHL and personal exposure to noise in a workplace must not exceed 87 dBA.

Material and Methods: We measured the average noise levels in T&O theatres using a Decibel X sound level meter app to determine the daily exposure to noise at work level (LEPd) and compared these to the recommended values set by the Control of Noise at Work Regulations 2005. We convenience sampled a selection of elective and trauma procedures to determine average noise levels. The surgeons and theatre teams were blinded to the study to prevent a Hawthorne effect. The data was analysed using descriptive statistics, R-squared and the Mann-Whitney U test. 

Results: The greatest contributors to the noise levels were the surgical instruments. More than two tibial plateau fixations, two acetabular fixations or two total hip replacements (THRs) per day in isolation were found to exceed the safe LEPd levels. The number of people in the room and whether music played was found to not contribute significantly to the overall noise level. 

Discussion: The average noise levels in T&O theatres were within the hazardous range. Reduction of noise levels, careful list planning and mandatory hearing protection are potential options for preventing NIHL in theatre staff. There is a need for further studies in this area to determine the cumulative effect of an operating list with different surgical procedures and the effect on patients as well as staff.

Conclusions: Operations with power tools in T&O theatres can exceed the Health and Safety at Work recommendations.

150 - Incidence of patients with potential post-traumatic stress disorder (PTSD) after sustaining an orthopaedic injury in a Trauma Unit – a service evaluation project

Titilope Jempeji1, Henry Burnand2

1Bristol University, Bristol, United Kingdom; 2University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, United Kingdom

Background: The National Institute for Health and Care Excellence (NICE) guideline (NG116) advise that patients with subthreshold symptoms of PTSD should have active monitoring within a month of the traumatic event. Various mechanisms may result in PTSD including orthopaedic trauma injuries. The psychological impact of orthopaedic trauma on general health outcomes is not commonly considered in management plans.

Aim: The purpose of this service evaluation was to evaluate the incidence of PTSD amongst patients presenting with an orthopaedic trauma and to assess compliance with the NICE guidelines.

Methods: Patients with orthopaedic trauma were identified from the fracture clinic and the trauma meeting handover, 149 patients were identified over a 4-week period. A questionnaire was created and offered to the patients. This questionnaire included the Michigan Critical Events Perception Scale (MCEPS) questions (a 5 item self-reported measure of peri-trauma dissociation) and a perceived general health score question with a visual analogue scale (VAS). Injury data and demographic data were also collected.

Results: Out of 149 patients, 101 completed the whole questionnaire. 15.8% (95% CI 8.7% – 23.0%) of participants met the criteria for peri-trauma dissociation and were therefore more at risk of PTSD. Mean screening time post-injury was 79 days. 66.3% of participants were male, and the mean age was 35.9 years ± 14.8 years. Of those with a positive MCEPS, 19% were advised for self-referral service within a month of their injury. Female sex and lower limb fractures were associated with a higher likelihood of developing PTSD.

Conclusions: PTSD is a devastating condition on its own; therefore, when it occurs alongside orthopaedic trauma, it may have a greater negative impact on general health outcomes. Consequently, further awareness should be made of the psychological impact of orthopaedic trauma on patients.

175 - Investigating the relationship between clavicle fractures and changes in cycling habits in a Major Trauma Centre in London during the COVID-19 pandemic

Rebecca Beni1, Duncan Tennent2, Emmett O’Flaherty2, Eyiyemi Pearse2, Magnus Arnander2

1St. George's University of London, London, United Kingdom; 2Shoulder and Elbow Unit, St. George's Hospital, London, United Kingdom

Background: Clavicle fractures are a common injury, with an estimated annual incidence of 55.9/100,000/yr [1]. The COVID-19 pandemic led to three lockdown periods in the UK which drastically changed daily habits nationwide, consequently producing a change in injury patterns. Cycling for leisure and as a means of transport increased significantly during the lockdown periods [2]. We hypothesize that this led to an increase in the incidence of bike-related clavicle fractures. 

Methods: A retrospective, observational study was performed in a Major Trauma Centre in London. The confirmed cases of clavicle fractures were selected and reviewed from all the clavicle X-rays available between April and June 2019 (pre-pandemic), April and June 2020 (first lockdown) and April and June 2021 (after the last lockdown). Patient demographics, mechanism of injury, fracture pattern and type of management were recorded. 

Results: A total of 169 fractures were included. As anticipated, there was a decrease in the number of clavicle fractures during the first lockdown (n=41) compared to 2019 (n=64) but this had returned to pre-pandemic numbers by 2021 (n=64). Pre-pandemic (2019) 18.8% of the clavicle fractures were bicycle-related and this increased 2.1 times during the first lockdown (39.0%) and remained 1.7 times higher in 2021 (31.1%). 

Conclusion: There was an increase in the percentage of bike-related clavicle fractures due to the increasing use of bikes in the population. The trend did not appear to change following the removal of restrictions. 

Indications: There needs to be work undertaken both on methods of prevention and public awareness of the risks related to cycling. 


[1] Vun S.H., Aitken S.A., McQueen M.M., and Court-Brown C.M. Orthopaedic Proceedings 2013 95-B:SUPP_12, 11-11

[2] Department for Transport. Transport use during the coronavirus (COVID-19 pandemic). Available at: www.gov.uk/government/statistics/transport-use-during-the-coronavirus-covid-19-pandemic

198 - Exploring medical student perceptions on soft tissue orthopaedics

Julian Aquilina1, Hariharan Subbiah Ponniah2, Rebecca Beni3, Simon Fleming4

1University College London Medical School, London, United Kingdom; 2Imperial College School of Medicine, London, United Kingdom; 3St. George's University of London, London, United Kingdom; 4Barts and The London School of Medicine and Dentistry, QMUL, London, United Kingdom

Background: 30% of primary care consultations focus on musculoskeletal injuries and 24% of the presentations to the ED in 2020 were related to trauma and orthopaedics. Specifically, soft tissue inflammation and sprain/ligament injury were among the top 10 A&E diagnoses, accounting for more than 1.4 million cases. Despite this, Trauma and Orthopaedics (T&O) is underrepresented in the undergraduate curriculum, with only 21% of medical schools teaching T&O as a standalone unit or block and the median teaching time of just 15 days. This study aims to evaluate the perception that medical students have of soft tissue orthopaedics. 

Methods: A survey was sent to all students who registered to an online orthopaedic conference aiming at undergraduates. The questionnaire contained 15 questions aimed to collect demographics, interest and understanding of a career in orthopaedics, and explored students’ perceptions of soft tissue orthopaedics (STO). A framework analysis of the answers regarding the perceptions on STO was conducted. 

Results: 42 students completed the questionnaire. Six macro-thematic areas were identified amongst the answers. Majority of responses (32) were focused on anatomical structures. Notably, 11.8% of students associated bones with STO. 24 responses focused on concepts associated with STO such as surgery and pain. Twenty answers focused on conditions, associating fractures with STO. Eighteen answers focused on the perception of STO, with many students (7) describing it as “overlooked”. Seven answers focused on various procedures, such as joint replacement and wound debridement. Five answers regarded career perception. 

Conclusions: There is wide variability in the perception of what STO comprises among students. A significant proportion feels that STO is an overlooked subject in their curriculum. We recommend a review of the undergraduate orthopaedics curriculum to stress the importance and frequency of soft tissue injuries. 

230 - Establishing the Normal Range of Movement for Dart Thrower’s Motion at the Wrist in an Adult Cohort

Magdalena Markiewicz1, Michael Carvill2, Lydia Robb3, Claudia CH Chan1, Philippa Rust4,5

1Edinburgh Medical School, The University of Edinburgh, Edinburgh, United Kingdom; 2Department of Plastic and Reconstructive Surgery, St John’s Hospital, Livingston, United Kingdom; 3Department of Plastic and Reconstructive Surgery, Ninewells Hospital, Dundee, United Kingdom; 4Hooper Hand Unit, St John’s Hospital, Livingston, United Kingdom; 5Department of Anatomy, The University of Edinburgh, Edinburgh, United Kingdom

Background: Dart-thrower’s motion (DTM) is the functional wrist movement from radial extension (RE) to ulnar flexion (UF). As DTM is used in most activities of daily living (ADLs), it is important to measure, compare to the expected range, and preserve DTM when treating wrist pathologies and injuries. However, a normal reference range for DTM has not been established. The primary aim of this study was to define the normal range of DTM in a healthy adult population aged between 18 and 45 years. The secondary aim was to investigate the relationship between the range of DTM and hand dominance, sex, and age.

Methods: The range of DTM in both wrists of 326 healthy subjects aged between 18 and 45 years was measured using manual goniometry. Intraclass correlation coefficients (ICC) for intra-rater and inter-rater reliability were calculated. Hand dominance, age, and sex were recorded. 

Results: Mean age was 25.1 years. 220 subjects (67.5%) were female and 289 (88.7%) were right-hand dominant. Mean ICC values indicated excellent intra-rater and inter-rater reliability. Median values for the normal range of DTM were 72.4° for RE, 51.5° for UF, and 122.7° for DTM arc. No significant difference was found in the range of DTM between the dominant and non-dominant wrist. On multiple regression analysis, increasing age was associated with significantly lower range of DTM and female sex was associated with significantly greater range of DTM. 

Conclusions: Manual goniometry is reliable for the measurement of the range of DTM. The normal range of DTM in healthy adults was defined. As no significant difference was found in the range of DTM between the dominant and non-dominant wrist, the healthy contralateral wrist could be used as a reference in unilateral wrist injuries.


283 - Investigating Primary and Long-Term Fixation of the Oxford Unicompartmental Knee Replacement Tibial Component: Ten-year results of a Randomised Controlled Trial Comparing Cemented and Cementless Fixation Using Radiostereometric Analysis

Lachlan Arthur1, Stefano Campi1, Benjamin Kendrick1,2, William Jackson2, Christopher Dodd2, Andrew Price1,2, Stephen Mellon1, David Murray1,2

1University of Oxford Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, Oxford, United Kingdom; 2Nuffield Orthopaedic Centre, NHS Foundation Trust, Oxford, United Kingdom

Introduction: Cementless fixation of Oxford Unicompartmental Knee Replacements (UKRs) is an alternative to cemented fixation, however, it is unknown whether cementless fixation is as good in the long-term.  This study aimed to compare primary and long-term fixation of cemented and cementless Oxford UKRs using radiostereometric analysis (RSA).

Methods: Twenty-nine patients were randomised to receive cemented or cementless Oxford UKRs and followed for ten years. Differences in primary fixation and long-term fixation of the tibial components (inferred from 0/3/6-month and 6-month/1-year/2-year/5-year/10-year migration, respectively) were analysed using RSA and radiolucencies were assessed on radiographs. Migration rates were determined by linear regression and clinical outcomes measured using the Oxford Knee Score (OKS).

Results: Preliminary analysis of Maximum Total Point Motion (MTPM) indicated cementless tibial components undergo significantly more migration than cemented components during the first 6 months (1.6mm/year, SD=0.92 versus 1.3mm/year, SD=1.1, p<0.001). Cementless migration was predominantly subsidence inferiorly (Mean=0.51mm/year, SD=0.29, p<0.001) and posteriorly (0.13mm/year, SD=0.21, p=0.03). Contrastingly, from 6 months to 10 years cemented components migrated significantly (MTPM=0.039mm/year, SD=0.11, p=0.04) whereas cementless components did not (MTPM=0.002mm/year, SD=0.02, p=0.744). Radiolucent lines occurred more frequently below cemented (10/13) than cementless (4/16) tibial components, but radiolucencies did not correlate with differences in migration or OKS. There was no significant difference in OKS between cemented and cementless.

Conclusion: These results suggest that cementless tibial components migrate more than cemented before achieving primary fixation. However, long-term fixation of cementless tibial components appears to be as good, if not better, than cemented with the benefit of fewer radiolucent lines.

Disclosure: One or more of the authors have received or will receive benefits for personal or professional use from a commercial party related directly or indirectly to the subject of this article.

298 - Low intensity pulsed ultrasound (LIPUS) in delayed union and non-unions after elective foot and ankle procedures

A V Koithara1, M Philpott2, N Dalal2, S Sirikonda2

1University College London, London, United Kingdom; 2Royal Liverpool University Hospital, Liverpool, United Kingdom

Background: Delayed union and non-unions after elective foot surgery are uncommon complications. However, they are associated with significant morbidity and often need multiple further interventions. Low Intensity Pulsed Ultrasound [LIPUS] technology has been advocated as an effective non-invasive treatment for delayed union and non-unions. The aim of this study was to evaluate the effectiveness of LIPUS technology [Exogen® Bioventus LLC] in promoting bony union in these patients. 

Methods: 61 patients, who had LIPUS therapy for delayed union or non-union, after their elective foot and ankle procedures, between September 2011 to November 2020, were identified from the Liverpool University Hospitals database. A successful outcome was defined as objective evidence of bony union. MOXFU scores were used to assess qualitative improvement. 

Results: Of 61 patients, 5 had an isolated forefoot operation, 24 were mid-foot and 14 hindfoot. 18 were more complex with a combination of forefoot, midfoot and/or hindfoot procedures. Of the 61, 32 patients were diagnosed as non-unions and 29 were delayed unions. LIPUS was administered using commercially available equipment [Exogen®]. The median duration of usage was 4 months with a range from 0.75 to 12 months. 15 cases [24.59%] achieved radiological union, 43 cases remain ununited and needed further interventions. Three cases had clinical union but there was no convincing evidence of radiological union. However, these patients did not require any further intervention. 

Conclusion: LIPUS [Exogen®] therapy is not an effective treatment method to achieve union for delayed unions and non-unions following elective foot surgery. 

346 - Epidemiology of Ankle Fractures in an East of Scotland Major Trauma Centre

Ahmed Elsayed, Aalap Asurlekar, Matthew Amer

University of Dundee School of Medicine, Dundee, United Kingdom

Background: Epidemiological studies help inform the allocation of healthcare provisions in a population. Ankle fracture rates are changing worldwide so it is important for communities to assess their local burden. Therefore, our aim is to assess the incidence and epidemiology of ankle fractures presenting to Ninewells Hospital Major Trauma Centre (Scotland) over a 5-year period.

Methods: We gathered data on 1,126 ankle fractures found using the local trauma database between 2016 and 2020. Any patients that received conservative treatment or who were listed as returning with complications were excluded. For the remaining cases, we populated a spreadsheet with the patient's age, sex, laterality and mechanism of injury.

Results: During the study period the annual incidence rate of ankle fractures increased by 55%. Of the 1,126 ankle fractures analysed, 463 were in males and 663 in females. Ankle fractures were consistently more common in females. The mean age of individuals with ankle fractures was between 50 and 54 years. On average July, January and December months had the highest incidence. Simple mechanical falls were the most common mechanism of injury, this was followed by sporting injuries and accidental injuries.

Conclusions: This study shows that the local incidence of ankle fractures is increasing. The data provides valuable trends in the number and demographic of individuals presenting with ankle fractures in NHS Tayside. We hope these results can be used to inform local decisions made on the allocation of resources and help organise strategies to cope with the increasing local burden.

421 - Gamification in Medical Education: Just fun and games?

Catriona Luney1, Diluxshy Elangaratnam2

1Royal Berkshire NHS Foundation Trust, Reading, United Kingdom; 2Buckinghamshire Healthcare Trust, Stoke Mandeville, United Kingdom

Aims: Gamification uses the competitive and engaging elements of a game in medical education. There has been increasing traction about this method of teaching while some educationalists remain sceptical. In this study we sought to enhance learning and engagement in musculoskeletal radiology teaching through gamification.

Methods: Students received a tutorial on description and interpretation of MSK radiographs after which they played ‘Radiograph Pictionary’. Students drew images based on technical descriptions given by their team who were shown radiographs. Marks were awarded for accurate drawings. Feedback was obtained through a questionnaire focussing on students’ perception of gamification and information retention.

Results: 22 students took part in the study. 2 main themes were identified: enjoyability (73%) and knowledge retention (55%). Students commonly described gamification as ‘fun’ and ‘interactive’ with one student commenting ‘it is a relief to have laughter whilst learning’ and another: ‘competitive nature kept [them] on their feet’. 35% of students acknowledged it improved team working and communication skills. 91% felt that gamification had a role in medical education.

Conclusions: Gamification has been proposed to make learning more enjoyable, improve interaction and information retention while supporting development of Community of Practice. 

‘Radiograph Pictionary’ introduces active learning into the traditional lecture and promotes engagement and learning among the students. The competitive element of being ‘on-top’ in gamification can lead to enhanced motivation to learn. Students perceive gamification enhances their engagement in learning processes and supports their information retention and revision of knowledge.

529 - Hand held scanners, are they as accurate as CT scans for determining trochlear groove geometry in knees

Jayanth Ramesh1, Simon Harris2, Vivian Ejindu3, Caroline Hing3

1St George's University London, London, United Kingdom; 2Imperial College London, London, United Kingdom; 3St George's University Hospitals NHS Foundation Trust, London, United Kingdom

Background: Trochlear dysplasia is one of the primary risk factors for symptomatic patellar instability. Trochleoplasty is used to treat severe trochlear dysplasia as determined by trochlear measurements. 3D portable scanning technology offers a potential cheap and quick, real-time alternative to traditional CT and MRI scans. The goal of this research project is to compare the 3D handheld scanner in assessment of the trochlear depth, sulcus angle, trochlear inclination angle, and lateral trochlear inclination angle of the trochlear groove of lamb cadaveric knees to those metrics obtained from CT scans.

Methods: This study compared the Artec Space Spider 3D portable scanner to the Gold Standard CT scans using cadaveric lamb knees. Cadaveric lamb knees were scanned in a CT scanner using conventional protocols. The cadaveric knees were then dissected to expose the trochlear groove. A 3D digital model was created by scanning them to create an optical image. The trochlear parameters were calculated and compared using the optical model as a comparator to the CT scan.

Results: The Root Mean Square Error (RMS-E) was utilised to compare the datasets of CT and optical imaging. Trochlear Inclination Angle was 1.31° RMS-E after removing all outliers. The Lateral Trochlear Inclination Angle was also 1.66°. The RMS-E for the Sulcus Angle was 2.06°, while the RMS-E for the Trochlear depth was just 0.33mm.

Conclusion: The trochlear depth and sulcus angle were exceptionally accurate, with RMS-E of 0.33mm and 2.06° meeting the clinically significant accuracy standard. This research indicated that the Artec Space Spider is a viable intraoperative imaging option. Its portability, speed, and image accuracy, support its applicability. Additional research into 3D optical scanning of human cadaveric knees is required to establish the true clinical applicability of this emerging technology.



549 - Exploring the association between DXA-derived hip geometric measures and hip osteoarthritis: findings from 40,000 individuals

Sophie V. Heppenstall1, Raja Ebsim2, Fiona R. Saunders3, Claudia Lindner2, Jennifer S. Gregory3, Nicholas C. Harvey4, Timothy Cootes2, Jonathan H. Tobias1, Monika Frysz1, Benjamin G. Faber1

1University of Bristol, Bristol, United Kingdom; 2University of Manchester, Manchester, United Kingdom; 3University of Aberdeen, Aberdeen, United Kingdom; 4University of Southampton, Southampton, United Kingdom

Background: Abnormalities in hip shape have been shown to increase risk of hip osteoarthritis (HOA). These can be quantified using geometric parameters (GPs), although the independent effects of these are unclear. The aim of this study was to investigate the associations between GPs and radiographic HOA (rHOA), hip pain, hospital diagnosed OA (HESOA) and total hip replacement (THR) in UK Biobank (UKB).

Methods: Narrowest neck width (NNW), diameter of the femoral head (DFH), hip axis length (HAL) and neck shaft angle (NSA) were obtained from left hip dual-energy x-ray absorptiometry (DXA) scans in UKB using automatically placed points around the hip and custom python scripts. Correlations were calculated between GPs, age, height, and weight. Logistic regression was used to examine the relationship between GPs with rHOA, hip pain, hospital diagnosed (HESOA), and Cox proportional hazard models with THR. Analyses were adjusted for sex, age, height, weight, and GPs. 

Results: Complete data was available for 40,313 participants (47.9%/52.1%, male/female). Strong correlations (r2≥0.75) were observed between NNW, DFH, HAL and height. NNW, HAL and NSA demonstrated associations with rHOA that were strengthened on adjustment for covariates [NSA OR 0.78 (95% CI 0.75-0.81), NNW 2.38 (2.18-2.59) and HAL 1.25 (1.15-1.36)]. In unadjusted analyses an association was seen with DFH [1.58 (1.52-1.64)], however on adjustment the direction of effect was reversed [0.55 (0.50-0.61)]. Only NNW showed an association with hip pain [1.19 (1.10-1.30)], HESOA [2.19 (1.80-2.67)] and THR [HR 2.51 (1.89-3.32)]. 

Conclusions: GPs are strongly correlated with height and each other. We observed the strongest relationships between NNW and HOA outcomes. When considered collectively GPs are closely related, however they show independent associations with HOA.

Implications: Further research is justified to determine whether these relationships are causal which may allow us to target hip shape to prevent or delay HOA onset.

693 - Arthroscopic Meniscectomy vs Meniscal Repair: Comparison of Clinical Outcomes

James Bottomley, Oday Al-Dadah

Newcastle University, Newcastle upon Tyne, United Kingdom

Background: Meniscal tears are the most common injury of the knee. Surgical treatment has fallen into contention recently and includes arthroscopic meniscectomy and meniscal repair. The primary aim of this study was to quantitatively evaluate patients with isolated meniscal tears and compare their outcome with patients who have undergone arthroscopic meniscus surgery. The secondary aim of this study was to compare the clinical outcomes of patients who have undergone arthroscopic meniscectomy with patients who have undergone arthroscopic meniscal repair. 

Methods: This comparative clinical study screened 334 patients to identify subjects who underwent arthroscopic knee surgery for isolated meniscal tears and compare them to patients with symptomatic isolated meniscal tears awaiting surgery using validated patient reported outcome measures. These included the Knee Injury and Osteoarthritis Outcome Score, International Knee Documentation Committee Subjective Knee Form, Lysholm score, Tegner score, EuroQol-5 Dimension and the 12-Item Short Form Health Survey.

Results: A total of 117 patients (Meniscal Tear group (n=36), Meniscectomy group (n=64), Meniscal Repair group (n=17)) were included in the final data analysis. Both the Meniscectomy group and the Meniscal Repair group (mean 55-months follow-up) showed significantly better clinical outcomes than patients in the Meniscal Tear group (p<0.05). Overall, the Meniscal Repair group demonstrated superior clinical outcomes when compared to the Meniscectomy group (p<0.05). 

Conclusion: Arthroscopic knee surgery showed significant clinical benefit at medium-term follow-up in treating patients with isolated meniscal tears. When feasible, meniscal repair should be performed preferentially over meniscectomy.  

702 - The clinical implications of Graf type IIA hip dysplasia

Gregor Ramage1, Arwell Poacher2, Joseph Froud1, Claire Carpenter3

1Cardiff Medical School, Cardiff, United Kingdom; 2University Hospital of Wales, Cardiff, United Kingdom; 3Noah's Ark Childrens Hospital, Cardiff, United Kingdom

Introduction: There is little evidence surrounding the clinical implications of a diagnosis of IIa hip dysplasia with no consensus as to its efficacy as a predictor pathological dysplasia or treatment. Therefore, we evaluated the importance of categorising 2a hip dysplasia in to 2a- and 2a+ to better understand the clinical outcomes of each.

Methods: A 9-year retrospective cohort study of patients with a diagnosis of type IIa hip dysplasia between 2011 – 2020 (n=341) in our centre. Ultrasound scans were graded using Graf’s classification, assessment of management and DDH progression was completed through prospective data collection by the authors.

Results: The prevalence of IIa hip dysplasia within our population was 6.7/1000 live births. There was significantly higher incidence of treatment in the IIa- (31.4%, n=17/54) group when compared to the 2a+ group (10%, n=28/287), (p<0.01).  In those that had an abnormality (torticollis and/or foot abnormality) treatment rates (24% n=7/29) were significantly (p<0.05) higher than those without anatomical abnormality (15%, n=48/312).

Conclusion: This study has demonstrated the significant clinical impact of a IIa- diagnosis on progression to pathological dysplasia and therefore higher rates of treatment in IIa- hips. Furthermore, we have demonstrated the importance of detection of IIa hips through a national screening program, to allow for timely intervention to prevent missing the acetabular maturation window.

Implications: Therefore, it is our recommendation that all patients with additional anatomical abnormalities and those with a diagnosis of type IIa- hip dysplasia be considered for immediate treatment or urgent follow up following their diagnosis to prevent late conservative intervention.

817 - Clinical outcomes in the management of humerus shaft fractures with functional bracing

Deep Ghaghda1, Vail Karuppiah2

1University of Nottingham, Nottingham, United Kingdom; 2Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom

Introduction: The management of humeral shaft fractures have been widely accepted to be non-operative. However complex fractures may have a higher chance of complication including non-union requiring surgical intervention from presentation. 

Aim: To identify humeral shaft fracture types associated with a higher risk of non-union 

Materials and methods: This is a retrospective study of all patients with traumatic humerus shaft fractures treated non-operatively with functional bracing in a Major trauma centre. Other causes of fractures including tumour and patients treated with surgery from the beginning were excluded from the study. Patient notes and radiographs were reviewed and assessed for demographics, fracture pattern, time to union, radial nerve palsy, any delayed operative intervention and outcome at the time of discharge. Fractures were classified according to AO classification into type A, B and C. Union was defined as absence of pain and movement at the fracture site and presence of bridging callus formation on two views of radiographs at 8 weeks.

Results: This study included 118 humerus diaphysis fracture patients of average age 55 years (range 12-89) (F-64;M-54). Overall Union rate was 85% (n=100) with 70% fractures uniting within 10 weeks. 18 fractures A=9 (11%), B=4 (20%), C=5 (24%) underwent open reduction internal fixation (ORIF) for failed conservative management including non-union.

There were two radial nerve palsies after bracing, both of which were transient. 10 cases of mal-union were observed. 20% patients were diagnosed with shoulder, elbow and/or wrist stiffness and needed physiotherapy for the same. There was one case of re-fracture due to a fall at five months post intervention. 

Conclusion: Non operative management of humeral shaft fractures has a good clinical outcome in simple fracture patterns. However, treatment of complex humerus shaft fractures with functional bracing is associated with higher non-union rate and these may well serve by ORIF.


Podium Presentation Abstracts

117 - Developing an artificial intelligence diagnostic tool for paediatric distal radius fractures, a proof of concept study

Sriharsha Aryasomayajula1, Caroline Hing2, Martin Siebachmeyer2, Fariborz Naeini1, Vivian Ejindu2, Patricia Leitch2, Yael Gelfer2, Yahya Zweiri1

1Kingston University, London, United Kingdom; 2St George's University Hospitals NHS Foundation Trust, London, United Kingdom

Introduction: In the UK 1 in 50 children will sustain a fractured bone yearly yet studies have shown that 34% of children sustaining an injury do not have a visible fracture on initial radiographs. Wrist fractures are particularly difficult to identify as the growth plate poses diagnostic challenges when interpreting radiographs. 

Materials and methods: We developed convolutional neural network (CNN) image recognition software to detect fractures in radiographs of children. A consecutive dataset of 5000 radiographs of the distal radius in children from 2014-2019 were used to train the CNN. Additionally transfer learning from a VGG16 CNN pre-trained on non-radiological images was applied to improve generalization of the network and classification of radiographs. Hypermeter tuning techniques were used to compare the model to the radiology reports that accompanied the original images to determine diagnostic test accuracy.

Results: The training set consisted of 2881 radiographs with a fracture and 1571 without a fracture, 548 radiographs were outliers. With additional augmentation the final dataset consisted of 15,498 images. The dataset was randomly split into three subsets, a training dataset (70%), a validation dataset (10%), and a test dataset (20%). After training for 20 epochs, the diagnostic test accuracy was 85%.

Discussion: A CNN model is feasible in diagnosing paediatric wrist fractures. We demonstrated that this application could be utilized as a tool for improving diagnostic accuracy. Future work would involve developing automated treatment pathways for diagnosis, reducing unnecessary hospital visits and allowing staff redeployment to other areas.

Keywords: Wrist Fracture, Artificial intelligence, Convolutional neural network, Image classification, X-rays, radiographs

125 - Neonatal Hip Assessment - Predictable Failure

Justine Burt, Nourah AlKandari, Donald Campbell, Jamie Maclean

Ninewells Hospital, Dundee, United Kingdom

The UK falls behind other European countries in the early detection of Developmental Dysplasia of the Hip (DDH) and there remains controversy surrounding screening strategies for early detection. Clinical detection of DDH is challenging and recognised to be dependent on the experience of the examiner. No studies exist assessing the number of personnel currently involved in such assessments. 

Our objective was to study the current screening procedure by studying a cohort of new-born babies in one teaching hospital and assess the number of health professionals involved in neonatal hip assessment and the number of examinations undertaken during one period by each individual. 

This was a retrospective observational study assessing all babies born consecutively over a 14-week period in 2020.  Record of each initial baby check was obtained from Maternity or Neonatal Badger (determined by the site of initial assessment). Follow-up data on ultrasound or orthopaedic outpatient referrals were obtained from clinical records.

1037 babies were examined by 65 individual examiners over the 14-week study period from 9 different healthcare professional groups. The range of examinations conducted per examiner was 1- 97 with a mean of 15.9 examinations per person. 49% individuals examined 5 or less babies across the 14 weeks, with 18% only performing 1 examination. 18 babies were found to have an abnormal hip examination, but only 7 were referred for an ultrasound scan. Of the 5 babies (0.48%) treated for DDH, 1 was picked up on neonatal assessment. 

In a system where so many examiners are involved in neonatal hip assessment the experience is limited for most examiners. It is little surprise that high current rates of late presentation of DDH are observed locally. These rates are in accordance with published national experience and compare poorly with historic series where limited number of specialist examiners were utilised.

201 - Development of a language free universal outcome tool for upper limb Assessment in Children (VisULiM Kids)

Sara Dorman1, Mehnoor Khaliq2, Elinor Flatt1, John Cashman1

1Sheffield Childrens Hospital, Sheffield, United Kingdom; 2Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom

Background: There are very few PROMS for assessment of the upper limb in children. Outcome measures available have typically been developed in English and validated for use in a developed health system.  

Barriers to research in low-income settings include lack of PROMS with appropriate translations, cultural adaptations and variable literacy skills. It is not uncommon for neuro-divergent children worldwide to communicate non-verbally, using sign, symbols or pictures. There are no outcome scores in existence for assessment of the upper limb that are suitable for non-verbal children.

Aim: This study aims to modify a validated outcome score (PROMIS® Upper Extremity fixed length short form) into a child friendly, universal tool available for use worldwide with no prerequisite for language, reading or writing skills.  

Method: Translation methodology was adapted from the standardised PROMIS guidelines and ISPOR Task force for translation and cultural adaptation. Two independent, native English speaking surgeons developed a pictorial representation of the PROMIS UE.  This was reconciled by a 3rd reviewer. The reconciled version was distributed to an experienced young person advisory group. The YPAG completed blinded back-translations and ratified the final version illustrated by an independent graphic designer 

Results: 24 children from 2 international tertiary paediatric centres where included. PROMS were given individually, in a random order to allow for blinding. Statistical testing and subgroup analysis (order of completion, country and pathology) demonstrated non-inferiority of VisULim. The majority of children preferred the VisULim. 

Conclusion: The VisULim is acceptable to children and demonstrates equivalence to the original PROMIS. In an era of child and family centred care we believe that development of an inclusive child friendly outcome measure, that caters for individuals who may communicate non verbally and that does not exclude children based on their literacy or primary language is essential for research across the modern world.

313 - Parental Acceptance Of Emergency Department Paediatric Forearm Manipulations In A UK District Hospital Emergency Department Based On The Swedish Pyramid Questionnaire

Jacob Koris, Sunny Deo

Great Western Hospital NHS Foundation Trust, Swindon, United Kingdom

Background: Paediatric forearm fractures are a common injury presenting to Emergency Departments (ED). Standard treatment for a proportion of displaced fracture is manipulation and casting.

Introduction: There is some debate as to whether these procedures should be undertaken in the ED under sedation or in an operating room under anaesthetic. Studies of efficacy of ED management have been undertaken but parental concerns about the acceptability of such have not been assessed.

Methods: A prospective case series review of all paediatric patients presenting with closed forearm fractures who underwent a manipulation under sedation in the Emergency department by the Orthopaedic Trauma on-call team was collected over 12 months. Parents were invited to complete an acceptability questionnaire, adapted from the Swedish Pyramid Questionnaire for Treatment.

Results: Of 77 patients meeting inclusion criteria and parents invited to complete a Swedish Pyramid Questionnaire of Treatment, 44 parents (55%) fully completed it. Patient demographics and fracture characteristics were compared between the responding and non-responding groups and no differences were noted. The mean level of satisfaction was 9.4/10 (range=7–10). There was 98% satisfaction from respondents with the level of analgesia and information provided, but only 86% with the timeliness of administration. For 80% of children, the ED manipulation represented definitive treatment.

Conclusion: There are high levels of parental satisfaction with the management of paediatric forearm fractures in the Emergency Department. It data provides insights about parental concerns relating to the injury and information provision which is useful to further improving care, a template for assessing quality improvement and should be considered in further studies of Orthopaedic care.

Implications: This study further validates the role of manipulation of suitable closed forearm fractures in ED and introduces the use of a parental treatment questionnaire for orthopaedic interventions, which could be used more widely.

568 - The Modified Dunn subcapital realignment osteotomy for the treatment of moderate and severe slipped capital femoral epiphysis; a tertiary referral centres experience

Daniel Winson, William Cundy, Megan Roser, Christopher Carty, Sheanna Maine, Geoffrey Donald

Queensland Children's Hospital, Brisbane, Australia

Background: The surgical treatment of moderate and severe slipped capital femoral epiphysis (SCFE) is controversial. Treatment ranges from pinning in situ (PIS) to open dislocation and reduction. The modified Dunn procedure has been used in the management of moderate and severe SCFE but is associated with variable Avascular Necrosis (AVN) and complication rates. The aim of this study was to evaluate the outcomes and complications of patients who have undergone a modified Dunn Subcapital Realignment Osteotomy (SCRO) in our centre.

Method: A retrospective longitudinal study of the SCROs performed between 2009 and 2019 in a tertiary referral centre for Paediatric Orthopaedics in Queensland, Australia. Patient demographics, stability and severity of slip and surgical outcomes were collected. 

Results: 123 SCROs were performed on 166 patients. The mean age was 12.4 years (range 7 to 17 years), 65 patients were male and the mean PSA was 60.10 (range 360 to 880) with 93 (75%) being severe slips. There were 51 (41.5%) Loader stable and 72 (58%) unstable SCFE. Our overall AVN rate following SCRO was 17.8%. Stable slip AVN rate was 7.8%. Of the unstable hips, 16.7% of the moderate slips went onto develop AVN and 26.7% of the severe slips developed AVN. Surgery within 24hrs of diagnosis did not have an effect on AVN rates with 25% of unstable hips operated on in <24hrs versus 22.9% in 24hrs to 7 days and 26.1 >7days. 

Conclusions: The modified Dunn subcapital realignment osteotomy remains a controversial and complex procedure for the management of moderate and severe SCFE. We found that our SCRO cohort demonstrated an AVN rate better than similarly sized cohorts in the literature. This indicates that when performed in a high-volume centre with experienced surgical staff it can be an effective treatment option for these patients.

687 - Child and parent satisfaction with telemedicine in paediatric orthopaedics - a survey of children and parents regarding the switch to virtual outpatient appointments during the COVID-19 pandemic

Luke Granger, Andreas Rehm, Elizabeth Ashby

Paediatric Orthopaedic Department, Addenbrookes Hospital, Cambridge, United Kingdom

Background: During the COVID-19 pandemic, our institution converted all face-to-face (F2F) outpatient appointments to telemedicine appointments (video and telephone) unless very clinically urgent. This study explores the views of children and parents regarding telemedicine appointments in the paediatric orthopaedic outpatient setting during the COVID pandemic.

Methods: Satisfaction surveys were sent to all children and parents who received an orthopaedic telemedicine appointment between 29/01/21 – 15/07/21 at a single centre. Both new and follow-up appointments were included. The survey rated the satisfaction of the appointment, how it compared to a F2F appointment and the perceived advantages and disadvantages of telemedicine.

Results: 90 parents and 50 children responded to the survey (45% response rate).  72% of children and 71% of parents were satisfied with their paediatric orthopaedic telemedicine consultation. However, 56% of children and 54% of parents preferred F2F appointments to telemedicine.  Only 18% of children and 22% of adults preferred telemedicine consultations to F2F, given the choice.  The commonest perceived advantages of telemedicine from children were avoidance of the anxiety associated with hospital and avoidance of a long wait in clinic. Parents liked the greater convenience, reduced travel time and avoidance of a long wait. The perceived disadvantages from children were not being involved in the consultation and feeling ignored. Adults disliked the lack of a formal examination and the impersonal nature of the consult.

Conclusion: Children and parents are satisfied with telemedicine consultations when necessary but prefer F2F appointments. With the option of either F2F or telemedicine, we believe new appointments should be F2F where possible as the parents strongly value a physical examination and children feel more included in the decision making. These views should be considered when planning future clinics, together with clinical efficacy and available resources.

725 - Role of MRI in Acute Paediatric Musculo Skeletal Infections - Lessons learnt from a Busy District General Hospital Orthopaedic Unit

Mohanraj Venkatesan1, Maneesh Sinha1, Balasubramanian Balakumar2, Aabha Sinha1

1Russells Hall Hospital, Dudley, United Kingdom.; 2Rusells Hall Hospital, Dudley, United Kingdom

Objective: We present our findings and learning points from a retrospective review of 45 paediatric patients referred consecutively to a DGH orthopaedic unit with suspected musculoskeletal infection.

Study Design and Methods: 45 children admitted over one year with a suspected diagnosis of musculoskeletal infection and underwent investigations and treatment were included in the review. We analysed the clinical, serological and imaging findings.

Results: All 45 children had general and local joint clinical examination, biochemical markers, blood cultures and orthogonal x-rays. Further imaging studies were MRI or ultrasound scans. 18 patients had positive MRI finding confirming a septic focus; in the remaining 27 patients MRI excluded infection as a cause of symptoms but 14 of these had received at least one dose of antibiotic before the scan. In the 18 patients who had a confirmed septic focus on MRI, 12 had MRI within 48 hours and 6 had it after 48hours. In the 27 patients where MRI scan excluded infection, 19 had the MRI within 48 hours and in 8 patients it was delayed more than 48 hours.  

Conclusion: The management of paediatric musculoskeletal infections is best done with a multidisciplinary approach. Uncomplicated osteomyelitis/musculoskeletal infection in children responds well to antibiotic therapy and less than 5% go on to develop chronic infection. A delay of greater than 4 days in the initiation of antibiotic therapy increases the risk of septic sequel such as deformity.  Prompt and appropriate imaging is therefore key to early diagnosis. Our experience shows that close discussion with radiology and an early MRI scan is the best way of achieving this. We did not find ultrasound helped in prompt diagnosis. Our findings are consistent with the recently published BOAST guidelines and our experience will help to formalize a local protocol for the management of paediatric musculoskeletal infections.

775 - Determining image usability and femoral head coverage using artificial intelligence: A future avenue in newborn hip screening

Abhinav Singh1, Stamper Andrew2, Daniel Perry3, Sandeep Hemmadi4, Irina Voiculescu2

1Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom; 2Department of Computer Science, University of Oxford, Oxford, United Kingdom; 3Alder Hey Children's Hospital NHS Foundation Trust, Liverpool, United Kingdom; 4Cardiff and Vale University Health Board, Cardiff, United Kingdom

Background: Developmental dysplasia of the hip (DDH) represents the largest cause of hip osteoarthritis in young adults. Late diagnosis leads to multiple operations and persistently poorer outcomes. The UK screening programme has not improved early DDH detection since 1986. Artificial Intelligence (AI) assisted diagnostics represents an evolving field with the potential to improve accuracy and objectivity of DDH screening. 

Methods: This pilot study utilised an anonymised dataset obtained by experienced radiologists during routine NHS practice. The dataset contained 190 2D hip ultrasound images (normal= 71, dysplastic= 66, dislocated= 53) from 100 multi-ethnic babies (aged 4-12 weeks). Two clinical experts provided the anatomical ground truth masks for ilium, femoral head, and labrum. They used literature-derived femoral head coverage (FHC%) ranges to classify screening diagnosis - normal (>50%) or abnormal (<50%). We designed a multiclass convolutional neural network (modified U-Net, 94:47:49 training:validation:testing data split) to produce anatomical masks for classifying clinically usable images, calculating FHC% and providing a screening diagnosis. 

Results: Within the test dataset (n=49), ilium and femoral head were identified in all images and labrum was identified in 93.6% (n=46). We measured the pixel overlap per structure between ground truth and AI-derived masks. Mean pixel overlap sensitivities were - ilium (84.6% range 61.1-99.5%), femoral head (93.3% range 80.4-100%) and labrum (53.6% range 0-97%). Automated FHC% diagnosis agreed with clinical experts in 89.8% (n=44) of the images with a sensitivity of 89.2% and specificity of 91.7%.

Conclusions: Our AI successfully identifies key features and generates masks to decide whether an ultrasound image is clinically usable. The algorithm-generated diagnosis agrees with expert clinicians on 89.8% of images, exceeding the existing state of the art AI performance. 

Implications: When translated into the clinical setting, this method will reduce reporting workload, and improve accuracy and objectivity of DDH screening.

794 - How good is your GIRFT? A cautionary tale for data collectors

Munzir Gaboura, Bhushan Sagade, Kakra Wartemberg, Kirsten Elliott, Edward Lindisfarne, Farokh Wadia, Matt Barry, Alexander Aarvold

Southampton Children's Hospital, Southampton, United Kingdom

Background: Get It Right First Time (GIRFT) is a national programme designed to improve medical care within the NHS by reducing unwarranted variations. This has been extended to Children’s Orthopaedics. GIRFT review highlighted Southampton Children’s Hospital as an outlier in three areas: length of stay (LoS) for patients with tibial fractures, the number of toe-straightening procedures and the number of meniscectomies. The departmental data was internally audited to check the GIRFT data. 

Methods: All cases of these three outlier conditions were identified, from 2016 to 2019, by the trust coding team, to enable a full internal review of radiographs and patient notes. The data provided to GIRFT by the hospital trust was directly compared to the departmental audit of tibial fracture LoS and numbers of toe-straightening and meniscectomy operations. 

Results: According to the data provided directly by the coding team internally, 52 tibial fractures were admitted over the three-year period. The number provided by the trust to the GIRFT review was 149. Similarly, there were 104 toe-straightening procedures performed, as opposed to 679 in the data given to GIRFT. 33 meniscectomies were performed according to hospital coding, compared to 54 in the GIRFT data.  LoS for tibia fractures was 3.85 days, as determined by review of patients’ notes. According to GIRFT data it was 2.5 days. 

Conclusion: Far from being outliers, we are below the national average for numbers of tibia fractures, at level with other centres for toe-straightening surgeries and above the national average for meniscectomies. However, the numbers are well below those provided for the GIRFT review, and the discrepancy between the two sets of data is shocking. 

Significance: Further investigation is required into how data is provided for GIRFT and we would recommend local re-audit to elucidate discrepancies and caution for interpretation of GIRFT data. 

Quality Improvement

Podium Presentation Abstracts

32 - Electric scooter related orthopaedic injuries

Suraj Sankar, Magdalena Antonik, Sami Hassan

Northampton General Hospital, Northampton, United Kingdom

Background: The e-scooter trial is part of a wider initiative from the Department for Transport in response to COVID pandemic. New emergency legislation was introduced in 2020 to make e-scooters legal in the UK for the first time. This scheme was launched in our county from September 2020. The aim of this case series is to identify the types of orthopaedic injuries resultant from electric scooter transport that presented to our District General Hospital over a 16-month period between September 2020 and December 2021.

Methods: This study involved retrospective collection of data from electronic hospital records. Data on demographics, laterality, date of injury, type of injury, treatment, HDU/ITU admissions, mortality, and operating time were collected to characterize the types of e-scooter-related fractures and to investigate the frequency of such injuries over the duration of our search.

Results: A total of 79 orthopaedic patients identified with electric scooter injuries between September 2020 and December 2021. 78.5% were males and the mean age was 30.1 years. Warmer months accounted for most of the injuries. 17 patients required inpatient care. 23 patients required surgical intervention and a total of 29 surgeries were performed in our hospital. This accounted for a total surgical time of 2088 minutes. One patient admitted with shaft of femur fracture developed pulmonary embolism after the definitive operation and died in HDU.

Conclusions: Electric scooters provide a space efficient, affordable, environmentally friendly mode of transportation which reduce the urban congestion and parking issues. This study demonstrates an increasing frequency of significant orthopaedic injury associated with e-scooter use treated at our centre over the course of 16 months. This small series underlines an important problem given that this increase has occurred after the start of the electric scooter trial. Legalization might result in further increase in the incidence of injury.

122 - VFC and Torus Fracture Management: A Closed 3 Loop Cycle Quality Improvement Project

Nikita Nathoo, Melissa Mahoney, Peter Domos

Royal Free Hospital Trust, London, United Kingdom

Background: A torus fracture is an incomplete fracture of the shaft of the long bone. Evidence supports it is a ‘safe discharge condition’ which can be managed by urgent treatment centre (UTC), using a splint and referral to virtual fracture clinic (VFC). Historically these cases would have repeat x-rays, plaster and clinical review, leading to significant use of clinical and financial resources.

Methods: A 3 loop quality improvement project was conducted at the Royal Free Hospital Trust over 3 years, involving 143 patients. Data was collected pertaining to referral from UTC, number of follow ups, number of x-rays and plasters. Change was instigated by education of appropriate management to emergency care staff. The audit was repeated leading to the introduction of a new electronic-VFC (e-VFC), with a final loop completed post instigation.

Results: In cycle 1 18% (12/66) of patients were appropriately managed with 25% having a VFC review, with a cost of in person review of £7000. Cycle 2 improved VFC review to 45% and in cycle 3 to 81%. In cycle 3, 81% were appropriately managed and 100% had a eVFC review, successfully avoiding the need for a fracture clinic review.

Conclusions: The introduction of the VFC management plan led to an annual saving of £21,400. The introduction of e-VFC after cycle 2 had the greatest impact in reduction of unnecessary referrals to fracture clinic, and improved care.

Implications: Use of VFC for Torus fractures led to a significant financial saving to the trust as well as saving patient and doctor time in needing to attend fracture clinic.

197 - Positive impact of walk in Trauma clinics on the NHS post Covid 19

Raghav Nand, Venkata Bodapati, Siddarth Kakuturu, Asif Pardiwala

Scunthorpe General Hospital, Scunthorpe, United Kingdom

Hospitals up and down the country were faced with extreme pressures during the time of Covid 19, most notably Emergency Departments. This led to delays in treatment for patients in Trauma and Orthopaedics. In order to support Emergency Departments and improve the quality of service provided this District General Hospital introduced a Speciality Doctor and Consultant led walk in trauma clinic running on weekdays from 9am-5pm.   

Patients were referred to these clinics from the Emergency Department and General Practioners. This article focusses on three measurable factors. Firstly the time spent in A&E, secondly the time taken for patients to receive basic radiographic imaging and finally the time taken to be followed up in an Orthopaedic fracture clinic. A random sample of 100 patients were selected over a 4 week period prior to introduction of this walk in clinic. This was compared with 100 patients after this service began. Patients who were admitted to the ward directly or referred to other specialties were removed from the overall total.

The average time spent in A&E before this service was 197 minutes which was reduced by 86% by to 27 minutes. The average time taken to receive basic imaging reduced by 18.5% from 81 minutes to 66 minutes. Finally prior to the introduction of these clinics the waiting time of the next fracture clinic varied from 3 to 17 days where as now the patient can be seen by a Consultant in a fracture clinic the next working day.

Walk in Trauma clinics have proven to be an invaluable service to this DGH & the NHS. As a result of this service patients are receiving a higher quality of care sooner and a case can be made for the introduction of these clinics throughout the country.

211 - Adherence to BOAST guidelines in the management of acute ankle fractures - a closed loop audit

Matthew Amer1, Lim Qi Xun2, Jennifer Dunn2

1University of Dundee, Dundee, United Kingdom; 2NHS Tayside, Dundee, United Kingdom

Background: Ankle fractures are common injuries; early appropriate management is needed to reduce swelling and expedite surgery. British Orthopaedic Association Standards for Trauma (BOAST) guidelines are the gold standard for management. 

Aim: This closed loop prospective audit aimed to assess the management of ankle fractures in emergency departments (ED) in a major trauma centre against BOAST guidelines.

Methods: Patients were identified prospectively on trauma worklists and electronic imaging database over two 3-month periods before and after intervention. All adult patients with acute ankle fractures were included. Open, pilon and soft tissue injuries, and children were excluded.  The outcome measures were numbers of ankles appropriately reduced in Emergency Department (ED), if check x-rays were done and appropriate documentation of neurovascular status. Our definition for successful reduction is a congruent joint and symmetric joint space on AP/mortise view.

Intervention: Presentation of findings in the hospital trauma meeting and results shared with the ED clinical lead.

Results: Successful reduction of ankle fractures improved from 79 -92% between cycles 1 and 2. Documentation of post-reduction neurovascular status improved slightly from 50-53%. All patients who had a reduction had appropriate check x-rays post-attempt. 

Conclusion: There has been improvement in successful ankle reduction in ED after intervention although this and documentation of neurovascular status still require improvement. 

Proposal: To create an 'Ankle fracture reduction' sticker for the ED notes with a picture of a symmetrical ankle joint space for reference and reminder to document neurovascular status and encourage a second attempt at reduction in ED if a first attempt is unsuccessful.

265 - A Novel Mid-Third Clavicle Fracture Management Pathway Identifying Patients Benefitting From Acute Fixation and Preventing Non-Union

Hasan Daoud, Daniel Morris, Lalassa Bommireddy, Marius Espag, Amol Tambe, David Clark

Royal Derby Hospital, Derby, United Kingdom

Purpose: Mid-third clavicle fracture management is controversial; with proponents of acute fixation and delayed fixation only for those developing non-union. Local outcome data guided implementation of a management pathway with subsequent evaluation.       

Methods: Retrospective analysis of mid-third clavicle fractures presenting 04/2017–04/2019 with subsequent prospective analysis of fractures presenting 10/2020-10/2021 (pathway introduced 10/2020).

Patient demographics were recorded and fracture shortening measured using Matsumura technique on presentation anteroposterior clavicle radiograph. 

Retrospective cohort divided into <15% and >15% shortening; with subdivision into operative and non-operative management. 

Union time and non-union occurrence was noted. QuickDASH and recovery questionnaires were posted to >15% shortening patients.

Pathway offered acute fixation in >15% shortening; with <15% shortening reviewed at 6 weeks to identify non-union risk as per Edinburgh protocol with delayed ORIF offered accordingly. QuickDASH and recovery questionnaires performed at 3 months.

Results: Retrospective cohort included 141; 69<15%, 72>15% shortening.  Acute ORIF in 15(22%) <15% and 34(47%) >15%. 2 asymptomatic non-union in <15% non-operative group. 5 non-union requiring ORIF in >15% non-operative group. No significant patient differences between groups. 

Union time significantly longer for >15% non-operative than <15% non-operative (18.4 vs 12.0 weeks; p<0.05). >15% ORIF union time was 13.4 weeks. 

QuickDASH significantly worse for >15% non-operative than >15% ORIF (17.6 vs 2.8; p<0.05; MCID 14, n=24). Weeks until undisturbed sleep significantly less for >15% ORIF (2.3 vs 10.1; p<0.05).

Prospective cohort included 37; 17<15% (of which 1 underwent delayed ORIF), 20>15% shortening (of which 15 underwent acute ORIF). No significant increase in overall proportion of ORIF (43% vs 38%). 

No non-union occurred. No significant differences in outcome scores between groups.  

Conclusion: Retrospective analysis identified >15% shortening associated with increased union time and inferior outcome with non-operative management. Our pathway identifies patients benefitting from acute fixation and prevents non-union in patients managed non-operatively.

311 - One stop MDT Foot and Ankle clinic: Our experience and results

Parag Garg, Andrea Sott, Paul Hamilton, Sohail Yousaf

Epsom & St Helier's University Hospitals NHS trust, London, United Kingdom

Introduction: Management of foot and ankle pathology often require patients to attend multiple visits to healthcare institutions for various assessments, investigations and interventions.  We envisioned a “One stop foot and ankle clinic” model to offer our patients all of this in the same visit, aiming to improve patient experience whilst reducing cost to the Trust.

Methods: We set up a monthly multidisciplinary outpatient clinic with three foot and ankle consultants, a BOA fellow, a Specialist registrar, a Physiotherapist, a nurse practitioner, a Radiologist for Ultrasound diagnostics and interventions, an Orthotist and an Orthopaedic Practitioner providing Electro-shock wave therapy along with image guided injections.

We measured the service improvement by counting the additional services offered to attending patients on the same day thus reducing repeated patient attendances. We measured patient satisfaction by a special feedback form assessing their experience of the clinic.  Cost savings were recorded through reduction of follow up visits, increased surgical conversion rates and decreasing DNA rates.

Result: We saw between 40 and 50 patients per event. The same day referral rate for investigations/ treatments averaged 58% (range 52%-66%). Both discharge rates and booking for surgery rates were increased as compared to the previous model by 12%. 

There was an overwhelming positive patient feedback .96% thought it was a better and efficient experience and 92% preferring this clinic model.

Cost analysis showed an overall saving of costs incurred with this model by decreasing overall DNAs and increasing discharge and surgery conversion rates.  

Conclusion: “One stop clinic model” has been an enormous service improvement with great increase in patient satisfaction and overall cost savings. It aligns with the national drive to reduce follow ups and making the service more patient centered. We would want to promote this as a model for the future of foot and ankle clinics.

411 - First Results Of 'Joint Drive' Model- High volume, low complexity joint arthroplasty in elective setting across North West London region. JOINT Collaborative (Joint Orthopaedic Initiative In North-West Thames London)

Shireen Ibish1, Dinesh Nathwani1, Rajarshi Bhattacharya1, Ian Holloway2, Andrew Sanke3, Naresh Somasheker4, Sara Maki4, Michael Wilson4, Sam Nahas3, Kapil Sugand4, Sachi Shah4, Muhammad Jamshed4, Elizabeth Mclean1, Athavan Thirukumar1, Indrani Mandal2, Zain Naqvi2, Prarthana Venkatesh3

1Imperial College Healthcare NHS Trust, London, United Kingdom; 2London North West University Hospital, London, United Kingdom; 3Chelsea & Westminster Healthcare Trust, London, United Kingdom; 4The Hillingdon Hospital NHS Trust, London, United Kingdom

Background: Rising pressures on elective services and surgical waiting lists lead to the Joint Drive (JD) Initiative. Established across four Trusts in North West London, with pooling of high volume, low complexity patients (ASA 1&2 requiring primary joint replacements- Hip, Knee, & Shoulder) operating lists on a 1 in 8 weeks cycle with a strict flow pathway.  Patient with ASA 1&2 are shown to have lower post-operative complications and account for a large proportion of the outpatient waiting list (up to 60%). 

Methods: The JOINT Collaborative worked on data collection looking at patient demographics, ASA, operation type length of stay, complications, and readmission within 30 days all recorded looking at retrospective and prospective data. 2 comparison weeks (CW) with additional data comparing to national benchmarks from Hospital Episode Statistics (HES).

Results: 237 patients across the 4 trusts in the 2 JDs, in comparison to 73 patients for the CW.  Equal demographics distribution of gender (male, female) & age (<65, 65+).

JD cases Vs CW respectively: THR 35% Vs 44 %, TKR 47% Vs 36%, UKR 13% Vs 3%, Hip resurfacing 2% Vs 0%, TSR 2% Vs 3%,PFJ 1% Vs 0%. 

Note was made of efficient theatre utilization with improved operating time, transfer to recovery from theatre and transfer to ward from recovery. 

82% of patients in JD were discharged by day 3 post-operative, compared to only 59% of ASA 1&2 in CW. 

Median stay compared to National Benchmark: JW Vs GIRFT respectively, THR 2 days Vs 2.7, TKR 2 days Vs 2.7, UKR 2 Vs 2 days.  

Conclusions: High volume, low complexity operating lists show more efficient theatre utilisation, increased arthroplasty turnover, improved patient flow on day of procedure, shorter length of stay, and improved 30 days hospital readmission rates. Appropriate and thorough pre-op planning and patient selection is crucial.

442 - Distal radius fracture manipulation quality improvement project utilising an orthopaedic-led outpatient pathway and Bier block regional anaesthesia

Hasan Daoud,Daniel Morris, Mina Abdalla, Tom Calderbank, Steve Milner, David Clark

Royal Derby Hospital, Derby, United Kingdom

Background: BOAST Guidelines recommend manipulation of distal radius fractures (DRF) should be undertaken using regional anaesthesia. We report a quality improvement project implementing an orthopaedic-led outpatient pathway for manipulation of DRF amenable to nonoperative management. 

Method: Retrospective analysis of DRF presenting to a teaching hospital 04/2021–07/2021 with subsequent prospective analysis of fractures presenting 08/2021-11/2021 (pathway introduced 08/2021).

Pathway included ‘Bier block’ regional anaesthesia and manipulation of suitable DRF in patients presenting Monday-Thursday; utilising pre-existing plaster room staff and equipment (plaster room unavailable Friday-Sunday). Suitable patients presenting to ED after 1700 were scheduled to attend for manipulation the following day if plaster room was available, otherwise ED-led manipulation performed. All pathway manipulations were performed by orthopaedic staff.

Data collected pre- and post-pathway included patient demographics, fracture configuration, manipulation cast plaster-index ratio, time spent in ED, manipulation analgesia and subsequent ORIF requirement. Patient satisfaction questionnaires were completed by the prospective cohort. 

Results: Retrospective cohort included 58 patients that underwent manipulation (34 ED, 24 T&O) with no regional anaesthesia used in ED-led manipulation and 5% orthopaedic manipulation.  Significantly fewer patients who underwent orthopaedic manipulation required ORIF (21% vs 50%, p<0.03). Mean plaster index significantly better (79% vs 53% <0.8) and time spent in ED significantly shorter (258 vs 361 minutes; p<0.04) in orthopaedic manipulation.

Following pathway introduction, 91 patients underwent manipulation (49 ED, 42 T&O as per pathway). A trend was identified towards decreased requirement for ORIF in patients receiving orthopaedic manipulation (26% vs 41%, p=0.14). All pathway patients would recommend ‘to family or friend’. No Bier block complications occurred.

Conclusion: An orthopaedic-led outpatient pathway for manipulation of DRF utilising Bier block yields excellent patient satisfaction and may decrease subsequent ORIF requirement.

Implication: All units managing DRF should consider implementation of an outpatient manipulation pathway utilising Bier block regional anaesthesia.

450 - Sustainability in Orthopaedic Theatres. Where Are We?

Mahmoud Awadallah, Mohamed Onsa, Paul Robinson

North West Anglia NHS Foundation Trust, Peterborough, United Kingdom

Background: Operating theatres are one of the main sources of waste in hospitals and they make a major contribution to their carbon footprint. We prospectively audited the waste produced from orthopaedic procedures and surveyed staff for their views and suggestions about this issue.

Methods: We conducted a prospective audit to evaluate wasted and un-used items in our orthopaedic theatres. Forms were completed by theatre staff in trauma and elective theatres during March 2022. All un-used equipment was recorded. Additionally, we obtained staff views on waste by conducting an anonymous online survey created using Microsoft forms.

Results: We collected 36 wastage forms from 88 procedures. Un-used items from the packs included table covers in 31% of the cases (n=27), blades 27% (n=24) and bowl liners 16% (n=14). Swabs were the most wasted items in 11% (n=10), drapes 10% (n=9) and syringes 7% (n=6). Gloves and gowns were commonly wasted on the gowning trolley (gloves 13 pairs, gowns 23). We received 32 survey responses. Over 40% (n=13) thought that surgical packs are highly wasteful. 19% (n=6) believed that waste is increased from multiple packaging around sterile items, such as individually packed screws. 16% (n=5) agreed that items are wasted when opened without request from the operating surgeons.

Conclusion: As a result of our findings we are reviewing the contents of surgical packs. We are introducing a more basic pack for “equipment light” procedures such as K-wiring. We have introduced an “ask before opening” policy, mandating theatre staff to confirm with the surgeon that an item is required before opening it. Finally, we are conducting staff education on waste separation and we are reviewing our recycling streams in theatres.

530 - Teamwork and Innovation for Achilles Tendon Rupture - A multidisciplinary Quality Improvement Project

Andrew Gaukroger, Lucy Bailey, Alexandra Boxall, Andrew Carne, Chintu Gadamsetty, Iwona Kolodziejczyk, Emily Moore, Charlotte Morley, Katy Western, Matthew Solan

Royal Surrey Hospital, Guildford, United Kingdom

Background: Rupture of the Achilles tendon is common and has a long recovery period. Contemporary literature supports non-operative treatment for most cases. Many Foot and Ankle Surgeons advise an ultrasound scan to check the gap between the torn ends. A large gap (with the ankle in equinus) is a relative indication for surgery. The patient journey involves many steps and varies between hospitals. It may take 2-3 weeks from Emergency Department visit before a final specialist treatment plan. We re-designed our protocol to reduce delays.

Methods: Thirty consecutive patients treated with our new pathway were prospectively followed and compared to 30 consecutive cases from 2019. New pathway includes:

1. Contoured splint bandaged to front of the injured limb (Thetis Medical Achilles Trauma splint). This is easily removed and replaced for ultrasound scanning (unlike plaster-casts), making plaster-room visits unnecessary.

2. Triage to Foot and Ankle specialist.

3. Ultrasound assessment, including both rupture gap and DVT check. Radiographers were dual-trained to facilitate this.

4. Early transfer to prosthetic walking boot, ankle in equinus.

5. Extended VTE prophylaxis (tablets).

Results: There were no significant differences in patient demographics, rates of surgical vs non-operative treatment or re-rupture. Time taken for both ultrasound scan and specialist review fell > 60%. All New Pathway patients reached their definitive treatment decision within one week (Mean 3.4 days).                      


Old Protocol      

New Pathway

Mean days A&E to Specialist and scan      



Maximum days A&E to Specialist and scan   



Mean days A&E to Specialist       



Maximum days A&E to Specialist and scan



Conclusion: Teamwork, training and innovation improved the patient journey after Achilles tendon rupture. All patients now reach a definitive plan within a week, rather than up to 3 weeks.

534 - Head injury admissions - who is taking the lead?

Samuel Haines1, Alex Witek1, Benjamin Lin1, Andrew Stevenson2

1Bristol Royal Infirmary, Bristol, United Kingdom; 2Musgrove Park Hospital, Taunton, United Kingdom

Approximately 200,000 people are admitted to hospitals across the UK each year due to a head injury, however there is no standardised care pathway for these patients in terms of which specialty should take admitting responsibility for them.

NICE Clinical CG176 for head injury states: “… admit the patient only under the care of a team led by a consultant who has been trained in the management of this condition during their higher specialist training.”

The medical, general surgical, ENT and and neurosurgical curricula include head injury care, however the curriculum for trauma and orthopaedics does not.

We therefore wanted to conduct a multi-centre audit, with this section of NICE CG176 as our standard, to clarify the current situation in England with regards to which specialty admits these patients. 

All acute trusts in England have been contacted to enquire about head injury patients who require admission for a period of observation.

We have thus far received 72 responses from acute trusts in England. Of those 72, 22 (31%) are admitted under the care of the trauma and orthopaedic service. The others are a mixture between general surgery (32%), neurosurgery (10%) and medicine (14%) and others.

This study shows that across England there is a wide split between a number of specialties as to who cares for these patients and these preliminary findings indicate that approximately 1/3 of head injury patients admitted to hospital are being admitted directly against NICE guidance. With raw figures extrapolated, this equates to approximately 60,000 admissions per year.

We put forward that those specialties that don’t include this patient group on their higher specialty training should not be taking care of these patients. By standardising care using this principle there will be knock on effects of improving patient care.

548 - Reducing discharge paperwork for knee arthroplasty patients: A sustainable Quality Improvement project

Perry Liu, Lauren Guest, Victoria Deegan, Irrum Afzal, David Sochart, Deiary Kader, Vipin Asopa

South West London Elective Orthopaedic Centre, Epsom, United Kingdom

Background: Knee arthroplasty patients are discharged with significant paperwork. Summarising this information onto a single A5 card can reduce the carbon footprint. Our aim was to calculate the carbon footprint saving that can be achieved over a one-year period by switching accordingly. 

Methods: A retrospective evaluation of all patients undergoing knee arthroplasty between March 2021 and March 2022 at an elective institution. To reduce the footprint, an A5 discharge card was developed containing information on: contact details, red-flag symptoms, procedure performed, wound review advice and QR codes to the full discharge summary and physiotherapy exercises. 

The total number of A4 sheets used for discharge summaries was calculated, along with the carbon footprint and cost saving that could be achieved from switching to a single A5 card.

Results: Over one-year, 1565 patients underwent primary knee arthroplasty (total=1298, unicompartmental=267). The average number of discharge summary sheets for each patient was four. This equated to a carbon footprint of around 17.16g CO2eq (carbon dioxide equivalent)/ patient (4.29g CO2eq/ 5g A4 sheet x4) or 26.9kg CO2eq yearly.

Anecdotal feedback from patients about the new discharge card was positive and would result in a carbon footprint saving of 9.12g CO2eq/patient (8.04g CO2eq/ 9.375g A5 sheet x1) or 14.3kg CO2eq yearly. Each kg of CO2 is estimated to be around £2.67, meaning a carbon cost saving of roughly £38/year. 

Conclusion/Findings: The use of single discharge cards instead of multiple A4 sheets can reduce CO2 emissions and cost significantly, without impacting the key take-home messages for patients. 

550 - "No longer Wet" – A quality improvement project standardising peri-operative urinary catheterisation in Neck of Femur Fracture Patients

Sharan Sambhwani, Ashan Kandiah, Faizal Rayan, Nomaan Sheikh

Kettering General Hospital, Kettering, United Kingdom

Background: There is significant variation regarding the urinary catheterisation of neck of femur fracture (NOFF) patients with impacts on perioperative timing and management in a frail cohort of patients.  We noted that 73% of our patients were catheterised peri-operatively; majority being intra-operative. We prospectively evaluated our practice and developed a protocol to standardise our care, with an aim to improve the overall pathway of our patients.  

Methods: Prospective data from NOFF patients over a 3 month period was recorded on cognitive impairment, catheterisation and location of procedure, general skin condition, removal instructions and UTI rates. This data was analysed and led to the development of our protocol.

Results:  From 107 patients, 73 were catheterised. Of those, 50% were found to have at risk or broken skin on admission and 89% percent were catheterised in theatres with a mean addition of 14 minutes, per case, to theatre time.
Timing to remove the catheter varied greatly with poor documentation and compliance with a removal instruction was delayed by a mean of 3 days in cognitively impaired patients. 2.8% of patients developed worsening skin condition post operatively.
Piloting our new protocol led to a reduction by 50% of at risk skin and 78% of patients catheterised out of theatres, thus saving theatre time. Early removal and compliance with instructions increased dramatically leading to early discharge with no change in infection rates and more clarity amongst ward staff.

Conclusion: Our protocol resulted in a successful optimisation of catherisation in a frail cohort of patients with no adverse impact on infection rates. Moreover, patient safety and patient comfort improved with skin quality and pre-operative toileting and many non-cognitively impaired patients electing to be catherised.  With better theatre efficiency and safer practice, this protocol has been locally adopted as standard care.

763 - Interruption of long-term warfarin is not necessary in patients undergoing total hip arthroplasty

Mohamed Mussa, Pratheek Chikkalur, James Isbister, Shreeram Deshpande, Eric Isbister

Royal Wolverhampton NHS Trust, Wolverhampton, United Kingdom

Introduction: The management of anticoagulation in patients undergoing arthroplasty remains a challenge. Guidelines for perioperative management of long-term warfarin recommend discontinuation of warfarin preoperatively in low risk patients. We hypothesised that patients who had their warfarin continued during the perioperative period would have shorter hospital stay and no significant increase risk of surgical complications compared to patients who had their warfarin interrupted.

Methods: This was a retrospective review of 20 consecutive patients receiving long-term warfarin who underwent total hip replacement without stopping warfarin. As a control group, we collected same data from 20 age and gender matched patients also on long term warfarin but their warfarin was stopped prior to surgery and restarted postoperatively.

Results: There was no significant difference in age, BMI or comorbidities between the 2 groups. There was a statistically significant difference between the two groups in postoperative INR (P < 0.0001) levels. The mean drop in Hb postoperatively was 25.95 g/L in the warfarin group and 35.7 g/L in the control group, which was statistically significant (P=0.0066). Hospital stay was statistically significant with shorted stay observed in the warfarin group (P=0.0447). The odds ratio for developing a postoperative complication was 1.5882 which was not statistically significant (P=0.6346).

Conclusion: Our results support the hypothesis that it is safe to continue warfarin in patients on long term anticoagulation undergoing total hip replacement. Continuation of warfarin was associated with significantly shorter hospital stay and less INR fluctuations. There was no significant increase in the risk of complications or blood transfusion.

798 - Retrospective Review Of Arthroplasty Radiographs: How to Define An Adequate Radiograph

Ahmad Faraz1, Mohammad Al-ashqar2, Shoaib Khan3

1Royal Victoria Hospital, Belfast, United Kingdom; 2Leeds General infirmary, Leeds, United Kingdom; 3Alder Hey Hospital, Liverpool, United Kingdom

Background: Adequacy of post-operative hip and knee radiographs have direct impact on its interpretation. There have been no previously defined criteria or guidelines to describe an adequate radiograph after hip and knee arthroplasty.

Aim and objective: We undertook a quality improvement project by creating local standards to meet arthroplasty team expectation for a satisfactory radiograph. 

Methodology: Stage I: We conducted a single centre, retrospective audit to check adequacy of a postoperative radiography following a total hip or knee replacement .100 radiographs were assessed against the 9 criteria laid out with consensus of orthopaedics and radiologists. 

Stage 2: Quality improvement proforma was used in radiology department highlighting the below mentioned criteria. We re-assessed 100 radiographs during second cycle against these below mentioned criteria.

Criteria for adequate radiograph:

- Is whole prosthesis and cement visible on both views?* 

- Is all of relevant anatomy visible?* 

- Is exposure satisfactory?* 

- Are 2 views present? (AP/Lateral)* 

- Is there obvious rotation on lateral? 

- Is there obvious rotation on AP? 

- For AP Pelvis: is Pubic Symphysis in the centre? 

- For AP Pelvis: are GT/LTs at equal level? 

- Are there duplicates?  (ie >2 X-rays same view) 


Stage I: Of 100 radiographs, 51 from knee and 49 of hip arthroplasty group. 69 radiographs were adequate considering overall criteria, and 31 radiographs were inadequate. The inadequacy in radiographs was related to the visibility of prosthesis, cement or relevant anatomy. 

Stage II. We created a quality improvement proforma for use in radiology department, highlighting the 9 initial criterias.100 radiographs of hip (56) and knee (44) arthroplasty were re-assessed. Overall, 84 radiographs fulfilled the criteria of being adequate. 

Conclusion: Adequacy of knee and hip arthroplasty radiographs is essential in picking up pathologies that can be missed otherwise. We present a simple criteria which improves adequacy of x-ray and prevents repetition of radiographs.

808 - The Upper Hand of Sustainability. Reducing carbon footprint in surgery

Preetham Kodumuri1, Edwin Jesudason2, Vivien Lees3

1Wrexham Maelor Hospital, Wrexham, United Kingdom; 2Bangor Hospital, Bangor, United Kingdom; 3Manchester Foundation Trust, Manchester, United Kingdom

Background: There are concerns around the carbon footprint of surgery. The purpose of this study was to look at the most commonly performed operation in hand surgery, namely Carpal Tunnel Release (CTR).  The focus was to investigate the possibility and consequences of reducing carbon footprint in CTR.  


1. To define the carbon footprint of CTR performed under standard patient pathway

2. To reduce the carbon footprint by changing to a “lean and green theatre set up” utilising

  • Smaller trays with fewer surgical instruments 
  • Smaller drapes.
  • Minimising use of single-use items.

3. To assess the financial costs of traditional and ‘lean and green’ pathways.

Methods: The key elements of carbon useage were mapped out following extensive discussions with stakeholders involved. High levels of clinical waste were being generated with each CTR. Over six months, dedicated lists for CTR using the ‘lean and green’ theatre protocol were undertaken. A “green patient pathway” was introduced involving direct admission and discharge from theatre reception bypassing the ward admission. 

Results: In a series of Lean and Green CTR lists involving 43 patients over a 6 month period, 

  1. Measured clinical waste reduced from 3.5 Kg to 1.23 Kg per CTR. 
  2. Carbon footprint modelling reduced CO2 emissions by 24.8 Kg per CTR. 
  3. “Lean and Green" set up offers a potential saving of £34.72 per CTR. 

The Green pathway and lean and green theatre setup could potentially reduce carbon footprint by 1,378,000 Kg of CO2 annually in UK. Changing to smaller drapes and essential instruments alone can save £1.84 million annually.

Conclusion: This project has demonstrated that a Lean and Green theatre setup and an environmentally friendly patient pathway can deliver a safe, efficient, cost-effective and sustainable service for CTR. It would be possible to consider a similar exercise for a variety of other hand surgery procedures.

840 - Metal on metal hip replacement virtual follow up clinic

Amin Abukar, Jamie Barnett, Jamie McConnell

Royal Free Hospital Trust, London, United Kingdom

Background: Currently there is no dedicated metal on metal hip replacement follow up clinic in DGH. We aimed to identify if metal on metal hip replacement follow up care is in line with MHRA guidance and the cost implications. The secondary aim was to assess feasibility of setting up a metal on metal hip replacement virtual telephone clinic follow up.

Method: A retrospective mapping exercise (phase I) examined follow up care adherence to MHRA guidance including documenting Oxford Hip Score, availability of up to date blood ion levels, radiographs and reasons for supplementary follow up appointments including cost implications. Phase II was a prospective pilot study to trial the feasibility of setting up a virtual metal on metal telephone clinic.

Results: In phase I, 75 patients (35F:40M; mean age 70.4 [40-90] years old) were identified as having regular follow up in elective orthopaedics hip and knee clinic. Only 9.3% of patients had their Oxford Hip Scores documented, only 4% had further follow up in line with MHRA guidance. 72 of the 75 (96%) patients required a further follow up appointment to review results including metal ion levels or radiographs, the cost implication being £5795. In phase 2, 12 patients (6F:6M; mean age 70 [43-85] underwent pre-triaged virtual telephone clinic appointment. All patients had Oxford Hip Scores documented, all patients had necessary available metal ion levels or radiographs, all patients had follow up frequency in line with MHRA guidance. Patient satisfaction with metal on metal hip arthroplasty follow up care improved from an average of 5/10 to 9/10.

Conclusion: Phase I highlighted the deficiencies in follow up care of metal on metal hip replacement patients and the cost implication. Phase II identified the feasibility of setting up a metal on metal hip replacement virtual telephone clinic follow up.

Shoulder and Elbow

Podium Presentation Abstracts

158 - Mapping the Oxford Shoulder Score onto the EQ-5D utility index

Epaminondas Markos Valsamis1, David Beard1, Andrew Carr1, Gary Collins1, Stephen Brealey2, Amar Rangan2, Rita Santos2, Belen Corbacho2, Jonathan Rees1, Rafael Pinedo-Villanueva1

1Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Oxford, United Kingdom; 2University of York, York, United Kingdom

Background: In order to enable cost utility analysis of shoulder pain conditions and treatments, this study aimed to develop and evaluate mapping algorithms to estimate the EQ-5D health index from the Oxford Shoulder Score (OSS) when health outcomes are only assessed with the OSS.

Methods: 5437 paired OSS and EQ-5D questionnaire responses from four national multicentre randomised controlled trials investigating different shoulder pathologies and treatments were split into training and testing samples. Transfer to utility (TTU) regression (linear, polynomial, spline, categorical, two-part logistic-linear, tobit, and adjusted limited dependent variable mixture models) and response mapping (ordered logistic regression and seemingly unrelated regression) models were developed on the training sample. These were internally validated, and their performance evaluated on the testing sample. Model performance was evaluated over 100-fold repeated training-testing sample splits. 

Results: All predicted mean EQ-5D health index values deviated no more than 0.06 from the observed mean. The linear and cubic splines models had the lowest mean square error of 0.0374, followed by the categorical model. The ordered logistic regression model had the lowest mean absolute error of 0.137. Model performance was greatest in the mid-range and best health states, and lowest in poor health states. Model performance was not improved by including age and sex as covariates or by employing regularisation techniques. 

Conclusion: The developed models now allow accurate estimation of the EQ-5D health index when only the OSS responses are available as a measure of patient-reported health outcome.

Implications: Shoulder data collected by the National Joint Registry and other sources that only record the OSS can now be included in cost utility analysis.

436 - A comparison of open and arthroscopic surgery for elbow stiffness. A mid-term follow-up

Jamie Hind1, Neil Ashwood2, Muhammad Fazal3, Ilias Galanopoulos4, Sajjad Athar2

1Oxford University Hospitals, Oxford, United Kingdom; 2University Hospital Derby and Burton, Derby, United Kingdom; 3Royal Free, London, United Kingdom; 4General Military Hospital, Athens, Greece

Introduction: Open elbow arthrolysis remains a traditional approach for surgical treatment of elbow stiffness. Recently arthroscopic surgery is gaining popularity. The purpose of this study was to evaluate elbow function, complications and revision surgery following open and arthroscopic surgery for elbow stiffness.

Materials and Methods: One hundred and thirty five patients who underwent surgery for elbow stiffness from 2004 to 2019 were included in the study. Patient demographics, pre and postoperative range of elbow motion, complications, revision, Mayo score, visual analogue pain and patient satisfaction scores were collected blinded to surgeon.

Results: Seventy-five (55.55%) patients had open elbow surgery and 60 (44.44%) arthroscopic surgery (mean age of 51 and 50 respectively). There was significant improvement in range of motion, VAS, Mayo score and high patient satisfaction in both groups.  Patients undergoing arthroscopy had a lower pain score (p<0.05), higher patient satisfaction (p<0.05), higher gains in flexion extension and pronation supination arc (p<0.05) and higher Mayo score (p<0.05). The complications and reoperation were higher in open surgery. 

Conclusion: Both modalities yield satisfactory results in treatment of elbow stiffness. Arthroscopic surgery yields higher patient satisfaction, higher functional outcome, low complications and low revision surgery hence should be the preferred approach where possible.

486 - Outcomes following surgery for forearm stiffness – results from a single tertiary referral centre

Rumina Begum, Ben Hughes, Adam Watts

Wrightington, Wigan and Leigh Hospital, Wigan, United Kingdom

Background: The elbow range of motion (ROM) in sagittal and rotational planes is vital for normal upper limb function and the positioning of the hand in space. Despite this, optimal management of elbow and forearm stiffness remains controversial, and few published studies have focused on outcomes from surgery for forearm stiffness.

Method: We retrospectively reviewed medical records for all patients undergoing surgery for forearm stiffness at a tertiary centre in the UK, over a ten-year period (2011 to 2021). The primary pathology and classification of forearm stiffness were identified for each patient. Forearm ROM including pronosupination, and flexion-extension arc data were collected pre-operatively, and at 6 weeks, and at 3, 6, 12, and 24 months post-operatively.

Results: 54 patients were included, 35 male (64.8%) 19 female (35.2%) with an age range of 17-79 (average 47). Primary pathology of forearm stiffness included elbow fractures, simple elbow dislocation/ instability, biceps rupture, distal radius fracture, and primary osteoarthritis. Forearm stiffness was classified based on primary pathology into traumatic, heterotrophic ossification, malunion, and degenerative. Average change in pronation at 6 weeks, 3 months, 6 months, and one year post-operatively were 16, 18, 14, and 14 degrees respectively, and average change in supination was 26, 42, 34, and 27 degrees at the same time points. Over the same intervals, the average improvement in flexion-extension arc from pre-operative measurement was 26, 36, 38, and 29 degrees respectively. Few complications were recorded; four patients required repeat arthrolysis, one patient had a transient radial nerve palsy, one reported ulnar nerve symptoms, and one patient had residual symptoms of proximal impingement.

Conclusion: From our series with two-year follow-up, we have demonstrated that a significant improvement in forearm ROM can be achieved. The benefits are most evident up to 6 months post-operatively, with minimal further improvement demonstrated beyond this point.

498 - Clinical outcomes in patients undergoing Distal Humeral Hemiarthroplasty (DHH) for complex intra-articular distal humeral fractures

Gopikanthan Manoharan, Shah Sohan, Amanda Wood, Rishee Parmar, Inigo Guisasola-Gorrochateguia, Matthew Kent

Liverpool University NHS Trust, Liverpool, United Kingdom

Background: Distal humeral hemiarthroplasty (DHH) is a treatment option for complex intra-articular distal humerus fractures not amenable to open reduction internal fixation (ORIF). ORIF has a reported high complication rate and Total elbow arthroplasty (TEA) places significant limitations on patient functionality, in addition to its own complications. The literature on clinical outcomes from DHH is limited.

The aim of this study is to present the clinical outcomes in patients undergoing hemiarthroplasty for distal humeral fracture with early to mid-term follow up.

Methods: Prospectively collected data at a Major Trauma Centre was reviewed retrospectively. Minimum follow up was 2 years. The implant used was Tornier Lattitude elbow hemiarthroplasty. Outcome measures constituted Oxford Elbow Score (OES), Disabilities of the Arm Shoulder and Hand Score (DASH) and Range of motion (ROM).

Results: 22 patients were reviewed with 1 lost to follow up and 2 deaths. 19 elbow hemiarthroplasties in 19 patients (male:female of 1:18) were identified with mean follow up of 55 months (26 to 111), over a 7 year period from 2012 to 2019. The mean age was 67 years (49 to 77) with 88% ASA grade 2 and 12% ASA grade 3. The reported mean OES was 32 (9 to 47) and mean DASH score was 37.4 (2.3 to 79.6). The mean post-operative ROM was flexion 122.4 degrees (90 to 150), extension 14.7 degrees (0 to 45), pronation 88.4 degrees (80 to 90) and supination 85.6 degrees (40 to 90). The complication rate was 16% (n=3) and included permanent ulnar neuropathy, complete ankyloses and olecranon erosion requiring revision to total elbow replacement at 48 months. 

Conclusions: Our study supports DHH as a good option for complex un-reconstructable distal humerus fractures. The functional outcomes in our cohort were satisfactory with a lower complication rate than reported in the literature.


Podium Presentation Abstracts

214 - Ankle fracture internal fixation performed by cadaveric simulation-trained vs standard-trained orthopaedic residents: a multi-centre randomised controlled trial

Hannah James1,2, Damian Griffin1,2, James Griffin2, Joanne Fisher2, Giles Pattison1

1University Hospitals Coventry & Warwickshire, Coventry, United Kingdom; 2Warwick Clinical Trials Unit, Warwick, United Kingdom

Background: Ankle fracture fixation is commonly performed by junior orthopaedic residents. Simulation training using cadavers may shorten the learning curve and result in a technically superior surgical performance in the real-world operating theatre. 

Methods: Pragmatic, single-blinded, multicentre randomised control trial of cadaveric simulation versus standard training. The primary outcome was accuracy of fracture reduction on the first postoperative radiograph against pre-defined acceptability thresholds. Secondary outcomes were procedure time and intraoperative radiation dose administered to the patient. 

Results: 139 ankle fractures were fixed by 28 postgraduate year 3-5 trainees randomised (1:1), mean age 29.4 years 71% males, during 10 months of follow-up. Primary analysis was a random effect model with surgeon-level fixed effects of patient condition, patient age and surgeon experience, with a random intercept for surgeon. 

Under the intention-to-treat (train) principle, the surgical reduction achieved by the cadaveric-trained group was superior compared to that by the standard-trained group as measured by acceptable (<2mm) lateral malleolar displacement (OR 6.82, 95% CI 2.92-15.95, p=<0.001), acceptable medial malleolar displacement (<2mm)   (OR 5.90, 95%CI 1.00-34.67, p=0.049) and acceptable tibiofibular clear space (<5mm) (OR 12.56, 95%CI 5.25-30.05, p=<0.001). 

The cadaveric-trained group used less intra-operative radiation than the standard-trained group (mean difference 0.011 Gym2, 95% CI 0.003-0.019, p=0.009). There was no difference in procedure time.

Conclusions: Cadaveric-trained residents performed technically superior ankle fracture fixations and irradiated patients less during surgery compared to standard-trained residents. 

Implications: This trial shows that how we train our surgeons has a measurable impact on patients. Cadaveric simulation appears to shorten the surgical learning curve. The clinical meaning of this impact and the best application of simulation training for orthopaedic and trauma surgery requires further research. 

Disclosure: This work was supported by Versus Arthritis 


Podium Presentation Abstracts

209 - Utility of telephone consultations during COVID-19 and beyond: a study of orthopaedic spinal patients

Michael Woodmass, Kathryn Ramshaw, Palaniappan Lakshmanan

Sunderland Royal Hospital, Sunderland, United Kingdom

Background: Due to the COVID-19 pandemic, hospital clinic lists have abruptly shifted towards remote appointments via telephone. This study investigated the views and experiences of telephone consultations in a population of orthopaedic spinal patients.

Methods: A 10-item telephone questionnaire was completed by 202 orthopaedic spinal patients. Questions addressed patient perceptions towards: confidence in telephone consultations; their impact on treatment outcome; their advantages and limitations and how satisfied they were with their telephone consultation.

Results: 94% of patients were confident in their doctor providing effective care via telephone consultation. 81% of patients were confident that their treatment outcome would not have changed with a face-to-face appointment and 75% would consider choosing a telephone consultation in the post-pandemic era. Key benefits of telephone consultations for patients are the convenience of not travelling and avoiding travel-related expenses. The most commonly reported limitation is the lack of a clinical examination. Satisfaction scores were consistently high with no significant differences between different treatment groups.

Conclusions/Findings: This study demonstrates that telephone calls are a favourable method of consultation for patients requiring orthopaedic spinal care. Satisfaction levels are consistently high, patient confidence in their clinician is nearly unanimous and a majority of patients would consider choosing this method for future follow-up appointments. Issues with telephone consultations appear to chiefly concern the lack of physical examination, difficulties with the communication and retention of clinical information, and brevity of the appointment. However, consistent satisfaction scores suggest broad utility across a comprehensive range of treatment outcomes for orthopaedic spinal patients.

495 - Dual modality of vertebral body tethering - Anterior Scoliosis Correction versus Growth Modulation with mean follow-up of five years

Shahnawaz Haleem1, J Herzog2, Bisola Ajayi3, Darren Lui3, Tim Bishop3, Jason Bernard3

1Royal Orthopaedic Hospital, Birmingham, United Kingdom; 2Royal National Orthopaedic Hospital, London, United Kingdom; 3St. George's University Hospital, London, United Kingdom

Background: Vertebral body tethering (VBT) is a non-fusion technique to correct scoliosis allowing correction of scoliosis through growth modulation (GM) by tethering the convex side to allow concave unrestricted growth similar to the hemiepiphysiodesis concept. The other modality is anterior scoliosis correction (ASC) where the tether is able to perform most of the correction immediately where limited growth is expected.

Methods: A retrospective analysis of clinical and radiological data of 20 patients (range 9 - 17 years old - F:M = female:male) between January 2014 to December 2016 with a mean five-year follow-up.

Results: There were ten patients in each group with a total of 23 curves operated on. VBT-GM mean age was 12.5 years (9 to 14) with a mean Risser classification of 0.63 (0 to 2) and VBT-ASC was 14.9 years (13 to 17) and mean Risser classification of 3.66 (3 to 5). Mean preoperative VBT-GM Cobb was 47.4° (40° to 58°) with a Fulcrum unbend of 17.4 (1° to 41°), compared to VBT-ASC 56.5° (40° to 79°) with 30.6 (2° to 69°)unbend. Postoperative VBT-GM was 20.3° and VBT-ASC Cobb angle was 11.2°. The early postoperative correction rate was 54.3% versus 81% whereas Fulcrum Bending Correction Index (FBCI) was 93.1% vs 146.6%. The last Cobb angle on radiograph at mean five years’ follow-up was 19.4° (VBT-GM) and 16.5° (VBT-ASC). Patients with open triradiate cartilage (TRC) had three over-corrections. Overall, 5% of patients required fusion. 

Conclusion: We show a high success rate (95%) in helping children avoid fusion at five years post-surgery. VBT is a safe technique for correction of scoliosis in the skeletally immature patient. This is the first report at five years that shows two methods of VBT can be employed depending on the skeletal maturity of the patient: GM and ASC.

564 - Systematic Review and Meta-analysis: Does Anterior Release still have a role in Severe Thoracic Adolescent Idiopathic Scoliosis?

Laasya Dwarakanath, Mathew Sewell, Enid Leung, Timothy Knight, Morgan Jones, Matthew Newton-Ede, George McKay, David S Marks, Jonathan Spilsbury, Jwalant S Mehta, Adrian Gardner

Royal Orthopaedic Hospital, Birmingham, United Kingdom.

Study Design: Systematic review and Meta-analysis 

Introduction: Debate exists as to whether anterior-posterior spinal fusion (APSF), rather than posterior-only spinal fusion (PSF), provides benefit for treating severe thoracic adolescent idiopathic scoliosis (AIS). This systematic review and meta-analysis compares 1) Cobb angle correction, 2) complication and reoperation rate, 3) pulmonary function, 4) number of fused segments, and 5) patient-reported outcome measures (PROMs) in both groups. 

Methods: Electronic databases were searched to identify studies that met the following inclusion criteria: comparative studies (level 3 or above), severe thoracic curves (≥70o), age ≤16, AIS aetiology, Lenke 1-4 curves and follow-up ≥1 year for ≥95% of patient population. Literature was graded for quality using GRADE criteria. 

Results: Eight studies were included, defined by GRADE as low or moderate level evidence. There was a non-significant trend towards greater curve correction in the APSF group (95%CI -3.45-12.96, P=0.26). There was a non-significant trend towards more complications in the APSF group (95%CI 0.53-3.39, P=0.54; I2=0%, P=0.78). There were no reoperations in either group. Two studies reported pulmonary function; one better function in the APSF group, the other better function in the PSF group. There was a non-significant trend towards fewer fused segments in the APSF group (95%CI -1.65-0.31, P=0.18). Three studies reported PROMs with no differences between groups. 

Conclusion: Based on low and moderate quality evidence, there is a weak GRADE recommendation that APSF results in superior scoliosis curve correction with fewer fused vertebral levels. The present evidence cannot support recommendations for effect on complications, reoperations, pulmonary function or PROMs.

593 - Collapsing Corpectomy Cages, a Cause for Concern?

Oliver Flannery1, Susannah Liddiard2, Sophie Gatfield3, Ashok Subramanian3

1Musgrove Park Hospital, Taunton, United Kingdom; 2Musgrove park Hospital, Taunton, United Kingdom; 3Musgrove park hospital, Taunton, United Kingdom

Background: Expandable cages can be used to support the anterior column of the cervical spine following corpectomy. Fortify titanium expandable corpectomy cages (Globus Medical TM) were introduced to our unit (Musgrove Park Hospital, UK) in 2015. A cage failure with complete collapse of the expandable portion of the cage was noted post operatively on Xray and an MRI demonstrated buckling of the ligamentum flavum at this level with cord signal change. The patient required further surgery to remedy this. Literature shows that subsidence or dislocation of the implant may occur but mechanical failure like this has not been properly assessed. This project aimed to assess for further cases of cage failure.  

Methods: We searched the British Spinal Registry and local theatre system (Maxims) for cervical corpectomy procedures performed in our unit since 2015. Three clinicians independently compared intra operative imaging with serial post-operative radiographs. We assessed for change in height of the cage based on the number of exposed threads visible and took measurements to confirm any discrepancies. 

Results: 72 Fortify cages were implanted between 2015 and February 2022 into 71 patients (36 male and 35 female patients, mean age 62 years and mean follow up 14.2 months). Operations were performed by all 5 spinal surgeons in the unit. We noted 3 complete collapses of the expandable portion of the cages at an average time point of 3.75 months. We noted 5 further cases where partial collapse of the cage was evident. 

Conclusions and Implications: Our results show an overall failure rate of 11% with complete collapse of the expandable portion of the cage in 4%. This raises serious concerns regarding the ongoing use of the device in our unit. Further work is ongoing to investigate the morbidity associated with these cage failures  

627 - External Validation of the New England Spinal Metastatic Score (NESMS) - A Pilot Feasibility Study for 12-Month Survival in Patients with Metastatic Spinal Cord Compression

William Giles1, Anna Watts2, Shreya Srinivas2, James Tomlinson2

1University of Sheffield, Sheffield, United Kingdom; 2Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom

Background: The New England Spinal Metastasis Score (NESMS) is an intuitive and accessible tool for predicting survival in patients with spinal metastases. A 2021 multi-centre prospective study validated the NESMS within the affluent metropolitan USA population it was developed in, and showed it to be superior to alternative prognostic scores.

This pilot study aimed to externally validate the predictive ability of the NESMS score within a UK population, and determine the feasibility and justification of a further, more extensive external validation study in the UK. 

Methods: The NESMS score components, and mortality data at 3, 6 and 12 months were collected for 75 patients. All patients, referred between January 2019 and December 2020, were identified via the British Spinal Registry (n= 38) and the “Referback'' portal (n= 37).

Results: The distribution of NESMS scores seen in the original dataset was not observed in this population, as patients had higher scores on average.

Twelve-month mortality followed the general trend that a decreasing NESMS score had higher rates of mortality (p= 0.027): 48% for NESMS 3 vs. 100% for NESMS 0. A similar pattern was observed at 6 months (p= 0.008) but not 3 months (p= 0.162). Those who underwent surgical procedures had an improved NESMS score (p= 0.003) and a reduced 12-month mortality (p= 0.002).

Conclusion: External validation of the NESMS score in our population is feasible. This data shows significant trends of increasing mortality with decreasing NESMS score similar to the original population, but with a differing distribution of scores.

Further validation studies in collaboration with oncologists are now being planned to allow detailed validation in a large UK population. The NESMS has the potential to improve clinical decision making but further work is needed before widespread UK use.

762 - What is the Rate of Degenerative Disc Disease in Adolescent Idiopathic Scoliosis? Does it Impact SRS-22 Scores? A Review of 968 Cases

Conor Boylan1, Ravindra Thimmaiah2,3, George McKay2, Adrian Gardner2,3, Matthew Newton Ede2, Jwalant Mehta2, Jonathan Spilsbury2, David Marks2, Morgan Jones2

1The Rotherham NHS Foundation Trust, Rotherham, United Kingdom; 2The Royal Orthopaedic Hospital NHS Foundation Trust, Birmingham, United Kingdom; 3University of Birmingham, Birmingham, United Kingdom

Background: Many studies report the rate of degenerative disc disease (DDD) to be high in unfused caudal segments after corrective surgery for adolescent idiopathic scoliosis (AIS), but none provide a reliable baseline of its prevalence in non-operative patients. Additionally, few studies satisfactorily correlate DDD with patient-reported outcome scores.

We report the rate and severity of MRI findings of DDD in non-surgical AIS patients and correlate these findings with SRS-22 scores. Additionally, we quantify the rate of concurrent pathological radiological findings in this group.

Methods: AIS patients aged 10-16 who had received a whole spine MRI between September 2007 and January 2019 and who had not received surgical intervention were included. For scans identifying DDD, discs were graded using the Pfirrmann grading system. SRS-22 scores were extracted and correlated with MRI findings.

Univariable analysis used independent two-tailed Mann-Whitney U test for continuous data and Fisher exact tests for nominal and ordinal data. Multivariable analysis was performed using simple linear regression.

Results: In total, 968 participants were included. Of these, 93 (9.6%) had evidence of DDD, which was Pfirrmann grade ≥3 in 28 (2.9%). The most affected level was L5/S1.

A total of 55 patients (5.7%) had evidence of syringomyelia, 41 (3.4%) had evidence of spondylolisthesis (all L5/S1), 14 (1.4%) had bilateral L5 pars defects, and 5 (0.5%) had facet joint degeneration.

SRS-22 scores were available in 580 cases. Function (p=0.04), pain (p=0.04) and self-image (p=0.04) SRS-22 scores were worse in patients with DDD.

Conclusion: We found that 9.6% of non-operative AIS patients had at least some evidence of DDD. Presence of DDD negatively impacts SRS-22 pain, function and self-image domains.

Implications: This data should assist in decision making and counselling of patients prior to surgery.

785 - Morbidity and Mortality Following Posterior Lumbar Decompression in Octogenarians and Nonagenarians

Prateek A Saxena, Sandeshkumar Lakkol, Rajendra Bommireddy, Abdal Zafar

University Hospitals of Derby & Burton NHS Foundation Trust, Derby, United Kingdom

Background: Elderly patients with degenerative lumbar disease are increasingly undergoing posterior lumbar decompression without instrumented stabilisation. There is a paucity of studies examining clinical outcomes, morbidity & mortality associated with this procedure in this population. Our aim was to assess these and determine any associations relevant to this population.

Methods: A retrospective analysis of 167 eligible patients aged 80-100 years who underwent posterior lumbar decompression without instrumented stabilisation at University Hospitals of Derby & Burton between 2016-2020.

Results: Mean age of our cohort was 82.78±3.07 years, of these 163 were octogenarians and 4 were nonagenarians. The mean length of hospital stay was 4.79±10.92 days. 76% of the patients were pain free at 3 months following decompression. The average Charleston co-morbidity index (CCI) was 4.87. No statistically significant association was found with CCI in predicting mortality (ODD ratio 0.916, CI95%). 17 patients suffered complications. The incidence were dural tear (0.017%), post-op paralysis (0.017%), SSI (0.01%), and 0.001% of hospital acquired pneumonia, delirium, TIA, urinary retention, ileus, anaemia. High BMI (35+) was associated with increased incidence of complication (CI 95%, p<0.002). There was statistically significant social drift following discharge as 147 patients went home and 4 patients to rehabilitation facility (p<0.001FE test). The mean operative time was 91.408±41.17 mins and mean anaesthetic time was 36.8±16.06 mins. Prolonged operative time was not associated with increased mortality. 2 year revision decompression rate was 0.011%.

Conclusion: Posterior lumbar decompression without instrumented stabilisation in elderly is associated with low mortality with 99.5%survival at 1 year. It significantly improves PROMs & has extremely low revision rate. Incidence of post-op complication is <0.05% and 54% of patients get discharged within 72 hours of surgery. Careful selection and optimising patients with high BMI would reduce perioperative morbidity and mortality.

Sports Trauma

Podium Presentation Abstracts

223 - Knee Injuries in English Community Rugby Union: a ten-season prospective cohort study 2009-2018

Ben Gompels1,2, Simon Roberts3, Keith Stokes3,4

1Bristol University, Bristol, United Kingdom; 2Wirral University Teaching Hospital, Liverpool, United Kingdom; 3University of Bath, Department for Health, Bath, United Kingdom; 4Rugby Football Union, London, United Kingdom

Aims: This prospective cohort study aims to analyse the incidence, severity, and type of knee injuries in senior community rugby in England between 2009-2018.

Methods: English adult community rugby clubs competing within the Rugby Football Union league system were invited to participate in the study. Data were collected over 9 seasons: 2009-2018. Participating clubs were classified by level into three groups based on level with data collected by medical staff. 

Results: In total, 701 time-loss injuries to the knee were sustained over 12622 team games. Players sustaining an injury had a mean age of 26.75 (95% CI 25.67-25.84) and a mean BMI of 28.38 (95% CI 28.11- 28.64). The overall incidence was 2.8 per 1000 match hours (95% CI 2.6-3.0) and the mean injury severity was 11.6 weeks (95% CI 10.8-12.5) missed per injury. The semi-professional group had a higher incidence 3.1 per 1000 match hours (95% CI 2.6-3.6) compared to the amateur (2.8, 95% CI 2.4-3.1) and recreational (2.7 p5% CI 2.4-2.9). 

The most common type of injury sustained were ligamentous injuries. Medial Collateral Ligament injuries having the highest incidence across all diagnosed ligamentous injuries, accounting for 0.71 knee injuries per 1000 match hours (95% CI 0.58- 0.78). They had a higher incidence at lower playing levels. The injury event with the highest incidence was the player being tackled (53% of all injuries), with the contact scenario accounting for 72% of all injuries. 

Conclusions: The incidence of knee injuries is greater at higher levels of English community rugby and is higher at semi-professional level compared to amateur level. Lower standards of playing level have a higher mean average age than higher playing levels. It is plausible that greater fitness and conditioning in the community game may have an impact on injury prevention and the overall good health of players.

365 - Comparative Reliability of 3 Tesla Magnetic Resonance Imaging to Arthroscopy Findings in Femoroacetabular Impingement

Chun Hong Tang, Colin Holton, Emma Rowbotham, Bill Pass, Philip Robinson

Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom

Introduction: Femoroacetabular impingement (FAI) has been recognised as a cause of pain to patients, particularly affecting the younger population, with a relatively normal joint surface. We set out to determine the diagnostic accuracy of 3-Tesla Magnetic Resonance Imaging (3T MRI) against the gold standard of hip arthroscopy findings. 

Methods: This was a retrospective review of a single surgeon series of 59 operative cases, over a period of 3 years. The inclusion criteria were arthroscopically confirmed diagnosis of FAI, and pre-operative imaging with 3T MRI scans. The surgical reports were analysed and compared to the radiological reports, that were produced independently by 2 consultant musculoskeletal radiologists. The key findings included were: presence of labral tear, presence of CAM deformity, presence of acetabular and femoral cartilage damage.  

Results: We found that 3T MRI is sensitive in detecting the presence of labral tears, CAM deformities and also femoral cartilage damage. (96%, 83% and 100% respectively) It was however, less sensitive in detecting acetabular cartilage damage. (69%) The specificity of excluding cartilage wear on both the femoral and acetabular side was also high, (83% and 85%) but low for labral tears and CAM deformities. (9% and 69%) The positive predictive value of 3T MRI was high in labral tears, CAM deformities and acetabular wear (82%, 74%, 97%), but low in predicting femoral cartilage damage. (25%) The negative predictive value was high in detecting CAM lesions and femoral wear (80% and 100%) but low for labral tears and acetabular wear. (33% and 27%) 

Conclusion: 3T MRI is particularly good at detecting the presence of labral tears, and CAM deformities. It is also sensitive at detecting cartilage damage on the femoral side, but we acknowledge a higher false positive rate. 3T MRI is however, more accurate in diagnosing cartilage wear on the acetabular side. 

Technology, Data and Recovery

Podium Presentation Abstracts

617 - Do live-stream telemedicine routine follow-up appointments for Ponseti treated clubfoot patients compare favourably with face to face review?

Christine Douglas1,2, Sally Tennant1, Jane Simmonds2, Louise Kedroff2

1The Royal National Orthopaedic Hospital NHS Trust, Stanmore, United Kingdom; 2University College London, London, United Kingdom

Background: Regular clinical review is vital during the first five years of treatment for Ponseti clubfoot patients, to ensure bracing (FAB) compliance and prevention of recurrence. Restrictions on face-to-face clinics during the COVID-19 pandemic prompted us to introduce a live-stream telemedicine (TM) service as a temporary measure. This offers advantages for patients and health care providers, saving travel time and costs, but must be clinically effective. This study assessed equivalence of telemedicine with usual F2F care.

Methods: A test cohort of 78 patients in FAB seen via TM during COVID-19 restrictions, was compared to a matched historical control cohort of 78 patients who attended for usual F2F care. Retrospective review of clinical notes was performed to identify rates of compliance, relapse and type of intervention required (management of skin problems, change to alternate bracing, stretching exercises).

Results: There were no significant differences in the incidence of compliance problems between the two groups (23% in TM, 26% in F2F, p=0.71).

There was no significant difference in the incidence of relapse between the two groups (TM 5%, F2F 10%, p=0.3).

Subsequent F2F review of the TM cohort showed that the rate of detection of non-compliance did not change for the TM group, and in a few, compliance improved.

Intervention was required in 64% of TM group and 72% of F2F group (p=0.3)

Conclusion: A one-off Telemedicine review is as effective as F2F in the routine follow-up of Ponseti treated clubfoot patients and has the potential for integration into the routine follow-up care of these patients.

Implications: Telemedicine offers a viable alternative assessment modality for Ponseti treated clubfoot patients. Provision of some virtual follow-up for these frequent attenders may provide significant time and cost savings with no detriment to clinical care.

781 - Automatic identification of clinical landmarks and calculation of Graf angles in newborn hip screening: A pilot study

Abhinav Singh1, James McCouat2, Daniel Perry3, Sandeep Hemmadi4, Irina Voiculescu2

1Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom; 2Department of Computer Science, University of Oxford, Oxford, United Kingdom; 3Alder Hey Children's Hospital NHS Foundation Trust, Liverpool, United Kingdom; 4Cardiff and Vale University Health Board, Cardiff, United Kingdom

Background: The UK screening programme has not improved early detection of developmental dysplasia of the hip (DDH) since 1986. Late diagnosis leads to multiple operations and persistent pain. Artificial Intelligence (AI) assisted diagnostics represents the potential for a universal ultrasound screening programme with improved accuracy and objectivity. 

Methods: This study utilised an anonymised dataset obtained by experienced radiologists during routine NHS practice. The dataset contained 190 2D hip ultrasound images (normal= 71, dysplastic= 66, dislocated= 53) from 100 multi-ethnic babies (aged 4-12 weeks). Two clinical experts provided the five anatomical landmarks representing base of ilium (1st and 2nd points), turning point (3rd), lower limb (4th) and labrum (5th). Corresponding Graf angles were used to classify screening diagnosis - normal (Graf 1/2a) or abnormal (Graf 2b,2c,D,3,4). We designed a convolutional neural network (modified U-Net, 94:47:49 training:validation:testing data split) to detect anatomical landmarks for automatically calculating Graf angles and providing a screening diagnosis. 

Results: Within the test dataset (n=49), the five landmarks were identified in all images with a mean pixel error of 7.1. When comparing Graf angles between ground truth and AI-derived landmarks the mean difference for alpha was 2.8 degrees (range 0-7.6; interclass correlation coefficient (ICC) 0.88) and beta was 5.4 (range 0.3-16; ICC 0.87) degrees. Automated Graf angle diagnosis agreed with clinical experts in 85.7% (n=42) of the images with a sensitivity of 90.6% and specificity of 76%.

Conclusions: Our AI successfully identifies key landmarks with minimal pixel error. It automatically calculates Graf angles, exceeding the existing state of the art AI performance and provides a diagnosis which agrees with expert clinicians on 85.7% of images. 

Implications: This method will improve the accuracy of DDH screening programme, whilst reducing clinician fatigue and improving resource allocation. Objective data will also facilitate high-quality outcomes research.



Podium Presentation Abstracts

83 - Re-operations after cannulated screws for neck of femur fracture

Mohannad Ammori, Junaid Aamir, Hassan Hamid, George McLauchlan, Amol Chitre

Royal Preston Hospital, Preston, United Kingdom

Background: The current recommendations by the National Institute for Health and Care Excellence are to offer replacement to patients with a displaced intracapsular neck of femur fracture. This is based on a significantly greater re-operation rate for internal fixation compared to hemiarthroplasty from 1 to 5 years (355/1,001; 35.5% vs. 99/1,033; 9.4%, respectively). The aims of this study were to determine the re-operation rate after cannulated screws for neck of femur fracture, and to determine the variables predictive of re-operation.

Methods: Six-hundred-and-three patients who underwent 608 operations were identified using a query created in Bluespier from May 2007 to February 2021. Data were retrospectively collected and included patient demographics, fracture classification (Garden, Pauwels) and operative details including an assessment of the reduction and configuration of the screws.

Results: The re-operation rates were 5.6% (n=33) at six months, 14.6% (n=79) at 2 years and 21.0% (n=87) at 5 years. The conversion rate to total hip arthroplasty was 9.4% (n=57) and removal of metalwork was performed in 5.4% (n=33). Common complications included avascular necrosis (n=29; 4.8%), metalwork irritation (n=25; 4.1%), non-union (n=21, 3.5%), and failure (n=21, 3.5%). A Cox proportional hazards regression found Garden IV vs. I and anatomical or valgus-impacted reduction to be the only independent predictors of re-operation.

Conclusion: Our re-operation rates after cannulated screws for neck of femur fracture are substantively lower than that reported elsewhere. Anatomical or valgus-impacted reduction was more predictive of re-operations than initial fracture displacement.

Disclosure: The authors have no conflicts of interest to declare.

217 - Reverse shoulder arthroplasty for the treatment of three and four-part fractures of the proximal humerus in the elderly. A prospective review of 70 cases with a medium-term follow up

Ali Abdelwahab, Bijayendra Singh, Catherine Flood

Medway NHS Foundation Trust, Medway, United Kingdom

Background: Reverse shoulder arthroplasty (RSA) is being increasingly used for complex, displaced fractures of the proximal humerus in elderly patients. The main goal of the current study was to evaluate the functional and radiographic results after primary RSA of three or four-part fractures of the proximal humerus in patients older than 75 years old. 

Methods: Between 2012 and 2020, 70 consecutive patients with a recent three- or four-part fracture of the proximal humerus were treated with an RSA. There were 41 women and 29 men, with a mean age of 76 years (range 65 to 87). The dominant arm was involved in 42 patients (60%). All surgeries were carried out within 21 days of the injury by a single surgeon. Displaced three-part fracture sustained in 16 patients, 24 had fracture dislocation and 30 sustained a four-part fracture of the proximal humerus as described by Neer. Patients were followed up for a mean of 26 months (range 10 to 36). 

Results: The mean postoperative Oxford Shoulder Score at the end of the follow-up period was 32.4 (range 16 to 42). The mean DASH score was 44.3 (range 10 to 92). Tuberosity non-union occurred in 18 patients (12.6%), malunion occurred in 7 patients (4.9%), heterotopic ossification in 4 patients (2.8%) and scapular notching was observed in one patient. In this study anatomical reconstruction was achieved in 25 patients (17.5%) but the influence of greater tuberosity healing on shoulder function could not be demonstrated. Heterotopic ossification seems to affect the OSS and QDASH, we found statistically significant relation between HO and clinical outcomes. Patients with heterotopic ossification had significantly lower postoperative scores on DASH and OSS (P = .0527).

Conclusion: Despite expecting good functional outcome with low complication rate after RSA, the functional outcome was irrespective of healing of the tuberosities. 

257 - Weight-bearing in Trauma Surgery (WiTS) Study: A national survey of UK Trauma & Orthopaedic multidisciplinary health professionals

Mohsen Raza1, Samuel Walters2, Charlotte Richardson2, Christopher Bretherton3, Karen Longhurst1, Alex Trompeter1

1St George's University Hospitals NHS Foundation Trust, London, United Kingdom; 2Epsom & St Helier University Hospitals NHS Trust, London, United Kingdom; 3Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom

Introduction: Weight-bearing (WB) status following a fracture or surgical fixation is an important determinant of the mechanical environment for healing. In order for healthcare professionals to communicate and understand the extent of bearing weight through a limb, clear terminology must be used. There is widespread variation in the usage and definitions of WB terminology in the literature and clinical practice. This study sought to define the understanding and extent of variation across the United Kingdom.

Methods: A nationwide online survey of UK-based Trauma & Orthopaedic (T&O) multidisciplinary healthcare professionals was conducted. Participants answered seven questions assessing their usage and understanding of various WB terminology.

Results: A total of 707 responses were received: 48% by doctors, 32% by physiotherapists, 13% by occupational therapists and 7% from other healthcare professionals. In terms of understanding of WB terminology with respect to percentage body weight (BW), 89% of respondents interpret 'full WB' as 100% BW, 97% interpret 'non WB' as 0% BW, 80% interpret 'partial WB' as 50% BW, and 89% interpret 'touch/toe-touch WB' as 10% or 20% BW. There were statistically significant differences between the responses of doctors and therapists for these four terms, with doctors tending to give higher %BW values. 'Protected WB' and 'WB as tolerated' had less consensus and more variability in responses. The majority (68%) of respondents do not usually quantify terminology such as 'partial WB' with a value, and 94% agreed that standardisation of WB terminology would improve communication amongst professionals.

Conclusion: This study provides evidence of the substantial variation in the understanding of WB terminology amongst healthcare professionals, which likely results in ambiguous rehabilitation advice. Existing literature has shown that patients struggle to comply with terms such as 'partial weight-bearing'. We recommend consensus within the T&O multidisciplinary community to standardise and define common weight-bearing terminology.

284 - Hip Fractures in the Non-Elderly: Outcomes in Young Adult Patients with Intracapsular Femoral Neck Fractures

Boris Wagner1, William Oliver2, Katrina Bell2, Chloe Scott3, Nick Clement2, John Keating2, Timothy White2, Andrew Duckworth4,2

1Edinburgh Medical School, The University of Edinburgh, Edinburgh, United Kingdom; 2Edinburgh Orthopaedics, Edinburgh, United Kingdom; 3Edinburgh Orthopaedics, Edinburgh, Luxembourg; 4Centre for Population Health Sciences, Usher Institute, University of Edinburgh, Edinburgh, United Kingdom

Background: The aim of this study was to evaluate the outcomes for young adult patients undergoing intracapsular femoral neck fracture fixation and to assess factors associated with healing complications and patient-reported outcomes.

Methods: From 2008-2018, we retrospectively identified 112 consecutive patients (mean age 48yrs [20-60], 54% male). Healing complications were defined as failure of fixation, nonunion and avascular necrosis (AVN). Long-term patient-reported outcomes – including Oxford Hip Score (OHS), Forgotten Joint Score (FJS), EuroQol 5-Dimension (EQ-5D)/Visual Analogue Scale (EQ-VAS) and UCLA Activity Scale – were obtained via telephone survey.

Results: Union occurred in 77% (n=86/112) at a mean of nine months (3-87), with 23% developing failure of surgical management (n=26/112), including loss of fixation (5.4%, n=6/112), nonunion (4.5%, n=5/112) and AVN (14.3%, n=16/112). Time to surgery >24hrs (adjusted odds ratio [aOR] 3.84, p=0.025) and fracture malreduction (aOR 10.64, p=0.003) were independently associated with failure. Overall, 35% (n=39/112) required secondary surgery, including metalwork removal (18.8%, n=21/112), total hip replacement (THR; 18.8%, n=21/112) and excision arthroplasty (1.8%, 2/112).  Long-term outcomes were obtained for 72% (n=81/112) at a mean of 7yrs (2.8-12.8). The mean OHS was 41.4 (4-48), FJS 63.3 (0-100), EQ-5D 0.823 (-0.59-1.0) and EQ-VAS 79.5 (5-100). The mean UCLA score fell from 6.8 pre-injury to 6.0 post-injury (p<0.001). Compared with primary union, developing a healing complication was associated with significantly lower OHS (33.8 vs. 43.9, p<0.001), EQ-5D (0.621 vs. 0.889, p=0.001), EQ-VAS (68.4 vs. 83.1, p=0.01) and UCLA scores (4.5 vs. 6.5, p=0.001). 

Conclusion: Most young adult patients unite and reported satisfactory outcomes following fixation of their intracapsular hip fracture. However, one in four experience a complication, resulting in inferior long-term function and health-related quality of life. Delay to surgery and fracture malreduction were independently associated with failure of surgical management.

Disclosure: Authors have no conflict of interest to declare.

408 - Does time to surgery influence outcomes for those undergoing total hip arthroplasty for hip fracture? A nationwide study from the Scottish Hip Fracture Audit

Lewis Mitchell1, Caroline Martin2, Kirsty Ward2, Karen Adam2, Andrew Hall2,3, Nick Clement2,3, Alasdair MacLullich2,3,4, Luke Farrow1,2,5

1Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, United Kingdom; 2Scottish Hip Fracture Audit, Public Health Scotland, Edinburgh, United Kingdom; 3Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom; 4Ageing and Health, Usher Institute, University of Edinburgh, Edinburgh, United Kingdom; 5Grampian Orthopaedics, Aberdeen Royal Infirmary, Aberdeen, United Kingdom

Background: Patients undergoing total hip arthroplasty for hip fracture (THA#) commonly experience delays to theatre to access sufficient surgical expertise. There are established links between surgical delay and poorer outcomes in hip fracture patients, but there is little evidence regarding the impact in the less frail THA# group. We therefore set out to establish the influence of surgical delay on key healthcare outcomes in this setting.

Methods: A retrospective cohort study was undertaken using patient data from the Scottish Hip Fracture Audit (SHFA) covering 2016-2020. The SHFA includes all units managing hip fracture care within Scotland. Only patients undergoing THA# were included, with categorisation according to attainment of Scottish Standards of Care of Hip Fracture Patients Standard 4 (patients must undergo surgical management within 36 hours of admission).

Results: 1375 patients undergoing THA# were included, with 397 (28.9%) experiencing a surgical delay greater than 36 hours. There were no significant differences in the age; sex; residence prior to admission; and Scottish Index of Multiple Deprivation (SIMD) for those with, and without, surgical delay.

Both groups had similar 30-day (99.7% vs 99.3%, p=0.526) and 60-day (99.2% vs 99.0%, p=0.876) survival. There was however a significantly longer length of mean stay for the delay group (acute: 7.0 vs 8.9 days, p<0.001; overall: 8.7 vs 10.2 days, p<0.002). Operative delay did not significantly affect 30-day readmission (p=0.085) or discharge destination from acute care (p=0.884). Estimated additional cost from surgical delay was £467,666.

Conclusion: Operative delay >36 hours from admission in the THA# group was not associated with increased mortality. Delayed patients did however have a longer acute and overall length of stay, which has health economic consequences. Further research is required to evaluate the balance of ethical considerations, service provision and optimisation of outcomes when evaluating surgical delay in the THA# setting.

426 - A Retrospective Study Comparing Patient Radiation Exposure and Overall Operative Time In The United Kingdom's First Experience of CT Navigated Pelvic and Acetabular Trauma Surgery

Jordan Bethel, Elmunzar Bagouri, John Vu, Glafkos Havariyoun, Sian Rees, Matt Gee, Paul Harnett, Aswinkumar Vasireddy, Ibraheim El-Daly

King's College Hospital, London, United Kingdom

Background: Intra-operative CT guided navigation of screws has been used for over 20 years in spinal procedures with evidence of reduced radiation exposure, operative times, and improved accuracy.

We investigated patient radiation exposure & operative times of CT guided navigation of pelvic & acetabular fracture fixation against conventional methods of fixation, carried out at a single Major Trauma Centre (MTC). To our knowledge this is the largest UK based navigated pelvic fixation series.

Methods: 19 navigated patients were cross matched according to the Young & Burgess classification to 17 patients treated with standard fixation using intra-operative 2D fluoroscopy, over a two-year period.

Individual radiation exposure, operative times & patient demographic details were collected retrospectively & compared between the two groups.

Estimations of intra-operative effective spin dose (mSv) on navigated patients was performed using the rotational version of the Monte Carlo patient dosimetry software. mSv estimations for 2D fluoroscopy and post-operative CT scans were performed using DAP and DLP to mSv conversion factors.

Results: The mean total spin mSv for CT navigated patients was 4.4±1.9 and the control group mean total mSv was 4.5±2.1 (p=0.9). The mean total operative time was 231.1±131 minutes for the navigated group and 195±126.4 in the fluoroscopy guided group (p<0.5). Mean age was 58.7±17.1 & 49.8±20.7 in the navigated and control group, respectively (p=0.4).

Conclusions: Our results show no statistically significant difference in radiation exposure to the patient or the overall operative time between CT-guided navigation & conventional 2D intra-operative fluoroscopic-guided fixation with a post-operative check CT.

Implications: CT guided navigation has the potential to reduce radiation exposure to patients and eliminating exposure to the surgical team. Reported benefits include increased accuracy of metalwork placement and reduced revision rates. Operative times should reduce after overcoming the steep learning curve and unfamiliarity of equipment by the surgical team.

430 - The complications and outcomes of cannulated-screw tension-band constructs for patella fractures: A systematic review

Peter Legg, Effie Menyah, Baljinder Dhinsa

East Kent Hospitals University Foundation Trust, Ashford, Kent, United Kingdom

Background: Patella fractures represent 1% of all fractures. Operative management aims to restore the extensor mechanism function and congruency of the patellofemoral articulation. In simple fracture patterns, the use of tension-band Kirschner-wire (TBW) constructs convert the unbalanced tension and compression forces across the patella into compression across the whole fracture-plane with the aim to achieve absolute stability and primary bone union. A modification of the TBW technique is the cannulated screw tension band (CSTB): Using partially-threaded cannulated screws and a figure-of-eight tension-band passing through the screws.

Methods: This systematic review examines original literature from 01 Jan 2000 to present pertaining to the complications, clinical and functional outcomes of CSTB in treatment of patella fractures.

Results: 11 articles were included with a total cohort of 510 patients undergoing CSTB for patella fractures. The distribution of AO fracture classifications (43 C-type) were: 43% simple-transverse (C1), 15% transverse plus single fragment (C2), 25% comminuted (C3) and 15% unclassified. Mean age was 50.6 +/- 10.9 years. 21% underwent cerclage augmentation in addition to the CSTB.

Complications included 2% deep infection requiring re-operation and 0.5% wound complications managed non-operatively; 1.4% delayed union, 1% malunion and 0.4% non-union. 7.7% hardware irritation and 11.8% subsequent removal of hardware. Reporting of patient-related outcome measures was heterogenous. The mean Bostman score was 28.5 +/- 1.2; this constitutes an “excellent” reported outcome. Two studies reported flexion and extension values of mean 126.3+/-13 degrees and 1.2+/-1.1 respectively. Two studies reported movement arcs of mean 125.9 +/- 10.4 degrees.

Conclusion: This review article provides a summary of the current evidence of CSTB for simple and comminuted patella fractures. It demonstrates high union rates and significantly lower rates of hardware irritation when compared to conventional tension band Kirschner wiring. Although reporting was variable, the data suggests satisfactory clinical outcomes with this technique.

732 - Operative versus non-operative management of distal radius fractures in adults: a systematic review and meta-analysis of randomised controlled trials with an elderly subgroup analysis

Katrina Bell1, William Oliver1, Timothy White1, Samuel Molyneux1, Nicholas Clement1, Andrew Duckworth1,2

1Edinburgh Orthopaedics, Edinburgh, United Kingdom; 2University of Edinburgh, Edinburgh, United Kingdom

Background: This systematic review and meta-analysis aimed to compare the outcome of operative and non-operative management in adults with distal radius fractures, with an additional elderly subgroup analysis.  The main outcome was 12-month PRWE score. Secondary outcomes included DASH score, grip strength, complications and radiographic parameters. 

Methods: Randomised controlled trials of patients aged ≥18yrs with a dorsally displaced distal radius fractures were included. Studies compared operative intervention with non-operative management. Operative management included open reduction and internal fixation, Kirschner-wiring or external fixation. Non-operative management was cast/splint immobilisation with/without closed reduction. Searches were performed using MEDLINE, Embase, CINAHL, PubMed and CENTRAL. Version 2 of the Cochrane risk-of-bias tool was used.

Results: After screening 1258 studies, 16 trials with 1947 patients (mean age 66yrs, 76% female) were included in the meta-analysis. Eight studies reported PRWE score and there was no clinically significant difference at 12 weeks (MD 0.16, 95% confidence interval [CI] -0.75 to 1.07, p=0.73) or 12 months (mean difference [MD] 3.30, 95% CI -5.66 to -0.94, p=0.006). Four studies reported on scores in the elderly and there was no clinically significant difference at 12 weeks (MD 0.59, 95% CI -0.35 to 1.53, p=0.22) or 12 months (MD 2.60, 95% CI -5.51 to 0.30, p=0.08). 

There was a no clinically significant difference in DASH at 12 weeks (MD 10.18, 95% CI -14.98 to -5.38, p<0.0001) or 12 months (MD 3.49, 95% CI -5.69 to -1.29, p=0.002). Two studies featured only elderly patients, with no clinically important difference at 12 weeks (MD 7.07, 95% CI -11.77 to -2.37, p=0.003) or 12 months (MD 3.32, 95% CI -7.03 to 0.38, p=0.08).  

Conclusions: There was no clinically significant difference in patient-reported outcome according to PRWE or DASH at either timepoint in the adult group as a whole or in the elderly subgroup.


Podium Presentation Abstracts

36 - Return to Sports Following Lower Limb Musculoskeletal Tumour Surgery – A Systematic Review

Metin Tolga Buldu1, Federico Sacchetti2, Adam Yasen1, Sherron Furtado3, Veronica Parisi3, Craig Gerrand1

1RNOH, Stanmore, United Kingdom; 2Ortopedia Oncologica e Ricostruttiva, Firenze, Italy; 3UCL, London, United Kingdom

Primary malignant bone and soft tissue tumours often occur in the lower extremities of active individuals, including children, teenagers and young adults. Survivors often face long-term physical disability. Participation in sports is particularly important for active young people but the impact of sarcoma treatment is not widely recognised and clinicians may be unable to provide objective advice about returning to sports. We aimed to identify and summarise the current evidence for involvement in sports following treatment of lower limb primary malignant bone and soft tissue tumours. 

A comprehensive search strategy was used to identify relevant studies combining the main concepts of interest: (1) Bone/Soft Tissue Tumour, (2) Lower Limb, (3) Surgical Interventions and (4) Sports. Studies were selected according to eligibility criteria with the consensus of three authors. Customised data extraction and quality assessment tools were used.

Twenty-two studies were selected, published between 1985 – 2020, including 1005 patients. Fifteen of the 22 studies valid data on return to sports, with 705 participants, of which 412 (58.4%) returned to some form of sport swimming, cycling and skiing, at a mean follow-up period of 7.6 years. Four studies directly compared limb sparing surgery and amputation; none of these were able to identify a difference in sports participation or ability.

Return to sports is important for patients treated for musculoskeletal tumours. However, there is insufficient published research to provide good information and support for patients. Future prospective studies are needed to collect better pre- and post-treatment data at multiple time intervals. Validated clinical and patient sports participation outcomes such as type of sports, level, frequency and a validated sports specific outcome score, such as the University of California at Los Angeles (UCLA) activity scale, should be recorded. In particular, more comparison between limb sparing surgery and amputation would be welcome.

141 - Predictors of survival, local recurrence and metastasis in Leiomyosarcoma of trunk wall and extremities: A multicentre data analysis of 488 patients

Sudhir Kannan1,2, Jay Dee Ferguson1, Bryan Chew3, Nicholas Eastley4, Han Hong Chong3, Nicholas Mackenzie5, Viswanath Jayashankar6, Maria Anna Smolle7, Sanjay Gupta6, Andreas Leithner7, Tom McCulloch8, Olga Zaikova9, Jonothan Stevenson4, Kenneth S Rankin1, Robert U Ashford3

1Newcastle University, Newcastle Upon Tyne, United Kingdom; 2Health Education England, Newcastle Upon Tyne, United Kingdom; 3University Hospitals of Leicester, Leicester, United Kingdom; 4Royal Orthopaedic Hospital, Birmingham, United Kingdom; 5Glasgow Royal Infirmary, Glasgow, United Kingdom; 6Glasgow Royal Infirmary, Glasgow, United Kingdom; 7Medizinische Universität Graz, Graz, Austria; 8Nottinghamshire University Hospitals, Nottingham, United Kingdom; 9The Norwegian Radium Hospital Oslo University Hospital, Oslo, Norway

Introduction: Leiomyosarcomas are aggressive neoplasms and there are no universally accepted prognostic factors. We aimed to identify the risk factors for early recurrence, metastases, and poor survival and build a prediction model.

Methods: We present data of 488 patients from 6 centres who had Leiomyosarcomas involving trunk wall and extremities. Purely cutaneous tumours with no subcutaneous extension, RP, major vessel, and uterine LMS were excluded. Overall survival, local recurrence, and metastasis were the outcome measures.

Results: The mean survival was 56.2 months (SD 48.6). 10% (46/488) patients had local recurrence. More importantly, 37% (17/46) of these local recurrences were within 12 months of diagnosis. 37% (181/488) of patients developed metastases, 0.8% (4/488) had metastasis at presentation. 50.2% of metastasis occurred in less than 36 months. 

Our analysis shows that younger age (p-value 0.0001), deep location (p-value 0.001), trunk site (p-value 0.02), Grade (p-value 0.0001), Stage (p-value 0.0001) and mitoses >10/HPF (p-value 0.0001) are prognostic factors predicting survival. 

Further, our analysis suggested that age (p-value 0.0001), site (p-value 0.02), deep location (p-value 0.06), mitoses (p-value 0.001), necrosis (p-value 0.03), pre-op adjuvant therapy (p-value 0.005) and stage (p-value 0.01) were predictive of local recurrence. Similarly, age (p-value 0.0001), size (p-value 0.004), depth (p-value 0.05), grade (p-value 0.002) and IHC cladesmon (p-value 0.0001) were predictive of metastasis. Finally, our models has displayed a good predictive accuracy. 

Conclusion: Younger age of occurrence and deep location are poor prognostic factors for all 3 outcome variables. Site, stage and mitoses were negative predictors of survival and local recurrence. Pre-op adjuvant therapy was predictive of reduced local recurrence. The size >5 cms and high grade tumours were predictive of metastasis. The nomograms provide accurate, accessible, multivariate predictive models to estimate individual risk of mortality, local recurrence and metastasis.

252 - Wound complication risk factors of soft tissue sarcoma resection following neoadjuvant radiotherapy: A 14-year single centre retrospective study

Zhengxiao Ouyang1,2, Sally Trent3, Thomas Cosker1, Harriet Branford White1, Duncan Whitwell1, Max Gibbons1

1Nuffield Orthopaedic Centre, University of Oxford, Oxford, United Kingdom; 2The Second Xiangya Hospital, Central South University, Changsha, China; 3Churchill Hospital, Oxford, United Kingdom

Background: Neoadjuvant Radiotherapy (NART) is recommended by guidelines for the treatment of high-grade soft tissue sarcomas, but post-operative wound problems are a barrier to its widespread use and are a major consideration for surgeon. The purpose of this study aims to analyse wound complication rate with or without reoperation and determine risk factors for it.

Methods: Using our orthopaedic center database, we retrospectively studied 128 cases of STS treated with NART and surgery between 2007 and 2021. All patients received NART and 15 patients received post-operative chemotherapy. Wound complications were defined as minor wound complication (MiWC) without surgical intervention or major wound complication (MaWC) if they received secondary surgical intervention. Univariate and multiple regression analyses on sex, age, tumor site, size, grade, SUVmax of PETCT, BMI, diabetes, anxiety, smoking, alcohol, surgery type, margin, tumor depth, tumor type and complication start time were performed using frequency of MiWC and MaWC as a dependent variable.

Results: The incidence of MiWC and MaWC was 43.0% (55/128) and 18.8% (24/128). Tumor diameter, age, diabetes, and site were associated with MiWC in univariate analysis. Tumor diameter (OR:1.2, 95%CI:1.0-1.3, p=0.036) and site (proximal lower limb vs upper limb, OR:16.28, 95%CI 1.53-172.68, p=0.021) were risk factors on multivariate analysis. In nested case control analysis, the incidence of MaWC was 43.6% (24/55), the mean recovery time is 143 days in patients with MaWC. Smoking may increase the risk for MaWC (OR:8.32, 95%CI:1.36-49.99, p=0.022). Moreover, period between surgery and complication may reduce the risk for MaWC (OR:0.91, 95%CI:0.84-0.99, p=0.028) in multivariate analysis. 

Conclusions: Tumor diameter and tumor site are risk factors for incidence of MiWC. Smoking and period between surgery and complication are risk factor for rate of MaWC compare with MiWC. Patients experienced wound complication after surgery in a short time and with smoking appear to have reoperation.

628 - Pathologic evaluation nomogram of soft tissue sarcoma resection following neoadjuvant radiotherapy: A 14-year single centre retrospective study

Zhengxiao Ouyang1,2, Jennifer Brown1, Zsolt Orosz1, Nick Athanasou1, Sally Trent3, Thomas Cosker1, Duncan Whitwill1, Harriet Branford White1, Max Gibbons1

1Nuffield Orthopaedic Centre, University of Oxford, Oxford, United Kingdom; 2The Second Xiangya Hospital, Central South University, Changsha, China; 3Churchill Hospital, Oxford, United Kingdom

Background: Neoadjuvant Radiotherapy (NART) is recommended by guidelines for the treatment of high-grade soft tissue sarcomas (STS), but debates still exist on how to evaluate pathologic response after NART. The purpose of this study aims to analyse the pathologic character and prognosis of STS patients to build a new nomogram evaluation system.

Methods: Using our Orthopaedic Center database, we retrospectively studied 128 cases of STS treated with NART and surgery between 2007 and 2021. Histologic subtype and tumor grade were determined following initial diagnositic biopsy and confirmed with surgically resected specimens. Two nomograms were separately established by multivariate logistic regression analysis using pathologic factors, necrosis, mitotic count, gross tumor size, hyalinization/fibrosis and infarction which were scored by 2 expert sarcoma pathologists. Local recurrence-free (LFR), metastasis-free (MFS) and overall survival (OS) were calculated using Kaplan-Meier estimator.

Results: Median tumor size was 7.5 cm; 92% were intermediate or high grade. Most common histology were unclassified pleomorphic sarcoma (34%) and myxofibrosarcoma (25%). Median follow-up was 71 months. The 5-year MFS 60%, 5-year RFS was 98%, and 5-year OS was 71.4%. The areas under the curve (AUC) of nomogram 1 and nomogram 2 were 0.66 and 0.75 (p < 0.05), with accuracy of 0.62 and 0.69, respectively. 

Conclusions: Nomograms based on pathologic factors, necrosis, mitotic count, gross tumor size, hyalinization/fibrosis and infarction were useful for predicting the prognosis and pathological response of STS with treatment of NART.

490 - Trabecular metal collars in Endoprosthetic Replacements: do they osteointegrate?

Ewen Fraser, Stephanie Spence, Omer Alanie, Helen Findlay, James Doonan, Ashish Mahendra, Sanjay Gupta

Glasgow Royal Infirmary, Glasgow, United Kingdom

Background: Limb salvage surgery (LSS) is the primary treatment option for primary bone malignancy. It involves the removal of bone and tissue followed by reconstruction to save a limb and prevent amputation. Endoprosthetic replacements (EPRs) are used for LSS, and Trabecular Metal (TM) collars have been developed to encourage bone ingrowth (osteointegration) into EPRs. Several studies were identified that looked at various types of collar material in EPRs for a bone tumour. No studies, however, were found that looked solely at TM collars in EPRs. The primary aim of this study was to assess whether osteointegration occurs when TM collars are used in EPRs for tumour. 

Methods: All patients (n=124) from 2010-2021 who underwent an EPR for tumour under the West of Scotland orthopaedic oncology team were identified. 65% (n=81) of patients met the inclusion criteria and two consultants independently analysed radiographs at 3 months, 12 months, and last x-ray using the Stanford Radiographic Assessment System (SRAS). Interobserver reliability was also assessed.

Results: Osteointegration of the TM collar was found to have occurred in approximately 65% of patients at last x-ray. The percentage of patients with osteointegration at 3 months (65.4%) reflected 12 months (65%) and last x-ray (64.4%). Radiolucency at the bone:collar junction was present in 28.4% (n=23) of cases at 3 months but only 6.7% (n=4) showed progression of this at 12 months. The interobserver reliability was found to be highly reliable in all parameters (p<0.001). 

Conclusion: Osteointegration occurs in TM collars but at rates lower than that of Hydroxyapatite for the same purpose. Osteointegration will occur by 3 months and will reflect osteointegration at 12 months and last x-ray. Furthermore, radiolucency at the bone:collar impact junction does occur in some patients but only a low number will show radiolucency progression at longer term follow-up.


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