BOA Annual Congress 2025

Title
The impact of social deprivation and ethnicity on patient-reported outcome measures for primary and revision hip and knee replacement at a specialist UK centre. 

Akash D Sharma, David J Dunlop, Adrian Gardner, Yuvraj S AgrawaL

Aims
There is paucity in the literature on impact of social deprivation and ethnicity on patient reported outcome measures (PROMs). This study aimed to assess the impact of social deprivation and ethnicity on PROMs after hip and knee arthroplasty in a healthcare system which is free at the point of care.

Methods
We reviewed prospectively collected data on patient demographics, co-morbidities and PROMs (EQ-5D, Oxford Hip Score (OHS) and Oxford Knee Score (OKS)), in patients who underwent hip and knee arthroplasty procedures. The primary outcome was impact of social deprivation on PROMs. Secondary outcomes included the impact of ethnicity, religion and co-morbidities on PROMs.

Results
We identified 10,646 hip arthroplasties and 8,138 knee arthroplasties from the database. Of these, 6,093 patients who underwent hip arthroplasty and  4,681 patients who underwent knee arthroplasty were included. Patients from the most deprived areas, ethnic minorities and in those who English is not their first language had lower pre-operative PROMs. Higher levels of social deprivation were associated with higher levels of co-morbidity. The trends are similar in revision hip and knee arthroplasty but the net improvement in the PROMs were significantly lower in patients who underwent revision procedures.

Conclusion
This study highlights that healthcare inequality exists in the UK among those undergoing hip and knee arthroplasty procedures, despite the substantial benefit these procedures can provide to patients, irrespective of social deprivation, ethnicity or first language. PROMs depend on several factors and hence requires a multifaceted approach to improve this.

Title
Biomechanical assessment of bone loss in transfemoral and knee disarticulation amputees

Louise McMenemy 1,4,5, Linjie Wang 2,4, Alison H. McGregor 3,4, Andrew T. M. Philips 2,4
1. Academic Department of Military Surgery and Trauma, RCDM, Birmingham, UK; 2. Structural Biomechanics, Department of Civil and Environmental Engineering, Imperial College London, UK; 3. Department of Surgery and Cancer, Imperial College London, UK; 4. Centre for Injury Studies, Imperial College London, UK. 5. Institute of Naval Medicine, Gosport, UK

Aims
Bone mineral density (BMD) reduction in amputees risks stress and fragility fractures potentially preventing the wearing of prostheses and hence reducing mobility. BMD loss occurs in military veteran amputees predominantly in the amputated side neck of femur [1], with transfemoral amputees most severely affected. BMD reduction is not systemic; therefore we propose this change is due to reduced mechanical stimulation. To assess this, we used a computational modelling framework to compare the mechanical stimulation of the femur for a body matched control subject (CS), transfemoral amputee (TFA), and knee disarticulation amputee (KDA).

Methods
Musculoskeletal models were developed and used with motion capture data to derive joint contact and muscle forces for walking, stair-ascent and stair-descent, sit-to-stand and stand-to-sit. Corresponding finite element models were developed and forces used as input, with the resulting mechanical stimulus (strain) in the femur compared between subjects. Bone adaptation simulations were run using a strain-based algorithm [2].

Results
Compared to CS, BMD reduction of 32% for TFA and 8% for KDA was predicted in the proximal femur. For CS stair-ascent and stair-descent provided the highest level of stimulation. For TFA reduced stimulation was observed for all activities, while for KDA stair-descent provided stimulation close to that for CS. Both amputees descended stairs using a reciprocal motion and ascended using a non-reciprocal motion. Both amputees favoured their intact leg in sit-to-stand and stand-to-sit. Maximum hip joint contact force (HJCF) was similar between CS and both amputees, suggesting HJCF is not a suitable proxy indicator of bone health.

Conclusions
Physiological load transfer was not achieved between prosthetic socket and distal femur for either amputee. Retention of the cortex in KDA resulted in a more physiological mechanical environment in the proximal femur than in TFA, suggesting knee disarticulation compared to femoral resection is beneficial for maintaining bone health.
[1] McMenemy L et al., J Bone Miner Res, 38:1227-1233, 2023.
[2] Villette and Phillips, PLoS One, 19(4): e0297932, 2024

Title
Mini-open Achilles Repair: 100 patient case series using the Achillon system

Author:  Emily Cartwright, Carys Brown, Matthew Morris, Jonathan May

Background
Achillon is a minimally invasive system for tendo-achilles repair used in our trust for all acute repairs. A retrospective analysis was performed on prospectively collected data for 100 consecutive patients with minimum follow up of 6 months from 2020 to 2024 from a single-centre district general hospital in England.  All repairs were performed with a Foot and Ankle consultant present under tourniquet and all followed the same post operative rehabilitation protocol.

Results
The demographic had an average age of 41, predominantly men and with an average tourniquet time of 29 minutes.  There were no immediate or delayed sural nerve injuries.  Our DVT rate was 2% and 1% healed in a lengthened position requiring re-operation (in a non-compliant individual). There were no re-ruptures and no superficial or deep infections.  Successful rehabilitation was achieved in 99% of patients; they were either satisfied or very satisfied based on physiotherapy reports and clinic letters.  Furthermore a basic cost and NHS resource assessment was carried out – examining the cost in terms of the purchase of the Achillon jigs, operative materials, theatre time, appointments and post operative footwear (boot with wedges).

This case series represents one of the largest reported and adds to the growing body of evidence currently published.  It identifies resources needed to deliver an acute operative tendo-achilles treatment protocol with a low complication rate and a high success rate within an NHS district general hospital setting.

Title
The cost of implant waste in trauma orthopaedic surgery and sustainability considerations: an observational study
Author: Rasi Mizori, Fizza Ali, Muhayman Sadiq, Yasser Al Omran, Thomas Lewis, Omar Musbahi & Karthik Karuppaiah 

Purpose
Implant wastage in trauma and orthopaedic (T&O) surgery remains an under-reported yet significant issue, contributing to rising healthcare costs and environmental concerns. With increasing surgical demand driven by an ageing population and the growing prevalence of conditions like osteoporosis, this study aimed to quantify implant wastage in T&O procedures at a Level 1 Major Trauma Centre in London, assessing both its frequency and financial impact.

Methods
A retrospective cohort study was conducted on all weekday T&O procedures performed between 1st December 2023 and 31st January 2024. Two of the authors identified wasted implants using intraoperative implant logbooks, and cross-referencing implant stickers with post-operative radiographs. Data pertaining to patient demographics, procedure types, surgical sites, and implant usage were collected. Cost analysis was performed using procurement data to determine the financial impact of implant wastage.

Results
Among 184 procedures analysed, 131 (71.2%) used implants, with wastage observed in 108 (82.4%) cases. A total of 141 implants were wasted, with screws accounting for 92.9% (n = 131) of wasted implants. Locking screws were the most frequently discarded (n = 65; 46.1%). Across ORIF and intramedullary nailing procedures, an overall screw wastage rate of 20% (17–31%) was observed with 2.4 screws wasted per trauma procedure. The financial cost of implant wastage over the 44-day study period amounted to approximately £335 per day and £136 per case.

Conclusion
This study highlights the substantial economic burden associated with implant wastage in T&O surgery, with screws, particularly locking screws, being the primary contributors. Targeted interventions, including improved preoperative planning, precision-based implant selection, and enhanced intraoperative decision-making, are essential to reducing waste and improving cost-efficiency and sustainability in surgical practices. Further research should explore the broader economic and environmental impact of implant wastage, incorporating factors such as operative time and carbon footprint to develop comprehensive waste-reduction strategies.

Title
Epidemiology and survivorship of primary knee arthroplasty in young adults: analysis of 3069 cases from the Scottish Arthroplasty Project

Author: Scott R Morrison, Andrew J Hall, Jon V Clarke, Andrew Brunt, Muhammad Adeel Akhtar, Phil Walmsley

Background
There is a lack of information regarding survivorship and epidemiology in young adult patients undergoing primary knee arthroplasty (KA), despite increasing case load. This study aimed to evaluate the epidemiology of young adult patients undergoing KA and assess implant survivorship and revision risk.

Method
Retrospective review of prospectively collected national registry data from the Scottish Arthroplasty Project database evaluated patients aged 16 – 49 undergoing primary KA between January 2000 and December 2019. Data were analysed using SPSS.

Results
There were 3069 patients, 58.6% were female, mean age was 44 years, and median follow-up duration was 8 years. 79.6% of procedures were for osteoarthritis, with non-osteoarthritis causes more common in patients aged <35 years. 8.3% of cases required revision throughout the follow-up period, with the cumulative revision rate at 21 years being 14.2%. Lifetime revision risk for the cohort was estimated at 38.3%. Revision rate was lowest for patients aged <25 years and highest for those aged 40 – 44 years (3.1% vs 9.6%). Total mortality rate was 6.2%, which is greater than the age-adjusted general population mortality rate of 4.6%; the mortality rate was 4.7% in patients undergoing KA for osteoarthritis, versus 12.2% in non-osteoarthritis cases.

Conclusion
Revision risk for patients aged <50 years is greater than for those aged ≥50 years. Overall mortality was higher than in the general population; accounted for by an increased mortality in the non-osteoarthritis arthroplasty group. Revision risk remains high for younger patients, but specific groups appear at higher risk than others.

Title
Functional ultrasound assessment of Flexor Pollicis Longus (FPL) tendon to distal radius watershed line distance - variability amongst healthy participants. 

Authors: Jonathan Cormack, Zakaryia Abdulazeez, Reem Bedir, Adrian Chojnowski

Aim
To use ultrasound to measure the distance between FPL tendon and watershed line of the distal radius, in functional positions of healthy participants, to inform radiology protocols investigating tendon irritation post distal radius volar plate fixation and identify patients at higher risk of injury.

Methods
The ultrasound assessment of distance was performed by a consultant musculoskeletal radiologist in; 30o flexion, neutral and 30o extension. Function included pincer grips of 0/2/4kg. Preliminary data was limited to 6 healthy wrists aged 20-30 years, producing 42 data points. 

Results
In neutral, 4kg pincer grip produced the shortest distances (mean; 1.08mm), compared to 0kg (1.2mm). 2kg conversely increased distances (1.3mm).

In extension, any grip shortened distances (4kg 0.86mm; 2kg 1.0mm), compared to 0kg (1.12mm).

Unlike neutral and extension positions, in flexion, any grip increased distances (4kg 6.35mm; 2kg 5.35mm), compared to 0kg (2.45mm).

Conclusions
The results suggest that the FPL tendon is in closest proximity and most at risk in extended grip positions. Preliminary data suggests variability of tendon position with wrist position and pincer grip pressure.

The post-operative management of distal radius volar locking plates is controversial; from routine removal to ultrasound guided decision making in case tendon complications develop. However, ultrasound assessment can provide false reassurance. Indeed, the authors note case studies of FPL tendon rupture after normal ultrasound studies. Therefore, a clinically accurate, consistent and reproducible protocol is needed to measure the distance between FPL tendon and watershed line of the distal radius under various wrist positions and pincer grip pressures.

Title
Nail Plate Construct in Complex Distal Femur Fractures allow safe, early unrestricted weight bearing with high rates of union and a low rate of failure: five-year experience at a UK Major Trauma Centre

Authors and Affiliations

Tom Barrow MBBS, BSc, PGCert, MRCS,¹ Orthopaedic Registrar, Anthony Rayner MBBS, BSc, MRCS,¹ Orthopaedic Registrar, David Crone MBBS, FRCS (Tr&Orth), MIoL¹, Trauma & Orthopaedic Consultant, Enis Guryel MBBS, BSc, FRCS (Tr&Orth)¹, Trauma & Orthopaedic Consultant, Simon Francis Bellringer MBBS, BSc, FRCS (Tr&Orth), FEBHS,¹ Trauma & Orthopaedic Consultant, Alastair Robertson MBBS, BSc, FRCS (Tr&Orth),¹ Trauma & Orthopaedic Consultant, 1 – Department of Trauma and Orthopaedics, University Hospitals Sussex, Brighton, UK

Aims 
Distal femur fractures can be challenging to manage and fixation with either intramedullary nails or plates can result in failure of fixation. The use of linked nail plate constructs (NPC) has gained popularity for managing complex distal femur fractures. The five-year’s experience from a UK major trauma centre is reported and aims to identify appropriate indications and describe patient outcomes.

Methods
Patients treated for a distal femoral fracture with a NPC between 1^st January 2019 and 1^st January 2025 were identified. Patient demographics, fracture classification, procedural characteristics, post operative weight-bearing status, union rates, complications and mortality were recorded.

Results
32 patients were identified with a mean age of 70 years (20 to 98). 24 patients were female (75%) with a median ASA of 3. There were 5 open fractures (16%) and 10 peri-prosthetic fractures (31%). 8 NPCs were revision operations following failure of primary fixation (25%). All operations were performed by at least one consultant. In total 31 patients were permitted unrestricted weight bearing post-operatively (97%). Clinical union was achieved in 24 of 25 patients available for follow up (96%). There were no significant complications. Mortality rate at 30-days, 3-months and 12-months was 6%, 6% and 13% respectively.

Conclusions
This study supports the use of nail plate construct (NPC) in the management of both primary and revision surgery for complex distal femoral fractures. Among 32 patients with a mean age of 70 years, NPC permitted immediate unrestricted weight bearing (97%) with a high rate of union (96%) and a low complication and mortality rates. These findings highlight NPC as an effective option for managing complex distal femur fractures.

Title
SOS: Surviving Orthopaedic Surgery – preparing new SHOs for battle

Authors
John Ferns, Joseph Walker, Matthew Langstroth, Hunaynah Patel, Vladislav Kutuzov

Aim
To evaluate the usefulness of a half-day course in preparing new resident doctors for orthopaedic on calls and to understand the anxieties of new starters.

Method
All doctors attended a tailor-made 5-hour course in the North-West for new starters on the basics of orthopaedic examinations, managing emergencies and radiograph interpretation. To be eligible, they had to have minimal orthopaedic experience and be starting a T&O rotation the following month. After the course, a survey was sent out to all participants seeking demographic data and feedback.

Results
Respondents had an average of less than 4 weeks orthopaedic teaching in medical school. 53% of respondents deliberately sought an orthopaedic job and 29% were considering a career in orthopaedics. Overall confidence in managing an on call before the course was rated as 1.7/5 which rose to 3.8/5 after the course. 71% listed ‘lack of senior support’ as their main concern before starting orthopaedics.

Conclusions
Orthopaedics education is under-represented nationally in most medical school curricula. Most new orthopaedic FY2s are not considering a career in T&O. A half-day course can significantly increase the confidence of new SHOs about to start a rotation in orthopaedics. This may address a need for additional education in orthopaedics, make FY2s aware of avenues of senior support and could lead to improved SHO performance in the North-West.

Title
Closed Loop Audit Cycle of North of Scotland Deanery Trauma and Orthopaedic Surgery Post-Graduate Teaching achieved improved Trainee Satisfaction and Attendance

Background
Post-graduate teaching (PGT) is a vital part of trauma and orthopaedics (T&O) training. The intercollegiate surgical curriculum programme (ISCP) T&O curriculum outlines that a teaching programme should supplement clinical practice and achieve curriculum learning outcomes. Additionally it states educational governance should continuously improve the quality of education and training by audit, accountability and responding when standards are not met. This audit aimed to assess the quality and trainee satisfaction of PGT in the North of Scotland Deanery. The ultimate aim was to improve PGT in the deanery.

Methods
Qualitative data were collected via SurveyMonkey surveys. A baseline survey was circulated to all trainees in March 2024 recording PGT attendance, satisfaction, absence reasons, suggestions for improvements, and suitability of mandatory attendance. Interventions included teaching on the last Friday of every Month, allocated Lead Consultant for each PGT day, mandatory attendance of 70%, Viva practice at the end of each session, and Programme circulated in advance. Second survey 1 year post changes assessing same criteria.

Results
Overall Satisfaction (Satisfied/ Very Satisfied) improved from 0% to 100% with 92.3% of trainees selecting Very Satisfied. Initial Attendance was poor with 100% of trainees attending <5 sessions annually. The number attending <5 sessions dropped to 7.7%. Average attendance amongst pre-exam trainees was 8.2 sessions out of a possible 12 (68.3%).

Conclusions
This closed loop audit cycle achieved dramatic improvements to PGT in the North of Scotland Deanery. Further efforts are required to solidify the improvements, maintain standards and stive for better attendance.

Title
Enhanced tumour delineation using fluorescence lifetime imaging with ICG in human sarcomas

Corey D Chan¹, Rahul Pal², Thinzar M Lwin³, Murali Krishnamoorthy², Hannah R Collins², Kenneth S Rankin^1,4, Santiago Lozano-Calderon⁵, Anand T N Kumar²

1. Newcastle University Centre for Cancer, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
2. Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA, USA
3. Department of Surgical Oncology, City of Hope Hospital, Duarte, CA, USA
4. The North of England Bone and Soft Tissue Tumour Service, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
5. Department of Orthopedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA

Introduction
Despite advances in local and systemic therapies, the mainstay treatment of wide surgical resection of sarcomas has remained largely unchanged. Incomplete resection can lead to local recurrence and poorer survival. This work has demonstrated the potential of fluorescence lifetime (FLT) imaging using indocyanine green (ICG) for improving the sensitivity and accuracy of tumour margin identification in sarcoma surgery.

Methods
We performed an IRB approved clinical study of 22 patients undergoing surgery for sarcomas at Massachusetts General Hospital and Newcastle Hospitals who received ICG intravenously (0.5-1mg/kg) prior to surgery. Resection specimens were imaged using white light, fluorescence, and time-domain (FLT) imaging (Kumar lab), and histology images were annotated by pathologists. The distribution of fluorescence intensity and FLT within the tumour and normal tissue regions were measured and sensitivity, specificity, and ROC analyses were performed. 

Results
Of the 22 enrolled patients, paired tumour and normal tissue data were available for 8 patients. The average fluorescence intensity in the tumour was highly heterogeneous. Mean FLT in all tumours were significantly longer than the normal tissue FLT. The sensitivity and specificity for ICG-FLT in detection of tumours was 94.2 ± 3.0% and 93.3 ± 2.2% respectively, with an accuracy of 97.1± 1.3%.

Conclusion
In patients who have received ICG prior to surgery, the measurement of FLT demonstrated significantly longer lifetimes in tumour tissue compared to the surrounding normal tissue. While standard fluorescence intensity was able to highlight the tumour, FLT imaging had a higher sensitivity, specificity, and accuracy. This work demonstrates the promising potential application of FLT for next-generation fluorescence-guided surgery.

Title
MTC designation and its effect on DGH level trauma provision in Northern Ireland

Background
The NI Major Trauma Network provides a HEMS service, call and send protocol, and Major Trauma Ward serving the regional population.

The regional MTC also continues to deliver district general trauma care. The aim of this study was to review our fully operational system and define major trauma demographics, volume of major trauma cases and the impact this has on the provision and timely delivery of DGH level care.

Methods
A retrospective review was undertaken of all trauma calls to the MTC over a 6-month period.  Patient and injury demographics, operative details and number of theatre sessions utilized were reviewed to determine the number of operations provided in the MTC which would have previously been delivered in a peripheral trauma unit. 

Results
248 trauma calls occurred during the 6-month period.  69.8% came from outside the MTC trust.  83.4% were “bypass” calls.

The total number of bed days was 3139 days, of which 77% were for patients not within the MTC trust boundary.

A total of 96/248 (38.7%) patients sustained orthopaedic trauma, requiring a total of 136 theatre sessions, delivered by 149 consultants providing 163 individual operations.  These patients occupied a total of 1816 days, of which 72.5% were occupied by patients from outside MTC trust boundary.

After review, 108/136 sessions (79.8%) would have previously been performed in a peripheral trauma unit – equating to 216 hip fracture operations, or single theatre downturn of 41.5% (10.8 weeks in the 6 month) for DGH level trauma.

Conclusion(s)
Provision of a MTC significantly impacts hospital bed days.  It is resource intense and impacts on the availability to deliver DGH level care.

Implications
This data provides insight into the effect of being a major trauma unit and its impact on delivering DGH level surgery and would be useful for strategic and logistical planning.

Title
PREDICTING PATIENT REPORTED OUTCOME MEASURES FOLLOWING HIP AND KNEE ARTHROPLASTY USING SUPERVISED MACHINE LEARNING

Authors: Samantha Davies, Amr Selim, Andrew Roberts, Geraint Thomas, Paul Cool

Introduction
The role of machine learning (ML) in orthopaedics is expanding, with potential applications in analysing patient data and making predictive assessments. This project utilised NHS PROMs data from primary hip and knee replacements to identify key trends and assess whether this data can reliably predict recovery rates based on patient-reported outcomes and comorbidities.

Methods
The study used the NHS England national PROMs dataset for the 2018/2019 financial year, comprising 37,725 primary hip replacement entries and 43,639 primary knee replacement entries, each containing 139 variables. Key outcome measures included the Oxford Hip Score (OHS), Oxford Knee Score (OKS), EQ5D-3L, and EQ5D-Visual Analogue Scale (VAS). Python, with the scikit-learn (sklearn) library, was used to program and develop the ML models. Three supervised ML algorithms—Stochastic Gradient Descent (SGD), Classification and Regression Trees (CART), and Support Vector Machines (SVMs)—were tested independently.

Results
For primary hip replacements, the accuracy scores showed that SGD achieved 70%, CART 68%, and SVM 48%, while for knee replacements, SGD achieved 65%, CART 67%, and SVM 54%.

The ROC-AUC analysis further indicated AUC values for hip replacements as 0.72 for SGD, 0.70 for CART, and 0.59 for SVM. While for knee replacements AUC was 0.59 for SGD, 0.68 for CART, and 0.52 for SVM.

In precision-recall analysis, the average precision scores were 0.89 for hips and 0.79 for knees with SGD, 0.88 for hips and 0.84 for knees with CART, and 0.82 for hips and 0.74 for knees with SVM.

Interestingly, feature importance analysis revealed that preoperative anxiety and depression had the highest feature importance score (28.1) for predicting postoperative knee scores, whereas preoperative disability had the highest feature importance score (5.8) for predicting postoperative hip replacement scores.

Conclusion
ML models showed higher predictive accuracy for primary hip replacements compared to knee replacements. While this study demonstrates the potential of ML for predicting patient-reported outcomes, limitations in the reliability of current national PROMs data hinder its broader application. The lack of data validation within the national dataset raises concerns about accuracy, making it difficult to fully trust the model’s predictions without verification from individual organizations.

Title
Evaluation of X-Ray PPE for Orthopaedic Surgeons in TheatrE (EXPOSEd) Study: A National Survey of Trauma and Orthopaedic Surgeons

Authors: S Donoghue, C Miller, K Chui, H Sevenoaks, D Eastwood

Aims
To evaluate the accessibility and utility of current radiation personal protective equipment (PPE) provision and understand the experiences and radiation protection practises offered to all levels of Trauma and Orthopaedic (T&O) surgeons in the United Kingdom.

Methods
An incentivised electronic survey was sent to all UK T&O Surgeons during a 6-week period in 2024.  Responses to 27 multiple-choice questions were collected and free-text responses analysed by theme.

Results
677 responses from 196 UK NHS Hospitals were received: 33% were female. 67.2% were resident doctors and 32.8% were consultants representing a response rate of 39% for trainees and 11% for consultants. 25% agreed they could find appropriate lead gown PPE. 12% had been given dosimeters, although few had received feedback. 26% received mandatory training but many more (48%) had sought training individually. When undertaken, it was felt useful. Symptoms attributed to ill-fitting PPE were common and more likely to be reported by women (OR 2.5). 55% did not feel protected by their current PPE and 84% were concerned about the effects of IR on their health. Thematic analysis confirmed concerns relating to PPE availability, education, and inconsistent advice and guidance across hospitals. Health concerns and poor morale were also highlighted.

Conclusion
Employers must address the lack of compliance with the UK legislation Ionising Radiations Regulations 2017 (IRR17) in relation to access to PPE, training and monitoring.  There is a need for standardised national guidelines and training.

Clinical Relevance

• The current T&O workforce is concerned about both the perceived and real lack of relevant information concerning radiation risk in the workplace, PPE availability and appropriateness.
• These factors discourage doctors from entering our profession and leave those in the profession feeling unsafe.

Title
Final Destination Part III - Evaluating 4 years of the Transition to Consultant T&O Surgeon Course

Authors 
R Jayasuriya^1,2, Z Siddiqui¹, C Lewis^2,3,A Myatt^2,3, S McGrann¹, P Renwick², J Tomlinson^1,2

INSTITUTIONS: 1) Sheffield Teaching Hospitals NHS, UK; 2) Health Education Yorkshire and the Humber, NHSE, UK; 3) Leeds Teaching Hospitals NHS

Background
The transition from HST to consultant is complex, with gaps in non-clinical training unaddressed. Stage 1: Previous work by our group utilising a mixed methods approach characterised key topics within overarching themes that informed the development of the Transition to Consultant T&O Surgeon course. Stage 2: Delivered 4 iterations of the course between 2022-25. Stage 3: Aims to evaluate delegates’ perceptions of topic relevance and self-reported preparedness before and after course completion. Does an academic approach to course design lead to intended course outcomes?

Methods
A digital survey incorporating Likert scales and domains based on the Kirkpatrick model was administered pre- and post-course. Likert data was analysed using the Wilcoxon Signed Rank Test due to non-parametric distribution (Kolmogorov–Smirnov p<0.001). Post-course consolidation activity included reflective free-text responses analysed using a content directed approach (framework derived from traditional NVivo thematic analysis), using a large language model (LLM). Ethical approval: UoS REC 036405.

Results
Over 4 years, 85 post-fellowship exam participants completed pre-course assessments; 72 attended the course and completed post-course evaluation. Participants included 78% Trauma & Orthopaedics, 20% other surgical specialties, and 2% intensivists.

Significant increases in perceived importance were observed for Job Planning (p=0.033) and Managing Trainees and Fellows (p=0.017). Other topics—such as Departmental Roles, Private Practice, and Service Development—retained consistently high importance ratings (78–100% rated “important” or “very important”).

Self-assessed preparedness significantly improved across all domains post-course (p<0.001), with 1%-22% pre course increasing to 67-91% “Prepared” to “Very-Prepared” across key topic areas.

Qualitative analysis of reflective data aligned closely with themes from the course development study, reinforcing relevance. Kirkpatrick model evaluation demonstrated strong session performance, with six sessions reported likely to influence future behaviour and performance.

Conclusion
A mixed methods approach to course development yielded high relevance and impact as perceived by delegates. The Transition to Consultant Surgeon course effectively addresses non-clinical training gaps, enhancing preparedness for consultant responsibilities—an area not comprehensively covered in current surgical curricula. This academic approach to course design has led to well aligned outcomes.

Title
Outcomes of Robotic Total Hip Arthroplasty for Atypical Hip Anatomy:  Component Positioning, Functional Outcomes, Survivorship and Complications in 192 cases

B Kayani¹, J Enson*¹, J Donaldson¹, J Miles¹, S Newman¹, C Jayadev¹, J Stammers¹, JA Skinner¹

1. Royal National Orthopaedic Hospital, Brockley Hill, Stanmore HA7 4LP

Background
The objectives of this study were to determine the accuracy of component positioning, patient satisfaction, functional outcomes, component survivorship, and complications of robotic-arm assisted total hip arthroplasty (RO THA) in patients with atypical hip anatomy.

Methods
This study included 192 RO THAs performed in 182 patients for developmental dysplasia of the hip (n=122), Leg-Calve-Perthes disease (n=27), slipped capital femoral epiphysis (n=20), previous acetabular fracture (n=12), and skeletal dysplasia (n=11). Predefined radiological outcomes, patient satisfaction scores, the University of California at Los Angeles (UCLA) activity score, the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), the Oxford Hip Score (OHS), the Forgotten Joint Score (FJS), and any complications were recorded. The mean follow-up was 3.8 ± 1.7 years (range, 2.1 to 5.4 years).

Results
RO THA was associated with high accuracy in executing the planned horizontal (root mean square error (RMSE): 1.5 ± 1.4 mm) and vertical centres of rotation (RMSE: 1.8 ± 1.7 mm), combined offset (RMSE: 2.9 ± 3.8 mm), and leg-length correction (RMSE: 1.5 ± 1.4 mm). Acetabular component positioning within Lewinnek’s safe zones was 94.7%, and within Callanan’s safe zones was 93.8%. The median patient satisfaction score was 90 (IQR, 85 to 95), median WOMAC score was 18 (IQR, 12 to 20), and mean FJS score was 77.8 ± 10.8 at final follow-up. RO THA was associated with improvements in the mean UCLA (P < 0.001) and OHS (P < 0.001) at final follow-up. Five-year survivorship was 98.8% (95% CI: 95.8% to 100%) with implant revision for any reason as the end point.

Conclusions
RO THA in patients with atypical hip anatomy was associated with high accuracy in executing the planned hip biomechanics and acetabular component positioning. In this challenging patient population, RO THA was associated with excellent component survivorship, high patient satisfaction, good functional outcomes, and low risk of complications at short-term follow-up.

Title
Maternal and Foetal Health Outcomes in Pregnant Trauma Patients

Mr Usama Rahman, Dr Francesca Bladt, , Miss Hiba Junaid, Miss Shaimaa Ibrahim, Miss Jennifer Lane

Background
Trauma during pregnancy is rare in the United Kingdom (UK), affecting approximately 1% of pregnancies, yet it accounts for 20% of non-obstetric maternal deaths [1]. Despite its significant contribution to maternal and foetal morbidity and mortality, there are currently no UK national guidelines for the management of pregnant trauma patients (PTP). This is largely due to the absence of large-scale, randomised controlled studies [2] and observational studies that reflect current obstetric practices. Our aim is to explore maternal and foetal health outcomes in PTP of any trauma severity and at any gestational age.

Methods
This retrospective service evaluation uses anonymised, routinely collected clinical OMOP mapped dataset generated from EPR to better characterise pregnant trauma patients within the Barts Health NHS Trust. Trauma was be defined as any injury sustained during pregnancy. Patients included in the study were followed up for 270 days. Key outcomes included maternal, obstetric, and foetal complications, most notably, venous thromboembolism (VTE).

Results
Our data set includes around 140000 pregnancies with 8000 PTP. Preliminary data suggests PTP have a higher incidence of VTE events when compared to the general pregnant Barts Health population, irrespective of the anatomical location of the injuries with comparable proportions of patients with VTE prophylaxis. PTP also had a higher incidence of adverse maternal outcomes when compared the general Barts Health pregnant population. On the other hand, the assessment of foetal outcomes was limited by the lack of integrated maternal-infant record linkage, hindering the analysis of the effects of trauma on foetal well-being.

Conclusion
The preliminary analysis of this unique data set is promising and warrants further investigation on the occurrence of VTE and additional maternal and obstetric outcomes. Further findings and research may help improve the current handling of trauma during pregnancy and reduce the risk of adverse outcomes through tailored mitigation measures.

References

1. Ahmed, Z., Zargaran, A., Zargaran, D., Davies, J., Ponniah, A., Butler, P., and Mosahebi, A. (2024) ‘Fostering innovation and sustainable thinking in surgery: An evaluation of a surgical hackathon’, The Annals of The Royal College of Surgeons of England, 106(6), pp. 1–7. doi: 10.1308/rcsann.2024.001
2. De Vito, M., Capannolo, G., Alameddine, S., Fiorito, R., Lena, A., Patrizi, L., … Rizzo, G. (2022). Trauma in pregnancy clinical practice guidelines: systematic review. The Journal of Maternal-Fetal&amp;NeonatalMedicine, 35(25),9948–9955. https://doi.org/10.1080/14767058.2022.2078190

Title: 
Standardising lower limb elevation in trauma and orthopaedics to improve patient care

LJ Peck¹, C Gabarra¹, K Konar¹, M Ouwendijk¹, R Dyke¹, MJ Oddy^{1 1}Department of Trauma & Orthopaedics, University College London Hospital, 235 Euston Road, London NW1 2BU

Background:
Trauma and surgery to the lower limb cause swelling which can increase pain, delay surgery, and lead to wound complications (1,2). Lower limb elevation (LLE) improves swelling and pain in foot and ankle surgical patients, who are at risk of neurological or pressure-related complications including compartment syndrome. There are no agreed standards for LLE, and we observe marked variation of LLE practice.

Aims:
We aim to establish a new standard for LLE in adult trauma and orthopaedic (T&O) inpatients, optimising patient comfort (3).

Methods:
We conducted a point-prevalence observational study of 20 consecutive adult inpatients with T&O lower leg pathology. We assessed elevation method, limb position, and patient-reported comfort (“Yes/No”) at a single time point. A second cycle of 20 patients was conducted according to the same parameters after implementation of standardised re-usable devices (OrthoFoam) contoured to provide optimum elevation, knee support and lower limb orientation.

Results:
First cycle: All patients had LLE, however we identified significant variability in limb positioning. Only 55% were comfortable; this was significantly associated (p<0.001, Fisher’s Exact Test) with a supported (9/9 comfortable) versus unsupported (2/11 comfortable) knee position.

Second cycle: We collected data from 20 patients using OrthoFoam for LLE. There was significant reduction in variation of limb positioning, knee support and alignment of the shank (P<0.05).  Additionally, 95% of patients in the second cohort reported being comfortable (p<0.05 compared with non-standardised measures for LLE).

Conclusion:
We identified inconsistent LLE practice, risking prolonged discomfort and swelling for patients. The correlation between knee support and patient comfort was striking. OrthoFoam devices standardise limb positioning, and we have seen significant improvement in patient comfort as well as standardisation of limb positioning in this PDSA cycle. We plan to further analyse length of stay and opioid use, to assess cost-effectiveness and analgesic benefit of these devices.

References:

1.          Riedel MD, Parker A, Zheng M, Briceno J, Staffa SJ, Miller CP, et al. Correlation of Soft Tissue Swelling and Timing to Surgery With Acute Wound Complications for Operatively Treated Ankle and Other Lower Extremity Fractures. Foot Ankle Int. 2019 May 1;40(5):526–36.

2.          Chou LB, Lee DC. Current concept review: Perioperative soft tissue management for foot and ankle fractures. Foot Ankle Int. 2009 Jan;30(1):84–90.

3.          Manoukian D, Leivadiotou D, Williams W. Is early operative fixation of unstable ankle fractures cost effective? Comparison of the cost of early versus late surgery. Eur J Orthop Surg Traumatol. 2013 Oct 1;23(7):835–7.

Title
Predicting the survival of Meniscal Allograft Transplants – a multi-centre cohort study

Authors – Dylan Mistry, Faizan Arshad, Nicholas Smith, Tim Spalding

Background
Meniscus deficit knees do not benefit from the functions of the meniscus such as load distribution and chondroprotection. Meniscal allograft transplant (MAT) is a novel surgical management option and the MRI appearance in Meniscal Transplant Score (MIMS) is a validated tool for MAT health, scored out of 11. This study aimed to evaluate whether MIMS were predictive of patient related outcome measures (PROMS) or failure rate.

Methods
A retrospective study was carried out on a prospectively collected database of MAT patients in multiple centres. MIMS scores, relative percentage extrusion (RPE) and cartilage grading were judged based on an MRI scan taken one year post-operatively. Regression analysis and survival analysis were then used to predict the improvement in PROMS data from pre-operatively levels (KOOS 4 taken at year 1, 2, 3, 5, 10) and survival of the MAT.

Results
Of the 218 MAT patients with a mean follow up of 4.95 years, mean MIMS score was 6.87 (1–11) and RPE 36% (0-100). Mean improvement in KOOS 4 score was 21.2 (-34–79.5) pre- and post-operatively. As part of regression analysis, MIMS was shown to predict an improvement in KOOS 4 scores (p=0.002) but RPE was not significant (p=0.096). Fifteen patients experienced failure of their MAT, at a mean time of 3.65 years. Both MIMS and RPE were able to predict failure (p=0.007 and 0.004 respectively), as did survival analysis when splitting the cohort with a MIMS score ³6 or <6 (p=0.005), but cartilage grading did not.

Conclusion
This study is the first to our knowledge to compare a recognised MAT assessment tool to PROMS. This gives clinicians treating patients with a MAT the ability to predict the likely success and survival of the transplant based on the MRI findings at 1 year post-operatively. 

Title
Vertical Patellar Height Index (VPHI): A Simple Sagittal MRI-Based Tool for Assessing Patellar Lateralisation

Gad A, Thekkinithethil M, Elbannan M, Bayley MTrauma & Orthopaedic department, Swansea Bay UHB

Introduction
Patellar lateralisation plays a key role in patellofemoral instability, a common cause of knee pain and dysfunction. The tibial tubercle–trochlear groove (TT–TG) distance is widely accepted for assessing lateralisation, but it has limitations, particularly in knees with trochlear dysplasia or when axial MRI images are of poor quality. These challenges can make TT–TG measurements less reliable. To overcome this, we developed the Vertical Patellar Height Index (VPHI), a straightforward sagittal MRI measurement that reflects patellar lateralisation by comparing vertical patellar heights on different slices.

Methods
We retrospectively reviewed MRIs from 44 patients: 23 with diagnosed patellar mal-tracking and 21 controls undergoing knee MRI for unrelated reasons. To calculate the VPHI, we first identified the sagittal slice at the level of the anterior cruciate ligament (ACL), where we measured the vertical height of the patellar bone, spanning from its superior to inferior poles. Next, we measured the maximum vertical patellar height seen on any sagittal slice for that knee. The VPHI was then calculated as the ratio of these two measurements. A lower VPHI indicates greater lateral displacement of the patella since it reflects reduced patellar presence at the ACL level. We also measured TT–TG distances on axial images following standard procedures. Both VPHI and TT–TG values were analysed as continuous data and further classified into clinical grades. Groups were matched for age, sex, and affected side.

Results
Patients with mal tracking exhibited a significantly lower median VPHI of 0.69 compared to 0.90 in controls (p = 0.006), indicating increased lateralisation. Median TT–TG
distances were significantly greater in the mal-tracking group at 17 mm versus 10 mm in controls (p < 0.001). When graded clinically, severe VPHI lateralisation (Grade 4) was present in 30.4% of mal-tracking cases compared to just 4.8% of controls. Notably, VPHI grades correlated moderately with TT–TG grades (Spearman’s ρ = 0.425, p = 0.004), though continuous values did not show a significant correlation. These findings suggest that VPHI may provide complementary information to TT–TG in assessing patellar position.

Conclusion
The Vertical Patellar Height Index is a simple, reproducible sagittal MRI measurement that distinguishes patterns of patellar lateralisation effectively. Because it relies on sagittal images, VPHI may offer a practical alternative or adjunct to TT–TG, particularly in situations where axial imaging is suboptimal or trochlear morphology is abnormal. Future work will involve validating this index in larger patient groups and evaluating its reliability through inter- and intra-observer variability studies.

Title
The impact of co-locating Orthoplastic services at a major trauma centre on the management of Gustilo-Anderson grade IIIB and IIIC tibial fractures

Authors: Matthew Flintoft-Burt, Olivia Morgan, Matthew Towner, Nicholas Hancock
University Hospital Southampton

Background
This study aims to investigate the outcomes of open tibial fractures following a regional restructuring from offsite plastic surgery cover to a singlecentre Orthoplastics service within a major trauma centre (MTC).

Methods
Gustilo-Anderson grade IIIB and IIIC open tibial fractures presenting to the MTC from September 2012 to April 2018, and January 2019 to December 2023, were reviewed as pre- and post-restructuring groups. Demographics, injury mechanisms, and treatment details were recorded. Primary outcomes including time to initial debridement and definitive cover, rates of superficial and deep infection, non-union, and amputation were recorded.

Results
16 verses 91 fractures were identified in each group respectively. Mean follow-up was 46 verses 35 months. 95% verses 83% were grade IIIB, 5% verses 16% were grade IIIC. The mean hours to initial debridement were 11.3 verses 12.8, and definitive soft-tissue cover was achieved in 9.9 verses 9.8 days. 14% verses 20% achieved definitive fixation and soft-tissue cover within 72 hours. Outcomes were: superficial infection; 36% and 9%, deep infection; 12% and 8%, non-union requiring revision; 19% and 11%, early amputation; 9.5% and 28%, late amputation; 8.6% and 5%.

Conclusion
Implementing a single-centre Orthoplastics service improved the percentage of patients receiving definitive cover within 72 hours, and lower rates of superficial and deep infection and were observed. A higher number of primary amputations were performed, potentially due to increased early decision-making, with reduced late amputations. This study shows improved outcomes, but numerous clinical and logistical challenges remain. 

Title
Impact of Cryotherapy on Discharge Rates and Pain Management Following Knee Arthroplasty

P Zace¹, Y Roy², O Bailey¹, R Bhattacharrya¹, G Hopper¹ ¹NHS Lanarkshire, ²University of Glasgow