BOA Annual Congress 2025

Peter Eckersley, Rachel Lis, Chloe Willoughby 

North Manchester General Hospital, Manchester, United Kingdom 

Abstract 

Background: 

Pre-operative education is established in the pathway of care within elective orthopaedic surgery, with studies showing a positive effect upon several factors including early mobilisation.  

Achievement of early post-operative mobilisation is a Key Performance Indicator for all patients presenting to hospitals in England and Wales with hip fracture – and is recorded within the National Hip Fracture Database (NHFD). 

This study sought to ascertain whether pre-operative therapy education for patients awaiting surgery for hip fracture affected their achievement of the NHFD measure for early mobilisation, which is documented as: 

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

Methods: 

Pre-operative education was introduced for patients with hip fracture. This included verbal education of the full post-operative rehabilitation pathway, and verbal/written information regarding the importance of achieving early post-operative mobility.  

The effect of this change was measured in achievement of ‘Mobilised by Day 1’ for 150 patients either side of the change date.  

All patients within the samples had no documented cognitive impairment at the time of their admission to hospital. 

Results: 

150 patients prior to the introduction of pre-operative education: 

• Mobilised by Day 1: 69.3% 

(Average age 81.7 years; 70.4% female) 

150 patients following the introduction of pre-operative education: 

• Mobilised by Day 1: 83.0% 

(Average age 80.5 years; 73.0% female) 

Conclusion/Findings: 

The results indicate that the introduction of pre-operative education has helped to increase the rate of patients achieving early mobilisation following hip fracture surgery.  

Implications: 

For pre-operative education to be effective, patients need to be able to recall the information provided post-operatively. One limitation, therefore, of this project is that it excludes patients with a cognitive impairment.  

However, the results indicate positive benefits of our change of approach. Pre-operative education as described has therefore become embedded within our therapy offer to this patient group.  

Lucy Silvester1, Rebecca Kearney2, David McWilliams3, Gemma Pearce3, Shea Palmer4 

1University Hospitals Coventry and Warwickshire NHS Trust, Coventry, United Kingdom. 2Bristol Trials Centre, Bristol, United Kingdom. 3Coventry University, Coventry, United Kingdom. 4Cardiff University, Cardiff, United Kingdom 

Abstract 

Background 

Complex fractures are severe injuries that cause considerable disability. Effective rehabilitation is essential to achieve good outcomes, however, the literature shows a broad and varied approach with insufficient evidence to inform clinical practice¹. This study investigated stakeholder experiences to understand what components of rehabilitation were important to facilitate recovery. 

Methods  

Thirty-three interviews were conducted. Participants included adults with complex fractures, healthcare professionals who treat complex fractures, and commissioners who contract rehabilitation services. Inductive reflexive thematic analysis² was used to derive themes. Deductive analysis was applied to extract data on potential intervention components using the Template for Intervention Description and Replication checklist³.  

Results 

Themes: 

1. Personalisation – needs led and holistic, meaningful to the person, desire to see progress 

2.  Adjustment to reality – making sense of the situation, support system, practical reality 

3. Accessibility and delivery – skilled and flexible workforce, accessible, systems approach 

4. Professional support – guidance and active monitoring, navigate transitions, supervised physical activity. 

The rehabilitation components identified were exercise prescription, activities to regain function, self-management strategies, education, practical advice, psychological screening and talking therapies. Important components included coordination, personalised needs assessment, value-based goal setting, and peer support or social group interactions.  

People wanted a ‘menu of support’ delivered flexibly to meet their individual needs. There was a contradiction between what people wanted and what could be delivered, with workforce challenges and service capacity frequently mentioned.  

Conclusion 

This study identified what rehabilitation people want after complex fractures; however, questions remain around the best way to package and deliver an intervention. Rehabilitation should be personalised and holistic, with guidance from an experienced and competent professional. The approach should be consistent and coordinated focusing on meaningful activities specific to the individual. Further research is required to address the key uncertainties and design a rehabilitation intervention that could be adopted into clinical practice. 

Matt Dennies 

Mersey & West Lancashire Hospitals, Prescot, United Kingdom 

Abstract 

Background: Although most patients report high levels of satisfaction following Total Knee Replacement (TKR), 5% of patients will experience arthrofibrosis, leading to prolonged and challenging physiotherapy input and potential need for further surgery such as manipulation under anaesthetic (MUA). 

This audit assessed the feasibility of a pathway that treats patients with a JAS brace that are at risk of arthrofibrosis following TKR, aiming to improve range of movement, function, and prevent for further surgery. 

Methods: Patients were assessed for the pathway at six weeks post-op if they had not achieved 70° flexion or -20° extension, and at 12 weeks if they had not achieved 90° flexion or -10° extension. 

Outcomes measures assessed were: range of movement, Timed Up and Go (TUAG), Oxford Knee Score (OKS), complications, time from surgery to pathway, number of appointments, staffing costs. 

Results: Data was collected between June 2023 and June 2024. Eight patients were placed on the pathway, seven completed treatment. Two patients had flexion braces, average pre-pathway flexion was 75° (70-80), increasing by 13.5° (10-17) to 89° (87-90). Six patients had extension braces, average pre-pathway extension was -19° (15-30), increasing by 11° (5-16) to -8.5° (-5,-15). 

No complications from treatment were reported. OKS improved by an average of 7 (0-18), TUAG improved by 1.5 seconds (-3, 8). 

Average time from surgery to commencing the pathway was 73 days (25-121), with an average of 6 (4-10) appointments. Staffing cost £53.79 per patient. Total cost including the JAS Brace was £893, £463 less than an MUA. 

Conclusion: The pathway is safe and effective, improving range of movement, function and gait. Although the sample size is small, it suggests a cost-effective alternative to an MUA. A retrospective analysis of MUA rates 1 year post TKR should be conducted to assess the impact of the pathway. 

Disclosure: None 

Bernard van Duren1,2, Mohamad Taufiqurrakhman2, Alison Jones2, Mark Higgins1, Andrew Manktelow1, Benjamin Bloch3, Hemant Pandit2 

1Nottingham University Hospitals Trust, Nottingham, United Kingdom. 2University of Leeds, Leeds, United Kingdom. 3University of Leeds, Nottingham, United Kingdom 

Abstract 

Cemented polished taper slip (PTS) stems are the femoral implant of choice for total hip replacement in many locations worldwide. There is increasing evidence that peri-prosthetic fracture contributes significantly to reoperation with these stems. The aim of this study was to explore how mismatches at the implant-cement interface (ICI) may occur and the potential effect of these incongruities on the contacting area and the forces transmitted to the cement mantle. 

A parametric equation-based model was developed to determine the contact mismatch relative to axial stem rotations. This model was also used to calculate the restoration of contact surface area with stem subsidence for both a dual-taper and triple-taper cross-sectional geometry. A finite element analysis (FEA) was subsequently used to compare the effects of reduced contact area due to the incongruent hip implant-cement interface. Specifically maximum stresses, total strain, and deformation were calculated. 

The contact model showed a large decrease in surface contact area with even only a small rotation going from 100% at 0° to 50.00% at 0.25° for both geometries. There was a gradual further decrease in contact with increasing further rotation. For both cross-sectional geometries, there was an increase in contact surface area with an increase in subsidence resulting in contact for up to a 5° mismatch being restored with 2mm subsidence. FEA showed that with increasing mismatches and consequent contact area reduction there was an increase in forces and stresses at the ICI. Analysis of von Mises stress at the ICI showed an increase of up to 235% when there was a decrease in contact area. 

With increasing mismatch there was an increase in maximum stresses, total strain, and subsidence in the cement mantle. These findings highlight the importance of achieving an optimal implant-cement interface at the time of implantation of cemented PTS femoral stems. 

Mohamad Taufiqurrakhman1, Mark Higgins2, Andrew Manktelow2, Benjamin Bloch2,3, Hemant Pandit1, Bernard van Duren2,1 

1University of Leeds, Leeds, United Kingdom. 2Nottingham University Hospitals, Nottingham, United Kingdom. 3University of Nottinham, Nottingham, United Kingdom 

Abstract 

Cemented polished-taper slip (PTS) stems are the most commonly used design for primary THA in the UK. Periprosthetic fracture is a major contributor to reoperations after PTS implantation. Stem centralisers help create an even cement mantle and allow subsidence, which is essential to the “force-closed” PTS design for maintaining fixation. However, if subsidence exceeds the centraliser's allowance, the implant becomes “shape-closed,” potentially introducing stress concentrations within the cement mantle. This study used finite element analysis (FEA) to assess changes in stress distribution when further subsidence is restricted. 

A 3-D scanner (0.08 mm accuracy) and CAD software were used to model three commonly used PTS stems: C-Stem, Exeter, and CPT. Stems were modelled with a 4 mm cement mantle and centraliser gap. FEA simulated loading conditions (6,900 N) with and without distal space to represent scenarios with/without a subsidence gap. Stem material variations (SS316L, Co-Cr) were also modelled. Peak stress, von Mises stress, and cement deformation under load were evaluated. 

With space to subside, maximum von Mises stresses occurred mostly in Gruen zone 7, with CPT showing the highest (~45 MPa). Without a subsidence gap, peak stress shifted to the distal tip (zone 4), increasing by 49–102% depending on stem design and material. Across all models, Co-Cr further increased distal stress compared to SS316L. 

This study demonstrates that when PTS stems reach the centraliser's subsidence limit, stress in the distal cement mantle increases markedly. Stem design, material, and implant-cement interface friction affect stress distribution and subsidence, potentially contributing to cement failure and periprosthetic fracture risk. 

Matthew Welck1, Alexander Beer1, Hussain Al-Omar1, Ali Najefi2, Shelain Patel1, Nicholas Cullen1, Togay Koc3, Karen Malhotra1 

1Royal National Orthopaedic Hospital NHS trust, London, United Kingdom. 2Northwick Park Hospital NHS trust, London, United Kingdom. 3University Hospital Southhampton, London, United Kingdom 

Abstract 

Background 
 
First metatarsal Pronation is increasingly recognised as an important component of Hallux valgus (HV) and can contribute towards intraoperative malreduction, postoperative recurrence and patient reported outcome measures (1,2,3). There are numerous radiological ways to measure metatarsal rotation on plain radiographs and weight bearing CT (WBCT), however there are no clinical tests to evaluate metatarsal pronation pre- or intra-operatively.  

This study aimed to examine the relationship between clinical pronation of the toe and metatarsal pronation. 
 
Methods 
Single-centre, retrospective analysis over 5 years. Measurements were performed on WBCT images with digital reconstructions to add soft tissues. First metatarsal rotation was measured using the Metatarsal Pronation Angle as previously described (4). Toe rotation was measured by the Phalangeal Condylar Angle (PCA), the angle between the condyles of the proximal phalanx and the floor, and the Nail Plate Angle (NPA), the angle of the base of the nail plate to the floor in the coronal Plane. These were obtained from 50 feet in Hallux valgus patients, and 50 control patients with CTs done for osteochondral lesions without hallux valgus or hindfoot malalignment. 
 
Results 
The HV group comprised 41 women and 9 men, mean age 52.4. Control group, 23 women and 23 male, mean age 40.25. Inter and Intra Observer reliability both excellent (ICC >0.95) for all measurements. When comparing HV vs control, MPA was 11.7 vs 6.0 (p<0.001), PCA 31.8 vs 4.7 (p<0.001), NPA 18.3 vs 6.0 (p<0.0001). NPA correlated with PCA. NPA and PCA correlate with Hallux valgus Angle (p<0.001), but not with MPA (p 0.567). 
 
Conclusions 
These results suggest that clinical toe pronation increases as HV angle increases but not with metatarsal pronation, which therefore cannot be used as a clinical marker.  Toe pronation is similar at the base and at the nail, suggesting rotation happens at the MTPJ. 

Arvind Vijapur1, Mohammed Shaath2, Shelain Patel3, Nick Cullen3, Matthew Welck3, Karan Malhotra3 

1Buckinghamshire Healthcare NHS Trust, Aylesbury, United Kingdom. 2ROYAL FREE LONDON NHS FOUNDATION TRUST, London, United Kingdom. 3Royal National Orthopaedic Hospital, Stanmore, United Kingdom 

Abstract 

Aim 

The distal metatarsal articular angle (DMAA) is a measurement used in surgical decision making of hallux valgus correction. However, it is difficult to measure on plain radiographs, is subject to projection bias, and its role in pathology is unclear. With the advent of weight-bearing CT (WBCT), our understanding of hallux valgus as a multiplanar deformity has evolved. The aim of study was to investigate whether there is a relationship between the DMAA and pronation of the first metatarsal head in patients with hallux valgus. 

 Methods 

This was a single-centre, retrospective analysis of 50 patients with hallux valgus deformity who had WBCTs obtained as part of routine pre-operative work-up. Patients with metatarsophalangeal joint arthritis, hindfoot deformity and previous surgery were excluded. From the WBCT images digital radiographs were created and the DMAA measured. Measurements were taken by 2 authors, each repeated twice and the average of all four measurements used in analysis. We also measured intermetatarsal angle (IMA), hallux valgus angle (HVA) and metatarsal pronation angle (MPA). 

 Results 

There were 41 females and 9 males, mean age 52.4±15.8 years. IMA was 14.5±3.3 degrees, HVA was 29.3±8.4 degrees, MPA was 11.7±6.3 degrees, and DMMA was 15.5±5.3 degrees. Intraclass correlation coefficient (ICC) for intra-observer reliability was 0.829 for assessor 1 and 0.910 for assessor 2.  ICC for inter-observer reliability was 0.727. Pearson’s correlation revealed no link between IMA and DMAA, nor HVA and DMAA. However, there was a significant (albeit small) correlation between MPA and DMAA (r=0.337, p=0.017).  

 Conclusion 

There was reasonable reliability in measuring DMMA between authors on WBCT although there was variation in measurements. Despite this, DMAA appeared to increase with increasing metatarsal pronation. The DMAA may therefore be  projection artefact secondary to metatarsal pronation and surgeons should be aware of this during surgical planning.  

Prashant Singh, Amy Still, Karan Malhotra, Panagiotis Poulios, Muhammad Chatoo, Shelain Patel, Nick Cullen, Matthew Welck 

Royal National Orthopaedic Hospital, London, United Kingdom 

Abstract 

Background 

This study aimed to examine the relationship between sagittal plane alignment and patient-reported outcomes measures (PROMs) in patients undergoing ankle / tibiotalocalcaneal (TTC) arthrodesis.  

Methods: 

Retrospective review of patients undergoing ankle or TTC arthrodesis over 8 years. Measurements were performed on WBCT images: anterior/medial distal tibial angles (aDTA / mDTA), coronal talar tilt, and sagittal tibial-sole angle (TSA), tibio-talar angle (TTA), and tibio-calcaneal inclination angles (TCA). These were obtained from 50 normal patients and 42 patients undergoing fusions pre-operatively and at 3 and 12 months postoperatively. MOxFQ scores were collected pre- and post-operatively and post-operative subjective alignment was recorded.  

Results: 

Mean age was 56±12.9 years and BMI was 30.5±5.1 kg/m2. Ankle arthrodesis was performed in 35/42 (83.3%) patients. Pre-operative deformity was >10 degrees from normal in sagittal/coronal plane in 8 patients (19%) and moderate (±5 degrees) in 8 patients (19%). There was no difference between normal group and post-operative group TSA (p=0.058), although there was a lower (more dorsiflexed) TTA (5.0 degrees, p<0.001) and TCA (2.9 degrees, p=0.037) in post-operative scans. There was no difference in sagittal post-operative position by type of fixation, ankle/TTC, arthroscopic/open or degree of pre-operative deformity. Significant improvements were observed in all MOxFQ domains (p<0.01). Age/BMI/final position did not influence PROMs. On regression analysis, lower TSA was the only factor predictive for a subjective feeling of a dorsiflexed foot (p=0.021, Exp(B)=0.472).  

Conclusions 

Regardless of pre-operative deformity, Ankle/TTC arthrodesis is effective at restoring sagittal alignment and improves PROMs. Although variation exists in TTA, TCA may compensate partially for this resulting in a balanced foot (TSA). TSA influenced perceptions of sagittal balance, particularly when dorsiflexed. It is important to strive for optimal sagittal alignment in ankle and TTC arthrodesis, which is judged intra-operatively by the TSA. 

Philippa Dolphin1, Sarah Johnson-Lynn1,2 

1The James Cook University Hospital, Middlesbrough, United Kingdom. 2University of York, York, United Kingdom 

Abstract 

Background 

The lifetime prevalence of symptomatic ankle arthritis is 3.4% (Murray, 2018) and symptomatic mid- and hindfoot arthritis affects 1 in 6 older adults (Thomas, 2015). The majority of this disease burden falls on women, manual workers and those with higher markers of socioeconomic deprivation (Roddy, 2015). 

There is no agreed pathway in the UK for physiotherapy after foot and ankle arthritis surgery and there is little evidence to guide treatment. This has led to the role of physiotherapy in foot and ankle conditions being made a JLA top 10 priority. 

Methods 

A survey of current physiotherapy practice following foot and ankle arthritis surgery was conducted in the UK via the BOFAS AHP network and a paired questionnaire was disseminated to the BOFAS surgical membership. There were 106 surgeon questionnaire responses, 95% from consultant members. There were 26 responses to the AHP questionnaire, 92% of responses being from band 7 and 8a specialist foot and ankle or lower limb physiotherapists. 

Results 

Most surgeons felt that the most important purpose of post-operative physiotherapy was to normalise gait (60% after ankle fusion, 64% after foot fusions), however physiotherapists were equally likely to believe that managing patient expectations was most important (29%; 29%). 

Only 35% of units employed a specialist foot and ankle physiotherapist and 32% of surgeons felt that their patients had inadequate access to foot and ankle physiotherapy. 18% of units have rehabilitation protocols for patients after foot and ankle fusion surgery. Most patients receive 5 or fewer sessions of physiotherapy post-operatively (73% of ankle fusion and 78% of foot fusion patients). 

Conclusion 

Most UK patients will receive physiotherapy after foot and ankle fusion surgery but access is variable and most centres do not use a protocol. 

Disclosure 

Senior author is a member of the BOFAS Scientific Committee. 

Kanatheepan Shanmuganathan1, Ahmed Zainy1, Rewant Singh1, Mansi Chitnis2, Ali Najefi1 

1Northwick Park University Hospital, London, United Kingdom. 2Imperial College London, London, United Kingdom 

Abstract 

Background: 

The management of ankle fractures in the elderly is complicated by comorbidities, poor local soft tissue quality, and osteoporosis. Recent trends have shifted from non-operative approaches to rigid fixation techniques, such as Fibula Pro-tibia (FPT) fixation, to facilitate earlier mobilisation in osteoporotic fractures. 

Objectives: 

This study primarily aims to compare revision rates and time to full weight-bearing between patients undergoing FPT fixation and those receiving standard open reduction and internal fixation (ORIF). Secondary outcomes include hospital length of stay, functional status, and complication rates. 

Methods: 

A retrospective review was conducted of 52 patients over the age of 70 who underwent surgical management for unstable ankle fractures at a District General Hospital between January 2020 and December 2024. Patients were treated with either ORIF (n=38) or FPT fixation (n=14). Data collected included patient demographics, comorbidities, operative times, weight-bearing status, and postoperative complications. 

Results: 

The two groups were comparable in terms of demographics and fracture patterns. All patients sustained closed fractures, with similar rates of dislocation (~63%). FPT fixation was associated with a shorter time to full weight-bearing (32.2 days vs. 43.4 days) and a reduced length of hospital stay (8.7 days vs. 12.9 days) compared to ORIF. Revision rates were similar between groups (7.1% for FPT vs. 7.8% for ORIF), as were overall complication rates (21.4% vs. 21.1%) including wound complication rates (7.1% vs. 7.8%). There were no cases of metalwork failure. Operative time was also shorter in the FPT group (92.0 minutes vs. 107.3 minutes). 

Conclusion: 

FPT fixation enables earlier full weight-bearing in elderly patients with unstable ankle fractures compared to standard ORIF, without increasing the risk of complications or revision surgery 

Wajiha Zahra1, Abdul-Rahman Gomaa2,3, Jubri Babatunde4, Mina Seifo1, David Ford1,5, Paul Cool1,5,6, Simon Pickard1,5 

1The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust, Oswestry, United Kingdom. 2Trauma & Orthopaedics Department, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, United Kingdom. 3School of Medicine, University of Liverpool, Liverpool, United Kingdom. 4Royal Wolverhampton NHS Trust, Wolverampton, United Kingdom. 5Royal Shrewsbury Hospital, Shrewsbury and Telford Hospital NHS Trust, Shrewsbury, United Kingdom. 6School of Medicine, Keele University, Keele, United Kingdom 

Abstract 

Introduction 

Ankle fractures are common injuries, with a significant proportion requiring surgical intervention. Despite established treatment principles, the optimal timing for open reduction and internal fixation (ORIF) remains debated. Concerns regarding wound infection risk have led some surgeons to delay fixation, while others advocate for early intervention. This study aimed to assess the impact of surgical timing on postoperative wound infections.   

Methods 

A retrospective review was conducted on 1,130 patients with surgically treated closed ankle fractures at a single institution between 2000 and 2022. Patients were categorised into three groups based on time to surgery: Early (<48 hours), Intermediate (48 hours to 5 days), and Delayed (>5 days). Postoperative complications, including superficial and deep wound infections, were recorded. The Kruskal-Wallis test was used to assess associations between surgical timing and infection rates.   

Results 

There was no significant association between surgical timing and either superficial (p=0.127) or deep wound infections (p=0.050). Diabetes, particularly Type 1, was significantly associated with both superficial (p<0.001) and deep infections (p=0.030). Patients over 60 years old were significantly associated with an increased risk of superficial infections (p=0.016) but showed no significant correlation with deep infections (p=0.261).Superficial wound infections required longer hospital stay (p<0.001) due to the need for intravenous antibiotics and monitoring purposes, while the number of procedures significantly correlated with both superficial (p<0.001) and deep infections (p<0.001).   

Conclusion 

In this study, the timing to surgery did not influence postoperative wound infection rates following ORIF for ankle fractures. Instead, patient-related factors including diabetes and age are stronger predictors of wound complications. Length of hospital stay, and the number of procedures were longer in patients with infection. Delaying surgery to reduce infection risk appears unnecessary. 

Yizhe Lim, Laura Clifton, Anji Kingman, Paul Rushton, An Murty, Rajesh Kakwani, Jonathan Coorsh, David Townshend 

Northumbria Healthcare NHS Foundation Trust, North Shields, United Kingdom 

Abstract 

Background: 

The HINTEGRA is a third-generation, mobile-bearing total ankle replacement (TAR) that has been popular in the UK. We present the long-term outcomes with a minimum of follow-up period of 10-years. 

Methods: 

In this prospective single-centre cohort study, all HINTEGRA TARs performed between 2010–2014 were analysed. Demographics, complications (Glazebrook classification), reoperations and revisions (COFAS classification), and patient-reported outcome measures (PROMS) were collected. Survivorship was assessed using Kaplan-Meier analysis. 

A total of 69 patients (70 ankles) were included. Mean age was 69 years (48-84 years). 21 patients died (30%) and 8 patients were lost to follow-up. 

Results: 

Implant survivorship was 81.7% at 5 years (mean 6.4 years), and 71.7% at 10 years (mean 12.3 years, 10.1-14.3 years). Complications included low (12.9%), medium (2.8%), and high-grade events (18.6%), with aseptic loosening being the most common serious complication (12.9%). 

Revision surgery was performed in 16 ankles (22.9%). Non-revision procedures were carried out in 9 patients (12.9%) with majority being cyst debridement and grafting (n=6, 8.6%). 

Periprosthetic cysts were identified in 36 patients (51.4%), most were asymptomatic and located in the tibia. Average volumes measured on CT scan for tibial, talar and fibular cysts were 1.5 cm³, 1.9 cm³, and 1.1 cm³ respectively. Indication of grafting of cysts were symptomatic ankles with stable implants, and/or >50% weight-bearing surface and/or expanding in size (n=6). Graft incorporation was variable, irrespective of impaction autograft or synthetic graft. Loose implants with cysts prompted revision arthroplasty (n=7) and tibiotalar joint fusion (n=1). 

Conclusion: 

The 10-year survivorship of the HINTEGRA TAR was 71.7%. We identified high rates of periprosthetic cysts and would recommend a low threshold for radiographic surveillance.  

Disclosures: 

The authors declare no competing interests relating to this study. DT, RK, AM are paid consultants for Stryker and Exactech. 

Matthew Farrugia1, Siva Sirikonda2, Anjani Singh2 

1Leighton Hospital, Crewe, United Kingdom. 2Liverpool University Hospitals, Liverpool, United Kingdom 

Abstract 

Background 

Metatarsalgia is an generic term used to describe localised forefoot pain around the metatarsals. Primary metatarsalgia is thought to be caused by excessive loading over one or multiple metatarsal heads resulting in localised inflammation and painful callosities. Maestro et al.in 2003, described an ideal foot morphotype which is currently used to plan for corrective osteotomy in patients with  metatarsalgia. The aim of this study is to investigate whether there is a true difference in metatarsal lengths between symptomatic and asymptomatic individuals. 

Methods 

A retrospective single centre study was carried out between 2019 and 2020. Weightbearing dorsoplantar foot radiographs and patient notes were screened. Patients were grouped into two groups, Group A: Asymptomatic and Group B: Primary metatarsalgia. Exclusion criteria were set to exclude patients with previous foot surgery and secondary causes of metatarsalgia (e.g. Morton’s Neuroma). Metatarsal length differences were measured according to Maestro’s criteria using Carestream. Measurments were taken as, 1st metatarsal - 2nd metatarsal (M1-M2), M2-M3, M3-M4 & M4-M5. 

Results 

There were 172 patients in Group A and 34 patients in Group B. There was no statistically significant difference across all four metatarsal length differences. This highlights that there is no true overall difference in the metatarsal arcade between the two groups. Twelve patients in group B (35%), underwent Weil’s osteotomy. In this sub-group there was a significant difference in the pre-operative metatarsal length difference between M2-M1 only (p = 0.035) compared to Group A. This was due to a longer 2nd metatarsal (p = 0.039).  

Conclusion/Findings 

Our results highlight that primary metatarsalgia is an uncommon condition and these patients have a similar metatarsal arcade when compared to the “normal” asymptomatic foot. A subset of patients with primary metatarsalgia have a long 2nd metatarsal which may benefit from Weil’s osteotomy correction. 

Disclosure 

Nothing to declare. 

Thumri Paavana, Joanna Reeves, Harry Poole, Neil Postans, Caroline Stewart, Catriona Heaver 

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

Abstract 

Background 

Tibialis posterior is commonly involved in neuromuscular and degenerative conditions. Obtaining electromyography (EMG) can be helpful in determining pathological muscle function. Due to its deep posterior compartment location it can only be reached with fine wire electrode placement.  

At our institution we traditionally place these fine wires using a measured palpation technique, with nerve stimulator confirmation. This has not been documented in the literature. As part of a recent BOFAS funded study of tibialis posterior function, we adopted a mid-calf level of insertion (in line with published studies) under ultrasound guidance to standardise wire placement 

This study compares new and old fine wire insertion techniques. 

Method 

We compared data from our old, distal technique to the new, more proximal and USS guided technique. 

Distal technique: N=20, 10 Female, Mean Age 40.5 years (SD 10.7) 

Proximal technique: N=30, 15 Female, Mean Age 43.5 years (SD 16.1) 

Subjects walked at self-selected speed, with EMG data collected from six walks. The EMG signal was rectified, low pass filtered, and amplitude normalised to the maximum for the walk. A minimum of two gait cycles from each walk were used to create an average EMG profile for each subject. Ensemble average EMG profiles for each cohort were compared using statistical parametric mapping. 

Results 

EMG signals from both techniques were comparable in healthy control subjects.   

Discussion 

The new technique is technically more challenging, requiring basic ultrasound skills. It provides better assurance that the electrode is located in the tibialis posterior muscle. The old technique does not require ultrasound expertise but risks electrode misplacement especially in pathology where the anatomy may be altered. 

Conclusions 

Either approach is appropriate in subjects with near normal anatomy. The new approach is however supported by published studies and gives greater assurance of placement in the presence of significant pathology. 

Abdul-Rahman Gomaa1,2, Jejelola Apata-Omisore1, Arjun Paramasivan1, Ahmed Galhoum1, Luke Marsh1, Nicholas Ward1, Shahjahan Aslam1, Lyndon Mason1,2 

1Liverpool Orthopaedic & Trauma Service, Liverpool University Hospitals NHS Foundation Trust, Liverpool, United Kingdom. 2School of Medicine, University of Liverpool, Liverpool, United Kingdom 

Abstract 

Introduction 

Fifth metatarsal fractures are common injuries. There is current disagreement on the preferred treatment, with certain fracture types. The aim of this study was to investigate time to discharge across all 5th metatarsal fracture and their respective fracture mapping patterns. 

Methods 

A historic cohort study was performed of all fifth metatarsal fractures presenting to our unit between February 2016 - July 2021 was performed. Date of injury, fracture morphology and zones involved, clinical and radiographic follow up as well as surgical interventions were collected. 

Results 

1331 fractures were included in this study. The fracture pattern with the longest time before discharge was a fracture spanning zones 2-3 (mean 11.40, 95% CI 5.65, 17.15), followed by a fracture limited to zone 3 (mean 9.72, 95% CI 1.14, 7.31). Both fractures patterns had significantly longer times to discharge than zone 1 (p<.001), zone 1-2 (p<.001), zone 2 (p<.001), zone 2-shaft (p=.001), zone 3-shaft (p=.004) and shaft fractures (p<.001).  

Fractures spanning zone 2-3 and zone 3 were the highest to undergo surgery (11.63% and 9.09% respectively) which was significantly greater than other fracture types (p=.003). The average time to surgery was 21.85 weeks (95% CI 8.87, 34.82), with the average time to discharge post-surgery of 8.07 weeks (95% CI 5.08, 11.07).  

Conclusions 

Fractures spanning zone 2-3 (typical Jones) and zone 3 fractures have the highest time to discharge and highest rate of surgery. Time to surgery is low, in keeping with surgery proceeding not typically for chronic non unions but for more acute presentations. All fractures undergoing surgery united, with only short follow up required post-surgery. 

Akhilesh Pradhan1, Parmjeet Chattha2, Jay Ghelani2, Randeep Aujla1 

1University Hospitals Leicester NHS Trust, Leicester, United Kingdom. 2University of Leicester, Leicester, United Kingdom 

Abstract 

Background: The advent of social media has increased exposure to orthopaedic surgery and heralded a new platform for the discussion of ideas, education and career insight that was not previously possible. This study seeks to explore the platforms most frequently used by medical students, their engagement with content, and how social media shapes their perceptions of different medical specialties. 

 Methods: A prospective national questionnaire was electronically sent to medical students across the United Kingdom. Questionnaires were collecting using the Google Forms platform and consisted of 21 questions with both qualitative and quantitative question styles. 

 Results: 155 responses were received from 13 different medical schools. 43.8% of responses were final year students with 81.8% between 18-25 years. On average, each student had 2.6 social media platforms with 94.8% of students using Instagram and only 22.7% using X/Twitter. 57.8% actively follow orthopaedic accounts; 73.2% follow educational accounts. 46.1% felt social media had changed their perception regarding orthopaedics with 66.2% rating this to be in a negative manner. 70.8% felt that orthopaedic social media accounts did not adequately showcase diversity; only 4.5% strongly agreed that women in surgery are fairly represented on orthopaedic social media. However, 75.3% felt that social media can improve networking and professional development within the orthopaedic community. 65.6% believe future orthopaedic social media accounts can help positively influence the perception of orthopaedics to medical students.  

 Conclusion: Social media is an important tool in enhancing the transfer of knowledge, networking and opportunity within the orthopaedic community. Medical students use social media for education/increasing their exposure to the speciality. While social media offers significant opportunities for medical students to explore orthopaedics, intentional efforts to promote diversity and inclusivity will be key to positively influencing perceptions and encouraging a broader range of students to consider this dynamic and rewarding speciality. 

Patrick Cook, Chris Wakeling 

University Hospitals Sussex, Brighton, United Kingdom 

Abstract 

Background 
Patient-Reported Outcome Measures (PROMs) have revolutionised the evaluation of patient-centred care in orthopaedics, shifting focus from clinical and implant-survival metrics to holistic patient experiences. However, traditional paper-based systems burden healthcare systems with inefficiencies and unknown rising costs. This study quantifies NHS expenditures on PROMs collection from 2015–2025, revealing a £31.1 million financial footprint.  

Methods 
Freedom of Information (FOI) requests were issued to all NHS trusts participating in the National Joint Registry. Data from 71 trusts were analysed after exclusions for incomplete records, commercial sensitivities, or non-compliance. Costs were extrapolated using statistical modelling to estimate national expenditures for trusts unable to provide data.  

Results 
Total estimated NHS spending reached £31.1 million over the decade, peaking at £4.3 million in 2024. Notably, only 35 trusts could respond to the FOI request, also indicating systemic fragmentation in data governance. 

Conclusion 
Digital integration and centralisation could save significant costs while improving data accuracy. This study advocates for hybrid, more automated, systems, dedicated PROMs roles, and real-time analytics to address declining response rates. Orthopaedics should lead this transformation to align with the NHS Long Term Plan’s digital ambitions before further expansion to PROMS and Implant Registries. Centralised and accessible data collection could also allow the avoidance of duplication for future studies. 

Mueed Ijaz1, Rasi Mizori1, Ali Hassan1, Hamza Tareen1, Yasser Al Omran2, Omar Musbahi3 

1King's College London GKT School of Medicine, London, United Kingdom. 2Royal Free London NHS Foundation Trust, London, United Kingdom. 3Imperial College London, London, United Kingdom 

Abstract 

Background: Intraoperative fluoroscopy is indispensable in orthopaedic surgery, enabling minimally invasive techniques. However, its growing use raises concerns about cumulative radiation exposure to patients and surgical teams. This systematic review aimed to identify and synthesise key factors influencing intraoperative radiation exposure in orthopaedic procedures. 

Methods: A systematic search of Medline, Web of Science, and Cochrane CENTRAL was conducted in February 2025. Eligible studies reported intraoperative radiation metrics—such as fluoroscopy time, dose area product (DAP), or effective dose—and stratified outcomes by surgeon experience (consultant vs trainee) or imaging modality. Risk of bias was assessed using the Newcastle–Ottawa Scale. 

Results: Fourty-one studies were included: fifteen assessed surgeon experience, and twenty-six examined imaging modality. Twenty-seven used radiation dose as the outcome, while fourteen measured fluoroscopy time. Of the fifteen studies assessing surgeon experience, twelve reported significantly lower exposure when consultants operated, with dose differences ranging from a 42.3% reduction to a 14.4% increase. The twenty-six studies on imaging modality spanned various orthopaedic procedures. On average, navigation reduced radiation exposure by 55.4% compared to freehand techniques, while robotic-assisted surgery resulted in a 56.2% reduction versus fluoroscopy-guided methods. Dual fluoroscopy achieved a 33.9% reduction compared to single fluoroscopy. Protocol modifications such as ALARA settings halved exposure, and FLASH imaging cut fluoroscopy time by over 94%. 

Conclusion: Both surgeon experience and imaging modality significantly influence radiation exposure during orthopaedic procedures. Consultants typically used less radiation than trainees, though variability exists. Advanced imaging methods—including navigation, robotics, and dual fluoroscopy—consistently reduced exposure. These findings support adopting dose-minimising technologies and targeted training to enhance radiation safety. Effectiveness of these techniques is dependant on factors such as appropriate training, standardisation and complexity of procedure.  

Disclosure: Authors have no COI to declare. 

Saran Gill, Kapil Sugand, Chinmay Gupte 

Imperial College London, London, United Kingdom 

Abstract 

Background 

Litigation in Orthopaedic Surgery poses a significant financial challenge to healthcare systems. Orthopaedic-related claims accounted for 10.8% of the 10,900 total claims in the NHS in 2023/24, costing approximately £250 million. Yet, no extended analysis of Orthopaedic-related litigation trends has been conducted. This study examined NHS litigation data from 1996/97 to 2023/24 identifying trends, causes, and financial impact to provide actionable insights for improving clinical practice. 

Methods 

Orthopaedic-related claims data from NHS Resolutions between 1996/97–2023/24 were analysed under the Freedom of Information Act. The dataset, focused on closed claims with settlements, included causes, injury types, and payouts. Broader classifications were applied due to GDPR constraints. Non-parametric distributions were confirmed using the Shapiro-Wilk test. Subsequent analyses, using the Kruskal-Wallis tests, calculated significant differences between categories and across years. 

Results 

Between 1996/97 and 2023/24, 22,606 clinical negligence claims resulted in 14,702 settlements exceeding £2.2 billion, including £1.2 billion in damages. Musculoskeletal injuries were most frequent primary injuries (21%, £407.53 million), followed by unnecessary operations and postoperative pain (22%, £328.27 million). Neurological issues (8%) and poor outcomes (13%) accounted for £254.74 million and £129.14 million, respectively. Surgical errors (24%) caused the highest damages of the primary causes (£309.47 million), followed by failure or delayed treatment (23%, £277.02 million) and decision-making errors (22%, £287.57 million). Settlement values peaked in the early 2010s before declining, with significant differences in median claims, damages, and total payouts per annum (p < 0.001). 

Conclusion 

Between 1996/97 to 2023/24, over £2.2 billion was paid in settlements, with £1.2 billion in damages. Musculoskeletal injuries, surgical errors, and delayed treatment were leading causes, highlighting persistent clinical challenges. Although claim volumes and payouts have declined since 2011/12, improved consent and multidisciplinary meetings may offer potential opportunities to enhance patient outcomes and reduce litigation against Orthopaedic Surgeons in the NHS. 

Suresh Kumar1, Sundas Karimi2, Pervez Ali3, Naresh Kumar Ladhwani4, FNU Sunita5 

1Muhammad Medical College Hospital, Mirpurkhas, Pakistan. 2Luton and Dunstable University Hospital, Luton, United Kingdom. 3Jinnah Postgraduate Medical Centre, Karachi, Pakistan. 4Dow University of Health Sciences, Karachi, Pakistan. 5Liaquat University of Medical and Health sciences, Jamshoro, Pakistan 

Abstract 

Background: 
 Distal femoral fractures account for <1% of all fractures and approximately 3–6% of femoral fractures. The incidence is expected to rise with the aging population, particularly due to low-energy trauma in osteoporotic bone. The estimated annual incidence is around 37 per 100,000 individuals. 
This study aimed to compare the functional outcomes of extra-articular supracondylar femur fractures treated with either Locked Compression Plate (LCP) Plating or Retrograde Intramedullary Interlocked (IMIL) Nailing. 

Methods: 
 A randomized controlled trial was conducted over six months in Karachi, Pakistan. A total of 60 patients were enrolled, with 30 allocated to each treatment group using non-probability consecutive sampling. Data were collected using a structured proforma and analyzed using SPSS version 21. Functional outcomes were assessed using the Lysholm Knee Scoring System and categorized as excellent, good, fair, or poor. A p-value <0.05 was considered statistically significant. 

Results: 
 The mean age was 51.1 ± 8.4 years in the LCP group and 53.7 ± 9 years in the IMIL group. In the LCP group, functional outcomes were excellent (10%), good (36.7%), fair (33.3%), and poor (20%). In the IMIL group, outcomes were excellent (13.3%), good (42%), fair (23.3%), and poor (3.3%). The difference in outcomes between the groups was statistically significant (p=0.048), favoring the IMIL nailing method. 

Conclusion: 
 Retrograde IMIL nailing was associated with significantly better functional outcomes than LCP plating in managing extra-articular supracondylar femur fractures. However, residual confounding cannot be ruled out. 

Disclosure: 
 The authors declare no conflicts of interest or financial disclosures related to this study. 

Wilfred Saunders1, Charlie Gamble1, Alexander Glenndenning2, Rich Roberts1 

1Department of Trauma and Orthopaedic Surgery, Wrexham Maelor Hospital, Wrexham, United Kingdom. 2Morriston Hospital, Swansea, United Kingdom 

Abstract 

Background: Clear, effective communication is fundamental to orthopaedic practice, particularly when securing informed consent in the wake of the landmark Montgomery v Lanarkshire ruling. Escalating NHS workforce and time constraints necessitate tools that streamline, yet enhance, patientclinician dialogue. By analysing complication coverage, readability metrics and PEMAT understandability, this study aims to determine the feasibility of Large Language Model (LLM) correspondence to support equitable, patientcentred consent and decisionmaking. 

Methods: Six frequently performed orthopaedic operations were chosen. Standardised, clinicfriendly prompts were fed to four LLMs—ChatGPTO1, DeepSeek, Gemini and Copilot—each producing two letters per procedure. An identical prompt was provided to clinicians to produce letters for the same operations serving as a human benchmark. Goldstandard complication inclusion, readability (FleschKincaid, Gunning Fog and SMOG indices) and understandability (PEMAT) were recorded. 

Results: GPTO1 achieved the greatest complication profile compliance (0.923 ± 0.104, P < 0.001), followed by Gemini (0.860 ± 0.079). All LLMs produced text at a 7th–8th grade level (FleschKincaid 6.850–8.517), markedly simpler than human letters (10.6 ± 0.94). Gemini’s outputs were easiest to read on Gunning Fog and SMOG (10.657 ± 1.291 and 11.583 ± 1.191), whereas clinician letters were harder (14.13 ± 1.1 and 13.33 ± 0.55). Gemini also delivered the highest PEMAT understandability (0.826 ± 0.054) compared with GPTO1 (0.718 ± 0.071) and the human benchmark (0.722 ±  0.019). 

Conclusion: LLMs can outperform traditional clinician correspondence in readability and understandability, while simultaneously incorporating gold standard complication profiles into clinic letters. Embedding optimised, LLM workflows within outpatient practice could markedly reduce administrative burden, minimise transcription delays and empower patients to make better informed, shared decisions. Future research must refine LLM search capability, evaluate cost effectiveness, ensure ethical and medicolegal oversight, integrate outputs with electronic health records and establish rigorously validated pathways for safe clinical deployment. 

Amy Firth1, Ross Sian1, Jessica Nightingale2, Bernard van Duren1, Mark Higgins1, Andrew Manktelow1, Benjamin Bloch1 

1Nottingham Elective Orthopaedics, Nottingham, United Kingdom. 2Nottingham University Hospitals, Nottingham, United Kingdom 

Abstract 

Background 

Patient factors such as male sex, extremes of age, increasing BMI, pre-existing medical co-morbidity and smoking are associated with increased rates of revision for prosthetic joint infection (PJI).  

Surgical factors such as use of perioperative antibiotics, alcoholic skin preparation, shorter operating times and watertight wound closure have been shown to be protective. Other surgical factors are less well understood. Single-use surgical gowns are often used due to their perceived superior sterility in absence of clear evidence. No studies have been undertaken reviewing the incidence of PJI observed between reusable and single use gowns.  

Methods  

Data from 9239 primary elective hip and knee combined with the Health Security Agency Surgical Site Infection (SSI) Dataset and National Joint Registry (NJR) captured sex, age, BMI, and pre-existing co-morbidity. Gown preference data was used to to determine the rate of PJI observed in single use versus reusable gown groups.  

Results  

A total of 76 patients (0.82%) developed a PJI. A significantly higher proportion occurred in the disposable gown group (1% vs. 0.60%, p = 0.017). Single-use surgical gowns were associated with a 67% higher infection rate (OR 1.67, CI 1.11 – 2.67, P=0.029). Following multivariable adjustment, the increased risk of PJI remained statistically significant (OR: 1.73, 95% CI: 1.09–2.76, p = 0.02). 

Conclusion 

Single-use surgical gowns were associated with a significantly increased risk of PJI in hip and knee replacement surgery in our institution. Reusable gowns are more cost effective, more environmentally responsible and at worst are not inferior to single-use gowns when considering rates of PJI. This finding should encourage further investigation and analysis of the possible causal factors contributing to this outcome.  

Disclosures 

This work received no funding and the authors declare no relevant outside financial or academic conflicts of interest.   

Amy Firth1, Evie Gittings2, Manasi Shrike2, Mohammed Remtulla1, Bernard van Duren1, Benjamin Bloch1 

1Nottingham Elective Orthopaedics, Nottingham, United Kingdom. 2Nottingham University Hospitals, Nottingham, United Kingdom 

Abstract 

Background  

Glucagon-Like Peptide agonists (GLP-1s) such as Semaglutide mimic GLP-1- a hormone that plays a critical role in glucose metabolism. The National Institute for Health and Care Excellence (NICE) has approved such medications as part of Tier 3 weight management services. In particular, these drugs are indicated for all patients with a BMI>35 and a weight-related co-morbidity such as hypertension, dyslipidaemia, obstructive sleep apnoea and diabetes.  

GLP-1s decrease the rate of Prosthetic Joint Infection in patients with a body mass index (BMI) >40kg/m2. They also appear to decrease hospital Length of Stay (LoS), re-admissions and potentially life-threatening complications such as pulmonary embolism. Moreover, by acting on the spinal cord GLP-1 agonists decrease pain hypersensitivity up to 90% potentially decreasing analgesic requirements and perceived post-operative pain.   

Methods  

Community patient referrals to the Nottingham Elective Orthopaedic Service (NEOS) for lower limb arthroplasty were retrospectively screened. In particular, suitability for referral to Tier 3 weight management services was assessed according to local guidelines.  

Results  

50 consecutive new patient records were examined. The average BMI was 34.3. 10 referrals did not contain a BMI and were excluded. 30/40(75%) met the criteria to referral for Tier 3 weight management services and 14/40(35%) meet NICE criteria for treatment with GLP-1 agonists.       

Conclusion  

A significant proportion of patients undergoing large joint arthroplasty would benefit from prescription of GLP-1 agonists which are available via Tier 3 weight loss management services. The use of these agonists is known to reduce the rate of PJI in patients with BMI>40kg/m2 and to decrease inflammation, pain and hospital LoS. Requirement for referral to community weight loss service for eligible patients could form a key part risk reduction in the primary lower limb arthroplasty referral pathway.   

Peter Eckersley, Rachel Lis, Chloe Willoughby 

North Manchester General Hospital, Manchester, United Kingdom 

Abstract 

Background: 

Pre-operative education is established in the pathway of care within elective orthopaedic surgery, with studies showing a positive effect upon several factors including early mobilisation.  

Achievement of early post-operative mobilisation is a Key Performance Indicator for all patients presenting to hospitals in England and Wales with hip fracture – and is recorded within the National Hip Fracture Database (NHFD). 

This study sought to ascertain whether pre-operative therapy education for patients awaiting surgery for hip fracture affected their achievement of the NHFD measure for early mobilisation, which is documented as: 

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

Methods: 

Pre-operative education was introduced for patients with hip fracture. This included verbal education of the full post-operative rehabilitation pathway, and verbal/written information regarding the importance of achieving early post-operative mobility.  

The effect of this change was measured in achievement of ‘Mobilised by Day 1’ for 150 patients either side of the change date.  

All patients within the samples had no documented cognitive impairment at the time of their admission to hospital. 

Results: 

150 patients prior to the introduction of pre-operative education: 

• Mobilised by Day 1: 69.3% 

(Average age 81.7 years; 70.4% female) 

150 patients following the introduction of pre-operative education: 

• Mobilised by Day 1: 83.0% 

(Average age 80.5 years; 73.0% female) 

Conclusion/Findings: 

The results indicate that the introduction of pre-operative education has helped to increase the rate of patients achieving early mobilisation following hip fracture surgery.  

Implications: 

For pre-operative education to be effective, patients need to be able to recall the information provided post-operatively. One limitation, therefore, of this project is that it excludes patients with a cognitive impairment.  

However, the results indicate positive benefits of our change of approach. Pre-operative education as described has therefore become embedded within our therapy offer to this patient group.  

Lucy Silvester1, Rebecca Kearney2, David McWilliams3, Gemma Pearce3, Shea Palmer4 

1University Hospitals Coventry and Warwickshire NHS Trust, Coventry, United Kingdom. 2Bristol Trials Centre, Bristol, United Kingdom. 3Coventry University, Coventry, United Kingdom. 4Cardiff University, Cardiff, United Kingdom 

Abstract 

Background 

Complex fractures are severe injuries that cause considerable disability. Effective rehabilitation is essential to achieve good outcomes, however, the literature shows a broad and varied approach with insufficient evidence to inform clinical practice¹. This study investigated stakeholder experiences to understand what components of rehabilitation were important to facilitate recovery. 

Methods  

Thirty-three interviews were conducted. Participants included adults with complex fractures, healthcare professionals who treat complex fractures, and commissioners who contract rehabilitation services. Inductive reflexive thematic analysis² was used to derive themes. Deductive analysis was applied to extract data on potential intervention components using the Template for Intervention Description and Replication checklist³.  

Results 

Themes: 

1. Personalisation – needs led and holistic, meaningful to the person, desire to see progress 

2.  Adjustment to reality – making sense of the situation, support system, practical reality 

3. Accessibility and delivery – skilled and flexible workforce, accessible, systems approach 

4. Professional support – guidance and active monitoring, navigate transitions, supervised physical activity. 

The rehabilitation components identified were exercise prescription, activities to regain function, self-management strategies, education, practical advice, psychological screening and talking therapies. Important components included coordination, personalised needs assessment, value-based goal setting, and peer support or social group interactions.  

People wanted a ‘menu of support’ delivered flexibly to meet their individual needs. There was a contradiction between what people wanted and what could be delivered, with workforce challenges and service capacity frequently mentioned.  

Conclusion 

This study identified what rehabilitation people want after complex fractures; however, questions remain around the best way to package and deliver an intervention. Rehabilitation should be personalised and holistic, with guidance from an experienced and competent professional. The approach should be consistent and coordinated focusing on meaningful activities specific to the individual. Further research is required to address the key uncertainties and design a rehabilitation intervention that could be adopted into clinical practice. 

Matt Dennies 

Mersey & West Lancashire Hospitals, Prescot, United Kingdom 

Abstract 

Background: Although most patients report high levels of satisfaction following Total Knee Replacement (TKR), 5% of patients will experience arthrofibrosis, leading to prolonged and challenging physiotherapy input and potential need for further surgery such as manipulation under anaesthetic (MUA). 

This audit assessed the feasibility of a pathway that treats patients with a JAS brace that are at risk of arthrofibrosis following TKR, aiming to improve range of movement, function, and prevent for further surgery. 

Methods: Patients were assessed for the pathway at six weeks post-op if they had not achieved 70° flexion or -20° extension, and at 12 weeks if they had not achieved 90° flexion or -10° extension. 

Outcomes measures assessed were: range of movement, Timed Up and Go (TUAG), Oxford Knee Score (OKS), complications, time from surgery to pathway, number of appointments, staffing costs. 

Results: Data was collected between June 2023 and June 2024. Eight patients were placed on the pathway, seven completed treatment. Two patients had flexion braces, average pre-pathway flexion was 75° (70-80), increasing by 13.5° (10-17) to 89° (87-90). Six patients had extension braces, average pre-pathway extension was -19° (15-30), increasing by 11° (5-16) to -8.5° (-5,-15). 

No complications from treatment were reported. OKS improved by an average of 7 (0-18), TUAG improved by 1.5 seconds (-3, 8). 

Average time from surgery to commencing the pathway was 73 days (25-121), with an average of 6 (4-10) appointments. Staffing cost £53.79 per patient. Total cost including the JAS Brace was £893, £463 less than an MUA. 

Conclusion: The pathway is safe and effective, improving range of movement, function and gait. Although the sample size is small, it suggests a cost-effective alternative to an MUA. A retrospective analysis of MUA rates 1 year post TKR should be conducted to assess the impact of the pathway. 

Disclosure: None 

Bernard van Duren1,2, Mohamad Taufiqurrakhman2, Alison Jones2, Mark Higgins1, Andrew Manktelow1, Benjamin Bloch3, Hemant Pandit2 

1Nottingham University Hospitals Trust, Nottingham, United Kingdom. 2University of Leeds, Leeds, United Kingdom. 3University of Leeds, Nottingham, United Kingdom 

Abstract 

Cemented polished taper slip (PTS) stems are the femoral implant of choice for total hip replacement in many locations worldwide. There is increasing evidence that peri-prosthetic fracture contributes significantly to reoperation with these stems. The aim of this study was to explore how mismatches at the implant-cement interface (ICI) may occur and the potential effect of these incongruities on the contacting area and the forces transmitted to the cement mantle. 

A parametric equation-based model was developed to determine the contact mismatch relative to axial stem rotations. This model was also used to calculate the restoration of contact surface area with stem subsidence for both a dual-taper and triple-taper cross-sectional geometry. A finite element analysis (FEA) was subsequently used to compare the effects of reduced contact area due to the incongruent hip implant-cement interface. Specifically maximum stresses, total strain, and deformation were calculated. 

The contact model showed a large decrease in surface contact area with even only a small rotation going from 100% at 0° to 50.00% at 0.25° for both geometries. There was a gradual further decrease in contact with increasing further rotation. For both cross-sectional geometries, there was an increase in contact surface area with an increase in subsidence resulting in contact for up to a 5° mismatch being restored with 2mm subsidence. FEA showed that with increasing mismatches and consequent contact area reduction there was an increase in forces and stresses at the ICI. Analysis of von Mises stress at the ICI showed an increase of up to 235% when there was a decrease in contact area. 

With increasing mismatch there was an increase in maximum stresses, total strain, and subsidence in the cement mantle. These findings highlight the importance of achieving an optimal implant-cement interface at the time of implantation of cemented PTS femoral stems. 

Mohamad Taufiqurrakhman1, Mark Higgins2, Andrew Manktelow2, Benjamin Bloch2,3, Hemant Pandit1, Bernard van Duren2,1 

1University of Leeds, Leeds, United Kingdom. 2Nottingham University Hospitals, Nottingham, United Kingdom. 3University of Nottinham, Nottingham, United Kingdom 

Abstract 

Cemented polished-taper slip (PTS) stems are the most commonly used design for primary THA in the UK. Periprosthetic fracture is a major contributor to reoperations after PTS implantation. Stem centralisers help create an even cement mantle and allow subsidence, which is essential to the “force-closed” PTS design for maintaining fixation. However, if subsidence exceeds the centraliser's allowance, the implant becomes “shape-closed,” potentially introducing stress concentrations within the cement mantle. This study used finite element analysis (FEA) to assess changes in stress distribution when further subsidence is restricted. 

A 3-D scanner (0.08 mm accuracy) and CAD software were used to model three commonly used PTS stems: C-Stem, Exeter, and CPT. Stems were modelled with a 4 mm cement mantle and centraliser gap. FEA simulated loading conditions (6,900 N) with and without distal space to represent scenarios with/without a subsidence gap. Stem material variations (SS316L, Co-Cr) were also modelled. Peak stress, von Mises stress, and cement deformation under load were evaluated. 

With space to subside, maximum von Mises stresses occurred mostly in Gruen zone 7, with CPT showing the highest (~45 MPa). Without a subsidence gap, peak stress shifted to the distal tip (zone 4), increasing by 49–102% depending on stem design and material. Across all models, Co-Cr further increased distal stress compared to SS316L. 

This study demonstrates that when PTS stems reach the centraliser's subsidence limit, stress in the distal cement mantle increases markedly. Stem design, material, and implant-cement interface friction affect stress distribution and subsidence, potentially contributing to cement failure and periprosthetic fracture risk. 

Matthew Welck1, Alexander Beer1, Hussain Al-Omar1, Ali Najefi2, Shelain Patel1, Nicholas Cullen1, Togay Koc3, Karen Malhotra1 

1Royal National Orthopaedic Hospital NHS trust, London, United Kingdom. 2Northwick Park Hospital NHS trust, London, United Kingdom. 3University Hospital Southhampton, London, United Kingdom 

Abstract 

Background 
 
First metatarsal Pronation is increasingly recognised as an important component of Hallux valgus (HV) and can contribute towards intraoperative malreduction, postoperative recurrence and patient reported outcome measures (1,2,3). There are numerous radiological ways to measure metatarsal rotation on plain radiographs and weight bearing CT (WBCT), however there are no clinical tests to evaluate metatarsal pronation pre- or intra-operatively.  

This study aimed to examine the relationship between clinical pronation of the toe and metatarsal pronation. 
 
Methods 
Single-centre, retrospective analysis over 5 years. Measurements were performed on WBCT images with digital reconstructions to add soft tissues. First metatarsal rotation was measured using the Metatarsal Pronation Angle as previously described (4). Toe rotation was measured by the Phalangeal Condylar Angle (PCA), the angle between the condyles of the proximal phalanx and the floor, and the Nail Plate Angle (NPA), the angle of the base of the nail plate to the floor in the coronal Plane. These were obtained from 50 feet in Hallux valgus patients, and 50 control patients with CTs done for osteochondral lesions without hallux valgus or hindfoot malalignment. 
 
Results 
The HV group comprised 41 women and 9 men, mean age 52.4. Control group, 23 women and 23 male, mean age 40.25. Inter and Intra Observer reliability both excellent (ICC >0.95) for all measurements. When comparing HV vs control, MPA was 11.7 vs 6.0 (p<0.001), PCA 31.8 vs 4.7 (p<0.001), NPA 18.3 vs 6.0 (p<0.0001). NPA correlated with PCA. NPA and PCA correlate with Hallux valgus Angle (p<0.001), but not with MPA (p 0.567). 
 
Conclusions 
These results suggest that clinical toe pronation increases as HV angle increases but not with metatarsal pronation, which therefore cannot be used as a clinical marker.  Toe pronation is similar at the base and at the nail, suggesting rotation happens at the MTPJ. 

Arvind Vijapur1, Mohammed Shaath2, Shelain Patel3, Nick Cullen3, Matthew Welck3, Karan Malhotra3 

1Buckinghamshire Healthcare NHS Trust, Aylesbury, United Kingdom. 2ROYAL FREE LONDON NHS FOUNDATION TRUST, London, United Kingdom. 3Royal National Orthopaedic Hospital, Stanmore, United Kingdom 

Abstract 

Aim 

The distal metatarsal articular angle (DMAA) is a measurement used in surgical decision making of hallux valgus correction. However, it is difficult to measure on plain radiographs, is subject to projection bias, and its role in pathology is unclear. With the advent of weight-bearing CT (WBCT), our understanding of hallux valgus as a multiplanar deformity has evolved. The aim of study was to investigate whether there is a relationship between the DMAA and pronation of the first metatarsal head in patients with hallux valgus. 

 Methods 

This was a single-centre, retrospective analysis of 50 patients with hallux valgus deformity who had WBCTs obtained as part of routine pre-operative work-up. Patients with metatarsophalangeal joint arthritis, hindfoot deformity and previous surgery were excluded. From the WBCT images digital radiographs were created and the DMAA measured. Measurements were taken by 2 authors, each repeated twice and the average of all four measurements used in analysis. We also measured intermetatarsal angle (IMA), hallux valgus angle (HVA) and metatarsal pronation angle (MPA). 

 Results 

There were 41 females and 9 males, mean age 52.4±15.8 years. IMA was 14.5±3.3 degrees, HVA was 29.3±8.4 degrees, MPA was 11.7±6.3 degrees, and DMMA was 15.5±5.3 degrees. Intraclass correlation coefficient (ICC) for intra-observer reliability was 0.829 for assessor 1 and 0.910 for assessor 2.  ICC for inter-observer reliability was 0.727. Pearson’s correlation revealed no link between IMA and DMAA, nor HVA and DMAA. However, there was a significant (albeit small) correlation between MPA and DMAA (r=0.337, p=0.017).  

 Conclusion 

There was reasonable reliability in measuring DMMA between authors on WBCT although there was variation in measurements. Despite this, DMAA appeared to increase with increasing metatarsal pronation. The DMAA may therefore be  projection artefact secondary to metatarsal pronation and surgeons should be aware of this during surgical planning.  

Prashant Singh, Amy Still, Karan Malhotra, Panagiotis Poulios, Muhammad Chatoo, Shelain Patel, Nick Cullen, Matthew Welck 

Royal National Orthopaedic Hospital, London, United Kingdom 

Abstract 

Background 

This study aimed to examine the relationship between sagittal plane alignment and patient-reported outcomes measures (PROMs) in patients undergoing ankle / tibiotalocalcaneal (TTC) arthrodesis.  

Methods: 

Retrospective review of patients undergoing ankle or TTC arthrodesis over 8 years. Measurements were performed on WBCT images: anterior/medial distal tibial angles (aDTA / mDTA), coronal talar tilt, and sagittal tibial-sole angle (TSA), tibio-talar angle (TTA), and tibio-calcaneal inclination angles (TCA). These were obtained from 50 normal patients and 42 patients undergoing fusions pre-operatively and at 3 and 12 months postoperatively. MOxFQ scores were collected pre- and post-operatively and post-operative subjective alignment was recorded.  

Results: 

Mean age was 56±12.9 years and BMI was 30.5±5.1 kg/m2. Ankle arthrodesis was performed in 35/42 (83.3%) patients. Pre-operative deformity was >10 degrees from normal in sagittal/coronal plane in 8 patients (19%) and moderate (±5 degrees) in 8 patients (19%). There was no difference between normal group and post-operative group TSA (p=0.058), although there was a lower (more dorsiflexed) TTA (5.0 degrees, p<0.001) and TCA (2.9 degrees, p=0.037) in post-operative scans. There was no difference in sagittal post-operative position by type of fixation, ankle/TTC, arthroscopic/open or degree of pre-operative deformity. Significant improvements were observed in all MOxFQ domains (p<0.01). Age/BMI/final position did not influence PROMs. On regression analysis, lower TSA was the only factor predictive for a subjective feeling of a dorsiflexed foot (p=0.021, Exp(B)=0.472).  

Conclusions 

Regardless of pre-operative deformity, Ankle/TTC arthrodesis is effective at restoring sagittal alignment and improves PROMs. Although variation exists in TTA, TCA may compensate partially for this resulting in a balanced foot (TSA). TSA influenced perceptions of sagittal balance, particularly when dorsiflexed. It is important to strive for optimal sagittal alignment in ankle and TTC arthrodesis, which is judged intra-operatively by the TSA. 

Philippa Dolphin1, Sarah Johnson-Lynn1,2 

1The James Cook University Hospital, Middlesbrough, United Kingdom. 2University of York, York, United Kingdom 

Abstract 

Background 

The lifetime prevalence of symptomatic ankle arthritis is 3.4% (Murray, 2018) and symptomatic mid- and hindfoot arthritis affects 1 in 6 older adults (Thomas, 2015). The majority of this disease burden falls on women, manual workers and those with higher markers of socioeconomic deprivation (Roddy, 2015). 

There is no agreed pathway in the UK for physiotherapy after foot and ankle arthritis surgery and there is little evidence to guide treatment. This has led to the role of physiotherapy in foot and ankle conditions being made a JLA top 10 priority. 

Methods 

A survey of current physiotherapy practice following foot and ankle arthritis surgery was conducted in the UK via the BOFAS AHP network and a paired questionnaire was disseminated to the BOFAS surgical membership. There were 106 surgeon questionnaire responses, 95% from consultant members. There were 26 responses to the AHP questionnaire, 92% of responses being from band 7 and 8a specialist foot and ankle or lower limb physiotherapists. 

Results 

Most surgeons felt that the most important purpose of post-operative physiotherapy was to normalise gait (60% after ankle fusion, 64% after foot fusions), however physiotherapists were equally likely to believe that managing patient expectations was most important (29%; 29%). 

Only 35% of units employed a specialist foot and ankle physiotherapist and 32% of surgeons felt that their patients had inadequate access to foot and ankle physiotherapy. 18% of units have rehabilitation protocols for patients after foot and ankle fusion surgery. Most patients receive 5 or fewer sessions of physiotherapy post-operatively (73% of ankle fusion and 78% of foot fusion patients). 

Conclusion 

Most UK patients will receive physiotherapy after foot and ankle fusion surgery but access is variable and most centres do not use a protocol. 

Disclosure 

Senior author is a member of the BOFAS Scientific Committee. 

Kanatheepan Shanmuganathan1, Ahmed Zainy1, Rewant Singh1, Mansi Chitnis2, Ali Najefi1 

1Northwick Park University Hospital, London, United Kingdom. 2Imperial College London, London, United Kingdom 

Abstract 

Background: 

The management of ankle fractures in the elderly is complicated by comorbidities, poor local soft tissue quality, and osteoporosis. Recent trends have shifted from non-operative approaches to rigid fixation techniques, such as Fibula Pro-tibia (FPT) fixation, to facilitate earlier mobilisation in osteoporotic fractures. 

Objectives: 

This study primarily aims to compare revision rates and time to full weight-bearing between patients undergoing FPT fixation and those receiving standard open reduction and internal fixation (ORIF). Secondary outcomes include hospital length of stay, functional status, and complication rates. 

Methods: 

A retrospective review was conducted of 52 patients over the age of 70 who underwent surgical management for unstable ankle fractures at a District General Hospital between January 2020 and December 2024. Patients were treated with either ORIF (n=38) or FPT fixation (n=14). Data collected included patient demographics, comorbidities, operative times, weight-bearing status, and postoperative complications. 

Results: 

The two groups were comparable in terms of demographics and fracture patterns. All patients sustained closed fractures, with similar rates of dislocation (~63%). FPT fixation was associated with a shorter time to full weight-bearing (32.2 days vs. 43.4 days) and a reduced length of hospital stay (8.7 days vs. 12.9 days) compared to ORIF. Revision rates were similar between groups (7.1% for FPT vs. 7.8% for ORIF), as were overall complication rates (21.4% vs. 21.1%) including wound complication rates (7.1% vs. 7.8%). There were no cases of metalwork failure. Operative time was also shorter in the FPT group (92.0 minutes vs. 107.3 minutes). 

Conclusion: 

FPT fixation enables earlier full weight-bearing in elderly patients with unstable ankle fractures compared to standard ORIF, without increasing the risk of complications or revision surgery 

Wajiha Zahra1, Abdul-Rahman Gomaa2,3, Jubri Babatunde4, Mina Seifo1, David Ford1,5, Paul Cool1,5,6, Simon Pickard1,5 

1The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust, Oswestry, United Kingdom. 2Trauma & Orthopaedics Department, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, United Kingdom. 3School of Medicine, University of Liverpool, Liverpool, United Kingdom. 4Royal Wolverhampton NHS Trust, Wolverampton, United Kingdom. 5Royal Shrewsbury Hospital, Shrewsbury and Telford Hospital NHS Trust, Shrewsbury, United Kingdom. 6School of Medicine, Keele University, Keele, United Kingdom 

Abstract 

Introduction 

Ankle fractures are common injuries, with a significant proportion requiring surgical intervention. Despite established treatment principles, the optimal timing for open reduction and internal fixation (ORIF) remains debated. Concerns regarding wound infection risk have led some surgeons to delay fixation, while others advocate for early intervention. This study aimed to assess the impact of surgical timing on postoperative wound infections.   

Methods 

A retrospective review was conducted on 1,130 patients with surgically treated closed ankle fractures at a single institution between 2000 and 2022. Patients were categorised into three groups based on time to surgery: Early (<48 hours), Intermediate (48 hours to 5 days), and Delayed (>5 days). Postoperative complications, including superficial and deep wound infections, were recorded. The Kruskal-Wallis test was used to assess associations between surgical timing and infection rates.   

Results 

There was no significant association between surgical timing and either superficial (p=0.127) or deep wound infections (p=0.050). Diabetes, particularly Type 1, was significantly associated with both superficial (p<0.001) and deep infections (p=0.030). Patients over 60 years old were significantly associated with an increased risk of superficial infections (p=0.016) but showed no significant correlation with deep infections (p=0.261).Superficial wound infections required longer hospital stay (p<0.001) due to the need for intravenous antibiotics and monitoring purposes, while the number of procedures significantly correlated with both superficial (p<0.001) and deep infections (p<0.001).   

Conclusion 

In this study, the timing to surgery did not influence postoperative wound infection rates following ORIF for ankle fractures. Instead, patient-related factors including diabetes and age are stronger predictors of wound complications. Length of hospital stay, and the number of procedures were longer in patients with infection. Delaying surgery to reduce infection risk appears unnecessary. 

Yizhe Lim, Laura Clifton, Anji Kingman, Paul Rushton, An Murty, Rajesh Kakwani, Jonathan Coorsh, David Townshend 

Northumbria Healthcare NHS Foundation Trust, North Shields, United Kingdom 

Abstract 

Background: 

The HINTEGRA is a third-generation, mobile-bearing total ankle replacement (TAR) that has been popular in the UK. We present the long-term outcomes with a minimum of follow-up period of 10-years. 

Methods: 

In this prospective single-centre cohort study, all HINTEGRA TARs performed between 2010–2014 were analysed. Demographics, complications (Glazebrook classification), reoperations and revisions (COFAS classification), and patient-reported outcome measures (PROMS) were collected. Survivorship was assessed using Kaplan-Meier analysis. 

A total of 69 patients (70 ankles) were included. Mean age was 69 years (48-84 years). 21 patients died (30%) and 8 patients were lost to follow-up. 

Results: 

Implant survivorship was 81.7% at 5 years (mean 6.4 years), and 71.7% at 10 years (mean 12.3 years, 10.1-14.3 years). Complications included low (12.9%), medium (2.8%), and high-grade events (18.6%), with aseptic loosening being the most common serious complication (12.9%). 

Revision surgery was performed in 16 ankles (22.9%). Non-revision procedures were carried out in 9 patients (12.9%) with majority being cyst debridement and grafting (n=6, 8.6%). 

Periprosthetic cysts were identified in 36 patients (51.4%), most were asymptomatic and located in the tibia. Average volumes measured on CT scan for tibial, talar and fibular cysts were 1.5 cm³, 1.9 cm³, and 1.1 cm³ respectively. Indication of grafting of cysts were symptomatic ankles with stable implants, and/or >50% weight-bearing surface and/or expanding in size (n=6). Graft incorporation was variable, irrespective of impaction autograft or synthetic graft. Loose implants with cysts prompted revision arthroplasty (n=7) and tibiotalar joint fusion (n=1). 

Conclusion: 

The 10-year survivorship of the HINTEGRA TAR was 71.7%. We identified high rates of periprosthetic cysts and would recommend a low threshold for radiographic surveillance.  

Disclosures: 

The authors declare no competing interests relating to this study. DT, RK, AM are paid consultants for Stryker and Exactech. 

Matthew Farrugia1, Siva Sirikonda2, Anjani Singh2 

1Leighton Hospital, Crewe, United Kingdom. 2Liverpool University Hospitals, Liverpool, United Kingdom 

Abstract 

Background 

Metatarsalgia is an generic term used to describe localised forefoot pain around the metatarsals. Primary metatarsalgia is thought to be caused by excessive loading over one or multiple metatarsal heads resulting in localised inflammation and painful callosities. Maestro et al.in 2003, described an ideal foot morphotype which is currently used to plan for corrective osteotomy in patients with  metatarsalgia. The aim of this study is to investigate whether there is a true difference in metatarsal lengths between symptomatic and asymptomatic individuals. 

Methods 

A retrospective single centre study was carried out between 2019 and 2020. Weightbearing dorsoplantar foot radiographs and patient notes were screened. Patients were grouped into two groups, Group A: Asymptomatic and Group B: Primary metatarsalgia. Exclusion criteria were set to exclude patients with previous foot surgery and secondary causes of metatarsalgia (e.g. Morton’s Neuroma). Metatarsal length differences were measured according to Maestro’s criteria using Carestream. Measurments were taken as, 1st metatarsal - 2nd metatarsal (M1-M2), M2-M3, M3-M4 & M4-M5. 

Results 

There were 172 patients in Group A and 34 patients in Group B. There was no statistically significant difference across all four metatarsal length differences. This highlights that there is no true overall difference in the metatarsal arcade between the two groups. Twelve patients in group B (35%), underwent Weil’s osteotomy. In this sub-group there was a significant difference in the pre-operative metatarsal length difference between M2-M1 only (p = 0.035) compared to Group A. This was due to a longer 2nd metatarsal (p = 0.039).  

Conclusion/Findings 

Our results highlight that primary metatarsalgia is an uncommon condition and these patients have a similar metatarsal arcade when compared to the “normal” asymptomatic foot. A subset of patients with primary metatarsalgia have a long 2nd metatarsal which may benefit from Weil’s osteotomy correction. 

Disclosure 

Nothing to declare. 

Thumri Paavana, Joanna Reeves, Harry Poole, Neil Postans, Caroline Stewart, Catriona Heaver 

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

Abstract 

Background 

Tibialis posterior is commonly involved in neuromuscular and degenerative conditions. Obtaining electromyography (EMG) can be helpful in determining pathological muscle function. Due to its deep posterior compartment location it can only be reached with fine wire electrode placement.  

At our institution we traditionally place these fine wires using a measured palpation technique, with nerve stimulator confirmation. This has not been documented in the literature. As part of a recent BOFAS funded study of tibialis posterior function, we adopted a mid-calf level of insertion (in line with published studies) under ultrasound guidance to standardise wire placement 

This study compares new and old fine wire insertion techniques. 

Method 

We compared data from our old, distal technique to the new, more proximal and USS guided technique. 

Distal technique: N=20, 10 Female, Mean Age 40.5 years (SD 10.7) 

Proximal technique: N=30, 15 Female, Mean Age 43.5 years (SD 16.1) 

Subjects walked at self-selected speed, with EMG data collected from six walks. The EMG signal was rectified, low pass filtered, and amplitude normalised to the maximum for the walk. A minimum of two gait cycles from each walk were used to create an average EMG profile for each subject. Ensemble average EMG profiles for each cohort were compared using statistical parametric mapping. 

Results 

EMG signals from both techniques were comparable in healthy control subjects.   

Discussion 

The new technique is technically more challenging, requiring basic ultrasound skills. It provides better assurance that the electrode is located in the tibialis posterior muscle. The old technique does not require ultrasound expertise but risks electrode misplacement especially in pathology where the anatomy may be altered. 

Conclusions 

Either approach is appropriate in subjects with near normal anatomy. The new approach is however supported by published studies and gives greater assurance of placement in the presence of significant pathology. 

Abdul-Rahman Gomaa1,2, Jejelola Apata-Omisore1, Arjun Paramasivan1, Ahmed Galhoum1, Luke Marsh1, Nicholas Ward1, Shahjahan Aslam1, Lyndon Mason1,2 

1Liverpool Orthopaedic & Trauma Service, Liverpool University Hospitals NHS Foundation Trust, Liverpool, United Kingdom. 2School of Medicine, University of Liverpool, Liverpool, United Kingdom 

Abstract 

Introduction 

Fifth metatarsal fractures are common injuries. There is current disagreement on the preferred treatment, with certain fracture types. The aim of this study was to investigate time to discharge across all 5th metatarsal fracture and their respective fracture mapping patterns. 

Methods 

A historic cohort study was performed of all fifth metatarsal fractures presenting to our unit between February 2016 - July 2021 was performed. Date of injury, fracture morphology and zones involved, clinical and radiographic follow up as well as surgical interventions were collected. 

Results 

1331 fractures were included in this study. The fracture pattern with the longest time before discharge was a fracture spanning zones 2-3 (mean 11.40, 95% CI 5.65, 17.15), followed by a fracture limited to zone 3 (mean 9.72, 95% CI 1.14, 7.31). Both fractures patterns had significantly longer times to discharge than zone 1 (p<.001), zone 1-2 (p<.001), zone 2 (p<.001), zone 2-shaft (p=.001), zone 3-shaft (p=.004) and shaft fractures (p<.001).  

Fractures spanning zone 2-3 and zone 3 were the highest to undergo surgery (11.63% and 9.09% respectively) which was significantly greater than other fracture types (p=.003). The average time to surgery was 21.85 weeks (95% CI 8.87, 34.82), with the average time to discharge post-surgery of 8.07 weeks (95% CI 5.08, 11.07).  

Conclusions 

Fractures spanning zone 2-3 (typical Jones) and zone 3 fractures have the highest time to discharge and highest rate of surgery. Time to surgery is low, in keeping with surgery proceeding not typically for chronic non unions but for more acute presentations. All fractures undergoing surgery united, with only short follow up required post-surgery. 

Akhilesh Pradhan1, Parmjeet Chattha2, Jay Ghelani2, Randeep Aujla1 

1University Hospitals Leicester NHS Trust, Leicester, United Kingdom. 2University of Leicester, Leicester, United Kingdom 

Abstract 

Background: The advent of social media has increased exposure to orthopaedic surgery and heralded a new platform for the discussion of ideas, education and career insight that was not previously possible. This study seeks to explore the platforms most frequently used by medical students, their engagement with content, and how social media shapes their perceptions of different medical specialties. 

 Methods: A prospective national questionnaire was electronically sent to medical students across the United Kingdom. Questionnaires were collecting using the Google Forms platform and consisted of 21 questions with both qualitative and quantitative question styles. 

 Results: 155 responses were received from 13 different medical schools. 43.8% of responses were final year students with 81.8% between 18-25 years. On average, each student had 2.6 social media platforms with 94.8% of students using Instagram and only 22.7% using X/Twitter. 57.8% actively follow orthopaedic accounts; 73.2% follow educational accounts. 46.1% felt social media had changed their perception regarding orthopaedics with 66.2% rating this to be in a negative manner. 70.8% felt that orthopaedic social media accounts did not adequately showcase diversity; only 4.5% strongly agreed that women in surgery are fairly represented on orthopaedic social media. However, 75.3% felt that social media can improve networking and professional development within the orthopaedic community. 65.6% believe future orthopaedic social media accounts can help positively influence the perception of orthopaedics to medical students.  

 Conclusion: Social media is an important tool in enhancing the transfer of knowledge, networking and opportunity within the orthopaedic community. Medical students use social media for education/increasing their exposure to the speciality. While social media offers significant opportunities for medical students to explore orthopaedics, intentional efforts to promote diversity and inclusivity will be key to positively influencing perceptions and encouraging a broader range of students to consider this dynamic and rewarding speciality. 

Patrick Cook, Chris Wakeling 

University Hospitals Sussex, Brighton, United Kingdom 

Abstract 

Background 
Patient-Reported Outcome Measures (PROMs) have revolutionised the evaluation of patient-centred care in orthopaedics, shifting focus from clinical and implant-survival metrics to holistic patient experiences. However, traditional paper-based systems burden healthcare systems with inefficiencies and unknown rising costs. This study quantifies NHS expenditures on PROMs collection from 2015–2025, revealing a £31.1 million financial footprint.  

Methods 
Freedom of Information (FOI) requests were issued to all NHS trusts participating in the National Joint Registry. Data from 71 trusts were analysed after exclusions for incomplete records, commercial sensitivities, or non-compliance. Costs were extrapolated using statistical modelling to estimate national expenditures for trusts unable to provide data.  

Results 
Total estimated NHS spending reached £31.1 million over the decade, peaking at £4.3 million in 2024. Notably, only 35 trusts could respond to the FOI request, also indicating systemic fragmentation in data governance. 

Conclusion 
Digital integration and centralisation could save significant costs while improving data accuracy. This study advocates for hybrid, more automated, systems, dedicated PROMs roles, and real-time analytics to address declining response rates. Orthopaedics should lead this transformation to align with the NHS Long Term Plan’s digital ambitions before further expansion to PROMS and Implant Registries. Centralised and accessible data collection could also allow the avoidance of duplication for future studies. 

Mueed Ijaz1, Rasi Mizori1, Ali Hassan1, Hamza Tareen1, Yasser Al Omran2, Omar Musbahi3 

1King's College London GKT School of Medicine, London, United Kingdom. 2Royal Free London NHS Foundation Trust, London, United Kingdom. 3Imperial College London, London, United Kingdom 

Abstract 

Background: Intraoperative fluoroscopy is indispensable in orthopaedic surgery, enabling minimally invasive techniques. However, its growing use raises concerns about cumulative radiation exposure to patients and surgical teams. This systematic review aimed to identify and synthesise key factors influencing intraoperative radiation exposure in orthopaedic procedures. 

Methods: A systematic search of Medline, Web of Science, and Cochrane CENTRAL was conducted in February 2025. Eligible studies reported intraoperative radiation metrics—such as fluoroscopy time, dose area product (DAP), or effective dose—and stratified outcomes by surgeon experience (consultant vs trainee) or imaging modality. Risk of bias was assessed using the Newcastle–Ottawa Scale. 

Results: Fourty-one studies were included: fifteen assessed surgeon experience, and twenty-six examined imaging modality. Twenty-seven used radiation dose as the outcome, while fourteen measured fluoroscopy time. Of the fifteen studies assessing surgeon experience, twelve reported significantly lower exposure when consultants operated, with dose differences ranging from a 42.3% reduction to a 14.4% increase. The twenty-six studies on imaging modality spanned various orthopaedic procedures. On average, navigation reduced radiation exposure by 55.4% compared to freehand techniques, while robotic-assisted surgery resulted in a 56.2% reduction versus fluoroscopy-guided methods. Dual fluoroscopy achieved a 33.9% reduction compared to single fluoroscopy. Protocol modifications such as ALARA settings halved exposure, and FLASH imaging cut fluoroscopy time by over 94%. 

Conclusion: Both surgeon experience and imaging modality significantly influence radiation exposure during orthopaedic procedures. Consultants typically used less radiation than trainees, though variability exists. Advanced imaging methods—including navigation, robotics, and dual fluoroscopy—consistently reduced exposure. These findings support adopting dose-minimising technologies and targeted training to enhance radiation safety. Effectiveness of these techniques is dependant on factors such as appropriate training, standardisation and complexity of procedure.  

Disclosure: Authors have no COI to declare. 

Saran Gill, Kapil Sugand, Chinmay Gupte 

Imperial College London, London, United Kingdom 

Abstract 

Background 

Litigation in Orthopaedic Surgery poses a significant financial challenge to healthcare systems. Orthopaedic-related claims accounted for 10.8% of the 10,900 total claims in the NHS in 2023/24, costing approximately £250 million. Yet, no extended analysis of Orthopaedic-related litigation trends has been conducted. This study examined NHS litigation data from 1996/97 to 2023/24 identifying trends, causes, and financial impact to provide actionable insights for improving clinical practice. 

Methods 

Orthopaedic-related claims data from NHS Resolutions between 1996/97–2023/24 were analysed under the Freedom of Information Act. The dataset, focused on closed claims with settlements, included causes, injury types, and payouts. Broader classifications were applied due to GDPR constraints. Non-parametric distributions were confirmed using the Shapiro-Wilk test. Subsequent analyses, using the Kruskal-Wallis tests, calculated significant differences between categories and across years. 

Results 

Between 1996/97 and 2023/24, 22,606 clinical negligence claims resulted in 14,702 settlements exceeding £2.2 billion, including £1.2 billion in damages. Musculoskeletal injuries were most frequent primary injuries (21%, £407.53 million), followed by unnecessary operations and postoperative pain (22%, £328.27 million). Neurological issues (8%) and poor outcomes (13%) accounted for £254.74 million and £129.14 million, respectively. Surgical errors (24%) caused the highest damages of the primary causes (£309.47 million), followed by failure or delayed treatment (23%, £277.02 million) and decision-making errors (22%, £287.57 million). Settlement values peaked in the early 2010s before declining, with significant differences in median claims, damages, and total payouts per annum (p < 0.001). 

Conclusion 

Between 1996/97 to 2023/24, over £2.2 billion was paid in settlements, with £1.2 billion in damages. Musculoskeletal injuries, surgical errors, and delayed treatment were leading causes, highlighting persistent clinical challenges. Although claim volumes and payouts have declined since 2011/12, improved consent and multidisciplinary meetings may offer potential opportunities to enhance patient outcomes and reduce litigation against Orthopaedic Surgeons in the NHS. 

Suresh Kumar1, Sundas Karimi2, Pervez Ali3, Naresh Kumar Ladhwani4, FNU Sunita5 

1Muhammad Medical College Hospital, Mirpurkhas, Pakistan. 2Luton and Dunstable University Hospital, Luton, United Kingdom. 3Jinnah Postgraduate Medical Centre, Karachi, Pakistan. 4Dow University of Health Sciences, Karachi, Pakistan. 5Liaquat University of Medical and Health sciences, Jamshoro, Pakistan 

Abstract 

Background: 
 Distal femoral fractures account for <1% of all fractures and approximately 3–6% of femoral fractures. The incidence is expected to rise with the aging population, particularly due to low-energy trauma in osteoporotic bone. The estimated annual incidence is around 37 per 100,000 individuals. 
This study aimed to compare the functional outcomes of extra-articular supracondylar femur fractures treated with either Locked Compression Plate (LCP) Plating or Retrograde Intramedullary Interlocked (IMIL) Nailing. 

Methods: 
 A randomized controlled trial was conducted over six months in Karachi, Pakistan. A total of 60 patients were enrolled, with 30 allocated to each treatment group using non-probability consecutive sampling. Data were collected using a structured proforma and analyzed using SPSS version 21. Functional outcomes were assessed using the Lysholm Knee Scoring System and categorized as excellent, good, fair, or poor. A p-value <0.05 was considered statistically significant. 

Results: 
 The mean age was 51.1 ± 8.4 years in the LCP group and 53.7 ± 9 years in the IMIL group. In the LCP group, functional outcomes were excellent (10%), good (36.7%), fair (33.3%), and poor (20%). In the IMIL group, outcomes were excellent (13.3%), good (42%), fair (23.3%), and poor (3.3%). The difference in outcomes between the groups was statistically significant (p=0.048), favoring the IMIL nailing method. 

Conclusion: 
 Retrograde IMIL nailing was associated with significantly better functional outcomes than LCP plating in managing extra-articular supracondylar femur fractures. However, residual confounding cannot be ruled out. 

Disclosure: 
 The authors declare no conflicts of interest or financial disclosures related to this study. 

Wilfred Saunders1, Charlie Gamble1, Alexander Glenndenning2, Rich Roberts1 

1Department of Trauma and Orthopaedic Surgery, Wrexham Maelor Hospital, Wrexham, United Kingdom. 2Morriston Hospital, Swansea, United Kingdom 

Abstract 

Background: Clear, effective communication is fundamental to orthopaedic practice, particularly when securing informed consent in the wake of the landmark Montgomery v Lanarkshire ruling. Escalating NHS workforce and time constraints necessitate tools that streamline, yet enhance, patientclinician dialogue. By analysing complication coverage, readability metrics and PEMAT understandability, this study aims to determine the feasibility of Large Language Model (LLM) correspondence to support equitable, patientcentred consent and decisionmaking. 

Methods: Six frequently performed orthopaedic operations were chosen. Standardised, clinicfriendly prompts were fed to four LLMs—ChatGPTO1, DeepSeek, Gemini and Copilot—each producing two letters per procedure. An identical prompt was provided to clinicians to produce letters for the same operations serving as a human benchmark. Goldstandard complication inclusion, readability (FleschKincaid, Gunning Fog and SMOG indices) and understandability (PEMAT) were recorded. 

Results: GPTO1 achieved the greatest complication profile compliance (0.923 ± 0.104, P < 0.001), followed by Gemini (0.860 ± 0.079). All LLMs produced text at a 7th–8th grade level (FleschKincaid 6.850–8.517), markedly simpler than human letters (10.6 ± 0.94). Gemini’s outputs were easiest to read on Gunning Fog and SMOG (10.657 ± 1.291 and 11.583 ± 1.191), whereas clinician letters were harder (14.13 ± 1.1 and 13.33 ± 0.55). Gemini also delivered the highest PEMAT understandability (0.826 ± 0.054) compared with GPTO1 (0.718 ± 0.071) and the human benchmark (0.722 ±  0.019). 

Conclusion: LLMs can outperform traditional clinician correspondence in readability and understandability, while simultaneously incorporating gold standard complication profiles into clinic letters. Embedding optimised, LLM workflows within outpatient practice could markedly reduce administrative burden, minimise transcription delays and empower patients to make better informed, shared decisions. Future research must refine LLM search capability, evaluate cost effectiveness, ensure ethical and medicolegal oversight, integrate outputs with electronic health records and establish rigorously validated pathways for safe clinical deployment. 

Amy Firth1, Ross Sian1, Jessica Nightingale2, Bernard van Duren1, Mark Higgins1, Andrew Manktelow1, Benjamin Bloch1 

1Nottingham Elective Orthopaedics, Nottingham, United Kingdom. 2Nottingham University Hospitals, Nottingham, United Kingdom 

Abstract 

Background 

Patient factors such as male sex, extremes of age, increasing BMI, pre-existing medical co-morbidity and smoking are associated with increased rates of revision for prosthetic joint infection (PJI).  

Surgical factors such as use of perioperative antibiotics, alcoholic skin preparation, shorter operating times and watertight wound closure have been shown to be protective. Other surgical factors are less well understood. Single-use surgical gowns are often used due to their perceived superior sterility in absence of clear evidence. No studies have been undertaken reviewing the incidence of PJI observed between reusable and single use gowns.  

Methods  

Data from 9239 primary elective hip and knee combined with the Health Security Agency Surgical Site Infection (SSI) Dataset and National Joint Registry (NJR) captured sex, age, BMI, and pre-existing co-morbidity. Gown preference data was used to to determine the rate of PJI observed in single use versus reusable gown groups.  

Results  

A total of 76 patients (0.82%) developed a PJI. A significantly higher proportion occurred in the disposable gown group (1% vs. 0.60%, p = 0.017). Single-use surgical gowns were associated with a 67% higher infection rate (OR 1.67, CI 1.11 – 2.67, P=0.029). Following multivariable adjustment, the increased risk of PJI remained statistically significant (OR: 1.73, 95% CI: 1.09–2.76, p = 0.02). 

Conclusion 

Single-use surgical gowns were associated with a significantly increased risk of PJI in hip and knee replacement surgery in our institution. Reusable gowns are more cost effective, more environmentally responsible and at worst are not inferior to single-use gowns when considering rates of PJI. This finding should encourage further investigation and analysis of the possible causal factors contributing to this outcome.  

Disclosures 

This work received no funding and the authors declare no relevant outside financial or academic conflicts of interest.   

Amy Firth1, Evie Gittings2, Manasi Shrike2, Mohammed Remtulla1, Bernard van Duren1, Benjamin Bloch1 

1Nottingham Elective Orthopaedics, Nottingham, United Kingdom. 2Nottingham University Hospitals, Nottingham, United Kingdom 

Abstract 

Background  

Glucagon-Like Peptide agonists (GLP-1s) such as Semaglutide mimic GLP-1- a hormone that plays a critical role in glucose metabolism. The National Institute for Health and Care Excellence (NICE) has approved such medications as part of Tier 3 weight management services. In particular, these drugs are indicated for all patients with a BMI>35 and a weight-related co-morbidity such as hypertension, dyslipidaemia, obstructive sleep apnoea and diabetes.  

GLP-1s decrease the rate of Prosthetic Joint Infection in patients with a body mass index (BMI) >40kg/m2. They also appear to decrease hospital Length of Stay (LoS), re-admissions and potentially life-threatening complications such as pulmonary embolism. Moreover, by acting on the spinal cord GLP-1 agonists decrease pain hypersensitivity up to 90% potentially decreasing analgesic requirements and perceived post-operative pain.   

Methods  

Community patient referrals to the Nottingham Elective Orthopaedic Service (NEOS) for lower limb arthroplasty were retrospectively screened. In particular, suitability for referral to Tier 3 weight management services was assessed according to local guidelines.  

Results  

50 consecutive new patient records were examined. The average BMI was 34.3. 10 referrals did not contain a BMI and were excluded. 30/40(75%) met the criteria to referral for Tier 3 weight management services and 14/40(35%) meet NICE criteria for treatment with GLP-1 agonists.       

Conclusion  

A significant proportion of patients undergoing large joint arthroplasty would benefit from prescription of GLP-1 agonists which are available via Tier 3 weight loss management services. The use of these agonists is known to reduce the rate of PJI in patients with BMI>40kg/m2 and to decrease inflammation, pain and hospital LoS. Requirement for referral to community weight loss service for eligible patients could form a key part risk reduction in the primary lower limb arthroplasty referral pathway.   

Lucy AR Reason, Segun Ayeko, Sarah L Whitehouse, Matthew WJ Hubble, Matthew J Wilson 

Royal Devon University Healthcare Trust, Exeter, United Kingdom 

Abstract 

Background 

This is follow-up long term study expands on the excellent medium-term survival previously identified of acetabular impaction grafting using morcellated impacted bone graft to restore bone stock in both cavitary and segmental deficiencies. Histological findings suggest successful revascularisation but there is minimal research in primary total hip replacements at long-term follow-up with more focus on revision surgery and medium-term outcomes. 

Aim: Identify failure rates of acetabular impaction grafting of primary THR at 20-years.  

Methods 

Over a 8-year period n=129 primary THAs were performed at one institution using full acetabular impaction grafting to reconstruct both cavitary and segmental defects. 

Plain radiographs were taken pre- and post-operatively at routine follow-up. Radiological evaluation of failure and migration of the graft was determined by experienced senior hip surgeons after failure of reproducible results using radiological measurements.  

Clinical assessment was performed using Harris and Oxford hip scores.  

The fate of every implant is known and those who had revision or died were censored and radiographs examined before the event.  

Results 

129 primary THR were performed using full acetabular impaction grafting with 27 surviving and 86 deceased. This adds to the original paper with a further 4 revisions in subsequent follow-up of mean 21.7 years (std 2.0) and n=0 further radiological failures identified, of those who had been revised 2 were identified as failures without revision in the previous paper, and 2 were revised due to other indications. We also observe acceptable PROMS including Oxford Hip Score post operatively of 36.6 (std 10.1) in the surviving participants at last follow up. 

Conclusions/findings 

Various strategies can be used for acetabular bone grafting, what this research demonstrates is acetabular bone grafting allows patients an excellent long-term prognosis with a surgical approach achieved using bone graft from patients.  

Implications 

This provides reassurance when counselling patients. 

Disclosure 

None.  

Andreas Fontalis1, Denis Nam2, Manoshi Bhowmik-Stoker3, Ahmad Faizan3, Fares Haddad4, Michael Masini5, Sebastian Lustig6 

1UCL, London, United Kingdom. 2Rush, Chicago, USA. 3Stryker, Mahwah, USA. 4University College Hospitals, London, United Kingdom. 5Trinity Health, Ypsilanti, USA. 6Lyon North University Hospital, Lyon, France 

Abstract 

Introduction: Additively manufactured, 3D-printed acetabular shells were designed to mimic complex characteristics of cancellous bone, and to promote biologic fixation. While these devices show promising early results in osteointegration and patient recovery, midterm results have not yet been demonstrated.  The purpose of this study was to report 7 year clinical and radiographic outcomes in patients with a 3D-printed acetabular shell. 

Methods: Six hundred and ninety cases, 670 patients, were prospectively enrolled at 20 centers receiving a 3D-printed acetabular shell of the same design.  The cohort was 44% men and 56% women, with a mean age of 62.8 +/- 9.74 years and mean BMI of 29.4 +/- 29.4 kg/m². Most subjects (97%) had unilateral implants. Adverse events including reoperations and revisions were determined out to 7 years patient follow-up.  Radiographic assessments were completed by an independent reviewer to determine implant stability and zonal fixation.  Harris Hip Score (HHS) and quality of life (EQ-5D) was determined for all patients. Descriptive statistics were used to determine improvement in patient reported outcome measures. 

Results: Patient reported HHS and EQ-5D VAS scores demonstrated sustained improvement at all subsequent post-op visits (p<0.001). The 7-year all-cause device survivorship was 99.19% (95% CI: 97.17% - 99.77%). There   were 3 acetabular revisions: 1 due to the fracture of the acetabular bone around the shell, 1 due to infection, 1 due to aseptic acetabular loosening. All shells were reported as stable at final radiographic follow-up as defined by ≤2mm radiolucency in 3 zones. One patient had 1mm radiolucency in all 3 zones at 1- and 2-years post-operative This patient was not revised and did not report any adverse events and had excellent HHS at 5 year follow-up. 

Conclusion: In this multicenter study, the 3D printed acetabular shell demonstrated excellent survivorship, clinical, and radiographical outcomes. Long-term follow-up of these patients will continue. 

Sanket Gandhi, Mohamed Shakshak, Kasetti Ravikumar, Syed S. Ahmed 

Maidstone & Tunbridge Wells NHS Trust, Royal Tunbridge Wells, United Kingdom 

Abstract 

Background 
Femoral stem design in cementless total hip arthroplasty (THA) has evolved to improve implant stability and minimise early failure. The addition of a collar is hypothesised to enhance proximal load transfer and reduce micromotion. This study compares outcomes of collared versus collarless cementless stems, focusing on revision rates, periprosthetic fracture risk, and benchmarking collared stems against cemented hybrid THAs. 

Methods 
Data were extracted from the National Joint Registry (NJR) for England, Wales, Northern Ireland, and the Isle of Man, including primary THAs performed between 2005 and 2022. Patients ≥18 years with uncemented collared or collarless femoral components were included. Hybrid THAs (cemented femur, uncemented acetabulum) served as a comparator. Primary outcomes included cumulative revision rates and incidence of periprosthetic femoral fractures within 5 years. Multivariable Cox regression adjusted for age, sex, BMI, ASA grade, and surgical approach. 

Results 
Among over 250,000 uncemented THAs, collared stems demonstrated a significantly lower 5-year revision rate (1.8%) compared to collarless stems (2.7%) (HR 0.71, 95% CI: 0.66–0.77, p<0.001). The incidence of periprosthetic femoral fracture was markedly lower in the collared group (0.6%) versus collarless (1.5%, p<0.001). When compared to hybrid THAs, collared stems showed comparable revision rates (1.8% vs 1.7%, p=0.48), but with a slightly higher early fracture risk, particularly in patients >75 years. 

Conclusion/Findings 
Collared femoral stems are associated with significantly lower revision rates and reduced risk of early periprosthetic fracture compared to collarless designs. Their performance closely mirrors that of hybrid THAs, supporting their use in uncemented fixation strategies, especially in patients at higher fracture risk. These findings inform stem selection to optimise outcomes in modern THA practice. 

Srikar Namireddy1,2,3, Kellen Mulford2, Amirali Khosravi2, Anish Kanabar2, Miguel Girod-Hoffman2, Sami Saniei2, Kartik Logishetty4,3, Cody Wyles2,5 

1Faculty of Medicine, Imperial College London, London, United Kingdom. 2Orthopedic Surgery Artificial Intelligence Laboratory (OSAIL), Department of Orthopedic Surgery, Mayo Clinic, Rochester, USA. 3The MSk Lab, Department of Surgery and Cancer, Imperial College London, London, United Kingdom. 4University College London Hospital, London, United Kingdom. 5Department of Orthopedic Surgery, Mayo Clinic, Rochester, USA 

Abstract 

Introduction: Hip osteoarthritis affects over 240 million people globally, with total hip arthroplasty (THA) rates projected to rise 174% to 600,000 procedures in the United States by 2030. Early identification of patients at highest risk of progression could enable targeted interventions. Radiomics, the analysis of large numbers of imaging features related to size, shape, and texture within regions, represents a promising avenue for risk stratification. We aimed to develop a machine learning model to predict time to THA using clinical, radiological, and radiomic features. 

Methods: Anteroposterior pelvis radiographs of 32,484 hips (17,746 patients)—including asymptomatic contralateral hips evaluated for THA due to degenerative hip disease—were obtained from a single academic institute between 2000-2024. Hips with prior arthroplasty, inadequate imaging, or <12 months of radiographic follow-up were excluded. We trained a random survival forest model to predict time to THA using 314 features encompassing demographics (n=4), radiological measurements (n=4), and radiomics (n=306). Separate models were developed using clinical and radiological data, radiomic features alone, and a fully combined feature set. Model performance was assessed using five-fold cross-validation. Discriminative ability was measured using dynamic area under the curve (AUC) and concordance index (C-index), while calibration was evaluated using the integrated Brier score. 

Results: The combined model achieved the highest performance (AUC=0.81, C-index=0.73, Brier score=0.17), demonstrating strong predictive accuracy and calibration. Radiological-only (AUC=0.77) performed comparably, followed by radiomics (AUC=0.71), and clinical-only (AUC=0.55). The five most important features were minimum joint space width, hip extrusion index, tönnis angle, sourcil brightness asymmetry, and lateral center-edge angle. 

Conclusion: We developed a machine learning model that accurately predicts time to THA using clinical, radiological, and radiomic features. Radiological data alone provided strong predictive performance, with incremental gains from radiomics and clinical variables. This model may inform clinical decision-making, guide patient counselling, and enable earlier, personalised care. 

Asim Rajpura1, Linden Bromwich2, Chris Plaskos2, Jim Pierrepont2 

1Wrightington Hospital, Appley Bridge, Wigan, United Kingdom. 2Corin Group, Cirencester, United Kingdom 

Abstract 

Introduction 

Preoperative rotational profile analysis has thus far mainly focussed on the femoral segment, only considering femoral anteversion. This study aims to investigate the rotational profile of the entire limb (femoral anteversion and tibial torsion) in patients undergoing hip arthroplasty, to try and identify specific rotational phenotypes.   

Methods 

In this retrospective study, a registry was utilised with data from 30,340 THA operations, with all patients undergoing a lower-limb bilateral CT (hip, knee and ankle joints). This data was used to analyse rotational profiles of the lower limbs including anatomical femoral version (FV), tibial torsion (TT), femoral and tibial rotation relative to CT coronal (FR and TR), and femorotibial index (FTI=TT-FV, [1]). A 3x3 classification system for FV vs TT was developed (low/medium/high = A/B/C: 5°≤FV≤25°,1/2/3: 25°≤TT≤45°). 

Results 

From the dataset, a total of 12,456 THA’s had all the required datapoints, with no hip or knee implants present (demographics; 53.2% female, 63.7±11.8 years old). Mean FV and TT measured 15.8°±10.1° and 39.7°±8.7° respectively. Mean FTI measured 23.9°±11.4°. 27.1% of patients had a TT > 45°, 13.2% had a FV <5° and 16.9% had a FV > 25°. Both FTI and FR were strongly correlated with TR in CT, R=0.585, p<0.001 and R=0.721, p<0.001 respectively.  

Conclusions 

Considerable variation in rotational profiles exists within patients undergoing hip arthroplasty. Only 48.9% of the cohort was within normal limits for both FV and TT. Preoperative planning should consider both FV and TT to help better predict changes in post operative foot progression angle. Patients with increased TT may encounter dynamic retroversion of the hip with gait, especially in those with low or normal FV (19.9%), potentially contributing to hip instability.   

Disclosures 

LB, CP and JP are paid employees of Corin.  

Alexander Aquilina1, Rebecca Fox2, Wenjuan Cong1, Tom Krause3, Emily Howell3, Wendy Bertram1, Flossie Carpenter1, Vikki Wylde1, Josh Lamb1, Michael Whitehouse1, Jonathan Evans2 

1University of Bristol, Bristol, United Kingdom. 2University of Exeter, Exeter, United Kingdom. 3Torbay and Devon NHS Foundation Trust, Torbay, United Kingdom 

Abstract 

Background 
Post-operative periprosthetic femoral fractures (POPFF) following hip and knee arthroplasty are the leading cause of implant failure and are associated with high morbidity, mortality, and healthcare costs. However, outcome reporting in the literature is heterogeneous, limiting evidence synthesis and hindering improvements in care. This study aims to develop a Core Outcome Set (COS) for adult patients with POPFF to standardise outcome reporting in future research and audit. 

Methods 
Candidate outcomes were identified through a systematic review of 616 full-text publications and a secondary thematic analysis of 20 in-depth qualitative interviews with POPFF patients, conducted as part of the Periprosthetic Femoral Fractures – Understanding the Patient Experience and Impact study. Outcomes were categorised using the Core Outcome Measures in Effectiveness Trials (COMET) taxonomy and refined through structured discussions with healthcare professionals (via the POPFF Study Management Group, SMG) and patients (via the University of Bristol Patient Experience Partnership in Research, PEP-R). 

Results 
The systematic review and thematic analysis yielded 62 and 59 outcomes, respectively, which were consolidated into a long-list of 97 unique outcomes. This list was refined by the SMG and PEP-R groups to identify 18 priority outcomes. Patients prioritised life-impact domains such as mobility, emotional well-being, and pain. Clinical outcomes commonly reported in the literature, such as bone union and reoperation, appeared less important to patients. The 18 priority outcomes reflect a multidimensional perspective on recovery after POPFF. 

Conclusion 
The 18 priority outcomes will be taken forward into a two-round online Delphi survey involving patients, healthcare professionals, and researchers. This will be followed by a final consensus meeting to define the COS. 

Implications 
This work will produce a patient-informed COS to support consistent and meaningful outcome reporting in future POPFF research and quality improvement initiatives. 

Disclosure 
Funding was received from Orthopaedic Research UK and the Academy of Medical Sciences. 

Shahjahan Aslam1, Henry Crouch-Smith1, James Edwards2, Waseem Abbas1, Oliver Palmer2, Hashim Khan3, Harrison Town2, Beatrice Peacock2, Gunasekaran Kumar1 

1Liverpool University Hospitals NHS Foundation Trust, Liverpool, United Kingdom. 2University of Liverpool, Liverpool, United Kingdom. 3Rawalpindi Medical University, Rawalpindi, Pakistan 

Abstract 

Background: 
Obesity significantly increases the risk of venous thromboembolism (VTE) following total hip replacement (THR). Enoxaparin, a low-molecular-weight heparin, is commonly used for thromboprophylaxis. However, standard dosing (40 mg once daily [OD]) may be inadequate in obese patients, prompting consideration of higher doses. In November 2023, our institution implemented a policy mandating a higher enoxaparin dose (40 mg twice daily [BD]) for patients over 100 kg. This study evaluates the safety and efficacy of this escalation. 

Methods: 
A retrospective cohort study was conducted of 1,081 patients who underwent elective THR between January 2022 and December 2024. Patients were stratified into three groups: (i) patients <100 kg receiving 40 mg OD, (ii) patients >100 kg receiving 40 mg OD, and (iii) patients >100 kg receiving 40 mg BD post-policy change. Outcomes included VTE events (deep vein thrombosis [DVT] or pulmonary embolism [PE]) and wound-related complications: infection, antibiotic use, return to theatre, and multiple wound clinic visits. Chi-squared analysis was used, with p<0.05 considered significant. 

Results: 
Among patients <100 kg, 449 received 40 mg OD. In the >100 kg cohort, 57 received 40 mg OD and 37 received 40 mg BD. No significant difference in VTE rates was found between patients >100 kg on OD vs BD dosing. However, those on 40 mg BD had significantly higher rates of wound complications, including infection, antibiotic use, return to theatre, and additional clinic visits, compared to patients <100 kg on 40 mg OD (p<0.05). No VTE events were observed in any group. 

Conclusion: 
In obese patients undergoing THR, escalation of enoxaparin to 40 mg BD did not reduce VTE incidence but was associated with increased wound morbidity. 

Implications: 
Routine high-dose enoxaparin for obese patients may increase complications without added VTE protection. Further prospective studies are warranted. 

Disclosure: 
The authors declare no conflicts of interest. 

Aatif Mahmood, Hisbullah Mohammad, Reuben Johnson, Aslam Mohammed 

Wrightington Wigan and Leigh NHS Trust, Wrightington, United Kingdom 

Abstract 

Background:  

Hip arthroscopy for the treatment of femoroacetabular impingement syndrome (FAIS) has seen a massive increase over the last two decades. However, there is paucity of literature comparing the long-term outcomes of labral debridement vs labral repair in terms of conversion to total hip replacement (THR) 

Purpose:  

To compare rates of conversion to THR in patients with Tönnis grade 0 or 1 undergoing hip arthroscopy for FAIS 

Methods:  

This was a retrospective cohort study of patients who underwent primary hip arthroscopy at Wrightington hospital between January 2010 and December 2015. 

Results:  

Of the 100 hips included in the study, 43 (43%) underwent labral repair, and 57 (57%) underwent debridement. In total, 20 (20%) of the 100 patients underwent conversion to THA within 10 years after hip arthroscopy. Labral repair was associated with a significantly lower risk of conversion to THR compared with debridement. Additional factors associated with risk of conversion to THR included older age at the time of arthroscopy and Tönnis grade. 

Conclusion:  

Patients who underwent labral repair were less likely to be converted to THR compared with patients who underwent labral debridement. 

Ronald Hang Kin Nam1,2, Amr Selim1,3,2, Zaina Gaddoura1, Zain Choudhary1, Geraint Thomas3,2 

1Department of Trauma and Orthopaedic Surgery, Royal Stoke University Hospital, Stoke on Trent, United Kingdom. 2School of Medicine, Keele University, Stoke on Trent, United Kingdom. 3Robert Jones And Agnes Hunt Orthopaedic Hospital, Oswestry, United Kingdom 

Abstract 

Introduction 
 Over 100,000 primary total hip arthroplasties (THAs) are performed annually in the UK. Despite routine pharmacological prophylaxis, venous thromboembolism (VTE) remains one of the common complications following THA. While NICE recommends extended-duration prophylaxis (28-35 days), it highlights the need for further research. We conducted a Bayesian meta-analysis comparing short (10-14 days) versus extended (28-35 days) thromboprophylaxis regimens. 
  
 Methods 
 This PROSPERO-registered (CRD420251021533) review followed PRISMA-NMA guidelines. Databases were searched through April 2025 for studies comparing prophylaxis durations after elective THA using LMWH (short/long), DOACs (apixaban/rivaroxaban/dabigatran, short/long), or aspirin (long). Outcomes included symptomatic-deep vein-thrombosis (DVT), pulmonary embolism (PE), major-bleeding, and 90-day mortality. Bayesian random-effects meta-analysis models with binomial likelihoods and logit links were used. 
  
  
 Results 
 Twenty-four studies comprising 33,387 patients (4,864 short-duration vs. 28,523 extended-duration), with a mean age of 62.6 years and 53.7% female, were analysed. Extended-duration prophylaxis reduced symptomatic-DVT events compared with short-duration (OR 0.60, 95% CrI 0.38–0.93). Pulmonary embolism rates were also lower with extended-prophylaxis (OR 0.48, 95% CrI 0.25–0.86). Major-bleeding rates were similar between groups (OR 0.99, 95% CrI 0.72–1.36). No significant difference was observed in 90-day mortality (OR 0.63, 95% CrI 0.31–1.29). Subgroup analysis by publication year suggested that the reduction in symptomatic-DVT became less pronounced in more recent studies, with no significant benefit observed since 2010 (OR 0.77, 95% CrI 0.32–1.81). 
  
 Discussion 
 Overall, Extended-duration (28–35 day) prophylaxis reduced symptomatic-DVT and PE following THA. However, the magnitude of DVT reduction appeared less pronounced and was not statistically significant in studies published since 2010. Given modern enhanced-recovery protocols promoting early mobilisation and likely reductions in baseline-VTE risk, alongside the clinical consequences of bleeding, including infection and reoperation, a contemporary trial is required to evaluate the net clinical benefit of short versus extended prophylaxis. 

Poojit Borra1, Rajeev Sureshkumar1, Shameel Suhail2, Akash Patel2 

1UCL, London, United Kingdom. 2Royal Free London, London, United Kingdom 

Abstract 

Background 

Virtual Reality (VR) is increasingly used in surgical training, but its lack of haptic feedback remains a limitation. While systematic reviews have explored VR haptics in laparoscopic simulations, none have specifically examined orthopaedics. This study evaluates the effectiveness of haptic VR in orthopaedic training compared to other modalities. 

Method 

A systematic literature search was conducted up to March 2024 in MEDLINE, Embase, CENTRAL, Scopus, and WoS using search terms related to haptics, orthopaedics, and surgical training. Randomised controlled trials (RCTs) comparing haptic VR training with VR alone, conventional training or no training methods were included. 

Results 

Eight RCTs with 213 participants met the inclusion criteria. Four studies compared haptic VR with non-haptic VR, one compared it to no training, and three compared it to conventional training. Primary outcomes assessed included error rates, operating time, and face validity. 

Six RCTs reported a significant reduction in error with haptic VR training. A meta-analysis of three studies found haptic VR significantly improved error rates compared to non-haptic VR (Mean Difference = -1.98; 95% CI: -3.17 to -0.78). Two studies reported superior realism with haptic VR over non-haptic VR. However, two studies found longer operating times in haptic VR groups, and one study suggested bench-top simulators were preferred. 

Conclusion 

Haptic VR improves training outcomes in orthopaedic surgery, particularly in reducing errors, but realism concerns remain compared to conventional training. Further research is needed to evaluate its cost-effectiveness, fidelity's impact on training, and its role across different training stages. 

Disclosure 

No disclosures to note. 

Benjamin Schapira, Emmanuel Spanoudakis, Parag Jaiswal, Akash Patel 

Royal Free London NHS Foundation Trust, London, United Kingdom 

Abstract 

Background 

Orthopaedic trainees are finding it increasingly challenging to meet operative requirements and coupled with the increasing demand for elective procedures, we face a future of insufficiently trained surgeons to meet demand. High-fidelity-virtual-reality (HFVR) simulator training has become more prevalent across surgical disciplines yet remains novel in hip arthroscopy. This project aimed to validate HFVR hip arthroscopy simulation and assess its functional use in training. 

Methods 

Seventy-two participants were recruited to perform two arthroscopic tasks on a HFVR hip arthroscopy simulator and stratified to novice (39) and senior (33) groups, testing hip anatomy, scope manipulation and triangulation. Metric parameters recorded from the simulator were used to assess construct validity. All recordings were reviewed by 2 hip arthroscopy experts for blinded ASSET score assessment. Face validity was evaluated using a Likert-style questionnaire. 

Results 

Senior participants completed both tasks significantly faster than novices (p<0.001). Senior participants produced significantly less cartilage damage than novice participants (p=0.011) with significantly reduced path length of both scope and instrument across both tasks respectively (p=0.001, p=0.007). Senior participants demonstrated significantly higher total ASSET scores than novice participants (p=0.041) with excellent correlation between task time, cartilage damage and instrument path length and corresponding ASSET criteria. All participants demonstrated a relative 43% improvement in skill between tasks 1 and 2 (p<0.001). At least 81.8% of senior participants reported high realism of all facets of external , technical and haptic experience. 

Conclusion 

This is the largest study to date validating the use of simulation in hip arthroscopy training. These results confirm a high degree of both construct and face validity, excellent agreement between objective measures and subjective ASSET scores, significant improvement in skill with continued use. 

Implications 

This study recommends HFVR simulation to be a valuable asset in hip arthroscopy training for all grades. 

Charles Taylor1, Chuck Lam1, Nikhil Manoj1, Omkaar Divekar2 

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

Abstract 

Background: Spinal fusion surgery, particularly pedicle screw placement (PSP), is a commonly performed orthopedic procedure. Despite its benefits, PSP is associated with various intraoperative complications. Augmented Reality Surgical Navigation (ARSN) has emerged as a potential solution to improve surgical outcomes. This systematic review aims to assess whether ARSN enhances screw accuracy and operative outcomes compared to traditional methods, including freehand, fluoroscopic, and intraoperative image-guided navigation.  

Methods: A comprehensive search of PubMed, Ovid MEDLINE, Cochrane Library, Embase, and Web of Science was conducted for studies published between January 7, 2023, and January 8, 2024. Data was analysed according to PRISMA guidelines, with risk of bias assessed using the ROBINS-I tool. A modified Newcastle–Ottawa Scale determined the certainty of the evidence. 

Results: From 521 identified papers, 31 studies were included in the final review. Results indicated that ARSN significantly increased the accuracy of screw placement, with 93.33% of screws achieving Gertzbein-Robbins grade 1 or 2 compared to 85.86% in non-ARSN surgeries (p < 0.000). ARSN also resulted in a significant reduction in intraoperative blood loss (470.32 ml vs 802.44 ml, p = 0.050), though operative duration (281.6 min vs 255.5 min, p = 0.819) and screw placement time (2.71 min vs 3.1 min, p = 0.703) were comparable. A nonsignificant reduction in hospital stay was observed (5.4 vs 7.5 days, p = 0.097). 

Conclusion: Our findings support ARSN as a safe and effective technological advancement in PSP surgery. ARSN significantly enhances screw placement accuracy and reduces intra-operative blood loss, making it a valuable innovation. 

Sam Barrow1, Kailash Devalia2, Aysha Rajeev2 

1Newcastle University, Newcastle upon tyne, United Kingdom. 2Queen Elizabeth Hospital, Gateshead, United Kingdom 

Abstract 

Background 

Cancellation of surgical procedures has significant physical, psychological, and financial consequences for patients and wastes hospital time and resources. Our study aimed to identify reasons for cancelling elective orthopaedic surgery at a district general NHS hospital and subsequently suggest interventions to address avoidable reasons for cancellation. 

Methods 

We performed a retrospective audit looking at all elective orthopaedic procedures cancelled within 7 days of the intended surgery date between 1/12/23 and 30/11/24 using Careflow, Bluespier, and hospital records. We then identified all reasons for cancellation and classified them as related to patient, clinical, or hospital factors. Reasons were also divided into avoidable and unavoidable, and the number of upper and lower limb cancellations was identified. 

Results 

We identified 600 cancellations, of which 47% were attributed to clinical factors, 25% to patient factors, and 28% to hospital factors. 48% of cancellations were for avoidable reasons and 52% were for unavoidable reasons. Of cases cancelled for avoidable reasons, 44% were upper limbs and 56% were lower limbs. For unavoidable reasons, 31% were upper limbs and 69% were lower limbs. 132 (25%) of cancellations happened on the intended day of surgery. 

The most significant avoidable reasons for cancellation were patient unable to attend (13%), surgeon unavailability (8%), and lack of theatre time (6%). Administrative factors relating to staff availability, equipment, and pre-operative assessment were responsible for 13% of cancellations. 

The unavoidable reasons responsible for most cancellations were patient unfit (24%), priority cases requiring urgent surgery (13%), and the need for further investigations (6%).                      

Conclusion 

Avoidable reasons were responsible for many cancellations and may be prevented through improved communication with patients and between staff. Unavoidable reasons may have root causes which can be tackled. For example, earlier pre-operative assessment to identify changes to clinical status and optimisation of emergency theatre use. 

Ibrahim Muhammad1, Ben Gabbott2, Yuk Wong2, Andrew Price3, Xavier Griffin2 

1Queen Mary University London, London, United Kingdom. 2Bone and Join Health Department, Queen Mary University London, London, United Kingdom. 3NDORMS, Oxford University, Oxford, United Kingdom 

Abstract 

Introduction: 

The relationship between arthritis and mental health disorders (MHD) is bidirectional. Arthritis induces pain, which is associated with MHD, while MHD can exacerbate arthritis symptoms. Arthroplasty likely shares a complex relationship with Mental Health Symptoms (MHS).  

Our previous research revealed 8–12%of patients develop moderate or severe MHS of depression and anxiety following arthroplasty, which may effect functional outcomes. 

Recent literature suggests growing waiting lists lead to pre-operative MHS deterioration. Our project aims to explore whether post-operative MHS are also affected. 

Methods: 

Pseudonymised PROMS data from NJR reports extracted including; EQ5D question about MHS , and pre-existing diagnosis of MHD 

 A multivariable regression model was constructed, with MHS at 6months as the primary outcome. Covariates included sex, age, formal MHD diagnosis, pre-operative MHS, and change in PROMS function score. 

Adjusted MHS odds ratios reported by operation year. Secondary analysis compared pre- and post-COVID odds ratios. 

Results:  

Data available for 656,343operations.  

Figure 1 presents the multivariable regression model results.  

The adjusted ORs of reporting MHS at 6 months is reported displaying a stepwise significant increase from 2016/2017 to 2021/22. For patients undergoing arthroplasty post-COVID, there is an increased odds ratio of 1.22compared to pre-COVID (1.22,1.18–1.26). 

Discussion: 

Our findings suggest the risk of reporting MHS post-arthroplasty is increasing steadily over time. This trend may be attributed to increasing wait times, further exacerbated by the COVID-19 pandemic. We hypothesize that as wait times increase, patients experience MH deterioration, which may predispose them to report MH symptoms post-operatively. This may affect patients' perceptions of arthroplasty success. 

Figure 1  

Year                 OR               P - Value 

2013/14    -     

2014/15    0.98 (0.95, 1.01)    0.24 

2015/16    0.99 (0.96, 1.02)    0.51 

2016/17    1.01 (0.98, 1.04)    0.66 

2017/18    1.03 (1.00, 1.07)    0.03 

2018/19    1.08 (1.05, 1.12)    <0.001 

2019/20    1.15 (1.12, 1.19)    <0.001 

2020/21    1.17 (1.08, 1.26)    <0.001 

2021/22     1.29 (1.23, 1.34)    <0.001 

Colette Revadillo1, Joshua MacIntyre2,3, Katie Hughes1,2,3, Emily Baird2,3 

1University of Edinburgh, Edinburgh, United Kingdom. 2Royal Hospital for Children and Young People, Edinburgh, United Kingdom. 3Edinburgh Orthopaedics, Edinburgh, United Kingdom 

Abstract 

Introduction: 
The management of paediatric musculoskeletal infections have relied on prolonged intravenous (IV) antibiotics despite increasing evidence questioning the necessity of extended treatment duration. This study evaluates the safety and outcomes of early IV-to-oral transition in real-world practice, with particular attention to bacteraemic cases and IV access challenges. 

Methods: 
A retrospective review was conducted of all patients under 16 years treated for acute osteomyelitis or septic arthritis at a major tertiary paediatric referral centre (2018–2023). Inclusion criteria were patients who transitioned to oral antibiotics before completing 14 days of IV therapy. Primary outcomes included treatment failure (defined as infection recurrence), re-admission, or development of complications. Secondary outcomes examined the reasons for early transition and the relationship between treatment duration and clinical outcomes. 

Results: 
27 patients were included (mean age 7.4 years; range 0-14.9). Of these, 56% had septic arthritis and 44% osteomyelitis. Surgical intervention was performed in 74% (n=20), including all cases of septic arthritis. Microbiology identified 11 culture-positive cases (5 staphyloccocus aureus) and 4 bacteraemias (3 staphylococcus aureus, 1 staphylococcus epidermis). IV antibiotic duration averaged 4.7 days (median 5, range 2-10). Total antibiotic duration averaged 34 days (median 28, range 10-47): 70% (n=19) completed ≥4 weeks, 19% (n=5) received 3-4 weeks, and 11% (n=3) treated with <3 weeks of antibiotics. 30% (n=8) experienced significant IV access difficulties prompting early switch in 62% (n=16). No major complications occurred in any patient, including all bacteraemic cases.  

Conclusion: 
This study supports the safety of early IV-to-oral transition in clinically stable paediatric musculoskeletal infections, including those with confirmed bacteraemia. Individualised treatment duration based on clinical response may be both safe and pragmatic, particularly when IV access proves challenging. These findings challenge traditional protocols and advocate for further prospective research to establish evidence-based criteria for optimal treatment durations across different clinical scenarios.  

Saran Gill1, Ahmed Al-Saadawi2, Gareth Jones1, Justin Cobb1, Omar Musbahi1 

1Imperial College London, London, United Kingdom. 2Queen Mary University of London, London, United Kingdom 

Abstract 

Background: Emerging data suggest ethnic minority patients face poorer outcomes after total hip and knee replacement (THR, TKR), though most evidence is based in the US and limited for procedures like hip resurfacing (HRA) and unicompartmental knee replacement (UKR). We aimed to assess disparities based on ethnicity in (1) all-cause mortality, and (2) post-operative outcomes in patients undergoing TKR, THR, HRA, and UKR in England.  

Methodology: A retrospective cohort study was conducted using linked healthcare datasets, including Hospital Episode Statistics and Office for National Statistics, Clinical Practice Research Datalink records between 1998-2021 in England. Patients were stratified into Caucasian or ethnic minority cohorts. Primary outcomes were all-cause mortality across the study period, given as firth corrected cox proportional Hazard Ratios (HRs) and Odds Ratios (ORs) at specific timepoints up to 20 years. Secondary outcomes included postoperative complications up to a year. Propensity Score Matching for Caucasian:ethnic minority patients were performed using a Random Forest Model, with and without Body Mass Index (BMI). Statistical significance was set at p<0.05. 

Results: After exclusions, 109,539:21,613 and 238,531:46,587 procedures were matched with BMI and without BMI. Ethnic minority patients had significantly lower mortality with (HR: 0.76 [95% CI: 0.73–0.78], p < 0.001) and without (HR: 0.74 [95% CI: 0.72–0.76], p < 0.001) BMI adjustment. However, odds were higher for A&E attendance (OR: 1.384 [95% CI: 1.338–1.430], p < 0.001), critical care (OR: 1.442 [95% CI: 1.343–1.547], p < 0.001), readmission (OR: 1.285 [95% CI: 1.228–1.344], p < 0.001), and longer postoperative hospital stays (β: 0.477 days [95% CI: 0.368–0.586], p < 0.001). 

Conclusion: This study provides novel insights into ethnic disparities in post-operative outcomes, highlighting decreased long-term mortality among ethnic minority patients alongside varied hospital-based complications. Future research should focus on evaluating targeted interventions and risk stratification models to address these disparities. 

Beverly Low1,2, Azmi Rahman2, Stephen Mellon2, David W Murray2 

1University of Oxford, Oxford, United Kingdom. 2Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom 

Abstract 

Background 
The cemented OUKR tibial component has a window in its keel allowing cement infill for secure attachment. The cementless OUKR keel retains this window, adding a porous titanium surface. Fixation of the cementless component is superior to the cemented, but it is unclear whether bone growth into the window promotes this. This study characterises changes in radio-opacity of bone in contact with the keel of the cementless OUKR tibial component 5 years post-implantation and its relationship to patient-reported outcome measures (PROMS).  

Methods 
From 545 knees in 441 patients, 114 OUKR performed across 2 UK hospitals were identified and measured to have adequately aligned anteroposterior radiographs where the bone-keel interface was not obscured, post-operatively and 5 years after surgery. The radio-opacity of a 1mm region of bone around the keel was measured by two assessors. 5-year change in radio-opacity was calculated and compared between different bone regions. 5-year PROMS were collected and compared. 
 
Results 
Interoperator correlation was very good (ICC 0.86). A decrease in radio-opacity was noted on both sides of the keel which progressively increased inferiorly (Medial: -5.7%, 95%CI: -6.5%, -4.9%; Lateral: -3.0%, 95%CI: -3.7%, -2.3%). No step change in radio-opacity occurs at the edges of the keel window. Highest increase in radio-opacity was observed in bone under the keel (+16.1%, 95%CI: +14.4%, +17.8%). No relationships between PROMS and radio-opacity changes adjacent to the window were identified (all p>0.05).  

Conclusions  
Increased radio-opacity under the keel suggests load transmission through the keel into bone directly below. The marked decrease in radio-density on both sides of the keel, particularly in the region of the window, suggests stress shielding of bone beside the keel and minimal bone formation in the window, implying no clear contribution to fixation. The window could be potentially removed for a smaller keel design without compromising fixation.  

Long-Term Outcomes of Paediatric Bone and Joint Infections: A Systematic Review of Recurrence and Complications at Twelve Months Follow-Up. 

Patrick J Robinson1, Colette Revadillo1, Katie Hughes2,1 

1Edinburgh Medical School, The University of Edinburgh, Edinburgh, United Kingdom. 2Edinburgh Orthopaedics, NHS Lothian, Edinburgh, United Kingdom 

Abstract 

Background  
Most paediatric bone and joint infections (BJIs) are successfully treated, but risks of recurrence, growth disturbances, chronic pain, and functional impairment remain. The British Orthopaedic Association recommends at least 12 months of clinical and radiographic follow-up to detect long-term complications, yet data on incidence and risk factors are limited.  

This systematic review synthesises evidence on recurrence and sequelae of paediatric BJIs at ≥1-year follow-up.  

Methods:  
A systematic search of Medline, Embase, CENTRAL, and Scopus (2010–2025) identified observational and interventional studies with ≥12 months of follow-up. Two reviewers independently screened studies, with a third resolving conflicts. Data extracted included recurrence rates, complications, treatment regimens, and risk factors. Risk of bias was assessed using ROB 2 (RCTs) and ROBINS-I V2 (non-RCTs).  

Results:  
Fourteen studies met inclusion criteria (21% RCTs, 29% mixed-methods-cohort, 43% retrospective). Follow-up ranged from 3–24 months. Seven studies explicitly reported recurrence rates at 1 year (0.0%–10.6%). Definitions varied (clinical, microbiological, radiological). Thirteen studies documented complications, most commonly growth disturbances, chronic pain, joint stiffness, and chronic osteomyelitis. Risk factors included delayed treatment, bacteraemia, and MRSA infection. Treatment involved IV antibiotics (2–14 days) followed by oral therapy (20–30 days); conversion to surgery ranged from 0.0-40.8%. S. aureus (methicillin-susceptible) was the most common pathogen.  

Conclusions/Implications:  
Despite low recurrence rates, complications highlight the need for structured long-term follow-up. A paucity of research; prospective studies should identify predictors of poor outcomes to refine follow-up protocols and improve patient care.  

Disclosures:  

The authors have no disclosures for this work.   

Rajapriyian Murugaiyan1, Jed Smith2, Andrew Grainger2,3, Dimitri Kessler3,4, Graham Tytherleigh-Strong2, Joshua Kaggie2,3, Salma Chaudhury2 

1University of Cambridge, Cambridge, United Kingdom. 2Cambridge University Hospitals, Cambridge, United Kingdom. 3Department of Radiology, University of Cambridge, Cambridge, United Kingdom. 4Facultat de Matemátiques i Informática, Universitat de Barcelona, Barcelona, Spain 

Abstract 

Background 

Anterior shoulder dislocations (ASDs) before age 25 increase the risk of glenohumeral osteoarthritis (OA), with 61% developing OA within 25 years. Treatment options for irreversible end-stage OA remain limited. Quantitative MRI has demonstrated the potential to detect early degenerative damage in the knee. This study assessed the feasibility and reproducibility of 3D Cartilage Surface Mapping for producing quantitative cartilage maps of the shoulder joint, given the challenges of thinner cartilage. We employed this imaging technique to evaluate the early identification of cartilage damage in patients who sustained ASDs. 

Methods 

23 patients aged 16-40 years with ASDs underwent additional MRI sequences for cartilage mapping. A 3D visualisation software (Stradview v7.3), enabled the segmentation of humeral head and glenoid cartilages independently by two experienced readers, and their thicknesses were measured to assess inter-rater reliability. 

Results 

The mean humeral head and glenoid cartilage thicknesses were 1.59mm and 2.42mm, with mean bias of 0.04mm and-0.06mm and 95% limits of agreement from -0.11 to 0.20mm and -0.31 to 0.20mm, respectively. The Intraclass Correlation Coefficients (ICC) between readers displayed excellent reproducibility, measured at 0.92 for the humeral head and 0.94 for the glenoid. 

Conclusions/Findings 

This study illustrates the feasibility and reproducibility of using cartilage thickness mapping techniques. Quantitative MRI can identify and quantify early arthritic changes following shoulder dislocations, overcoming the limitations of qualitative MRI. This can help categorise patients based on the extent of cartilage damage, which can guide clinical decision-making, regarding conservative or early surgical interventions, ultimately improving shoulder stabilisation and reducing the risk of developing OA in the future.  

Implications 

Further research investigating additional indicators of cartilage damage and serial monitoring of patients with repeat scans at 1 year to monitor OA progression, has the potential to improve long-term functional outcomes and reduce severe disease progression. 

Disclosure 

Nothign to disclose. 

Saakithyan Sritharan1, Leon Srikantha1, Wen Xian Low2, Stephen McDonnell1, Nicolas Nicolaou3, Ignatius Liew1 

1Department of Trauma and Orthopaedics, University of Cambridge, Cambridge, United Kingdom. 2Queen Mary University of London, London, United Kingdom. 3Department of Paediatric Orthopaedics and Spinal Surgery, Sheffield Children’s Hospital, Sheffield, United Kingdom 

Abstract 

Background  

Complex patellofemoral disorders are associated with poor function and osteoarthritis. Whilst substantial literature exists on patellar instability, evidence remains heterogeneous in the management of congenital, fixed, or habitual dislocations in children and adolescents. This study aims to systematically review evidence on management strategies in these subgroups. 

Methods 

Following PRISMA guidelines and a prospectively registered protocol (ID: CRD420251044529), a systematic search was conducted on MEDLINE, Embase, CENTRAL, ClinicalTrials.gov, and WHO ICTRP. Included studies reported management techniques for congenital, habitual, or fixed patellar dislocations in the skeletally immature or individuals ≤18 years. Skeletally mature patients and first-time/recurrent dislocations were excluded. Meta-analyses were performed using random-effects models; heterogeneity was evaluated using I² and risk-of-bias using ROBINS-I. 

Results 

77 studies (769 patients) were included. 37 studies (174 patients) addressed congenital dislocations, 38 studies (536 patients) investigated habitual dislocations, and 21 studies (158 patients) involved fixed dislocations. Mean age and post-operative follow-up were 11.5 years (0–18) and 4.98 years (0.5–13.17), respectively. 

Congenital dislocation management included 45 distinct interventions, predominantly surgical (43/45), most commonly medial plication (8.6%). For habitual dislocations, 47 surgical techniques were reported, with medial patellofemoral ligament reconstruction (MPFLR) (12.5%) being most frequent. Fixed dislocations involved 41 surgical techniques, most commonly MPFLR (11.6%). 

87% of studies assessed outcomes using recurrent instability, post-operative range of motion, and radiological assessment, with no single technique demonstrating superiority. 

Only 39% employed validated patient-reported outcome measures (PROMs: Kujala score, Lysholm score, pedi-IKDC), limiting comparative analysis and synthesis.  

Conclusion 

Reported patient outcomes were highly heterogeneous, limiting cross-technique comparison with no clear superior surgical intervention. Randomised control trials to evaluate interventions and management of these complex subgroups in view of the rarity and heterogeneity of this cohort are difficult to perform. Future research should prioritise standardisation of variables and terminology, registry data, and validated core outcome sets. 

Cameron Pinn, Arun Dahil, John Dawson, Yanghee Kim 

University of Southampton, Southampton, United Kingdom 

Abstract 

Aims: 
 Bone morphogenetic protein-2 (BMP-2) is an osteoinductive factor used in fracture healing. However, its clinical application requires high doses, causing adverse effects including inflammation and ectopic ossification (1,2). Nanoclay-based Laponite powder can promote skeletal stem cell differentiation and mineralisation (3), making it a promising alternative to current BMP-2 delivery systems.  However, the effects of BMP-2 localisation on Laponite particles remains unexplored. This study evaluates whether Lapnoite can serve as a controlled BMP-2 delivery system to enhance its bioactivity while reducing systemic exposure (1,2). 

Methods: 
 We assessed the osteogenic potential of BMP-2 localised to Laponite particles using C2C12 myoblasts. Serial dilutions (640 ng/mL to 0 ng/mL) of BMP-2 were introduced under four conditions: (A1) freeze-dried BMP-2 with freeze-dried Laponite, (A2) freeze-dried BMP-2 alone, (B1) BMP-2 with Laponite, and (B2) BMP-2 alone. The formulations were added to C2C12 cells, followed by 72 hours of incubation. Alkaline phosphatase (ALP) activity, a marker of osteogenic differentiation, was quantified via biochemical staining and CellProfiler™ image analysis. Statistical analysis was performed using two-way ANOVA. 

Results: 
 Laponite significantly enhanced BMP-2 bioactivity, with higher ALP activity in BMP-2 groups mixed with Laponite (A1 vs. A2, p<0.0001, B1 vs. B2, p<0.0001). Notably, non-freeze dried formulations of Laponite with BMP-2 resulted in superior osteogenic stimulation compared to their freeze-dried formulations (A1 vs. B1 p <0.0001). Our study demonstrated BMP-2 osteoinductive activity at 10 ng/mL, the lowest concentration tested to date, suggesting that lower doses could be still be clinically effective. 

Conclusions: 
 Laponite enhances BMP-2 osteoinductive activity, supporting their use as biomaterials for bone regeneration. Laponite’s ability to induce bone formation at lower BMP-2 concentrations suggests clinical benefits in fracture healing. Future studies will explore the integration of BMP-2 loaded Laponite into human bone derived extracellular matrix hydrogels to further optimise their therapetuic potential (4). 

Dominic Tso1, Samantha Goodchild1, Kevin Cheah2 

1Anglia Ruskin University, Chelmsford, United Kingdom. 2Nuffield Health Brentwood Hospital, Brentwood, United Kingdom 

Abstract 

Background 

Periprosthetic fractures of the femur (PPFFs), fractures of bone that are associated around the introduction of an implant, are a well-known risk of cementless hip replacements. There have been many iteration of classification systems to categorise cementless femoral stems based on design and shape. Radaelli et al. (2022) has been one of the most recently developed classification systems which encompasses newer femoral designs. 

Method 

Using PubMed studies were screened for primary data reporting PPFFs in cementless hip replacements. 1,652,625 cementless THAs were found, of those, 298,662 were able to be categorised into stem types A, B2 and C1. Meta-analysis, meta regression analysis (pairwise Wald test) and risk ratio/odds ratio were performed on these stems. 
  
 Results 

Meta analysis of stem types A, B2 and C1 showed a significant association with PPFFs however pairwise meta regression analysis showed no significant difference in PPFF prevalence when comparing stems against each other. Risk and odds ratio both showed stem C1 having a statistically lower risk and odds of fracture occurring.  

Conclusion 

We found no significant difference in PPFF prevalance between the most popular stem designs but a reduced risk and odds of fracture in stem C1. Although we analysed ~300,000 stems, a bigger sample size must be analysed and confounding factors such as patient age, co-morbidities, intraoperative or postoperative periprosthetic fracture and coating must be taking into account.  

Joanna Craven1,2, Wesley Theunissen3, Olivia O’Malley4, Dan Winson5, Clare Carpenter6, Daniel Perry1 

1University of Liverpool, Liverpool, United Kingdom. 2Wales Deanery, Cardiff, United Kingdom. 3Máxima Medical Center, Veldhoven, Netherlands. 4Imperial College London, London, United Kingdom. 5Children's Health Queensland Hospital and Health Service, Queensland, Australia. 6University Hospital Wales, Cardiff, United Kingdom 

Abstract 

Background Developmental Dysplasia of the Hip (DDH) is a common congenital condition affecting the hip joint, with approximately 1% of newborns affected to some degree. Early diagnosis and treatment with a brace, such as a Pavlik harness, can reduce the need for surgical intervention and improve long-term outcomes. Despite the overall success of brace treatment, considerable variability in clinical practice exists due to a lack of high-quality evidence guiding protocols. Additionally, the impact of brace treatment on families is often overlooked in clinical research. A family-centred core outcome set (COS) is essential to standardize outcomes that matter to families and caregivers in trials evaluating brace treatment for DDH. 

Methods A comprehensive list of potential outcomes was generated through a literature review and a survey of key stakeholders, including caregivers, clinicians, and researchers. These outcomes were then assessed through a two-round Delphi consensus process involving an international panel of orthopaedic surgeons, physiotherapists, nurse practitioners, researchers, parents, and charity representatives. Outcomes that did not achieve consensus were discussed during a final consensus meeting, where a broader stakeholder group voted on their inclusion. 

Results Fourteen family-centred outcomes were identified for evaluation. Of these, eight reached consensus during the Delphi rounds, while six were further discussed at the final consensus meeting, resulting in one additional outcome being included. The final COS comprises nine outcomes: infant cleanliness, sleep, comfort, development, skin irritation, and feeding, along with parental well-being, bonding, and the availability of information and resources. 

Conclusion This family-centred COS provides a standardized framework for evaluating the impact of brace treatment on families of infants with DDH. 

Implications Implementing this COS will ensure consistent reporting of family-centred outcomes in future clinical trials, aiding treatment decision-making and improving care for infants with DDH. 

Disclosure The authors have no conflicts of interest to disclose. 

Joanna Craven1,2, Daniel Perry1, Catrin Plumpton3 

1University of Liverpool, Liverpool, United Kingdom. 2Wales Deanery, Cardiff, United Kingdom. 3Bangor University, Bangor, United Kingdom 

Abstract 

Background 
 Developmental Dysplasia of the Hip (DDH) is often treated with a removable brace when diagnosed early. While effective, there is wide variation in how and when brace use is stopped. In the UK, 65% of clinicians stop immediately, while 35% use a weaning period. Internationally, weaning is more common, but evidence is limited and regimens vary. 

A discrete choice experiment (DCE) is a stated preference method that quantifies the trade-offs participants make in hypothetical scenarios. Understanding parental preferences is key to designing meaningful trials and supporting shared decision-making. 

Methods 
 An online DCE was completed by 197 parents of infants treated in a brace for DDH, recruited via the STEPs charity. Attributes and levels were developed from surveys and a literature review. The DCE included three attributes: timing of brace wear (4 levels), length of weaning (6 levels), and risk of further intervention within two years (4 levels). Participants completed 16 choice tasks, each comparing two weaning regimens and a fixed-risk "no weaning" option. Preferences were analysed using conditional logistic regression. 

Results 
 Parents preferred night-time-only wear over other regimens. Longer weaning and higher risk significantly reduced preference for weaning (p<0.001). A secondary analysis excluding irrational responders (n=91) showed stronger preference for no weaning. 

Conclusion and Implications 
 Parents are open to weaning if it reduces the risk of further treatment; however, they prefer night-time regimens and shorter weaning durations. These findings can inform the design of a future randomised controlled trial comparing weaning with immediate brace cessation by identifying preferred weaning strategies which supports intervention design, guiding sample size calculations through the minimally important difference in risk and ensuring outcome interpretation reflects family preferences. 

Disclosure 
 This study is funded by a National Institute for Health Research (NIHR) doctoral fellowship (ID: NIHR303304). 

Natalie Bishop, Jennie Quilter, Jo Cripps, Gemma Green, Gregory Firth, Jo Dartnell, Chun Tang, Marcos Katchburian 

Maidstone and Tunbridge Wells NHS Trust, Maidstone and Tunbridge Wells, United Kingdom 

Abstract 

Background: Congenital talipes equinovarus (CTEV) is a common congenital condition, which can result in long term deformity, functional debility and pain if untreated. Primary treatment is serial casting (Ponseti method). We present a large series of children with CTEV, documenting radiological outcomes after using the Ponseti method with at least 10 year follow up. 

Aim: We aimed to describe clinical and radiological outcomes of all CTEV patients treated at a UK District General Hospital (DGH) with at least a 10 year follow up period. 

Methods: Patients were identified using a local database. Patients born between July 2001 and December 2014 with a diagnosis of CTEV were included. Patients had radiographs at age five years. Antero-posterior and lateral Kite angles and calcaneal pitch were measured. Reoperation rates and recasting rates were recorded. Clinical outcomes were noted at five years. 

Results: 180 patients (263 feet) were included, with median age at initial treatment 3 weeks. Male to female ratio was 3:1. Mean number of cast changes was 6.24. 24/180 patients (13%) underwent secondary procedures. 132/180 patients (74%) had radiographs at age five years. All Kite angles were within normal range, however there was a significant difference in Kite angle in unilateral cases when comparing corrected to normal feet. p<0.000001. No difference was seen in bilateral cases. 

Conclusion: We concluded that at five years of age, Ponseti method corrects all Kite angles to within normal range. In unilateral cases there is a significant difference in both AP and lateral Kite angles, which may represent the expected clinical picture of an often imperfectly shaped but functional foot. Clinically, the majority of cases had acceptable morphological and functional feet.  

Laith Sinan1, David Hewson1, Ben Marson1,2 

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

Abstract 

Background 
Defining research priorities in paediatric orthopaedic perioperative care is essential to address gaps in evidence and guide future clinical practice. Despite advances in perioperative management, significant variability persists in anaesthetic techniques, pain control strategies, and multidisciplinary approaches. We conducted a national survey to systematically identify and map research uncertainties in this field. 

Methods 
An open survey was disseminated through multiple channels, including social media outreach via Twitter and targeted email invitations to members of national anaesthetic societies. Respondents submitted research questions related to perioperative care for children undergoing orthopaedic surgery. Submitted questions underwent thematic analysis and structured literature review to classify them as fully answered, partially answered, or unanswered according to existing evidence. Fully answered questions were excluded from further prioritisation. 

Results 
Seventy-nine research questions were collected. Participants included 45 anaesthetists (57%), 25 orthopaedic surgeons (32%), and 9 patients or carers (11%). After review and refinement, 49 questions (62%) were retained for further consideration, comprising 37 partially answered and 12 unanswered questions. Thematic analysis identified key domains including regional anaesthesia, multimodal pain management, perioperative multidisciplinary care, intraoperative management, and discharge planning. 

Conclusion 
This survey-based study has systematically mapped major research gaps in paediatric orthopaedic perioperative care. The large number of unresolved clinical questions underscores the need for structured prioritisation. These findings have provided the foundation for the launch of a national Delphi study to achieve expert consensus on future research priorities and drive improvements in perioperative care for children undergoing orthopaedic surgery. 

Ghiath Ismayl, Ali Alabbas, Anthony Howard, Adelle Fishlock, Mohamed Sabouni 

Leeds General Infirmary, Leeds, United Kingdom 

Abstract 

Background: 

Flexible intramedullary nailing (FIN) is a common treatment method for paediatric forearm fractures. They are routinely removed after fracture healing. This study aims to assess the 15-years’ experience of managing paediatric forearm fractures with FIN, with comparison between the outcomes of implant retention versus removal. This is the first study on FIN retention in paediatric forearm fractures. 

Methods: 

This was retrospective study for children who underwent FIN for forearm fractures between 2009 and 2024 at Leeds General Infirmary, a level one trauma centre in the United Kingdom. We noted a significant decline in scheduled elective removal of forearm FIN following the Coronavirus pandemic (COVID-19). The cohort was therefore divided into two comparative groups: implant “removal” (pre-COVID) and “retention” (post-COVID). Primary outcome measured was incidence of secondary (unplanned) surgery. Secondary outcomes measured were indications for surgery, time from index procedure to FIN removal and subjective patient/parents’ satisfaction. 

Results: 

268 patients were included in the study. Both bones fixation was at 71.6%, with single bone fixation at 18.3% radius and 10.1% ulna. The “removal” group comprised of 212 patients, and the “retention” group 56 patients. Elective implant removal was performed in 68.9% (n=146) of patients in the earlier group and 3.6%(n=2) in the latter. Secondary surgery was required in 14.2% (n=30) of patients in the “removal” group, with mean time to removal of 12 months, and 12.5% (n=7) in the “retention” group, with average time of 28 months. Irritation and discomfort were the most common causes for secondary surgery across both groups (73.3% and 85.7%, respectively). Patients/parents were satisfied with the results in 98.5% of cases. 

Conclusion: 

FIN retention after paediatric forearm fracture fixation is a safe and reasonable option, as it does not carry a higher risk of secondary surgery when compared to routine nail removal. 

Kittigon Seehaboot2 

1Department of Orthopaedics, Faculty of Medicine, Chulalongkorn university, Bangkok, Thailand. 2Excellence Centre for Gait and Motion, King Chulalongkorn Memorial hospital, Bangkok, Thailand. 3Department of Orthopaedics, King Chulalongkorn Memorial Hospital, Bangkok, Thailand 

Abstract 

Background: Clinical Gait Analysis is a useful tool for Orthopaedic surgeon to specify walking problems in patients. IMUs have been developed with advantage of being portable, easily to conduct a gait study without a solid and cumbersome setting of the standard motion laboratory1. There has been research show the capability of IMUs for gait analysis in adults1 and some specific motion problems in children2,3. This study aimed to find correlation between children gait analysis obtained from IMUs and standard motion capture system. 

Material and Method: IRB was approved, nines typically developed children (average age 10.78 (9-15) y.o. were recruited in the study, IMUs and reflective markers were attached to the lower extremities from pelvis to toes. Five regular speed walks were performed on a 10 m. walkway and gait data were captured by IMUs (xsens Awinda 2021) and a standard motion capture system (OptiTrack, NaturalPoint,Inc., Corvallis, OR, USA) and were processed with Visual3D x64 Professional 6.00.33 software (C-Motion, Inc., Ger-mantown, MD, USA). Kinematic data were normalised to 100% GC. Correlation study was performed. 

Results: at normal walking speed, there were excellent correlations between sagittal plane motion of ankle, knee and hip joints obtained from IMUs and standard motion capture at 0.91(0.79-0.98), 0.96 (0.91-0.99) and 0.95 (0.82-0.99) for ankle, knee and hip respectively.  

Conclusion: The IMUs system has demonstrated the possibility of capturing gait data in children compared to the standard motion capture system. This could be an option for gait data collection for children who have gait deterioration but have limited opportunity to access to standard motion capturing. 

Disclosure: The authors have no relevant financial or non-financial interests to disclose. 

Ref:  

1.         Osateerakun P, Liverpool John Moores University; 2021. 

2.         Ferrari A et.al.,Med Biol Eng Comput. 2010 

3.         van den Noort et.al., Med Biol Eng Comput. 2013 

Anna Porter1,2, Marc Farcasanu3, Katarzyna Pirog2, Kenneth Rankin2,1 

1Newcastle upon Tyne NHS foundation Trust, Newcastle upon Tyne, United Kingdom. 2Newcastle University, Newcastle upon Tyne, United Kingdom. 3Newcastle University, Newcastle uponTyne, United Kingdom 

Abstract 

Background: 

Guided growth techniques are minimally invasive surgical procedures used to correct angular deformities in paediatric patients. Compression on one side of the bone prevents growth and tension on the opposite side promotes it. However, the underlying molecular mechanisms remain largely unknown and approximately 30% of patients develop a reoccurrence of their deformity after plate removal. Skeletal dysplasias are rare genetic conditions resulting from mutations involved in the regulation of bone growth and patients develop lower limb deformities that are more resistant to guided growth correction. 

Objectives: 

1. Characterise chondrocyte cellular stress pathways activated by mechanical compression 

2. Establish a regional biobank of patient tissue and registry of clinical data 

Methods 

A chondrocyte cell line (TC28a2s) was cultured, pelleted and suspended in hydrogel constructs. They were allowed to free swell, loaded with 10g or 20g or underwent daily dynamic loading over a 21-day period. Histochemical analysis was performed to investigate the effects of mechanical pressure on the cells. 

Results 

Histology showed zonal stratification, indicating that pelleted cells maintained chondrocyte properties.  Real time PCR showed that chondrocytes under dynamic and static loads had gene changes in IRE1/XBP1 and ATF6 endoplasmic reticulum (ER) stress pathways. Ethical approval was granted to collect samples from paediatric patients to the local biobank. 

Conclusions 

These preliminary results demonstrate that mechanical pressure over the physis causes ER stress and subsequent apoptosis in chondrocytes. Patients with skeletal dysplasias often have pre-existing ER stress causing a slower response to guided growth. The novel paediatric tissue biobank will allow us to verify our findings in patient cell lines to investigate the differences in the pathological and non-pathological physis under mechanical load. 

Erin Flaherty1, Firas Raheman1,2, Pranai Buddhdev1 

1Broomfield Hospital, Chelmsford, United Kingdom. 2Royal National Orthopaedic Hospital, Stanmore, United Kingdom 

Abstract 

Background 

Paediatric forearm fractures are a common childhood injury that often necessitates flexible intramedullary (IM) nailing; however, the procurement of these nails is typically dictated by hospital contracts, leaving surgeons with minimal influence over choice of implant. We aimed to assess the difference in peri-operative outcomes of paediatric forearm fractures based on flexible nailing implants used from different manufacturers. 

Study Design and Methods 

This retrospective study reviewed paediatric patients listed for forearm flexible nailing from a single unit between August 2020 and November 2024, with a change in implant provider in June 2023. Data on patient demographics, procedure performed, operative time, intra-operative change of surgical plan, need to open fracture site and number of implants used per case were collected. Data analysis was conducted using SPSS. 

Results 

A total of 73 patients (average age 9 years) underwent IM fixation or conversion to ORIF;  44 patients were operated using implant A and 29 patients using implant B. Usage of implant B was significantly correlated with an increase in conversion to open, from 31.82% to 58.62% (p=0.031, OR=3.04), intra-operative change of surgical plan, from 36.36% to 65.52% (p=0.018, OR=3.33) and implant wastage, from 6.57% to 23.81% (p=0.011, OR=4.407).  

Conclusions 

Our study confirms that implants from different suppliers, though approved for the same indications, can have substantial differences in peri-operative outcomes, causing increased harm to paediatric patients. Increased opening of fractures and changing of intraoperative plans impacts upon optimal patient care, and increased implant wastage contributes to an economical and environmental burden on the hospital. 

Surgeons should involve themselves in proper consultation with hospital procurement when deciding on changing surgical implants contracts to promote cost-savings and sustainability as well as ensure best and safe surgical practice for their patients.  

Jenna Shepherd1,2, Darren Puttock1, Pip Divall1, Anna Peek1 

1University Hospitals of Leicester NHS Trust, Leicester, United Kingdom. 2University of Leicester, Leicester, United Kingdom 

Abstract 

Background 

Congenital talipes equinovarus (CTEV) is a common congenital condition. Following initial treatment patients can relapse, requiring further intervention. Gait analysis evaluates kinematics throughout gait, which have been demonstrated to differ between CTEV children and typically developing children. However, it is unclear whether there is a difference in kinematic parameters between those with CTEV who relapse and those who do not. We therefore aimed to synthesise current evidence to answer this question and to determine whether gait analysis could play a role in relapse monitoring. 

Methods 

Systematic review of the literature was conducted according to PRISMA guidelines. MEDLINE, Embase, CINAHL, Emcare and Cochrane databases were searched to identify studies comparing gait analysis in children <18 years with CTEV with and without relapse. End points included Gait Deviation Index (GDI) score and individual kinematic parameters. Random-effects meta-analysis was performed using Stata 17.0 BE to calculate pooled mean-difference in GDI score, walking-velocity and stride-length between groups. 

Results 

Seven studies were included (306 participants, 343 feet). Reduced dorsiflexion and increased forefoot adduction and supination were detected by gait analysis in relapse. Lower GDI scores were observed in relapse compared to non-relapse (pooled mean-difference 5.33,95% CI 2.57–8.09,p<0.001). No overall difference was detected in walking-velocity (pooled mean-difference 0.05m/s,95% CI 0–0.11,p=0.06) or stride-length (pooled mean-difference 0.04m,95% CI 0.02–0.1,p=0.18). 

Conclusions 

Differences in GDI score and individual kinematic parameters, particularly of the forefoot, are detected between relapse and non-relapse through gait analysis, suggesting gait analysis may have a potential role to aid detection of relapse. 

Abhinav Singh1, Christine Douglas2, Benan Dala-Ali3, Claudia Maizen4, Alexander Aarvold5, Deborah Eastwood2, Daniel Perry1 

1Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Oxford, United Kingdom. 2Royal National Orthopaedic Hospital, London, United Kingdom. 3Milton Keynes University Hospital, Milton Keynes, United Kingdom. 4The Royal London Hospital, London, United Kingdom. 5University Hospital Southampton, Southampton, United Kingdom 

Abstract 

Introduction: Although ultrasound is commonly used to diagnose developmental dysplasia of the hip (DDH), the femoral head coverage (FHC) parameters for ‘normal’, ‘dysplastic’ or ‘subluxed/dislocated’ hips remain poorly defined. This creates diagnostic confusion and impedes clear communication. 

Methods: Two routine hip screening datasets were used, containing 2032 paired alpha angle and FHC measurements from 1419 patients (age range 0.43-25.0 weeks, mean 7.83 weeks, 66.2% female). It included the following DDH severities (Graf1 971, G2 672, G3/4 389) and age groups (0-6 weeks 833, >6-12 875, >12-25 324). 1031/2032 (50.7%) retrospective scans were obtained in one hospital from 842 patients (age range 0.86-25.0 weeks, mean 9.24 weeks, 57.5% female) and underwent prospective re-measurement by expert clinicians. The remaining 1001 measurements from 577 patients (age range 0.43-22.42 weeks, mean 6.38 weeks, 80% female) were prospectively collected from four regional paediatric centres (including the UK Global Hip Dysplasia Registry). The temporal correlation between ultrasound methods and the 90th percentile for FHC in each Graf class was calculated.  

Results: The overall correlation (rho) between the methods in the datasets (combined/retrospective/prospective) was 0.73/0.79/0.75. By age groups in weeks (0-6/>6-12/>12-25), these values were 0.77/0.79/0.78, 0.68/0.78/0.71, 0.72/0.80/0.64, respectively. The 90th percentile value for FHC was 60% in Graf 2 and 35% in Graf 3/4.  

Conclusion: There was a strong positive correlation between Graf alpha angle and FHC, which persisted across different age groups. In 9 out of 10 patients, FHC <35% would likely identify a subluxed/dislocated hip and >60% would be normal.  

Implications: Following the FHC 50% rule may lead to incorrect discharge of patients that would benefit from further surveillance.   

Disclosure: None.  

Ahsan Iftikhar1, Mak Macapagal1, Emma Gravett2, Andrea Yeo2 

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

Abstract 

Introduction:  

Management of children with spine and lower limb deformities often require multiple x-rays, raising concerns about high radiation exposure and its consequent cancer risk. Standard EOS (sEOS) provides low radiation dose imaging compared to conventional radiographs, and the microdose setting (mEOS) can further reduce this. This study aims to evaluate the clinical application of mEOS, and to quantify the reduction in radiation exposure and lifetime cancer risk reduction.  

Methods:  

All children requiring long leg imaging from Feb-Nov 2024 were prospectively included with one cohort receiving mEOS and the other sEOS. Additionally, children who had both sEOS and mEOS spine imaging from 2022-2023 were prospectively reviewed. Two independent raters performed standard measurements of leg length, LDFA, MPTA, and Cobb angle. Intraclass correlation coefficient (ICC) was used to assess reliability.  

Radiation dose was compared between groups, and cancer risk estimated using a validated risk calculator.  

Results:  

54 children had long leg imaging, with 34 receiving sEOS and 20 mEOS. The average radiation dose for sEOS and mEOS was 0.0410mSv and 0.00546mSv respectively (p<0.0001). 25 children had both sEOS and mEOS spine imaging. The average radiation dose for sEOS and mEOS was 0.0895mSv and 0.0167mSv respectively (p<0.0001). ICC showed excellent agreement in all measurements, with mean differences in all metrics <2mm or degrees.  

Conclusion:  

mEOS reduces radiation dose by x7.5 in long leg imaging and x5 in spinal imaging, equating to a >500% reduction in lifetime cancer risk. Despite the lower radiation dose, image quality remains high for clinical radiological assessments. 

Kayden Chahal, Valentina James, Murtaza Rasheed, Yazan Shalan, Pamela Leventis, David Bodansky 

Maidstone & Tunbridge Wells NHS Trust, Tunbridge Wells, United Kingdom 

Abstract 

Background 

Osteoporotic fractures are associated with significant morbidity and mortality. Effective screening tools allow early identification of patients at risk and guide osteo-therapeutic intervention to reduce fracture incidence. Previous research has demonstrated correlation between bone mineral density and  the second metacarpal cortical percentage (2MCP) score. This study aimed to demonstrate whether 2MCP is predictive of fracture outcomes. 

Methods 

This retrospective cohort study measured  2MCP in 1498 patients aged  50 years or older who had hand radiographs within a 6 month period in 2018.  Subsequent fracture incidence data, including rate of major osteoporotic fracture (MOF), was gathered for all patients up to January 2025.   

Results 

222 patients sustained a  MOF mean 2MCP 44.93%, 8.21% (95% CI [6.8,9.7]) lower than the fracture naïve population (t(1433)=11.0362,P<.0001). 115 patients sustained a non-major osteoporotic fracture mean 2MCP 47.4%, 5.82% (95% CI [3.8,7.8]) lower than the fracture naïve population (t(1326)= 5.7485,P <.0001). 2MCP of 49.33 % gave 68.6% sensitivity and 66.7% specificity in detecting MOF incidence. Positive predictive value 26.47% negative predictive value 92.39%. There was 54.46% sensitivity and 62.7% specificity in detecting non-major osteoporotic fracture. Positive predictive value 10.55% negative predictive value 94.46%.  

Conclusion/Findings 

Our study suggests 2MCP has utility in osteoporotic fracture risk stratification. Further adding to the body of evidence that 2MCP can be used as a resource efficient and accessible adjunct in guiding osteotherapy. 

Louise McMenemy1,2, Linjie Wang1, Alison McGregor1, Andrew Phillips1 

1Imperial College, London, United Kingdom. 2Royal Centre for Defence Medicine, Birmingham, United Kingdom 

Abstract 

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, 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). 

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

Compared to CS, BMD reduction of 32% for TFA and 8% for KDA was predicted in the proximal femur. For CS, stair-ascent and -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.  

Physiological load transfer was not achieved between prosthetic socket and distal femur for either amputee. Retention of the distal 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. These results may help guide surgical practice. Stair-descent also provides a potential area of interest to begin research into loading strategies to reduce BMD loss in an ageing population at risk of neck of femur fractures.  

Jane Peters1, Glory Uche Abugu2,1, Swati Chopra1, Jon Clarke1,2, David Wallace1,2, Fahd Mahmood1,2, Nicholas Holloway1 

1Department of Orthopaedics, Golden Jubilee University National Hospital, Clydebank, United Kingdom. 2Department of Biomedical Engineering, University of Strathclyde, Glasgow, United Kingdom 

Abstract 

Background: Acute kidney injury (AKI) is a frequently reported complication associated with prolonged admission and increased morbidity following lower limb arthroplasty. The aims were to determine AKI incidence after elective hip and knee replacement, explore temporal trends in these rates and investigate the impact of select factors on AKI development. 

Methods: This single-centre retrospective cohort study comprised all patients with pre- and postoperative serum creatinine (SCr) levels undergoing elective primary hip and knee arthroplasty between January 2013 and March 2024. AKI was diagnosed and staged according to KDIGO criteria. Data were derived from the CORS (Clinical Outcome Report Study) project and linked to laboratory biochemistry results. Univariate analysis examined relationships between AKI and several clinical factors. 

Results: Of 28604 cases evaluated, 1999 (7.0%) developed AKI based on initial postoperative SCr. Poisson regression modelling demonstrated a minor, but significant rise in annual AKI rate (1.7%, p=0.020), controlling for demographic shifts. Incidence fell from 7.4% to 5.0% after antibiotic regimen change from flucloxacillin/gentamicin to cefuroxime. Among patients with AKI identified on postoperative day 1 who had follow-up bloodwork, over half (616/1195) recovered within 24 hours, while 28.3% (338/1195) showed partial recovery. Higher AKI rates were seen with SCr measurement on postoperative day 1 versus 2 (p<0.001) and total hip replacement compared with total knee (p=0.034) and unicompartmental knee replacement (p<0.001). Advancing age (p<0.001), males (p<0.001), increasing body mass index (p=0.002), and decreasing baseline estimated glomerular filtration rate (p<0.001) were associated with AKI. Strong, significant associations (p<0.001) were observed between AKI and both postoperative length of stay and death. 

Conclusion: This large evaluation of primary lower limb arthroplasty cases identified a 7% risk of AKI and associated factors. The apparent rise in AKI incidence may be due to the change in timing of blood tests from postoperative day 2 to day 1. 

Mueed Ijaz1, Amelia Johnston1, Louisa Berdjane1, Ali Abdelwahab2, Howard Cottam2 

1King's College London, London, United Kingdom. 2Medway NHS Foundation Trust, Medway, United Kingdom 

Abstract 

Background/Introduction: 
Non-Fragility Ambulatory Fractures (NAFFs) pose significant risks to elderly patients, leading to prolonged hospital stays and increased mortality. These fractures require prompt multidisciplinary care and surgery within 36 hours to optimize outcomes. However, NAFFs remain underdiagnosed due to inconsistent criteria. National classification trends prioritize age and location over frailty markers and ambulatory status, contributing to inequitable care. This Quality Improvement Project (QIP) aimed to enhance NAFF identification by integrating a novel screening tool within the hospital’s e-trauma platform.  

Methods: 

As the first trust in the South-East of England to conduct this audit, we sought to establish a scalable, data-driven model for equitable fragility fracture identification and management. Two Plan-Do-Study-Act (PDSA) cycles were conducted. The first cycle assessed current practices and trends, assessing each admitted patient against a NAFF diagnostic questionnaire, developed by our team in line with recent GIRFT guidelines. The second cycle integrated a mandatory three-question questionnaire assessing trauma mechanism, ambulatory status, and frailty using the Clinical Frailty Score (CFS). Comprehensive staff training ensured adherence and uptake. 

Results: 
The first cycle revealed a stark 41% NAFF underdiagnosis rate. . Post-intervention, accurate NAFF identification surged by 48%, with total NAFF cases rising from 20.9% to 39.4%. This enabled earlier multidisciplinary involvement, reduced complications and improved discharge efficiency. Overall, our findings highlight a significant step forward in equitable patient care. 

Conclusion: 
By embedding a cost-effective, sustainable solution into routine clinical practice, we have established a new benchmark for fragility fracture care in the region. Given its success, the model offers a replicable framework that can be integrated into e-trauma platforms across NHS trusts, promoting equitable and data-driven fracture management and standardising NAFF recognition to enhance patient outcomes across the UK. 

Disclosure:  

The authors have nothing to declare 

Jimena Soto-Hernaez1, Ewen Fraser1, Gavin Love2 

1Ninewells Hospital & Medical School, Dundee, United Kingdom. 2Ninewells Hospital &, Dundee, United Kingdom 

Abstract 

Background: Hip fractures are the leading cause of admission in the elderly population. The 2024 Scottish Hip Fracture Audit revealed that less than half of the patients with a neck of femur (NOF) fracture received the full inpatient bundle care within 24 hours of admission. According to the Scottish Standards of Care for Hip Fracture Patients (SSCHFP) this indicates a gap in delivering high-quality care. We aimed to develop and implement a Hospital Electronic Prescribing and Medicines Administration (HEPMA) protocol to improve the quality of care for patients aged ≥ 50 admitted with a NOF fracture.  

Methods: A NOF fracture HEPMA protocol was implement in the Orthopaedics department at Ninewells Hospital (Scotland). It incorporated the four prescribable elements of the SSCHFP bundle: analgesia, laxatives, nutrition, and vitamin D.  We collected data on admission and prescription times, recording whether all elements of the bundle were prescribed within two hours of admission. The Plan, Do, Study, Act (PDSA) methodology guided implementation, and a binary system supported data analysis. 

Results: Prior to the introduction of the protocol (1st-30th November 2023), 65% of patients aged ≥ 50 admitted with NOF fracture did not receive the full SSCHFP bundle within two hours of admission to the ward. After implementation (12th June - 12th of July 2024), this figure dropped to only 29% (P < 0.001).  

Conclusions: The introduction of the NOF fracture HEPMA protocol reduced the proportion of patients not receiving the full SSCHFP inpatient bundle within two hours of admission by more than half. This intervention enabled timely, efficient and sustainable care delivery in line with national standards.  

Implications: Following regional approval, this protocol was easily integrated into clinical practice and could be implemented in other Orthopaedics departments across Scotland. 

Disclosure: The authors declare no potential conflict of interest relevant to this study.  

Laith Sinan1, Haseeb Khawar1, Ross Sian1, Benjamin Bloch1, Ben Marson1,2 

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

Abstract 

Background 

Integrated Care Boards (ICBs) replaced Clinical Commissioning Groups (CCGs) in 2022 and are responsible for providing funding for secondary care treatments in England. Our study aimed to highlight the most up-to-date criteria for obtaining an elective hip or knee replacement on the National Health Service (NHS), and whether previously identified sources of inequality (including commissioning policies on smoking and body mass index (BMI)) are still contributing.   

Methods 

Policy data defining criteria for funding of an elective hip or knee replacement was obtained from internet searches and Freedom of Information (FOI) requests for each of the 42 ICBs in England. A descriptive analysis of policy type and key criteria for referral was performed. 

Results 

Policy data was available for 100% (42/42) ICBs at the time of the search in March 2025. For current ICBs, 73.8% (31/42) mention pain within the referral criteria, with 35.7% (15/42) specifically requiring pain to impact quality of life (QOL), and 9.5% (4/42) requiring pain to impact function. 54.8% (23/42) mention smoking, with 40.5% (17/42) only requiring cessation advice, and 11.9% (5/42) defining a requirement to stop smoking pre-operatively. 64.3% (27/42) mention BMI, with 57.1% (24.42) defining a strict BMI cut off to be eligible for surgery. 14.3% (6/42) require mandatory use of a patient-specific outcome measure (PROM) with a score cut-off to be eligible for surgery. 

Conclusion 

There is high variation in eligibility criteria for elective hip and knee arthroplasty in England, which is likely contributing to healthcare inequality. There remains a focus on smoking and BMI being key criteria for surgery, with a minority of ICBs also insisting on the use of PROMS to determine eligibility for surgery. This goes against current NICE guidance and further work should focus on how these inequalities can be improved. 

Aadithiyavikram Venkatesan, Andre Martins, Tanvir Khan 

Northampton General Hospital, Northampton, United Kingdom 

Abstract 

Background 
Acute Knee Clinics (AKC) enable early specialist assessment and streamlined management of acute knee injuries. Timely intervention is particularly critical in cases of suspected anterior cruciate ligament (ACL) disruption and bucket handle meniscal tears, where delays may compromise outcomes. This audit evaluated the impact of targeted service improvements on clinical and operational performance across two audit cycles. 

Methods 
A retrospective analysis was conducted using data sourced from medical records for all patients referred to AKC between July–December 2023 (Cycle 1) and July–September 2024 (Cycle 2). Key metrics included time from emergency department (ED) attendance to first outpatient (clinic) appointment, interval from clinic to definitive surgery, and diagnosis and treatment pathways. 

Results 
Cycle 1 demonstrated an average wait of 12.8 days from ED to clinic review and 55 days from clinic to surgery. Among patients diagnosed with bucket handle meniscal tears, the average time from clinic to surgery was 34 days. 
Following implementation of a dedicated soft tissue knee surgeon and increased AKC capacity in Cycle 2, the average wait from ED to clinic reduced to 10 days, and clinic-to-surgery wait fell to 41 days. For bucket handle tears, surgical wait time further reduced to 24 days—a 48% improvement. MRI was not a limiting factor in surgical decision-making in either cycle. 

Conclusion 
The service enhancement significantly improved compliance with NHS targets for outpatient access and timely surgery. Earlier assessment and expedited surgical pathways—particularly for high-priority cases such as ACL injuries and bucket handle tears—led to more efficient care delivery. 

Implications 
Reducing delays in outpatient appointments and enabling swift surgical intervention for acute knee injuries directly enhances patient outcomes and care quality. These results support wider implementation of structured referral criteria and expanded AKC services across NHS trusts. 

Disclosure 
The authors declare no conflicts of interest. 

Hussayn Shinwari1, John Tucker2, Olga Taylor2, Robert Scott2 

1St George's University of London, London, United Kingdom. 2Orthopaedic Data Evaluation Panel, Hemel Hempstead, United Kingdom 

Abstract 

Background: Since 2003, the Orthopaedic Data Evaluation Panel (ODEP) has benchmarked orthopaedic implants based on revision rates at defined time points. Over time, ODEP has progressively tightened its benchmarks to reflect global improvements in revision rates. ODEP awards A*, A, and B ratings based on the strength of supporting evidence. This study assesses variation in revision rates across Total Hip Replacement (THR), Total Knee Replacement (TKR), and Total Shoulder Replacement (TSR) implants submitted for ODEP benchmarking since 2021. The aim was to analyse variation across benchmarks, propose updated survival thresholds, and evaluate registry-related differences. 

Methods: Revision data for THR, TKR, and TSR implants were collected from 2021 onwards. Scatter plots mapped revision rates against benchmark time points (3, 5, 7, 10, 13, and 15 years). Registries were recorded, and implants were anonymised. The dataset included 364 THR, 534 TKR, and 128 TSR implants. 

Results: Revision rates increased over time across all joints, but considerable variation existed between implants within each benchmark. The source registry occasionally appeared to influence revision rates. Some implants showed revision rates comparable to early benchmarks (e.g., 3 years) even at 15 years. Proposed reductions in revision thresholds would reclassify several implants. For THR, changes would mainly affect those with 7+ years of follow-up. For TKR, the impact would begin from year 5, with the most substantial effects at 13 and 15 years. 

Conclusion: Lowering revision rate thresholds for A and A* ratings would significantly affect implant classifications, particularly for TKR from year 5 and THR from year 7 onwards. These findings support updating survival benchmarks to ensure implants available to patients reflect current performance standards. 

Disclosure: The authors declare no conflicts of interest. No funding was received for this study. 

Hannah Mancey1, Deborah Eastwood2, Lynn Hutchings3, Charlotte Lewis4, Nicky Gibbens1, Kinga Zmijewska1, Stephen Barnard1 

1UKHSA, London, United Kingdom. 2British Orthopaedic Association, London, United Kingdom. 3North Bristol NHS Trust, Bristol, United Kingdom. 4Portsmouth NHS Trust, Portsmouth, United Kingdom 

Abstract 

Background: A recently published epidemiological study reported a 2.9–3.9 fold excess risk of breast cancer within 672 female trauma and orthopaedic (T&O) surgeons compared to an age matched female population [Chou et al, 2022], causing concern amongst our workforce. The BOA approached the UK Health Security Agency (UKHSA) with these concerns, prompting a dose monitoring exercise to inform on radiation doses received by T&O surgeons during their working week.  

Method: Participating surgeons received two thermoluminescent dosemeters (TLDs): one worn under their gown at chest level and one attached to their scrub suit sleeve seam in the axilla. Each surgeon was monitored for 3 months. All participants completed an electronic survey collecting information on sex, career stage, workload, recent radiation safety training and availability, use and appropriateness of personal protective equipment.  

Results: 294 TLDs were returned from 154 surgeons across 22 UK NHS trust. Females were relatively over-represented. The distribution between MTCs and Trauma units was even. No surgeon received a dose that placed them at risk of exceeding the 20 mSv yearly dose limit set by the 2017 HSE Ionising Radiations Regulations (IRR 17). The survey did not identify any factor that significantly influenced radiation exposure dose. 

Women (who favoured wrap-around PPE tops) received no recordable chest wall dose. Both men and women received a higher axillary dose suggesting that PPE modifications be considered for procedures exposing the axilla to the radiation beam.  

The survey identified a clear lack of radiation protection training: 58.8% of respondents had received no training in the past three years 

Conclusion: National guidance is required on PPE provision to ensure that all employers comply with IRR 17.  The BOA has published advice on appropriate PPE for its members and is working with others to develop a standardised radiation protection training scheme.  

Peter Cay1,2, Ka Sui Fan1,3, Belal Amini1, Chintu Gadamsetty1, Andrew Carne1, Matthew Solan1 

1Royal Surrey Hospital, Guildford, United Kingdom. 2Brighton and Sussex Medical School, Brighton, United Kingdom. 3University of Surrey, Guildford, United Kingdom 

Abstract 

Background  

Injections are commonly used in orthopaedic practice for both diagnostic and therapeutic purposes. The optimal timing of follow-up review is not clear.  A recent survey found that 85% of clinicians review patients in clinic 6-8 weeks after injection. This is nearly always a waste of the patient’s time and a valuable appointment slot.  

The aim of this project was to reduce unnecessary follow-up appointments, using an App-based pain diary.   

Methods  

After an injection the patients track their progress (VAS scores and supplementary comments) with the Patient Watch App. No routine follow-up is arranged.  

The App collects pain scores intensively for 48hrs after injection to capture diagnostic information from the local anaesthetic effect; then weekly scores to track longevity of pain relief from the steroid.  

Scores are visible to the clinician and alerts aid management decisions.  

Results  

Eighty-one injections were followed in this way.  

Eighty of the injections were performed under ultrasound guidance in the radiology department. One patient had an injection in theatre. Nine patients had two injections over the study period.  

We found that in only 8 (10%) instances was a follow-up required within 8 weeks of injection.  The other patients remained under active monitoring at a minimum of 3 months follow-up.  

The average patient satisfaction score with the App was 4.4 / 5 and the majority of patients “would use the app again”.  

Conclusions  

Use of the Patient Watch pain diary meant that only 10% of patients required a routine 6–8-week outpatient follow-up appointments after injection treatment.  

Our hospital performs approximately 6,000 injections per year.  

Potential savings with wider use of this innovation would increase capacity and help achieve the GiRFT “Further-Faster” goals.  

Priyanshu Saha1,2, Allen Albert1, Charlotte Nichols1, Shreerang Khambekar1, Akash Shakya1, Amarjeet Singh1, Suresh Chandrashekar1, Yaser Ghani1 

1Homerton University Hospital, Department of Orthopaedic Surgery, London, United Kingdom. 2University of Oxford, London, United Kingdom 

Abstract 

Background 
Artificial Intelligence (AI) is transforming surgical workflows by improving efficiency, accuracy, and decision-making. Orthopaedic trauma meetings are fast-paced, complex, and often under-documented due to time constraints and inconsistent manual note-taking. AI-powered transcription tools offer a novel solution—capturing conversations in real time, extracting clinically relevant data, and generating structured documentation to support better patient care. 

Methods 
A prospective observational study was conducted involving 60 trauma and orthopaedic cases. Thirty cases were documented manually via typed entries, while another 30 were transcribed using AI dictation software. Three outcome measures were assessed: average word count per case, documentation accuracy (validated by senior clinicians), and perceived usefulness rated on a 5-point Likert scale by five orthopaedic registrars. Statistical significance was analysed using two-tailed Student’s t-tests. 

Results 
AI-generated documentation yielded significantly more comprehensive records (51.63 ± 16.14 words) compared to manual entries (14.17 ± 4.74; p < 0.05). Documentation accuracy was slightly higher in the AI group (98.67% ± 3.78) versus the manual group (95.43% ± 10.07), though not statistically significant (p > 0.05). Usefulness ratings were markedly higher for AI (4.53 ± 0.62) compared to manual documentation (1.70 ± 0.53; p < 0.05). 

Conclusion/Findings 
AI dictation tools significantly enhanced the volume and perceived quality of trauma meeting documentation without compromising accuracy. The resulting structured outputs offer clear potential to improve communication, documentation standards, and continuity of care. 

Implications 
This study highlights the transformative role AI can play in high-pressure surgical environments. By automating documentation and improving workflow, AI tools may offer a scalable solution to support busy orthopaedic teams and ultimately enhance patient outcomes. 

Gopalkrishna Verma, Chandan Noel Vincent, Pankaj Sharma, Vishal Kumar, Sanat Shah 

Manchester University Hospitals NHS Foundation Trust, Manchester, United Kingdom 

Abstract 

Background: Traditional consent process for joint replacement surgery often use generic risk statements, which can cause anxiety and patients struggle to personalize. Patient-Specific Consent Process (PSCP) as a transformative approach aim to revolutionize patient engagement by enhancing autonomous decision making and improving outcomes. 

Methods: A prospective study was conducted with 85 patients considering hip or knee replacement surgery (May 2024 - April 2025). The PSCP involved two steps; first, obtaining history, examination, and investigations to diagnose osteoarthritis and discussing traditional surgical complications. Second, generating individualized risk scores and graphs for pain/function, infection, revision, death and general surgical risks using online tools (National Joint Registry, International Consensus Meeting Prosthetic Joint Infection calculator and American college of Surgeons risk calculator). Patient satisfaction was assessed using a 5-point Likert scale. 

Results: Of the 85 patients, 52 (61%) confidently chose surgery, while 33 (39%) did not immediately opt for it. Fifteen took time to reflect, with four agreeing to surgery. Eight (24%) patients chose to lose weight and optimise their health for surgery, two were reassured about pursuing non-operative treatment was correct, four declined surgery due to increased risk from comorbidities, five remained undecided and ten awaited further investigations. All patients reported high satisfaction (scores 4-5) with the PSCP. 

Conclusion: Enumerating complications, can trigger anxieties and feeling of powerlessness over surgical outcome. PSCP directly addresses these emotional challenges, providing confidence and sense of total control. It empowers patient to engage in shared decision-making with clear judgement ability to gain balanced perspective for aligning their choices with personal values and circumstances. High patient satisfaction scores indicate that PSCP fosters a supportive and comprehensible consultation experience. 

Implications: The PSCP enhances patient engagement, adherence to treatment plans, and potentially improved outcomes. Integrating personalised risk visualisation in to PSCP adopts a ethically sound, patient-centred approach to surgical care. 

Callum Craig, Caroline Hing 

St George's, London, United Kingdom 

Abstract 

Background: Patient-reported outcome measures (PROMs) are validated questionnaires used to determine patient satisfaction and outcome. Over 7.1 million adults in the UK have a reading age of less than 9 years, resulting in concern that the readability of PROMs may exclude patients with a low reading age. The Patient Information Forum (PIF) advises to aim for a reading age of 9 to 11 years for patient information material. This study explored whether generative pretrained transformers could enhance the readability of PROMs commonly used in orthopaedic surgery.  

Methods: The readability of the 11 most commonly used PROMs in UK practice were assessed using the Flesh Reading Ease (FRE) score. Each PROM was then processed through OpenAIs ChatGPT with the prompt: “Please revise this questionnaire so that it is easier to read. Aim to make it easy enough for someone with a reading age of 9 years to be able to read it.” The FRE score was then calculated for the revised questionnaires.  

Results: Ten of the 11 PROMs assessed did not align with the PIF’s recommendations as they had a FRE score equating to a reading age of greater than 11 years old. Ten of the 11 revised PROMs generated by ChatGPT had a higher readability score compared to the original. Seven of the 11 revised PROMs aligned with the PIF recommendation. The mean improvement in the FRE across a total of 123 questions from all 11 PROMs was 10.07, which equates to an improvement in required reading age of up to 2 years. This improvement was statistically significant (p<0.001).  

Conclusion: Current commonly used PROMs require a reading age of greater than 11 years old. ChatGPT can improve the readability of PROMs, ensuring improved representation of the outcomes of the whole patient population. 

Disclosures: The authors disclose no conflicts of interest.  

Medialised or Lateralised? Clinical and Patient Reported outcomes by design of Reverse Shoulder Arthroplasty: A cohort study using National Joint Registry and Hospital Episode Statistics for England 

Olivia O'Malley1, Meeran Hamawandi1, Andrew Davies2, Mansour T.A. Sharabiani1, Amar Rangan3, Sanjeeve Sabharwal1, Peter Reilly1 

1Imperial College, London, United Kingdom. 2Imperial College NHS Foundation Trust, London, United Kingdom. 3Hull York Medical School, York, United Kingdom 

Abstract 

Introduction: Since the initial Reverse Shoulder Arthroplasty design by Grammont in 1985, there have been various modifications aimed to improve clinical and patient outcomes post-operatively. This study aims to review clinical and patient outcomes associated with medialised and lateralised RSA designs.   

Methods: Data was requested from the National Joint Registry from 1st April 2012 to 31st March 2022 and linked to Hospital Episode Statistics. Implants were categorised into medialised and lateralised designs. Primary outcome was implant survival. Secondary outcomes were non-revision re-operation and Oxford Shoulder Score at 6 months, 3 & 5 years post operatively.  

Results: In matched groups, there were 2,641 patients in the lateralised and 889 in the medialised group. There was a clear trend towards increased utilisation of lateralised implants since 2018. Kaplan Meir analysis showed at 1,3,5,7 & 10 years lateralised implants had a lower cumulative survival rate however this was not significant (HR1.40 (CI 95% 0.90-2.17 p=0.14). There was no statistical difference in re-operation or mean OSS between groups.  

Conclusion:  While there has been an increasing use of lateralised RSA implants and a significant focus in design development of the RSA, based on NJR data, the clinical and patient reported outcomes are similar between designs.   

Olivia O'Malley1, Andrew Davies2, Amar Rangan3, Sanjeeve Sabharwal1, Peter Reilly1 

1Imperial College London, London, United Kingdom. 2Imperial College Healthcare NHS Trust, London, United Kingdom. 3Hull York Medical School, York, United Kingdom 

Abstract 

Introduction: 
Shoulder arthroplasty procedures have increased significantly, with reverse shoulder arthroplasty (RSA) becoming more common. While RSA revision rates are reported as low, these figures may not accurately reflect implant success. Factors such as older patient demographics and surgeon reluctance to perform complex revisions may contribute to lower revision rates. This perception may encourage broader RSA use in younger patients, potentially increasing long-term revision burdens. This study examines whether revision thresholds differ between implant types. 

Methods: 
Mean postoperative Oxford Shoulder Score (OSS) was calculated for RSA, total shoulder arthroplasty (TSA), and hemiarthroplasty (HA). Revision rates were analysed for patients with an OSS <29 (a pre-defined unsatisfactory score), the lowest 25%, and lowest 10%. Chi-squared tests with Bonferroni correction assessed differences among implant groups. 

Results: 
Among 21,918 NJR patients with postoperative OSS data, HA had the highest proportion of patients with ‘unsatisfactory’ function (38.12%), followed by RSA (26.99%) and TSA (15.35%). 4.87% of RSA patients with unsatisfactory function were revised, significantly less than TSA (10.58%) and HA (13.86%) (p<0.001). In the lowest 25%, revision rates were 4.78% for RSA, 8.76% for TSA, and 15.02% for HA (p<0.001). In the lowest 10%, revisions occurred in 6.53% of RSAs, 12.44% of TSAs, and 17.03% of HAs (p<0.001). No significant difference was found between TSA and HA (p=0.06). 

Conclusion: 
RSA has lower revision rates than HA and TSA; however, this may not reflect superior implant performance. Patients with poor RSA function are less likely to undergo revision, suggesting higher revision thresholds. As RSA use expands, its assumed low revision rate must be reassessed to prevent long-term burdens of poorly functioning implants. Further research is needed to determine whether surgical selection bias influences revision rates and to establish additional benchmarks or surrogates in joint registries for a more comprehensive assessment of implant performance. 

The association of body mass index with patient outcomes after elective primary shoulder replacement surgery: population-based cohort study using linked national registry and hospital data from the United Kingdom and Denmark 

Epaminondas Markos Valsamis1, Josefine Beck Larsen2, Adrian Sayers3, Timothy Jones3, Stephen Gwilym1, Pia Kjær-Kristensen2, Theis Thillemann2, Inger Mechlenburg2, Michael Whitehouse3, Jonathan Rees1 

1University of Oxford, Oxford, United Kingdom. 2Aarhus University, Aarhus, Denmark. 3University of Bristol, Bristol, United Kingdom 

Abstract 

Background 

Access to joint replacement surgery is being restricted based on body mass index (BMI) but no recommendations currently exist for shoulders. The aim of this study was to investigate the association between BMI, patient complications and implant survival after elective primary shoulder replacement surgery using linked national datasets from two countries. 

Methods 

All adults having primary elective shoulder replacement surgery from the National Joint Registry linked to NHS Hospital Episode Statistics (2018-2022), and from the Danish Shoulder Arthroplasty Registry linked to the Danish National Patient Registry (2006-2021) were included. The main outcome measure was all-cause mortality within 365 days of surgery. Secondary outcome measures included mortality within 90 days, serious adverse events within 90 days of surgery and revision surgery. Flexible parametric survival models and logistic regression models were used to adjust for patient and surgical factors. 

Results 

A total of 15,320 and 5,446 shoulder replacement procedures from within the United Kingdom and Denmark, respectively, were included. There was a decreased risk of 365-day mortality in obese patients (HR 0.40 (95%CI 0.21-0.73)) and an increased risk in underweight patients (HR 1.18 (95%CI 1.06-1.32)), compared to the average of ‘normal’ weight. Underweight patients had an increased risk of 90-day mortality (OR 1.69 (95% CI 1.14-2.52)), 90-day serious adverse events (HR 1.36 (95% CI 1.05-1.77)) and revision surgery (HR 1.70 (95% CI 1.25-2.33)). 

Conclusion 

Patients with high BMI had neither increased mortality nor poorer outcomes after elective primary shoulder replacement surgery. Increasing BMI was associated with lower 365-day mortality. 

Implications 

Shoulder replacement surgery is safe and effective in obese patients and access to this surgery should not be restricted based on high BMI alone. Clinicians and hospitals should be aware that underweight patients appear more at risk of mortality, serious adverse events and revision surgery after a shoulder replacement. 

Case-mix adjustment for outlier analysis after elective primary shoulder replacement surgery: population based cohort study using data from the National Joint Registry and Hospital Episode Statistics for England 

Epaminondas Markos Valsamis1, Adrian Sayers2, Jie Ma1, Paula Dhiman1, Stephen Gwilym1, Jonathan Rees1 

1University of Oxford, Oxford, United Kingdom. 2University of Bristol, Bristol, United Kingdom 

Abstract 

Background 

National joint registries are increasingly using routinely collected data to conduct outlier analysis of surgeons and hospitals. Importantly, patient and procedure factors can influence the risk of mortality and revision surgery, so case-mix adjustment is needed. The aim of this study was to determine the most appropriate variables to use for case-mix adjustment when predicting mortality and revision surgery after elective primary shoulder replacement surgery. 

Methods 

Linked data from the National Joint Registry and NHS Hospital Episode Statistics (HES) were used to identify all elective primary shoulder replacements from 6 January 2012 to 30 March 2022 in England. Patient comorbidity scores were derived from HES. Flexible parametric survival models were used to predict the risk of mortality at 90 and 365 days, and the risk of long-term revision surgery after primary surgery. We evaluated model performance by assessing discrimination, calibration and decision curve analysis. 

Results 

A total of 37,176 primary shoulder replacements were included.A total of 102 patients died within 90 days and 445 died within 365 days. A total of 1,219 patients had revision surgery over a maximum follow-up period of over 10 years. The addition of comorbidity measures on simpler models made little improvement in predictive performance. Optimism-adjusted performance of models including age, sex, American Society of Anaesthesiologists (ASA) grade and main surgical indication had a C-index of 0.76[95% CI 0.72-0.81] for 90-day mortality, a C-index of 0.74[95% CI 0.71-0.76] for 365-day mortality, and a C-index of 0.64[95% CI 0.63-0.66] for revision surgery. Models were well calibrated, with decision curve analysis demonstrating clinical utility, with net benefit across relevant risk thresholds. 

Conclusion 

Patient comorbidity scores added little improvement beyond simpler models including age, sex, ASA grade and main surgical indication for predicting mortality and revision surgery after elective primary shoulder replacement surgery. 

Minimum Ten Year Outcomes of Reverse Total Shoulder Arthroplasty Using a Trabecular Metal Glenoid Base Plate 

Daniel Thurston, Salman Mushtaq, Heather Swaile, Lisa Pitt, Andrew Dekker, Tim Cresswell, Amol Tambe, Marius Espag, David Clark 

University Hospitals of Derby & Burton, Derby, United Kingdom 

Abstract 

Background 

Glenoid loosening and scapular notching remain a concern in Reverse Total Shoulder Arthroplasty (RTSA). Trabecular Metal-backed (TM) glenoid components have a highly porous structure permitting bony in-growth to minimise risk of loosening, but notching may still occur. We present here minimum 10 year clinical and radiological outcomes for patients treated with TM-RTSA. 

Methods 

From a prospectively maintained in-house database, we identified all patients treated with TM-RTSA (Zimmer Biomet, USA) between 2009 - 2014. Digital notes were reviewed to collect data on functional outcomes (validated Oxford Shoulder Score (OSS), and Constant & Murley Score (CMS)), and range of movement (ROM). Radiographs were reviewed to ascertain presence & degree of notching (as classified by Sirveaux), and glenoid and humeral lucency. 

Results 

190 patients identified; average 76 years, 143 females. 

91 deceased within 10yrs, 23 lost to follow up, 11 shoulders (5.8%) were revised within 10 years. 

64 patients with clinical outcome data at average 11.4 years (10 – 14.8). Average total OSS was 32 (5 - 48), average pain sub-score 12 (4-16). The average CMS was 52 (12 - 88). Average flexion: 110 degrees (25 - 170), abduction: 100 degrees (25 - 170), and external rotation: 25 degrees (-30 - 75). 

57 patients with radiological outcome data at average 11.2 years (10 – 14.3). Scapular notching was noted in 73.7% patients (42/57), with grade 2 notching most common. 15.8% of patients (9/57) had some degree of lucency around glenoid baseplate or peg. There was no difference in outcome scores in patients with radiological evidence of notching compared with the rest of the cohort. 

Conclusions 

This long-term follow up series in patients treated with TM-RTSA suggests that patient outcomes and ROM remain very satisfactory at a minimum of 10 years with almost 95% survival rate of implant. Whilst scapular notching occurs commonly, it does not appear to negatively impact patient outcomes. 

Radiation Exposure and Cancer Risk of Young People Undergoing Adolescent Idiopathic Scoliosis (AIS) Treatment. 

Olivia Waite, Fiona Wall, Andrew Cottam, Alexander Aarvold 

University Hospital Southampton, Southampton, United Kingdom 

Abstract 

Background: Treatment of AIS, the commonest form of scoliosis, involves numerous radiographs and/or CT scans. These involve ionising radiation, a human carcinogen. AIS predominantly affects teenage girls, who are at greater risk of radiation-induced malignancy due to their young age, rapid cell turnover and the vulnerable pelvic organs exposed.  

Method: The Dose Area Product was extracted from every medical image of 40 consecutive patients throughout their AIS treatment and follow-up at a major NHS paediatric spinal unit. Specific conversion coefficients for age, sex and body area were used to quantify the Effective Dose (ED). The Cumulative ED was mapped to validated risk models to estimate the possibility of radiation-induced cancer. 

Results: Mean age at surgery was 14.1years (range 11-17, 30♀ 10♂), with an average exposure of 7.4 whole spine radiographs over 3.1 years, plus intra-operative screening at surgical correction. Five of these 40 patients underwent a post-operative CT scan, three of whom had a second surgical episode. The mean cumulative ED for the standard uncomplicated group was 2.90mSv, giving a radiation-induced malignancy risk of 0.030% (~1 in 3,300), categorised as LOW risk. Patients who received a CT scan had a significantly higher ED at 13.19mSv (p=0.01), 4.55-fold increase in radiation exposure and significantly higher cancer risk (0.14%, ~1 in 700), defining their risk profile as MODERATE. 

Conclusions: There is a low lifetime risk of radiation-induced malignancy for standard uncomplicated treatment of AIS. However, this risk is moderate if CT scans are additionally used. 

Implications: CT use is increasing in AIS, not just for complications/revisions. Surgeons must be aware of the significantly increased cancer risk when considering CT requests. 

Disclosure: None 

Neurological Recovery Patterns After Decompressive Surgery for TB Spine with Advanced Paraplegia 

Dr. ROHIT TYAGI 

MGUMST, Jaipur, India 

Abstract 

Background: Spinal tuberculosis (TB) remains a significant cause of morbidity, with advanced paraplegia being its most devastating complication. Despite the established role of surgery in management, the patterns and predictors of neurological recovery following decompressive surgery remain incompletely understood. 

Methods: This prospective observational study included 78 consecutive patients (45 males, 33 females) with spinal tuberculosis and advanced paraplegia (ASIA Impairment Scale grades A, B, or C) who underwent decompressive surgery between January 2018 and December 2022. Patients were assessed preoperatively and postoperatively using ASIA motor and sensory scores, AIS grading, and Spinal Cord Independence Measure (SCIM). Neurological recovery patterns were analyzed based on temporal progression and extent of improvement. 

Results: The thoracic spine was most commonly involved (60.3%), followed by thoracolumbar junction (24.4%). Posterior decompression with instrumented fusion was the most frequent surgical approach (53.8%). At mean follow-up of 24.3±8.7 months, 75.6% of patients demonstrated improvement in AIS grade. Mean ASIA motor scores improved from 28.4±15.3 preoperatively to 64.7±23.9 at final follow-up (p<0.001). Neurological recovery initiated early (≤3 months) in 57.7% patients, with the highest rate of motor improvement observed during the first three months (6.4±3.7 points/month). Independent predictors of favorable neurological recovery included shorter symptom duration, less severe initial AIS grade, absence of T1 signal changes on MRI, and early surgical intervention. Mean SCIM scores improved from 24.3±13.8 to 62.7±26.4, with 55.1% of patients returning to previous occupation. 

Conclusion: Decompressive surgery for TB spine with paraplegia results in significant neurological and functional improvement in a majority of patients. Recovery follows a predictable temporal pattern with substantial early gains, although late improvement is possible . Early surgery, shorter symptom duration, less severe initial deficit, and absence of T1 signal changes are independent predictors of favorable recovery. 

DISCLOSURE: No funding has been granted. 

The Diagnosis of Pyogenic Spondylodiscitis with Next-Generation Sequencing: A Performance Comparison with Traditional Diagnostic Methods 

Santhosh Thavarajasingam1,2,3, Daniel Scurtu4, Ahmed Salih5,2, Srikar Namireddy5,2, Jonathan Neuhoff6,3, Florian Ringel1,3, Andreas Kramer1,3 

1Department of Neurosurgery, Universitätsmedizin Mainz, Mainz, Germany. 2Imperial Brain & Spine Initiative, Imperial College London, London, United Kingdom. 3Department of Neurosurgery, LMU University Hospital, LMU, Munich, Germany. 4Department of Neurosurgery, Universitätsmedizin Mainz, Mainz, United Kingdom. 5Faculty of Medicine, Imperial College London, London, United Kingdom. 6Center for Spinal Surgery and Neurotraumatology, Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Frankfurt, Germany 

Abstract 

Background: The incidence of pyogenic spondylodiscitis is rising, posing significant diagnostic challenges. Traditional methods, such as blood cultures, frequently fail to timely and accurately detect causative pathogens, leading to suboptimal treatment outcomes. This study introduces a novel approach using Next-Generation Sequencing (NGS) of cell-free DNA, aimed at enhancing diagnostic accuracy and improving patient management. 

Methods: This prospective study at a tertiary care university hospital enrolled 21 patients suspected of having pyogenic spondylodiscitis. Participants were tested using both conventional blood culture and advanced NGS with the DISQVER platform, adhering strictly to ethical standards in compliance with the Helsinki Declaration. The study evaluated diagnostic efficacy, sensitivity, and specificity of the methods. 

Results: NGS demonstrated a significantly higher sensitivity (70%) compared to blood culture (50%), and was comparable to histopathology (80%). It also showed superior specificity (75%) relative to traditional diagnostics (blood culture: 67%, histopathology: 33%). NGS reduced the time-to-diagnosis, influencing therapeutic decisions, particularly in cases with inconclusive traditional results. Additionally, NGS identified pathogens in 45% of cases where traditional methods were limited, detecting pathogens such as Streptococcus pneumoniae, Parvimonas micra, and Enterococcus faecalis. The intraclass correlation coefficient (ICC) analysis highlighted the diagnostic concordance of NGS with intraoperative swabs (ICC: 0.46), compared to lower ICC values for blood cultures (0.16) and histopathology (0.12). The lack of statistical significance in these findings (p>0.05) is likely due to the small sample size, with further data collection planned to confirm the initial findings. 

Conclusion: Early results support the integration of NGS as a standard diagnostic tool for managing pyogenic spondylodiscitis. By offering rapid and precise pathogen identification, NGS has the potential to transform the diagnostic landscape for complex infections, enabling more effective, tailored therapeutic interventions. Further research will validate these findings and potentially expand the use of NGS in diagnosing other complex infectious diseases. 

Professional Sport Participation of Football and Rugby Players after ACL Reconstruction with Associated MCL Injuries Compared to Isolated ACL Reconstruction 

Wahid Abdul, Mary Jones, David Haslhofer, Arman Motesharei, Simon Ball, Andy Williams 

Fortius Clinic, London, United Kingdom 

Abstract 

Background 

Medial collateral ligament (MCL) injuries are commonly sustained in conjunction with anterior cruciate ligament (ACL) ruptures but the optimum management of MCL injuries remains controversial. Return to play (RTP) rate, time, and career longevity of professional football and rugby players following primary ACL reconstruction (ACLR) with non-surgically and surgically treated MCL injuries were compared with isolated ACL reconstructions. 

Methods 

A consecutive series of professional football and rugby players who underwent  primary ACL reconstruction (ACLR), with and without MCL injury and treatment between 2015-2022 were retrospectively reviewed.  Indications for MCL surgery were medial opening on valgus stress in full extension and/or grade II/III valgus laxity at 30 degrees, positive dial test for anteromedial rotatory instability, and a ‘Stener-like’ lesion or intra-articular MCL incarceration. RTP was defined as first match appearance following ACLR. RTP, and career longevity information  was extracted from publicly available databases. 

Results 

230 athletes (238 knees) were included; 97 (40.8%) had ACLR only, 97 (40.8%) had ACLR + non-operative MCL and 44 (18.5%) had ACLR + MCL reconstruction. 135 (56.7%)  were football and 103 (43.3%) were rugby players. 

Overall RTP rate was 95.4% (96.3% football, 94.2% rugby). This varied between 99% in the ACLR only group,   94.8% ACLR + non-operative MCL and 88.6% ACLR + MCL reconstruction (p=0.06). 

RTP time was 12.0 (+/- 4.4) months; 11.8 months ACLR only, 12.2 months ACLR + non-operative MCL and 11.9 months ACLR + MCL reconstruction (p=0.88).  

Overall 2 and 5-year still playing rates were 79.8% and 67.7%   with no significant difference between subgroups at 2 (p=0.55) or 5 years (p=0.53). Mean follow up was 5.8 (+/-2.4) years. 

Conclusion 

Outcomes of ACLR with and without MCL injury in professional football and rugby players are similar even following concomitant MCL surgery. 

IS THERE A GENDER DIFFERENCE IN THE MANAGEMENT OF THOSE UNDERGOING ANTERIOR CRUCIATE LIGAMENT (ACL) RECONSTRUCTION? 

Raja Abbas1, David Johnson2,1,3 

1University of Manchester, Manchester, United Kingdom. 2Stockport NHS Foundation Trust, Stockport, United Kingdom. 3University of Salford, Salford, United Kingdom 

Abstract 

Background: This study aimed to assess gender differences in accessing surgery following anterior cruciate ligament (ACL) injury. 

Methodology: A retrospective review of 514 patients undergoing ACL reconstruction at an NHS Foundation Trust between 1/3/2014 and 31/3/2024 was undertaken. Data collected included: demographics, injury details, dates of treatment steps, and operative details. 

Results: No difference was noted with respect to demographics, except females were older than males (30.3 vs 26.8 years p<.001) and more likely to be married (22% vs 15.9% p<.05). First presentation was to the emergency department equally for males and females, with males reporting more contact injuries (25% vs 14% p<.05). Time from injury to reconstruction was 15.0% longer for females than males, with longer differences noted in females from injury to first presentation (54.5%), first presentation to orthopaedic consultation (39.5%), orthopaedic consultation to listing (10.7%) and listing to reconstruction (0.8)%. Due to wide variation in timings these differences were not significant. Females were more likely to have additional injuries requiring staged procedures (15% vs 8.3% p<.05) and had a higher listing priority for reconstruction. Males had a higher rate of non-knee related delay to operation (23% vs 19% NS). For those with more significant injuries requiring staged procedures, excluding non-knee related delays, females took significantly longer from first presentation to orthopaedic consultation (125 days vs 29 days p<.05). 

Conclusion: We found a trend for females to take longer to access ACL reconstruction, with the largest discrepancy occurring between initial presentation to being seen by an orthopaedic surgeon.   

Return to Sport Following Surgical Repair of Distal Biceps Tendon Rupture in Rugby Players: A Retrospective Review 

Aakaash Venkatesan 

Aneurin Bevan University Health board, Newport, United Kingdom 

Abstract 

Distal biceps tendon ruptures are uncommon but functionally limiting injuries, particularly in rugby players. While surgical repair yields favorable outcomes, limited evidence exists regarding return to sport (RTS) timelines and predictive factors. This study evaluates RTS outcomes following surgical repair in rugby athletes. 

Methods: 
A retrospective analysis was performed on 50 male rugby players who underwent distal biceps tendon repair between 2018 and 2024 at Aneurin Bevan University Health Board, Newport. The cohort included amateur/professional (n=15) and recreational (n=35) players. Surgical techniques included suture anchor (n=37) and Endobutton fixation (n=13), performed by two upper limb surgeons. Outcome measures included patient-reported questionnaires (pain, confidence, functional recovery) and objective metrics (grip strength, biceps flexion, ROM, isokinetic testing). Statistical analysis used paired t-tests and multivariate regression to evaluate RTS predictors. 

Results: 
Mean time from injury to surgery was 2.4 weeks. Most injuries (98%) occurred mid-season and in forward positions. Mean RTS time was 3.6 months in amateur/professional players and 10.2 ± 3.1 months in recreational players, with 80% returning within 12 months. Significant improvements were observed in biceps flexion strength (90%, p<0.01), grip strength (94%, p<0.01), and ROM (95% of pre-injury levels). Seventy-two percent returned to pre-injury performance levels, and 88% reported moderate to high confidence in RTS. Younger age (<30 years) and early surgery (<2 weeks) were significant predictors of RTS success (OR 2.5, 95% CI 1.4–4.7). Complication rate was 8% (mainly superficial wound infections); 2% experienced re-injury. 

Conclusion: 
Most amateur/professional rugby players returned to sport within 3.6 months, while recreational players returned in 10.2 ± 3.1 months. Key predictors of successful RTS included younger age, early surgical intervention, and adherence to a structured rehabilitation protocol. Timing of injury within the rugby season also influenced RTS outcomes. 

The ‘Valley’ Protocol For Acute Achilles Tendon Ruptures: A Prospective Observational Study 

Louis John Stephen1,2, Conor Rankin2, Charlie Erskine1, Soorya Siva2, Catriona Phin3, Kevin McCloskey2, Turab Syed2, Efstathios Drampalos2,1 

1School of Medicine, Veterinary & Life Sciences, University of Glasgow, Glasgow, United Kingdom. 2Department of Trauma & Orthopaedics, Forth Valley Royal Hospital, Stirling, United Kingdom. 3Department of Physiotherapy, Stirling Community Hospital, Stirling, United Kingdom 

Abstract 

BACKGROUND 

This prospective study examines outcomes of the ‘Valley Protocol’ for acute Achilles tendon ruptures. The protocol uses ultrasound-measured tendon gap as the primary criterion to stratify patients into surgical or conservative treatment, both supported by a standardised early rehabilitation protocol (ERP). This novel approach addresses a gap in the literature and aims to provide evidence for the role of the tendon gap in guiding management. 

OBJECTIVES 

Primary objectives were to assess re-rupture and complication rates to evaluate safety, and to measure ATRS, Global Satisfaction, and Plantarflexion Strength (MRC Power Grade) to assess patient outcomes. We aimed to validate the Valley Protocol as an effective tool for managing ruptures using a ≤1.5 cm gap threshold. Secondary outcomes included time to re-rupture, injury mechanism, and rupture location (distance from calcaneal insertion). 

STUDY DESIGN & METHODS 

All patients with acute tendoachilles rupture over three years were included. Exclusion criteria: age <18, chronic ruptures (>3 weeks), prior ipsilateral rupture or surgery. Patients with gaps ≤1.5 cm were treated conservatively; those >1.5 cm underwent surgery if candidates. All followed an ERP. ATRS and satisfaction scores were collected retrospectively at study end; MRC strength was assessed post-ERP. Fischer’s exact and Mann-Whitney U tests were utilised. 

RESULTS 

152 ruptures (n=146 patients; mean age 52.7) were included. Mean tendon gap: 1.64 cm; rupture distance from calcaneus: 5.25 ± 1.94 cm. 138 ruptures were managed conservatively, 14 surgically. Re-rupture rate: 3.3% (n=5; all conservative, P=1.0). Mean time to re-rupture: 271 days. Complication rate (excluding re-rupture): 2.7%. ATRS, satisfaction, and strength were comparable (P=0.723, 0.144, 0.913). Mean ATRS: 85.7. 

CONCLUSIONS / IMPLICATIONS 

The Valley Protocol exhibits low re-rupture, complication rates and high patient satisfaction (ATRS) using tendon gap to guide treatment approach. Patients with ≤1.5 cm gaps can be managed conservatively with ERP,  potentially improving outcomes, patient satisfaction, and cost-effectiveness.  

DISCLOSURES 

None. 

Risk of Requiring Revision ACL Reconstruction based on the Posterior Tibial Slope Delta Angle: A Single-Institute Case-Control Study of 1206 Patients with Minimum 5-Year Follow-up 

Siddarth Raj1,2, Atif Ayuob1,2, Jonathan Jessup1,2, Henry Searle1,2, Thomas Thorne1, Imran Ahmed1,2, Peter Thompson1,2, Andrew Metcalfe1,2, Feisal Shah1,2, Nicholas Smith1,2 

1University Hospitals Coventry & Warwickshire NHS Trust, Coventry, United Kingdom. 2Warwick Clinical Trials Unit, Clinical Sciences and Research Laboratories, Coventry, United Kingdom 

Abstract 

Background: An increased posterior tibial slope (PTS) is an established risk factor for both anterior cruciate ligament (ACL) rupture and ACL reconstruction (ACLR) failure. This study aimed to assess the relationship between PTS and revision ACLR risk within a single-institution cohort. 

Methods: Patients who underwent primary ACLR and subsequent revision ACLR at our institution between 2007 to 2018 were eligible for inclusion. Patients with prior osteotomies, multi-ligament injuries or intra-articular fractures were excluded. Two authors independently measured medial PTS (MPTS) and lateral PTS (LPTS) on plain film radiographs via an established method. Inter-user agreement was calculated for validation. Thereafter, the Delta Angle (difference between LPTS and MPTS) was calculated. An imputation analysis was conducted for missing data and revision risks were subsequently calculated for MPTS, LPTS and Delta Angles across multiple ranges. 

Results: Overall, 1,206 primary ACLR and 102 revision ACLR cases were eligible for inclusion. In the primary ACLR group, the mean MPTS was 5.18°, LPTS 8.31° and Delta Angle 3.13°. In the revision ACLR group, the mean MPTS was lower at 3.41°, whereas the mean LPTS and Delta Angle were higher at 9.57° and 6.20°, respectively. Following imputation analysis, revision ACLR rates were highest in patients with an MPTS of 0–4° (13.2%), an LPTS of 10–12° (16.4%) and a Delta Angle of 6–8° (52.8%).  

Conclusion: A higher Delta Angle was associated with increased risk of requiring revision ACLR. Lower MPTS and higher LPTS ranges were also associated with revision ACLR. Delta Angle is a potentially greater predictive metric than MPTS or LPTS alone. Biomechanically, a greater Delta Angle may induce greater internal tibial rotation, which can load the ACL graft and subsequently lead to ACLR failure. 

Implications: Delta Angle measurement can guide patient-counselling and surgical decision-making by identifying patients at greater risk of ACLR failure. 

Malunion, Intervention and Patient-Reported Outcomes in Patients Aged 65 Years and Older with a Fracture of the Distal Radius 

Katrina Bell1, James Balfour1, Timothy White1, Samuel Molyneux1, Nicholas Clement1, Andrew Duckworth2,1 

1Edinburgh Orthopaedics, Edinburgh, United Kingdom. 2University of Edinburgh, Edinburgh, United Kingdom 

Abstract 

Background: The aim was to determine the rate of radiographic malunion and subsequent intervention following a dorsally displaced fracture of the distal radius in patients aged 65 and older.  

Methods: Patients were identified from a retrospective database and radiographs at a minimum of 28 days post-injury measured to determine whether or not radiographic malunion was present. Electronic records were examined to obtain demographic data, details of complications in patients managed operatively within 28 days of injury and details of any operative intervention for the management of malunion. Patient-reported outcome measures in the form of the QuickDASH, PRWE, Normal Wrist Score (NWS) and ED-5D-3L were obtained at a mean of 5 years post-injury. 

Results: There were 385 distal radius fractures in the cohort. Patients had a mean age of 75 years (65-95) and were predominantly female (88.1%, n=339). Of the 73 (19.0%) patients managed with primary operative intervention, a complication occurred in 20.5% (n=16). There was a 77.9% (n=300) rate of radiographic malunion, with 86.67% (n=260) occurring in patients managed non-operatively. Five patients (1.67%) underwent a surgical procedure for the management of a symptomatic malunion (all non-operatively managed initially). There were no significant differences in the QuickDASH (p=0.636), PRWE (p=0.964), NWS (p=0.192) or EQ-5D-3L (p=0.506) when comparing patients who developed and malunion and those who did not.  

Conclusions: There was a high rate of radiographic malunion but a low rate of surgical intervention for symptomatic malunion. Malunion was significantly more likely following non-operative management although there was no significant difference in patient-reported pain and functional outcome when comparing patients with and without radiographic malunion.  This tolerance of malunion, combined with the complication rate with primary operative management and the low rate of further surgery required for symptomatic malunion, has implications regarding better defining the optimal management of these injuries the elderly. 

Validation of a set of quality indicators for older adults hospitalized for injuries 

Marianne Giroux1,2, Marie-Josée Sirois1,2,3, Marcel Émond1,2,3, Mélanie Bérubé4,2, Michele Morin1,5, Lynne Moore1,2 

1Université Laval, Faculté de médecine, Quebec City, Canada. 2Centre de recherche du CHU de Québec-Université Laval – Axe Santé des Populations et pratiques optimales en santé, Quebec City, Canada. 3Centre de recherche en santé durable VITAM – Centre intégré de santé et service sociaux de la capitale nationale, Centre d’excellence sur le Vieillissement de Québec, Quebec City, Canada. 4Université Laval, Faculté de sciences infirmières, Quebec City, Canada. 5Centre de recherche du CISSS de Chaudière-Appalaches, Quebec City, Canada 

Abstract 

Introduction: Assessing the quality of care in trauma systems is essential to identify areas needing improvement. However, although older people account for >50% of admissions and adverse health outcomes are more frequent in this population, most trauma systems do not use quality indicators specific to this population.  

Objective: We aim to validate a set of quality indicators for geriatric trauma. 

Methodology: We conducted a retrospective cohort study of patients aged  ³65 admitted to a trauma center in Quebec (2013-2020). Using the Quebec Trauma Registry, we measured six indicators from a recent consensus study: surgical delay for hip fractures, management by a geriatric specialist, access to rehabilitation and screening for malnutrition, pressure ulcer and discharge destination. Adherence was measured for patients with an injury severity ³ 2 on the Abbreviated Injury Scale and a length of stay ³ 3 days. Multi-level logistic regression models with a random effect on trauma centres were used to estimate adherence in each centre. Stratified analyses were performed based on age, frailty risk, and designation level. 

Preliminary results: A total of 75 191 people from 57 trauma centers were included. Global adherence was 13% for management by a geriatric expert, 20% for malnutrition screening, 61% for surgical delay <36h in hip fracture patients and 86% for access to rehabilitation. Significant variations were observed between centers of the same level for all process indicators. Adherence was generally better for older and more frail patients and in centers with a higher designation level. Pressure ulcers were reported in only 2% of patients, and 53% had a favourable discharge destination 

Conclusion: Preliminary analyses show low to moderate adherence to indicators, as well as variations in practice, suggesting that there is potential for improving the quality of care for elderly trauma patients.  

Outcomes in Necrotising Fasciitis: Impact of Early Surgical Intervention and Structured Orthopaedic Management in a Tertiary Centre 

Aakaash Venkatesan 

Aneurin Bevan University Health Board, Newport, United Kingdom 

Abstract 

Introduction: 
Necrotising fasciitis (NF) is a rapidly progressive, life-threatening soft tissue infection that requires urgent multidisciplinary management. This audit evaluates the morbidity and mortality outcomes in NF patients, with a focus on the role of orthopaedic surgical interventions and the implementation of a structured clinical pathway in a tertiary care setting. 

Methods: 
A retrospective-prospective clinical audit was conducted over a two-year period (2022–2024) within Aneurin Bevan University Health Board. Thirty patients diagnosed with NF and managed by the orthopaedic department were included. A structured management proforma was introduced to assess documentation of LRINEC scoring, finger sweep findings, time to surgical debridement, and escalation of care. Statistical analysis was performed using SPSS v25.0. Chi-square testing and logistic regression were used to evaluate associations between clinical variables and outcomes. 

Results: 
The cohort included 30 patients (male:female ratio 2.5:1; mean age 52.1 ± 11.3 years). Diabetes mellitus was the most common comorbidity (70%), followed by chronic kidney disease (20%). Lower limb involvement was most frequent (80%). Early debridement (<24 hours from presentation) was performed in 14 patients (46.7%), with a significantly lower mortality rate (14.3%) compared to delayed debridement (>48 hours), which was associated with a 50% mortality rate (p<0.001). Overall mortality was 30%, with significantly higher rates in patients with septic shock (66.7%, p<0.001). Six patients (20%) required amputation, and 40% had prolonged ICU admissions (>7 days). Implementation of the structured management proforma was associated with a 15% reduction in mortality (p=0.04). 

Conclusion: 
Early surgical debridement and use of a standardized NF management proforma significantly reduce mortality and improve clinical outcomes in NF. Orthopaedic teams play a critical role in early diagnosis and intervention. Multicentre studies are needed to validate these findings and support widespread implementation of structured care pathways. 

THE EPIDEMIOLOGY AND OUTCOMES OF PERIPROSTHETIC FEMUR FRACTURES: The Scottish National Audit of Periprosthetic Femur Fractures (SNAP Femur) Study 

Matt Kennedy Kennedy1,2, Nick Clement2,3,4, Luke Farrow5,6, Ian Kennedy7, Thomas Harding8, *SNAP Femur Group9, Calum Blacklock3, Rose Penfold10, Jon Clarke1,11, Andrew Duckworth3,12, Alasdair Maclullich10,3, Phil Walmsley13, Andrew Hall2,4,13 

1Golden Jubilee National Hospital, Clydebank, United Kingdom. 2School of Medicine, University of St. Andrews, St. Andrews, United Kingdom. 3Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom. 4Scottish Centres for Orthopaedic Treatment & Innovation in Surgery & Healthcare (SCOTTISH) Network, St Andrews, United Kingdom. 5Department of Orthopaedics & Trauma, Aberdeen Royal Infirmary, Aberdeen, United Kingdom. 6Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, United Kingdom. 7QEUH Orthopaedics, Queen Elizabeth University Hospital, Glasgow, United Kingdom. 8Department of Orthopaedics & Trauma, Ninewells Hospital, Dundee, United Kingdom. 9SNAP FEMUR Group, Edinburgh, United Kingdom. 10Age and Ageing, Usher Institute, University of Edinburgh, Edinburgh, United Kingdom. 11Department of Biomedical Engineering, University of Strathclyde, Glasgow, United Kingdom. 12Centre for Population Health Sciences, Usher Institute, University of Edinburgh, Edinburgh, United Kingdom. 13Fife Orthopaedics, Victoria Hospital, Kirkaldy, United Kingdom 

Abstract 

Background 

Periprosthetic femur fracture (PFF) data capture in national registries is incomplete, and its burden on healthcare services is a challenge to quantify. Aims included: establishing the characteristics of patients sustaining a PFF, PFF management, mortality, and comparison to native hip fractures (NHF) using Scottish Hip Fracture Audit (SHFA) data. 

Methods 

A nationwide retrospective cohort study of all patients ≥50 years sustaining a PFF managed in 16 centres over 12 months (2019). Data collected included: patient, PFF and management characteristics, and outcomes including frailty and mortality. Comparison to NHF data and independent associations of PFF with mortality were assessed with Cox regression survival analysis, adjusted for confounders. 

Results 

There were 328 PFF with a mean age of 79 (SD 10) years, and 66% were female. Median follow-up was 2.8 (Inter-Quartile Range 1.67-3.22) years post-injury. Compared to NHF, PFF patients were less frail (Clinical Frailty Scale score [CFS] 4 v 5, p-value ≤0.001) and more likely to be home-dwelling (91% versus 76%, p≤0.001). The majority of PFF were relative to arthroplasty implants (307 (93.5%): 228 (70%) hip; and 79 (24%) knee. 175 (53%) patients were managed with fixation, 99 (30%) with revision arthroplasty and 50 (15%) managed conservatively. Median length of stay was 15 days (IQR 8-28 days), and the one-year mortality rate was 21%. Factors independently associated with increased mortality risk were: inter-periprosthetic fractures versus all other types (aHR 2.65, p=0.003), male patients (aHR 1.76, p=0.015), older age (per year aHR 1.07, p=≤0.001), and higher pre-injury frailty (CFS 5-9: aHR 4.16, p=0.027).  

Conclusion 

PFF occurred in less frail patients than NHF but were associated with prolonged hospital stay and significant mortality risk at one-year. The majority (70%) of PFF could be missed if reliant on revision arthroplasty numbers reported in national arthroplasty registry data alone. 

Disclosure 

Nil 

The Clinical Frailty Scale is a valid and independent predictor of one-year survival in patients sustaining a hip fracture: Scottish Hip Fracture Audit data from 8092 patients 

Matthew Kennedy1,2,3, Rose Penfold4,3, Lorraine Donaldson3, Andrew Hall3,2, Martin Davison5,3, Alasdair Macullich4,3, Phil Walmsley6,2, Nicholas Clement7,3,2, Jon Clarke1,8 

1Golden Jubilee National Hospital, Clydebank, United Kingdom. 2School of Medicine, University of St. Andrews, St. Andrews, United Kingdom. 3Scottish Hip Fracture Audit, Edinburgh, United Kingdom. 4Ageing and Health, Usher Institute, University of Edinburgh & Advanced Care Research Centre, Usher Institute, University of Edinburgh, Edinburgh, United Kingdom. 5Department of Orthopaedics & Trauma, University Hospital Wishaw, Wishaw, United Kingdom. 6National Treatment Centre, Victoria Hospital, Kirkaldy, United Kingdom. 7Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom. 8Department of Biomedical Engineering, University of Strathclyde, Glasgow, United Kingdom 

Abstract 

Background: Risk stratification tools are important in guiding management and family discussions for hip fracture patients. Aims were to assess the associations, and validity, of the Clinical Frailty Scale (CFS) in predicting mortality and return to original residence within thirty days using national hip fracture registry data. 

Methods: Routinely collected clinical registry data for all patients presenting with a hip fracture in Scotland aged 50 years and over between February 2022 and December 2023 with a completed CFS score were analysed. The association of frailty with mortality and return to original residence was assessed using multivariable Cox regression and logistic regression analysis, respectively, adjusting for confounders to present adjusted hazard (aHR) and odds ratios (aOR). 

Results: Of 15546 patients, 8573 had completed CFS. Exclusion for missingness gave a final sample of 8092. Most (71.4%) were female with a median (interquartile range) ASA grade of 3 (3-3) and CFS of 5(4-7). Vulnerable and frail patients (CFS ≥4) were older, more likely to be admitted from a higher care setting and had increased mortality risk on the same admission. Higher CFS scores were associated with increased mortality risk: mildly frail (CFS 4-5) aHR 1.67 (95%CI 1.53-1.87) and frail (CFS 6-8) aHR 3.01 (95%CI 2.59-3.50). CFS and ASA grade showed similar performance in predicting one-year mortality (CFS: area under curve [AUC] 0.72, 95%CI 0.71-0.73, ASA:AUC 0.66, 95%CI 0.65- 0.67) and return to residence (CFS: AUC 0.63, 95% CI 0.62-0.65, ASA: AUC=0.61, 95% CI 0.60-0.62). 

Conclusion: The CFS is a pragmatic and validated tool for assessing frailty, which has a strong association with mortality risk in patients with hip fractures. Its predictive accuracy supports its integration into national hip fracture registries. While its utility in predicting return to pre-injury residence is moderate, it remains a valuable component of comprehensive patient assessment. 

Disclosures-nil 

Fixing the Unfixable? Outcomes from Femoral Neck System Procedures in a Major Trauma Centre 

Megan Baker1, Tom Hall1, Rory Padkin2, Edward Mills1 

1Sheffield Teaching Hospitals, Sheffield, United Kingdom. 2University of Sheffield Medical School, Sheffield, United Kingdom 

Abstract 

Introduction: 
Femoral neck fractures are common in the elderly and present significant treatment challenges due to the risk of avascular necrosis (AVN), particularly in displaced fractures. The Femoral Neck System (FNS) was developed to improve biomechanical stability and reduce AVN risk. However, concerns about a perceived high complication rate within our institution prompted a retrospective review of FNS outcomes over a five-year period. 

Methods: 
We retrospectively reviewed all patients who underwent FNS fixation for femoral neck fractures at Northern General Hospital from 2019 to 2024. Data collected included patient demographics, comorbidities, fracture classification, surgical timing, and postoperative outcomes, with particular attention to AVN and reoperation rates. Patients who died within 90 days postoperatively were excluded from specific outcome analyses. 

Results: 
Seventy patients were identified, with 67 included in the final analysis. The mean patient age was 73.6 years. The overall complication rate was 22.4%, increasing to 25.9% after excluding early postoperative deaths. AVN accounted for 60% of all complications. Patients under 65 years experienced significantly higher complication (43.8%) and reoperation (37.5%) rates compared to those over 65 (19.0% and 16.6%, respectively). No statistically significant associations were found between complication rates and fracture displacement, injury mechanism, gender, or time to surgery. Comparatively, a previous departmental audit of cannulated hip screws in a similar over-65 cohort showed an 11.7% reoperation rate—4.9% lower than the FNS group. 

Conclusion: 
FNS fixation in femoral neck fractures was associated with a higher-than-expected rate of AVN and reoperation, particularly in younger patients. Despite its theoretical biomechanical benefits, the FNS does not appear to prevent biologically driven complications like AVN. Our department has since returned to using cannulated hip screws in most cases. Further prospective studies are needed to better define the role of FNS in contemporary femoral neck fracture management. 

Fracture-related Infection operations after Internal Fixation of Ankle Fractures in England: a 20-year study 

Conor Hennessy1, Andrew Hotchen2, Simon Abram3, Constantinos Loizou1, Jamie Ferguson2, Martin McNally2, Adrian Kendal1 

1Nuffield department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Oxford, United Kingdom. 2The Bone Infection Unit, Oxford University Hospitals, Oxford, UK, Oxford, United Kingdom. 3Musculoskeletal Sciences Institute, University of Bristol, Bristol, UK, Bristol, United Kingdom 

Abstract 

Background: 

We investigated the rate of ankle fracture related infection (FRI) after fracture fixation (ORIF) and the need for reoperation, using Hospital Episodes Statistics (HES) data for England.  

Method:  

HES data was obtained from NHS Digital and combined with Office of National Statistics (ONS) data. We included all adult patients who underwent an ORIF for ankle fracture from 2002-2022. Reoperation-free survival was calculated with Kaplan-Meier curve analysis. Cox proportional hazard modelling determined factors which increased the risk of reoperation for infection.  

Results:  

We identified 144,284 eligible ankle fractures, of which 1,749 were open fractures. The rate of ankle ORIF increased by 50% over the 20-year study period, from 10/100,000 in 2002 (95% CI 9.7–10.2/100,000) to 15/100,000 in 2022 (95% CI 14.7–15.3/100,000). The overall rate of re-operation for infection in open fractures was 6.06% (95% CI 4.98–7.21%) versus 2.60% in closed fractures (95% CI 2.2–2.69%, Figure 1). The incidence of reoperation for infection after ankle ORIF increased four-fold from 0.3/100,000 in 2002 (95% CI 0.3–0.4/100,000) to 1.3/100,000 in 2022 (1.2–1.4/100,000 in 2022). 

Female patients (HR 1.09; 95% CI 1.02–1.16), those in the lowest Index of Multiple Deprivation quintile (HR 1.16; 95% CI 1.05–1.27), those aged 20-39 years old (HR 1.36; 95% CI 1.21–1.53) and 40-59 years old (HR 1.19; 95% CI 1.06–1.34) had higher risk of reoperation for FRI. 

Conclusions:  

This large national study shows that both surgical fixation of ankle fractures and subsequent FRI have significantly increased over a 20-year period. The infection rate is now double that seen in arthroplasty and often occurs in young people. With 1 in 37 patients now needing surgery for FRI, do we need to re-evaluate the place of surgery in closed ankle fractures and the infection prevention measures we have in place? 

Trauma salvage with femoral endoprosthetic replacement for failed internal fixation following femoral fragility fracture surgery 

Chryssa Neo, Catherine James, Liam Yapp, James Patton, Matthew Moran, Chloe Scott 

Edinburgh Orthopaedics, Edinburgh, United Kingdom 

Abstract 

Introduction 

Despite significant advances in fracture fixation techniques and implants for treating femoral fragility fractures, fixation failures still occur. To restore function, conversion to high stakes endoprosthesis may be preferable to repeated attempts at fixation. The aim of the study is to explore the outcomes of femoral endoprostheses, proximal and distal, when performed for trauma salvage. 

Methods 

We identified 35 patients who underwent femoral endoprosthesis for trauma salvage between 2012 and 2022 through review of our prospectively collected institution implant database Electronic notes and national PACS were interrogated and data on demographics, co-morbidities, surgical details and outcomes were collated and analysed using SPSS. The primary outcome measure was reoperation. Secondary outcomes included readmission and mortality. 

Results 

Of the 35 endoprostheses performed, 26 were proximal femoral replacements (PFRs) and 9 were distal femoral replacements (DFRs). Mean age was 71.7±12.3 (range 42-86 years of age) and 25/35 (71.4%) were female. A median of 1 trauma surgery (IQR 1-2, range 1-7) had been performed prior to endoprosthesis. Modes of failure requiring conversion to endoprostheses included non-union (n=9), fixation failure (n=6), lag screw cut out (n=4), refracture (n=2) and infection (n=4).         

Reoperations were required in 4/35 cases, all PFRs, due to infection (n=2) and instability (n=2). At 3 years, survival free from reoperation was 82.0% for PFRs and 100% for DFRs. Six patients required readmission (17%) all occurring in PFR cases. Mortality at 90 days and 1 year was low, with most deaths unrelated to the procedure. 

Conclusion 

Endoprostheses for trauma salvage was associated with significant but acceptable complication rates. Reoperation and readmission were limited to patients who had undergone PFRs and infection rates were lower than expected. Femoral endoprostheses  are a feasible option in cases of failed fixation(s). 

Radiographic Imaging in Tibial Fracture Management Assessed by RUST: A Retrospective Analysis. 

Laith Alawneh, Borna Guevel, Zakaria NOOR, Reem Zenatyarebi, Nur Mahadi, Srushti Mehta, Mudassar Khan, Mona Hassan, Zahra Awan, Satyajit Naique 

Imperial College NHS, London, United Kingdom 

Abstract 

Background 

Routine postoperative X-rays are common in tibial fracture care despite unclear impact on outcomes. We examined whether timing/frequency of follow-up radiographs influence clinical decisions and resource use. 

Methods 

Retrospective review of 384 tibial fractures in trauma centre (April 2024–2025). 180 patients met inclusion criteria (exclusions: no follow-up imaging, age<18, transfers with prior imaging.). We recorded follow-up imaging timing, RUST progression, and any management changes. Two alternative follow-up protocols aligned with healing milestones were modelled (Scenario A: second X-ray at ~9 weeks when RUST≈8; Scenario B: second X-ray at ~12 weeks when RUST≈10) 

Results 

Initial post-op imaging was obtained at ~2.5 weeks. Second and third follow-ups occurred at a median of 6- and 12-weeks post-op. RUST scores improved from a median of ~5 at first follow-up to ~7 at 6 weeks and ~8 by 12 weeks, reflecting progressive healing. By the second X-ray, 68 patients (37.8%) had achieved RUST ≥8, and 10 patients (5.6%) had achieved RUST ≥10; by the third, 105 patients (58.3%) reached ≥8, and 23 (12.8%) reached ≥10. Only 13 patients (7.2%) required any change in management, and just 5 cases (2.8%) were influenced by radiographic findings. 

Avoidable follow-up X-rays under two proposed protocols (delaying routine follow-up to ~9 weeks in Scenario A or ~12 weeks in Scenario B). Scenario A would eliminate ~127 X-rays vs ~253 in Scenario B out of 598, translating to considerable cost savings (£12.8k–£25.5k) without missing significant clinically relevant issues. 

Conclusion 

Most 6-week follow-up X-rays showed limited value and did not alter management. Aligning follow-up imaging timing with patient-specific healing milestones can safely reduce unnecessary X-rays. 

Implications 

Optimising the schedule of routine X-rays could significantly cut healthcare costs. An evidence-based protocol focusing imaging at meaningful healing points maintains effective monitoring of fracture union while improving the efficiency. 

URGENT ELECTIVE (PLANNED) SURGERY FOR PATIENTS WITH HIP BONE METASTASES LEADS TO SHORTER INPATIENT STAY AND REDUCED COSTS COMPARED TO EMERGENCY ADMISSION WITH FRACTURE 

Sri Ram Ramasamy Muthuraman1, Daisy Lockie1, Samantha Downie2, Michael Kelly2, Peter Young3 

1University of Glasgow Medical School, Glasgow, United Kingdom. 2Department of Orthopaedic Surgery, Queen Elizabeth University Hospital Glasgow, Glasgow, United Kingdom. 3Department of Trauma and Orthopaedics, University Hospital Ayr, Ayr, United Kingdom 

Abstract 

Background 

Patients with bone metastases (BMD) are a complex surgical cohort. National guidance supports tertiary pathways, consultant-led decision making and prophylactic surgery in appropriate patients, however, this service can be costly. The aim was to compare the outcomes and economics of post-fracture emergency surgery against urgent planned prophylactic surgery in patients requiring complex hip arthroplasty due to hip metastases. 

Methods 

This was a comparative cohort study using a prospectively collected database at a tertiary MBD service. 145 consecutive patients were treated with arthroplasty at a single centre by two consultants (MK & PY) (2009-2025).  After inclusion criteria (confirmed MBD, acetabular +/- femoral arthroplasty for BMD & single procedure during admission) 112 were grouped into acute trauma admission including fracture (n=43, 38%) and planned urgent elective (n=69, 61%).  

The primary outcome was total length of admission.  Secondary outcomes included complications, transfusion requirement and one-year mortality.  Mean follow-up was 25 months. 

Results 

Demographics were similar, however, patients admitted with fracture had a propensity to be male (53% vs 46% female, p=0.052).   

Median total inpatient stay was significantly longer for the trauma versus the elective group (21 versus 6 days, p<0.001).  Median time from surgery to discharge was longer for the trauma group (14 versus 5 days, p<0.001) 

21% of post-fracture patients experienced post-operative complications compared to 9% of patients in the prophylactic group (p<0.05) in particular, peri-prosthetic joint infections. Patients in the trauma group were significantly more likely to receive a transfusion post-surgery (42% versus 25%, p<0.001). Based on average inpatient stay, implant cost and complication rate, trauma patients cost an additional £7,100. 

Conclusion 

Patients who underwent urgent planned pelvic reconstruction for MBD had a shorter hospital stay by 15 days, significantly lower complication rate and better outcome. Managing patients with BMD on an elective basis is cost effective due to reduced inpatient care costs. 

Categories 

Tumours ( incl Infection) 

650 

THE USE OF A LONG UNCEMENTED MODULAR FEMORAL STEM IS SAFE AND EFFECTIVE IN THE MANAGEMENT OF BONE METASTASES IN THE FEMUR 

Samantha Downie1, OM Farhan-Alanie1, JW Kennedy1, Greg McKean1, D Young2, Michael Kelly1, Peter Young3 

1Queen Elizabeth University Hospital, Glasgow, United Kingdom. 2University of Glasgow, Glasgow, United Kingdom. 3NHS Ayrshire & Arran, Ayr, United Kingdom 

Abstract 

Background 

Cemented arthroplasty is commonly recommended for treating bone metastases (BMD) around the hip.  However, cementation has disadvantages, including restricted stem length, loosening due to proximal disease progression and bone cement implantation syndrome (BCIS). A long uncemented implant spanning the whole femur could negate these disadvantages, however there is a paucity of data regarding their use. Our aim was to assess the outcomes of a long uncemented femoral stem. 

Methods 

204 patients with femoral bone metastases who underwent femoral reconstruction using the Restoration Modular Revision Hip System Plasma stem (Stryker, UK) between 2009 and 2025 were identified from the prospectively collected database of a tertiary BMD service. Inclusion criteria included BMD affecting the femoral head to subtrochanteric region with either completed or impending metastatic fracture.  The primary outcome measure was femoral implant survival, with failure defined as the requirement for any surgical re-intervention.  

Results 

There were 48 pathological fractures (24%) and 156 impending fractures (76%). Mean follow-up was 17 months (range 1-43 months). 157 patients (77%) died during the study period at a mean of 15 months postoperatively. The mean distance from the centre of the femoral head to the most distal femoral metastasis was 124 mm (range; 3 to 405). Using death as a competing risk, 50-month probability of re-intervention was 5%, probability of death was 79%. At 100 months, probability of re-intervention remained 5% and the risk of death was 84%.  Overall complication rate was 8%. 

Conclusion 

This technique demonstrates excellent survival, with no patient requiring femoral revision for loosening, and a comparatively low complication rate. We would recommend the use of along uncemented stem in patients presenting with femoral metastases due to systemic cancer and haematological malignancy. 

COST-BENEFIT ANALYSIS: A TERTIARY METASTATIC BONE DISEASE (MBD) PATHWAY IS ECONOMICALLY JUSTIFIED WHEN TREATING COMPLEX PERI-ACETABULAR METASTASES 

Samantha Downie1, Graeme Nicol2, Peter Young3, Michael Kelly1, Jonathan Stevenson4, Matthew Moran5, Cathie Sudlow6, A Hamish Simpson6 

1Queen Elizabeth University Hospital, Glasgow, United Kingdom. 2Ninewells Hospital & Medical School, Dundee, United Kingdom. 3Crosshouse Hospital, Ayr, United Kingdom. 4Royal Orthopaedic Hospital, Birmingham, United Kingdom. 5Edinburgh Royal Infirmary, Edinburgh, United Kingdom. 6University of Edinburgh, Edinburgh, United Kingdom 

Abstract 

Background 

Patients with peri-acetabular bone metastases (MBD) are currently treated by trauma services ad hoc, or by tertiary referral services such as sarcoma teams. These patients are high risk, with a significant complication rate, and benefit from a tertiary MDT approach. We aimed to assess the cost benefit of instituting a tertiary MBD service in a medium size DGH. 

Methods 

This prospective modelling study estimated the cost of managing the MBD workload at a medium-sized orthopaedic centre (population 423,000) over ten years (2026-2035).  The analysis projected cost differences in the following areas: implants, outpatient/inpatient care costs, intraoperative fracture rate and metalwork failure. 

Results 

In the study Health board, cancer prevalence will increase from 4528 to 8004 and the number of complex hip metastases will rise from 19 to 34/year (2026-2035).  Mean cost for MBD patients managed electively was £4,500 versus £11,600 for a similar patient admitted as trauma. 

A tertiary MBD service would see implant costs rise from a mean £94,536/year (baseline model) to £153,839 (£593,026 over ten years).  With more patients managed electively, patient care cost will fall from £2 million (baseline model) to £1.7 million in the MBD service (average saving of £29,748/year). 

Three metalwork failure scenarios were modelled versus the baseline projected 5% failure rate (13 with metalwork failure over ten years).  Overall, failure rates of 2% and 1% would favour an MBD service over the status quo (less expensive by £215/year 2% failure rate and £10,917/year 1% failure rate). 

Conclusions 

This is the first cost-analysis to be performed on setting up a tertiary referral MBD service in a UK orthopaedic trauma unit.  With a metalwork failure rate of 1% at five years, a tertiary MBD service would save £109,168 over ten years and improve patient outcomes.  

Management and surveillance of metastatic giant cell tumour of bone 

David Fellows1, Julia Kotowska2, Thomas Stevenson3, Jennifer Brown1, Zsolt Orosz1, Ather Siddiqi1, Duncan Whitwell1, Thomas Cosker1, Christopher LMH Gibbons1 

1Oxford Sarcoma Service, Nuffield Orthopaedic Centre, Oxford, United Kingdom. 2Hampshire Hospitals NHS Foundation Trust, Basingstoke, United Kingdom. 3Institute of Naval Medicine, Alverstoke, United Kingdom 

Abstract 

Background 

Giant cell tumour of bone (GCTB) is viewed as a benign, locally aggressive primary bone tumour with metastatic potential. Current management is surgery with bone curettage or resection and systemic therapy with denosumab. Diagnosis is confirmed histologically prior to surgery, with staging for pulmonary disease, as pulmonary metastases (PM) reportedly occur in <8%. This study aimed to assess incidence, surveillance and management of PM in patients with GCTB, with histopathological review.  

Methods 

A retrospective audit of the Oxford bone tumour registry was performed from January 2014 – October 2023. Inclusion criterion was histological confirmation of GCTB. Exclusion criteria were incomplete medical, imaging or histology records, or referral for secondary MDT opinion for diagnosis.  

Results 

83 patients met the full selection criteria. PM were identified in 8 (9.6%) patients. One had PM at presentation and seven at follow-up between 2 and 42 months. Two were histologically confirmed after cardiothoracic surgery and biopsy, six radiologically diagnosed. Three (37.5%) patients with PM have died (between 1 and 12 months after confirmed PM), five alive with stable disease. Five (62.5%) with pulmonary disease had recurrence of local disease requiring further surgery. Local recurrence was an independent risk factor for PM on statistical analysis.  

Conclusion 

GCTB may present with PM, but more commonly, metastasis occurs after surgery, presenting on surveillance and can progress. There were no distinct differences in histopathological appearance between patients with GCTB that developed PM and those that did not. PM can behave aggressively, necessitating identifying histological markers to recognise patients at risk of metastatic GCTB, for example, through mRNA single cell analysis.  

Implications 

We propose GCTB patients with PM receive regular chest surveillance with PET scan and/or CT to monitor disease progression, and a multi-centre audit of GCTB outcome undertaken to further define optimal clinical management. 

Categories 

Tumours ( incl Infection) 

813 

Hand Tumours: A Retrospective Analysis of Aetiology and Referral Pathways Safety 

Tanmay Jitendra Talavia1, Anatolia Nix2, Mohamed Onsa1, Parthavi Mehta1, Sharan Sambhwani1, Robert Ashford1, Nicholas Eastley1, Kunal Kulkarni1 

1University Hospitals of Leicester NHS Trust, Leicester, United Kingdom. 2University of Leicester, Leicester, United Kingdom 

Abstract 

Background:   

Increasing workloads necessitate evaluation of referral pathways for hand swellings. While hand sarcomas are rare, their early diagnosis and appropriate management in a specialist centre is key to optimise outcomes. We reviewed hand tumours managed at our Sarcoma Treatment Centre to evaluate their aetiology and our current referral pathways.  

Methods:   

We retrospectively analysed patients between 2019–2024 that underwent excision of a soft tissue tumour (Excluding ganglions) from the hand/digits by either the East Midlands Sarcoma Service or University Hospitals of Leicester NHS Trust elective hand service. Datasets collected included demographics, tumour characteristics, imaging modalities, histopathology results, complications, and oncological outcomes.  

Results:   

92 patients (mean age 50.8 years, M:F 1:1) were included. Most tumours were located in digits (n=64), followed by the palm (n=25).  3 lesions involved palm and a digit.   

The use of pre-excision imaging varied: 22.8% patients had ultrasound only, 5.4% MRI only, and 3.2% radiographs only. 60% underwent a combination of imaging modalities, and 8.6% had no imaging. Mean tumour size was 1.83cm (range 0.4-6.0 cm). 34.7% of cases were discussed in our regional sarcoma MDT, of which 5 subsequently underwent core needle biopsy before excision.   

Most excisions (81/92) were performed by a hand surgeon, with the remainder removed by a sarcoma surgeon. Tenosynovial giant cell tumour was most common diagnosis (n=28), followed by lipoma (n=9). No malignant tumours were identified. 6 required surgery for local recurrence, with no major complications reported.  

Conclusion:   

Our data confirms that the vast majority of hand tumours are benign in aetiology. Despite this, clinicians must remain vigilant for sarcoma through the use of ultrasound +/- MRI.  If no concerning features are identified on imaging, our results suggest that this cohort can be safely managed with a marginal excision under the remit of either a sarcoma or elective hand service.