BOA Annual Congress 2026

Sanjana Mehrotra1, Mihira Mehrotra2, Jim Gollogly3 

1Sheffield Medical School, Sheffield, United Kingdom. 2Nottingham Medical School, Nottingham, United Kingdom. 3Children's Surgical Centre, Phnom Penh, Cambodia 

Abstract 

Background 
International surgical outreach is often criticised for “fly-in” missions with limited local impact. The Children’s Surgical Centre (CSC) in Phnom Penh hosts long-standing partnerships in orthopaedics aimed at building Cambodian surgical capacity for complex reconstructive care. 

Methods 
We conducted a qualitative study of CSC’s training model using semi-structured interviews with 9 visiting surgeons, 1 visiting audiologist, 6 Cambodian surgeons and 1 ENT nurse involved in long-term capacity-building at CSC (8–25 years’ involvement). Interviews explored collaboration, training, ethics and sustainability. Transcripts were thematically analysed using an inductive–deductive approach. 

Results 
Participants consistently contrasted CSC’s model with mission-style outreach. Visiting teams return over many years, work with an expectation to train, and operate with a Khmer surgeon scrubbed for every case. Long-term mentorship and high case volume enabled local surgeons to progress from observers to independent operators in procedures including brachial plexus reconstruction, deformity correction, arthroplasty and advanced ENT/ophthalmic surgery. 

Trust and personal relationships, supported by CSC’s strong leadership, were crucial for shared decision-making and open discussion of challenges. Many participants described relationships between visiting and local clinicians as extending beyond professional collaboration, with some likening the partnership to an extended family. Partnerships were bidirectional: Cambodian surgeons gained specialised skills and international fellowships, while visiting surgeons reported sharper clinical judgement, exposure to rare pathology, and recognition through research and leadership roles. CSC has emerged as a national referral and teaching centre influencing standards in other Cambodian hospitals. 

Key threats to sustainability included staff turnover, fragile equipment, and scarce resources. Clinicians emphasised the need for protected funding, structured training pathways and succession planning. 

Conclusions 
A long-term, mentorship-based partnership centred on joint operating, trust and two-way learning can transform a charitable orthopaedic service into a national training hub. This model offers a practical alternative to mission-style outreach in similar low-resource settings. 

Emmanuel Oladeji1,2, Olorunnisola Olatide2, Israel Olaosebikan2, Oluwatobi Olayode2, Oluwafisayo Awi2, Noah Oyedokun2,3, Patrick Okonkwo2,1, Abdulahi Zubair2, Abdulshakor Ali2, Oghofori Obakponovwe1,2 

1St Richard's Hospital, Chichester, United Kingdom. 2Surgery Interest Group of Africa, Lagos, Nigeria. 3National Orthopaedic Hospital Igbobi, Lagos, Nigeria 

Abstract 

Background 

Orthopaedic implant reuse is widespread in low-resource settings, driven by cost constraints and limited availability. Recent evidence suggests the practice is considered acceptable and likely to continue. However, unclear sourcing, weak quality assurance, and a lack of standardised guidance create avoidable safety risks. This modified Delphi Study aims to develop a practical guideline for safer reuse of implants. 

Methods 

The Delphi panel comprised 17 orthopaedic surgeons from Africa and Asia. 29 statements were identified through a targeted literature review and expert consultation, and organised into six domains: sourcing and traceability, reprocessing and sterilisation, recertification and quality assurance, safe intraoperative reuse, patient consent and ethics, and infection risk. Panel members rated their agreement with each statement on a five-point Likert scale in each iterative survey round. An a priori threshold of at least 75% agreement was required to reach consensus. 

Results 

All 29 statements reached consensus after three rounds of anonymous voting. Notable recommendations include: formal documentation and traceability of all reprocessed implants, including auditable implant registries and verified prior-use histories, and the exclusion of devices with unverifiable histories; standardised reprocessing protocols, validated sterilisation, competency-based staff training, and formal recertification checks before reuse; prioritisation of mandatory intraoperative fitness-for-use assessments, documentation, surveillance, and incident reporting systems in theatre; transparent informed consent and disclosure of risks associated with implant reuse, uncertainties, and available alternatives; and infection-related guidance advising against the reuse of arthroplasty components and hollow implants because of infection risk and biological safety concerns. 

Conclusions 

This modified Delphi study provides an expert-informed framework for safer reuse of orthopaedic implants in resource-constrained settings. The proposed recommendations may support the development of standardised governance pathways that balance patient safety, ethical transparency, sustainability, and equitable access to orthopaedic care.

Emmanuel Oladeji1,2, Oluwatobi Olayode2, Abdulahi Zubair2, Imobhio Okhifun2, Oluwafemi Olayinka2, Patrick Okonkwo1,2, Onyeka Omerenma2, Abdulshakor Ali2, Oghofori Obakponovwe1,2 

1St Richard's Hospital, Chichester, United Kingdom. 2Surgery Interest Group of Africa, Lagos, Nigeria 

Abstract 

Background 

Over 90% of the estimated 7.74 million individuals with sickle cell disease (SCD) live in low-resource settings, yet evidence guiding the management of SCD-related osteonecrosis largely derives from high-income contexts. This scoping review synthesises the available literature on management practices and outcomes in low-resource settings and compares them with those in high-resource settings to assess global disparities in care and identify gaps in context-specific evidence. 

Methods 

Following PRISMA-ScR guidelines, we systematically searched MEDLINE, Embase, Web of Science, Google Scholar, and African Journals Online through February 2025. Eligible studies reported on clinical features, management, or outcomes of osteonecrosis in patients with SCD in Africa. Findings were compared with practice in high-income settings. 

Results 

Thirty-two studies involving 779 patients met the inclusion criteria. Patients typically presented late: 85% at Ficat stages III–IV, with delays exceeding 20 years in some series. Diagnosis relied almost exclusively on radiographs, with MRI reported in only 6% of studies. Due to late presentation, joint-preserving treatments were rarely reported. Arthroplasty predominated, yielding functional improvement but was technically demanding and associated with high complication rates, particularly in patients with the SS genotype. Comparison with high-resource settings highlights striking inequities. In these settings, MRI surveillance enables early detection and the integration of joint-preserving interventions, including cell-based therapies and structured physical therapy. None of these was reported in African studies, reflecting infrastructural constraints and global disparities in translating advances to high-burden, resource-limited settings. Patients in Africa, where the burden is highest, have the least access to evolving interventions. 

Conclusion 

This scoping review highlights the considerable burden of late presentation with advanced-stage disease, which limits the role of joint-preserving interventions and leaves salvage procedures, such as arthroplasty, as the predominant management options. Addressing these gaps requires prioritising early detection and developing capacity for joint-preserving interventions.

Ghazal Hodhody1, Jonathan Topping1, Jane Ashton1, Daniela Ghio2, Naomi Davis1 

1Royal Manchester Childrens Hospital, Manchester, United Kingdom. 2University of Manchester, Manchester, United Kingdom 

Abstract 

Background 
Orthopaedic trainees frequently report low confidence and high anxiety when starting paediatric rotations, particularly in communication and non-technical skills during complex consultations with children and families. This has implications for patient safety, quality of care and trainee engagement. 

Although mandated within ISCP, GMC and Royal College of Surgeons frameworks, these competencies are not routinely taught in a structured way. The CANDY course was developed to address this gap and better prepare trainees for paediatric practice. 

Methods 
The CANDY course is a one-day, simulation-based programme delivered at a tertiary paediatric orthopaedic centre. Scenarios include infant examination, neurodivergence, adolescent consent/conflict and safeguarding. 

Teaching is delivered by a multidisciplinary faculty to groups of 5-10 trainees, integrating clinical and behavioural expertise and ensuring alignment to ISCP competencies. 

A prospective quality improvement study evaluated impact using pre and post confidence questionnaires and ISCP-aligned reflective entries. Reflections were analysed using reflexive thematic analysis and the COM-B framework to explore behavioural change. 

Results 
Baseline confidence in paediatric communication was low (mean 4.7/10) despite high perceived importance (mean 9.0/10). Following the course, confidence increased to 7.8/10 (+2.6), with the greatest improvement in high-complexity scenarios (+4.0–4.4). Applied communication scores improved to a mean of 7.6/10, with perceived knowledge and skills increasing by >3 points. 

Thematic analysis demonstrated how trainees can improve their patient-centred communication and consider structured and flexibility of consultation approaches and management of complex interactions alongside awareness of environmental and multidisciplinary factors, indicating enhanced capability and motivation (COM-B) with early behavioural change. 

Conclusion 
A targeted, multidisciplinary, simulation-based course can address a critical gap in orthopaedic training, significantly improving trainee confidence and preparedness for paediatric practice. By strengthening non-technical skills in high-risk clinical interactions, the CANDY course supports safer, higher-quality, child-centred care and enhances trainee experience. It provides a scalable, curriculum-aligned model for wider implementation. 

Meg Baker1,2, Joanna Craven3,2, Hannah Wise4,2, Joseph McKay5,2,6, Samantha Sharkey7,2 

1Sheffield Teaching Hospitals, Sheffield, United Kingdom. 2British Orthopaedic Trainees Association, Nationwide, United Kingdom. 3Univeristy of Liverpool, liverpool, United Kingdom. 4Prince Charles Hospital, Merthyr, United Kingdom. 5Usher Institute, University of Edinburgh, Edinburgh, United Kingdom. 6Royal Infirmary of Edinburgh, Edinburgh, United Kingdom. 7Leeds General Infirmary, Leeds, United Kingdom 

Abstract 

Background 
High-quality orthopaedic training is essential for developing a competent consultant workforce to deliver the best patient outcomes. There is limited clarity on what constitutes “good” training in theatre and outpatient clinics. Existing metrics emphasise volume rather than the quality of training environments, with variation in trainee experience and limited objective oversight. This study aims to define consensus-based, measurable gold standards for higher surgical training. 

Methods 
A multistage, mixed-methods modified Delphi design was used. Stage 1 combined a targeted literature review with a national scoping survey of key stakeholders (trainees, consultants and educational leaders) to generate candidate training statements. Statements were refined into defined, auditable items. 

Stage 2 comprised a two-round online Delphi using a 9-point Likert scale, with predefined consensus thresholds (>70% rating 7–9; <15% rating 1–3). 

Stage 3 will involve a structured consensus meeting to ratify findings and define auditable standards.. 

Results 
The survey received 166 responses (87 Trainees, 79 Trainers) from across the UK. Delphi round 1 included 118 participants (58 Trainees, 60 Trainers) with broad geographic and subspecialty representation. 

Consensus was achieved on these theatre standards: Including appropriate case selection (≥50% suitable for trainee operating), Pre-list planning, Defined learning goals, Consultant presence (≥90%), Graded autonomy, Structured feedback. 

Clinic consensus standards included: Supported minimum appointment durations, Avoidance of double-booking, Consultant Presence, Continuity with trainers, Access to appropriate facilities 

Structured debriefs and minimum assessment requirements did not reach consensus and are being re-evaluated in round 2. The final consensus meeting is scheduled for June 2026. 

Conclusion/Findings 
This study has defined new gold standards for effective training in theatre and clinic with agreement from trainees and trainers. 

Implications 
This study will deliver a consensus-derived, audit-ready gold standard checklist to support standardisation, benchmarking and quality improvement in Orthopaedic training. 

Robert Winstanley, Glen Alger, Lee Longstaff 

CDDFT, Durham, United Kingdom 

Abstract 

Background
Despite growing awareness of the ‘second victim’ phenomenon and initiatives to support surgeons, the lived experience of UK orthopaedic trainees following adverse events remains poorly understood. Trauma & Orthopaedic (T&O) trainees frequently work in high-risk surgical environments and may be particularly vulnerable to psychological impact, especially early in their careers. 

Methods
A qualitative study using Interpretative Phenomenological Analysis (IPA) was conducted with seven purposively sampled UK T&O trainees (ST3–ST8). Semi-structured interviews explored the emotional, cognitive, and behavioural impact of adverse events and the role of workplace culture. Data was transcribed and analysed ideographically before cross-case synthesis. 

Results
Four superordinate themes emerged: 1) The Visceral Reaction — trainees described an immediate, profound, almost physical response following adverse events. 2) Emotional Consequences and Self-Perception — adverse events triggered vulnerability, perceived failure, and persistent intrusive recollections. 3) Navigating Surgical Culture — experiences varied markedly depending on senior behaviours; supportive consultants contextualised events, whereas blame-oriented environments amplified distress and deterred disclosure. A pervasive expectation of stoicism was widely reported. 4) Learning, Growth, and Technical Adaptation — trainees identified adverse events as catalysts for reflective practice, influencing operative planning, communication, and future supervision style. 

Conclusions
Surgical adverse events profoundly shape the professional formation and psychological well-being of orthopaedic trainees. Outcomes are strongly influenced by departmental culture and the quality of senior support. We believe training programmes should incorporate structured, psychologically informed debrief processes, faculty development for supportive supervision, explicit teaching on coping with adverse events, and deanery-level access to peer support programmes for trainees.

Prakrit Kumar1, muhamed farhan-alanie1, ranya kumar2, aminul haque3, Andrew Metcalfe3 

1University Hospital Coventry & Warwickshire NHS Trust, Coventrry, United Kingdom. 2university of cambridge, cambridge, United Kingdom. 3university of warwick, warwick, United Kingdom 

Abstract 

Introduction 
Operative exposure is fundamental to achieving competence in core surgical training. Structural changes in training delivery, such as increasing service provision demands, rota gaps and reduced working hours have limited access to theatre opportunities. Despite initiatives such as the Improved Surgical Training programme, there remains limited contemporary quantitative evidence evaluating operative experience and competence. We aimed to provide a national assessment of operative exposure and procedural competence among UK core surgical trainees. 

Methods 
A national cohort study was conducted using anonymised data from the Intercollegiate Surgical Curriculum Programme and eLogbook databases. All trainees who successfully completed core surgical training between 2010 and 2024 were included. Operative exposure was assessed by case volume and level of participation, while competence was evaluated using procedural based assessments. Temporal trends were analysed using correlation coefficients and linear regression models. 

Results 
A total of 8,011 trainees and 2,968,529 procedures were analysed. Over half of procedures were recorded as observed or assisted (51.5%), with fewer than one third performed at supervisor trainer scrubbed level (39.98%). Operative exposure declined over time. In 2010, trainees assisted in a mean of 371 cases (39.9%), performed 242 cases at supervisor-trainer-scrubbed level (26.1%), and completed 227 cases independently (24.5%). By 2024, this had reduced to 59 (61.8%), 24 (25.1%)), and 5 (5.2%) cases respectively. This was accompanied by a reduction in procedural competence e.g. hip hemiarthroplasty, with the modal procedural-based assessment level decreasing from level 3 to level 2. 

Conclusion 
Operative exposure and procedural competence have declined over time in UK core surgical training. These findings demonstrate a need to optimise training opportunities and support competency development. Further qualitative work is warranted to explore underlying factors and inform targeted interventions across training programmes. 

Jonathan Hobby1, Elisabeth Haas2, Camillo Fulchignioni3 

1Hampshire Hospitals, Basingstoke, United Kingdom. 2University Hospital Munich, Munich, Germany. 3Catholic Univeristy of the sacred heart, Rome, Italy 

Abstract 

Background
Training in hand surgery varies widely in Europe. There is little evidence and no consensus as to the ideal hand surgery training program. This survey reviews current training pathways, and assesses the satisfaction of surgeons with current training models to identify best practise. 

Material & Methods: We performed an on-line survey. A QR code was used at the Federation of European Hand Surgery Socieities congress  (FESSH) and at two recent FESSH courses. It was also e-mailed to national socities. National societies were approached to clarify the training pathway in each country. A two tailed unpaired t-test was used for hypothesis testing. 

Results
We received 223 responses, 14 from non FESSH countries and two incomplete forms were excluded leaving 207 for analysis. We received responses from all 29 FESSH societies. There were 71 trainees and 136 trained surgeons. 

Training pathways varied. Two nations recognise hand surgery as a speciality and have a dedicated program, 3 have a specific program including other surgical disciplines, 14 have a program after board certification and 10 nations have no defined program. 

Satisfaction with training was 3.5/5. Satisfaction was higher in those in dedicated hand surgery training 3.9 vs 3.3 (p <0.001). 

Completing a fellowship was considered important 4.5/5, it was considered more important by orthopaedic and plastic trainees than those with a specific hand surgery program 4.6 vs 4.0 (p=0.003) 

A hand surgery exam was considered important 4.1/5. Seven nations have a mandatory exam, 4 require EBHS, 9 have an optional exam and in 9 there is no exam. 

Surgical logbooks were mandatory for 85 (62%), optional for 21 (15%) and not required for 31 (23%) 

Conclusions
Hand surgery training and accreditation varies widely across Europe. Additional fellowship training is considered important, particularly in nations in which hand surgery training is completed after accreditation.

Sarah Whitehorn1, Ivy Kuo2, Linda de Cossart1 

1Imperial College London, London, United Kingdom. 2Portsmouth Hospitals University Trust, Portsmouth, United Kingdom 

Abstract 

Background
Professionalism is an evolving and contentious topic. Difficulties in creating a definition, or even a consensus on meaning, are likely due to the effect of wider social context and cultural values. Differentiation of personal values from a surgical identity can never be complete, and as such wider social movements create changes in the working practices and moral values of the next generation of surgeons. This paper explores how ST5+ T&O trainees in the UK understand and experience professionalism through the hidden curriculum, and whether these experiences align with the Royal College of Surgeons Code of Conduct (RCS CoC). 

Methods
Using a hermeneutic phenomenological approach, eight semi-structured interviews were conducted with orthopaedic trainees, and the data was analysed using Interpretative Phenomenological Analysis via NVivo software. 

Results
Key attributes of professionalism were identified: prioritising the patient’s best interests, fostering interpersonal warmth, team cohesion, diligence, kindness, and humility. The study also highlights concerns about a perceived erosion of the social contract between surgeons and society, and how stress, insecurity, and learned behaviours can contribute to disruptive conduct in clinical settings. 

Conclusions/Findings
Despite the above concerns, the values expressed by the participants generally aligned with the RCS CoC. 

Implications
The number of interviewees was limited and since interviewees were self-volunteered, there is the possibility of selection bias, reducing the generalisability and potential transferability of the findings. This may be remedied by further research into the development of professionalism in surgical training, especially that which incorporates participant perspectives and captures a wider range of experiences. Recommendations include review of the RCS CoC to involve key stakeholders such as trainees. 

Naadir Nazar1, Matthew Bellamy2,3, Shivam Kolhe4, Ibrahim Muhammad5, Andrew Shearer6, Wen X Low7, Rahul Geetala8, Marie Barberon9, Vishal Chandanani8, Ciaran O’Hanlon10, Apoorva Khajuria11, Yusuf Michla12, Paul Banaszkiewicz13, Andrew McCaskie14, Stephen McDonnell14 

1Barts Health NHS Trust, London, United Kingdom. 2Sheffield Teaching Hospitals NHS Trust, Sheffield, United Kingdom. 3The University of Sheffield, Sheffield, United Kingdom. 4South Tees Hospitals NHS Trust, Middlesbrough, United Kingdom. 5Queen Mary University of London, London, United Kingdom. 6The University of Glasgow, Glasgow, United Kingdom. 7East Suffolk and North Essex NHS Foundation Trust, Colchester, United Kingdom. 8Manchester University NHS Foundation Trust, Manchester, United Kingdom. 9The Queen Elizabeth Hospital King's Lynn NHS Foundation Trust, King's Lynn, United Kingdom. 10Chelsea and Westminster Healthcare NHS Trust, London, United Kingdom. 11The Royal London Hospital, London, United Kingdom. 12South Tyneside and Sunderland NHS Foundation Trust, Sunderland, United Kingdom. 13Gateshead Health NHS Foundation Trust, Gateshead, United Kingdom. 14Cambridge University Hospitals, Cambridge, United Kingdom 

Abstract 

Purpose
Musculoskeletal (MSK) conditions account for approximately one-third of UK primary care consultations and 20% of emergency attendances, yet undergraduate trauma and orthopaedic (T&O) education remains inconsistent. This study evaluates the delivery of T&O teaching, clinical exposure, and preparedness for MSK practice among UK medical students and foundation doctors. 

Methods
This national cross-sectional study (July–October 2025) utilised a structured online survey, mapped to the British Orthopaedic Association (BOA) undergraduate curriculum and UK Medical Licensing Assessment (UKMLA) content map. Participants included UK medical students and foundation year one doctors, recruited via institutional and professional networks (BOA,BOTA,BOMFA). Survey domains assessed curriculum coverage, teaching modalities, clinical and operative exposure, career aspirations, and self-reported preparedness. Quantitative data was analysed descriptively with inferential testing (χ² and correlation). Free-text responses underwent thematic analysis. Ethical approval was granted by the University of Cambridge (HBREC.2025.13). 

Results
A total of 2,055 participants responded (54.0% female; 77.5% aged 19–23), with representation across all training stages. Despite high interest in T&O (54%), 42% reported no orthopaedic clinical placement and 20% received no formal MSK teaching in the preceding year. Teaching was predominantly lecture-based (61%), and 61% perceived the curriculum as inadequate, with 52% feeling unprepared for foundation practice. Orthopaedics accounted for 15.9% of the perceived curriculum, with 35.2% of MSK learning self-directed. Limited exposure to clinical skills, placements, and teaching frequency were significantly associated with reduced preparedness (p<0.05). Overall, 70% reported insufficient career information, and male students were more likely than females to pursue an orthopaedic career (15.3% vs 7.9%,p<0.001). 

Discussion
UK undergraduate T&O education is characterised by limited clinical exposure, reliance on self-directed learning, and low preparedness for practice. Addressing curriculum gaps, improving clinical access, and strengthening career guidance are essential to align training with healthcare demand and support sustainable future workforces. 

Rohan Rajan, Jabez Vhanda, Jyoti Shrestha, Islam Sarhan 

University Hospital of Derby and Burton, Derby, United Kingdom 

Abstract 

Background 
More cases of 1st metatarsophalangeal joint (MTPJ) arthroplasty are being offered as an alternative to primary arthrodesis. This study aims to determine the outcomes following conversion arthrodesis for failed total 1stMTPJ replacement. 

Methods
A retrospective study of patients who had 1stMTPJ arthrodesis for failed total joint arthroplasty from 2011 to 2024 was performed. The primary aim was to assess the union rate and the secondary aims were to assess functional outcomes and surgical complications. Union was assessed radiographically and functional outcomes were determined by using the Manchester-Oxford-Foot Questionnaire (MOXFQ) scores postoperatively. Surgical complications were evaluated.  

Results 
18 1stMTP joints in 14 patients had arthrodesis for failed arthroplasty. 4 patients had bilateral arthrodesis at different sittings. The mean age at revision arthrodesis was 57.9years(48-79years).  13 explanted joints were Toefit-PlusTM and 5 were Roto-GlideTM. The mean time from primary arthroplasty to arthrodesis was 59.9months (11-112months). 17 joints had tricortical iliac crest grafting and one had sliding metatarsal graft. The mean time to radiographic union was 16.6 weeks (SD 6.0; 95% CI 13.7-19.4; range 8-28weeks). The median postoperative MOXFQ score was 3.5 (IQR 2.25-8; range 0-22). 1 patient (5.6%) had symptomatic nonunion, 2 patients (11.1%) had malunion and 2 patients (11.1%) had symptomatic hardware. One patient lateral femoral cutaneous nerve injury. 

Conclusion 
1stMTPJ arthrodesis after failed total joint replacement is a complex procedure due to bone loss. The use of structural iliac crest bone graft reduces the nonunion rates to be closer to those of primary arthrodesis. There are also favorable functional outcomes following this procedure. There is however, relatively high surgical complications and the time to radiographic union is more than that of primary arthrodesis. Further highly powered comparative studies are required to better guide the management of failed total 1stMTPJ arthroplasty. 

Rebecca Martin1,2,3, William Gray1, Toby Jennison4, Sarah Johnson-Lynn3,5, Tim Briggs1,6, David Townshend2,7 

1NHS England, London, United Kingdom. 2Northumbria Healthcare NHS Foundation Trust, North Shields, United Kingdom. 3University of York, York, United Kingdom. 4University Hospitals Plymouth NHS Trust, Plymouth, United Kingdom. 5South Tees Hospitals NHS Foundation Trust, Middlesbrough, United Kingdom. 6Royal National Orthopaedic Hospital, London, United Kingdom. 7Northumbria University, Newcastle Upon Tyne, United Kingdom 

Abstract 

Background and Purpose 
End-stage ankle arthritis is a disabling condition treated definitively with ankle arthrodesis or total ankle replacement (TAR). TAR use in the United Kingdom has increased substantially over the past decade. While volume–outcome relationships are well established in hip and knee arthroplasty, evidence in TAR is limited. This study aimed to determine whether surgeon and hospital trust TAR volumes are associated with revision and early postoperative outcomes. 

Methods
A retrospective cohort study was conducted using Hospital Episode Statistics (HES) data for England. All NHS-funded adults undergoing elective primary TAR between 1 April 2013 and 31 March 2025 were included. Surgeon and trust volume were defined as the number of TAR procedures performed in the preceding 12 months. The primary outcome was revision within two years. Secondary outcomes included five-year revision, length of stay, and post-procedural complications. Multilevel logistic regression and negative binomial models were used, adjusting for age, sex, frailty, deprivation, diabetes, financial year, and surgical complexity (COFAS grade). 

Results
A total of 8,768 TARs were performed across 117 trusts by 322 surgeons. No significant association was observed between surgeon or trust volume and revision at two years (adjusted OR range 0.85–1.23; p>0.35) or five years (OR 0.74–1.07; p>0.20). Length of stay demonstrated a modest, non-linear association with surgeon volume, with an approximate 8% reduction among surgeons performing 15–19 cases annually (IRR 0.92, p=0.020). Higher surgeon volume was associated with significantly lower 30-day readmission rates, with progressively reduced odds observed across increasing volume categories (lowest vs 10–14 cases: OR 0.30, p=0.010). 

Conclusion 
Surgeon volume in TAR is associated with improved early postoperative outcomes but not with reduced medium-term revision risk. Experience appears to influence perioperative care rather than implant survivorship. 

George Matheron1, Richard Pearse1, Spilios Delis1, Thomas Lewis1, Matthew Welck1, Shelain Patel1, Nick Cullen1, Karan Malhotra1,2 

1Royal National Orthopaedic Hospital, London, United Kingdom. 2University College London, London, United Kingdom 

Abstract 

Background
Nonunion remains a major complication after ankle and hindfoot arthrodesis. Biologic augmentation is frequently used to try to mitigate nonunion risk, but incremental benefit is unproven and must be balanced against morbidity, operative burden, and cost. This study aimed to determine the CT-verified union rate after ankle and hindfoot arthrodesis performed without bone graft. Secondary aims were to assess the union rates associated with graft use, to compare case-mix between non-graft and graft procedures, and to identify factors associated with nonunion.

Methods
We retrospectively reviewed consecutive adult ankle and hindfoot arthrodeses performed at a UK tertiary centre between 2022 and 2024. Included procedures were ankle (tibiotalar), subtalar, tibiotalocalcaneal (TTC), and double/triple arthrodeses with postoperative weightbearing CT at 12 weeks. Procedures were classified as non-graft or graft (any biologic augmentation). Union was defined as ≥50% osseous bridging across all intended fusion surfaces assessed by reviewers blinded to graft use. Univariable screening and multivariable logistic regression evaluated factors associated with nonunion.

Results
A total of 227 procedures were included; graft was used in 69 (30.4%). Overall CT-verified union was achieved in 210/227 (92.5%). Union did not differ between non-graft and graft procedures (146/158, 92.4% vs 64/69, 92.8%; p=1.00). Union by fusion site was 93.9% for ankle, 92.3% for subtalar, 82.9% for TTC, and 96.7% for double/triple arthrodesis across all patients. On multivariable analysis, previous adjacent hindfoot fusion was independently associated with nonunion (adjusted OR 5.65; 95% CI 1.91 to 16.68; p=0.0017), whereas graft use was not associated to higher union (adjusted OR 2.02; 95% CI 0.64 to 6.42; p=0.233). 

Conclusion
High CT-verified union rates were achieved without routine graft use, supporting selective rather than routine biologic augmentation, particularly in cases with previous adjacent hindfoot fusion. 

I-Han Cheng1, Rui Loureiro1, Peter Snow1, Stephen Taylor1, Matthew Welck2, Karan Malhotra2 

1University College London (UCL), Department of Orthopaedics and Musculoskeletal Science, London, United Kingdom. 2Royal National Orthopaedic Hospital (RNOH), Foot and Ankle Unit, London, United Kingdom 

Abstract 

Background  
Foot drop, commonly caused by peroneal nerve injury, impairs gait and increases fall risk. Tibialis posterior tendon transfer (TPTT) is the definitive surgical option when neurological recovery is unlikely, yet no consensus exists on the optimal configuration. Existing cadaveric and clinical studies are limited by small samples, subjective outcomes, and lack of dynamic biomechanical analysis. This study used musculoskeletal simulation to quantify the biomechanical impact of key surgical variables. 

Methods 
A validated OpenSim Gait2392 model was modified to simulate 11 TPTT configurations across three variables: (1) routing technique—interosseous (IO) vs. circumtibial (CT); (2) rerouting height—5 to 11 cm above the medial malleolus in 1 cm increments; and (3) insertion site—Intermediate cuneiform vs. Cuboid. Dorsiflexion and inversion/eversion moment arms were computed across ankle and subtalar joint angles. Primary outcomes included peak moment arm, range-of-motion–weighted capacity (AUC), stability index, and joint angle at peak torque. Data were analysed using paired t-tests, Wilcoxon signed-rank tests, and polynomial regression. 

Results 
The IO route produced significantly greater dorsiflexion leverage than CT (0.0406 m vs. 0.0318 m, p<0.001) with reduced inversion bias (–0.0089 m vs. –0.0220 m, p<0.001). Rerouting height significantly influenced performance (Friedman χ²(6)=57.89, p<0.001), with an optimal zone at approximately 9 cm, beyond which gains plateaued (<0.2%). Classic insertion maximised dorsiflexion (0.0406 m vs. 0.0338 m, p<0.001), while modified insertion reduced inversion bias, reflecting a torque-stability trade-off. 

Conclusion 
The biomechanically optimal TPTT configuration is interosseous routing at approximately 9 cm above the medial malleolus with classic midfoot insertion. This reproducible, simulation-based framework enables objective comparison of surgical strategies and has potential to support personalised surgical planning for foot drop. 

Ziad Elmenawy1, MOHAMED ABDO KHALAFALLAH2, Nabil Elmaleh3, Ahmed Shalaan4, Mohamed Hashem5 

1University Hospitals of Dorset, Bournemouth, United Kingdom. 2Alexandria University, Alexandria, Egypt. 3Royal Lancaster Infirmary NHS, Lancaster, United Kingdom. 4Bedfordshire Hospitals NHS Foundation Trust, Bedfordshire, United Kingdom. 5Frimley Health NHS Foundation Trust, Frimley, United Kingdom 

Abstract 

Weber B (AO/OTA 44-B) ankle fractures have traditionally been considered stable and suitable for conservative treatment. However, emerging evidence suggests that a meaningful proportion of these fractures may actually involve unrecognized syndesmotic or medial instability, leading to poorer outcomes when misdiagnosed. 

This systematic review, conducted as per PRISMA 2020 guidelines, analyzed 20 studies (n = 4,255). Findings showed that 0.4% to 24.1% of fractures initially labeled as “stable” were later found to be unstable. Early weight-bearing radiographs were useful in confirming cases safe for non-operative management but failed to predict delayed instability. Delayed weight-bearing imaging identified instability in a smaller subset (0.7%–3.5%).

Stress testing revealed higher rates of occult instability: external-rotation stress tests detected instability in 24.1%–37.1% of cases, while intra-operative testing identified syndesmotic injury in up to 56.1% of patients with medial clear space asymmetry. Despite increasing surgical intervention rates, routine stress testing did not consistently improve functional outcomes. 

Advanced imaging showed strong diagnostic potential. MRI demonstrated 100% sensitivity and 81% specificity, CT had 77.8% sensitivity, and weight-bearing CT achieved excellent accuracy (AUC 0.96) for detecting syndesmotic incongruity. 

Outcomes were generally favorable when instability was identified early. In contrast, missed instability was associated with worse radiological results, higher non-union rates, and increased reoperations. Economic data were limited, with no comprehensive cost-effectiveness analyses available. In conclusion, a notable proportion of Weber B fractures classified as stable are biomechanically unstable. Selective use of advanced imaging is recommended in uncertain cases. Further high-quality research is needed to standardize diagnostic pathways and reduce missed instability. 

Daniel Tadross1, Ashka Moothoosamy1, Sachin Khemkar1, Mohamed Abdellatif1, Joseph Hanna2, Naeem Jagani1, Amirul Islam1 

1Liverpool University Hospitals Foundation Trust, Liverpool, United Kingdom. 2Countess of Chester Hospital, Chester, United Kingdom 

Abstract 

Background
Diabetic foot disease presents a significant healthcare challenge, frequently culminating in lower extremity amputation (LEA) with severe morbidity and high mortality rates. Post-operative outcomes are influenced by comorbidities, biochemical markers, health behaviours and socioeconomic factors. This study evaluated morbidity, mortality, wound healing and recovery following diabetic LEA, as well as their predictors. 

Methods
A retrospective cohort study was conducted at a single tertiary centre, including all patients undergoing diabetic LEA between 2020 and 2024 (inclusive). Demographics, comorbidities, biochemical markers and socioeconomic deprivation status were analysed. Primary outcomes were mortality, re-amputation and wound healing success. Binary logistic regression was used to evaluate predictors of the outcome measures. 

Results
206 patients (mean age 59.7 years, 83% male) were included. Mortality rates were 10.2%, 24.8%, and 35% at one, three and five years respectively. 73.8% of patients achieved wound healing following LEA, with a mean time to healing of 14.4 weeks (range 2–72). However, 40.3% had reamputation at any timepoint. Elevated CRP significantly correlated with increased re-amputation risk (p < 0.05). Re-amputation was associated with increased likelihood of one-year mortality (OR 3.17, p=0.050). Raised HbA1c was associated with poorer five-year survival (OR 2.64, p = 0.038). Poorer socioeconomic status was independently associated with non-healing wounds (OR 1.39, p=0.003), alongside raised CRP (OR 0.30, p=0.037) and smoking (OR 0.67, p=0.029). Increasing Charlson Comorbidity Index (CCI) independently predicted mortality at all time points (p<0.05). 

Conclusion
Diabetic LEA is associated with high mortality and reamputation rates. Over one quarter of wounds fail to heal and those that do often require prolonged healing times. Socioeconomic deprivation, biochemical markers, CCI and smoking are useful predictors of outcomes. These findings enable patient counselling and support the potential use of prognostic markers to stratify risk and enable early multidisciplinary intervention with structured long-term follow-up, therefore improving outcomes. 

Alexander Witek1, Andrew Gardner2, Oliver Flannery3, Ben Zucker1, Dan Yeomans4, Ruth Halliday1, Mark Dahill1 

1Southmead Hospital, Bristol, United Kingdom. 2Musgrove Park Hospital, Taunton, United Kingdom. 3Weston General Hospital, Weston-super-Mare, United Kingdom. 4Royal United Hospital, Bath, United Kingdom 

Abstract 

Background 
Headed and headless screws are commonly used during arthroscopic ankle arthrodesis.  There are no studies directly comparing the two methods of fixation. The choice of screw type is currently driven by surgeon preference rather than comparative evidence. This study aims to compare union and complication rates for both fixation devices across a large patient cohort. 

Methods 
A retrospective multi-centre cohort study was conducted across four hospitals in the South West of England, who utilise similar joint preparation, fixation and post-operative strategies.  Adult patients who underwent arthroscopic ankle arthrodesis between August 2015 and August 2024 were captured using departmental databases. Data collected included patient demographics, co-morbidities, screw type, screw configuration, radiographic union, time to union, and any complications. 

Results 
A total of 280 patients were included (216 headed, 64 headless). The overall union rate for all ankles was 86.4% (95% CI 81.9–90.2%). Union rates were comparable between headed and headless screws at 86.1% and 87.5% respectively (OR 0.89, 95% CI 0.38–2.04, p=0.94). Peripheral neuropathy was the only risk factor significantly associated with non-union (45.5% vs 12.4%, p=0.009). Median time to radiographic union was shorter in the headless screw group (88 vs 122 days, p<0.001). Ten patients (4.6%) in the headed group required removal of metalwork for symptomatic screws compared to none in the headless group. Mean follow up was 5.54 years. 

Conclusion 
Headed and headless screws demonstrate comparable union rates for arthroscopic ankle arthrodesis. The 4.6% rate of metalwork removal in the headed screw group, compared to none in the headless group, is clinically relevant and should be discussed during the consent process. In the absence of a difference in union rate, the lower reoperation rate may favour the use of headless screws. 

Hengshuo Zhang1, Jitendra Mangwani2, Feng Wei3, Samuel Ling4, Qipeng Song5, Daniel Fong6, Simin Li1 

1Wolfson School of Mechanical, Electrical and Manufacturing Engineering, Loughborough University, Loughborough, United Kingdom. 2Department of Trauma and Orthopaedics, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom. 3Orthopaedic Biomechanics Laboratories, Michigan State University, Michigan, USA. 4Department of Orthopaedics and Traumatology, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China. 5College of Sports and Health, Shandong Sport University, Jinan, China. 6National Centre for Sport and Exercise Medicine, School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough, United Kingdom 

Abstract 

Background 
The Lapidus procedure is commonly used to treat first tarsometatarsal joint instability, arthritis and hallux valgus but delayed union, non-union, and fixation failure remain concerns. Two commonly used fixation constructs are (1) crossed cannulated compression screws and (2) a locking plate combined with an interfragmentary compression screw. The current study aimed to compare the biomechanical performance of these two constructs using Finite Element (FE) analysis and to determine which configuration may provide more favourable stability for first tarsometatarsal arthrodesis. 

Methods 
A three-dimensional FE model of the right foot was developed from computed tomography data of a healthy adult. The model included all foot-ankle bones and 36 ligaments. Lapidus arthrodesis was simulated by removing the articular cartilage of the first tarsometatarsal joint and creating two fixation models: (1) crossed cannulated compression screws and (2) a dorsal locking plate with an interfragmentary compression screw. All implants were assigned titanium alloy material properties. Axial loads equivalent to 0.5, 1.0, and 2.0 times body weight were applied. Von Mises stress was used to evaluate stress distribution in bone and implants, and peak displacement at the fusion interface was used to assess construct stability. 

Results
Both constructs provided mechanical support across all loading conditions. However, the crossed screw construct showed a greater local stress concentration around the screw-bone interface and a larger increase in fusion-site displacement as loading increased. In contrast, the locking plate combined with screws demonstrated a more uniform stress distribution and a lower peak displacement at the arthrodesis interface under each of the three loading conditions. 

Conclusion
Both fixation methods appear mechanically acceptable for the Lapidus procedure. Compared with crossed screws, the locking plate combined with an interfragmentary compression screw may provide more even stress distribution and greater fusion-site stability, particularly under increased weight-bearing conditions. 

Thomas Lewis1, Karan Malhotra1, Nilesh Makwana2, Edward Wood3, Joel Humphrey4, Lyndon Mason5 

1Royal National Orthopaedic Hospital, Stanmore, London, United Kingdom. 2The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust, Oswestry, United Kingdom. 3Countess of Chester Hospital NHS Foundation Trust, Chester, United Kingdom. 4Milton Keynes University Hospital, Milton Keynes, United Kingdom. 5Liverpool University Hospitals NHS Foundation Trust, Liverpool, United Kingdom 

Abstract 

Background
Hallux valgus is the most prevalent forefoot condition and is associated with substantial pain, functional impairment and reduced health-related quality of life. Despite established clinical effectiveness, since 2021 an increasing number of Integrated Care Boards in the UK have classified surgical correction as a procedure of limited clinical benefit, citing a perceived absence of population-level cost-effectiveness data. National-scale evidence is required to inform commissioning decisions and ensure equitable access to care. 

Methods
A cost-utility analysis was performed using BOFAS Registry data for adults undergoing primary hallux valgus correction by osteotomy (open or minimally invasive surgery, MIS). EQ-5D-5L utility scores at baseline and 12 months were used to estimate quality-adjusted life year (QALY) gains. A six-state Markov model simulated lifetime costs and outcomes over 40 annual cycles from the UK NHS perspective. Incremental cost-effectiveness ratios (ICERs) were calculated against conservative management and deterministic sensitivity analysis was performed across procedural cost, utility gain and benefit duration. 

Results
321 patients had complete EQ-5D-5L datasets comprising 139 open and 182 MIS procedures. EQ-5D-5L utility improved from 0.69 (95% CI 0.65 to 0.72) at baseline to 0.84 (95% CI 0.81 to 0.88) at 12 months in the open group, and from 0.69 (95% CI 0.66 to 0.72) to 0.82 (95% CI 0.79 to 0.84) in the MIS group (both p < 0.001). The base-case lifetime Markov model produced an ICER of £8,737 per QALY for open correction and £11,969 per QALY for MIS correction, both well below the NICE willingness-to-pay threshold. 

Conclusion
Hallux valgus correction surgery is highly cost-effective from the UK NHS perspective, with cost per QALY values substantially below those reported for total hip and total knee arthroplasty. The current restriction of access in some UK regions is not supported by national health-economic evidence. 

Benjamin Lau1, Linzy Houchen2, Amirah Essop-Adam2, Peng Liu3, Jitendra Mangwani2 

1Guys and St Thomas', London, United Kingdom. 2University of Leicester, Leicester, United Kingdom. 3Loughborough University, Loughborough, United Kingdom 

Abstract 

Hallux valgus is a common forefoot deformity that affects pain, function, quality of life, and mobility. Despite its high prevalence and substantial rates of surgical treatment, the lived experience of patients – particularly those not seeking or receiving surgical care – remains poorly characterised. The inaugural UK National Hallux Valgus Think Tank (2024) identified understanding the patient's lived experience as the foremost research priority. 

Methods 
A large-scale, cross-sectional online survey was distributed to adults registered with primary care networks in Leicestershire. The survey was co-developed with Patient and Public Involvement from individuals with lived experience of hallux valgus. Participants self-identified as having current or previously treated hallux valgus. The survey incorporated the EQ-5D-5L health-related quality of life (HRQoL) framework and a Visual Analogue Scale (VAS) pain score, alongside questions exploring psychosocial burden, functional limitations, treatment-seeking behaviour and patient education. 

Results 
1773 respondents with current or previously treated hallux valgus were included, 80% were female and 46% had bilateral involvement with bilateral disease associated with significantly worse pain, mobility, and psychosocial outcomes.  48% reported a positive family history, with a maternal predominance (63% of those with a family history). Pain was reported by 79% of respondents with 34% reporting moderate-to-severe pain. Functional impacts included mobility limitations (46%), difficulties with usual activities (38%), and foot-wear adaptations (65%). 28% reported a mental health impact (anxiety or depression) attributable to their bunion, and 66% experienced self-consciousness, with 29% affected most or all of the time. Notably, 67% had not sought formal treatment and 92% had received no patient education. 

Conclusion 
Hallux valgus confers substantial physical, functional, and psychosocial burdens in the primary care population, extending well beyond pain alone. A large 'hidden population' of untreated patients exists — many living with significant symptoms yet not engaged with formal healthcare — compounded by a marked deficit in patient education. 

Ramy Khojaly1,2,3,4, Fiachra E. Rowan2, Vinay Shah5, Matthew Nagle6, Muhammad Shahab2, Amir Sohaib Ahmed2, Darren Dahly7, Colm Taylor6, Ruairí Mac Niocaill2, May Cleary2,3 

1Department of Surgery, Royal College of Surgeon, Dublin, Ireland. 2Department of Trauma and Orthopaedic Surgery, University Hospital Waterford, Waterford, Ireland. 3Department of Orthopaedic Surgery, University College Cork, Cork, Ireland. 4Department of Orthopaedic Surgery, University Hospital of North Midlands, Stoke-on-Trent, United Kingdom. 5Royal National Orthopaedic Hospital, London, United Kingdom. 6Department of Trauma and Orthopaedic Surgery, Cork University Hospital, Cork, Ireland. 7HRB Clinical Research Facility University College Cork, University Hospital Waterford, Waterford, Ireland 

Abstract 

Background
There is weak consensus and a paucity of robust literature with regard to the best postoperative weight-bearing and immobilisation regime for operatively treated ankle fractures. This trial compared immediate protected weight-bearing (IWB) with non-weight-bearing (NWB) with cast immobilisation following ankle fracture surgical fixation (ORIF), with a particular focus on functional outcomes, complication rates, and cost utility. 

Methods
This INWN (Is postoperative Non-Weight-bearing Necessary?) study was a multicentre, prospective, pragmatic, randomized controlled trial (RCT), with participants randomised to 1 of 2 parallel groups. IWB in a walking boot was compared with NWB in a cast for 6 weeks, following ORIF of all standard types of unstable ankle fractures. Skeletally immature patients and tibial plafond fractures were excluded. Analysis was performed on an intention-to-treat basis. The primary outcome was the functional outcome assessed by the Olerud-Molander Ankle Score (OMAS) at 6 weeks. A cost-utility analysis via decision tree modeling was performed. 

Results
We recruited 160 patients (80 per arm) between January 2019, and June 2020, aged 15 to 94 years of age (mean, 45.5 years), and 54% were female. The IWB group demonstrated a higher mean OMAS at 6 weeks (43 ± 24 for the IWB group and 35 ± 20 for the NWB group, with a mean difference of 10.4; p= 0.005). The complication rates were similar in both groups, including infection, wound dehiscence and further operations. Per patient, IWB was €798.02 less expensive than NWB, with an improved quality of life year gain (0.04 QALYs) over 1 year. 

Conclusion
IWB in a walking boot following ankle fracture fixation demonstrated superior functional outcomes, cost savings, earlier return to work, and similar complication rates compared with NWB in a cast for 6 weeks. These findings support the implementation of IWB as the routine mobilisation protocol following ankle fracture fixation.

Owen Morris1, Alexander Glendenning2, Zakiyy Azeez3, Richard Roberts1 

1Department of Trauma and Orthopaedic Surgery, Wrexham Maelor Hospital, Wrexham, United Kingdom. 2Department of Trauma and Orthopaedic Surgery, Morriston Hospital, Swansea, United Kingdom. 3Department of Trauma and Orthopaedic Surgery, Royal Glamorgan Hospital, Pontyclun, United Kingdom 

Abstract 

Background 
High-quality patient communication is essential to informed consent in orthopaedic practice. Audiovisual information may improve accessibility, comprehension, and retention, but producing accurate, procedure-specific material at scale remains challenging. Generative artificial intelligence may offer a novel solution. This study aimed to evaluate AI-generated videos designed to accompany orthopaedic clinic letters and support patient understanding and engagement. To our knowledge, this is the first study to demonstrate this approach. 

Methods 
Fifteen AI-generated videos were produced using ‘HeyGen’ for common elective orthopaedic procedures. Clinician-written clinic letters were provided to create patient-facing videos containing equivalent information. Videos were independently assessed by two blinded reviewers using the Patient Education Materials Assessment Tool for Audiovisual Materials (PEMAT-A/V), examining understandability and actionability. Educational quality was also evaluated using Global Quality Score. 

Results 
Across the 15 videos, the overall mean PEMAT-A/V score was 0.922 (95% CI 0.897–0.946), indicating strong performance. Multiple domains achieved perfect mean scores of 1.00, including clarity of purpose, use of everyday language, active voice, logical flow, direct address to the viewer, and clear explanation of actions. Other domains also scored highly, including use of short sections (0.93, 95% CI 0.79–1.00), summaries (0.93, 0.84–1.00), visual cues (0.97, 0.89–1.00), readable on-screen text (0.93, 0.84–1.00), and clear audio delivery (0.97, 0.89–1.00). Mean Global Quality Score was 4.67 (95% CI 4.32–5.01). 

Conclusion 
AI-generated videos demonstrated high understandability, actionability, and overall educational quality, supporting their potential as adjuncts to orthopaedic clinic letters. These findings suggest generative AI could provide a scalable, standardised multimodal approach to patient education and consent. Such tools may reduce variation in information delivery and reinforce key messages after consultation. Further work should assess patient comprehension, recall, acceptability, clinical integration, and the safety and governance requirements for routine implementation. 

Alexandra Macmillan, Hayat Muhammad, Rawiya Al Hosni, Ilias Epanomeritakis, Alagu Subramanian, Wasim Khan, Stephen McDonnell, Mark Birch, Andrew McCaskie 

University of Cambridge, Cambridge, United Kingdom 

Abstract 

Background 
After cartilage injury, healing is limited with a tendency towards fibrosis. Improving the regenerative potential of chondrocytes to enhance healing may be achieved through modifying the inflammatory environment through M2 macrophages, which aid regeneration in other fibrotic disorders. This could apply to enhancement of either resident populations or implanted autologous chondrocytes. We sought to understand this response of chondrocytes treated with M1 and M2 macrophage conditioned media (CM). 

Methods 
Human monocytes were directed towards M1 and M2-type macrophages for 7 days in vitro. Resultant M1 and M2 CM was applied to isolated human chondrocytes from three donors in 2D and 3D (pellet) culture for 24 hours. Sequential application of M1 followed by M2 CM was performed (12 hours each). 2D chondrocyte RNA was submitted for bulk RNA seq. Differential gene expression analysis was performed in R (edgeR/limma workflow) and transcription factor activity inferred. Overrepresentation analysis was performed (Gene Ontology). 

Results 
M1-exposed chondrocytes showed enhancing differential expression of pro-inflammatory genes (PTGS1, ADAMSTS4, ICAM1). M2 exposed macrophages displayed increased expression of SERPINA1, CA-9 and LEP. M1 followed by M2 application led to enhanced expression of genes associated with cell cycle activation (MCM2, CCNE2). GO term ‘DNA replication’ was enhanced. Analysis of inferred transcription factors highlighted STAT 1 (downregulated when adding M2 after M1) and E2F4 (upregulated). 

Conclusion
When applying M2 macrophage CM to chondrocytes previously exposed to M1 macrophage media, genes associated with proliferation are enhanced. This does not occur with either M1 or M2 media alone, suggesting a post-inflammatory proliferative effect is unique to this sequential exposure to M1 and M2 secretomes. Proliferation of chondrocytes and resolution of inflammation is undoubtedly important in cartilage healing after injury. Understanding the mechanisms of this phenomenon may therefore lead to novel therapeutic approaches to treat cartilage damage and early disease. 

Hannah Newey, Abdul Gomaa, Emily Hall, Ahmed El-Sallakh, Lois Campbell, Thumri Paavana, Thomas Banks, William Gibson, Iain McFadyen 

University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, United Kingdom. Keele University School Of Medicine, Stoke-on-Trent, United Kingdom 

Abstract 

Background 
Severe soft tissue infections (SSTIs) are associated with high early mortality. Physiological drivers of early death and high-risk phenotypes remain poorly defined, with emphasis often placed on surgical timing. This study aimed to identify biochemical and clinical predictors of mortality and characterise high-risk patients. 

Methods 
A retrospective cohort study was performed evaluating suspected SSTI referrals to a tertiary United Kingdom Orthopaedic centre between January 2020 and December 2023. Patients were grouped by early mortality (≤72 hours), late mortality (>3 days), and survivors. Comparative analyses were conducted using Mann-Whitney U and chi-square tests. Unsupervised machine learning (K-means clustering) identified clinical phenotypes associated with early mortality. Analyses were performed in SPSS v31.0; statistical significance set at p < 0.05. 

Results 
145 patients were included (65.5% male, mean age 58.9 ± 20.8 years). 15 patients died within 28 days. Mortality was associated with acute kidney injury (AKI) (p<0.0001), acidosis (p=0.033), and elevated lactate (p=0.001); each 1 mmol/L increase above 2 mmol/L conferred 33% increased odds of death (OR 1.33). 

Seven patients (4.8%) died within 72 hours and demonstrated a distinct “lethal triad” of hyperlactataemia (>5 mmol/L), acidaemia (pH <7.25), and low/normal white cell count (WCC) (<8.0 ×10⁹/L). Three patients underwent surgery; four died beforehand. Clustering identified a high-risk phenotype encompassing advanced age, multiple co-morbidities, and AKI. 

Conclusions 
Early mortality in limb SSTIs is driven by a phenotype of metabolic collapse and immune dysregulation rather than delayed surgical intervention alone. The presence of a “lethal triad” identifies patients at high risk of imminent deterioration; early multidisciplinary and family discussions regarding ceiling of care are important. 

Implications 
Early recognition of patients presenting with suspected SSTI and the lethal triad of acidaemia, high lactate, and low/normal WCC is critical due to their high risk of early mortality. 

Disclosures 
N/A

Chryssa Neo, Andrew Ablett, Tony Feng, Nick Clement, Andrew Duckworth, Tim White 

Edinburgh Orthropaedics, Edinburgh, United Kingdom. Usher Institute, Edinburgh, United Kingdom 

Abstract 

Background 
Necrotising fasciitis (NF) is a rapidly progressive surgical emergency.  The effects of time from hospital presentation to theatre on short- and long-term outcomes, as well as specific modifiable aspects of the care pathway that would enable early surgery, remain poorly defined. 

Methods 
A retrospective cohort study of all suspected cases of limb NF presenting across a large health board region over 10 years was undertaken. Early surgery was defined as ≤6-hours from presentation (triage time) to theatre (operation start time). The independent associations between surgical timing and 30-day mortality or amputation were assessed. A timeline analysis identified areas where delays occurred. Survivors completed the EQ-5D-5L and Toronto Extremity Salvage Score (TESS) outcome assessments. 

Results 
Of 359 referrals, four patients died prior to surgery and 80 patients underwent emergency surgery due to surgeon suspicion of NF. For cases of intraoperatively confirmed NF (n=63/80), early surgery was associated with a five-fold reduction in 30-day mortality rate (overall rate 22% (n=14/63); adjusted hazard ratio 0.19, 95% CI 0.04 to 0.87, p=0.032; absolute risk difference 25%). Additionally, early surgery was associated with reduced rates of 30-day amputation (overall rate 30% (n=19/63); adjusted hazard ratio 0.19, 95% CI 0.05 to 0.66, p=0.009; absolute risk difference 32%).  At a median of 27 months follow-up (range 6 to 113), only 35 patients (56%) were alive. Survivors having early surgery reported significantly better patient-reported outcomes (EQ-5D: 0.785 vs. 0.133, p=0.003; TESS: 64.9 vs. 28.7, p=0.007). 

Conclusion 
Early surgery for patients with NF was associated with a lower risk of mortality, amputation, and severe long-term disability. Early recognition and transfer to theatre represent modifiable targets for improving survival and outcomes.

Andrew Davies, Matthieu Durand-Hill, Vasia Panagi, Iman Ghaffari, Sophie Hunt, Lara Alsadoun, Timothy Gourbault, Andrew Zhao, Shubhra Kamat, Sivanshankar Sivaloganathan 

Chelsea and Westminster, London, United Kingdom 

Abstract 

Introduction 

Discharge summaries are essential for safe transitions of care but are frequently time-consuming to produce and variable in quality. Within orthopaedic surgery, high patient turnover and complex postoperative plans increase this burden. This quality improvement project aimed to deploy and optimise an AI-assisted discharge summary tool to improve the efficiency, completeness and quality of discharge summaries. 

Method 
The AI tool was integrated with Cerner electronic health records. Clinical data were extracted and categorised, followed by large language model generation of a structured draft for clinician review. A pre-implementation audit was conducted, followed by 3 iterative Plan–Do–Study–Act (PDSA) cycles and a final audit. Discharge summary quality and the completeness of information were assessed according to Professional Record Standards Body guidelines. Safety was assessed through prospective clinician identification of errors, omissions and hallucinations. 

Results 
The study included 94 discharge summaries. Baseline pre-AI data demonstrated variability in documentation quality and frequent omission of key clinical information such as medications and follow-up instructions. Across PDSA cycles the interventions performed were grouped into 4 areas: optimisation of data extraction, prompt engineering to improve accuracy and conciseness, changes to the LLMs used in different parts of the process and improvements to clinical workflow. 

Following implementation, mean documentation quality scores improved from 82% to 92%, completeness increased from 80% to 96%. System reliability improved: AI generation failure rates reduced from 57% to 0%. Three clinically significant content errors were identified during the cycles, including 1 hallucination. None occurred in the final audit. Outputs were safely used with clinician oversight. AI outperformed human summaries in safety netting and social context. 

Conclusion 
AI-assisted discharge summary generation within a clinician-in-the-loop framework was safe, reliable and can improve completeness and quality. Iterative optimisation was essential to achieving reliable performance. Significant efficiency savings are anticipated with wider implementation. 

Sunny Deo, Dan Yeomans, Tom Russell 

Great Western Hospital, Swindon, United Kingdom 

Abstract 

Background 
Total Knee Arthroplasty (TKA) is a well-established and frequently undertaken major procedure with excellent results based on implant survival and quality of life improvements. Factors such as severe deformity, patella tracking, ligament deficiencies and bone loss can impact length of procedure, physiological insult and therefore outcomes, including complications. 

Methods 
The 37 specialist knee surgeons across hospitals in a single Deanery were emailed an invitation to complete a 12-part Likert questionnaire to gauge their perceptions of surgical site complexity in primary TKA surgery and additionally its representation in national documentation. Cumulated responses were scaled to percentages. Data was collected using Google Forms. All participants consented to data usage. The response rate was 65% (24 of 37). 

Results 
The cohort mean specialist arthroplasty experience was 17 years (range 1-30, SD 6.8), with mean 98 (range 15-200, SD 57.5) TKA’s performed per annum, with an estimated cumulative experience of approximately 40,000 TKA. There was 95% agreement that local complexity factors impact patient outcomes. Patella baja 93.4% and maltracking 91.6% scored highest of 8 suggested factors. The lowest score was 73% for varus deformity. 

The scores for whether these complexities were reflected in the UK National Joint Registry (NJR) or hospital coding were far lower at 38.4% and 40.6% respectively. 

Thematic analysis confirmed additional suggestions for assessment of skin condition, local soft tissue envelope and other systemic comorbidities. 

Conclusion 
There is a mismatch between the importance of complexity factors from the perspective of specialist knee surgeons and how well they feel these are reflected in NJR or coding. 

There is consensus to better qualify and quantify pre-operative local and systemic complexities in TKA. 

Implications 
Complexities impacting outcomes and clinical risk are not currently documented. This methodology provides a template for further a larger study to define key local complexity factors. 

Disclosures: Nil. 

Simon Williams, Hashim Al-Hano, Bogdan Ciupe, Rojbin Yigit, Simon Tilley 

University Hospital Southampton, Southampton, United Kingdom. University of Southampton, Southampton, United Kingdom 

Abstract 

Background
Hemiarthroplasty implant selection varies within units despite national guidance. This study evaluates implant use, surgeon grade variation, outcomes, and cost implications in a single UK unit. 

Methods 
Retrospective review of 240 consecutive hemiarthroplasties (April 2025 to January 2026). Outcomes included length of stay (LOS), 30-day complications, 30-day mortality, one-year mortality, and discharge destination. Case-mix adjusted LOS used multivariable regression. Cost analysis applied a £350 bed-day rate with break-even thresholds against the lowest adjusted-LOS stem. 

Results 
Mean age 84.4 years; 65.4% female; 84.2% ASA 3 or 4. Bipolar heads predominated (81.3%). The commonest stems were Lubinus Link SP II (n=121) and Exeter V40 (n=68). Consultants used a significantly different stem mix to non-consultants, favouring Thompson and Furlong over Lubinus Link SP II (p<0.001). Unadjusted median LOS ranged from 14 days (Lubinus Link SP II, Furlong) to 19 days (Thompson); differences were not statistically significant (p=0.464). ASA grade was the only independent predictor of LOS on adjusted analysis (p=0.008). Thirty-day and one-year mortality were 2.9% and 19.2% respectively, with no significant difference between stem groups (p=0.076; p=0.555). Complications occurred in 2.1%. Overall, 55.6% were discharged home, 36.8% to rehabilitation, and 5.9% to a new care home. Discharge destination did not differ significantly by stem (p=0.728), though Furlong had the highest rehabilitation rate (55%) and Thompson the highest direct home discharge rate (61%). Exeter V40 and Thompson incurred £630 and £1,540 more per case in bed-day costs than Lubinus Link SP II, representing the price difference required for cost neutrality. Meaning these stems would need to cost that much less per unit to be financially equivalent. 

Conclusions 
Significant grade-driven variation in stem selection exists independent of case-mix. Patient frailty drives LOS and mortality more than implant choice. Cost modelling supports standardisation towards Lubinus Link SP II as a basis for value-based procurement. 

Slade Badenhorst, Nick Clement, David Sochart 

South West London Elective Orthopaedic Centre, Epsom, United Kingdom 

Abstract 

Introduction 
Total hip (THA) and total knee arthroplasty (TKA) are effective treatments for end-stage osteoarthritis, improving pain, function, and quality of life. Frailty, a multidimensional state of reduced physiological reserve, is associated with adverse perioperative outcomes, but its relationship with patient reported outcome measures (PROMs) remains unclear. Frail patients may achieve lower absolute postoperative scores but still derive meaningful improvement. However, the magnitude of this change is poorly understood with high heterogeneity in the literature. This study evaluated the impact of frailty on joint-specific and health-related quality-of-life outcomes following THA and TKA. 

Methods 
A single-centre prospective cohort study was conducted over 9 months. Demographics, Clinical Frailty Scale (CFS), ASA grade, length of stay (LOS), and complications were recorded. Preoperative and 1-year postoperative Oxford Hip and Knee Scores and EQ-5D were collected. Associations between CFS and outcomes were assessed with adjustment for confounders. 

Results 
A total of 387 patients were included (176 TKA, 211 THA), with a mean age of 71 years and 61% female. Most were CFS 3 (40.3%), with higher CFS being associated with older age (p<0.001) and worse ASA grade (p=0.033). Patients with higher preoperative CFS had significantly worse baseline Oxford scores (p<0.001), but greater postoperative improvement, resulting in similar postoperative scores for both TKA and THA after adjusting for confounders. Similar patterns were seen for EQ-5D. Higher CFS being associated with worse preoperative scores (p<0.001) but equivalent postoperative scores after greater improvement in TKA patients. However, in THA patients, postoperative EQ-5D scores remained worse. Higher CFS was also associated with significantly longer LOS (p<0.001) and an increased risk of postoperative complications (p=0.001). 

Conclusion 
Frailty is associated with worse baseline PROMs and increased perioperative risk but greater postoperative improvement. Despite poorer preoperative status, frailer patients achieved comparable joint-specific outcomes, supporting the value of arthroplasty across the frailty spectrum. 

Branavan Rudran, Christopher Little, Antony Palmer, Alberto Carli, Andrew Judge, Andrew Price, Abtin Alvand 

Oxford University, Oxford, United Kingdom. HSS, New York, USA. Bristol University, Bristol, United Kingdom 

Abstract 

GLP-1 receptor agonists (GLP-1a) promote weight loss and improve glycaemic control. This study assessed the impact of GLP-1a treatment on complications following hip and knee arthroplasty. 

A PRISMA-compliant systematic review included studies reporting outcomes following primary total hip (THA) or knee arthroplasty (TKA) in patients prescribed GLP-1a for type 2 diabetes or weight management. The primary outcome was 90-day surgical complications (periprosthetic joint infection, wound dehiscence, periprosthetic fracture, haematoma, nerve injury, and surgical site infection). Secondary outcomes included medical complications, readmission, revision, healthcare costs, and length of stay. 

Seventy-eight articles were reviewed, with ten matched cohort studies (96,356 patients; 30,350 hips and 66,606 knees). Mean age was 61.9 years, 60.3% female. Two studies had serious risk of overall bias and eight a moderate risk. The confidence of evidence as per GRADE was very low for all bar one outcome measures (healthcare cost: moderate). The rate of 90-day surgical complications was lower in the GLP-1a group: pooled risk ratio (RR) 0.73 (95% CI: 0.6-0.87). GLP-1a lowered 90-day medical complications and re-admission rates: RR 0.78 (95% CI: 0.63-0.96) and RR 0.79 (95% CI: 0.70-0.90) (I2 = 61.6%). Subgroup analysis demonstrated a stronger association in the THA cohort, where GLP-1a use was associated with lower rates of 90-day surgical complications (RR 0.63, 95% CI 0.48–0.83), 90-day medical complications (RR 0.55, 95% CI 0.44–0.68), and 90-day readmissions (RR 0.82, 95% CI 0.71–0.95). In contrast, in the TKA cohort, GLP-1a use was only associated with a lower 90-day readmission rate (RR 0.77, 95% CI 0.61–0.99). 

GLP-1a treatment prior to THA and TKA potentially reduces 90-day surgical complication, 90-day medical complication and 90-day readmission rates within higher-risk diabetic and obese populations. In addition to potential clinical benefit, adoption of GLP-1a may lead to substantial cost savings for healthcare systems. 

Sanket Dilip Gandhi, Chiyelu Menakaya, Lee David, Syed Ahmed 

Maidstone and Tunbridge Wells NHS Trust, Maidstone, United Kingdom 

Abstract 

Background 
Patients undergoing primary hip and knee arthroplasty have traditionally undergone Group and Save testing at pre-operative assessment and again on the day of surgery. However, modern arthroplasty practice, including pre-operative haemoglobin optimisation, tranexamic acid, meticulous haemostasis, electrocautery, minimally invasive techniques and enhanced recovery anaesthesia, has markedly reduced peri-operative transfusion requirements. Repeated routine testing may therefore represent avoidable duplication, increasing laboratory workload, phlebotomy demand, same-day surgical delays and cost. 

Methods 
A revised protocol was introduced whereby routine Group and Save testing was undertaken at pre-operative assessment rather than repeated automatically on the day of surgery. This enabled early identification of atypical antibodies and timely cross-matching where required. Routine day-of-surgery Group and Save testing was discontinued for non-anaemic, low-risk primary arthroplasty patients with a valid sample and/or confirmed historical blood group, while repeat testing remained mandatory for patients with anaemia, atypical antibodies, expired samples, no confirmed historical group, complex surgery or clinical concern. 

Results 
For approximately 1160 primary joint replacements performed annually at our centre, this eliminated up to 1160 routine day-of-surgery samples. Using an estimated cost of £25 per Group and Save sample, this equates to a local annual saving of approximately £29,000, excluding additional savings. No adverse events related to transfusion readiness. The pathway also improved operational efficiency by reducing unnecessary same-day testing and allowing earlier identification of patients requiring complex cross-matching. 

National Implications 
Based on approximately 251,000 primary hip and knee arthroplasty procedures performed annually, this represents a potential annual saving of approximately £3.5 million using a conservative UK median cost of £13.80 per sample. 

Conclusion 
A risk-stratified Group and Save protocol for primary arthroplasty safely reduces duplicate testing, preserves transfusion readiness and improves peri-operative efficiency. National implementation across primary hip and knee arthroplasty pathways could save the NHS several million pounds annually without compromising patient safety.

Amir Khan, Bob Handley, William Gray, Tim Briggs, Howard Cottam, Ashike Choudhury 

Medway Maritime Hospital, Gillingham, United Kingdom. Getting It Right First Time programme, London, United Kingdom 

Abstract 

Background
Fragility fracture is caused by low energy falls from standing height. Half a million fragility fractures are reported in UK annually. Traditionally hip fractures have been the focus of standardised care. In May 2024, GIRFT programme published Non-ambulatory fragility fracture (NAFF) pathway highlighting care needs in other fragility fractures. Humeral fractures are third most common fragility fractures with1 in 5 emergency presentations results in admission. Our aim was to explore outcomes in Humeral fracture patients, and variation in outcomes across providers and factors associated with poorer outcomes. 

Methods
Exploratory retrospective analysis of observational data from the Hospital Episode Statistics (HES) dataset for England. All patients aged ≥ 65 years admitted as emergencies with a fractured humerus between 1st April 2021 and 31st March 2025 were identified. The outcomes of interest were predictors of length of stay, variability across admission specialities and all England Hospital sites. one year mortality. 

Results
Total 44153 admission in 119 NHS Trust met the inclusion criteria. Median LOS was 7 days and 48% of patients stayed above median. Patients staying above median were older, frailer with more comorbid. 17% had surgical treatment. These patients were admitted under multiple specialties, highest number in trauma & orthopaedics followed by Geriatric and Internal medicine. Trauma and orthopaedics patients were discharged quicker than any other speciality. Across Hospitals, percentage of patients staying longer drops below average as number of admissions increase. one year mortality was 13.1% and 26% in above and below median length of stay groups. 

Discussion
Hospital length of stay is a significant driver of cost. Humeral Fractures are second highest requiring hospital admissions. The findings of this study highlight the patient population Similar to hip fracture patients. The variation observed across specialities and hospital sites suggests the need for standardised orthogeriatric led care pathways. 

Benjamin Dean, Oxford ScaphoidStudyGroup 

Oxford University Hospitals, Oxford, United Kingdom 

Abstract 

Introduction 
We aimed to describe the risk factors for both scaphoid fracture and traumatic pathology in a cohort of patients undergoing early MRI following acute wrist injury. 

Methods 
We conducted a single centre cohort study of suspected scaphoid fracture patients undergoing early MRI over a five year period. Data were gathered prospectively. Two outcomes were considered: 1) risk of scaphoid fracture, 2) risk of any traumatic pathology. The primary outcome of the study was risk of scaphoid fracture. Descriptive and regression analyses were performed. 

Results 
A total of 2487 patients underwent acute MRI over the 5 year period, of which 389 (15.6%) had a scaphoid fracture and 1520 (61.1%) had traumatic pathology.  Scaphoid non-union developed in 8 patients who were all younger males.  Age had a quadratic relationship with the risk of scaphoid fracture, with the risk highest in the youngest patients (age 12 and above) and reduced with increasing age. Male patients had a two fold higher risk than female patients for the risk of scaphoid fracture (OR 2.24 (95% CII: 1.65, 3.04)). When patients presented to emergency department delayed by one day from the time of their injury the odds of risk of scaphoid fracture occurring increases by 2%, (OR 1.02; 95% CI: 1.01, 1.04).  The effect of age on the risk of traumatic pathology was non-linear and quadratic, showing a clear bimodal distribution.  Male patients had a 1.77 higher risk than female patients for the risk of traumatic pathology (OR 1.77 (95% CI: 1.27, 2.47)). 

Conclusions 
The risk of having a scaphoid fracture is significantly higher in younger patients and in males.  These results reinforce having a particularly high index of suspicion for scaphoid fractures in young males as the incidence of scaphoid fracture is high and all non-unions occurred in this group. 

Amy Fuller, Sandeep Deshmukh, Paul Leighton, Hayley Babington, Christina Jerosch-Herold, Alexia Karantana 

University of Nottingham, Nottingham, United Kingdom. Nottingham University Hospitals, Nottingham, United Kingdom. Patient and Public Involvement collaborator, Norwich, United Kingdom. University of East Anglia, Norwich, United Kingdom 

Abstract 

Background 
There is need for high-quality evidence to improve flexor tendon injury (FTI) treatment, but no consensus on which outcomes to measure. A core outcome set (COS), an agreed minimum set of outcomes developed with input from clinicians and patients, can address this gap. This study developed a COS for FTI of the hand in adults. 

Methods 
A longlist of potential outcome domains was identified through systematic review of published studies, and content analysis of patient interviews exploring injury, treatment and recovery experiences. The longlist was entered into a three-round online Delphi survey where patients, hand surgeons and hand therapists prioritised outcome domains. The final COS was agreed in a multi-stakeholder consensus meeting involving group discussion and individual voting. 

 Results 
The systematic review of 91 studies and interviews with 19 patients resulted in a longlist of 26 outcome domains. This informed the Delphi, which had 80 participants (20 patients, 36 surgeons, 24 therapists). 19 outcome domains were rated as ‘highly important' for the COS. At the consensus meeting, 18 participants (8 patients, 5 surgeons, 5 therapists) put forward ten outcomes for the COS. Based on discussions and voting, these were categorised into two tiers. 

Tier one includes the mandatory outcomes to be measured in all FTI studies: ability to perform tasks of daily living, pain, patient satisfaction, hand/wrist movement, grip strength, returning to preferred work or study, and impact of injury on mental health, emotional and social wellbeing. Tier two includes outcomes to collect where relevant to the study question: numbness, dexterity, and complications. 

 Conclusion / Implication 
Adopting this patient-centred COS will standardise outcomes to measure and report in clinical research on FTI in adults, improve evidence synthesis, and strengthen the evidence base to improve FTI management. Work is ongoing to select outcome measurement tools for the COS. 

Amy Fuller, Alexander Kennedy, Jane Harvey, Justine Bullock, Sandeep Deshmukh, Paul Leighton, Christina Jerosch-Herold, Alexia Karantana 

University of Nottingham, Nottingham, United Kingdom. 2Nottingham University Hospitals, Nottingham, United Kingdom. 3University of East Anglia, Norwich, United Kingdom 

Abstract 

Background
Flexor tendon injuries (FTI) account for 15-20% of all hand trauma, with patients requiring prompt specialist surgical repair and at least 12 weeks of outpatient rehabilitation. Approximately 25% of patients have poor outcomes from rupture or scarring, risking lifelong disability. Despite the burden of this injury, there are no studies exploring patient experiences and priorities during treatment. This study aimed to address this gap. 

Methods
As part of the HAFTI-COS project, which developed a core outcome set (COS) for FTI in adults, FTI patients were recruited from a large trauma centre in East Midlands, UK and invited to take part in a one-to-one, semi-structured interview exploring their experience of injury, treatment and recovery. Interviews were conducted remotely by two experienced qualitative researchers not involved in the clinical care of patients, digitally audio-recorded and transcribed verbatim. 

While the primary objective was to generate outcome domains towards the COS, a secondary, inductive thematic analysis following the steps of Braun & Clarke (2006), was undertaken to explore patients lived experience and priorities in FTI recovery. 

Results
19 interviews were conducted. Participants were predominantly males (n=15) of working age. The time from injury ranged between one and 12 months. Participants reported functional, occupational and psychological challenges throughout recovery. Many initially underestimated their injury and reported feeling insufficiently informed about what treatment and recovery entailed until the rehabilitation phase of treatment began. Most prioritised an early return to normal function over optimal hand function to allow a return to normality. 

Conclusions
Improvements in perioperative communication methods could streamline the transition from surgery to rehabilitation, address patients’ underestimation of injury severity earlier on in recovery and alleviate uncertainty during treatment. Clinicians should prioritise patient-defined outcomes such as restoring hand function to boost engagement with recovery. 

Benjamin Sephton, Sinead Cabezon, Mike Woodruff 

Royal Preston Hospital, Preston, United Kingdom 

Abstract 

Background
This project was undertaken in a Level 1 Major Trauma Centre serving 1.5 million people. National guidance including Getting It Right First Time (GIRFT), British Orthopaedic Association Standards for Trauma (BOAST) and British Society for Surgery of the Hand (BSSH) Standards highlight the importance of timely, standardised hand trauma care. However, hand and wrist trauma is under-prioritised with variable referral quality and fragmented pathways. Locally, delays and poor-quality referrals to the Virtual Fracture Clinic (VFC) were identified. The aim was to improve the quality and timeliness of hand trauma referrals. 

Methods/Intervention
This project formed part of the national HandFirst2 quality improvement initiative. Six Plan–Do–Study–Act (PDSA) cycles were completed over 18 months. Three meetings involving Accident and Emergency clinicians, orthopaedic surgeons, fracture clinic nurses and administrative staff held to map the referral pathway, identify bottlenecks and co-design solutions. A digital referral platform was introduced due to compatibility with existing systems, familiarity among referrers and no additional cost. Changes were refined using feedback from referrers, reviewing consultants and VFC nurses. 

Results
Median time from patient presentation to VFC referral improved from 16 to 7 hours, inappropriate referrals reduced from 25% to 0%, clinical information provided improved from 71.4% to 100% and presentation to VFC assessment improved from 36 hours to 25 hours. Administrative efficiencies saved 17 hours per week and £17,000 per annum. 

Discussion/Conclusion
The success of this intervention was driven by multidisciplinary engagement and iterative refinement before implementation. 
The referral pathway improved the speed, quality and appropriateness of hand trauma referrals. This scalable model has potential for wider adoption to improve compliance with national standards and patient outcomes. 

Nicole Lyons, Shannon Halmkan, Victoria Jansen, Nick Johnson, Emma Reay, Ellie Fitzmaurice, Maise Wilding, Antonina Yakimova, Joy Adamson 

South Tees NHSFT, Middlesbrough, United Kingdom. University of York, York, United Kingdom. Pulvertaft Hand Centre, Derby, United Kingdom 

Abstract 

Aims
The thumb carpometacarpal joint replacement is gaining popularity for the surgical management of thumb base osteoarthritis in the UK. However, there is considerable variability in the literature regarding postoperative management with limited information on timescales for return to normal function. This study aims to develop consensus-based recommendations for postoperative best practice. 

Methods 
A three-round modified Delphi process was conducted involving 16 experienced hand surgeons and hand therapists from the UK and mainland Europe. The initial survey was informed by a comprehensive literature review and input from a patient and public involvement group. The second round was an interation of the first, including refinement of themes into statements. The third round presented the recommendations for overall agreement and comment. Consensus throughout was defined as ≥70% agreement. 

Results 
In round one, consensus was reached on postoperative immediate protection duration of 10–14 days and the need for a postoperative radiograph. In round two, agreement was achieved for 7 out of 10 statements that included the type of immediate postoperative protection to be a bulky bandage allowing restricted thumb movement, splinting practices, thumb full range of movement commencement and a return to driving timescale of four weeks. Return to timescales of light (two weeks), moderate (four weeks) and heavy tasks (6–8 weeks) were further defined in round three and accepted by the participants. 

Conclusion 
This Delphi study established consensus-based recommendations for best practice in the postoperative management of thumb CMCJR, with specific inclusion of timescales for return to normal function. This will be beneficial for clinics, particularly in the UK, that are newly adopting this technique. Recommendations regarding the timing and frequency of postoperative radiographs remain to be clearly defined. 

Amit Atrey1, Amir Khoshbin1, Mike Reed2, Michael Whitehouse3 

1University of Toronto, Toronto, Canada. 2Northumbria Health, Newcastle, United Kingdom. 3University of Bristol, Bristol, United Kingdom 

Abstract 
Total hip arthroplasty (THA) is a successful operation that aims to restore function and quality of life to millions globally. Knowing how long a THA may survive is important for patients, surgeons, and healthcare institutions for planning and resource allocation. Over the last 20 years, the use of contemporary THA bearing surfaces has significantly altered implant wear and possibly, longevity. Yet, to date, there has been no large-scale study that examines survivorship of these modern-day implants. The aim of this study is to determine the survivorship of contemporary THAs and bearing materials. 

Methods
This is a three-part study, focused solely on assessment of modern-day bearing surfaces: highly cross-linked polyethylene (XLPE) against metal or third- and fourth-generation ceramic heads and ceramic-on-ceramic primary THA in adult patients. 

First, a systematic review and meta-analysis with a search of Medline and Embase from database inception to June 13, 2024 with a minimum of 10 years of survivorship. Second, a meta-analysis combining data from eight National Joint Registries assessing all-cause revision within the various bearing combinations. The third element is extrapolation of the extracted data to estimate survivorship to 30 years. 

Results
1,522 studies were screened and 29 included, yielding 5,203 patients from randomised controlled trials, case-series, and cohort studies. Data from eight national joint registries yielded 1.89million THAs. At 15 years, the literature synthesis indicated a mean survivorship of between 96% to 97% and the Joint Registries’ data indicated overall survivorship of 93% at 20 years. Extrapolating this data indicates a predicted survivorship of 92% at 25 years and 91% at 30 years. 

Conclusions
The estimated 92% 25-year survivorship of contemporary THA contrasts with prior reports of 57%. This suggests substantially higher longevity and may influence patient counseling, healthcare planning, and device regulation.  

Implications
HIp arthroplasty has even greater longevity than first assumed.

Amit Atrey, Amir Khoshbin 

University of Toronto, Toronto, Canada 

Abstract 

Background 
Ceramic femoral heads are increasingly used in total hip arthroplasty (THA), driven by reduced polyethylene wear and concerns regarding mechanically assisted crevice corrosion. However, ceramic heads are more expensive than cobalt–chromium heads, and long-term registry data suggest minimal differences in revision rates between bearing types. The economic impact of widespread ceramic head use in publicly funded healthcare systems remains uncertain. 

Methods 
A cost-effectiveness and budget-impact analysis was performed using a Markov model informed by multinational registry survivorship data. Twenty-year implant survivorship of 93.8% for ceramic heads and 93.4% for metal heads was used in the base case. Implant and revision costs were obtained from published sources and national tariffs. Budget-impact analyses were conducted across four healthcare systems: the National Health Service (UK), publicly funded arthroplasty in the United States (Medicare/Medicaid), Australia (Medicare-funded care), and a large integrated healthcare system in the United States. Sensitivity analyses explored variation in implant cost differentials and revision rates. 

Results 
Ceramic heads were not cost-effective in the base-case model because revision rates were similar between bearing types. Incremental implant costs were estimated at £250–£350 per case in the UK, US$300–500 in the United States, and A$400–700 in Australia. 

Estimated annual budget impact attributable to ceramic head use was approximately £30–40 million in the UK, US$180–220 million in publicly funded arthroplasty in the United States, and A$25–35 million in Australia. Threshold analysis suggested that a reduction in revision risk of approximately 1–2% would be required for ceramic heads to become cost-neutral at a population level. 

Conclusion 
Without diceranable clinical benefits at a population level, the increased cost of ceramic heads in THA does not justify their use; especially in a state-funded system.

Rahul Senan, Prerna Kartik, Faizal Rayan, Pip Dhilon, Teresa Howard, Sayyied Kirmani, Srinivasan Shyamsundar 

Kettering General Hospital NHS Foundation Trust, Kettering, United Kingdom 

Abstract 

Background
Prompt surgery for fragility hip fractures is a cornerstone of care and a key metric within the Best Practice Tariff (BPT) in the United Kingdom. Yet, since 2020, time to theatre has steadily increased, BPT adherence has fallen, and paradoxically, mortality has reduced. Emerging evidence suggests that the causes of surgical delays on mortality may be more important predictors of mortality than the delay itself. 

Methods
A cohort study of 1,769 hip fracture patients above the age of 60 was conducted in a single centre in England. This study collected demographic data, timing to theatre (<36 hours vs ≥36 hours), reasons for any delays, 30-day mortality and 1-year mortality between March 2020 and December 2024. 

Results
The most common cause of delay was insufficient theatre capacity (N=365, 20.6%), followed by delays awaiting medical stabilisation (N=102, 5.8%). Age (Χ2 71.638 p<0.001), ASA grade (Χ2 37.045 p<0.001), sex (Χ2 27.721 p<0.001), pre-admission residence (Χ2 36.772 p<0.001), and reason for delay (Χ2 27.495 p=0.007) were significant predictors of mortality. Delays due solely because of theatre unavailability did not increase 30-day (OR 0.784 p=0.398) or 1-year mortality (OR 1.123 p=0.474). In contrast, delays due to medical optimisation were associated with markedly higher 30-day (OR 3.573, p<0.001) and 1-year mortality (OR 2.144, p=0.005). 

Conclusions
While early surgery remains beneficial, patients delayed solely due to administrative reasons did not demonstrate an associated increase in mortality. Mortality associated with operative delay was primarily associated amongst patients with concurrent acute illnesses and co-morbidities, independently increasing risk. To improve mortality, the focus must remain on pre-operative optimisation and robust orthogeriatric assessment, rather than surgical timing alone. Future iterations of the BPT may benefit from incorporating the cause of delay and physiological risk stratification to surgical timing targets to better align national incentives with clinical outcomes. 

Ibrahim Haq1,2, Nahid Ahmad3, Ajay Malviya4, Vikas Khanduja1,5 

University of Cambridge, Cambridge, United Kingdom. East Midlands South, Leicester, United Kingdom. James Lind Alliance, Southampton, United Kingdom. Northumbria Healthcare NHS Foundation, Northumbria, United Kingdom. Addenbrookes Hospital, Cambridge, United Kingdom 

Abstract 

Introduction
Young adults with hip pain represent an underserved population who frequently experience delays in diagnosis and treatment. Non-arthritic hip conditions, including femoroacetabular impingement, acetabular dysplasia, and labral pathology, can lead to chronic pain, functional limitation, and early degenerative joint disease. Despite advances in management, significant uncertainties remain regarding optimal diagnostic pathways, treatment strategies, and healthcare delivery, particularly within the UK. 

Methods
A UK-based Priority Setting Partnership was conducted using the methodology of the James Lind Alliance in collaboration with the British Hip Society. A multidisciplinary steering group, including clinicians and patient representatives, oversaw the process. A national UK survey collected research uncertainties from patients, carers, and healthcare professionals across all aspects of care. Responses were reviewed and thematically categorised into summary research questions. These underwent evidence checking, interim prioritisation through a second national survey, and final ranking during an in- person consensus workshop. 

Results
A total of 208 eligible UK survey responses generated 1,089 unique research questions. Following thematic analysis and removal of duplicate or out-of-scope submissions, these were consolidated into approximately 50 summary questions. Subsequent stakeholder prioritisation and structured consensus discussion culminated in the establishment of the final top ten research priorities. 

Conclusions
The identified UK 'top ten' research priorities provide a consensus-driven framework to guide future research. While developed within the UK healthcare context, these priorities have international relevance and may support funding allocation, study design, and collaborative research efforts to improve outcomes for young adults with hip pain. 

Diego Abelleyra Lastoria, Ashton Hunt, Ahsan Iftikhar, Hussayn Shinwari, Sophie Keynes, Caroline Hing 

City St George's, University of London, London, United Kingdom 

Abstract 

Background
There is limited evidence on the effects of malnutrition and obesity on trauma and orthopaedic surgery outcomes. We aimed to determine whether obesity and malnutrition have a synergistic effect on hip fracture outcomes. 

Methods
We included all patients admitted with a hip fracture to a major trauma centre from 2016 to 2024. Obesity was defined as BMI > 30 kg/m2, whereas patients with an albumin < 35 g/l were deemed malnourished. Patients were categorised into four groups: 1) non-obese non- malnourished, 2) non-obese malnourished, 3) obese malnourished, and 4) obese non-malnourished patients. Hospital length of stay, in-hospital mortality, and complication rates were compared between groups. All statistical analyses were conducted with IBM SPSS Statistics Version 31.0. 

Results
A total of 921 patients were included (62.9% female), with a mean age of 78.9 (standard deviation [SD] 14.5 years). Non-obese malnourished patients had an inpatient mortality of 9.7%, which was greater than the mortality among non-obese non-malnourished patients (3.4%) (p = 0.006). Non-obese malnourished patients had a longer hospital length of stay than non-obese non-malnourished patients (25.2 vs 19.9 days, p = 0.001) and obese non-malnourished patients (25.2 vs 16.8 days, p = 0.014). Obese malnourished patients had a longer length of stay than obese non-malnourished patients (33.1 vs 16.8 days, p = 0.017). Obese malnourished patients had higher rates of wound infections than non-obese non- malnourished (16.2% vs 1.6%, p = 0.006) and non-obese malnourished patients (16.2% vs 3.0%, p = 0.012). 

Conclusion
Combined malnutrition and obesity have a synergistic effect and lead to increased wound infection rates in hip fracture patients. Malnutrition is a greater determinant of inpatient mortality and length of stay than obesity. Appropriate preoperative optimisation and postoperative care are required to improve outcomes in this group of patients. 

Disclosure: none. 

Victor Omaonu1, Sathya Lakpriya1, Muhammad Tahir2, Evangelos Solovos1, Ali Adeeb Ilyas3, Todd Pierce4 

1East Kent University NHS Hospitals Foundation Trust, Margate, United Kingdom. 2University Hospitals North Midlands Trsut, Stoke-on-Trent, United Kingdom. 3Arrowe Park Hospital, Wirral, United Kingdom. 4University Pittsburg Medical Centre, Maryland, USA 

Abstract 

Background
Antibiotic-impregnated cement (AIC) is widely used in primary total knee arthroplasty (TKA) to prevent prosthetic joint infection (PJI), despite conflicting evidence. In an era of antimicrobial stewardship and cost-conscious care, its routine use warrants critical re-evaluation. 

Methods
A systematic review and meta-analysis were conducted in accordance with PRISMA guidelines. Four databases (PubMed, EMBASE, CINAHL, SCOPUS) were searched (2014–2025). Comparative studies of AIC versus plain cement in primary TKA with ≤2-year follow-up were included. Outcomes were pooled using fixed and random effects models. Heterogeneity (I²) and publication bias (Egger’s test) were assessed. 

Results
Eleven studies encompassing 3,656,194 TKAs were analysed. Fixed-effects modelling suggested a lower PJI risk with plain cement (RR 0.91, 95% CI 0.88–0.95; p<0.001), whereas random-effects analysis demonstrated no significant difference (RR 0.96, 95% CI 0.76–1.23; p=0.77). Subgroup analysis revealed inconsistent differences in age and BMI, with no difference in PJI risk between cohorts. High heterogeneity was observed across studies without evidence of publication bias. 

Conclusion
In one of the largest analyses to date, AIC does not confer a consistent reduction in short-term PJI risk following primary TKA. These findings challenge a deeply embedded practice and suggest that perceived benefit may reflect patient selection rather than true efficacy. Routine use of AIC should be reconsidered in favour of a targeted, risk-stratified approach. This work supports a shift from tradition-driven practice toward evidence-based, value-conscious arthroplasty care. 

Sheng-Chieh Lo1, Matilda Money1, Taushaba Hossain2, Edward Lindisfarne3, Alexander Aarvold1 

University of Southampton, Southampton, United Kingdom. NHS West Midlands, Birmingham, United Kingdom. University Hospitals Southampton, Southampton, United Kingdom 

Abstract 

Background 
Early Pavlik harness treatment for developmental dysplasia of the hip (DDH) has success rates of >90%. However, a subset of patients can develop residual acetabular dysplasia (RAD) and hip instability despite initial restoration of a congruent joint. RAD can result in early-onset arthritis, and optimal management in infancy remains unclear. Capsulorrhaphy combined with growth-stimulating minimal acetabuloplasty and spica (CAS) is proposed as a simpler, less invasive alternative to all existing procedures, developed and performed at Southampton Children's Hospital since 2008. 

Methods 
A prospective analysis was conducted on infants undergoing CAS at the initiating centre, with a minimum of ≥3 years follow-up and aged ≥5 years at final follow-up to enable reliable Severin classification and detect late complications. Teratological dislocations were excluded. Radiographic outcomes were assessed using acetabular index (AI), lateral centre-edge angle (LCEA) and Severin classification, with comparison to normal contralateral hips. All assessments were conducted by a minimum of 2 independent observers. Clinical outcomes were assessed using modified McKay criteria. 

Results 
Between 2008-2023, 68 hips in 62 patients underwent CAS. Mean age at surgery was 19.3 months (range 10-32) with a mean post-operative follow-up of 9.2 years (range 3-14). Post-operatively, CAS-treated AI values showed convergence to the normal contralateral hip by ~2 years. At final follow-up, mean AI (11.2° vs 11.9°, p=0.368) and LCEA (31.3° vs 30.2°, p=0.455) were comparable between treated and normal hips. Final Severin grade was excellent (i.e. normal morphology) in 98.5% of hips, with one hip being good. Clinically, all hips achieved Modified McKay outcomes of excellent or good. One postoperative infection occurred and resolved with antibiotics. 

Conclusion 
CAS is a safe and effective surgical technique for managing RAD in DDH. It is a simpler procedure than all existing surgical strategies and demonstrates excellent long-term outcomes, supporting its broader adoption into routine practice. 

Benjamin Zucker1, Joshua Howard2, Michael Whitehouse1,3, Andrew Judge1,3,4 

Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, BRISTOL, United Kingdom. Great Western Hospital, Great Western Hospitals NHS Foundation Trust, Swindon, United Kingdom. National Institute for Health Research Biomedical Research Centre at University Hospitals Bristol and Weston NHS Foundation Trust and the University of Bristol, BRISTOL, United Kingdom. 44. Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Nuffield Orthopaedic Centre, University of Oxford, Oxford, United Kingdom 

Abstract 

Background
Dual mobility total hip replacement (DMTHR) reduces dislocation risk but has been associated with increased periprosthetic fracture risk. Marked variation in DMTHR use across surgeons and institutions suggests that implant selection may be driven by practice patterns rather than patient need. This programme of research aimed to: (1) quantify sources of variation in DMTHR use; (2) develop a validated dislocation risk prediction model; (3) estimate the effectiveness of DMTHR and assess whether its use is appropriately targeted; and (4) determine whether frailty explains the association between DMTHR and periprosthetic fracture. 

Methods
Four studies were conducted using National Joint Registry data linked to Hospital Episode Statistics (2003–2022; up to 863,615 primary THRs). Multilevel modelling partitioned variation in DMTHR use across patient, surgeon, and institutional levels. A penalised Cox regression model was developed and validated to predict five-year revision for dislocation. Propensity score matching estimated the effect of DMTHR on revision for dislocation across risk-stratified subgroups. Mediation analysis assessed whether frailty explains the observed association between DMTHR and periprosthetic fracture. 

Results
Surgeon and institutional factors accounted for 55% of variation in DMTHR use; patient factors explained only 10%. The prediction model achieved excellent calibration (slope 0.976) with moderate discrimination (C-statistic 0.664). DMTHR halved revision for dislocation (HR 0.44, 95% CI 0.31–0.63) with no increase in all-cause revision (HR 1.00, 95% CI 0.87–1.14). Among DMTHR-using surgeons, 89% appropriately targeted high-risk patients; however, 61% never used DMTHR. DMTHR was independently associated with increased fracture revision (adjusted OR 1.67, 95% CI 1.25–2.21), not explained by patient frailty. 

Conclusions
DMTHR is effective but carries a trade-off with periprosthetic fracture risk independent of frailty. Most variation in use reflects surgeon adoption rather than patient selection. Implementation of risk prediction tools could support risk-stratified DMTHR selection and reduce unwarranted practice variation. 

Disclosure: NA 

Josh Lamb1,2, TIm Board1, Anil Gambhir1, Adrian Sayers2, Jonathan Evans3, Michael Whitehouse2 

Wrightington Hospital, Apley Bridge, United Kingdom. University of Bristol, Bristol, United Kingdom. University of Exeter, Exeter, United Kingdom 

Abstract 

Background 
Revision arthroplasty is universally employed as the failure endpoint in national total knee replacement (THR) surveillance, and results are used to evaluate surgeons, implants and healthcare providers. Non-revision reoperations represent significant patient events but are excluded from revision-only analyses. The aim of this study was to explore all first reoperation events after primary THR in a large national cohort. 

Methods 
A retrospective cohort study was conducted using Hospital Episode Statistics (HES) inpatient data from National Health Service (NHS) hospitals in England from 2003 to 2023. Primary THR procedures and all post-primary events were identified using OPCS-4 procedure codes; ICD-10 diagnosis codes were applied to confirm or sub-classify indication where available. Kaplan-Meier analysis was performed to compare time-to-event distributions between endpoints. 

Results 
Of 1,379,155 primary THAs, the revision-only endpoint captured 48,782 failures (3.5%), while the any-reoperation endpoint captured 65,653 (4.8%), a relative increase of 34.6%. A total of 16,871 THAs (1.2%) underwent a non-revision reoperation without subsequent revision, with a further 3,328 (0.2%) having a non-revision reoperation preceding revision. Median pre-revision interval following non-revision reoperation was 0.6 years (IQR 0.3–1.6). Relative to revision operations, non-revision reoperations have become more frequently performed year on year. The 10-year cumulative incidence of failure was 3.35% under revision-only and 4.52% under the any-reoperation endpoint (absolute difference 1.17 percentage points). All post-primary episodes by indication (revision and non-revision combined): mechanical complication 35,124 (2.52%), periprosthetic fracture 19,971 (1.43%), infection 13,968 (1.00%), instability/dislocation 9,562 (0.69%), unknown/other 4,434 (0.32%). 

Conclusion 
Revision-only surveillance captured approximately two-thirds of all reoperations after primary hip arthroplasty. The most common missed indications were periprosthetic fracture fixation and closed reduction of prosthetic dislocation. An any-reoperation endpoint is recommended for THR failure surveillance. 

Amr Selim1,2, Abdelrahman Ibrahim3, Abu Saeed1, Khadija Khamdan3, Muhamed M. Farhan-Alanie4,5, Salman Sadiq1, Siddharth Govilkar3, Geraint Thomas1,2 

Robert Jones and Agnes Hunt Orthopaedic Hospital, Oswestry, United Kingdom. School of Medicine, Keele University, Staffordshire, United Kingdom. University Hospital of North Midlands, Stoke-on-Trent, United Kingdom. University Hospitals Coventry and Warwickshire, Coventry, United Kingdom. University of Warwick, Warwick Medical School, Coventry, United Kingdom 

Abstract 

Introduction 
Periprosthetic joint infection (PJI) remains a devastating complication following total hip and knee arthroplasty. Revision strategies for chronic PJI include one-stage, 1.5-stage, and two-stage revision procedures. This study aimed to compare clinical outcomes of these revision strategies using a network meta-analytic approach. 

Methods 

A systematic review and Bayesian network meta-analysis were conducted in accordance with PRISMA-NMA guidelines and registered on PROSPERO (CRD420251159520). Databases were searched through October 2025. Randomized controlled trials and comparative cohort studies evaluating one-stage, 1.5-stage, and two-stage revision procedures for hip and knee PJI were included. Outcomes assessed were reinfection, infection control success, reoperation, readmission, aseptic loosening, and overall complications. Pairwise frequentist random-effects meta-analyses and Bayesian hierarchical models were performed. 

Results 
Fifty-four studies comprising 10,055 patients were included. Compared with two-stage revision, both one-stage and 1.5-stage revisions were associated with significantly lower odds of reinfection (OR=0.84, 95% CrI 0.72–0.99 and OR=0.58, 95% CrI 0.37–0.89, respectively) and reoperation (OR=0.79, 95% CrI 0.63–0.99 and OR=0.20, 95% CrI 0.05–0.82, respectively). The 1.5-stage strategy demonstrated significantly higher infection control success (OR=1.64, 95% CrI 1.07–2.51). One-stage revision was associated with fewer overall complications (OR=0.64, 95% CrI 0.48–0.86). The 1.5-stage strategy showed a significantly increased risk of aseptic loosening (OR=4.80, 95% CrI 1.57–20.79), while two-stage revision demonstrated the most favourable performance for this outcome. SUCRA rankings identified the 1.5-stage revision as the highest-ranked strategy for reinfection, reoperation, and infection control success, whereas two-stage revision ranked highest for aseptic loosening. Findings were consistent across hip and knee subgroup analyses. 

Conclusion 
The 1.5-stage revision showed the most favourable performance for infection-related outcomes, but was associated with higher rates of aseptic loosening. One-stage revision demonstrated intermediate performance with lower aseptic loosening, while two-stage revision was inferior for most infection-related outcomes but showed the lowest risk of aseptic loosening. 

Deepak Menon1,2, Smitha Mathew1, Jiacheng Cai1, Geraint Thomas1,2, Dahai Yu1 

Keele University, Keele, United Kingdom. The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust, Oswestry, United Kingdom 

Abstract 

Background 
Social determinants of health may affect hip osteoarthritis disease burden. Systemic variations exist in musculoskeletal pain treatment and access to joint replacement. However, evidence exploring socioeconomic inequalities in long-term longitudinal care pathways prior to total hip replacement (THR) remains limited. 

Methods 
A population-based retrospective case-control study was undertaken using the primary care CPRD Aurum database linked to secondary care HES APC data. 239,564 individuals undergoing primary THR between 2007 and 2021 in England were matched 1:1 by age, sex and practice to controls. Socioeconomic deprivation was defined by Index of Multiple Deprivation (IMD) deciles. Adjusted slope index of inequality (SII) estimated the absolute difference in prevalence of pharmacological and non-pharmacological care strategies between most and least deprived groups in yearly intervals over ten years prior to index date, adjusted for demographics, BMI, co-morbidities and index year. 

Results
Absolute socioeconomic inequality was present within all time periods for analgesic prescriptions (NSAIDs, paracetamol, opioids), most related medication prescriptions (antidepressants, antiepileptics and systemic corticosteroids) and specific non-pharmacological care strategies (GP visits, sick leave and physiotherapy referral). Prevalence was generally higher in more deprived areas. Exceptions included oral NSAIDs one-year pre-THR (SII -1.5% [95% CI -2.4,-0.6]) and physiotherapy referrals within all time periods ten years before surgery. Absolute inequality was greatest for strong opioids (SII 6.8% [95% CI 6.0, 7.5]) and antidepressants (SII 5.2% [95% CI 4.5, 5.9]) in the 0-to-12-month and 108-to-120-month periods, respectively. Disparities between socioeconomic groups persisted or increased over time across most care strategies as surgery approached, with the exception of weak opioids and oral NSAIDs. 

Conclusions 
Socioeconomic status influences the long-term clinical trajectory preceding THR. Individuals from more deprived areas may rely more on high-risk analgesics with lower access to certain non-pharmacological care. Future work should explore drivers of these disparities to promote equitable care.

Joe Dixon1, Tessa Rowlands1, Ben Niddrie-Davies1, Salman Sadiq1, Peter Logan1, Sophie Crooks1, Georgina Laing1, Hidayatul Abdullmalek2, Edmond U1, John Paul Whittaker1 

Robert Jones Agnes Hunt, Oswestry, United Kingdom. Royal Shrewsbury Hospital, Shrewsbury, United Kingdom 

Abstract 

BACKGROUND 
Revision Knee Arthroplasty (RKA) is a complex condition to manage with greater inpatient hospital costs incurred than with primary knee arthroplasty. The RKA networks have been designed to improve outcomes and cost efficiency for these complex procedures.  This study aimed to assess the inpatient hospital costs and associated renumeration of providing a high-volume tertiary RKA service. 

METHODS 
A detailed review of all RKA at Robert Jones Agnes Hunt (RJAH) over the previous three financial years was undertaken. Data collected included indication for surgery, procedure undertaken and Revision Knee Complexity Classification (RKCC). Financial data was acquired through the Patient-Level Information and Costings System, which provides a detailed itemised breakdown of individual costs incurred during a hospital admission episode. The primary aim of the study was to identify if inpatient costs were adequately reimbursed by the Healthcare Resource Group (HRG) Tariff and additional Major Revision Centre funding received. 
 

RESULTS 
463 NHS funded revision knee procedures were performed at RJAH in the financial years 2022-2025. The distribution of complexity was 278,112,75 for RKCC 1, 2 & 3 respectively. 107 (23%) of the revisions were for infection.  The median length of stay was 5 days for non-infected revisions and 18 days for infected revisions. The median deficit was £2,813, £7,057 and £16,507 per RKCC 1,2 and 3 respectively. 

CONCLUSIONS 
The Revision Knee networks mandate centralisation of complexity. This study has demonstrated that increased complexity is associated with increased deficit. The total deficit to the trust from providing a Revision Knee Service was £1,422,564 for the 2022-25 financial years, This study has demonstrated that the current HRG Tariffs do not adequately reimburse inpatient associated costs for providing a Major Revision Centre. 

IMPLICATIONS 
Without amendment to the current funding structures, this financial deficit may threaten the long-term sustainability of high-quality revision knee services. 

Arwel Poacher, Amy Smith, Elliot Kimber, Tariq Yasin, Matthew Larsen, Clare Hughes 

Cardiff University, Cardiff, United Kingdom. Trauma Unit, University Hospital of Wales, Cardiff, United Kingdom 

Abstract 

Background 
Autologous chondrocyte implantation (ACI) is a gold-standard cell-based treatment for symptomatic focal chondral defects larger than 2 cm², but repair quality may be limited by chondrocyte dedifferentiation and fibrocartilaginous matrix formation. Cartilage-derived progenitor cells (CPCs) offer a potential alternative cell source with enhanced proliferative and chondrogenic capacity. This study evaluated whether CPCs improve matrix formation and integration in an ex vivo cartilage defect model. 

Methods 
Disc-ring constructs (n=72) were generated from non-diseased cartilage. Central defects were filled with native cartilage, chondrocyte-seeded agarose or CPC-seeded agarose and cultured for four weeks. Repair tissue integration was assessed histologically using 2B6/DMMB staining. Matrix production was quantified by DMMB assay for glycosaminoglycan (GAG) content and collagen fluorescence imaging. 

Results 
Cartilage-cartilage controls showed limited cellular migration at the defect margin. Chondrocyte-seeded constructs demonstrated poor integration with minimal GAG deposition. By contrast, CPC-seeded constructs showed viable GAG-producing cells, stronger DMMB staining and migration into the wound interface. Quantitative analysis demonstrated significantly higher collagen content in CPC constructs compared with cartilage and chondrocyte controls (p<0.001), with similarly increased GAG content (p<0.01). 

Conclusion/Findings 
In this ex vivo model, CPCs generated a more cartilage-like repair matrix and achieved superior integration compared with chondrocytes. These findings support CPCs as a promising alternative cell source for biological cartilage repair strategies. 

Implications 
CPC-based augmentation may address a key limitation of ACI by improving matrix quality and host-graft integration. Further work should test durability, inflammatory phenotype and translational delivery in clinically representative defect models. 

Disclosure 
None declared. 

Ben Gabbott, Adam Brentnall, Nicole Tang, John Robson, Andrew Price, Xavier Griffin 

Bone and Joint Health, Queen Mary University London, London, United Kingdom. Queen Mary University London, London, United Kingdom. University of Warwick, Warwick, United Kingdom. 4NDORMS, University of Oxford, Oxford, United Kingdom 

Abstract 

Introduction 
Mental health disorders(MHDs) are recognised risk factors for poorer functional outcomes after total knee replacement(TKR). Identifying which patients are greatest risk remains challenging. This is because most studies treat MHD as a crude binary exposure. 

We created a granular linked dataset linking hospital, arthroplasty, PROMs and general-practice(including prescribing) records. This enabled detailed characterisation of MHD related risk factors, and their relationship with post-TKR function, in greater detail than previously achieved. 

Methods 
We conducted a retrospective cohort study of prospectively collected routine data from adults undergoing primary TKR in East London NHS hospitals between 2014-2024. Primary outcome was achieving a minimally clinically important difference(MCID) in Oxford Knee Score(OKS). 

Primary exposures included MHD diagnosis (depression, anxiety, and serious mental illness{SMI}). Secondary exposures included severity (using pharmacological treatment as proxy) and chronicity (defined as time from MHD code to surgery). Confounders included demographic, comorbidity, peri-operative, and prescribing variables. Multivariable regression models were constructed using a data-led, forward stepwise, ANOVA-guided approach, with patients without MHD as the reference group. Multiple imputation was used for sensitivity analysis. 

Results 
We linked 10,005 primary TKRs. Overall, 1905(19%)patients had an active MHD at time of surgery, higher than previously reported. 

Compared with no MHD, SMI was associated with the highest risk of not achieving MCID (aOR 2.63, p=0.02). Depression showed a smaller, non-significant association, while anxiety was not independently associated. Greater MHD severity was also associated with poorer functional outcome, Chronicity inferred no risk. Other key risk factors included ethnicity, pre-operative opioid use and chronic pain. Multiple imputation did not materially alter estimates. MHD was also a risk factor for missing PROMS. 

Discussion 
SMI and greater MHD severity were the main MHD-related predictors of poor function after TKR, providing a target for potential screening/optimisation in stratified operative pathways. 

Luke Granger, Gregory Wernecke, Khashayar Ghadirinejad, Carl Holder, Jil Wood, Ian Harris, Samuel MacDessi 

Sydney Knee Specialists, Sydney, Australia. AOANJRR, Sydney, Australia. University NSW, Sydney, Australia 

Abstract 

Background 
This study assessed rates of imbalance in total knee arthroplasty (TKA) and its effect on patient-reported outcome measures (PROMs), comparing robotic-assisted surgery (RAS) versus computer-assisted surgery (CAS), and functional alignment (FA) versus mechanical alignment (MA). 

Methods 
A pre-specified secondary analysis of the RASKAL trial was performed in 303 patients randomized to RAS or CAS, and FA or MA. Intraoperative compartment loads were measured using a sensor matching the thickness as the final articular insert after any soft-tissue releases. Surgeons were blinded to sensor readings. The primary outcomes included the proportion of TKAs with minor imbalance (intercompartmental (ICPD) 15–40lb) and major imbalance (ICPD>40lb); the frequency of absolute compartmental loads >60lb at any flexion angle; and the proportion of cases with condylar lift-off. Secondary outcomes assessed the effect of imbalance on PROMs from baseline at 3, 6, 12 months and at 2 years. 

Results 
The proportion of TKAs with minor or major imbalance was similar comparing RAS versus CAS, and FA versus MA at 10° and 90°, and across factorial groups. At 45° of flexion, a higher proportion of knees had minor imbalance with CAS compared to RAS (39.3% vs 24.8% respectively; p=0.015). There were no differences between groups in the proportion of TKAs with compartment load >60lb, or in the incidence of condylar lift-off. Furthermore, there were no differences in KOOS-12, Oxford Knee Score, Forgotten Joint Score, EQ-5D-5L, or VAS pain between knees with minor and major imbalance at any timepoint. 

Conclusions 
This study provides robust evidence that use of robotic-assisted technology does not significantly improve intraoperative balance in TKA compared to computer-assisted surgery, despite it delivering modest improvements in mid-flexion balance. While achieving balance is considered a key objective in TKA, neither imbalance nor condylar lift-off was associated with differences in patient-reported outcomes. 

Fenu Ediripolage, Umar Hayat, Islam Hamarsheh, Nimra Akram, Irrum Afzal, Sarkhell Radha 

South West London Elective Orthopaedic Centre, London, United Kingdom. Croydon University Hospital, London, United Kingdom 

Abstract 

The question, which remains unanswered, is should bilateral Total Knee Replacements (TKRs), be performed simultaneously or staged. If staged, what should the time interval be that yields the greatest improvement in two-year PROMs and PREMs? 
 
We conducted a retrospective analysis of prospectively collected data of 4162 patients (8324 TKRs) who underwent simultaneous or staged bilateral TKRs, between 01-01-2004 and 31-10-2023 by multiple surgeons.  The time interval between the first and the second TKR was divided into the following sub-groups: Zero (simultaneous under the same anaesthesia), less than (<) 6 months, 6 month intervals until 24 months, and greater than (>) 24 months apart. 
 
Of the 8,324 TKRs, 1,008 were performed simultaneously under the same anaesthetic. Among the staged procedures, 1,116 TKRs were performed 0-6 months apart, 1,276 were performed 6-12 months apart, 908 were performed 12-18 months apart, 864 were performed 18-24 months apart, and 3,152 were performed more than 24 months apart. 

Results from this study showed that the greatest OKS change in both knees occurred in patients who had their TKRs 0-6 months apart (P<0.001).  ANOVA analysis showed that patients who underwent their second knee replacement 6-12 months or 12-18 months after the first procedure had significantly worse outcome scores compared with those who had their surgeries within 0-6 months of each other. The 0-6 month interval group showed a statically significant difference in satisfaction for both the first and second TKR (p < 0.001). Patients who had their second TKR 0-6 months after their initial TKR had the shortest length of stay during their second admission (p <0.001). 
 
In conclusion, the results indicate that a shorter inter-surgical interval of less than six months between staged bilateral TKRs is associated with superior PROMs and PREMs, and reduced LOS. Awareness of this can be a useful tool for surgeons in their practice. 

Branavan Rudran, Simon Abram, Shiraz Sabah, Antony Palmer, Abtin Alvand, Andrew Judge, Andrew Price 

Oxford University, Oxford, United Kingdom. RNOH, London, United Kingdom. Bristol University, Bristol, United Kingdom 

Abstract 

There are growing concerns over the increased revision rate amongst younger patients. There is a need for investigation of the age on revision rates following TKA to aid patient decision making, which is a particular problem in younger patients deciding when to undergo a TKA. 

We analysed 1,122,136 primary knee arthroplasties from NJR-HES linked data (2003–2021), comparing patients aged under 60 vs aged 60 or over. A propensity score incorporating sex, ASA grade, BMI, indication for surgery, deprivation, surgical approach, fixation, and thromboprophylaxis was used for a 1:4 Caliper propensity match. The primary outcome was time to revision, analysed using Kaplan-Meier survival and Cox proportional hazards regression with time-splitting to address non-proportionality. Reason for revision in both cohorts were assessed. Fine-Gray models were used to assess competing risk of death. BMI interactions were assessed using likelihood ratio tests. 

Of 1,122,136 primary TKAs, 176,527 were performed in patients under 60 years. Following 1:4 propensity score matching (54,369 younger; 217,476 older), younger patients demonstrated significantly higher revision risk overall (HR 1.35, p<0.001). No significant difference existed within the first two years. At 10 years, younger patients had a 47% higher risk of revision (5.51% vs 3.76%; RR 1.47). Younger patients were 67% more likely to undergo revision for stiffness, 37% more likely for component wear, and 36% more likely for instability, whilst older patients were 61% more likely to undergo revision for infection. Obesity amplified complication risk disproportionately in younger patients for wound complications (interaction OR 1.42), surgical site infection (OR 1.39), and prosthetic complications (OR 1.46). Findings were robust to competing risks analysis, despite markedly higher mortality in older patients (HR 3.92). 

Age independently drives higher revision risk after TKA. Younger patients were more likely to undergo revision for stiffness, component wear and instability. 

Meraj Akhtar, Uday Mahajan 

City Hospital, Nottingham, United Kingdom. UHB, Nottingham, United Kingdom 

Abstract 

Segmental bone defects represent one of the most demanding challenges in trauma and orthopaedic surgery. These defects commonly result from high-energy trauma, tumour resection, infection, or non-union, often compounded by soft tissue loss and systemic comorbidities. A broad range of reconstructive strategies is available, including autologous grafting, vascularized fibular grafts, allografts, distraction osteogenesis, and the Masquelet induced membrane technique. 

Treatment selection depends on defect size, host biology, and soft tissue condition, with classification systems such as Ferreira and Tanwar offering structured guidance. While traditional methods remain essential, recent advances are reshaping the reconstructive landscape. Biologics, synthetic bone substitutes, and 3D printing technologies are expanding the armamentarium, though their roles in routine care remain under evaluation. Despite these innovations, complications such as infection, prolonged treatment, and graft failure persist. 

This review synthesizes current concepts in bone defect management, including established and emerging techniques. It emphasizes that success depends not only on surgical method but also on host optimisation, early soft tissue reconstruction, and multidisciplinary collaboration. Future progress will require robust multicenter trials and incorporation of patient-reported outcomes to refine treatment algorithms and validate novel approaches. 

Kathryn Duke, Alastair Robertson, Enis Guryel, Aman Sethi 

Royal Sussex County Hospital, Brighton, United Kingdom 

Abstract 

Background 
The management of long bone segmental bone loss following trauma is challenging. Bone loss may occur at the time of injury, during debridement of devitalised bone, or later in the course of treating fracture-related complications. Many centres now adopt an integrated Orthoplastic approach, in which collaboration with plastic surgeons provides robust soft-tissue coverage, enabling the use of all-internal fixation techniques and broadening limb salvage options. 

Techniques for managing bone loss include vascularised bone autograft, the Masquelet technique, and bone transport. Within bone transport, plate-assisted bone segment transport (PABST) has been widely reported in the literature; however, there remains a paucity of evidence regarding the use of bone transport nails (BTN) only. 

Methods 
We reviewed all BTNs used for acute trauma at a single Major Trauma Centre (MTC) in the United Kingdom (UK). Data was collected for cases performed between 01/11/2001 and 01/11/2025. 

Results 
The unit has completed five BTN procedures, including four males and one female. Two cases involved the tibia and three involved the femur, with bone loss ranging from 1 cm to 5 cm. All five cases have completed docking but have not yet completed definitive treatment. 

Conclusion 
BTNs represent a promising all-internal option for managing traumatic segmental bone loss, with early success demonstrated in a complex patient cohort. The use of a BTN alone eliminates some of the complications associated with PABST. However, the BTN construct relies on the nail to provide both stability and transport. The use of a larger-diameter nail may compromise the endosteal blood supply and, consequently, regenerate formation. These early results support the feasibility of BTNs in trauma, highlighting the need for larger, longer-term studies to clarify outcomes and regenerate biology. 

Jake Sumpton, Chirag Manwani, Ross Muir, William Groom, Gavin Barlow, Ciarstan McArdle, Joanna Bates, Yvonne Hadland, Cher Bing Chuo, Elizabeth Barron, Hemant Sharma, Oliver Goulden 

Hull University Teaching hospital NHS trust, Hull, United Kingdom 

Abstract 

Background
Chronic osteomyelitis (COM) can be debilitating disease with significant long-term morbidity. There are no published studies on long term outcome following surgical management of COM.  This study reports average 7 year (5 – 10 years) follow up outcomes of single stage and adequate, bone-preserving debridement for the treatment of chronic osteomyelitis from a single tertiary bone infection unit. 

Methods
This retrospective study included all patients from 2014. 
Inclusion criteria: single stage management of COM, thorough adequate (not segmental excision) local debridement, application of CaSO4 loaded with antibiotics and minimum 5 year follow up. All patients underwent MDT approach and soft tissue cover as needed. 

Primary outcome for evaluation was infection control. 

Results
A total of 53 patients were identified. 5 patients were excluded (3 (5.9%) died in 1st year of unrelated causes) and remaining 48 patients with a mean age of 50.2 years were analysed. The tibia was most commonly affected (25/48, 52.01%). Stimulan was used in 41(80.4%) and Cerament in 5(8.9%). 5 (10.4%) patients underwent surgery for recurrence of infection. Further 1 patient had amputation and another patient had surgery for fracture. Average stay was 16 days. 

At an average follow up of 7 years 43 patients (89.6%) had infection control. 

Conclusion
To the best of our knowledge, this is the longest reported follow up of single stage management of COM. 

We recommend single stage, bone preserving approach for debridement and local antibiotic application with CaSO4 carriers as standard of care. 

Jean-Marc Guichet, Giorgia Sortino, Barbara Deromedis, Silvia Frigerio 

Weymouth Street Hospital, London, United Kingdom. Columbus Clinic Center, Milan, Italy. Hospital C.T.O., Milan, Italy 

Abstract 

Introduction 
Hospital length of stay (LOS) is a key public health cost indicator, reflecting complexity, risks, and expertise involved in surgical reconstruction. Over the years, continuous auditing allowed care improvement, and decreased LOS. 

Method 
A longitudinal series of 209 patients (P, 176M/33F; no exclusion) of limb lengthening and reconstruction (2019-2026) monitored the LOS, aetiology, type of procedure, anaesthesia, surgical procedures and physiotherapy. 

Results 
Average LOS was 0.57 days (120 nights total for 209P). Daycare (113P-54%), or 1 (75P-36%), 2 (19P-9%), 3-4 nights (2P-1%). 

Procedures included initial lengthening/correction (Uni/bilateral; femur, tibia, foot) in 120P, MUA in 17, implant removal (uni/bilateral) in 65, and bone grafting in 7. 

Average LOS was 0.71D in initial unilateral and 0.83D bilateral procedures. Over time, it improved from 0.63D (first 145 patients), to 0.37D (last 64 patients). 

Discussion 
For complex lengthening and reconstruction procedures, improvement of care, reflects the quality of treatment, enabling shorter¹,². Continuous auditing allowed improvements of techniques and results (anaesthesia, surgery, physiotherapy). 

Conclusion 
Day-case surgery can be a realistic target even for complex limb lengthening and reconstruction procedures, reflecting high-quality care and favorable long-term outcomes. Continuous auditing and ongoing improvements are essential to further reduce LOS. 

References 
1. Characterizing the Limb Lengthening Experience: Length of Stay and Readmission Rates Following Limb Lengthening Surgery. Greenstein MD et al. J Am Acad Orthop Surg. 2025 Oct 17. doi:10.5435/JAAOS-D-25-00582. 

2. Mittal A et al. What factors correlate with length of stay and readmission after limb lengthening procedures? A large-database study.  Clin Orthop Relat Res 2022; 480:1754-1763. 

Asanka Wijendra, Shenaz Mohamed Ismail, Tajala Azizi, Prasun Saluja, Akshay Babu, Sahed Ahmed, Om Lahoti 

King's College London, London, United Kingdom 

Abstract 

Background 
Ankle osteoarthritis in younger, active patients remains challenging. Arthrodesis is reliable but sacrifices tibiotalar motion and may contribute to adjacent joint degeneration. Distraction arthroplasty is a joint-preserving option intended to reduce pain and improve function, potentially delaying fusion or total ankle arthroplasty. Outcomes vary in the literature, reflecting differences in frame constructs and the use of adjunctive procedures to restore motion and correct deformity. 

Methods 
We performed a retrospective review of consecutive ankle distractions undertaken between November 2019 and July 2025 by a single surgeon (OL) using a prospectively maintained dataset. 

Results 
Twelve patients underwent ankle distraction (mean age 48 years; 50% male): post-traumatic osteoarthritis (7/12), instability-related osteoarthritis (3/12), and primary osteoarthritis (2/12). All were treated with a hinged construct and early range of motion. Adjunctive procedures were used to correct alignment where required (supramalleolar osteotomy, 3/12), optimise range of motion (osteophyte excision: arthroscopic 9/12, open 3/12; Achilles lengthening 5/12), and address focal talar dome defects >10 mm (2/12). Paired AOFAS scores were available for 8/12 patients and improved from 35.5 (IQR 27.8-39.8) pre-operatively to 64.0 (IQR 53.8-72.0) post-operatively, a median change of +35.5 points (IQR 14.0-44.3), exceeding published estimates of clinically meaningful change. One patient deteriorated from 70 to 30 and had BMI 37.9. KL grade improved from grade 3 to grade 1 in 4 patients and persisted after frame removal. Median follow-up was 23.7 months (IQR 11.7-45.1). 

Conclusion 
Hinged ankle distraction with adjunctive procedures to correct alignment, restore motion, and address focal talar lesions was associated with improved AOFAS scores at short to mid-term follow-up, with radiographic improvement in a subset. Further work is required to identify patient and disease characteristics associated with greater treatment effect. 

Implications 
Ankle distraction may be a useful joint-preserving option for selected patients who wish to preserve motion. 

Disclosure 
None.

Alexandra Reeve, Lois Markey, Hannah James 

University of Warwick, Coventry, United Kingdom. University Hospital Coventry & Warwickshire, Coventry, United Kingdom 

Abstract 

Background
Trauma and Orthopaedic (T&O) Surgery remains a male-dominated speciality, with gender parity amongst specialist trainees projected not to be reached until 2070 (1). The lived workplace experiences of female T&O surgeons remains poorly understood. This qualitative study explores these experiences to generate insights into how gender impacts professional identity to help inform strategies for a more inclusive and equitable working environment. 

Methods
A phenomenological study with a feminist lens was conducted using 15 individual in-depth interviews with female orthopaedic surgeons from across the United Kingdom (UK). Descriptive thematic analysis was performed using NVivo. 

Results
Five main themes were determined: 1) Confidence gaps, 2) Societal expectations, 3) Misinterpretations, 4) Disempowerment, 5) Importance of community. Cross-cutting themes were: the hidden energy costs involved in navigating bias, managing expectation and compensating for inequities. 

Discussion
The findings indicate that gender bias in T&O has evolved from overt discrimination to a more subtle and insidious form embedded within everyday professional interactions and institutional norms. These behaviours are often harder to name and challenge. Gender-based microaggressions shape professional identity, sense of belonging, and career trajectories for female orthopaedic surgeons. The additional psychological burden of navigating these carries a substantial, cumulative and largely hidden energy cost. 

Conclusion
Gender-based discrimination still exists in T&O, manifesting in more subtle forms than previously described. These findings don't imply gender to be the only axis of inequality; rather that broader systemic change can benefit all surgeons. 

Implications
Progress towards equity in orthopaedics requires recognising everyday gender-based microaggressions, as well as amplifying the narratives of women surgeons to inform institutional and cultural change. Strengthening mentorship, improving workplace flexibility, and fostering inclusive working environments are key steps towards supporting and retaining women in the specialty. 

Disclosure
Nothing to disclose 

Neel Badhe, Christopher Busby, Thomas Kurien, Ben Marson 

University of Nottingham, Nottingham, United Kingdom. University Of Cambridge, Cambridge, United Kingdom 

Abstract 

Background
GLP-1 receptor agonists (GLP1-RA), commonly used in type 2 diabetes and weight loss, have potential benefits for osteoarthritis (OA) patients by influencing body weight, inflammation and articular cartilage. This systematic review evaluates the effects of GLP-1 RAs for treating OA in obese patients. 

Methods
A systematic review of randomised controlled trials (RCTs) and comparative studies was conducted in June 2025 according to PRISMA guidelines. Searches of OVID Medline, PubMed, Cochrane CENTRAL, and EMBASE databases were performed. Included studies measured OA-related outcomes in obese patients treated with GLP-1 RAs or placebo/non-pharmacological intervention. OMERACT-OARSI Core Domain Set outcomes, change in body weight, and need for joint replacement were extracted. 

Results
Nine studies involving 2,560,695 patients were included. GLP-1 RA treatment consistently reduced body weight compared to placebo/control (p<0.001). Improvements in WOMAC pain, stiffness, and physical function were inconsistent between trials. However, GLP-1 RAs improved worst daily knee pain (MD: -1.10, p<0.001), SF-36 physical function score (MD: 5.50, p<0.001) and 6-minute walk distance (MD: 42.60, p<0.001). Evidence on the impact of GLP-1 RAs on OA progression is inconsistent. There was no significant difference in serious adverse events between GLP-1 RA and placebo. 

Conclusion
GLP-1 RAs demonstrate promise for the management of OA in obese patients. Administering GLP-1 RAs after weight loss does not reduce pain or improve joint function. However, in patients without a preceding weight-loss requirement, GLP-1 RA therapy provides significant improvements in both pain and function. Further RCTs, with extended follow-up, are required to demonstrate long-term efficacy and safety. 

Yazan Al-Moghrabi, Pratham Dalwadi, Salma Chaudhury, Niel Kang, Gavin Jarvis, Cecilia Brassett, Peter Domos 

Human Anatomy Centre, Department of Physiology, Development and Neuroscience, University of Cambridge; Christ’s College, Cambridge, United Kingdom. Human Anatomy Centre, Department of Physiology, Development and Neuroscience, University of Cambridge; Peterhouse College, Cambridge, United Kingdom. Human Anatomy Centre, Department of Physiology, Development and Neuroscience, University of Cambridge, Cambridge, United Kingdom. Department of Trauma and Orthopaedics, Addenbrookes Major Trauma Unit, Cambridge University Hospitals, Cambridge, United Kingdom. School of Medicine, University of Sunderland, Sunderland, United Kingdom. Department of Physiology, Development and Neuroscience, University of Cambridge, Cambridge, United Kingdom. Royal Free London NHS Foundation Trust, Barnet and Chase Farm Hospitals, London, United Kingdom 

Abstract 

Introduction
The Latarjet procedure is an effective treatment for recurrent anterior shoulder instability with glenoid bone loss, but its adoption is limited by technical complexity and complications related to inaccurate drilling, including graft malposition and neurovascular risk. A novel robotic-assisted system has been developed to improve intraoperative accuracy by generating patient-specific drill guides using real-time glenoid surface mapping. 

Methods
This cadaveric study assessed feasibility and accuracy in 20 shoulders (10 matched pairs). A silicone mould was applied to the glenoid and matched to a pre-operative CT-derived 3D model to determine optimal screw placement. The robotic system drilled the mould to create a custom guide for k-wire placement, to guide cannulated screw positioning. Post-procedural CT scans were used to compare achieved versus planned trajectories. Clinically relevant measures included entry point error, angular deviation, and proximity to the spinoglenoid notch (adjacent to the suprascapular nerve). The relationship between glenoid morphology and accuracy was evaluated. A machine learning–based registration model was also developed to improve surface matching. 

Results
Mean entry point error was approximately 5mm with an inferolateral bias, and mean angular error was 17° with a superomedial bias. The achieved alpha angle (angle with the glenoid face) was significantly greater than planned (7.06° vs 2.20°), but remained lower than values reported for freehand techniques. There was no significant difference in distance to the spinoglenoid notch compared to the plan. Glenoid retroversion correlated significantly with increased drilling error. The machine learning model significantly improved registration accuracy. 

Discussion
This study demonstrated that robotic-assisted, patient-specific drill guidance for the Latarjet procedure is feasible and produced significantly improved trajectory control compared with conventional freehand techniques. Targeted optimisation of mould design and integration of advanced, machine learning–driven registration algorithms are essential next steps to unlock the system’s full potential and enable reliable clinical translation. 

Neel Badhe, Robert Kerslake, Thomas Kurien 

University of Nottingham, Nottingham, United Kingdom. Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom. Versus Arthritis Pain Centre, Nottingham, United Kingdom 

Abstract 

Aims 
To evaluate the association between MRI-detected features of knee osteoarthritis (articular cartilage loss, bone marrow lesions (BMLs), and synovitis) and pain thresholds at the knee and distant sites, measured objectively by quantitative sensory testing (QST). 

Methods
This prospective study included 42 patients with knee osteoarthritis and 21 healthy controls. Participants completed Oxford Knee Score (OKS), Visual Analogue Scale (VAS) pain, Total Intermittent and Constant Osteoarthritis Pain (ICOAP), and PainDETECT questionnaires. Pressure pain thresholds (PPTs) at the affected knee, distal (tibialis anterior), and remote (extensor carpi radialis longus) sites were assessed using QST. Knee MRI was performed and the MOAKS system was used to quantify articular cartilage loss, BMLs, and synovitis. Correlation analyses evaluated the association between PPTs and MRI findings. 

Results
Knee OA patients exhibited significantly lower PPTs at the knee, distal, and remote sites, and reported lower OKS and higher VAS pain, Total ICOAP, PainDETECT scores compared to healthy controls. In OA patients, knee PPTs correlated with overall knee articular cartilage loss (r = -0.4210) and more strongly with medial articular cartilage loss (r = -0.5775). Tibialis anterior PPTs correlated with medial cartilage loss (r = -0.3728) but not overall cartilage loss (r = -0.2693). ECRL PPTs correlated with both overall (r = -0.3786) and medial cartilage loss (r = -0.4765). BMLs were associated with PPTs at the knee (r = -0.5075), tibialis anterior (r = -0.4299) and ECRL (r = -0.3716). No associations between PPTs and synovitis were observed. MRI findings showed no association with PPTs in healthy controls. 

Conclusion
MRI-detected cartilage loss and BMLs in knee OA patients are associated with reduced PPTs locally and at distant sites, suggesting peripheral and central sensitisation. These associations may help to identify patients at risk of heightened pain sensitivity and potentially suboptimal outcomes following total knee arthroplasty.

Christopher Busby, Neel Badhe, Christopher Deacon, Jessica Nightingale, Benjamin Ollivere 

University of Nottingam, Nottingham, United Kingdom. Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom. University of Cambridge, Cambridge, United Kingdom 

Abstract 

Background
Open distal radius fractures are rare and potentially devastating, yet evidence to guide their management remains limited. In particular, the relationship between surgical timing and outcomes remains unclear. This study examines the epidemiology, management, complications, and prognostic factors of open distal radius fractures at a UK major trauma centre. 

Methods
A retrospective review of operatively managed open distal radius fractures treated at a UK major trauma centre between 2015 and 2022 was conducted. Demographic, injury, surgical, and outcome data were analysed. Logistic regression was used to identify predictors of malunion and complications. 

Results
A total of 106 open distal radius fractures were identified, representing 12.4% of all distal radius fractures. The cohort was predominantly female (n=71; 67%). Falls from standing height were the most common mechanism of injury (n=63; 59%), with a more bimodal age distribution compared with closed fractures. Gustilo type 1 (59%) and 2 (37%) injuries predominated. Volar locked plating was the definitive fixation in 86 (81%) cases, with 98% undergoing single debridement and closure at the time of definitive surgery. 

Deep infection was rare (n=2) and was not associated with time to theatre. Overall, 43 patients (41.6%) experienced complications, most commonly malunion (n=34; 32%). Twenty patients (19%) required further surgery. Mean time to theatre was 18.7 hours (SD 9.8). Delayed time to theatre independently predicted malunion (OR 1.053, 95% CI 1.003–1.11; p=0.043) but was not associated with deep infection. Increasing age was also associated with malunion (OR 1.039; p=0.012); however, there was no association between age and overall complication rates (p=0.283). 

Conclusion
Open distal radius fractures are associated with a high complication rate, with malunion being most common. Delay to theatre is associated with malunion but not infection. Single‑stage debridement and primary closure at definitive fixation appears to provide effective infection prevention. 

Kian Emami, Jack McNicol, Sameh Elsayed, Mostafa Elfakhrany, Bibhas Roy 

University of Manchester, Manchester, United Kingdom. Manchester University NHS Foundation Trust, Manchester, United Kingdom 

Abstract 

Background
Implant waste in Trauma and Orthopaedics carries significant environmental and financial implications, yet no clear benchmark for acceptable wastage exists. This study aims to quantify implant waste and documentation accuracy in a major trauma centre and assess the impact of a multidisciplinary educational intervention. 

Methods
A closed-loop audit was conducted at Manchester Royal Infirmary. Data was retrospectively collected for all trauma operations in March 2025, using theatre implant logbooks, operation notes and post-operative radiographs. Implants were categorised as screws, plates, nails and other. An educational intervention was delivered prior to March 2026, consisting of an environmental and cost-awareness presentation delivered to the multidisciplinary team. Additionally, posters promoting behavioural change were displayed in theatres. Data collection was repeated for March 2026 using identical methodology. Comparisons between cycles were performed using chi-square test of proportions. 

Results
In March 2025, 699 implants were opened, of which 113 were wasted, giving a wastage rate of 16.2%. Waste was most common among screws (92/566, 16.3%) and other implants (12/55, 21.8%). A total of 41 of 64 operations (64.1%) involved at least one wasted implant. Following intervention, 545 implants were opened in March 2026, of which 53 were wasted, giving a wastage rate of 9.7%. This represents an absolute reduction of 6.5% (95% CI 2.6-10.5, p=0.001) and a relative reduction of 39.6% in implant wastage. Waste among screws and other implants dropped to 11.1% (45/406) and 8.3% (7/84) respectively. The proportion of operations involving waste decreased to 46.4% (26/56), and undocumented implants reduced from 49.5% (346/699) to 48.3% (263/545). 

Conclusion
Implant wastage in trauma theatres is common but modifiable. A simple, low-cost educational intervention was associated with a reduction in wastage and improved documentation. These findings support targeted behavioural strategies to improve sustainability and reduce costs in orthopaedic practice. 

Disclosure
None declared.

Elie Najjar, Neel Badhe, Shahbaz Khan, Rawan Masarwa, Michael Grevitt 

Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom. University of Cambridge, Cambridge, United Kingdom 

Abstract 

Background
Cauda equina syndrome (CES) is a rare but critical spinal emergency. However, over 80% of urgent MRIs for suspected CES show no cauda equina compression. This diagnostic uncertainty places strain on imaging services and delays care. We aimed to develop and validate a clinical triage tool, the Suspected Cauda Equina Syndrome Score (SuCESS), to safely exclude CES and improve the accuracy of triage. 

Methods
We retrospectively developed the SuCESS score using the records of 259 patients who had been referred to a UK tertiary spinal unit between 2016 and 2018. Six clinical variables - saddle anaesthesia, reduced perianal sensation, motor weakness, bilateral sciatica, bladder post-void residual volume (PVR), and urethral catheterization - were identified using multivariable logistic regression, random forest, and XGBoost, and combined into an eight-point scoring system. Penalized regression was applied to minimize overfitting. External validation was undertaken using two temporally independent cohorts from 2020 and 2023 (n = 444). Primary outcomes were sensitivity and negative predictive value (NPV) for surgically confirmed CES. Model performance was assessed using area under the curve (AUC), Brier scores, calibration plots, and decision curve analysis. 

Results
At a threshold of ≥ 3.0, SuCESS achieved 100% sensitivity and 100% negative predictive value across all cohorts, correctly identifying all 64 cases of confirmed CES. Specificity increased from 37% in the development cohort to 54% after validation. AUC improved from 0.70 to 0.85, and Brier scores improved from 0.26 to 0.13. Use of the score might have safely deferred 38.7% of urgent MRIs, based solely on bedside clinical data. 

Conclusion
SuCESS is the first validated triage tool for CES to show perfect sensitivity. It offers a pragmatic and safe framework for reducing unnecessary MRI requests and for improving diagnostic accuracy in urgent spinal referrals.

Alisha Mahmud, Mihika Konduru, Amirah Hussain, Ashley Simpson 

Imperial College London, London, United Kingdom. University College London, London, United Kingdom. Royal National Orthopaedic Hospital, London, United Kingdom 

Abstract 

Background 
Peripheral Nerve Injuries (PNIs) are a significant cause of morbidity requiring timely recognition and management by doctors to optimise outcomes. The Medical Licensing Assessment content highlights key competencies graduates should have on the peripheral nervous system. This study evaluates the current state of peripheral nerve education, clinical exposure, and trainee confidence in diagnosis amongst UK medical students and foundation doctors. 

Methods 
NERVE-GAP is a national, cross-sectional study of medical students and foundation year doctors in the UK. The online survey was distributed through a multichannel strategy, including student societies and social media. Descriptive and comparative statistical analyses were performed. 

Results 
Analysis was performed on the first 950 responses. While 76.9% reported receiving formal undergraduate teaching on peripheral nerve conditions, teaching exposure was limited, with most participants reporting fewer than 5 hours of structured teaching. Greater teaching exposure (>2 hours) was significantly associated with feeling prepared for safe early clinical practice (p < 0.01). Teaching predominantly focused on peripheral nerve anatomy (73.4%), with less coverage of nerve repair/reconstruction (12.7%)  and rehabilitation (8.3%). Lectures (76.7%) and anatomy practicals (54.1%) were the most common teaching modalities, whereas theatre exposure (7.6%) was the least common. Confidence levels across key clinical competencies were generally low to moderate, particularly in immediate management, clinical investigation, and common referral pathways. Overall, 44.5% agreed that their training was insufficient for safe early clinical practice in PNIs. 

Conclusion/Findings 
There is substantial variability in peripheral nerve education and preparedness amongst early medical trainees. Limited teaching and clinical exposure may contribute to reduced confidence in managing PNIs. Greater standardisation of undergraduate T&O teaching may be key to improving perceived clinical confidence, thus improving patient care. 

Disclosure 
All authors have no conflicts of interest. 

Tanjot Singh, Seva NS Gill, Serkan Bayram, Muhammad Riaz, Muhammad A Siddiqi, Thomas DA Cosker 

Academic Department of Trauma and Orthopaedics, School of Medicine, University of Leeds, Leeds, United Kingdom. Nuffield Department of Surgical Sciences, University of Oxford, Oxford, United Kingdom. Oxford Sarcoma Service, Oxford University Hospitals, Oxford, United Kingdom. Department of Orthopedics and Traumatology, Istanbul University, Istanbul, Turkey 

Abstract 

Background
Pelvic chondrosarcoma is a rare primary bone malignancy resistant to chemotherapy and radiotherapy, making surgical resection the principal curative treatment. No prior synthesis has restricted itself to pelvic disease and pooled adjusted prognostic estimates. This systematic review and meta-analysis quantified prognostic factors for survival after resection. 

Methods
MEDLINE, EMBASE, Cochrane CENTRAL and Web of Science were searched from inception to January 2026. Studies reporting adjusted hazard ratios (HRs) for overall survival (OS) following pelvic chondrosarcoma resection were eligible. Dual independent screening and Newcastle-Ottawa risk-of-bias assessment were performed. Random-effects meta-analysis (REML) with Hartung-Knapp-Sidik-Jonkman confidence-interval adjustment was conducted; heterogeneity was assessed via I² and τ². Leave-one-out sensitivity analyses and influence diagnostics evaluated robustness. Prospectively registered (PROSPERO=CRD420261292717). 

Results
Forty-two studies met systematic review eligibility; eleven (2,804 patients across studies) reported adjusted HRs and contributed to quantitative pooling. Three factors were significantly associated with OS: high tumour grade (HR=4.04, 95% CI:1.99-8.20; p=0.005; I²=54.2%; k=5), surgical resection (HR=0.43, 95% CI: 0.33-0.57; p=0.005; I²=0%; k=3), and advanced disease at diagnosis (HR=2.56, 95% CI:1.10-5.99; p=0.041; I²=0%; k=3). Sex, tumour size, intermediate grade, chemotherapy, and radiotherapy were not significant. The surgical resection finding was the most robust, with zero between-study heterogeneity and a prediction interval entirely below the null. Leave-one-out analyses confirmed stability of all significant findings. 

Conclusion
Surgical resection, low tumour grade, and early-stage disease are independent predictors of improved survival; high tumour grade is the principal non-modifiable factor. 

Implications
Early diagnosis before systemic dissemination, and prioritisation of complete surgical resection at specialist centres, are likely to deliver the largest gains in pelvic chondrosarcoma survival. Future research should harmonise reporting of tumour size, margin status (R0-R2) and Enneking zones to enable larger, more granular prognostic synthesis. 

Disclosure
The authors declare no conflicts of interest. 

Younis W Peach, Ian Chan, Aron Abraham, Ryaan Sultan, Rajarshi Bhattacharya 

School of Medicine, Imperial College London, London, United Kingdom 

Abstract 

Background
Robotic-assisted total knee arthroplasty (rTKA) improves alignment and shortens hospital stay compared with conventional (cTKA), but NICE (HTG743, 2025) found no significant evidence of revision-rate reduction. We developed the first NHS-specific threshold Markov model to determine when rTKA is cost-effective at NICE Willingness-To-Pay thresholds. 

Methodology
A four-transitional-state Markov model (Post-Primary, Post-Revision, Post-Re-revision, Dead) was simulated. A cohort of 1,000 patients with age ≥70 years (56.1% female) was followed over 40 years (NJR) with 3.5% discounting (NICE). The base case applied the ROAM RCT 12-month QALY gain of +0.015/year as a per-year increment in the Well state, persisted across the horizon (NICE PMG36); a one-third-attenuation sensitivity scenario (+0.005/year) was pre-specified. The extra robotic cost was £1,829/case (ROAM). cTKA revision probability was 0.39%/year (NJR); rTKA revision rate was simulated across 0.10-1.50%. One-way deterministic and 10,000-iteration probabilistic sensitivity analyses (Monte Carlo PSA) were performed. 

Results
At equipoise revision rates, the base-case incremental cost-effectiveness ratio (ICER) was £10,508/QALY (ΔC £1,826). rTKA remained cost-effective at £25,000/QALY up to an rTKA revision rate of 0.69% (1.8 × cTKA) and at £35,000/QALY up to 0.78% (2.0 × cTKA). PSA indicated rTKA was cost-effective in 84% of iterations against cTKA at £25,000/QALY and in 89% at £35,000/QALY. One-way sensitivity identified additional robotic cost as the most influential parameter; cost-effectiveness was retained down to a sustained gain of +0.0063 QALY/year – less than half the +0.015 ROAM gain; under one-third attenuation (+0.005/year) the ICER rose to £31,523/QALY (cost-effective at £35,000). 

Conclusion
rTKA is robustly cost-effective for NHS provision across the plausible range of revision rates. NJR surveillance of robotic procedures will be required to confirm that real-world rTKA revision rates remain below this tolerance ceiling. 

Implications
To allow direct analysis of the presumed benefits we recommend NICE mandate NJR labelling of robotic procedures.

Emily Crane, Daniel Fontannaz, Sabba Hussain, Mark Harris, Fabian Norman-Taylor 

Barnet Hopsital, London, United Kingdom. Great Ormond Street Hopsital, London, United Kingdom. Barnet Hospital, London, United Kingdom 

Abstract 

Background 
Duchenne muscular dystrophy (DMD) involves significant respiratory and cardiac morbidity, making general anesthesia (GA) high-risk. While complications like rhabdomyolysis are recognized, data quantifying 30-day mortality across various procedures remain limited. Additionally, fatty marrow infiltration increases embolic risk during even minor skeletal manipulation. This study aimed to describe the frequency and characteristics of mortality within 30 days of GA in individuals with DMD. 

Methods 
A retrospective review was conducted at a UK tertiary paediatric hospital. From a sample of 259 individuals with DMD, 78 (30.1%) underwent at least one procedure requiring GA. The primary outcome was mortality within 30 days of exposure. Descriptive statistics and exact 95% confidence intervals (CI) were used to summarize the data. 

Results 
Procedures included posterior spinal fusion (n=32), foot tenotomies or lengthening (n=20), foot reconstruction (n=2), general surgery (n=6), and minor diagnostic or dental procedures (n=28). Mean BMI was 28.2; mean age of loss of ambulation was 9.9 years. Death within 30 days occurred in 4 of 78 individuals (5.1%; 95% CI 1.4–12.5%). Two deaths were intraoperative; two occurred on postoperative days 5 and 7. All mortality cases were receiving beta-blockers, steroids, and ACE inhibitors. Associated procedures for these deaths included bilateral Achilles tendon release, posterior spinal fusion, excision of perineal soft tissue, and drainage of a pilonidal abscess. Mortality risk for spinal surgery was 3.1%. Causes included cardiac arrest (n=2), liver failure, and septic shock. Relative risk of death was 4.7% for major and 5.5% for minor procedures. 

Conclusion/Findings 
Short-term mortality occurred in approximately 1 in 20 patients. Deaths followed both major and minor procedures, suggesting inherent physiological vulnerability in DMD may be as critical as procedural complexity. This underscores the need for meticulous perioperative risk stratification and extended surveillance.

Gerald Tan, Kannan Manohar, Viju Peter, Christopher Talbot 

Liverpool University Hospitals NHS Foundation Trust, Liverpool, United Kingdom. Alder Hey Children's Hospital NHS Foundation Trust, Liverpool, United Kingdom 

Abstract 

Background 
Total hip replacement (THR) in adolescents is uncommon and technically demanding, requiring coordinated paediatric and adult expertise. Evidence on outcomes in this population, particularly incorporating objective functional measures, remains limited. We describe the development of a tertiary adolescent THR service using an enhanced recovery pathway and report early outcomes. 

Methods 
A retrospective single-centre service evaluation was conducted of consecutive adolescents and young people undergoing THR between 2019 and 2025. Outcomes included patient-reported outcome measures (PROMs): Oxford Hip Score (OHS), EQ-5D-Y (health state and VAS), PedsQL, and Wong–Baker FACES pain scale. PROMs were analysed as within-person change for paired pre- and post-operative episodes, with baseline-only data reported descriptively. A subset underwent paired pre- and post-operative three-dimensional (3D) gait analysis. 

Results 
Thirty THRs were performed in 27 patients, including three bilateral cases. Median age at surgery was 16.2 years (IQR 15.4–17.1). Mean follow-up was 2.3 years (median 1.5, range 0.5–6.0). All cases had pre-operative PROMs; 25 had paired follow-up data. Significant improvements were observed in hip function and quality of life, and improvements across OHS and EQ-5D-Y domains, including mental health. Gait analysis demonstrated variable recovery: many patients showed improved temporospatial parameters, although some residual gait abnormalities persisted. Median length of stay was 2 days. One patient required return to theatre for haematoma evacuation; no revisions were recorded at latest follow-up. 

Conclusion/Findings 
A structured adolescent THR service delivered through a collaborative paediatric–adult model with an enhanced recovery pathway is safe and effective. Substantial improvements in function and quality of life are achievable. 

Implications 
PROMs demonstrate clear patient benefit, while 3D gait analysis provides additional insight into functional recovery and residual deficits. This model is reproducible and may support development of regional adolescent THR services. 

Disclosure 
None declared. 

Arsalan Baig, Saeef Ali Haque, Nirav Valand, Suhail Shetty, Sara Ahmad, Krishna Vemulapalli 

Queen’s Hospital, BHRUT, London, United Kingdom. School of Science and Technology, Department of Mechanical Engineering, City St George’s University, London, United Kingdom 

Abstract 

Background 
Paediatric lateral humeral condyle fractures (LHCFs) are the second most common elbow fracture in children and carry a significant risk of non-union and deformity. The widely used 2 mm displacement threshold guiding management remains controversial due to concerns regarding its accuracy and reproducibility. This study synthesises current clinical and biomechanical evidence comparing operative and non-operative management. 

Methods 
A PRISMA-compliant systematic review was conducted of English-language studies published between 2010 and 2025. Databases searched included PubMed, Embase, Scopus and Google Scholar. Inclusion criteria were patients under 16 years, treatment within 14 days of injury, and reporting of clinical or biomechanical outcomes. Primary outcomes included union and non-union rates. Secondary outcomes included displacement progression, functional outcomes, complications, and conversion to surgery. 

Results 
Fourteen clinical studies (approximately 700 patients) and five biomechanical studies were included. Non-operative management of fractures with ≤2 mm displacement and presumed intact cartilage hinge achieved union rates of 90–100%, although 10–20% required delayed surgery due to secondary displacement. Operative management, including closed reduction percutaneous pinning (CRPP) and open reduction internal fixation (ORIF), demonstrated union rates exceeding 97% with faster recovery and low complication rates. Early fixation within seven days was associated with improved range of motion and reduced stiffness. Biomechanical evidence showed that fracture stability depends primarily on cartilage hinge integrity and fracture morphology rather than displacement alone, and that radiographic measurement error limits the reliability of the 2 mm threshold. 

Conclusion/Findings 
Operative fixation provides predictable union and excellent functional outcomes in unstable LHCFs. Non-operative management is appropriate only in carefully selected minimally displaced fractures with strict radiological surveillance. 

Implications 
Management should shift towards a morphology-based approach incorporating cartilage hinge integrity and fracture configuration rather than relying solely on displacement measurements. Early surgical intervention should be prioritised in unstable or equivocal cases to optimise outcomes. 

Emily Crane, Kylin Hu, Kayaththery Varathen, Anouska Ayub, Dimitrios Manoukian, Paulien Bijlsma, Claudia Maizen, Manoj Ramachandran 

Barnet Hopsital, London, United Kingdom. Royal London Hospital, London, United Kingdom 

Abstract 

Background
Paediatric diaphyseal both-bone forearm fractures account for 3–5% of all childhood fractures. UK GIRFT and BOAST guidelines recommend Emergency Department (ED) based manipulation under procedural sedation, yet significant variation persists in the uptake of operative versus non-operative management. This study evaluates treatment outcomes at a high-volume Major Trauma Centre to determine whether ED-based manipulation should be the recommended first-line strategy. 

Methods
A retrospective cohort study was conducted over 7 years at a major trauma centre (MTC) in the UK. All patients under 16 years presenting with acute diaphyseal fractures of both the radius and ulna were included and categorised into three treatment groups: No Manipulation, Manipulation Under Anaesthesia (MUA), and Operative Fixation (OF). Outcomes included time to radiological union (TTRU), time to fracture clinic discharge (TTD), complication rates, functional outcome (Daruwalla criteria), and refracture rate. 

Results
A total of 188 patients were included. Median TTD was comparable for MUA (70 days) and No Manipulation (76 days), but substantially longer for OF (237 days; Kruskal-Wallis p<0.0001). The No Manipulation group had the highest refracture rate (14.3%), more than double that of MUA (6.1%) and OF (6.5%). ‘Excellent’ functional outcomes were achieved in 84.3% of MUA patients, 85.7% of No Manipulation patients, and 77.4% of OF patients. 

Conclusion
These findings are consistent with current BOAST and GIRFT guidelines recommending ED-based MUA as the first-line strategy for displaced paediatric diaphyseal forearm fractures. MUA was associated with the shortest time to fracture clinic discharge, a low refracture rate, and high rates of excellent functional outcomes, while avoiding the costs and risks of operative intervention. 

Laura Martou, Katie Hughes, Pranai Buddhev, Alexander Aarvold 

University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom. NHS Lothian, Edinburgh, United Kingdom. 3Mid and South Essex NHS Foundation Trust, Essex, United Kingdom 

Abstract 

Background 

Medial femoral head guided growth is increasingly used to manage hip displacement in neuromuscular patients as a minor alternative to major hip reconstruction. Yet, evidence remains limited and practice heterogeneous. The MEGA UK study aims to characterise current UK practice and explore treatment effect. 

Methods 

This national observational study collected patient demographics and radiographic outcomes. The primary outcome was change in Reimers’ migration percentage (RMP), classified as improved (≥5% reduction), stable (±5%), or worsened (≥5% increase). Secondary outcomes included length of stay (LoS), complications, and physis ‘growing off’ the screw. Regression analysis was performed for hips with ≥1 year follow up. 

Results 

There were 147 hips in 92 patients from ten UK children’s hospitals between 2018-2024. Mean age at surgery was 6years (range 2–11), with 84% GMFCS IV-V. Mean pre-operative RMP was 40.2% (range 10–82%, including prophylactic pinning but the majority for  progressive hip displacement (82%). Concurrent soft tissue release was performed in 51.5% of hips. Mean follow-up was 16months (range 2–61), with 73.5% of hips demonstrating improvement (ΔMP −12%, range −36 – 5%; n=53) or stability (ΔMP −0.3%, −4 – 4%; n=55), while 26.5% (ΔMP +14.5%, 5 – 41%; n=39) showed worsened hip migration. Improvement in hip displacement was more likely in those with lower RMP at time of surgery, but effectiveness was demonstrated across all severity. Median LoS was 1day (range 0–7). The physis grew off the screw in 53 hips (32.5%) at a mean of 16months (range 2–29). 

Conclusion 

This is the largest study to date on hip guided growth in neuromuscular patients. The technique appears to stabilise, or reduce, hip migration in most cases, including high-risk hips with severe migration. This may mitigate the need for major high risk reconstructive surgery. Prospective randomised controlled trials are imperative to fully assess this emerging technique. 

Hashim Abdelrazik, Mohamed Kenawey, Ahmed Abuyoussef 

Manchester University NHS foundation trust, Manchester, United Kingdom. Univeristy Hospital Southampton NHS foundation trust, Southampton, United Kingdom 

Abstract 

Background 
Equinus is the most common musculoskeletal deformity in cerebral palsy (CP), and gastrocsoleus lengthening remains the standard surgical treatment when conservative measures fail. Gastrocsoleus recession (GSR) is traditionally considered safer than tendo-Achilles lengthening (TAL), particularly in bilateral CP, because of concerns regarding calcaneal overcorrection and crouch gait. However, the influence of procedure type, CP subtype, and surgical context on outcomes remains unclear. 

Methods 
MEDLINE, Ovid MEDLINE, and Embase were searched according to PRISMA 2020 guidelines for studies reporting calcaneal overcorrection or equinus recurrence after gastrocsoleus lengthening in ambulatory children with CP, with a minimum follow-up of one year. Pooled proportions were calculated at the operated-limb level using generalized linear mixed models. Subgroup analyses compared GSR versus TAL, unilateral versus bilateral CP, and single-event multilevel surgery (SEMLS) versus isolated procedures. Risk of bias was assessed using ROBINS-I. 

Results 
Twenty-seven studies involving 1,560 patients and 2,431 limbs were included. The pooled calcaneal overcorrection rate was 5.1%, with no significant difference between GSR and TAL (5.9% vs 4.4%, p=0.61) or between unilateral and bilateral CP (4.0% vs 5.0%, p=0.70). Within bilateral CP, calcaneal rates remained similar between GSR and TAL (4.5% vs 3.3%, p=0.67) and between SEMLS and isolated procedures (4.7% vs 4.3%, p=0.91). Equinus recurrence also showed no significant differences between techniques (20.6% vs 15.7%, p=0.25) or CP subtypes (22.8% vs 17.8%, p=0.37). Heterogeneity was high (I²=72–88%), and 44% of studies had serious risk of bias. 

Conclusion 
Neither procedure type nor CP subtype independently predicted calcaneal overcorrection or recurrence. Surgical context, including gait analysis and correction of proximal deformities through SEMLS, appears more important than procedure choice alone. 

Implications 
Clinical decision-making should be guided by comprehensive gait analysis and integrated multilevel correction strategies, rather than relying solely on traditional preferences for a specific lengthening technique. 

Disclosure 
None declared