Peter Eckersley, jennifer heneghan, Rachel Lis North Manchester General Hospital, Manchester University NHS Foundation Trust, Manchester, United Kingdom

Abstract

Background

Whether patients with Hip Fracture are admitted to a designated Orthopaedic ward is recorded within the National Hip Fracture Database (NHFD).

The disruption to hospital systems caused by the Covid-19 pandemic resulted in a national reduction in performance for this measure. At our acute hospital site this result has declined from 67% in the 2020 NHFD Annual Report, to 57.2% in 2021, and to 29.6% in 2022.

Previous studies have highlighted the increased length of hospital stay and increased chance of postoperative medical complications associated with patients with Hip Fracture not being admitted to specialist Orthopaedic units.

The NHFD also records the percentage of patients ‘Mobilised out of bed by the day after surgery’. Our project sought to compare whether achievement of this measure was different for patients residing on the Orthopaedic ward in comparison to those on outlying wards.  

Methods

Relevant data was retrieved for each patient admitted to our acute hospital site for management of a Hip Fracture over the three-year period of 2020 – 2022; a total of 941 patients.

Results:

Of the 941 patients studied, 394 (42%) were resident on the Orthopaedic ward when mobilisation commenced on their day after surgery. 304 (77.2%) of these patients achieved the NHFD mobility measure.

The remaining 547 patients (58%) were therefore resident on an outlying ward instead. 364 (66.5%) of these patients achieved the NHFD mobility measure.

Conclusions

The results of the study suggest that achievement of early post-operative mobilisation for patients with Hip Fracture is reduced for patients who do not reside on a specialist Orthopaedic ward.

Implications

The results of this project have been discussed at our local Hip Fracture Governance meeting for reference.

Furthermore, the conclusion of this study has fortunately coincided with the decision to open a second Orthopaedic Trauma speciality ward within the hospital.

Sherif Ahmed Kamel^1,2, Jenna Shepherd^3,4, Awf Alshahwani², Eslam Abourisha², Divine Maduka⁵, Harvinder Singh^{2,5  1}Ain Shams University Hospitals, Cairo, Egypt. ²University Hospitals of Leicester NHS Trust, Leicester,United Kingdom. ³University Hospitals of Leicester, Leicester, United Kingdom. ⁴National Institute for Health and Care Research, Academic Foundation Programme Integrated Academic Clinical Training Pathway, London, United Kingdom. ⁵University of Leicester, Leicester, United Kingdom

Abstract

Background

Terrible triad injury is a complex injury of the elbow, which can result in significant disability. These injuries are commonly managed surgically with fixation or replacement of the radial head, and repair of collateral ligaments with or without fixation of the coronoid. Postoperative mobilisation is a significant factor that may affect the outcome. This study aims to systematically review the available literature about postoperative rehabilitation regimes.

Methods

We systematically reviewed PubMed, Embase, Cochrane, and CINAHL in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). We included studies aged 16 years or over with terrible triad injury, who had operative treatment with clear postoperative mobilisation protocol defined, and reporting outcomes of Mayo Elbow Performance Score (MEPS) as patient-reported outcome measures (PROMs). Secondary outcomes were pain, instability, and range of motion (ROM).

Results

A total of 119 articles were identified initially, of which 11 (301 patients) were included in the final review. The most common regimes (6 studies) favour early mobilisation whilst 5 studies chose late mobilisation. Meta-regression analysis including mobilisation as a covariate showed an estimated mean difference of pooled mean MEPS between the early and late mobilisation of 6.1 points (95% CI 0.24 – 12) with higher pooled mean MEPS in early mobilisation (MEPS 91.16) compared to late mobilisation (MEPS 85.03), p = 0.041.

Conclusion

Our findings suggest that early post-operative mobilisation confers a benefit in terms of functional outcome following surgical management of terrible triad injuries. The instability risk appears to be not higher in early mobilisation. Further research in the form of randomised controlled trials between early and late mobilisation is advised for higher evidence.

Implications

We think that this may encourage surgeons to allow early mobilisation after terrible triad surgery.

George Mathew Hampshire Hospitals NHS Foundation Trust, Basingstoke, United Kingdom

Abstract

Background  

The digital skills gap is estimated to cost the UK economy £63 billion per year in lost potential gross domestic product (GDP) and is expected to widen.¹

23.4 million people of working age can’t complete all the digital tasks that government and business agree are essential for the workplace. (https://futuredotnow.uk)

What good looks like framework ( NHSE )  has set a target that : 

- By March 2025 constituent organisations of an ICS have a minimum level of digital maturity. 

Interim milestones are:

Dec 2023 - 90% of NHS trusts with electronic health records. 

March 2025 - 100% of NHS trusts have electronic health records ² 

Aim

All HHFT (Hampshire Hospitals) staff to have self-confidence in basic (essential) digital skills by 2025. 

Objectives

•        To understand the perceived digital capabilities, attitudes, and values of HHFT staff      To improve self-confidence in basic ( foundational) and essential IT(digital) solutions (skills)  in all HHFT staff for life and work.

•        To explore the spread and scale of digital literacy across the wider Hampshire and Isle of Wight Integrated   Care System. (HIOW ICS)

•        To facilitate staff to have digital skills aligned with their learning and professional development plan and sustain digital literacy as a lifelong learning tool. 

Methods & Outcomes

•        Knowledge to Action Framework ³

•        Staff surveys on digital literacy The survey runs from 24th April to 31st May 2023.  

•        Focus groups/listening events to generate CHANGE IDEAS and driver diagrams

•        Thematic analysis of surveys

•        Fishbone and Pareto charts to inform outcomes

References

1.                   House of Commons Science and Technology Committee, Digital Skills crisis, (2016) (https://publications.parliament.uk/pa/cm201617/cmselect/cmsctech/270/270.pdf)

2.                   NHS England. Transformation Directorate. What Good Looks Like framework (2021). Available at: https://transform.england.nhs.uk/digitise-connect-transform/what-good-looks-like/(Accessed:

24 April 2023)

3. Graham et al. (2006) — https://www.ncbi.nlm.nih.gov/pubmed/16557505 

Disclosure

This project is part of a one year Clinical Education Improvement Fellowship with the Florence Nightingale Foundation from Oct 2023

Rebecca Mills¹, Zain Sohail², Mohit Bansal^{1  1}Princess Royal University Hospital, King's College Foundation Trust, Bromley, United Kingdom. ²Addenbrooke's Hospital, Cambridge, United Kingdom

Abstract

Background

Physiotherapy (PT) plays a crucial role in improving patients’ post-operative mobility. 

However, patients who return from theatre late in the evening may not benefit from same day postoperative mobilization with physiotherapy. Subsequent overnight stays in hospital remain common. 

We hypothesized that failure to reach mobility milestones frequently delayed discharge. Consequently, earlier same day post-operative physiotherapy intervention could reduce length of hospital stay.

Methods

Retrospective analysis of 38 patient records for patients undergoing elective lower limb arthroplasty procedures under one operating hospital team, for the month commencing April 2022.  

Results

Medical complications (particularly fatigue, wound issues, pain and blood pressure control) commonly delayed discharge (31.6%) and affected engagement with physiotherapy.   55.3% experienced post operative pain severe enough to limit physiotherapy input, (blood pressure and fatigue being other common causes). 

92.1% of patients had physiotherapy input of some form on the day of surgery (such as preoperative assessment), whilst 21.1% had a same-day post-operative PT assessment. The vast majority of patients required further physiotherapy sessions (92.1%). 

Most patients returned to the ward after 2pm and 92.1% stayed overnight. Of the patients who stayed overnight, only 17.1% had same day post-operative physio assessment. 60.5% were considered stable enough to mobilise post-operatively. However, of those well enough to mobilise, only 30.4% self-mobilised prior to physiotherapy input.

Conclusion/Findings

Optimising commonly encountered post-operative complications remains important, as medical complications often affected engagement with physiotherapy and delayed discharge. 

Interestingly, the majority of patients (68.4%) were discharged from hospital less than a day after discharge from inpatient PT, suggesting that patient mobility/PT engagement may be the final determining factor affecting discharge.

Implications

Same day post-operative mobilisation with physiotherapy in those patients well enough to do so could reduce length of hospital stay.

Jia Hui Gan^1,2, Lindsay Bearne^2,3, Samuel Walters⁴, Jonathan Room^5,6, Alex Trompeter^4,2, Dimitra Nikoletou^{2  1}Royal Surrey NHS Foundation Trust, Surrey, United Kingdom. ²St George's, University of London, London, United Kingdom. ³National Institute for Health and Care Research, London, United Kingdom. ⁴St George's University Hospitals NHS Foundation Trust, London, United Kingdom. ⁵Oxford Brookes University, Oxford, United Kingdom. ⁶Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom

Abstract

Background

Humeral fractures can cause functional disability, particularly in people with frailty. Regardless of surgical or non-surgical management, rehabilitation programmes for humeral fractures include instructions to maintain non-weight bearing (NWB) for variable periods. Current studies in lower limb injuries have shown that prolonged periods of NWB may be detrimental, and that EWB or even immediate weight bearing improves outcomes following fractures. However, there is no consensus on when to commence weight bearing in humeral fractures.  This study aims to comprehensively summarize the extent and nature of the evidence for the feasibility, acceptability, safety and effects of EWB in patients with humeral fractures.

Methods

We will search studies published between 1st January 2000 - 20th March 2023 in PubMed, CINAHL Plus and Embase electronic databases. Grey literature will also be searched on the following websites: ClinicalTrials.gov, Cochrane Central Register of Controlled Trials, NIHR Open Research and OpenGrey.EU. Studies will be included if they report the application of EWB protocols measuring feasibility, acceptability, safety, and effects on adults with humeral fractures. Exclusion criteria are studies that do not investigate humeral fractures or any weight bearing parameters, involve children, report pathological fractures, or cannot be retrieved in full text. Two of four reviewers will independently screen the titles and abstracts of retrieved studies on Rayyan software against the eligibility criteria. Selected full texts will be reviewed, and data extracted, using a priori protocol. 

Results/ conclusions

Results will be presented quantitively where possible or summarized narratively to describe the nature and extent of the evidence. The full review will be completed by the end of May 2023.

Implications

This is the first of four main phases of a larger research study that evaluates the evidence relating to EWB in humeral fractures. This scoping review aims to inform future research study and clinical practice guidelines.

Measuring differences in functional gait performance using the 6-Minute Walking Test in participants 10-15 years post-traumatic amputation

Jose Manuel Frias Bocanegra¹, Natalie Egginton², Daniel Fong¹, Alexander Bennett², David Williams¹, Sarah Stapley^{3 1}Loughborough University, Loughborough, United Kingdom. ²Defence Medical Rehabilitation Centre Stanford Hall, Loughborough, United Kingdom. ³Portsmouth Hospitals University Trust, Portsmouth, United Kingdom

Abstract

Background

It is 10 years since the Middle Eastern conflicts resulted in traumatic lower limb amputees. This cohort are now ~10-15 years since injury. A study of MSK issues evaluating gait asymmetries and assessing overall performance in injured vs non-injured military personnel.

Methods

Utilising gait analysis, with 6 embedded force plates in a 15m distance, 18-Vicon camera 3D-motion capture system and an 86 custom marker set, over a 6-minute walking test (6MWT) to evaluate maximal functional capacity. To date, 23 amputees and 4 control participants have been tested.

Results

Vertical ground reaction force, normalised to body weight, demonstrates significant overloading of the intact side. Asymmetries of greater than 0.5 body weight (BW) and up to a maximum of 1.4 times BW in the intact limb were found in comparison to the residual limb on the transfemoral (TF) cohorts whilst transtibial (TT) displayed a similar force pattern to controls. 

6MWT demonstrates a total distance covered of 579.8m for TT’s, 452.2m for UniateralTF, 520.1m, for BilateralTF and 665.8m for Controls. As expected, Controls (1.8m/s) and TT (1.6m/s) had the fastest walking speeds, however, unexpectedly BilateralTF displayed a higher walking speed (1.4m/s) when compared to UnilateralTF (1.2m/s).

Motion capture showed asymmetries of pelvic tilt and obliquity. Results in muscle thicknesses show that on the dominant side unusually the gluteus medius is larger than the maximus.

Conclusion

Significant overload on the normal side may lead to overuse and early onset pathologies. 6MWT results suggest that BilateralTF go faster to spend less time on either limb. Gait differences demonstrate the changes in the hip stabilizers should be a focus of any rehab programme.   

A Scoping review of studies relating to Digital healthcare utilisation in obese patients presenting with end stage hip and knee arthritis

Muhammad Adeel Akhtar¹, Hamzah Hanif², Calum Blacklock^{1 1}NHS Fife, Kirkcaldy, United Kingdom. ²University of Edinburgh, Edinburgh, United Kingdom

Abstract

Background  

Digital health technologies provide high-reach, low cost, readily accessible and scalable interventions for large patient populations that address time and resource constraints. Weight loss may reduce the risk for developing symptomatic lower limb osteoarthritis and may also lead to the resolution of arthritic symptoms.  Musculoskeletal-focused digital apps are increasingly being used for physical therapy and rehabilitation. The scoping review will yield evidence on how obese patients with musculoskeletal problems will benefit from digital advances in health care delivery which can support decision-making and provide excellent care.

Methods 

The electronic databases MEDLINE and CINAHL were searched in August 2022 to yield studies on our topic from the year 2000 onwards. An inclusion criterion was added for terms relating to ‘osteoarthritis’, ‘obesity’, ‘weight/exercise interventions’ and ‘digital technology’.

Results

Our initial search identified 109 results. After adding our additional search terms, 98 records were excluded. Of the 11 records remaining, 6 were included in this review. Several papers study the role of tele-rehabilitation by using online digital platforms for example Joint Academy under supervision of a physiotherapist. Several commercially available devices have been studied in activity monitoring of these patients, the most common being the Fitbit. Mobile-phone apps have been studied to monitor activity e.g. NEAT!2, drBart app, Hospitalfit, RECOVER-E. The review also identified recent trial protocols studying weight loss before total joint arthroplasty using a remote dietitian and mobile app intervention along with positive psychology and healthy living skills to slow symptomatic arthritic progression. 

Conclusion

This scoping review indicated that research on digital care is limited but that comprehensive digital care programmes can significantly improve functional outcomes in obese patients with end stage arthritis and identified the motives for weight loss, strategies utilized during past weight loss attempts, and preferences for future weight loss programmes. 

To evaluate the use of a TaurusTM walker within the first 24 hours following hip and knee arthroplasty in elective orthopedics, promoting patient independence and confidence in early mobilisation.

Alexa Coyle^1,2, Rebecca Fox^{3 1}MSEFT, Chelmsford, United Kingdom. ²Topro, Gjovik, Norway. ³Royal Devon University Healthcare NHS Foundation Trust, Barnstaple, United Kingdom

Abstract

Barriers to early mobilisation following hip and knee arthroplasty at Mid & South Essex NHS Foundation Trust had been identified as patients having reduced confidence to walk independently and a reliance on waiting for physiotherapists to get patients up first-time post op, these factors led to reduced efficiency in the enhanced recovery after surgery programme.  A 12 week trial using the TaurusTM walker was implemented to improve this.

Metrics from 3 areas were explored: 1) Patient level, patients were asked to complete a questionnaire for their experience on using the Taurus walker. 2) Service level, a questionnaire to all members of the MDT pre and post-trial to establish what mobility/manual handling equipment of choice would be for early mobilisation. 3) System level was comparing length of stay (LOS) data during the 12 week trial with the same 12 week period in 2022 on the same ward.

Pre trial transferring patients to a chair with a zimmer frame on day zero was considered ‘normal practice’. Nursing staff were trained and educated in using the Taurus walker and encouraged to mobilise patients to the toilet following surgery rather than use bedpans/commodes. 

Evaluation of the project found that 100% of patients reported that the Taurus walker made them ‘feel safe to walk independently’ within 24 hours post-surgery with 68% reporting the taurus as being excellent for ‘mobilising 60m independently’. Pretrial the MDT predominantly chose a zimmer frame to mobilise patients post op, post-trial the preferred mobility aid was the Taurus walker 100 % of the time, with an associated increase in mobility on day zero with 50% mobilising 2 times or more. The LOS across the trial reduced by an average of 0.86 days however, the number of day one discharges dramatically increased from an average of 12.6% to 57.%.

The Application of Large Language Models to Orthopaedic Practice

Arwel Poacher¹, Jessica Caterson², Olivia Ambler³, Nicholas Cereceda-Monteoliva⁴, Matthew Horner⁵, Andrew Jones^{6  1}Guys and St Thomas Hospital, London, United Kingdom. ²MSc Student in Health Data Science, London School of Hygiene & Tropical Medicine, London, United Kingdom. ³, Department of Plastic Surgery, Royal Devon and Exeter NHS Trust, Exeter, United Kingdom. ⁴Department of Plastic Surgery,Guys and St Thomas’ Trust, London, United Kingdom. ⁵Department of Orthopaedic Surgery , University Hospital of Wales, Cardiff, United Kingdom. ⁶, Department of Orthopaedic Surgery, University Hospital of Wales, Cardiff, United Kingdom

Abstract

Introduction 

Accurate and readable clinic letters are an essential but often time-consuming part of orthopaedic practice. The British Orthopaedic Association recommends including diagnosis, investigations, and management plans, but this is often not adhered to. Large Language Models (LLMs) provide an opportunity to streamline conversion of clinical notes into readable letters. The aim of this study is to explore whether LLMs GPT-3 and Chat-GPT can write clinic letters and predict management plans for common orthopaedic scenarios

Methods

Fifteen scenarios were generated and Chat-GPT and GPT-3 prompted to write clinic letters and separately generate management plans for identical scenarios with plans removed. Letters were assessed for readability using the Readable Tool. Accuracy of letters and management plans were assessed by three independent senior orthopaedic clinicians. 

Results 

Both models generated complete letters for all scenarios after single prompting. Readability, compared using Flesch-Kincade Grade Level (ChatGPT:8.77(SD0.918); GPT-3:8.47(SD0.982)), Flesch Readability Ease (ChatGPT:58.2(SD4.00); GPT-3,59.3(SD6.98)), SMOG Index (ChatGPT: 11.6 (SD0.755); GPT-3: 11.4 (SD1.01)), and reach (ChatGPT: 81.2%; GPT-3 80.3%). Chat-GPT produced more accurate letters (8.7/10 (SD0.60) vs. 7.3/10 (SD1.41), p = 0.024) and management plans (7.9/10 (SD0.63) vs. 6.8/10 (SD1.06), p < 0.001) than GPT-3. However, both LLMs sometimes omitting key information or adding additional guidance which was at worst inaccurate.

 Conclusions 

This study shows that LLMs are effective for generation of clinic letters. With little prompting, they are readable and mostly accurate. However, they are not consistent, and include inappropriate omissions or insertions. Furthermore, management plans produced by LLMs are generic but often accurate. In the future, a healthcare specific language model trained on accurate and secure data could provide an excellent tool for increasing the efficiency of clinicians through summarisation of large volumes of data into a single clinical letter.

Mock Examiners: Not all are created equal

Vivek Sharma, Dhiraj Sharma, Ignatious Liew, Kate Spacey, Anish Sanghrajka  Norfolk and Norwich Hospital, NORWICH, United Kingdom

Abstract

Introduction

Mock exams are frequently used to prepare for the FRCS exam, and to assess candidates' readiness for the actual examination. This study aims to investigate the variability of mock examiners and explore any potential correlation between their grades and objectivity.

Method 

The study involved recording a mock viva consisting of three separate questions, with predetermined scores for each question. The recordings were then distributed to four groups of Orthopaedic Surgeons (Junior-Registrars (JRs), Senior-Registrars (SRs), Specialty-doctors (SDs) and Consultants (Cons)), who were asked to score the recordings using JCIE descriptors. The objective was to analyse the reliability of the scores, as well as the variation within and between examiner grades. Examiners who scored above, below, or within pre-assigned threshold boundaries were classified as Dove, Hawk, and Owl, respectively.

Results

The study involved inviting 54 surgeons to participate, with a response rate of 45 (83%). Of the participants, there were 8 JRs, 10 SRs, 6 SDs, and 21 Cons. The level of agreement varied within the different grades, with only slight agreement (κ = 0.27-0.35) observed within Cons, SR, and JR grades, while moderate agreement (κ = 0.45) was observed within the SD grades. The prevalence of Owls was higher in the SD and Cons groups (JR 63%, SR 50%, SD 83%, Cons 71%), while Hawks were significantly more common in the SR group (JR 13%, SR 50%, SD 0%, Cons 14%, p = 0.049). Having passed the FRCS did not influence the objectivity of the scoring process(p=0.07).

Conclusion

Our study underscores the importance of fairness and balance in mock examination assessments. Cons and SDs tend to be fairer examiners, while SRs tend to be more hawkish. Standardisation across all levels of examiners is critical to reduce variation and ensure assessment reliability in highstakes decision-making scenarios.

Rajapriyian Murugaiyan¹, Tharushi Wijesena¹, Georgios Mamarelis², Niel Kang^{3 1}University of Cambridge, Cambridge, United Kingdom. ²The Royal London Hospital, London, United Kingdom. ³Cambridge University Hospitals, Cambridge, United Kingdom

Abstract

Background

Virtual Reality (VR) is a rapidly advancing technology, with recent emergence as an active learning method, offering trainees an immersive experience that is otherwise limited to operating theatres. This study was conducted to determine whether VR training is more effective than traditional lecture-based methods, by evaluating the performance of medical students in formal assessments about the Proximal Femoral Nail (PFN) procedure, which could guide future research and investment into VR,  with incorporation into orthopaedic training.

Methods

As part of a small-sample study, 32 medical students without prior experience of the PFN procedure were recruited and randomised into a Lecture Group or VR Group. The VR group completed the PFN module on PrecisionOS VR headsets, while the Lecture group viewed a recorded presentation designed by a specialty registrar (SpR) on the procedure. All participants were assessed on their knowledge of the PFN procedure pre- and post-training, through a standardised assessment consisting of 10 multiple-choice questions. 

Results

Whist the pre-training scores of both the VR (n=16) and Lecture (n=16) groups were similar [VR=3.38±1.75; 95% CI: ±0.86, Lecture=3.44±1.26; 95% CI: ±0.62, (p=0.454)], the post-training scores were statistically significant (p < 0.05), with the VR group performing better overall [VR=7.81±1.56; 95% CI: ±0.76, Lecture=6.50±1.83; 95% CI: ±0.89, (p=0.018)]. Both the Lecture and VR groups displayed improved knowledge, with mean improvements of 3.06 and 4.44 respectively, before and after training.

Conclusion and Implications

VR training is a more effective learning method for the PFN procedure, identifying the need for large-scale studies into its use in orthopaedic training. However, both VR and traditional lecturebased methods are shown to be valuable and should be integrated for better surgical training, and ultimately improved patient outcomes. 

George Koshy¹, Chryssa Neo¹, Andrew Berg², Balaji Purushothaman^{2  1}Queen Elizabeth Hospital Gateshead, Newcastle upon tyne, United Kingdom. ²Sunderland Royal Hospital, Sunderland, United Kingdom

Abstract

Background

Knowledge of basic surgical instruments is vital for a surgeon to have good communication with their scrub team for a more efficient surgery. Learning the names of commonly used surgical instruments has always been a part of surgical training, however more commonly this is gained by hands on time spent in theatre. There is very little literature assessing the knowledge of nomenclature of basic surgical instruments amongst trainees. The aim of this study was to gauge how well trainees knew the names of instruments that they use or see on a daily basis.

Methods

The data was collected by sending out an anonymous online questionnaire consisting of 18 pictures of basic surgical instruments. One mark was awarded for each correct answer with a maximum score of 18. Fifty questionnaires were completed by SHO’s and SpR’s within the North East deanery. Trainees within various surgical specialities took part in the study.

The questionnaire also looked into the level of training of the participant, any previous formal training in surgical instruments and whether they had undergone either their undergraduate or postgraduate training outside of the UK.

 Results

There were 50 responses from various surgical specialities.18 SHO’s and 32 SpR’s took part in the study. 43 Trainee’s (86%) felt it was important to be able to identify the correct instrument although only 22 trainees (43%) had reported prior formal training in instruments. The average score by an SHO was 5.4(30.2%) and the average score of registrars was 6.8 (37.8%) out of 18.

 Conclusion

It is evident that there is a clear lack of knowledge of names of surgical instruments amongst trainees which would suggest that further formal teaching opportunities are required.

Alexander Boucher, Jamie Johnson  QMC NUH Trust, Nottingham, United Kingdom

Abstract

Background

Medical students have limited orthopaedic experience and understanding compared to other specialities leaving them less prepared for foundation. Our aim is to demonstrate increased engagement by designing simulations to improve knowledge and confidence within orthopaedics.

Methods

We designed four simulations; cauda equina, hot swollen joint, compartment syndrome and neck of femur fractures. Students completed a pre and post questionnaire about their own ‘knowledge’, ‘confidence in management’ and ‘ability to SBAR/escalate’ (score 1= none to score 10= excellent). We collected feedback looking at whether material covered was ‘relevant’, ‘enhanced their practice’ and if they would ‘recommend the session’ (score 1 = strongly disagree to score = 5 to strongly agree). 

Results

Of the students (N= 67), 97% strongly agreed the simulations were clinically relevant, 91% that they would enhance their clinical practice and 90% recommending these sessions. 

With regards to knowledge we achieved an increase over all stations. Across ‘hot swollen joint’ this was 6.3 pre to 8.3 post, ‘compartment syndrome’ 4.9 to 7.7, ‘cauda equina’ 5.3 to 7.8 and ‘neck of femur fracture’ 5.7 to 7.8.  Confidence in management also showed an increase across all stations. With ‘hot swollen joint’ this was 5.8 pre to 7.9 post, ‘compartment syndrome’ 4.8 to 7.5, ‘cauda equina’ 4.7 to 7.4 and ‘neck of femur fracture’ 5.4 to 7.9. The simulations showed an average increase from 6.1 pre to 7.1 post with perceived SBAR ability.

Conclusions

Students found these sessions clinically relevant and enhanced their skills. There was a significant increase of knowledge and confidence in management of these conditions. Therefore we conclude that low-fidelity simulations are an effective teaching method that achieve the desired effects with regards to clinical knowledge, skills and further engagement. Simulations should be included as part of an orthopaedic curriculum to facilitate our future doctors’ education.

‘It’s not just fun and games’ – a series of novel gamification ideas to enhance Orthopaedic teaching for Junior Doctors

Savneet Lochab Great Western Hospital, Swindon, United Kingdom

Abstract

Background

Gamification encompasses the combination of academic components and game elements, from simple team-based exercises to virtual reality in training. There is an emergence of its adoption in healthcare-based teaching and evidence that its use can foster long term learning in a variety of subject areas for learners with different personality traits and styles.

This project aimed to deliver a series of novel sessions centred around a collaborative learning experience to build intrinsic motivation, strengthen engagement and knowledge retention.

Method

The following sessions were run multiple times over the course of 2.5 years across two District General Hospitals in the South West.  

Fracture Pictionary: An interactive way to teach x-ray interpretation and fracture presentation, where participants are split into two teams and alternate to describe a radiograph whilst a member ‘draws the fracture’. 

Trauma Treasure Hunt: A novel approach which provides exposure to an assortment of clinical tasks that are representative of the SHO workload on-call; adopting the idea of learning by doing.

Orthopaedic Heads Up: An app based game, where participants must guess which word - from operative abbreviations to eponymous fractures - the other players are describing.

Results

Collective feedback from the sessions demonstrated a 100% of attendees (25) scored the content, delivery, and structure of each sessions as 5/5. All participants stated an increase in overall confidence and common phrases in session feedback included; ‘innovative’, ‘memorable’, ‘useful’, ‘non-threatening’ and ‘fun’. 

Conclusion

Gamification in Orthopaedic teaching can be used to promote engagement and create a novel learning environment for skill development and knowledge acquisition. These sessions provide opportunities for practical application and risk-free decision making in a dynamic setting. These ideas are reflective of the need to foster originality and develop ways to impart knowledge on a new generation of learners that have an appetite for creativity.  

Trainee and trainer satisfaction with the Multi Consultant Report

Paul Harwood^1,2, James Tomlinson^3,2, Alex Kocheta^4,2, Kevin Wembridge^{4,2  1}Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom. ²Health Education England, Yorkshire and the Humber, Leeds, United Kingdom. ³Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom. ⁴Rotherham NHS Foundation Trust, Rotherham, United Kingdom

Abstract

Background

The multi-consultant report (MCR) assesses trainees against high-level curriculum outcomes in the generic professional capabilities (GPCs) and capabilities in practice (CIPs).  Recent introduction has proved contentious, with variable application. We sought to examine conduct of and satisfaction with the MCR in trainees and trainers.

Methods

An online survey was distributed to all Orthopaedic trainers and trainees in our region.  This contained Likert scale and free text questions.  Non-parametric methods and thematic analysis were used to examine responses. 

Results

Questionnaires were completed by 88 trainers and 58 trainees.  Opinions on the MCR varied, most respondents understood the MCR and felt it would identify trainees in difficulty.  Some felt that it would stimulate them to seek new training experiences.  Organisation varied between departments, 47% cancelled other commitments to hold the meetings, for 27% the meetings were centrally coordinated.  Both groups felt timing of the MCR was not conducive to meaningful feedback.

Analysis of qualitative results revealed consistent themes.  For trainers, having enough consultants available, time away from clinical practice for the meetings and having consultants from different specialties available were most important.  For trainees, having opinion from multiple consultants, the breadth of practice covered and having targeted feedback on how to improve were most valuable.  Again, timing of the assessments was highlighted as problematic by both groups.  Trainers from hospitals where clinical sessions were cancelled for the MCR returned significantly more favourable responses across all areas. There was a strong correlation between satisfaction and management team support.  

Conclusions

The MCR remains controversial and is variably implemented in our region.  Trainer engagement was significantly better where the leadership teams facilitated the meetings and time was allocated for completion.

Implications

As the MCR continues to mature, it is important to share good practice to improve its utility. Allocating protected time appears particularly important.

Strike while the union's hot - a presentation of Orthopaedic Trainee's views of industrial action.

Martin Hamilton-Flack, Mike Pullinger Addenbrooke's Hospital, Cambridge, United Kingdom

Abstract

Introduction

After a ballot by Junior Doctors in February 98% of the 77% of eligible BMA doctors voted to strike in a fight for pay restoration. This follows a series of five Junior Doctor Strikes in 2016 however these recent strikes did not allow for any derogation areas. The literature on motivations for strike day decisions is sparse. There are some reviews from the United States (eg Thomson and Salmon) and also discussions about ethics of healthcare workers going on strike (e.g Chima and Abbasi). Prior to the 2015 strikes a Lancet editorial concluded that there are always alternatives to strike action. This survey based study aims to provide information about motivations of those that strike and those that go to work, questions whether they feel supported by their organisations and assesses if there are patterns based on seniority or geography. The profession is at a concerning point with increasing demands, increasing burnout rates and more people leaving, the results of this survey may provide answers to suitable interventions to improve the sustainability of the workforce.   

Methods

A short survey was constructed using Google forms. This was sent out via group messaging with an emphasis on the anonymity of the responses. The results were analysed in Microsoft Excel with the free text portions assessed using a combination of coding and Text analytics. Word clouds will be generated and presented.

Results

As the strikes are currently in progress, we wish to present the results at the BOA Annual Congress however, currently, the strikes are ongoing and we are still collating the data. Initial responses are already showing some interesting themes.

Conclusion

Use of Virtual reality in the education of orthopaedic procedures as a potential succession of traditional methods.

Austin Gomindes¹, Elizabeth Sylva Adeeko², Chetan Khatri^1,2, John Carlos¹, Simran Sahdev¹, Imran Ahmed^1,2, Thomas Ward¹, James Laverington¹, Luke Debenham¹, Andrew Metcalfe^1,2, Jayne Ward^{1  1}University Hospitals Coventry and Warwickshire, Coventry, United Kingdom. ²University of Warwick, Warwick, United Kingdom

Abstract

Introduction 

Restricted working-hours, increased cancellation of operative-lists and the recent pandemic, have provided challenges to surgical training. Virtual reality (VR) simulation offers a safe environment for trainees to develop their skills in a controlled environment.  

The aim of this study was to assess whether VR-simulationwas better than traditional learning methods for a trochanteric femoral nail (TFNa, Synthes).

Methods

All participants were recruited from one university teaching hospital from medical students, Foundation Year and Core Surgical Trainees.  Participants completed a pre-procedurevalidated questionnaire assessing their confidence in TFNausing a Likert scale from -3 (Very distasfied to +3 (Very satisfied) as well as the State-Trait Anxiety Inventory (STAI). Participants were then randomised to using VR-simulation or traditional methods (reading operation manual & discussion with consultant). Participants then completed the TFNa on a model, and completed a postprocedure questionnaire.  

Results

28 participants were randomised to VR-simulation (13) and traditional (15). The VR group felt steps involved in the simulator were more accurate (1.83 (+/- 1.11) vs 0.92 (+/- 1.43)) they were also more prepared to attempt the procedure after simulation (0.66 (+/- 1.6) vs -0.35 (+/- 1.82)).  Simulation training also had a better user experience (2.41(+/- 0.90) vs 0.21 (+/- 1.67)) and provided a better learning environment (2.33 (+/- 1.07) vs 0.78 (+/- 1.76)).  

According to STAI-rating both groups were significantly comparable at base line apart from being content with the overall training experience (VR 3.08 (+/- 0.66) vs traditional2.64 (+/- 0.92)). Participants agreed the simulator provided a realistic learning environment, enjoyed using the simulator and recognised the need for simulation in formal training. 

 Conclusion

simulation offers a safe environment for trainees to develop their skills in a controlled environment.  

The aim of this study was to assess whether VR-simulationwas better than traditional learning methods for a trochanteric femoral nail (TFNa, Synthes).

Methods

All participants were recruited from one university teaching hospital from medical students, Foundation Year and Core Surgical Trainees.  Participants completed a pre-procedurevalidated questionnaire assessing their confidence in TFNausing a Likert scale from -3 (Very distasfied to +3 (Very satisfied) as well as the State-Trait Anxiety Inventory (STAI). Participants were then randomised to using VR-simulation or traditional methods (reading operation manual & discussion with consultant). Participants then completed the TFNa on a model, and completed a postprocedure questionnaire.  

Results

28 participants were randomised to VR-simulation (13) and traditional (15). The VR group felt steps involved in the simulator were more accurate (1.83 (+/- 1.11) vs 0.92 (+/- 1.43)) they were also more prepared to attempt the procedure after simulation (0.66 (+/- 1.6) vs -0.35 (+/- 1.82)).  Simulation training also had a better user experience (2.41(+/- 0.90) vs 0.21 (+/- 1.67)) and provided a better learning environment (2.33 (+/- 1.07) vs 0.78 (+/- 1.76)).  

According to STAI-rating both groups were significantly comparable at base line apart from being content with the overall training experience (VR 3.08 (+/- 0.66) vs traditional2.64 (+/- 0.92)). Participants agreed the simulator provided a realistic learning environment, enjoyed using the simulator and recognised the need for simulation in formal training. 

 Conclusion

Resilience in orthopaedic surgeons – a stress riser within?

Nichola McLaughlin¹, Kate Spacey^{2 1}Colchester General Hospital, Colchester, United Kingdom. ²Norfolk and Norwich Univeresity Hospitals, Norwich, United Kingdom

Abstract

The pandemic, rising waiting lists and a retention crisis have all taken their toll on the profession. The concept of surgery as a stressful career is not new. Resilience is defined as an ability to adapt well in the face of adversity or significant stress¹. A study in 2015 by Pegrum et al has suggested that ‘stress immunity’ is an overriding protective characteristic of consultant surgeons², however many newer analyses have suggested that resilience is often lower in surgeons than the general public³. Are orthopaedic surgeons really a stress immune population?

Our study of 47 participants spanning all grades of orthopaedic surgeon looked at self-reported levels of perceived stress, grit and resilience using  validated psychometric surveys.  We compared each set of responses to look for trends amongst surgical grades and gender.

We found that our population of 47 respondents were ‘moderately stressed’ on average. Average resilience (range 1.67 – 4.33) and grit scores (range 2.1 - 4.5) were in line with the general population. Respondents with lower resilience scores tended to report higher perceived stress.  Consultants tended to have lower perceived stress scores, slightly above average grit scores and lower than average resilience scores (but still within the normal range). Individuals reporting very high perceived stress scores tended to score lower than average resilience and grit. Conversely, individuals reporting lower perceived stress scored higher than average in resilience and significantly higher in grit. Interestingly, 78% of the respondents in this group were registrar and pre-ST3 level, suggesting that the group of surgeons likely exhibiting the stress immune trait are registrars.  

In summary, this small study illustrates that higher perceived stress is associated with lower resilience and grit. It also opens the door to further debate on the legitimacy of the often assigned “snowflake” label given to junior doctors.

Neurodiversity in Orthopaedics Trainees

maheswaran archunan¹, Ignatius Liew², Kate Spacey^{1 1}Norfolk and Norwich University Hospital, Norwich, United Kingdom. ²Norfolk and Norwich University Hospital, norwich, United Kingdom

Abstract

Background

Neurodiversity affects 20% of junior doctors. Neurodiverse conditions have  impact on learning, progression in training and exam success. Those failing previous examinations and screen highly are considered for free formal assessment. This pilot study aims to identify the incidence of dyslexia among Trauma & Orthopaedic trainees within the East of England deanery, identifying those with undiagnosed tendencies, and the accessibility of formal assessment. We want  to normalise these conversations, reducing the social stigma and embracing neurodiverse conditions. 

Methods

A survey distributed to 70 training Registrars and 16 lead Educational Supervisors within the Deanery. The survey contained the British Dyslexia Associations dyslexia screening tool, the outcomes are ‘probably non-dyslexic’, ‘signs consistent with mild- moderate dyslexia’, ‘signs consistent with severe dyslexia’. Additional questions explored perceived barriers to formal assessment, and interest to undergo neurodiversity training.

Results

38 responses contributed by 30 registrars and 8 AES were received (42.9% and 50% response rate). 5 responses (13.2%) demonstrated signs consistent with dyslexia, with 20% receiving formal assessment. 40% had prior examination failures and would be eligible for formal assessment. 3 additional trainees had borderline results which may increase the incidence at formal assessment to over 20%. The main barriers to pursuing formal assessment for neurodiversity were stigma (44.5%), time consuming process (34%) and being unable to self-refer (29%). 26% admitted that their own ego was a barrier to assessment. 100% of all AES had not received formal neurodiversity training, with an interest in training. 

Conclusion/Findings 

Trainees that screen for signs consistent dyslexia, may benefit from formal assessment. The frequency of reported stigma per response demonstrates that both trainees and trainers would benefit from neurodiversity awareness training. A larger study will drive change, accessibility, building and providing neurodiverse training programmes for trauma and orthopaedics. 

Less Than Full Training In Trauma And Orthopaedics: A Survey Of Prospective Trauma And Orthopaedic Surgeons In The UK

Habeeb Bishi¹, Kalsoom Altaf², Charmilie Chandrakumar³, Warran Wignadasan^{4  1}The Shrewsbury and Telford Hospital NHS Trust, Birmingham, United Kingdom. ²East Kent Hospitals University NHS Foundation Trust, Canterbury, United Kingdom. ³The Great Western Hospital, Swindon, United Kingdom. ⁴Barts Health NHS Trust, London, United Kingdom

Abstract

Background

Despite the fact that Less than Full Time Training (LTFT) has been an option in UK surgical training for some time, there are still trainees in the UK who may want to access LTFT but are unable to for a number of reasons. The aim of this study was to explore attitudes towards LTFT amongst current UK surgical trainees, particularly in orthopaedics.

Methods

This is a prospective, qualitative cohort study. An 18-item questionnaire was designed and disseminated via social media. Inclusion criteria was anyone currently working in the UK as a junior doctor. 

Results

Out of 299 respondents, 216 met the inclusion criteria. Of those 216, 160 (74%) were male, 56 (25%) were female, 1 was non-binary and 2 did not wish to reveal their gender.

91 (42%) said that they would consider LTFT with 59% of those 91 already in a LTFT post. The most common reasons that people gave for considering LTFT were child rearing/caring for a dependent (49%), burnout (36%) and travelling (21%).

In addition, 35% of male respondents and 63% of female respondents said they would consider LTFT. 70 (32%) respondents reported hearing or seeing negative behaviour or discrimination towards the idea of being a LTFT. On a Likert scale of 1(not receptive) - 10(extremely receptive), participants gave an average score of 4.9 ± 2.1 with regards to how receptive they thought the orthopaedic specialty was to LTFT.  Furthermore, 160 (74.6%) felt that there was no information readily available on LTFT applications.

Conclusion

Although many trainees in the UK have considered LTFT, if we want to recruit and retain a truly diverse surgical workforce, it is important that we address negative attitudes towards LTFT. Accessibility for trainees and trainers to access appropriate resources and support regarding LTFT is important. 

Chandra Pasapula¹, Makhib Choudkhuri¹, Gil Monzo², Vivek Dhukaram³, Sajid Shariff⁴, Vitalijs Pasterse⁵, Douglas Richie⁶, Tamas Kobezda¹, Georgios Solomou⁷, Steven Cutts^{8  1}Queen Elizabeth Hospital, King's Lynn, United Kingdom. ²Hospital Universitario Doctor Peset, Valencia, Spain. ³University Hospitals Coventry and Warwickshire, Coventry, United Kingdom. ⁴Medway Maritime Hospital, Gillingham, United Kingdom. ⁵Riga East Clinical University Hospital, Riga, Latvia. ⁶California School of Podiatric Medicine at Samuel Merritt University, oakland, USA. ⁷School of Clinical Medicine, Cambridge, United Kingdom. ⁸James Paget University Hospitals, Great Yarmouth, United Kingdom

Abstract

Background 

Classifications of AAFD/PCFD have evolved with increased understanding of the pathology involved. A review of classification systems helps identify deficiencies and respective contributions to the evolution in understanding classification of AAFD. 

Methods  

Using multiple electronic database searches (Medline, PubMed) and Google search, original papers classifying AAFD were identified. 9 original papers were identified that met the inclusion criteria. 

Results  

Johnson’s original classification and its multiple variants provided a great leap in understanding and communication of the pathology but remained tibialis posterior tendon focussed. Drawbacks of these classifications include the implication of causality, linearity of progression through stages, an over-simplification of stage 2 deformity and a failure to understand multiple tendons react, not just tibialis posterior. Later classifications such as the PCFD classification are deformity-centric. Early instability in non-cavus feet and all stages of cavus feet can present with pain and instability with little/no deformity. These may not be captured in deformity-based classifications which are biased to planus feet.’ The authors developed the ‘Triple Classification’ (TC) understanding that primary pathology is a progressive ligaments failure/instability that presents as tendon reactivity, deformity, and painful impingement. There is a variable manifestation dependant on starting foot morphology. 

Conclusions

Sami Merie, Arjun Patel, Varun Kothari, Andrew Roche Chelsea And Westminster Hospital, London, United Kingdom

Abstract

Introduction

Syndesmotic stabilisation following ankle injuries is a commonly performed procedure worldwide. Orientating the screw can be difficult particularly for inexperienced surgeons. Failures in syndesmotic reduction are a common cause of re-operation therefore there is a demand for reproducible techniques which can guide surgeons to inserting an optimal screw. We propose a technique to orientate the ‘perfect’ screw using easily identifiable soft tissue landmarks. crosssectional computed tomography imaging was used to validate the technique.

Methods

CT scans of uninjured ankles were identified from a single site between x and x. Axial images were marked with the ideal entry and exit points for the screw on the fibula and tibia respectively – an ideal screw position will bisect both the tibia and fibula in the transverse plane. Ideal entry points were measured in relation to the apex of the fibula. Ideal exit point were measured in relation to distance from the tibialis anterior tendon (D1) and tibialis posterior tendon (D2). The location of the ideal exit point was calculated as a percentage distance from the tibialis anterior tendon to the tibialis posterior tendon using the formula (D1/(D1+D2))*100

Results

40 scans were eligible for inclusion in this study. The ideal entry point was calculated as

0.11±0.72mm posterior to the apex of the fibula. The mean distance between the ideal exit point and the tibialis anterior tendon was 24.9±4.2mm. The mean distance between the ideal exit point and the tibialis posterior tendon was 26.6±4.2mm. The mean ideal exit point was calculated to be 48.3±4.8% of the distance between tibialis anterior and tibialis posterior.

Discussion

Orientating a syndesmosis screw through the apex of the fibula to a point approximately midway between the surface marking of tibialis anterior and tibialis posterior ensures a trajectory which is optimal and easily reproducible. 

India Cox¹, Alice Campion², Daphne Van Embden^{3  1}Queen Elizabeth University Hospital, Glasgow, United Kingdom. ²Bristol Children's Hospital, Bristol, United Kingdom. ³Amsterdam UMC, Amsterdam, Netherlands

Abstract

Introduction

No systematic reviews currently exist evaluating the wide-awake local anaesthetic no tourniquet (WALANT) technique in lower limb procedures. WALANT is well-established in upper limb surgery for both trauma and elective procedures, and has been shown to improve access to surgery, be sustainable, and confer patient safety and cost benefits. We aimed to collate all available evidence evaluating WALANT in the foot and ankle and assess the intraoperative and postoperative experience. The primary outcome was patient-reported intraoperative pain, measured through numerical rating scales. Secondary outcomes were anxiety, complications, satisfaction, postoperative pain and length of stay. 

Methods

Electronic databases were searched to identify all studies reporting on intraoperative pain in patients undergoing any foot and ankle procedure using WALANT (with or without a control of traditional anaesthetic techniques). For numerically-reported outcomes, statistical analysis was performed to estimate a measure of effect. Narrative analysis was performed for outcomes reported descriptively. 

Results

Eight studies (209 patients) were included after screening 69 identified studies. There was one randomised control trial, one case-control study and six case series. Over half the total patients underwent ankle fracture fixation under WALANT (n=117). Intraoperative pain scores were low across all studies. Anxiety levels decreased during the procedures. Both comparative studies found a significantly lower postoperative pain level in the WALANT group with effect estimate of -3.01 [95% confidence interval -6.65, 0.64]. Studies were mostly of moderate quality and high risk of bias.   

Conclusion

WALANT appears to be a safe, effective and well-tolerated technique for foot and ankle procedures. Further evidence particularly in the form of randomised trials is required to quantify the impact of WALANT in the lower limb.

The acute management of Pilon fractures (ENFORCE) Study: A national evaluation of practice.

Daniel Hill, James Davis, ENFORCE Study Collaborative South Devon NHS Foundation Trust, Torquay, United Kingdom

Abstract

Introduction

Pilon fractures are potentially limb threating injuries of the tibial plafond.  Staged soft tissue damage control (“span, scan, plan”) is described, but in the absence of national standards of care actual practices are unknown.    We report a national trainee collaborative aiming to evaluate how tibial Pilon fractures are acutely managed across the UK.

Methods

ENFORCE was a multi-centre retrospective observational study of the acute management of tibial Pilon fractures over a three-year period.  Mechanism, imaging, fracture classification, time to fracture reduction and cast, soft tissue damage control, and definitive management details were determined, and anonymously recorded on REDCap.  

Results

656 patients (670 fractures) across 27 centres were reported.  AO fracture classifications were: partial articular (n=294) and complete articular (n=376).  Initial diagnostic imaging mobilities were: plain radiographs (n=602) and CT-scan (n=54), with all but 38 cases having a planning CT-scan.  526 fractures had a cast applied in the Emergency Department (91 before radiological diagnosis), with the times taken to obtain post cast imaging being: mean 2.7 hours, median 2.3 hours, and range 28 mins – 14 hours.  35% (102/294) of partial articular and 57% (216/376) of complete articular fractures had an external fixator applied, all of which underwent a planning CT-scan.  Definitive management consisted of: open reduction internal fixation (n=495), fine wire frame (n=86), spanning external fixator (n=25), intra-medullary nail (n=25), other (n=18).  

Conclusion

The management of Tibial Pilon fractures is variable, with prolonged delays in obtaining post cast reduction radiographs, and just over half of complete articular fractures being managed with the gold standard “span, scan, plan” staged soft tissue resuscitation.  A BOFAS endorsed BOAST (British Orthopaedic Association Standard for Trauma) for tibial Pilon fractures would increase the profile and standardise management of these potentially limb threatening injuries, together with setting them apart from more straightforward ankle fractures.

Rebecca Martin¹, Michael Dean², Rajesh Kakwani¹, An Murty¹, Ian Sharpe², David Townshend^{1 1}Northumbria Healthcare NHS Trust, Cramlington, United Kingdom. ²Princess Elizabeth Orthopaedic Centre, Exeter, United Kingdom

Abstract

Introduction

Large bone defects such as those encountered after failed total ankle replacement have previously been a relative contraindication to revision ankle replacement due to inadequate bone stock. We describe our early experience and patient reported outcomes with a novel modular ankle replacement system with tibial and talar augments. 

Methods 

This is a retrospective case series analysis of patients who underwent a total ankle replacement using the INVISION system across two centres between 2016 and 2022. Local approvals were granted. Patients completed f the Manchester-Oxford Foot Questionnaire (MOXFQ), Ankle

Osteoarthritis Scale (AOS)  and EQ-5D pre-operatively and then post-operatively at 6 months, 1 year, 2 years, 3 years and 5 years. Medical records were reviewed for complications and re-operations. Xrays were reviewed for cysts or lucencies and alignment.

Results 

17 patients were included in the study; 14 men and 3 women with an average age at the time of surgery of 67.9 years (range 56 years to 80 years). The average follow up post operatively was 40.5 months (range 7 to 78) at the time of this study. The indication for surgery was revision of failed TAR in 16 and revision of failed ankle fusion in 1.

An augmented tibia was used in 13, an augmented talus in 13, and both augmented tibia and talus in 9 cases.

There were no early surgical complications. One patient required a debridement and implant retention for late deep infection. No implants have been revised.

The average MOXFQ score improved by 19.3 points at most recent follow up. The average AOS score improved by 25.2 points. 

Conclusion

The early results of a modular augmented  ankle arthroplasty system have shown satisfactory patient outcomes with a low complication and re-operation rate and present another option for patients with larger bone defects.

Neil Limaye, Tejas Kotwal, Yousif Alkhalfan, Thomas L Lewis, Ali Abbasian Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom

Abstract

Background 

Hallux valgus (HV) is a common foot deformity presenting with symptoms of pain, difficulty with footwear, and reduced quality of life. Severe HV is often managed with arthrodesis of the 1st Tarsometatarsal joint (TMTJ), although there are concerns regarding non-union and malunion (particularly recurrence of increased inter-metatarsal angle correction before arthrodesis is complete). We report the early results of a small series of patients that underwent an evolved surgical technique utilising orthogonal staples and a transverse suture button fixation to address biomechanical concerns with traditional Lapidus arthrodesis.

 Methods 

A retrospective study of patients underwent this surgical technique between February 2017 and

May 2022. Clinical outcomes were validated through Patient-reported outcomes measures (PROMS); EuroQol-5 Dimension (EQ-5D) and Manchester-Oxford Foot Questionnaires (MOXFQ). Radiographic parameters (hallux valgus (HVA), intermetatarsal (IMA), distal metatarsal articular angle (DMAA)) were assessed. 

Results 

During the study period, 9 feet underwent the procedure. Radiographic data was available for all nine and PROMS data for seven (77.8%). Significant improvement occurred in all radiographic deformity parameters at mean 6-month follow-up. Mean ± standard deviation correction calculated preoperatively as HVA 40.2°, IMA 19.3° and DMAA 15.8°, corrected to HVA 15.4°, IMA 5.8° and DMAA 5.9° postoperatively. (HVA; P<0.001, IMA; P<0.001, DMAA; P<0.001) Clinical PROMs at mean follow-up of 2 years were MOXFQ 34.4±25.2, EQ-5D-5L 0.819±0.150 and VAS pain 13.6±13.6. There were no cases of non-union, Tibialis anterior tendon irritation or hallux varus. Complications included first MTPJ stiffness in one case, CRPS and dorsiflexion mal-union of the first ray in another patient.

Conclusion 

This preliminary study of the procedure used in this series confirm that this is a safe surgical technique to address severe HV with a low rate of non-union and significant radiographic improvements. A larger patient dataset is needed to evaluate this procedure robustly. 

Gastrocnemius Release in the Treatment of Achilles Tendinopathy: A Systematic Review.

Christopher White, Edmund Ieong, Benjamin Rudge West Hertfordshire Teaching Hospitals NHS Trust, Watford, United Kingdom

Abstract

Background

Gastrocnemius release is an emerging operative treatment option for refractory Achilles tendinopathy. The aim of this study is to evaluate the use of gastrocnemius release in the treatment of Achilles tendinopathy. The primary outcome is change in patient-reported pain outcomes. Secondary outcomes include change in patient-reported foot and ankle function, ankle range of motion and strength, patient satisfaction and rate of surgical complications.

Methods

Systematic review of studies where patients were treated with an isolated gastrocnemius release for Achilles tendinopathy. Randomised controlled trials, cohort studies, case-control and case series were eligible. There was no restriction on the surgical technique for gastrocnemius release. Studies where gastrocnemius release was performed for another indication or in conjunction with another procedure were excluded. Ten studies met the criteria for inclusion in the systematic review. 

Results

Gastrocnemius release results in improved patient-reported outcome scores for pain, especially for non-insertional tendinopathy patients. Gastrocnemius release results in improved patient-reported outcome scores for foot and ankle function, especially for non-insertional tendinopathy patients. Gastrocnemius release results in improved ankle range of motion but reduced ankle strength. Patients report a high rate of overall satisfactory after gastrocnemius release.

Conclusion

Based on current evidence, gastrocnemius release shows promise as a treatment option in refractory non-insertional Achilles tendinopathy. Gastrocnemius release appears to offer maintained and clinically meaningful improvements in pain and foot and ankle function. An associated reduction in ankle strength may not be clinically meaningful in many patients. Further high-level research is needed.

First Tarsometatarsal Arthrodesis for Severe Hallux Valgus Using Orthogonal Staples and Suture Button Tight-Rope Fixation– Technical tip and case series

Neil Limaye, Tejas Kotwal, Yousif Alkhalfan, Thomas L Lewis, Ali Abbasian Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom

Abstract

Background 

Hallux valgus (HV) is a common foot deformity presenting with symptoms of pain, difficulty with footwear, and reduced quality of life. Severe HV is often managed with arthrodesis of the 1st Tarsometatarsal joint (TMTJ), although there are concerns regarding non-union and malunion (particularly recurrence of increased inter-metatarsal angle correction before arthrodesis is complete). We report the early results of a small series of patients that underwent an evolved surgical technique utilising orthogonal staples and a transverse suture button fixation to address biomechanical concerns with traditional Lapidus arthrodesis.

Methods 

A retrospective study of patients underwent this surgical technique between February 2017 and

May 2022. Clinical outcomes were validated through Patient-reported outcomes measures (PROMS); EuroQol-5 Dimension (EQ-5D) and Manchester-Oxford Foot Questionnaires (MOXFQ). Radiographic parameters (hallux valgus (HVA), intermetatarsal (IMA), distal metatarsal articular angle (DMAA)) were assessed. 

Results 

During the study period, 9 feet underwent the procedure. Radiographic data was available for all nine and PROMS data for seven (77.8%). Significant improvement occurred in all radiographic deformity parameters at mean 6-month follow-up. Mean ± standard deviation correction calculated preoperatively as HVA 40.2°, IMA 19.3° and DMAA 15.8°, corrected to HVA 15.4°, IMA 5.8° and DMAA 5.9° postoperatively. (HVA; P<0.001, IMA; P<0.001, DMAA; P<0.001) Clinical PROMs at mean follow-up of 2 years were MOXFQ 34.4±25.2, EQ-5D-5L 0.819±0.150 and VAS pain 13.6±13.6. There were no cases of non-union, Tibialis anterior tendon irritation or hallux varus. Complications included first MTPJ stiffness in one case, CRPS and dorsiflexion mal-union of the first ray in another patient.

Conclusion 

This preliminary study of the procedure used in this series confirm that this is a safe surgical technique to address severe HV with a low rate of non-union and significant radiographic improvements. A larger patient dataset is needed to evaluate this procedure robustly. 

Christopher White, Edmund Ieong, Benjamin Rudge West Hertfordshire Teaching Hospitals NHS Trust, Watford, United Kingdom

Abstract

Background

Gastrocnemius release is an emerging operative treatment option for refractory Achilles tendinopathy. The aim of this study is to evaluate the use of gastrocnemius release in the treatment of Achilles tendinopathy. The primary outcome is change in patient-reported pain outcomes. Secondary outcomes include change in patient-reported foot and ankle function, ankle range of motion and strength, patient satisfaction and rate of surgical complications.

Methods

Systematic review of studies where patients were treated with an isolated gastrocnemius release for Achilles tendinopathy. Randomised controlled trials, cohort studies, case-control and case series were eligible. There was no restriction on the surgical technique for gastrocnemius release. Studies where gastrocnemius release was performed for another indication or in conjunction with another procedure were excluded. Ten studies met the criteria for inclusion in the systematic review. 

Results

Gastrocnemius release results in improved patient-reported outcome scores for pain, especially for non-insertional tendinopathy patients. Gastrocnemius release results in improved patient-reported outcome scores for foot and ankle function, especially for non-insertional tendinopathy patients. Gastrocnemius release results in improved ankle range of motion but reduced ankle strength. Patients report a high rate of overall satisfactory after gastrocnemius release.

Conclusion

Based on current evidence, gastrocnemius release shows promise as a treatment option in refractory non-insertional Achilles tendinopathy. Gastrocnemius release appears to offer maintained and clinically meaningful improvements in pain and foot and ankle function. An associated reduction in ankle strength may not be clinically meaningful in many patients. Further high-level research is needed.

The impact of joint preserving fixation for acute Lisfranc injuries: Clinical and patient reported outcomes over a 5-year follow up period

Firas Raheman^1,2, Yanja Chuluunbaatar¹, Amit Chawla¹, Simon Mordecai¹, Radwane Faroug¹, Karan Johal¹, Rupinderbir Deol^{1  1}East and North Hertfordshire NHS Trust, Stevenage, United Kingdom. ²Royal Free London, London, United Kingdom

Abstract

Background

There is limited evidence on the optimal method of fixation of acute Lisfranc injuries. Joint preserving fixation has increasingly shown to improve early outcomes with shorter return to activity times. The aim of this study was to (1) Evaluate the clinical and functional outcomes for acute Lisfranc injuries treated by joint-preserving fixation. 

Methods 

All skeletally mature patients treated for Lisfranc injuries in our unit were retrospectively identified from January 2017 to May 2022. Exclusion criteria included patients <18 years of age, open injuries, and previous injury or surgery. Patients were treated with standardised joint preserving-fixation followed by a standardised rehabilitation regimen. Patient and injury demographics, hospital quality measures and AOFAS and FFI scores were measured. Univariate and multivariate analyses were used to assess predictors of all negative outcomes, whilst the cox proportional hazards model was used to evaluate patient reported outcome scores over time.  

Results 

70 patients were identified where 56 met the inclusion criteria. Mean age was 39.68 years [SD 16.01] with a mean follow of 48 months (range 10-66months). Average operative time was 93.87 minutes [SD 12.22] and time to presentation was 2.14 days [SD 3.87] where operative treatment was within 17.10 days [SD 16.53]. The average duration of non-weight bearing was 7.23 weeks [SD 1.29]. Mean AOFAS and FFI scores were 85.9 [SD 11.1] and 16.90 [SD 17.35], respectively. Functional scoring over a five year follow up was also consistent for both metrics AOFAS HR=0.860 [95% CI 0.780.95] p=0.004 and FFI HR=0.89 [95%CI 1.00-0.78] p=0.05, respectively. 

Conclusion 

Our study has shown joint preserving fixation could be considered optimal for management of acute Lisfranc injuries with positive clinical and patient reported outcomes, irrespective of injury severity.  

Does the underlying cause of arthritis affect the outcome of total ankle replacement? A 10 year follow up study.

Andrea Pujol Nicolas, Anna Porter, Samir Hakeem, Jayjasree Ramaskandhan, Matthew HarrisDouglas, Malik Siddique Freeman Hospital, Newcastle upon Tyne, United Kingdom

Abstract

Background  

Total ankle replacement (TAR) is gaining popularity as a treatment option for end stage arthritis. We analysed whether the underlying pathology leading to the arthritis has any bearing on patient reported or clinical outcomes.

Methods   

Patient-reported outcome measures (PROMs) for TAR performed from 2006 to 2010 by a single surgeon were reviewed. This included WOMAC score, SF-36 and patient satisfaction scores. Data was collected preoperatively and post-operatively at 1, 2, 5 and 10 year. The indications for TAR were obtained by review of clinical notes and radiographs and these included osteoarthritis (OA), inflammatory arthritis (IA), pilon fracture (PF), ankle fracture (AF), and post-traumatic arthritis without previous fracture (PTOA). 

Results

PROMs were available for 156 TARs: 81 (51.9%, mean age 65.29) for OA, 28 (17.9%, mean age 65.29) for AF, 23 (14.7%, mean age 64.28) for IA, 11 (7%, mean age 55.01) for PF, and 13 (8.3%, mean age 51.08) for PTOA. At 1 year WOMAC score showed significant worsening pain and stiffness on PTOA group (p=0.023, p=0.001) and worse general health and vitality for the IA group (p=0.0025, p=0.005). At 5 years The PTOA group showed significant worsening stiffness (p=0.048), social and emotional domains (p=0.004, P=0.029) and worsening pain, return recreational activities and surgery dissatisfaction (p<0.05, p=0.032, p=0.023). At 10 years 50% of IA patients were unhappy with return to ADLs but no other difference were found between groups. There was a higher revision rate at 10 years in the PTOA group with 30.7% of patients being revised (4/13) compared to other groups (OA-

6.17%, AF-3.57%, IA-4.35%, PF-9%)

Conclusion  

Similar outcomes in all groups were seen at 10 years but higher revision rates were present in PTOA group. In patients with PTOA careful consideration and counselling is needed prior to proceed with TAR. 

Does the Type of Peroneus Longus Insertion Relate to the Development of Hallux Valgus? An Anatomical Cadaveric Study

Abdul-Rahman Gomaa¹, Louisa Marie Hulls¹, Adam Rasell-Watson^1,2, Lyndon Mason^1,2, Alistair Bond^{1 1}University Of Liverpool, Liverpool, United Kingdom. ²Liverpool University Hospitals NHS Foundation Trust, Liverpool, United Kingdom

Abstract

Introduction 

Hallux valgus (HV) is a complex multifactorial deformity of the first ray of the forefoot. The peroneus longus (PL) muscle is one of the key dynamic stabilisers of the first ray, acting through its insertion. 

Aim

To assess the association between the type of PL insertion and the prevalence of HV.

Methodology

Twenty-five cadaveric foot specimens were dissected to expose the insertion of the PL. The head of the first metatarsal was exposed to determine the presence of morphological changes in keeping with HV. The type of PL insertion, anatomical HV status and number of tarsometatarsal facets were documented.

Results

Twenty-five foot specimens were reviewed from seventeen unique donors. Seven (28%) had morphological changes in keeping with HV deformity. There were 4 double insertions, which none had HV. Whereas 33.33% of the single insertions had evidence of HV. Regarding width of insertion to the peroneus longus tubercle, 15.38% (2/13) narrow insertions had HV, whereas 41.67% (5/12) had broad insertions. There were 2 unifacet tarsometatarsal joints, 19 bifacet and 4 trifacet in the cohort. HV was more common in the bifacet tarsometatarsal joints (31.58%).

Conclusion

Patients with HV were more likely to have single PL insertions which were broad. The pull of a narrow PL insertion may increase the stress concentration of the PL muscle action, therefore having a greater effect to the lateral and downward movement of the first ray, thus preventing HV. Further research is required to understand if the morphology change is a cause or effect relationship.

Effect of Fibula Shortening on Medial Clear Space and Lateral Translation of the Talus: An Anatomical Cadaveric Study

Abdul-Rahman Gomaa¹, Lucy Roper¹, Niamh Heeran¹, Grace Airey², Rajkumar Gangadharan², Benjamin Fischer², Lyndon Mason^2,1, Alistair Bond^{3 1}University Of Liverpool, Liverpool, United Kingdom. ²Liverpool University Hospitals NHS Foundation Trust, Liverpool, United Kingdom. ³University of Liverpool, Liverpool, United Kingdom

Abstract

Introduction

Fibular shortening with a medial and syndesmotic ligament instability causes lateral translation of the talus. We hypothesise that the interaction of the anterior inferior tibiofibular ligament (AITFL) tubercle of the fibular with the anterior tibial incisura would precipitate lateral translation due to the size differential.

Methods

Twelve cadaveric ankle specimens were dissected, removing all soft tissue except for ligaments.

They were fixed onto a bespoke jig allowing tibial fixation and free movement of the talus and fibula. The fibula was progressively shortened in 5mm increments until complete ankle dislocation, measuring the medial clear space with each increment.

Results

The larger AITFL tubercle interaction with the smaller tibial incisura caused a significant increase in lateral translation of the talus. This occurred in most ankles between 5-10mm of fibular shortening. The medial clear space widened following 5mm of shortening in 5 specimens (mean: 2.07, s.d: 2.53). All 12 specimens experienced widening by 10mm fibular shortening (Mean: 7.21mm, s.d: 2.21) and reached complete dislocation by 35mm fibular shortening.

Conclusion

This study shows, that with fibular shortening, the interaction between the distal fibular AITFL tubercle and the anterior tibial incisura precipitates a lateral translation of the talus in an ankle fracture model where the medial and syndesmotic ligaments have been transected and the lateral ligaments remain intact. The interaction occurred between 5 and 10mm of fibular shortening. Beyond this point there was a near linear correlation between fibular shortening and medial clear space widening.

Hindfoot Stability Test - Introduction and Validation of a Diagnostic Test of  Subtalar Instability in Deltoid Ligament injury Associated with Ankle Fractures

Lyndon Mason^1,2, Matthew Philpott¹, Abdul-Rahman Gomaa³, Alistair Bond^{3  1}Liverpool University Hospitals NHS Foundation Trust, Liverpool, United Kingdom. ²University Of Liverpool, Liverpool, United Kingdom. ³University of Liverpool, Liverpool, United Kingdom

Abstract

Background

The deltoid ligament complex (DLC) is well-known as an ankle joint stabiliser, however, through the superficial DLC, it also acts at the subtalar joint and helps to maintain the medial longitudinal arch. DLC repair in the presence of an ankle fracture remains a topic of controversy in the current literature. No studies have commented on hindfoot and subtalar instability testing in the presence of DLC injuries associated with ankle fracture fixation. 

Objective

Hindfoot instability has been observed during surgery under fluoroscopy via valgus stressing of the calcaneus, despite the maintenance of the medial clear space. Specifically, this was noted by referencing the proximity of the calcaneal tuberosity to a line parallel with the lateral aspect of the fibula, the lateral fibula line. We aim to validate this as a method of detecting subtalar instability with DLC injury when undertaking ankle fracture fixation. 

Methods

Ten morphologically normal cadaveric specimens were used to validate the test. Specimens were radiographed before and after simulated injury of the DLC. A line was drawn from the lateral aspect of the fibula on the radiographs and the position of the calcaneal tuberosity to this line was used to determine if the specimen had hindfoot instability.

Results

Pre-injury to DLC, no specimen illustrated bisection of the calcaneal tuberosity by the lateral fibular line on hindfoot stability test under fluoroscopy. Post-DLC injury, all specimens showed bisection of the calcaneal tuberosity by the lateral fibular line on hindfoot stability test. 

Conclusion

The hindfoot stability test assesses hindfoot stability on valgus stressing of the hindfoot using the calcaneal tuberosity bisection of a line drawn from the lateral border of the fibula as a reference point for instability. We demonstrated that hindfoot stability test is a useful measure to determine subtalar instability in the presence of a DLC injury.

Index of multiple deprivation , a predictor of lower limb amputation in diabetic foot disease.

Ahmad Bilal¹, Danuksha Amarasena², Anand Pillai^{1 1}Wyhtenshawe hospital Manchester foundation university, Manchester, United Kingdom. ²Manchester university Hospital, Manchester, United Kingdom

Abstract

Background  

 Prevalence of diabetes and its complications are on rise particularly in low and middle income countries. Diabetic foot neuropathy increases the risks of foot ulcers, infection and eventual need for amputation. This cause a huge effect on quality of life , morbidity and pre-mature mortality these patients. We analyzed the relation between areas of deprivation and diabetic foot amputations.

Methods  

We retrospectively evaluated the diabetic patients, who were admitted to our multidisciplinary unit  between March 2017-March 2022 and underwent surgery for diabetic foot ulceration. In our analysis we looked at index of multiple deprivation(IMD)as independent variable to predict the lower extremity amputation.Index of multiple deprivation for these amputees was calculated from their postcode address.   

Results  

In our study 70 patient had surgery for the foot ulceration. Majority of them were Males 55 (78.6%).

The mean age at diagnosis was 45.6 (SD 15.8) years and the mean age at first surgery was 61.5 (SD=11.4) years.Out of 70 patients 33(47%) had amputation. Majority of these amputation were of forefoot 75.6% followed by hind foot (18.1%)and  mid foot(6.06%).None of the patients had below knee amputation. Index of multiple deprivation for these amputees ranges from 576 to 32098 (Mean 9019.72). Twenty seven patients (81.81.%) had  IMD decile 5 or below, and only six patients had 5 or above (18.1%).

Conclusion  

Our study shows in diabetic foot ulceration, index of multiple deprivation  is strong predictor for amputation. When treating these patients it should be actively probed, should  these cohort of patients will likely need extra care and support.

Tibiotalocalcaneal arthrodesis – outcomes following early dynamization with dynamically locked nails versus conventional statically locked nails

Choon Chiet Hong¹, Yaser Hasan¹, Ken Jin Tan², Wei Mao^1,3, Wei Ting Lee^{1 1}National University Hospital, Singapore, Singapore. ²OrthoSports – Clinic for Orthopedic Surgery and Sports Medicine, singapore, Singapore. ³Yangpu Hospital, ShangHai, China

Abstract

Background

The use of retrograde nail for tibiotalocalcaneal (TTC) arthrodesis have been shown to provide good outcomes by allowing correction of deformity, stable rigid fixation as a load-sharing device with minimal soft tissue dissection. There is limited literature on early dynamization of TTC arthrodesis nail. Therefore, this study aims to compare the outcomes in terms of union rates and mechanical complications for TTC arthrodesis using hindfoot nail with early dynamization versus those without. 

Methods

A retrospective review of all TTC arthrodesis using the Expert Hindfoot Arthrodesis (HAN) from the 2010 to 2021 was performed. Demographic and surgical details were analysed. Primary outcomes were focused on union rates and mechanical complications arising from whether the HAN system was placed in dynamic compression mode utilizing the dynamic proximal interlocking screw hole to allow early dynamization compared to statically locked nail using the static proximal interlocking screw hole.

Results

35 patients with  TTC arthrodesis of which 20 (57.1%) HAN nails were dynamically locked to allow early dynamization while 15 (42.9%) nails were statically locked. In terms of union rates, all patients (91.4%) achieved union except for three (8.6%) patients with a mean time to radiographic union at 7.4 months.  Two out of three patients with nonunion had infective nonunion where both presented with deep infection and osteomyelitis resulting in multiple surgeries (1 in each group). There were no significant differences in the aseptic nonunion rate (5%vs0%; p=1.000) and time to radiographic union (7.3vs7.6 months; p=0.726) between the two groups. There were 6 mechanical complications with a preponderance in the dynamically locked nails group (25%vs6.7%; p=0.154) although it was not statistically significant. 

Conclusion

Early dynamization of TTC arthrodesis with dynamically locked nails provided good union rates without loss of fixation or additional complications when compared to the conventional statically locked nails after external compression. 

oes the mode of data acquisition affect the Oxford Hip and Knee score and EQ-5D score for patients undergoing Total Hip and Knee replacements?

Irrum Afzal, Richard Field South West London Elective Orthopaedic Centre, London, United Kingdom

Abstract

Patient Reported Outcome Measures (PROMs) can be completed using paper and postal services (pPROMS) or via computer, tablet or smartphone (ePROMs). We have investigated whether there are differences in scores depending on the method of PROMs acquisition for the Oxford Hip Score (OHS) and Oxford Knee Score (OKS) and the EQ-5D scores, at one and two years post operatively. 

Patient demographics, mode of preferred data collection and pre-and post-operative PROMs for Total Hip Replacements (THRs) and Total Knee Replacements (TKRs) performed between 1st January 2018 and 31st December 2018 were collected.  

During the study period, 1494 patients underwent THRs and 1573 patients underwent TKRs. 72.02% of the THR patients and 71.46% of the TKR patients opted to undertake post-operative questionnaires using ePROMs. 

At the one and two-year post-operative time intervals, a Mann-Whitney test showed statistical significance between the modes of administration for OHS (P-Value =0.043 and 0.01 respectively). There was no significance between the modes of administration for EQ-5D (P-Value: 0.13 and 0.07 respectively). At the one and two-year post-operative time intervals, a Mann-Whitney test showed statistical significance between the modes of administration for OKS (P-Value = 0.044 and 0.01 respectively). There was no significance between the modes of administration for EQ-5D (P-Value:

0.04 and 0.07 respectively). 

There is no agreed mode of PROMs data acquisition for the OHS, OKS and EQ-5D Scores. While we have demonstrated an apparent difference in scores depending on the mode of administration, further work is required to establish the influence of potentially confounding factors.

Role of Low Intensity Pulsed Ultrasound Therapy (exogen) in Recalcitrant Upper Limb Non-union

Bulelwa Bakumeni, Valliappan Muthukumar, Adel Tavakkolizadeh, Om Lahoti, Karthik KaruppaiahKing's College Hospital, London, United Kingdom

Abstract

Background

Intractable upper limb fracture non-unions are difficult to treat. Though NICE guidance supports the use of EXOGEN, there is some restraint among orthopaedic surgeons to use EXOGEN because of mixed results in the literature. We analysed the role of EXOGEN in upper limb non-unions in our institute. 

Methods

Between January 2010 and December 2022, 66 cases were identified where EXOGEN was used. After strict exclusion criteria, 53 cases were included in the study. The distribution of delayed/non-union was 7 clavicle; 21 humerus; 17 forearm (Radius/Ulna/both); 5 scaphoid; 3 wrists. 9 cases were conservatively managed and 44 were post-surgery. The average time between injury and application of EXOGEN was 3 to 30 months. All patients were assessed at the final follow up for both clinical and radiological union.

Results

40 (75.5%) fractures healed with EXOGEN. All patients with infected non-union (n=3) and open fractures (n=6) healed. 17 (100%) of forearm, 4 (80%) scaphoid, 5 (71%) clavicle, 13 (62%) humerus, 1 (33%) wrist fusion healed with EXOGEN.   The rate of union in patients with hypertrophic nonunion (n=10) was 100%, atropic non-union (n=17) was 65% and Oligotrophic non-union (n=33) was 73%. There was no significant difference in healing between open vs closed fractures (p=0.999), post-surgery vs conservatively managed (p=0.475) and smoking (p=0.219). Fractures with larger fracture gaps are more likely to not heal following EXOGEN treatment (p=0.087). There were no complications associated with EXOGEN use.

Conclusion  

The union rate following low intensity pulsed ultrasound therapy in stubborn upper limb non-unions is encouraging. In our series, all the patients with hypertrophic non-union, forearm non-union and non-union following previous open fractures healed. Except the fracture gap width, no other factors influenced the union rate. The outcome of our analysis is promising and recommends using EXOGEN in selected cases with cautious optimism. 

A Prospective Study Evaluating Outcomes of Acute Ulnar Collateral Ligament Repair in The Thumb Using Suture Anchors

Charles Wallace, Alexandra Foley, Johan Van Der Stok University Hospital Limerick, Limerick, Ireland

Abstract

Objective

This prospective study aimed to assess the outcomes of acute repair of the ulnar collateral ligament (UCL) of the thumb metacarpophalangeal joint using a suture anchor technique. This is one of the first studies to prospectively follow up patients and monitor their outcomes after suture anchor repair of the UCL.

Methods

Twenty adult patients who underwent acute thumb UCL repair within 6 weeks of injury at a single center between 2022-2023 were identified and followed prospectively. Patient demographics included a mean age of 37 years (range 16-70), with 69% being male. Short-term outcomes, including postoperative complications and repair failure, were assessed. Mid-term outcomes evaluated included QuickDASH, Visual Analogue Scale (EQ-VAS), return to sport and work, and patient satisfaction.

Results

Postoperative complications were minimal, with 5.5% of patients experiencing self-limiting sensory disturbance, 2% with superficial infection requiring oral antibiotics, and no patients had wound dehiscence requiring surgical debridement and re-closure. No failures of repair were reported.  The mean EQ-VAS score was 86 (range 50-100), indicating high patient satisfaction with their outcome. Of the employed patients, 98% returned to work at a median time of 0.7 weeks (range 0-41), with a mean QuickDASH Work Module score of 4.1 (range 0-52). Of the patients who played sports prior to injury, 96% returned to sport at a median time of 16 weeks (range 5-50). All patients reported being highly satisfied with their outcome, with a mean satisfaction score of 9.8 (range 8-10).

Conclusions

Acute repair of the thumb UCL using a suture anchor technique within 6 weeks of injury appears to be safe and effective, with low rates of postoperative complications and repair failure. Patients generally experience good upper limb function and high satisfaction with their outcome. Most patients are also able to return to work and sport following this surgical intervention.

CMC joint arthroplasty offers potential advantages over trapeziectomy and can be regarded as the new platinum standard in the surgical treatment for Osteoarthritis of the basal joint of the thumb

Simon Weil, Hiba Khan, Aanchal Jain, Ramakrishnan Raghavan, Johnathan Craik, Ritesh Sharma, Najab Ellahee Epsom & St Helier NHS Trust, Epsom, United Kingdom

Abstract

Background

Trapeziectomy is the gold standard surgery for thumb basal OA, but complications occur and there is no consensus on successful salvage surgery. In an era where treatment for OA is rising significantly and patient expectations are increasing, an improved standard is required.

Arthroplasty, although controversial for its cost, has higher satisfaction rates, faster recovery times and fewer complication rates than initially reported.

Methods

Patients were identified prospectively from a single surgeon’s practice over a 10 year period. Pre and post-operative Quick-DASH and patient satisfaction scores were obtained by questionnaire. Frequency of complications and details of further surgery were determined from patient notes.

Results

100 trapeziectomy procedures and 110 thumb cmc joint arthroplasties (uncemented implant with ball and socket articulation) were assessed over 10 years.  Questionnaire response was over 75% for both groups and any incomplete responses were excluded, as were patients with pantrapezial symptoms.

Patients undergoing arthroplasty had significantly worse pre-operative DASH scores. Both treatments resulted in significant improvements in scores, with no statistical differences in postoperative scores. In the arthroplasty group, patients were more satisfied with treatment, returned to function sooner and would undergo treatment again.

The arthroplasty group presented with earlier complications, mainly dislocation (6%). Implant survival was over 93% with no deep infections. The trapeziectomy group presented with later complications relating to pain, reduced ROM and functional deterioration.

Post hoc analysis was performed matching patients according to pre-operative Quick-DASH scores, demonstrating significantly better post-operative function following arthroplasty. 

Conclusion

Both procedures are effective surgical options for thumb CMCJ osteoarthritis. Arthroplasty offers potential advantages in terms of post-operative function, patient satisfaction and return to work.

Streamlined Hand Surgery Service in a Day surgery setting – Evolution from Pandemic

Sheela Vinay, Thomas Knapper, Suzanne Tolley, Wing Man, Andrew Bebbington, Frederik Schreuder, Dougie Russell  Swansea Bay University Health Board, Swansea, United Kingdom

Abstract

Background  

Hand surgery as a speciality often is outcompeted by other specialities for operating theatre time especially when healthcare is under pressure like during and following the recent pandemic. There has been an increasing need for service reconfiguration in Hand surgery.  A new Streamlined Hand surgery service model was developed in our trust for use in our Day Surgery Unit during the first wave of covid-19 with key changes like no covid screening for patients, direct bookings from VFC, Consultant-led or supervised operating by Hand surgeons, well-maintained training opportunities, one anaesthetist providing regional blocks for two theatres and minimising the duration of stay for patients. 

Methodology

Retrospective review of this model from March 2020 to April 2023 using data from our Operating theatre system.

Results

3750 hand surgical cases have been performed over three year period using 10 to 14 theatre sessions per week between the two theatres. Trauma cases made up 70% of cases. 64% were done under regional anaesthetic and 36% under Local anaesthetic. More than 90% of these lists had allocated trainees. A steady increase in the number of cases is noted every year. No patients contracted COVID.

Conclusion 

This new Model has not only shown that  Hand surgery service can be delivered safely and efficiently in patients using only block or local anaesthetic in a Day case setting but also has maintained a good training opportunity for orthopaedic and plastic surgical trainees even during the pandemic.

Implications   

It is very essential that the service provision within Hand surgery is reformed in accordance with the current need as suggested in a recent UK Guidelines which highlighted the necessity to establish new ways to treat patients outside the main theatre setting.

Variax Xpress plating system for distal radius fracture fixation in day surgery setting during and following the COVID-19 pandemic

Sheela Vinay, Sasan Dehbozorgi, Wing Man, Andrew Bebbington, Suzanne Tolley, Dougie Russell Swansea Bay University Health Board, Swansea, United Kingdom

Abstract

Background 

The COVID-19 pandemic undoubtedly imposed unprecedented pressure on already scarce acute hospital resources. We developed a service pathway for open reduction and internal fixation (ORIF) of unstable distal radius fractures using standardised implants with regional anaesthetic in a day surgery unit to reduce pressure on beds and theatre resources in acute hospital settings.

Methodology

Retrospective review of Distal radius Volar locking plating from March 2020 to March 2023 at our day surgery unit. None of the patients had pre-op COVID testing. All patients had regional anaesthetic and all the procedures were performed or supervised by consultant hand surgeons. The VariAx Xpress system (Stryker) was used exclusively which has single-use disposable instruments and an implant kit containing an anatomic volar plate and self-tapping screws offering instant accessibility. A standardized post-op rehab protocol was used. 

Results 

A total of 340 cases were performed over the three-year period. 80% of the patients were female with a mean age of 55 years old. The mean time from injury to operative fixation was 14 days. The mean time from the patient entering the operating theatre to the start of the procedure was 5 minutes and the mean operative time was around 55mins. A low complication rate was noted and No patients contracted COVID. 

Conclusion

Our findings support safe surgical management of distal radius fractures in a day surgery unit using regional anaesthesia. Our data demonstrates that optimal utilization of theatre time can be achieved with appropriate implant choice yielding an acceptable outcome and low complications.

Implications

Our pathway for Distal radius ORIF shows a Service change that’s in keeping with the suggestions in a recent Guidelines which highlighted the need for new ways to treat patients outside the main theatre setting.

Disclosure

The Senior author has an educational and consultancy role with Stryker.

Abu Saeed¹, Tahir Khaleeq¹, Usman Ahmed², Randeep Ajula³, Tarek Boutefnouchet⁴, Peter D’Alessandro⁵, Shahbaz Malik^{2 1}Robert Jones and Agnes Hunt Orthopaedic Hospital, Oswestry, United Kingdom. ²Worcestershire Acute Hospitals NHS Trust, Worcester, United Kingdom. ³University Hospitals of Leicester NHS Trust, Leicester, United Kingdom. ⁴University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom. ⁵Medical School, Discipline of Surgery, University of Western Australia,, Perth, Australia

Abstract

Introduction 

Total knee arthroplasty (TKA) can be performed with either conventional off-the-shelf (OTS) or customised individually made (CIM) implants. The evidence for CIM implants is limited and variable and the aim of this review was to compare clinical and radiological outcomes between CIM and OTS implants. 

Methods

A systematic review and meta-analysis were conducted in accordance with PRISMA guidelines. Studies reporting on clinical, radiological or alignment outcomes for CIM and OTS implants were selected. The studies were appraised using the Methodical index for non-randomised studies tool.

Results

23 studies fulfilled the inclusion criteria. The studies comprised 2,856 CIM and 1,877 OTS TKAs.

Revision rate was higher with CIM (5.9%) compared to OTS (3.7%) implants [OR 1.23, (95% CI 0.69 – 2.18)]. Manipulation under anaesthesia (MUA) was higher in CIM (2.2%) compared to OTS (1.1%) group [OR 2.95(95% CI 0.95–9.13)] and complications rate was higher in CIM (5%) vs. OTS (4.5%) [OR 1.45(95% CI 0.53-3.96)] but neither reached statistical significance. Length of stay was significantly shorter in CIM group 2.9 days vs. 3.5 days [MD -0.51(95% CI -0.82- -0.20)]. Knee Society Score showed no difference between CIM and OTS groups for Knee 90.5 vs. 90.6 [MD -0.27(95% CI -4.27– 3.73)] and Function 86.1 vs. 83.1 [MD 1.51(95% CI -3.69–6.70)]. There was no significant difference between post-operative ROM between PSI (117.3°) vs. OTS (115.0°) [MD 0.02 (95% CI -1.70 – 1.74)].

Conclusion

CIM implants in TKA have theoretical benefits over OTS prostheses. CIM implants were associated with higher revisions, MUA, and overall complication rates. There was no difference in outcome scores and CIM implants did not improve target alignment. The findings of this review do not support the general utilisation of CIM over OTS implants in TKA.  

Simone Castagno, Mark Birch, Mihaela van der Schaar, Andrew McCaskie University of Cambridge, Cambridge, United Kingdom

Abstract

Introduction

Precision health aims to develop personalised and proactive strategies for predicting, preventing, and treating complex diseases such as osteoarthritis (OA). Due to OA heterogeneity, which makes developing effective treatments challenging, identifying patients at risk for accelerated disease progression is essential for efficient clinical trial design and new treatment target discovery and development.

This study aims to create a trustworthy and interpretable precision health tool that predicts rapid knee OA progression based on baseline patient characteristics using an advanced automated machine learning (autoML) framework, "Autoprognosis 2.0".

Methods

All available 2-year follow-up periods of 600 patients from the FNIH OA Biomarker Consortium were analysed using “Autoprognosis 2.0” in two separate approaches, with distinct definitions of clinical outcomes: multi-class predictions (categorising disease progression into pain and/or radiographic progression) and binary predictions. Models were developed using a training set of 1352 instances and all available variables (including clinical, X-ray, MRI, and biochemical features), and validated through both stratified 10-fold cross-validation and hold-out validation on a testing set of 339 instances. Model performance was assessed using multiple evaluation metrics. Interpretability analyses were carried out to identify important predictors of progression.

Results

Our final models yielded high accuracy scores for both multi-class predictions (AUC-ROC: 0.858, 95% CI: 0.856-0.860) and binary predictions (AUC-ROC: 0.717, 95% CI: 0.712-0.722). Important predictors of rapid disease progression included WOMAC scores and MRI features. Additionally, accurate ML models were developed for predicting OA progression in a subgroup of patients aged 65 or younger.

Conclusions

This study presents a reliable and interpretable precision health tool for predicting rapid knee OA progression using "Autoprognosis 2.0". Our models provide accurate predictions and offer insights into important predictors of rapid disease progression. Furthermore, the transparency and interpretability of our methods may facilitate their acceptance by clinicians and patients, enabling effective utilisation in clinical practice.

Alexander Coombs¹, Abdullah El-Badawey¹, Sanjeev Agarwal², Rhidian Morgan-Jones^{2 1}Cardiff University, Cardiff, United Kingdom. ²Cardiff & Vale University Health Board, Cardiff, United Kingdom

Abstract

Background

A two-stage revision arthroplasty approach with an interim first-stage antibiotic-impregnated Interval Prosthesis (IP) is seen as an advance on static spacers in the treatment of periprosthetic joint infection, allowing greater mobility and function between stages. From our original series of 60 patients treated with an IP (Prasad 2014) a cohort of patients declined the second stage when infection-free, pain-free and with good function. The aim of our study was to follow-up those patients who did not proceed to the second stage.

Methodology

A retrospective analysis was conducted of the 22 patients that did not proceed to the planned second stage revision and retained their IP. The IP used consisted of a standard femur, polyethylene bearing, and occasionally stems or tibial tray with severe bone defects. All operations were performed by a single surgeon (RMJ) between 2001 and 2008 using a standardised surgical protocol.

Results

Nine patients with a long-term IP required a further revision (mean duration from IP to revision: 24.3 months). Five were revised for aseptic loosening, three for infection and one for instability. The remaining thirteen patients required no further revision and retained their IP (5 patients, mean duration IP to present: 191.6 months) or retained their IP until death (8 patients, mean duration IP to death: 45.6 months). The mean follow-up 103 months (range 11-104). 

Conclusion

The long-term use of an IP in infected knee revision can avoid a second operation. Aseptic loosening is the commonest cause of revision surgery, unsurprising as the IP was implanted with a view to explanting at the second stage, using limited fixation and reconstruction techniques. However, the long-term success of an IP adds further weight to the argument for single-stage revision of infected knee replacements in experienced, high-volume units.

What is the clinical value of SPECT-CT in the evaluation of patients with an unexplained aseptic problematic cemented primary Total Knee Replacement?

Daniel Hill, Jonathan Phillips, Ben Waterson, Andrew D Toms Royal Devon University Healthcare Foundation Trust., Exeter, United Kingdom

Abstract

Aim

To determine if SPECT-CT influenced suspected diagnosis and intention to perform revision surgery in patients with an unexplained aseptic problematic cemented Total Knee Replacement (TKR).

Methods

SPECT-CT was performed in patients with a problematic cemented primary TKR with an uncertain diagnosis despite a standardised assessment protocol.  Implant details together with suspected diagnosis and intention to perform revision surgery before and after SPECT-CT were prospectively collected.  SPECT-CTs were reported according to a standardised template.  

Results

123 patients had a SPECT-CT over a four-year period.  Implants were Cruciate Retaining (n=94) and Posterior Stabilised (n= 29), with mean implant age of 6 years (range 2-19 years).  The suspected primary diagnosis before and after SPECT-CT changed in 44% (54/123) following SPECT-CT, while the surgeon’s intention to perform revision surgery changed in 51% (63/123) of cases.  

SPECT-CTs were radiologically summarised as being: 

20% Normal (n=25)                   - 12% Intention to revise (3/25)

55% Possibly abnormal (n=68)   - 32% Intention to revise (22/68)

25% Definitely abnormal (n=30) - 50% Intention to revise (15/30)

Excluding equivocal investigations (i.e. a possibly abnormal investigation) SPECT-CT had a Sensitivity of 83%, Specificity of 59%, Positive Predictive Value of 50%, and a Negative Predictive Value of 88% in predicting surgeons’ intention to perform revision surgery.

Conclusion

SPECT-CT may have a negative predictive value in selected cases of diagnostic uncertainty; however, a lack of specificity may add to uncertainty in these challenging cases.  The discrepancy between the radiologists’ diagnostic suspicion, and surgeons’ diagnosis and intention to perform revision surgery questions the value of radiologically reported abnormalities.  However we find the test very useful when it is negative, and it can be useful when it is positive if it is reviewed by an MDT with experience in its use and an appreciation of other important clinical, serological and imaging information.

Wendy Bertram^1,2, Nick Howells^1,3, Simon White⁴, Emily Sanderson¹, Vikki Wylde^1,2, Erik Lenguerrand¹, Rachael Gooberman-Hill^1,2, Julie Bruce^{5 1}Bristol Medical School, University of Bristol, Bristol, United Kingdom. ²NIHR Bristol Biomedical Research Centre, Bristol, United Kingdom. ³North Bristol NHS Trust, Bristol, United Kingdom. ⁴Cardiff and Vale University Health Board, Cardiff, United Kingdom. ⁵Warwick Clinical Trials Unit, University of Warwick, Warwick, United Kingdom

Abstract

Introduction

Total knee replacement (TKR) is a successful operation for many patients, however 15-20% of patients experience chronic post-surgical pain (CPSP). Many will experience neuropathic characteristics although less in known about the postoperative pain trajectory.

We describe the prevalence and patterns of neuropathic pain in a cohort of patients with CPSP three months after TKR.

Methodology

Between 2016-2019, 363 patients from eight NHS hospitals with troublesome pain,  ≤14 on Oxford

Knee score pain subscale, at three months after TKR were recruited into the Support and Treatment After Replacement (STAR) trial. Self-reported neuropathic pain was assessed at three, nine and fifteen months after surgery using painDETECT and Douleur Neuropathique 4 (DN4).

Results

Mean participant age was 67 years (SD 8.7), 60% female, 94% White. Both measures were completed at 3 months (99%), nine months (91%), 15 months (93%).

At three months post-operative, 53% reported neuropathic pain on painDETECT, 74% on DN4 and 67% had neuropathic pain on lower painDETECT (score ≥ 13, ambiguous/possible). Half (56%) remained in neuropathic pain over the twelve-month follow-up period, 26% reported improvement, and 9% reported new neuropathic symptoms or fluctuated in and out of neuropathic pain (9%). When the painDETECT cut-off score of ≥13(ambiguous/possible) was used, DN4 and painDETECT measures showed similar prevalence rates at each timepoint.

Conclusions

Neuropathic pain is common among patients with CPSP at three months after TKR.

Although symptoms improved over time, one quarter to one half of our cohort continued to report neuropathic symptoms at fifteen months postoperatively. We propose a painDETECT cut-off score of ≥13 be used to identify neuropathic features in the TKR population, used alongside specialist clinical assessment for CPSP (such as the STAR care pathway).

A comparison of the periprosthetic fracture rate of unicompartmental and total knee replacements. An analysis of 108,430 knee replacements from the National Joint Registry of England, Wales, Northern Ireland and Isle of Man and Hospital Episode Statistics databases

Hasan Mohammad^1,2, Andrew Judge³, David Murray^{1 1}University of Oxford, Oxford, United Kingdom. ²Barts Bone and Joint Health, London, United Kingdom. ³University of Bristol, Bristol, United Kingdom

Abstract

Background

Total knee replacement (TKR) and Unicompartmental Knee Replacement (UKR) are the two main surgical treatments for end stage knee arthritis. Periprosthetic fractures are devastating complications of knee replacement associated with substantial morbidity and mortality. It is not known how the fracture rates following TKR and UKR compare. We performed the first matched study comparing long term periprosthetic fracture rates.

Methods  

54,215 UKRs and 54,215 TKRs from the National Joint Registry (NJR) and Hospital Episodes Statistics database were propensity score matched on patient and surgical factors. The International Classification of Diseases Revision code M96.6 was used to identify periprosthetic fractures. Kaplan Meier analysis was used to assess cumulative revision rates up to 10 years postoperatively. Cox regression to compare fracture risk. Hazard ratios (HRs) below 1 indicate a lower risk of fracture in the UKR group. Subgroup analyses were performed in different age groups, body mass index (BMI) categories and sexes. 

Results

The three month fracture rate in the UKR and TKR groups were 0.09% and 0.05% respectively with a

HR of 2.92 (CI 1.56-5.49, p=0.001). After three months, fracture rates were 0.32% and 0.61% with a HR 0.57 (CI 0.47-0.68, P<0.001). Overall at 10 years the cumulative fracture rate after TKR was 1.0% and after UKR 0.6% with an overall HR 0.66 (CI 0.55-0.78, p<0.001). Fracture rates increased with increasing age, decreasing BMI and female sex for both UKRs and TKRs. 

Conclusion/Finding  

During the first three postoperative months the fracture rate following UKR was 0.1% and was about twice as high as after TKR. However over the first ten years the cumulative fracture rate following TKR was 1% and was almost twice as high as after UKR. The fracture rate was particularly high in patients who were over 75 and of normal weight and in females. 

A comparison of the periprosthetic fracture rate of cemented and cementless total knee replacements. An analysis of 44,954 knee replacements from the National Joint Registry of England, Wales, Northern Ireland and Isle of Man and Hospital Episode Statistics databases

Hasan Mohammad^1,2, Andrew Judge³, David Murray^{1 1}University of Oxford, Oxford, United Kingdom. ²Barts Bone and Joint Health, London, United Kingdom. ³University of Bristol, Bristol, United Kingdom

Abstract

Background

Total knee replacement (TKR) is the main treatment option for end stage knee arthritis with over 100,000 TKRs performed in the United Kingdom annually. Periprosthetic fractures are rare but devastating complications often requiring complex surgery with substantial morbidity and mortality. There is concern of increased periprosthetic fracture risk with cementless components given the reliance on interference fit for primary stability. It is not currently known how the periprosthetic fracture risk compares between cemented and cementless TKRs. We performed the first big data matched study comparing cemented and cementless TKR periprosthetic fracture rates.

Method

22,477 cemented and 22,477 cementless TKRs from the National Joint Registry (NJR) and Hospital

Episodes Statistics database were propensity score matched on patient and surgical factors. The International Classification of Diseases Revision code M96.6 was used to identify periprosthetic fractures. Kaplan Meier analysis was used to assess cumulative revision rates up to 10 years postoperatively. Cox regression was used to compare fixation groups. Hazard ratios (HRs) below 1 indicate a lower risk of fracture in the cementless group. 

Results 

Overall during the study period there were no significant differences in fracture rates between cemented and cementless TKRs with a HR 1.14 (CI 0.94-1.37, p=0.20). The three month fracture rate in the cemented and cementless TKR groups were 0.02% and 0.04%. At 10 years the cumulative fracture rate after cemented TKR was 1.2% and after cementless was 1.4%. 

Conclusion/Findings 

The periprosthetic fracture rate following cemented and cementless TKR surgery are low being approximately 1.2% and 1.4% respectively at 10-years. There were no significant differences in periprosthetic fracture rates between cemented and cementless TKRs. We conclude that the fracture risk following cemented and cementless TKRs is equivalent both in the short and long term.

Jason Jia Shyan Ong^1,2, Sue Fen Tan³, Tom Kurien^{1 1}Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom. ²University of Edinburgh, Edinburgh, United Kingdom. ³Sherwood Forest Hospitals NHS Foundation Trust, Sutton-In-Ashfield, United Kingdom

Abstract

Objective

Articular cartilages are avascular and aneural, leading to poor healing potential of chondral lesions. Autologous Matrix Induced Chondrogenesis (AMIC) has been recently introduced as a surgical option that reduces pain and prevents or postpones the need for arthroplasty. This systematic review aims to assess pain and functional outcomes of AMIC in treating chondral knee defects.

Design

Studies with a minimum of 10 patients over a minimum of one year follow-up period, published over the last 10 years, and providing clinical results for AMIC procedures in the knee were included based on PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Methodological quality was assessed using MINORS (Methodological Index for Non-Randomised

Studies) criteria. The meta-analysis compared Lysholm, VAS (Visual Analog Scale), IKDC (International Knee Documentation Committee) and KOOS (Knee Injury and Osteoarthritis Outcome Score) clinical outcome measures at baseline and at follow-up.

Results

Twenty one studies (n =743) were included. The MINORS score demonstrated a moderate quality study design (10 – 14 for non-comparative and 17 – 20 for comparative studies). Mean age was 35.03 +/- 4.7 years and the mean defect size was 3.56 +/- 0.98 cm2. The random effects model analysis produced a clinically significant (p < 0.05) improvement in Lysholm at follow-up from baseline of 30.36 [95% CI (25.80, 34.93)], improvement in VAS at follow-up from baseline of -4.02

[95%CI (-4.38, -3.65)], improvement in IKDC at follow-up from baseline of 34.06 [95% CI (27.5, 40.62)], and improvement in KOOS at follow-up from baseline of 29.47 [95% CI (23.64, 35.29)].

Conclusion

AMIC demonstrated significant improvement in clinical status and functional scoring at follow-up and these benefits were sustained over time. These results correspond to real-life treatment of knee chondral defects as the data was analysed from non-selected patient population. This study, therefore, recommends AMIC in the treatment of chondral knee defects.

Timothy Alton¹, Erik Severson², Marcus Ford³, Ian Leslie⁴, James Lesko⁵, Ronald Delanois^{6 1}Proliance Orthopedics Association, Renton, USA. ²Cuyuna Regional Medical Center, Crosby, USA.³Campbell Clinic Orthopaedics, Germantown, USA. ⁴DePuy Synthes, Leeds, United Kingdom. ⁵DePuy Synthes, Warsaw, USA. ⁶Rubin Institute for Advanced Orthopedics, Baltimore, USA

Abstract

This study assessed the accuracy and early clinical outcomes of TKA using the recently introduced VELYS™ Robotic-Assisted solution. 

A multicenter, prospective non-randomized 1:1 cohort study was conducted at five sites. Subjects underwent TKA with either manual instrumentation or with Robotic-Assistance (RA). RA procedures were the first conducted at each site, therefore, representing the adoption phase for each surgeon. The primary objective was a non-inferiority analysis of the accuracy (actual vs. planned) of the Hip Knee Ankle Angle (HKA) for RA vs. manual, measured via post operative radiographs. The distal femoral v/v, tibial v/v and tibial posterior slope angles were also measured. Adverse events (AEs) and PROMs were collected at 12 weeks. 

One hundred participants were recruited for both manual and RA groups, the mean preoperative demographics and PROM scores were similar. HKA accuracy was statistically non-inferior in the RA group compared to manual control with a 1.5 degree non-inferiority margin (P<0.0001). The accuracy of the angles of individual cuts for the RA group was improved compared to manual (Femoral V/V 1.4 Vs. 2.2, P=0.001, Tibial V/V 1.2 Vs. 1.6, P=0.035, Tibial Slope 1.6 Vs. 2.7, P<0.0001).

Mean PROMs at 12 weeks in the RA group compared to manual were either equivalent (KOOS, EQ5D) or improved (FJS 35.4 Vs. 26.4, P=0.0165; Pain 2.3 Vs. 3.4, P=0.0074). There was no significant difference in the incidence of AEs, however, there was a reduction in the number of AEs requiring intervention within 90 days for RA compared to manual (2 Vs. 13, P=0.0101). 

This study found that the VELYS system can be safely adopted without adversely impacting the long leg alignment. Further it was observed at first follow up that the accuracy of the individual cuts, FJS and the incidence of AEs requiring intervention were improved compared to manual instrumentation.  

Wendy Bertram^1,2, Vikki Wylde^1,2, Nick Howells^1,3, Beverly Shirkey⁴, Tim Peters^1,5, Liang Zhu⁴, Sian Noble¹, Andrew Moore¹, Andrew Beswick^1,2, Andrew Judge^1,2, Ashley Blom⁶, David Walsh^7,8, Christopher Eccleston⁹, Julie Bruce¹⁰, Rachael Gooberman-Hill^{1,2  1}Bristol Medical School, University of Bristol, Bristol, United Kingdom. ²NIHR Bristol Biomedical Research Centre, Bristol, United Kingdom. ³North Bristol NHS Trust, Bristol, United Kingdom. ⁴Bristol Trials Centre, University of Bristol, Bristol, United Kingdom. ⁵Bristol Dental School, University of Bristol, Bristol, United Kingdom. ⁶University of Sheffield, Sheffield, United Kingdom. ⁷Pain Centre, Versus Arthritis/NIHR Nottingham Biomedical Research Centre, Nottingham, United Kingdom. ⁸University of Nottingham and Sherwood Forest Hospitals NHS Foundation Trust, Nottingham, United Kingdom. ⁹Centre for Pain Research, The University of Bath, Bath, United Kingdom. ¹⁰WarwickClinical Trials Unit, Division of Health Sciences, University of Warwick, Warwick, United Kingdom

Abstract

Introduction

15-20% of patients report chronic pain three months after total knee replacement (TKR).

The STAR Care Pathway is a clinically important and cost-effective treatment to improve pain outcomes over 1 year for people with chronic pain at 3 months after TKR.

In a multicentre RCT, the pathway improved pain at 6 and 12 months compared with usual care. This study examined the longer-term clinical and cost-effectiveness of the STAR Care Pathway.

Methodology

Participants enrolled on the trial at one year were contacted a median of four years after randomisation with a questionnaire comprising the same outcomes collected during the trial. 

Co-primary trial outcomes were the Brief Pain Inventory (BPI) pain severity and interference scales, analysed on an ‘as randomised’ basis. 

Electronic hospital informatics data on hospital resource use for the period of one to four years postrandomisation were collected from all eight trial sites. 

Results

Of the 337 participants active at trial completion, 326 had confirmed vital status, and 226 (67%) provided outcome data at a median of 4 years.  The between-group difference in mean BPI severity score was -0.42 (95% CI -1.07, 0.23; p=0.20) and BPI interference was -0.64 (95% CI -1.41, 0.12; p=0.10), favouring the intervention. 

Adjusted mean NHS costs (including original intervention) were £1001 (95% CI -£1236, £3238) lower in the intervention arm, with a 0.94 probability of being cost-effective at a £20k per QALY willingness to pay threshold.

Conclusion

The STAR care pathway continues to be cost-effective at four years with a cost saving of £1001 overall.

The main cost difference is in the first year (£724). While this is smaller between one and four years, it is always in favour of the STAR care pathway

Although the attrition rate leads to an equivocal effect at four years, the effects are not entirely attenuated.

Wendy Bertram^1,2, Vikki Wylde^1,2, Joel Glynn¹, Chris Penfold¹, Amanda Burston¹, Emma Johnson¹, Dane Rayment³, Nick Howells^1,3, Simon White⁴, Rachael Gooberman-Hill^1,2, Katie Whale^{1,2  1}Bristol Medical School, University of Bristol, Bristol, United Kingdom. ²NIHR Bristol Biomedical Research Centre, Bristol, United Kingdom. ³North Bristol NHS Trust, Bristol, United Kingdom. ⁴Cardiff and Vale University Health Board, Cardiff, United Kingdom

Abstract

Introduction

Approximately 15-20% patients report chronic post-surgical pain after TKR. There is a need to develop approaches to reduce chronic pain after total knee replacement. There is an established link between disturbed sleep and pain. We tested the feasibility of a trial evaluating the clinical and costeffectiveness of a pre-operative sleep assessment and complex intervention package for improving long-term pain after TKR.

Methodology

REST was a feasibility multi-centre randomised controlled trial with embedded qualitative study and health economics.

Participants completed baseline measures and were randomised to usual care or the intervention,  a tailored sleep assessment and behavioural intervention package delivered by an extended scope practitioner three months pre-operatively with a follow-up call up at four-weeks. Patient reported outcomes were assessed at baseline, one-week pre-surgery, and 3-months post-surgery.

Key feasibility aims included: recruitment and retention rates; intervention acceptability, adherence, and fidelity; and data completion rates.

Results

57 patients were randomised, 28 to the intervention and 29 to usual care, and 20 had surgery within the study timelines. All patients allocated  the intervention attended an appointment and most engaged with treatment. The intervention group reported improvements in sleep  (Sleep Conditions Indicator) and neuropathic pain (painDETECT) scores.

Participants found the sleep treatments and study processes to be acceptable. The mean cost of the intervention was estimated at £134.45 per patient.

Conclusion

The feasibility study has shown that patient recruitment is feasible, engagement with and adherence to the intervention is high, and the intervention is acceptable to patients and clinicians.

Ciara O'Donnell¹, Hashim Dadah^{2 1}Homerton University Hospital, London, United Kingdom. ²Kingston Hospital, London, United Kingdom

Abstract

Aim

To evaluate clinical outcomes after tranexamic acid (TXA) administration with the aim of reducing blood loss during and after high-tibial osteotomy (HTO) with available clinical evidence. 

Methods  

Systematic search methodology of PUBMED, EMBASE and CINAHL databases was conducted in July 2022. The search workflow was undertaken in adherence to PRISMA guidelines. Inclusion criteria: 1) randomised control trials, cohort or case-control studies. 2) Studies reporting outcomes after TXA administration, of any route, before or after HTO, compared to: placebo, control, different doses or routes. 3) Studies reporting blood loss, including haemoglobin drop, estimated blood loss, transfusion requirement and complications. Excluded: case reports, reviews, abstracts, non-HTO studies, non-human studies and duplicates.

Results

Eleven studies were identified comparing 974 patients. Nine studies had placebo comparison and two used single dose TXA vs multiple doses. All studies reported on post-operative haemoglobin, nine on blood loss. In the 6 TXA vs placebo studies reporting on total blood loss, the TXA group had a pooled, estimated standardised mean difference (SMD) in blood loss of -2.37 [95% CI -3.67, -1.07, P=0.0004]. For haemoglobin drop, on post-operative days 1, 2, and 5 SMDs were: POD1: -0.97 [95% CI -1.19, -0.75 P<0.00001], POD2: -0.74 [95% CI -1.03, -0.46, P<0.00001], POD5: -0.87 [-1.10, -0.64, P<0.00001].

Conclusion

The data demonstrates that TXA administration in HTO significantly reduces blood loss and haemoglobin decrease; results of particular relevance given supply shortages of NHS blood resources. Furthermore, this can greatly improve recovery, complications and post-operative stay.

Patient-reported Outcomes (proms) after Elective Revision Total Knee Arthroplasty (RTKA) in Elderly Patients (>85 years)

Samantha Downie¹, David Ridley², Graeme Nicol¹, Stephen Dalgleish^{1 1}NHS Tayside, Dundee, United Kingdom. ²University of Dundee, Dundee, United Kingdom

Abstract

Introduction

Revision total knee arthroplasty (rTKA) in elderly patients (>85 years) is associated with increased mortality, hospital stay and a high rate (55%) of complications.  The objective was to assess patientreported outcome in elderly patients (>85 years) undergoing elective rTKA.

Methods

A retrospective cohort study of consecutive patients undergoing rTKA at a UK arthroplasty centre from 2001-2022 were compared to a control group (aged 50-79 years) matched for gender, diagnosis & surgery year.  The commonest reasons for revision in elderly patients was aseptic loosening (53/100), infection (21/100) and fracture (7/100).  One-year patient-reported outcome data was available for 64%.  

Results

100 patients underwent rTKA with a mean age of 84 years (range 80-97 years, SD 3) compared to a matched control group of younger patients (mean age 69 years).    Preoperative function was poor, with a mean Oxford knee score (OKS) of 40/100 in elderly and 43/100 in younger patients (p=0.164).  Mean change in OKS at one year was +38/100 (range -28 to +75) for patients over 85 years.

At one-year post-surgery, mean OKS was comparable between elderly and young patients (81 and 84/100 respectively, p=0.289).  The number of patients with severe pain at one year was also comparable (4% elderly and 7% young, p=0.177).  The improvement in OKS for elderly patients was sustained at three (82 95% CI 58-100, 14/100 known) and five years. 

Overall complication rate was 54%.  14% were dead at 1 year and 56% were dead at five-year followup.

Conclusion

Elderly patients undergoing elective revision TKA show a significant mean improvement in Oxford knee score of +38/100 at one year.  This is comparable to younger patients matched for gender and diagnosis and is sustained at three and five years.  

Day Case Knee Arthroplasty - the SWAOC Experience

Robin Jones, Ben Waterson, Keith Eyres, Simon Middleton, Vipul Mandalia, Jonathan Phillips, Andrew Toms Royal Devon and Exeter Hospital, Exeter, United Kingdom

Abstract

Background

The South West Ambulatory Orthopaedic Centre (SWAOC) was developed in line with GIRFT guidance as a cold elective surgical site in order to respond to rapidly-growing waiting times for elective arthroplasty following the COVID-19 pandemic. SWAOC consists of two dedicated orthopaedic theatres, x-ray facilities, an orthopaedic physiotherapy team and two recovery wards designed to allow a day-case or short-stay pathway for suitable patients undergoing arthroplasty and other elective orthopaedic procedures.

This review was designed to assess the performance of, and patient satisfaction with the day case pathway for knee arthroplasty developed at SWAOC.

Methods

All patients undergoing TKA or UKA between the creation of SWAOC and 20/04/2023 were included in this review. Age, sex, ASA grade, procedure, length of admission, successful day of surgery discharge and patient satisfaction were recorded for all patients.

Results

328 patients were identified undergoing 350 procedures. The cohort was majority female (F: n=179, 54.6% M: n=149, 45.4%) with an average age of 68.4 years (range: 46-87 years) mean ASA of 2 (1: 45, 12.9% 2: 273, 78.0% 3: 32, 9.1% 4:0) mean length of stay was 17.8 hours (range: 7.0 - 36.4 hours) with discharge achieved on day of surgery in 201 cases (57.4%) and discharge in under 24 hours in 212 cases (60.6%). 90.0% (n=181) of day case patients found day of surgery discharge acceptable and overall 87.0% of patients (n=304) rated the service as either very good (n=185) or good (n=119). 

Conclusions

With appropriate systems and patient selection, day case knee arthroplasty is safe, achievable and acceptable to patients in the majority of cases. SWAOC has allowed greater throughput of primary arthroplasty patients and created space on operative lists at the main hospital site for higher-risk patients and more complex cases.

Chetan Khatri¹, Conrad Harrison², Nick Clement³, Chloe Scott³, Deborah MacDonald³, Andrew Metcalfe¹, Jeremy Rodrigues^{1 1}University of Warwick, Coventry, United Kingdom. ²University of Oxford, Oxford, United Kingdom. ³Edinburgh Royal Infirmary, Edinburgh, United Kingdom

Abstract

Background

The Oxford Knee Score (OKS) is a 12-item patient reported outcome measurement instrument. It was developed with classical test theory, without testing assumptions such as unidimensionality (all items reflect one underlying factor), appropriate weighting of each item, no differential item function (DIF, different groups answer the same way), and monotonicity (people with higher function have higher score). 

We aimed to establish whether the OKS reflected one latent trait, and thus provide a single score. In addition, we sought to apply item response theory (IRT) to improve the validity of the OKS to contemporary standards to optimise it for ongoing use.

Methods 

Participants undergoing primary total knee replacement (TKR) from a large teaching hospital provided pre-operative and post-operative (6 months) responses for OKS. An exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) were conducted. A graded response model was fitted to the data. 

Results

1288 response patterns were analysed. EFA showed a one factor model, with CFA demonstrating excellent model fit (X2 <0.001, Tucker Lewis Index = 0.96, Comparative fit index = 0.960. The score shows good monotonicity. There was DIF by sex for item 7 (kneeling), with women answering lower scores. When combined, this DIF was not observed in the combined score. A user-friendly, free-touse, web app has been developed to allow clinicians to upload raw data and instantly receive IRT scores and is available at https://conrad-harrison.shinyapps.io/IRTconverter/

Conclusions

The OKS can be used as a unidimensional instrument (and therefore combined into a single score). By using IRT, no alteration is required for the existing instrument, but rather the ‘scoring’ is changed.  

Implications

This adapted score can be retrospectively applied to existing response sets. This study provides IRT parameters that can convert into continuous measurements with greater granularity including individual measurement error.

Chetan Khatri¹, Imran Ahmed¹, Fatema Dhaif¹, Jeremy Rodrigues¹, Martin Underwood¹, Paul Mitchell², Andrew Metcalfe^{1 1}University of Warwick, Coventry, United Kingdom. ²University of Bristol, Bristol, United Kingdom

Abstract

Background

Total knee replacement (TKR) is a major operation. The process of undergoing and recovering from a TKR is complicated, with the hope for symptoms of arthritis improving, balanced with the sequelae of surgery causing new issues. Understanding how people perceive and prioritise these different issues is important in clinical practice and research.

This review aimed to identify aspects of recovery that are important to people after a total knee replacement.

Methods

Studies were identified from Medline, Embase, PsycInfo, Cochrane Library, and Web of Science. This mixed methods review included all original study types (quantitative, qualitative, discrete choice experiments, and mixed method design). Reviews and non-peer-reviewed publications were excluded. Studies with participants (age ≥18 years) who had a primary TKR for osteoarthritis were included. Studies of people with unicompartment knee, patella-femoral or revision knee replacement were excluded. Recovery attributes were extracted from individual papers and grouped into recovery themes, using thematic analysis as a theoretical framework. 

Results

A total of 23 studies with 8404 participants were included with 18 recovery themes developed.  The most frequently identified overarching theme was pain, followed by activities of daily living, mobility (walking), recreational activities, specific functional movements of the knee, use of walking aids, sexual activity, and range of motion of the knee. Medical complications were an infrequently reported theme, however, were deemed to be of high importance. 

Conclusions

Reducing pain, returning to activities and daily living and mobility are the three most important recovery domains for people after TKR. Future research should aim to determine the relative importance of these attributes compared to each other.

Implications

Clinicians should be aware of recovery themes, to ensure they are explored sufficiently when consenting for a TKR.

Early Outcomes Using the ATTUNE® Revision System in Complex Primary Total Knee Arthroplasty (TKA): Results from a Prospective International Multi-Center Study.

Anil Gambhir¹, Piers Yates^2,3, Heiko Graichen⁴, Michael Christie⁵, James Lesko⁶, Paul Lupinacci⁶, Grant Jamgochian^{6  1}Wrightington Hospital, Lancashire, United Kingdom. ²Fremantle Hospital, Fremantle, Australia. ³Murdoch Centre for Orthopaedic Research, Perth, Australia. ⁴Asklepios Klinik Lindenlohe GmbH, Schwandorf, Germany. ⁵Southern Joint Replacement Institute, Nashville, USA. ⁶Johnson & Johnson, New Jersey, USA

Abstract

Background 

The ATTUNE Revision System offers surgeons additional flexibility for use with primary TKA patients that have an advanced disease state or challenging anatomy requiring increased fixation and/or stability. This evaluation presents the two-year implant survivorship and patient reported outcomes from a prospective international multi-center study.

Methods 

Investigators prospectively enrolled N=215 subjects from August 2017 through March 2023 including both Posterior Stabilized Fixed Bearing (PSFB, N=112) and Rotating Platform (PSRP, N=103) designs. The study included subjects undergoing primary knee arthroplasty that necessitated implantation with this implant system to deal with complex anatomy and/or stability issues. Variables of interest included prosthesis combination, cumulative percent revision (CPR) via Kaplan-Meier(KM) methodology, revision reasons, and patient reported outcome measures (PROMs). 

Results 

Demographic analysis demonstrated age (years), BMI, and % female were 62.6(8.9), 36.17(7.9), and 67.9% for PSFB, and 62.5(8.9), 32.3(7.5), and 45.6% for PSRP. The implant configuration with the largest cohort was primary PS femur/revision FB tibial base/primary PSFB insert-(34%). Two-year follow-up in this ongoing study is currently 80.4%(90/112) for PSFB and 58.3%(60/103) for PSRP. Eight revisions occurred prior to 2-year timepoint (2 PSFB, 6 PSRP): infection(4), tendon rupture(1), arthralgia(1), joint instability(1), and limited ROM(1). CPR estimates (95% confidence intervals) were: PSFB: 1.9%(7.4%,.5%); PSRP: 7.4%(15.9%,3.3%). At 2-years, significant improvements were observed compared to pre-operative in PKIP, KOOS-PS, EQ-5D-5L, Health VAS, AKS (p-values<0.001). 

Conclusion 

The complex primary TKA patient often presents unique challenges (e.g. high BMI, severe bone loss, ligamentous instability). The current study limited surgeon selection towards this patient population, to evaluate management of their care using a Revision TKA system. The 2-year results demonstrate high implant survivorship and improved outcomes compared to baseline in patients with complex primary TKA managed with the ATTUNE Revision system. 

The effect of obesity on functional outcome scores and risk of revision after primary total knee arthroplasty (TKA): A systematic review and meta-analysis

Henry Searle^1,2, Jamaal Choudhry¹, Austin Gomindes¹, Simran Sehdev¹, Chetan Khatri², Andy Metcalfe^2,1, Fatema Dhaif^{1,2  1}University Hospitals Coventry and Warwickshire NHS Trust, Coventry, United Kingdom. ²Warwick Clinical Trials Unit, Warwick, United Kingdom

Abstract

Background

Obesity is increasing in prevalence worldwide and is a major cause for knee osteoarthritis. Literature suggests that people with obesity may have a higher risk of complications and many clinical commissioning groups restrict access to Total Knee Arthroplasty (TKA) based on Body Mass Index (BMI). The aim of this systemic review is to quantify the effect of obesity on patient reported outcome measures (PROMs) and risk of revision.  

Methods

A systematic review of MEDLINE, Embase and Web of Science was performed. Cohort and casecontrol studies which reported validated PROMs or risk of revision for any cause comparing obese (BMI ≥30) and non-obese (BMI<30) participants were included. Abstract screening, data extraction and analysis were performed independently by two review authors. Meta-analysis was performed using a random effects model. 

Results

19 studies (700,680 participants) were included in the final analysis.  The pooled risk ratio of studies reporting revision at greater than 12 months was 1.02 (95% confidence interval (CI) 0.83 to 1.25; 13 studies, 699,938 participants; I²=93%). The pooled risk difference was 0.00 (95%CI -0.00 to 0.01). 

The standardised mean difference (SMD) of studies reporting PROMs at greater than 12 months was 0.00 (95% CI -0.47 to 0.48;  7 studies, 1,093 participants; I²=95%). Re-expressing the SMD into the Knee Society Function Score, the mean difference was 0.00 (95% CI -12.12 to 12.38). 

Conclusion 

People with obesity have similar risk of requiring revision for any cause at 12 months. They have a similar post-operative function, as measured by validated PROMS, at 12 months compared with nonobese people.

Implications 

People with obesity can be counselled appropriately about their risk of requiring revision and the potential benefit from receiving a TKA. Commissioning groups should consider these risks when making decisions about access to TKA.

Robotic Arm-assisted versus Manual (ROAM) total knee replacement: a randomised controlled trial

Nick Clement¹, Steven Galloway², Jenny Baron², Karen Smith², David Weir², David Deehan^{2  1}Edinburgh Orthopaedics, Edinburgh, United Kingdom. ²Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle, United Kingdom

Abstract

Aims

The primary aim was to assess whether robotic total knee arthroplasty (rTKA) had a greater early knee specific outcome when compared to manual TKA (mTKA). Secondary aims were to assess whether rTKA was associated with improved expectation fulfilment, health-related quality of life (HRQoL), and patient satisfaction when compared to mTKA.

Methods 

A randomised controlled trial was undertaken and patients were randomised to either mTKA or rTKA. The primary objective was functional improvement at 6-months. One hundred patients were randomised, 50 to each group, of which 46 rTKA and 41 mTKA patients were available for review at 6-months following surgery. There were no differences between the two groups.

Results

There was no difference between rTKA and mTKA groups at 6-months according to the WOMAC functional score (mean difference (MD) 3.8, 95% CI -5.6to13.1, p=0.425). There was a greater improvement in the WOMAC pain score at 2-months (MD 9.5, 95% CI 0.6to18.3, p=0.037) in the rTKA group, however by 6-months no significant difference was observed (MD 6.7, 95% CI -

3.6to17.1, p=0.198). The rTKA group were more likely to achieve a minimal important change in their WOMAC pain score when compared to the mTKA group at 2-months (n=36;78.3% vs n=24;58.5%, p=0.047) and at 6-months (n=40;87.0% vs n=29;69.0%, p=0.041). There was a trend towards (p=0.109) higher satisfaction in the rTKA group (97.8%;n=46/47) compared to the mTKA group (87.8%;n=36/41) at 6-months. There were no differences in EQ-5D utility gain (p≥0.389) or fulfilment of patient expectation (p≥0.0.54) between the groups.

Conclusion

rTKA was associated with a greater improvement (2-months) and a higher likelihood of achieving a clinically important change in knee pain at (2&6-months) and a trend towards higher satisfaction when compared to mTKA, but no differences in knee specific function, HRQoL or expectation fulfilment were observed.

Bicruciate total knee arthroplasty using Vanguard XP - 5 year review.

Felix Morriss, James Murray Southmead Hospital, Bristol, United Kingdom

Abstract

Background

Total knee arthroplasty (TKA) is the accepted treatment for end-stage knee arthritis, with a number of design rationales available. Bicruciate TKA was designed in the 1970s and a series of Cloutier knees in the 1980’s had high failure rates for implant fracture, but the ‘survivors’ performed well at 20 years. This led to the design of the Vanguard XP knee and the ALLIKAT trial.

Methods

Thirty two BCR Vanguard XP arthroplasties were implanted into 29 patients from 2017 to 2018. This cohort was followed-up at 4-5 years to assess clinical outcome and revision rate. Patient-reported outcome measures were scored pre- and post-operatively.

We age-sex matched the Vanguard cohort to a 5 year follow-up of 18 Genesis CR TKA MIS recipients over a comparable time course.

Results

Within our Vanguard cohort, 23 patients with 25 implants were successfully reviewed at the 4-5 year interval.

 The mean pre-operative OKS was 26.7 (n=26) compared to 42.8 (n=25) post-operatively at the 4-5 year interval for our respondents. 

The mean OKS for the matched Vanguard XP and Genesis MIS cohorts were 41.17 and 35.89 respectively (p=0.0626, CI -0.29 to 10.85).

Conclusion

 Our Vanguard XP cohort showed substantial improvement in functional outcomes for the vast majority of patients. Our data showed no difference in implant survivorship at 5 years compared to minimally-invasive TKA analogous to the BCR technique.

Implications 

Our data suggest that the BCR performs equally well and may be superior on PROMs to conventional TKA with no difference in 5 year survivorship. Future cohort follow-up will be important as further BCR designs are developed.

Disclosure

No conflicts of interest. JRM has educational consultancies with Smith & Nephew and Zimmer

Early Outcomes Using the ATTUNE® Revision System in Revision Total Knee Arthroplasty (RTKA): Interim Results from an International, Multi-center, Post-Market Study

Anil Gambhir¹, Michael Hirschmann², Heiko Graichen³, Christie Michael⁴, James Lesko⁵, Paul Lupinacci⁵, Sukhjeet Kaur^{5  1}Wrightington Hospital,Wrightington, Wigan and Leigh NHS Trust, Wigan, United Kingdom. ²Kantonsspital Baselland, Bruderholz, Switzerland. ³Asklepios Klinik Lindenlohe GmbH, Schwandorf, Germany. ⁴Southern Joint Replacement Institute, Nashville, USA. ⁵DePuy Synthes, Warsaw, USA

Abstract

Introduction

There are few short or medium-term results reported for ATTUNE Revision system. Due to its compatibility with ATTUNE primary system, partial revisions can be performed. This interim evaluation presents clinical performance and survivorship of two-year data of full and partial revisions.

Materials+Methods

From Dec 2017 through March 2023, 37 investigators prospectively enrolled N=360 into this noncomparative study: Posterior Stabilized Fixed Bearing (PSFB, N=135) or Rotating Platform (PSRP, N=225). Two-year outcomes were compared to preoperative using t-test and survivorship was computed using Kaplan-Meier(KM) methodology.

Results

Age and BMI were similar for both configurations: 64.7(8.8) and 31.5(5.8) for PSFB and 65.6(7.9) and

32.4(6.3) for PSRP. Gender was 57.0% female in the PSFB group and 47.6% in PSRP. There were 127(94.1%) full and 8(5.9%) partial revisions in PSFB cohort and 212(94.2%) full and 13(5.8%) partial revisions in PSRP cohort. PSFB had the following utilization: femoral stem(85.2%), femoral sleeve(5.2%), tibial stem(97.8%); tibial sleeves are not available for PSFB. For PSRP, utilization was: femoral stem(83.1%), femoral sleeve(51.1%), tibial stem(90.2%) and tibial sleeve(88.0%). Two-year follow-up is currently 65.9%(89/135) for PSFB and 80.9%(182/225) for PSRP. There were 9 rerevisions (removal of any component) prior to 2-years (2 PSFB, 7 PSRP). Reasons for re-revisions included: infection(5), peri-prosthetic fracture (1), suture rupture(1), hematoma(1), and device loosening(1). The resulting KM survival at 2-year (95% confidence intervals) for PSFB was

98.4%(93.6%, 99.6%) and 96.8%(93.4%, 98.5%) for PSRP. Significant improvements (p<0.001) were observed at 2-years compared to preoperative in PKIP, KOOS-PS, EQ-5D-5L, Health VAS, AKS. 

Conclusion

These early results suggest PS ATTUNE Revision system is well-tolerated and provides good patient- and surgeon-reported outcomes at two-years with no evidence of design issues leading to early mechanical failures.

Gregory Hodgson¹, Jad Wehbe¹, Samantha Jones¹, Irrum Afzal¹, Nick Clement^1,2, Deiary Kader^{1,3  1}SWLEOC, London, United Kingdom. ²Edinburgh Royal Infirmary, Edinburgh, United Kingdom. ³University of Kurdistan Hawler, Kurdistan, Iraq

Abstract

Demand for primary total knee replacement (TKR) is expected to increase in future years, particularly within the elderly population with emphasis on improving quality of life. The aim of this study was to compare patient-reported outcome measures of elderly patients undergoing primary TKR with a standard age group.

A retrospective cohort study of prospectively collected data, comparing outcomes of TKR in elderly patients (≥80 years old) with a comparative group (65 to 75 year old) was performed. All primary TKR performed between 2010-2019, with complete pre and post-operative Oxford Knee Score (OKS), EQ-5D and outcome satisfaction (OS) at 2-years were analysed, using SPSS.

There were 1491 TKRs performed in the elderly and 4150 in the comparative group. The elderly group were more likely to be female (p<0.001), have a greater ASA grade (p<0.001) and have worse joint-specific knee function preoperatively (p=0.023), although this did not reach clinical significance. Both groups had a statistically (p<0.001) and clinically significant improvement in post-operative OKS and EQ-5D. No clinically significant difference between the groups was observed in the OKS, EQ-5D and OS post-operatively. When adjusting for confounding factors (Sex, Index of Multiple Deprivation, ASA grade, date of surgery, pre-operative OKS and EQ-5D) the elderly group was independently associated with worse post-operative OKS (-0.9, p=0.001) and EQ-5D (-0.018, p=0.001), although these were not clinically significant. The elderly group had a longer length of stay compared to the comparative group (5.6 versus 4.6 days, p<0.001). When adjusting for confounding factors listed above, the elderly groups was associated with an increased length of stay (0.8 days, p<0.001).

Patients 80 years and older should not be precluded access to TKR, as they benefit from the clinically similar improvement in their functional outcome. However, they should be aware of the potential of increased length of stay and perioperative complications.

Evaluation of changes in fixed flexion deformity in patients undergoing robotic-arm assisted medial unicompartmental arthroplasty; a prospective cohort study.

Warran Wignadasan, Ahmed Magan, Babar Kayani, Andreas Fontalis, Vishal Rajput, Fares Haddad University College London Hospital, London, United Kingdom

Abstract

Background

Unicompartmental knee arthroplasty (UKA) is an effective surgical treatment for patients with single-compartment knee arthritis. Residual fixed flexion deformity (FFD) has been shown to be associated with inferior functional outcomes. There is paucity in the literature concerning changes in FFD following UKA. The primary objective of this study was to assess alterations in FFD in patients undergoing medial UKA with robotic arm-assistance.

Methods          

This prospective cohort study included 134 patients (73 males and 61 females with a mean age of 62

± 5.7 years) undergoing robotic-arm assisted UKA at a single tertiary centre between 2018 and 2022. Patients were divided into four study groups based on the degree of preoperative FFD: 0.5-3 degrees, 3–6 degrees, 6-9 degrees, and >9 degrees. Intraoperative optical motion capture technology was used to assess pre- and postoperative FFD.   The Oxford Knee Score (OKS) was assessed in all patients pre-operatively and at one-year follow-up. 

Results

A statistically significant reduction in the post-operative FFD for each of the four treatment groups was evident compared to pre-operative FFD: : 0.5-3 degrees group (mean pre op FFD = 1.380, post op FFD = 0.460, P = 0.023), 30 – 60group (mean pre op FFD = 4.250, post op FFD = 1.900, P = <0.001), 60 – 90 group (mean pre op FFD = 7.110, post op FFD = 3.630, P < 0.001), >90 group (mean pre op FFD = 11.00, post op FFD = 6.370, P < 0.001). All treatment groups showed a statistically significant improvements from preoperative to postoperative OKS (p<0.001) at one year follow-up. 

Conclusion

This is the first study to use optical motion capture technology to quantify the change in FFD during robotic-arm assisted medial UKA. These findings provide insight into the utility of UKA and could inform the discussion regarding clinical criteria for medial UKA.

But how do you feel about your knee? A retrospective cohort study comparing the psychological well-being in patients who are managed operatively versus non-operatively for patella-femoral instability and recurrent patellar dislocation.

Peggy Miller¹, Daniah Alsaadi¹, Ryan Roopnarinesingh¹, Daniel McKenna¹, Gavin Calpin², Martin Kelly¹, Fiachra Rowan^{1  1}University Hospital Waterford, Waterford, Ireland. ²Royal College of Surgeons Ireland, Dublin, Ireland

Abstract

Background  

Patellar dislocation represents 3% of all knee injuries. (1) It is the disarticulation of the patella from the patellofemoral joint. A significant proportion of these injuries are seen in young patients with ligamentous laxity or bony malalignment. (2) Recurrence rates are high, and the burden of these injuries  pre-disposes this cohort to chronic knee pain and reduced quality of life.(3) 

Methods

All patients with recurrent patella dislocation referred to our service over a 4 year period were reviewed. Patients were divided into an operative and non-operative (protocolised physiotherapy) arm based on their treatment. Using the Banff Patellar Instability Instrument and the International Knee Documentation Committee (IKDC) Subjective Knee score, post-treatment patient reported outcomes (PROs) in both groups were analysed. Through these scoring systems, psychological wellbeing of both patient cohorts were assessed. 

Results 

144 patients with recurrent instability were reviewed in our centre between 2018-2022. Female patients represented 49% of the overall population. Average age for our patients was 21 years old.

111 of these were managed operatively with 60 patients having Medial Patello-femoral ligament (MPFL) reconstruction and 14 having a Tibial Tubercle Osteotomy (TTO). 33 patients had nonoperative treatment with protocolised bracing and physiotherapy. 

Conclusion

A significant psychological burden is associated with recurrent patellar dislocation. Patients who undergo surgical fixation have higher satisfaction scores, PROs and overall quality of life compared to those managed non operatively.

1.           Fithian DC et al. Epidemiology and natural history of acute patellar dislocation.

2.            Atkin DM, et al. Characteristics of patients with primary acute lateral patellar dislocation and their recovery within the first 6 months of injury. 

3.            Balcarek P et al and physical health-related quality of life in patients with recurrent patellar dislocations—a generic and disease-specific quality of life questionnaire assessment. 

Peter Cnudde^1,2, Jonatan Nåtman¹, Ola Rolfson^1,3, Nils Hailer^{1,4  1}Swedish Artrhoplasty Register, Gothenburg, Sweden. ²HDUHB, Llanelli, United Kingdom. ³Department of Orthopaedics, Institute of Clinical Sciences, University of Gothenburg, Gothenburg, Sweden. ⁴Department of Surgical Sciences, Uppsala University, Uppsala, Sweden

Abstract

Introduction

Dislocation after elective THA is a well-known complication and a common reason for revision surgery. Whilst registers report on revisions for dislocation, a true dislocation rate following THA is difficult to ascertain. In this study, we explored the dislocation rate, the association between bearing size and type, approach and dislocation, recurrent dislocation, and revision.         

Material and methods

We designed a longitudinal cohort study linking the Swedish Arthroplasty Register with the National Patient Register, including patients with a unilateral elective THA from 1999 to 2014. The total dislocation rate, proportion of patients having reoccurring dislocations, revision rate, and revision rate for instability were recorded. Kaplan-Meier survival analyses and Cox multivariable regression models were fitted to calculate hazard ratios (HR) for the complete cohort and following stratification for approach. 

Results  

145,062 patients with elective unilateral THA and complete data were available for analysis. The dislocation rate was 2.0% after 1 year, while the revision rate due to dislocation was 0.3%. The dislocation rate was higher for posterior (PA) compared to lateral approach (LA) (2.6% versus 1.3% at 1-year). Among patients with PA, a lower risk of dislocation was associated with bearing sizes >32 mm (HR=0.62, CI 0.48-0.80) and dual mobility THA (DMC-THA) (HR=0.22, CI 0.11-0.42). 11.6% of patients with a confirmed dislocation were revised within 1 year with female and younger patients as well as those operated through a LA were more likely to be revised.

Discussion

The dislocation rate after elective THA was expectedly considerably higher than the revision rate for this reason. When using a posterior approach, a bigger bearing size and DMC-THA might be better choices. Among patients with dislocation, those revised within 1 year differed considerably from those non-revised.

Do Full-Length Femoral Radiographs Influence Fixation Method in Neck of Femur Fractures in Patients with Co-existent History of Malignancy?

Thomas MacKinnon, Edward Matthews, Sophia Hashim, Mosab Ahmed, Rajarshi Bhattacharya Imperial College London NHS Trust, London, United Kingdom

Abstract

Background

Aim: In patients admitted with extracapsular neck of femur (NOF) fractures and co-existent history of malignancy, British Orthopaedic Association guidelines recommend pre-operative full-length femur radiographs (FLF-XRs) should be obtained to exclude bony metastases and select the appropriate fixation method. It is unclear whether such radiographs influence the surgeon’s chosen fixation method, even when no metastases are identified. Our primary aim was to identify whether FLF-XRs influenced fixation method in this cohort.

Methods

We performed a retrospective analysis of all patients with NOF fractures that underwent surgical fixation at a major London teaching hospital over a 3-year period (2018-20) using a search of electronic patient records. Data including history of any malignancy, FLF-XR status, fixation method (Intramedullary nail (IMN) or Dynamic hip screw (DHS)) and 1-year morbidity and mortality was collected.

Results

Our results showed that of the 308 extracapsular NOFs admitted during this time period, 23% had a history of malignancy, and of these, 55% had undergone FLF-XRs. Breast cancer was the most common primary co-existent malignancy. After excluding all subtrochanteric fractures (which structurally necessitate IMN fixation), there was no significant difference in fixation method resulting from presence (or absence) of FLF-XRs in either the co-existent malignancy NOF group (p=0.09), nor the without malignancy NOF group (p=0.84). Within the 1-year post-operative follow-up period, none of the NOF patients with co-existent malignancy subsequently re-presented to the study hospital with complications relating to their fracture or surgical fixation. The 1-year mortality rate was 28% amongst this group.

Conclusion

Excluding fracture patterns that necessitate a specific fixation method (subtrochanteric NOFs), the presence of FLF-XRs does not influence the chosen method of fixation method (between IMN and DHS. We concur with existing literature that pre-operative FLF-XRs in NOF patients with co-existent malignancy are a low-value investigation and should not delay surgery.

Dual-mobility acetabular components in primary total hip arthroplasty do not increase the risk of complication compared to conventional articulations: a matched cohort comparative analysis.

Mehnoor Khaliq¹, Neesha Jenkins¹, Bernard Van Duren², Jeya Palan¹, Hemant Pandit¹, Sameer Jain^{1 1}Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom. ²Nottingham University Teaching Hospitals NHS Trust, Nottingham, United Kingdom

Abstract

Background

Dual-mobility (DM) acetabular components reduce the risk of dislocation following total hip arthroplasty (THA) but as per the National Joint registry of England, Wales, Northern Ireland, the Isle of Man and Guernsey 2022 report, there is a higher risk of other complications than conventional articulation THAs. However, the indications and patient population are heterogeneous with multiple confounders, and it is not possible to determine if complications are different in patients with primary hip osteoarthritis (OA). This matched cohort study compares the two-year risk of complications between DM and conventional THA articulations when used in primary OA. 

Methods

Data were collected for consecutive primary THAs via a posterior approach, between January 2017 and June 2020. The conventional and DM cohorts were matched 3:1 for age, gender, ASA grade, BMI, and operative time using a propensity score and nearest neighbour matching method. Outcome measures were two-year local complication, reoperation, systemic complication, and mortality rates. Comparison of outcomes were made using appropriate statistical tests. Cumulative survival rates (%) were assessed using Kaplan-Meier methodology with two-year local complication as the endpoint. Statistical significance was set at p<0.05.

Results

412 THAs were included: 309 conventional and 103 DM articulations. There were no statistically significant differences between matched groups for local complications (7 [6.8%] in DM versus 23 [7.4%] in conventional, p=0.820), reoperations (3 [2.9%] in DM and 4 [1.3%] in conventional, p=0.374), systemic complications (3 [2.9%] in DM and 4 [1.3%] in conventional, p=0.374), or 1 year mortality (1 death in DM [1%] and 8 [2.6%] in conventional p=0.461). Kaplan-Meier survival analysis demonstrated similar two-year survival rates for conventional and DM THAs (93.3% [SE, 0.014] versus 91.9% [SE, 0.031], p=0.906).

Conclusion

In conclusion, from this matched population analysis, there is no difference in clinical outcomes between DM and conventional THA articulations.

Not all A1/A2 are the same: Rotationally unstable trochanteric proximal femoral fractures

Hetta Friend¹, Ignatius Liew², Martyn Parker^{3 1}Cambridge University, Cambridge, United Kingdom. ²Addenbrookes Hospital, Cambridge, United Kingdom. ³Peterborough City Hospital, Peterborough, United Kingdom

Abstract

Rotationally unstable trochanteric proximal femoral fractures are poorly defined within fracture classification systems and the literature. The main characteristics of these fractures are:

1.       A short proximal fragment (femoral head and neck) lying almost horizontally on AP X-ray 

2.       Gross comminution of the greater trochanter

3.       The lesser trochanter may/may not be intact

4.       Lack of lateral support allowing medial displacement of femur

5.       Invariable angulation at fracture site on lateral x-rays

Despite research suggesting these fractures have higher complication rates, inconsistencies in definitions make determining their incidence, complications and optimal management challenging. We hypothesise that this subtype will have higher complication rates than other A1/A2 fractures and consequently investigate its incidence and complication rates. 

We provide a prospectively analysed cohort study reviewing all Peterborough City Hospital patients in the database with hip fractures between May 1989 and April 2001. The 4615 patients with AO/OTA 31A1/A2 intertrochanteric fractures were included. Patients were divided into rotationallyunstable trochanteric type (n=206) and those defined clearly within the 31A1/A2 classification (n=4409). Average follow up in clinic was 12 months with prospectively recorded complications, pain scores and mobility status. 

206 (4.5%) of the 4615 patients with 31A1/A2 fractures were the rotationally unstable subtype. The subtype complication rate (10.19%,21/206) was three times the 31A1/A2 fracture type

(3.42%,151/4409). The 12 month complication rates were significantly higher in the subtype than A1/2 fractures (p<0.00001,chi-squared), including avascular necrosis, metalwork failure, cut-out, late propagation of fracture and non-union. 

Rotationally unstable trochanteric proximal femoral fractures have higher complication rates than other 31A1/A2 fractures. This is possibly explained by instability from limited soft tissue attachments increasing the risk of femoral head rotation, trochanteric comminution and loss of lateral and inner cortical buttresses. Categorising and acknowledging this fracture type will enable focused research into their management to reduce complication rates.

Osteosynthesis of Vancouverr B1, B2 fractures over the last five years, does the treatment algorithm for Vancouverr fractures needs to be reviewed?

Irfan Ahmad, Fouad Chaudhry  Russells Hall Hospital, Dudley, United Kingdom

Abstract

Background

The aim of this study was to review the outcome of periprosthetic hip fractures undergoing osteosynthesis at a DGH hospital over the last five years.

Methods

It was a retrospective review of all cases admitted in a DGH with periprosthetic fractures around hip between April 2017- April 2022.  The data was collected from the hospital database.

Results

149 patients were admitted with periprosthetic Hip fractures (PPHF), 80 (53.69%) female and 69 (46.30%) were male patients. Majority of the patient’s management plan was discussed with the tertiary care hospital via ‘refer a patient pathway’. 27 (18.12%) were accepted by the tertiary centre for revision surgery, 55 (36.91%) were managed non operatively at our hospital considering fracture pattern, or the patient been too unwell to have the surgery, the remaining 67 (44.96%) patients were surgically managed at our hospital. Out of the 57 operated patients, 27 patients had Van B1 fractures and ORIF with Zimmer NCB plate was done, 17 patients had Van B2 fractures and had osteosynthesis and only one patient had revision surgery, 13 patients had Van C fractures and underwent osteosynthesis. Complications included two superficial infections one in Van B1 and one in Van B2, two non-unions and both were reported in Van B1 and two patients were referred to tertiary centre due to re-fracture.

Conclusion

The data showed that not all Vanc B2 fractures needs to be managed with revision and all the B2 fractures managed with osteosyntheses showed satisfactory outcome in terms of function. The existing treatment algorithm advises revision for B2 fractures, but we believe that not all B2 fractures need revision and the algorithm may be modified by subdividing B2 fractures taking into consideration other factors.

Disclosure

The author has no relevant or material financial interests related to the research described in this paper.

Management of Periprosthetic fractures around Hip and Knee in a DGH over the last five years

Irfan Ahmad, Fouad Chaudhry  Russells Hall Hospital, Dudley, United Kingdom

Abstract

Background

The aim of this study was to review the management and outcome of periprosthetic fractures in DGH over the last five years.

Methods

It was a retrospective review of all cases admitted in a DGH with periprosthetic fractures around hip and knee between April 2017- April 2022. The data was collected from the hospital database.

Results

149 patients were admitted with PPF, 80 (53.69%) female and 69 (46.30%) were male patients.Majority of the patient’s management plan was discussed with the tertiary care hospital via ‘refer a patient pathway’. 27 (18.12%) were accepted by the tertiary centre for revision surgery, 55 (36.91%) were managed non operatively at our hospital considering fracture pattern, or the patient been too unwell to have the surgery, the remaining 67 (44.96%) patients were surgically managed at our hospital. Out of the 67 operated patients, 57 patients were treated with ORIF with Zimmer NCB plate following THR or TKR, 10 patients had revision surgeries with revision implants. Most of the patients were discharged from hospital without complications. Complications included two superficial infections, one patella fracture, two non-unions and two patients were referred to tertiary centre after recurrent dislocations. Our data showed that twenty patients out of 149 have passed away but that is unrelated to fracture treatment.

Conclusion  

The data shows that PPF’s presented to a DGH requiring ORIF or revisions can be managed locally, and results show acceptable patient’s outcome with minimal complications.

Disclosure

The author declares that he has no relevant or material financial interests that relate to the research described in this paper.

Ahmed Nasser, Rohan Prakash, Charles Handford, Khabab Osman, Govind Singh Chauhan, Rajpal Nandra, Ansar Mahmood, The PPF Study Collaborative  The Birmingham Orthopaedic Network, Birmingham, United Kingdom

Abstract

Background

Periprosthetic fractures (PPFs) around the hip joint are increasing in prevalence. This study investigated the impact of patient demographics, fracture characteristics, and management modalities on in-hospital mortality.  

Methods 

Using a multi-centre national collaborative study design, we identified adults presenting with a PPF around the hip over a 10 year period. Univariate and multivariable logistic regression analyses were performed to study the independent correlation between patient, fracture, and treatment factors on mortality.  

Results 

A total of 1,109 patients were included. The in-hospital mortality rate was 5.3%. Multivariable analyses suggested that age, male sex, abbreviated mental test score (AMTS), pneumonia, renal failure and a history of peripheral vascular disease (PVD) were each independently associated with mortality. Each yearly increase in age independently correlates with a 7% increase in mortality (OR 1.07, p=0.019). Patients with PVD have a six-fold greater mortality risk (OR 6.06, p=0.003). Mode of treatment was not a significant predictor of mortality. 

Conclusion 

In PPFs around the hip, certain modifiable patient factors should be carefully optimised, such as taking steps to reduce the risk of developing pneumonia or renal failure. Mortality rates are similar to the neck of femur fracture population, and a national PPF database as well as standardised management guidelines are currently needed. 

Andreas Fontalis^1,2, Babar Kayani¹, Jenni Tahmassebi¹, Alastair Chambers¹, Dia Eldean Giebaly^1,2, Ricci Plastow¹, Fares S Haddad^{1,2  1}Department of Trauma and Orthopaedic Surgery, University College London Hospitals NHS Foundation Trust, London, United Kingdom. ²Division of Surgery and Interventional Science, University College London, Gower Street, London, WC1E 6BT, London, United Kingdom

Abstract

Background

Accurate implant positioning and restoring native hip biomechanics are key surgeon-controlled, technical objectives in Total Hip Arthroplasty. The primary objective of this study was to compare the reproducibility of the planned preoperative centre of hip rotation (COR) in patients undergoing robotic-arm assisted THA versus conventional THA. Secondary objectives were to ascertain the accuracy in achieving the planned combined offset, acetabular cup orientation and leg-length correction.

Methods  

This prospective randomised controlled trial included 60 patients with symptomatic hip osteoarthritis, randomly allocated in a 1:1 ratio, to conventional THA or robotic-arm assisted THA(RO THA). Patients in both arms underwent pre-and post-operative CT scans and a patient-specific threedimensional plan was created, utilising the robotic software. The COR, combined offset, acetabular cup orientation and leg length discrepancy were measured on the pre-and post-operative CT scanogram at six weeks following surgery. 

Results 

Baseline characteristics were comparable between the groups. The mean absolute error for achieving the planned horizontal and vertical COR in the RO THA group was 1.9mm (1.3) and 1.4mm (1) versus 4.2mm (2.25),p<0.001 and 3mm (4), p=0.03 in CO THA. The post-operative mean leg length discrepancy was 0.75mm(0.91) in the RO THA versus 1.4mm(1.2), p=0.02. The root mean square for achieving the planned anteversion and inclination in the RO THA group were 2.9 and 2 versus 8.6 and 7. Patients in the RO THA group achieved a more accurate restoration of the combined offset, p=0.01.

Conclusion

This RCT showed that RO THA was associated with improved accuracy in restoring the native COR, better preservation of the combined offset and leg length correction. Differences were particularly pronounced in relation to achieving the desired acetabular cup positioning. Looking at longer-term and registry data, will be key to evaluating whether the above findings translate to improved implant survival and superior outcomes.

Alexander Yan¹, Angela Yan¹, Lee Hoggett², Anthony Helm^{2 1}Lancashire Teaching Hospital NHS Foundation Trust, Manchester, United Kingdom. ²Lancashire Teaching Hospital NHS Foundation Trust, Preston, United Kingdom

Abstract

Background

The increased amount of torque required to dislocate dual mobility (DM) acetabular components may increase peri-prosthetic femoral fracture (PPF) risk. Literature on this topic often relies on revision as an endpoint and may underestimate PPF. The aim of this study was to review PPF rate, risks and treatment following primary DM implantation.

Methods

A prospective cohort study of 549 patients following a primary DM total hip arthroplasty (THA) between 2013 and 2021. Information was collected on demographics, indication for surgery, cortical index and PPF. 

Results  

549 patients with a primary DM THA were included. Mean age was 73 years (26-96). 446 (81.2%) patients had their index surgery following hip fracture. 18 patients (3.27%) sustained a PPF. The cumulative rate of PPF was 1.5% at 1 year, 2.2% at 5 years and 3.27% overall. PPF was higher in patients who had surgery following hip fracture (4%) vs.other indications (1%). OR 4.04 (95% CI: 0.53, 30.72), p=0.219. There was no significant difference in age at index procedure and PPF p=0.540. Mean cortical index was lower in patients with subsequent PPF 0.4 (95% CI: 0.36, 0.45) compared to those without 0.46 (95% CI: 0.45, 0.46) p=0.029. Treatment for PPF included 10 (55.6%) open reduction internal fixation (ORIF), 7 (38.9%) revision THA and 1 conservatively managed.

Conclusion

PPF rate following DM use is higher in our cohort than published rates following THA. Our rates are comparable to some papers when subgroup analysis of age and cemented taper slip stems are taken into account. Risk of PPF with DM may be increased in patients undergoing surgery after hip fracture or with a lower cortical index preoperatively. Over half of PPF were managed with ORIF and may mask PPF risk in studies that report using revision as an endpoint. 

James Murray, Rathan Jeyapalan, Mike Davies, Ciara Sheehan, Michael Petrie, Tim Harrison Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom

Abstract

Background

Total Femoral Replacement (TFR) is a rare procedure used in cases of significant femoral bone loss; most commonly from cancer, infection and trauma. Low patient numbers have resulted in limited published work on long-term outcomes, and even less for non-oncological indications. The aim of this study was to evaluate the long-term clinical outcomes of all TFRs in our unit.

Methods

Data was collected retrospectively from a tertiary-referral revision arthroplasty unit’s database. Inclusion criteria included all patients who underwent TFR in our unit. Pre-operative demographics, operative factors, and short and long-term outcomes were collected. Outcome was defined using the MSIS outcome reporting tool.

Results

38 TFR were identified. The mean age was 73 years (range 42-80). All patients underwent TFR for non-oncological indications, most commonly as a consequence of infection (53%) and periprosthetic fracture (26%). The mean follow-up time was 10 years (range 0-26). 63% of TFR were considered a success based upon the MSIS outcome reporting tool. The average time between TFR and death was 8.5 years, with two patients dying within 12 months of surgery. 66% of the cohort suffered at least one complication; dislocation being most common (37%), and 55% of the total cohort required at least one subsequent operation. 70% of TFR undertaken for infection were considered infection-free at time of final follow-up. The percentage of mobile patients improved from 52% to 65% between pre- and post-op status, with all patients being able to at least transfer at time of final review.  

Conclusion / Findings

This is the largest study in the UK assessing the use of TFR in patients with bone loss secondary to non-oncological pathology. It demonstrates that TFR has a significant complication profile, however, it is favourable in terms of mortality and rehabilitation when compared to its alternatives; amputation and disarticulation. 

Jad Wehbe¹, Gregory Hodgson¹, Samantha Jones¹, Irrum Afzal¹, Nick Clement^1,2, David Sochart^{1 1}South West London Elective Orthopaedic Centre, London, United Kingdom. ²Royal Infirmary of Edinburgh, Edinburgh, United Kingdom

Abstract

Introduction  

As the population ages, the proportion of elderly patients requiring total hip arthroplasty (THA) is increasing and many older patients ask if their age will preclude them being offered surgery. We compared functional and quality of life outcomes at 2 years following THA in patients aged 80 and above, with a cohort of younger patients. 

Methods

A retrospective analysis was performed of a prospectively collected database of 5268 THA performed between 2011 and 2019, with complete outcomes data. 1509 THA were performed on patients aged 80 and above (28.7%) and 3759 in patients aged 65 to 75 (71.3%). Demographic data and pre-operative PROMS were assessed, as well as two-year post-operative EuroQol (EQ5D), Oxford Hip Scores (OHS) and Outcome Satisfaction Scores (OSS). Statistical regression analyses were performed to adjust for confounding factors.  

Results

Older patients were more likely to be female and have a higher ASA grade. Pre-operatively, the older group had a lower quality of life (EQ5d difference: 0.081), but achieved comparable improvement in EQ5d 2 years post-operatively when adjusting for confounding variables. The pre-operative OHS were similar (Older 19.2, Younger 21.3) and once again there was an equivalent post-operative improvement when adjusting for confounders. Older patients had more medical comorbidities and increased average hospital stay (1.1 days), which probably contributed to lower Outcome Satisfaction Scores (Older 89.6; Younger 91.6). 

Conclusions  

When adjusting for confounding variables, patients aged 80 and above achieved equivalent results with regards to function and quality of life after 2 years of follow-up, when compared to a younger cohort of patients aged 65 to 75. 

Implications

These results, based on a large patient population, confirm that age in itself, should not be a barrier to offering THA to older patients, and can also be used during the consenting process.  

Thomas Ward, Myrto Vlazaki, Sari Al Hajaj, Faizal Rayan,Srinivasan Shyamsundar, Kettering General Hospital, Kettering, United Kingdom

Abstract

Background

Hip fractures are common with over 60,000 recorded in 2021. In the UK the best practice tariff (BPT) outlines the expected management of hip fracture care. COVID-19 had a significant impact on patient care and the long term sequalae  is not yet fully understood, and whether hospitals have recovered to pre-pandemic performance.

Methods

Retrospective study of patients admitted between 2019-2022 with a hip fracture comparing time to surgery, time for ortho-geriatrician review, delirium assessment on admission and length of hospital stay pre (before 20/03/20), during (21/03/20-20/07/21) and post (after 20/07/21) COVID-

19. Analysis done using binomial testing, t-test, and statistical significance estimated with Bonferroni correction.

Results

1402 patients identified with a statistically significant effect (P <0.05) on compliance for delirium assessment on admission, ortho-geriatrician review in <72hours, and time to surgery in <36hours with a 4.9%, 8.9%, 6.3% drop during the pandemic respectively. The rate of ortho-geriatrician reviews returned to pre-pandemic levels but delirium assessments and time to surgery didn’t, with the latter dropping a further 5.7%. There was a statistically significant (P<0.05) increase in length of stay during the pandemic which persisted post-pandemic.

Conclusion

Hip fractures are common and often indicate frailty and a high mortality. The BPT was introduced to encourage improved care particularly concerning prompt surgery and ortho-geriatric involvement. Our study shows the COVID-19 pandemic had a negative impact on BPT compliance across multiple domains, some of which recovered; however, some continued to fall. Time to surgery was a specific area of needed improvement, we have therefore introduced an extra trauma list and prioritised hip fractures when possible and will re-evaluate our current practice moving forward.

Implications

The sequalae of the COVID-19 pandemic is unknown, our study indicates that we have not fully recovered to our pre-pandemic performance in some key areas. 

Post-Operative Dislocation Rates in a Large Prospective Continuous Series of Primary Total Hip Arthroplasties Using a Modern Dual Mobility Cup

Sébastien LUSTIG¹, Remi PHILIPPOT^{2  1}Hospices Civils de Lyon, LYON, France. ²CHU Saint Etienne, Saint Etienne, France

Abstract

Background

Prosthetic dislocation is a common early complication after total hip arthroplasty (THA), with rates ranging from 2% to 5% in most series. The use of a dual mobility cup (DMC) has been shown to reduce the risk of dislocation in primary and revision surgery. In our institution, we have exclusively used a modern DMC for primary THA over the past 20 years. The aim of this study is to report the post-operative dislocation rate in a large prospective continuous series of primary THA using a DMC.

Methods

This prospective continuous monocentric study included 1215 primary THA surgeries performed between 2009 and 2019 using the same cementless last generation DMC (cylindro-hemispherical press fit DMC with double coating of plasma spray titanium and hydroxyapatite). The mean followup was 6.56 years ±1.6 [4-14], and the mean age at implantation was 69.2 ±10 years. Patients received clinical and radiological follow-up at 45 days, 1 year, 5 years, and 10 years. Complications and revisions were reported prospectively.

Results

At the last follow-up, 31 patients had died and 36 were lost to follow-up. The post-operative dislocation rate was 0.57% (7 cases), with only 2 cases requiring revision. In addition, we report 16 femoral fractures, 12 infections requiring debridement and polyethylene liner exchange, and 4 deep infections requiring explantation and two stages revision. No aseptic cup revisions were reported at the last follow-up.

Conclusion

Our findings suggest that the use of a modern DMC is a viable option to decrease the post-operative dislocation rate in primary THA. The last generation of DMCs with double coating of plasma spray titanium and hydroxyapatite appears to have a lower risk of aseptic loosening than the previous generation. Therefore, the modern DMC can provide both stability and good long-term fixation and can be safely used in primary THA.

Artificial Intelligence can Identify Failing Total Hip Replacements before Radiographic Features or a Drop in Proms Scores

Andrew Womersley, Jad Wehbe, Vipin Asopa, Peter Harris, David Sochart, Keith Tucker, Richard Field South West London Elective Orthopaedic Centre, London, United Kingdom

Abstract

Background

Over 8000 total hip arthroplasties (THA) in the UK were revised in 2019, half for aseptic loosening. It is believed that Artificial Intelligence (AI) could identify/predict failing THA and result in early recognition of poorly performing implants and reduce patient suffering. 

The aim of this study was to investigate whether AI based machine learning (ML) / Deep Learning (DL) techniques could train an algorithm to identify and/or predict failing THA.

Methods  

Consent was sought from patients followed up in a single design, uncemented THA implant surveillance study (2010-2021). Oxford hip scores (OHS) and radiographs were collected at yearly intervals. Radiographs were analysed by 3 observers for presence of markers of implant loosening/failure: periprosthetic lucency, cortical hypertrophy, and pedestal formation. 

 DL using RGB ResNet 18 model, with images entered chronologically, was trained according to revision status and radiographic features. Data augmentation and cross validation were used to increase the available training data, reduce bias, and improve verification of results.

Results 

184 patients consented to inclusion. 6 (3.2%) patients were revised for aseptic loosening. 2097 radiographs were analysed: 21 (11.4%) patients had three radiographic features of failure. 166 patients were used for ML algorithm testing of various workflow scenarios to detect those who were revised. 

 We report the use of a novel combination of techniques and work-flow, using a trained algorithm,  to achieve an AUC of over 82% (true positive rate of 0.83, false positive rate 0.27) but 5/6 patients who had been revised were identified (total 66 identified), predicting failure unto 8 years before revision, before radiographic features were visible and before a significant fall in the OHS. 

Conclusions 

ML algorithms can identify failing THA before visible features on radiographs or before PROM scores deteriorate. This is an important finding that could identify failing THA early.

A Novel Method For Measuring Femoral Neck Anteversion On Computed Tomography

Vatsal Gupta, Mohammedabbas Remtulla, Santosh Rai, Wael Dandachli University Hospital Coventry & Warwickshire, Coventry, United Kingdom

Abstract

Background

Abnormalities in femoral neck anteversion (FNA) can be associated with hip pathology such as femoroacetabular impingement and dysplasia leading to morbidity and loss of function. Accurate radiological measurement of FNA is crucial in diagnosis of such conditions and planning management such as rotational osteotomies or arthroplasty procedures. Debate remains regarding the optimal computed tomography (CT) method for measuring FNA using PACS systems. We propose a novel method for measurement of FNA on CT which we hypothesise to be superior to current methods in terms of inter- and intra-observer reliability.

Method

We compared two current CT methods for measuring FNA using PACS systems (InSight PACS). Method 1 involved capturing the femoral head centre and neck in one slice to define the neck axis and Method 2 used an axial slice at the base of the femoral neck. We compared these two methods to our novel method, Method 3, which uses PACS axial reconstructions of the CT scan with an extended overlay of 40 mm. All methods compared the version to the posterior condylar axis. CT scans of 50 hips were examined by two independent assessors. Inter- and intra-observer agreements were measured by calculating intra-class correlation coefficients.  

Results

Inter-observer analysis showed a median difference between measurements of 5.9° (min 2.2°, max

11.7°) for Method 1, 6.1° (min 2.7°, max 10.9°) for Method 2, and 2.6° (min 1.1°, max 6.7°) for Method 3. The intraclass correlation coefficients were 0.84, 0.86 and 0.96 respectively. For intraobserver agreement, the respective intraclass correlation coefficients were 0.93, 0.91 and 0.98 for Method 1, 2 and 3 respectively.

Conclusion

All methods demonstrated excellent intra-observer agreement however, our novel CT overlay method (Method 3) also showed excellent inter-observer reliability. Our simple method allows clinicians to accurately calculate FNA using standard PACS without needing sophisticated 3D modelling software.

VISHESH KHANNA¹, SENTHIL SAMBANDAM², SATISH ROHRA¹, SURYA KHANNA^{3 1}Aneurin Bevan University Health Board, Newport, United Kingdom. ²University of Texas Southwestern, Dallas, USA. ³JNMC Belagavi, Belagavi, India

Abstract

Background

Long-term dialysis causes a sharp, 7-fold rise in the need for a total hip arthroplasty (THA) compared to 5.3/10,000 patient-years from the general population. Outcomes of THA between dialysed and renal-transplanted patients have shown poorer outcomes after THA in the former. The present study aimed to assess mortality rates between the dialysed and non-dialysed patients. We hypothesised that there would be significant differences in results and complications including morbidity and mortality between the 2 groups.

Methods  

Using a national prospectively constructed database of 367,894 THAs performed during 2016-2019, regularly dialysed patients were identified. Complex primary and revision THAs were excluded. Two groups were formed: dialysis-dependent (DD) and non-dialysed (ND) patients and comparisons were made for in-hospital mortality, demographic data, perioperative details, medical and surgical complications.

Results

Among 367,894 THAs, 383 patients needing dialysis had higher mortality (p=0.005), lower mean ages (p<0.001), longer LoS (p<0.001), higher costs (p<0.001) and a male preponderance (p<0.001). Postoperative dislocations (p=0.013) were more frequent in DD (3.1% vs 1.4 in ND) as were mechanical complications (p=0.032) and blood loss (p=0.031). Medical postoperative complications including myocardial infarction (p=1.000), pneumonia (p=0.631), deep vein thrombosis (p=0.117), pulmonary embolism (p=1.000) and acute renal failure (p=0.511) were not significantly different between DD and ND patients. Neither were periprosthetic fractures (0.812), wound dehiscence (p=1.000), superficial (p=1.000) and deep surgical-site infection (p=1.000) and periprosthetic joint infection (p=0.126).

Conclusions

This large study showed dialysed patients having higher morbidity and mortality following THA compared to non-dialysed controls. Based on the results from the present study and the existing literature, an informed discussion about choices and timing of a hip arthroplasty with respect to renal function, dialysis and transplant require careful consideration. Further improvements in healthcare could bridge gaps between outcomes and expectations in dialysed and non-dialysed patients.

How much do hip replacements cost? The burden and budget impact of implants and hip replacements on the National Health System for England and Wales

Elsa Marques¹, Kevin Deere¹, Petra Baji¹, Michael Whitehouse¹, Ashley Blom^{2 1}University of Bristol, Bristol, United Kingdom. ²University of Sheffield, Sheffield, United Kingdom

Abstract

Background

Total hip replacement (THR) is one of the most common and cost-effective elective procedures performed worldwide. In the National Health Service (NHS) of England and Wales a myriad of implants for THR are offered at a variety of prices negotiated locally by healthcare providers. This study aims to estimate the total burden of elective THR to the NHS, the expenditure on implants born by hospitals, and different scenarios of cost-savings or cost-increases if implant selection changed for different patient groups.

Methods

Using National Joint Registry (NJR) data and NHS reference costs, we estimated the number and expenditure of NHS funded primary and revision hip replacements in the 10-year period before COVID and forecasted the number and expenditure on THR over the next decade. Using NJR average NHS Trust prices for the different implant combinations we estimated the average cost of implants used in THRs and estimated the budget impact on NHS providers from switching to alternative implants offered to patients.

Results

The NHS spent over £4.76 billion performing 702,381 THRs between 2008-2017. The average cost of implants was £1,260 per surgery, almost a fifth of the cost of primary THR. Providing cemented implant combinations in primary elective THRs may potentially save up to £281 million over the next 10 years, whilst keeping 10-year revision risks low.

Discussion

The NHS is likely to spend over £5.6 billion providing primary elective THR over the next decade. There are efficiency savings to realise in the NHS by switching to more cost-effective implant combinations available for patients undergoing primary elective THR surgery, but these will need to be balanced against the risks inherent to a change in selection of implants and surgical practice.

Funding: Healthcare Quality Improvement Partnership and the National Joint Registry; National Institute for Healthcare Research.

Dalbavancin: Reducing Length of Stay Following Surgery for Gram-positive Bone and Joint Infection

Anil Dhadwal¹, William Giles², Tobias Stedman¹, Rob Townsend¹, Michael Petrie^{3 1}Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom. ²University of Sheffield Medical School, Sheffield, United Kingdom. ³Sheffield, Sheffield, United Kingdom

Abstract

Background

The management of bone and joint infection continues to be a challenge, associated with significant costs and patient morbidity. Dalbavancin is a recently-available glycopeptide antimicrobial for use against Gram-positive microorganisms with a half-life of 8.5 days, allowing for once weekly dosing. The aim of this study was to evaluate the outcome, length of stay and complications using dalbavancin following 5-7 days of broad-spectrum intravenous antibiotics for Gram-positive bone and joint infection. 

Methods

A retrospective review of our Institution’s prospectively-collected database identified those patients who received Dalbavancin following Gram-positive orthopaedic infection since 2017. Outcomes included demographics, microorganism, antibiotic therapy, length of stay (LoS), complications and mortality. All patients had a minimum of 1-year follow up and were assessed at the time of review using the MSIS working group outcome-reporting tool. They were then grouped into “successful” or “unsuccessful”.

Results

83 patients met our inclusion criteria. 89% (74/83) patients had positive tissue cultures;

Staphylococcus aureus (28/74; 38%), Streptococci (10/74; 14%) and low virulence Gram-positive (36/74; 49%). Mean age was 60 years. 56/83 (67%) patients were diagnosed with prosthetic joint infection (PJI) involving hip (25/56; 45%) or knee (31/56; 55%). Surgical procedures performed included; debridement, antibiotics and implant retention (DAIR) (24/56; 43%), single stage revision (19/56; 34%) and staged procedures (13/56; 23%). Median length of stay was 9 days, 75% (62/83) of patients were discharged within 24 hours following  single-dose Dalbavancin; at an average drug cost of £2237. 73% (41/56) patients had a successful outcome. No reported systemic complications from antimicrobial administration. 

Conclusion

Dalbavancin when used in conjunction with appropriate surgical intervention was successful in treating PJI for patients with Gram-positive bone and joint infection. Dalbavancin treatment conveys a significant reduction in LoS compared to standard 14-day inpatient intravenous antibiotic therapy and its associated costs. 

Precice vs Fitbone – The Regenerate Race

Alastair Robertson, Jonathan Wright, David Goodier, Peter Calder Royal National Orthopedic Hospital, Stanmore, United Kingdom

Abstract

Introduction

Distraction osteogenesis and limb lengthening technology has evolved through generations, including external fixators and internal lengthening nails. The current “gold standard” internal lengthening nails include FITBONE, with an electrically controlled motor, and PRECICE, with a magnetically controlled motor. Factors known to affect bone regenerate during limb lengthening include localisation of the osteotomy within the bone, osteotomy technique used, mechanical stability, latency period, rate and rhythm. Literature has also shown that both the presence of magnetic fields and electrical stimulation may also influence osteogenesis. To date no studies have compared the quality and rate of regenerate formation between the FITBONE and PRECICE systems.

Methods

A standardised nailing technique was used for all patients, solid reamers were used for FITBONE and flexible reamers for PRECICE. A di bastiani osteotomy was performed in all patients. From a prospective database, 12 patients were selected into each group (FITBONE/PRECICE) and matched for age and gender. All patients underwent femoral lengthening. Pixel value ratios were calculated from radiographs at 2, 4, 6 and 12 weeks post operatively. A Mann-Whitney U test was used to assess for statistical significance.

Results

24 matched patients were included in total, 12 males and 12 females. The average age was 36 years across both groups. The average total lengthening in the FITBONE group was 38.7mm and PRECICE group 43mm. No statistical significance in pixel-value ratio of regenerate formation (P<0.05) was found between the groups at week 2, 4, 6 or 12.

Conclusion

Advances in limb lengthening technology provide us with several options for femoral lengthening, with internal lengthening nails seen as a gold standard. Whilst both nailing systems have technical advantages and disadvantages, in our sample there appears to be no statistically significant difference in the rate and quality of regenerate formed with either the PRECICE or FITBONE systems.

Tomas Berg, Holly Morris, Andrew Dekker, Tim Cresswell, Marius Espag, Amol Tambe, David Clark University Hospitals of Derby and Burton, Derby, United Kingdom

Abstract

Introduction

The primary aim of this study was to better define the factors that increase the likelihood of failure of conservative treatment of calcific tendonitis of the shoulder. The secondary aim was to identify whether conservative or surgical treatment provides better outcomes. The hypothesis was that a patient with a deposit >10mm is more likely to require surgical intervention.

Methods

A retrospective review was performed on a consecutive series of patients diagnosed with CT at Hospital A between 2014 and 2018. All patients were assessed radiographically, and the largest diameter deposit size recorded. Patient demographics, co-morbidities, Oxford Shoulder Score, range of motion, details of presenting complaint and presentation were captured. Details of both conservative (physiotherapy, barbotage and cortisone injections) and surgical arthroscopic removal of the calcium deposit were recorded and analysed. Outcome measures include the Oxford Shoulder Score and range of motion, pre- and post-intervention. The complications of surgery were also recorded.

Results 

The study included 261 patients. Mean age was 52, mean BMI 31.1 and the gender split 98/163 (male/female). The rate of failure of conservative treatment was 40.6%.  A greater proportion of the surgical cohort had a deposit >10mm (52.8% versus 39.3%, p=0.005); were female (72.6% versus 55.5%, p=0.005); and had at least 6 months duration of symptoms prior to referral (75.5% versus 45.2%, p=<0.001). The surgical cohort had a lower mean range of forward flexion post-treatment (155.4° to 165.8°, p=0.031). Within the cohort, 19 patients had post-surgical complications.

Conclusion

Female gender, increased deposit size (>10mm), increased chronicity of condition (symptoms for more than 6 months), and previous conservative treatment were predictive of failure of conservative treatment. Surgical outcomes were good, though 11.5% of patients developed adhesive capsulitis. The conservative group had a greater range of forward flexion post-treatment.

Factors influencing successful day case total hip and knee arthroplasty - early experiences at Leeds Teaching Hospitals NHS Trust.

Milad Mossanen Parsi¹, Darius Oraee¹, Michal Bak², Benjamin Rippin², Jeya Palan^1,2, Hemant Pandit^1,2, Sameer Jain^{1,2 1}University of Leeds, Leeds, United Kingdom. ²Leeds Teaching Hospitals Trust, Leeds, United Kingdom

Abstract

Background

The demand for total hip arthroplasty (THA) and total knee arthroplasty (TKA) is increasing. There is an urgent need to increase efficiency in keeping with the Getting It Right First Time (GIRFT) and High-Volume Low Complexity (HVLC) programmes. Recent enhanced recovery advances have led to growing interest in performing these as day case procedures. There are currently no UK studies that have investigated factors associated with successful same-day discharge. Therefore, the aim of this study was to identify factors associated with a successful day case surgery pathway.

Methods

An analysis of 62 patients that were scheduled for day case THA or TKA at Leeds Teaching Hospitals NHS Trust between October 2019 and September 2022 was performed. Patients were offered day case surgery if they had stable health, predictable anaesthesia and surgery and someone at home for the first night. Median follow-up was 10 (IQR, 4-14) months. Data were collected from electronic records and statistical analyses were performed to identify factors associated with successful same-day discharge. Statistical significance was set as p<0.05.

Results

48.4% (n=30) of patients were successfully discharged as a day case. The most common reasons for unsuccessful same-day discharge were dizziness (28.1%), nausea (21.9%) and prolonged lower limb anaesthesia (18.8%). Short-acting prilocaine spinal anaesthesia (p=0.032) and postoperative energy drink consumption (p<0.001) were associated with day case success. Gabapentin premedication (p=0.054) and opiates in spinal anaesthesia (p=0.020) were associated with day case failure. In the day case group, there was one (3.3%) 30-day readmission (pain) and one (3.3%) local complication (ligament injury).

Conclusion/Findings

Day case THA and TKA can be performed safely within the NHS. This study supports the use of short-acting spinal anaesthesia and postoperative energy drinks. Further study outside the restrictions of COVID elective recovery is warranted.

George Cooper¹, John Bayram², Nicholas Clement^{2 1}University of Edinburgh Medical School, Edinburgh, United Kingdom. ²Department of Trauma and Orthopaedics, Royal Infirmary Edinburgh, Edinburgh, United Kingdom

Abstract

Background

This systematic review and meta-analysis aimed to explore the impact of presurgical waiting times on both pre- and post-operative joint specific function and health-related quality of life (HRQOL) and perspectives of patients awaiting primary elective total hip (THR) and knee (TKR) replacements.

Methods 

Preferred Reported Items for Systematic Review and Meta-Analysis guidance was followed throughout. We searched MEDLINE, EMBASE, PUBMED, and CENTRAL databases from inception until 30th January 2023 (CRD42022288128). Secondary literature, individual case-studies and unpublished data were ineligible. Datasets containing paediatric, non-elective, partial, or revision replacement populations were excluded to ensure internal and external validity.

Risk of bias from randomised, non-randomised, and cross-sectional studies were assessed with the recommended Risk of Bias 2, Risk of Bias in Non-Randomised Studies, and Joanna Briggs Institute frameworks, respectively. Residual maximum likelihood meta-analysis of summary patient data was performed, and the influence of presurgical waiting time on this was explored with linear meta-regression.

Results

Twenty-six studies were eligible for systematic review and sixteen for meta-analysis, including 89,996 patients between 1995-2022. Through meta-regression, a significant deterioration in joint specific function (mean difference (MD):0.0575%; 95%CI:0.0064,0.1086; p=0.028(4d.p.); I2=73.1%) and HRQOL (MD:0.05%; 95%CI:-0.0001.0009; p=0.011(4 d.p.); I2=80.6%) for each additional day of waiting time was identified. Although not statistically significant, a negative signal was also observed 6-12 months postoperatively, both quantitively and within the qualitative synthesis. Patients undergoing elective primary THR had a greater post-operative functional gain than TKR patients irrespective of waiting time. Finally, patient responses to delayed THR and TKR surgery were unanimously negative.

Conclusions

This meta-analysis demonstrated that increased waiting time was associated with deleterious patient perspectives, increased anxiety, and significant reductions in pre-operative joint functionality and HRQOL, which may persist post-operatively. Immediate action should be taken to minimise the impacts of prolonged waiting times on patients.

Kate Hardy^1,2, Oday Al-Dadah^{2,1 1}Newcastle University, Newcastle Upon Tyne, United Kingdom. ²South Tyneside District Hospital, South Tyneside, United Kingdom

Abstract

Background

Hyperparathyroidism occurs when levels of parathyroid hormone (PTH) rise due to increased activity of the parathyroid glands. PTH stimulates osteoclasts to increase bone resorption, leading to the release of skeletal calcium and loss of bone mass. Primary hyperparathyroidism (PHPT) is characterised by hypercalcaemia with inappropriately elevated PTH. When PTH secretion is excessive, it can result in osteoporosis. Parathyroidectomy (the surgical removal of the parathyroid glands) is the only curative treatment for PHPT. This retrospective study investigated whether bone mineral density (BMD) improved following parathyroidectomy and compared outcomes against patients managed non-surgically. 

Methods

A total of 82 patients with hyperparathyroidism were included, comprising the Surgical group (n=49) and Medical group (n=33). Patients had BMD assessed at the lumbar spine, hip and forearm using dual x-ray absorptiometry. These measurements were compared pre- and post-intervention, with an average of 51 months between scans.

Results

Lumbar spine BMD improved significantly in the Surgical group by 6.8% (+0.059g/cm2, p=0.004) and in the Medical group by 3.1% (+0.030g/cm2, p=0.016), with no significant difference between groups. There was no significant change in BMD at the hip in either group. The Medical group had a significant 7.1% decrease in forearm BMD (-0.040g/cm2, p=0.043), while the Surgical group had no significant change, resulting in a significant difference between groups (p=0.045).

Conclusions

This study demonstrated that BMD improves at the lumbar spine in patients with hyperparathyroidism following surgical or medical intervention. However, at the forearm, patients managed medically have worse BMD outcomes, indicating that parathyroidectomy is superior at preventing bone deterioration caused by excess PTH overall. 

Sophie Jakubow¹, Yat Wing Smart², Aswinkumar Vasireddy²

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

Abstract

Background

Patient education is a vital part of successfully managing patients’ injuries and expectations. The influx of mobile health and applications (apps) is one way to improve the delivery of information to patients, with systematic reviews showing that they greatly enhance patient care, advising for a wider implementation of their use (De La Cruz Monroy et al., 2019). The aim of this study was to assess the patient experience of a trauma patient education application (app: http://bit.ly/traumaapp) developed by clinicians in the US. 

Methods

This was a prospective study conducted at a UK major trauma centre over a 3-month period. Admitted orthopaedic patients as well as outpatients were approached and invited to use the app. Usability questionnaires were distributed to patients, consisting of a 1-7 scoring system (1 strongly disagree, 7 strongly agree) and free text section to assess the ease of use and satisfaction, information arrangement, and general usefulness of the app. 

Results

258 patients were approached about the app, of which 209 agreed to participate and try the app. A total of 46 completed questionnaires were returned. 85% of inpatients felt that the app helped them to understand their injury and recovery scoring above 5 (41% scoring 7, 30% scoring 6) with the majority of patients finding it easy to navigate and had consistent information. Almost all patients would recommend the use of the app. 

Conclusion

This study shows encouraging benefits of a trauma patient education app for patients to learn more about their injury and the rehabilitation period. Limitations of this study were the low questionnaire completion rate as well as not being able to modify the app information to respond to feedback. More information is needed regarding optimal app design and usability to improve patient education.  

Harri Jones¹, Amit Chandratreya², Rahul Kotwal^{2 1}Cardiff University, Cardiff, United Kingdom. ²Princess of Wales, Bridgend, United Kingdom

Abstract

Background

Smart phone apps are available to some patients undergoing hip and knee replacement. MyMobility is one of those and it aims to connect patients to their surgeon and care team, as well provide useful education and information on how to perform pre-operative and post-operative exercises. The Princess of Wales Hospital, Bridgend, is the first hospital in Wales to use this app.

Methods

The data of 85 post-operative knee replacement patients at the Princess of Wales was assessed for post-operative outcomes in those who are compliant with their exercises compared to those who weren’t compliant. Their Oxford Knee Score (OKS) and Numerical Rating Score for pain (NRS) was assessed at 90 days post-operation.

Results

43 patients completed their 90-day OKS and NRS assessment. 31 of these patients who were found to be compliant with their pre-operative and post-operative had an average OKS of 31.5 at 90 days post-operation, compared to an average OKS of 27 at 90 days in the 12 patients who were non-compliant with their pre and post-operative exercises. The average NRS in the compliant group at 90 days was 3, compared to an average NRS of 4 in the non-compliant group. 

Conclusion/Findings

My Mobility plays an effective role in improving patient reported outcomes in those who are compliant with their exercise program.

Does Open or Closed Reduction with Internal Fixation Reduces the Incidence of Complications following Neck of Femur Fractures in Paediatrics? A Metaanalysis and Systematic Review.

AHMED HAFEZ^1,2, Mohamed Aly³, Islam Omar⁴, George Richardson¹, Kyle James^{5  1}University College of London Hospital, London, United Kingdom. ²Queen Marry University of London, London, United Kingdom. ³Royal London Hospital, London, United Kingdom. ⁴Northern Health and Social Care Trust, Antrim, United Kingdom. ⁵University Hospital Sussex NHS foundation Trust, Brighton, United Kingdom

Abstract

Background 

Neck of femur fracture is a rare injury in the paediatric population with a high incidence of complications such as Osteonecrosis, Coxa-vara and Non-union. The main aim of this review is to compare the incidence of complications between Open and Closed reduction with internal fixation in Paediatric Neck of femur fractures. 

Methods 

Two independent reviewers searched the databases of EMBASE, MEDLINE, COCHRANE and PUBMED from inception until April 2022 according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Studies included comparison of complications between open and closed approaches for operative fixation of femoral neck fractures in patients less than 16 years old. Assessment of publication bias was done using Egger’s test while Newcastle Ottowa Tool used to assess methodological quality of the studies. 

Results 

A total of 727 participants from 15 included studies received either treatment for paediatric femoral neck fractures. Open reduction had lower incidence of Osteonecrosis compared to Closed approach (20% versus 23%) without statistical significance using fixed effect model at 95% CI (P=0.909). Insignificant heterogeneity was reported in Osteonecrosis studies (I2=3.79%, P=0.409). Coxa-Vara and Non-union were higher in the closed group with no statistical significance (P=0.693 and P=0.709, respectively). Coxa-Vara studies showed mild heterogeneity (I2=27.8%, P=0.218), while significant publication bias was encountered in Non-union studies (P = 0.048).

Conclusion 

There was no significant difference in the incidence of Osteonecrosis, Coxa-Vara and Non-union between open or closed reduction with internal fixation of paediatric neck of femur fractures. Several factors, including age, initial displacement, method of fixation and time to fixation may contribute to the risk of development of Osteonecrosis. 

Adam Galloway^1,2, Simon Pini³, Colin Holton², Daniel Perry⁴, Anthony Redmond¹, Heidi Siddle¹, Suzanne Richards^{1  1}University of Leeds, Leeds, United Kingdom. ²Leeds Children's Hospital, Leeds, United Kingdom. ³University of Leeds, l, United Kingdom. ⁴University of Liverpool, Liverpool, United Kingdom

Abstract

Background

Perthes’ Disease is idiopathic avascular necrosis of the developing femoral head, that often causes deformity that impairs physical function. Current treatments aim to optimise forces across the hip to enhance spherical growth of the hip. However, despite a century of research, there is no consensus regarding the optimal treatment. We describe the experiences of children, their families and clinicians’ when considering the treatment of Perthes’ Disease.

Methods

A qualitative study was performed to gather information from children and their families affected by Perthes’ Disease, along with treating clinicians. Interviews followed a coding framework, with the interview schedule informed by behavioural theory and patient and public involvement. Transcripts were analysed using the framework method.

Results

Twenty-four participants were interviewed, comprising 12 child/family dyads and 12 clinicians from UK NHS centres. Three main themes were derived in relation to:

•       Widespread variation of routine care exists, both in the lived experience of children and their families, as well as self-reported disagreement amongst clinicians. 

•       Children with Perthes’ Disease and their families recounted positive experiences when included in the decision-making process for treatment.

•       There is a strong desire from clinicians and children/their families for consistent evidence for everyone involved, and this should be based on clinical consensus.

Conclusion

This is the first study to describe the experiences of treatment for Perthes’ Disease. The results indicate a need for robust evidence to support treatment decisions. Children with Perthes Disease and their families valued feeling involved in the clinical decision-making process and clinicians acknowledged the central importance of providing patient-centred care in the absence of robust evidence on the optimal management of Perthes Disease. Findings from this study will inform a future Delphi project aiming to develop clinical consensus on treatment for Perthes’ Disease.

Incidence and Management of Paediatric Knee Hemarthroses – Are BOA Standards Being Met?

Tobias Stedman, Dominic O'Dowd, Nicolas Nicolaou Sheffield Children's Hospital, Sheffield, United Kingdom

Abstract

Background

BOA guidance recommends all paediatric patients with a hemarthrosis following a knee injury be managed via an acute knee pathway within 2 weeks of presentation.  Our aim is to assess the volume of acute knee injuries presenting to Sheffield Children’s Hospital (SCH) and determine if an acute knee clinic would be beneficial.

Methods

During a 1-year period, (01/01/22 - 31/12/22), 138 patients were identified who attended fracture clinic at SCH and received a knee radiograph.  Retrospective review of cases identified 105 of these patients had a hemarthrosis following acute injury.  8 were later excluded. 

Time from injury to MRI, surgery, or discharge was collected alongside patient demographics, diagnosis and specialist interest of treating clinician.

Results

Average age was 12 years (range 2-16 years).  Average number of ED presentations prior to clinic was 1 (range 1-3), with 10 patients having more than 1 attendance.  The most common diagnosis was traumatic patella dislocation (24 patients).  39 patients received MRI scans.  Average time to MRI was 29 days (16 days if seen by a knee specialist verses 37 days if seen by a non-knee specialist).  64 patients were discharged with non-operative treatment, 25 patients allocated to surgery and 8 remain under investigation.  Average time to surgery was 72 days; 63 days (range 23120) and 2 clinic appointments if initially seen by a knee specialist compared with 78 days (range 11232) and 3 clinic appointments if initially seen by a non-knee specialist. 

Conclusions

The annual volume of paediatric knee injuries presenting to a national children’s hospital justifies the provision of an acute knee pathway.  Patients initially seen by a knee specialist were more likely to meet the BOA guidelines for acute knee injury assessment and investigation.  Non-knee specialists should be aware of BOA guidelines relating to acute knee injuries with a hemarthrosis.

Paediatric medial patellofemoral ligament reconstruction provides superior results with anatomic bony fixation: a systematic review and meta-analysis.

Sara Maki¹, Amogh Patil², Chinmay Gupte^{2 1}University College London, London, United Kingdom. ²Imperial College London, London, United Kingdom

Abstract

Background  

Patellar dislocation is a common orthopaedic injury amongst the paediatric and adolescent population. Due to the risk of physeal injury in skeletally immature patients, several MPFL reconstruction techniques have been developed to reproduce the success rate seen in adult patients whilst minimising complications to paediatric patients. 

Purpose

The aim of this systematic review and meta-analysis was to evaluate the clinical outcomes and complications of MPFL reconstruction in skeletally immature patients and compare the redislocation rates of different femoral fixation techniques: anatomic fixation, dynamic soft tissue pulley and soft tissue fixation. 

Study design: Systematic review and meta-analysis.

Methods

A comprehensive literature searched was performed for original studies reporting outcomes and complications of paediatric MPFL reconstruction. Mean patient age, follow-up period, graft choice, femoral fixation method, patellar fixation method, redislocation and subluxation events, Kujala scores and complications were analysed. 

Results

471 cases of MPFL reconstruction were performed, with a mean patient age of 13.4 years and mean follow up of 43.7 months. Gracilis was the most used graft (66.5%). Femoral fixation included bone tunnels with interference screws or suture anchors (58.2%) and dynamic soft tissue pulley (24.2%). Pooled Kujala scores improved from 62.6 to 88.4. The pooled rate of recurrent dislocations was 3%. Anatomic fixation of the MPFL resulted in lower rates of redislocation (1%), compared to soft tissue dynamic pulley technique (10%), soft tissue femoral fixation (2%) and no femoral fixation (9%), which was statistically significant (p=0.01). 

Conclusion

MPFL reconstruction in the paediatric population is a relatively successful procedure with low redislocation rates and overall low non-stability related complication rate. Anatomic fixation of the MPFL graft under fluoroscopic guidance results in lower rates of redislocation compared to nonanatomic reconstruction techniques. 

How long is a piece of string? Duration of Pavlik Harness wear in the treatment of Developmental dysplasia of the hip (DDH).

Bhushan Sagade¹, Connor Thorn^2,1, Julia Judd¹, Safwan AbdulWahid¹, K Wartemberg¹, Edward Lindisfarne¹, Alexander Aarvold^{1 1}Southampton Children's Hospital, Southampton, United Kingdom. ²University of Southampton, Southampton, United Kingdom

Abstract

Intro

Pavlik Harness (PH) treatment for developmental dysplasia of the hip (DDH) is widespread. However, there is a lack of consensus on many aspects of PH treatment, with no high-level evidence to support any specific duration of treatment. Our institution employs a full-time PH programme for 6 weeks, followed by ten weeks of graduated weaning. Ultrasonography is performed at weekly or fortnightly intervals throughout. The aim was to determine the maturation of the hip joint throughout our institution’s 16-week PH treatment protocol.

Methods

This was a retrospective analysis of patient records and ultrasonography, over a two-year timeframe.  Sonographic timepoints of 6, 12 and 16 weeks were chosen for sequential analysis of Alpha angle, Beta angle and Femoral head coverage (FHC), performed by three independent raters. The Acetabular Index (AI) was measured at 2 years.

Results

There were 123 hips in 83 successfully treated in PH. The values for alpha, beta and FHC for all hips were in the normal range from the 6-week scan onwards, at which point a weaning process was commenced. There was significant improvement in the alpha angles from 6 to 12 weeks (72.1 to 74.3°, p<0.001). There was a less significant change in alpha angle between 12 and 16 weeks (74.3 to 75.3°, p=0.03). The beta angle did not significantly improve at the same time points. The FHC values did not change between the 12-and 16-week scans. AI’s were all normal at 2 years.

Conclusion

This study has found ongoing significant improvement in hip morphology throughout a weaning process from 6 to 12 weeks in the Pavlik harness. There was only marginal improvement in hip morphology between the 12- and 16-week time points. This retrospective study supports a Pavlik harness treatment regime to 12 weeks, but a further 4 weeks may not be necessary.

Improving clinician trust in automated hip screening: Utilising heatmaps to express confidence in anatomical landmarks

Abhinav Singh¹, Allison Clement¹, Daniel Perry¹, Sandeep Hemmadi², Irina Voiculescu^{1 1}University of Oxford, Oxford, United Kingdom. ²Cardiff and Vale University Health Board, Cardiff, United Kingdom

Abstract

Background  

The UK screening programme has not improved early detection of developmental dysplasia of the hip (DDH) since 1986. The Graf method has intra/inter-observer differences ranging from 4 to 10.1 degrees. Artificial intelligence (AI) assisted diagnostics can improve accuracy and objectivity. Improving clinician trust remains paramount in facilitating the adoption of these techniques. 

Methods

This study utilised an anonymised dataset obtained by experienced radiologists during routine NHS practice. The dataset contained 190 2D hip ultrasound images from 100 multi-ethnic babies (aged 412 weeks). Two clinical experts provided the five anatomical landmarks representing the base of ilium (1st and 2nd points), turning point (3rd), lower limb (4th) and labrum (5th). An alpha angle >60 degrees was normal (Graf 1) and <60 degrees was abnormal (Graf 2a,2c,D,3,4). We adapted a convolutional neural network (modified U-Net++, 70:15:15 training:validation:testing data split) to generate a confidence heatmap around each landmark prediction. The Graf angles were calculated from the ‘hottest’ (most confident) point to provide a screening diagnosis. 

Results 

Within the test dataset- ilium, femoral head and labrum heatmaps were identified in all images. In 93% of cases (n=27) the true and predicted alpha angles were within the same correct diagnostic threshold. An addition of 1-pixel radii outward from the centre of the ground truth led to a difference of 5.41 ± 0.82 degrees. The largest heatmap radius corresponded with the turning point and labrum which reflects identification difficulty in clinical practice. 

Conclusions

Our AI heatmap successfully indicates its ‘level’ of confidence in identifying key landmarks within scans. It automatically calculates Graf angles and provides a diagnosis which agrees with expert clinicians in 93% of cases, exceeding the existing state-of-the-art performance. 

Implications

This method will improve clinician confidence when selecting diagnostic landmarks. It will allow nonexperts to participate in universal screening. 

Jad Wehbe, Andrew Womersley, Irrum Afzal, Samantha Jones, Deiary Kader, David Sochart, Vipin Asopa South West Elective Orthopaedic Centre, London, United Kingdom

Abstract

30-day emergency readmission is an indicator of treatment related complication once discharged, resulting in readmission.  A board-approved quality improvement pathway was introduced to reduce elective re-admissions.

The pathway involved telephone and email contact details provision to patients for any non-life threatening medical assistance, allowing for initial nurse led management of all issues. A new clinic room available 7 days, and same day ultrasound scanning for DVT studies were introduced. A capability, opportunity and behavior model of change was implemented.

Readmission rates before and six months after implementation were collected from Model Hospital. A database used to document patient communications was interrogated for patient outcomes.

Prior to implementation, readmission rates  at the 1st business quarter of 2021 (April – June 2021), were 7.0%(benchmark 3.2%) for primary total hip replacement (THR) and 8.7%(benchmark 3.8%) for primary total knee replacement (TKR). Following implementation, readmission rates decreased to 3.8% for primary THR and 4.1% for primary TKR (October – December 2021). 51% of patients making contact were managed with telephone advice for THR, and 54% for TKR. 30% of THR patients and 31% of TKR required a same day scan to rule out a deep vein thrombus (0/4 and 1/4 respectively). 15% patients required face-to-face clinic. 5.1% of THR and 15% of TKR patients required a face to face follow up.

21 of 884 THRs and 20 of 684 TKRs performed following protocol introduction were re-admitted within 30 days. Readmissions were 60% and 41% surgical respectively, and  40% and 29% medical respectively. 52% of total patients readmitted were unaware of the newly implemented protocol. Further improvements have been made to the protocol based on these findings.

Implementation of a suitable pathway can significantly reduce re-admission rates in our center and could be used to reduce readmission rates in other national elective treatment centers.

Tony Feng, Virginia Dale, Solomon Xi Xiang Ong, Andrew Ablett, Chloe E H Scott, Nicholas D Clement  Department of Trauma and Orthopaedics, Royal Infirmary of Edinburgh, United Kingdom

Abstract

Background

Obtaining informed consent is a legal and ethical requirement however poor consent process is a major cause of litigation in patients undergoing trauma surgery. One aspect of the consent process is retention of information. The objective of this audit was to evaluate the extent to which hip fracture patients were able to recall information following completion of the consent form. 

Methods

A prospective study was undertaken to assess a patient’s ability to retain the information given to them during the consent process for their hip fracture surgery at a single major trauma centre. Inclusion criteria were: patients without cognitive impairment (pre or postoperative) sustaining a hip fracture that have signed and given consent to their surgery. A face-to-face questionnaire was completed postoperatively within a median of three days which assessed the patient's ability to recall the operation type, indication, alternative options and potential complications. Patient satisfaction was also evaluated to identify areas for quality improvement.

Results

There were 32 consenting individuals who underwent hip fracture surgery with a mean age of 78 years and 72% were female (23/32). 29 (90%) felt they received sufficient information to give informed consent. 28% (9/32) stated they did not know what operation they had and only 44% of individuals (14/32) were able to actively recall a single complication, with the most commonly retained complications being blood clots at 19% (6/32), stroke or myocardial infarction at 13% (4/32) and infection at 9% (3/32). Importantly, 69% of individuals (22/32) felt they could better retain knowledge of complications if they had an information booklet available prior to the operation. 

Conclusion

Despite most patients being satisfied with the consenting process, there was poor information recall, which is an important aspect of consent. An information booklet to aid in the consent process may facilitate improved information retention.

Regional, Multi-centre Study of Staff Attitudes to Radiation Exposure, and the Provision and use of Personal Protective Equipment in Orthopaedic Theatres

Sophie Howles¹, Joanna Richards², Margaret Brooks¹, Gemma Smith³, Veronique Spiteri⁴, Deepa Bose^{3  1}The Royal Orthopaedic Hospital, Birmingham, United Kingdom. ²Sandwell and West Birmingham Hospitals Trust, Birmingham, United Kingdom. ³University Hospitals Birmingham, Birmingham, United Kingdom. ⁴Birmingham Children's Hospital, Birmingham, United Kingdom

Abstract

Background

Increased risk of cancer has long been associated with exposure to ionising radiation, and recent evidence regarding increased incidence of breast cancer amongst female orthopaedic surgeons has prompted the British Orthopaedic Association (BOA) to issue further guidance on radiation exposure and the provision of personal protective equipment (PPE). 

The aim of this project was to assess the current provision of PPE within our region in relation to the guidelines set by the BOA, and to examine staff attitudes regarding radiation exposure and PPE.

Methods

There were two components to this study: Firstly, an audit of the total PPE currently available, with items counted and logged in a standardised table.  All accessible garments were included, including named items in general circulation, but garments that were locked away were excluded.

The second part of this study was an electronic, anonymous questionnaire, exploring staff attitudes towards radiation exposure, and their individual access to PPE.

Results

Data was collected from 8 trusts within the West Midlands. Provision of PPE varied significantly, however none of the trusts had easily accessible eye protection and most gowns were tabard-style single pieces without attached thyroid shields. There was limited access to the vest-style protection recommended by the BOA (<15%). 

Over 200 questionnaire responses were received from staff across the 8 trusts. Few participants had personalised gowns, or routine access to thyroid shields, eye protection or dosimeters. More than half of respondents reported difficulty in finding appropriately fitting gowns, and the majority had concerns about the impact of radiation on their health. 

Conclusions and Implications  

Veda vani Amara¹, Raghavendra Devisetty², Sidhu Gur Aziz Singh³, Venkataraman Raja^{2  1}Hayward heath, Hayward heath, United Kingdom. ²University Hospitals of derby and Burton, Burton, United Kingdom. ³Lewisham and Greenwich, Lewisham, United Kingdom

Abstract

Background

A Prospective study was Conducted from May 2021-Oct 2021at Queens Hospital, Burton.88 forms were collected and analyzed. The Purpose of the study was to determine the access and ability to use internet services among Arthroplasty patients. Patients presenting to clinics and elective admission for Hip and knee arthroplasty were involved in the study. Form included 13 Questionnaire which was analyzed after spreading on Excel sheet.

Objectives

How internet Savvy arthroplasty patients are?

Depending on results whether Preop Assessment can be done online

Study Design & Methods

88 forms collected were spread on an excel sheet and analyzed on a percentage basis.

Results

Patients age range between 45-89, Average age was 70.14. 27 were Male and 61 Females.77

Patients had access to the internet. Sources of Internet were Broadband + Mobile (20), Broadband

(52), Mobile (5).77 had personal devices which included Smart phones (54), Tablet (44), Computer (46).33 patients' needed help in using the device.68 patients had personal email ID,6 patients had alternate email id.59 patients were confident in Navigating website. Among which they 34 rated themselves in Navigation as Amateur, 15 as Professional and 10 as Beginner.16 Patients informed they need help in navigating websites. Only 15 among Amateurs,2 among Beginners and 12 among Professionals –In total 29 preferred online classes. On analysis only 32.9% among patients involved in the study showed interest in online classes.53 % preferred receiving information about arthroplasty in person.50% wanted to receive information in form of text and combination (Video, Audio).70% of patients wanted to know about recovery and return to normal activities. Next in order being how long joint lasts, Benefits and risks, types of joint and complications.

Conclusions

Despite advances in technology and ability to access and Navigate people preferred in person than Virtual.

Epaminondas Markos Valsamis¹, Rafael Pinedo-Villanueva¹, Adrian Sayers², Gary Collins¹, Jonathan Rees^{1 1}University of Oxford, Oxford, United Kingdom. ²University of Bristol, Bristol, United Kingdom

Abstract

Background

There is considerable variation in the growth of shoulder replacements across countries and there is no published literature reporting temporal trends or forecasts for the United Kingdom. The study’s objective was to investigate the temporal trends and future demand of elective shoulder replacement surgery in England including any geographic and socioeconomic variations in healthcare provision and patient outcomes.

Methods

This population-based cohort study used routinely collected Hospital Episode Statistics data in England from 1 January 1999 to 31 December 2020. Patients over 18 years having an elective shoulder replacement were included while procedures for malignancy or acute trauma were excluded. National population data including population projections were sourced from the Office for National Statistics. Incidence rates and hospital costs, serious adverse events (SAE) and revision surgery were stratified by geographical region, deprivation and patient age.

Results

A total of 78,435 elective primary and 5,915 revision shoulder replacements were available for analysis. Between 1999 and 2019 the age and sex standardised incidence of primary shoulder replacements in England quadrupled from 2.6 to 10.4 per 100,000 population. Up to 1 in 6 patients needed to travel to a different region for their surgery. 30-day SAE rates increased from 1.3% to 4.8% and 90-day SAE rates increased from 2.4% to 6.0%. Shoulder replacements are forecast to increase by up to 224% by 2050, reaching 20,334 procedures per year with an associated annual cost to hospitals of £224 million.

Conclusion

This study observed a rising incidence of shoulder replacements, regional inequalities in service provision and steadily increasing serious adverse event rates after surgery. With surgical waiting lists set to triple in size by 2050, commissioners and healthcare planners need to focus on providing sufficient resources for the surgical workforce to address regional variation and the rising complication rates.

Siddharth Virani^1,2, Karim Abdelghafour¹, Clarence Yeoh¹, Angelos Assiotis¹, Adam Rumian¹, Harpal Uppal^{1 1}East and North Hertfordshire NHS Trust, Stevenage, United Kingdom. ²Epsom and St Helier University Hospitals NHS Trust, Carshalton, United Kingdom

Abstract

Background

The primary aim of the study is to compare the clinical and radiological outcomes of patients undergoing total elbow arthroplasty (TEA) and hemiarthoplasty for distal humerus fractures.

Methods 

Retrospective analysis of data of patients undergoing hemiarthroplasty or TEA for comminuted distal humerus fractures (OTA- C3 Comminuted total articular fractures) was done. This is a single centre consecutive series and the decision to perform either procedure was taken by the operating surgeon. Patients with a minimum follow-up of 12 months were included. Arthroplasty for neglected trauma, delayed presentations and failed fixations was excluded.

Results

A total of 25 patients (13 TEAs and 12 hemiarthroplasties) were operated in the period between 2015-2021. One patient was excluded due loss of follow-up. The mean age of the patients undergoing total elbow replacement was 81.3 years against 68.4 years for hemiarthroplasty (p<0.05). The mean follow-up was 36.2 months and 35.4 months respectively. The mean arc of flexion-extension was 13-111 degrees and 22-124.5 degrees in the TEA and hemiarthroplasty group respectively (p>0.05). The mean range of supination was 84 and 74 degrees (p>0.05) while pronation was 84 and 86 degrees(p>0.05) in the TEA and hemiarthroplasty groups respectively. QuickDASH score was 7.8 and 8.9(p>0.05) in the TEA and Hemiarthroplasty groups. There were no cases of infection, dislocations, intra-operative fractures or revision surgery

Radiological evidence of heterotrophic ossification was seen in 5 patients with TEA and 7 patients with hemiarthroplasty. Osteolysis was seen around the ulnar component in 3 patients with TEA without any migration while none of the patients with hemiarthroplasty showed signs of loosening.

Conclusions 

Total elbow arthroplasty and hemiarthroplasty provide predictably comparative clinical outcomes for trauma. Osteolysis around the ulnar component appears to be an issue that could lead to loosening in the long-term for TEA.

Comparison of Interventions for Lateral Elbow Tendinopathy (LET) against placebo: A Systematic Review and Network Meta-Analysis for Patient-Rated Tennis Elbow Evaluation Pain Outcome

Hamish Lowdon¹, Han Hong Chong¹, Mohit Dhingra², Abdul-Rahman Gomaa³, Lucy Teece⁴, Sarah Booth⁴, Adam Watts⁵, Harvinder Pal Singh⁶¹University Hospital of Leicester NHS Trust, Leicester, United Kingdom. ²University Hospital of Leicester NHS Trust, University Hospital of Leicester NHS Trust, United Kingdom. ³University of Liverpool, Liverpool, United Kingdom. ⁴University of Leicester, Leicster, United Kingdom. ⁵Wigan and Leigh Teaching Hospitals NHS Foundation Trust, Wigan, United Kingdom. ⁶University Hospital of Leicester NHS Trust, Leicesetr, United Kingdom

Abstract

Background

There is controversy regarding the optimal treatment for lateral elbow tendinopathy (LET) and not all available treatment options have been compared directly to placebo/control. A network metaanalysis was conducted to compare the effectiveness of different LET treatments directly and indirectly based on the Patient-Related Tennis Elbow Evaluation (PRTEE) pain score. PROSPERO:CRD42022371020

Methods

Randomized controlled trials comparing different treatment methods for LET were included provided they reported the PRTEE Pain Score; novel therapies were excluded. The Cochrane Risk-ofBias tool 2 was used to evaluate the trials. A network meta-analysis was performed to compare direct and indirect evidence between treatments compared to placebo in the short-term (up to six weeks) and mid-term (more than six-weeks and up to six-months) after intervention.

Results

Thirteen studies with twelve comparators including control/placebo were eligible. The results indicate no significant improvement in PRTEE pain score in the short-term across all treatments compared to control/placebo. In the mid-term, only physiotherapy/exercise showed benefit against placebo. However, the limited number of small studies and paucity of data calls for caution in interpreting the results and need for further evidence.

Conclusions

Patients need to be informed that there is currently no strong evidence that any treatment produces more rapid improvement in pain symptoms when compared to control/placebo in the short and medium term.  The decision about which treatment options to offer patients should be based on clinical knowledge, patient acceptability, and accessibility, as well as managing patients' expectations about how long it will take for pain to improve.

Supraspinatus Muscle Atrophy in Relation to Aging with or without Shoulder Pathology: A Radiographical Study

Abdul-Rahman Gomaa^1,2, Abdul Ahad³, Aziz Haque³, Jan Muhammad³, Radhakan Pandey³, Harvinder Pa Singh^{3 1}University of Liverpool, Liverpool, United Kingdom. ²University Hospital of Leicester NHS Trust, Leicster, United Kingdom. ³University Hospital of Leicester NHS Trust, Leicester, United Kingdom

Abstract

Introduction

Supraspinatus muscle atrophy is commonly associated with shoulder disease, but the effect of ageing on atrophy is not well understood. It was the aim of this study to investigate this effect using MRI scans in older patients.

Methods and Materials

A retrospective review of MRI scans in patients aged >70years was performed between Jan 2016Dec 2018.Both normal and abnormal scans were included in the analysis which included quantifying muscle atrophy of the supraspinatus using Thomazeu’s occupation ratio.

Results

There were 39 normal shoulder MRI scans with a mean age of 75 years (range: 70 - 88) and 163 abnormal scans with a mean age of 77 years (range: 70 - 93). The mean supraspinatus occupation ratio for normal MRI scans was 0.57 (range: 0.33- 0.86) and abnormal scans 0.35 (range: 0.17 –

0.90). Occupation ratio was maintained with advancing until the age of 85 years before undergoing a significant declined following this. 

Conclusion

William Giles¹, Qais Wahdan¹, Anna Watts², James Tomlinson², Shreya Srinivas^{2 1}University of Sheffield, Sheffield, United Kingdom. ²Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom

Abstract

Background  

The New England Spinal Metastasis Score (NESMS) and the Oswestry Spinal Risk Index (OSRI) are intuitive and accessible tools for predicting survival in patients with spinal metastases.

Initial work has shown NESMS to be a superior prognosticator than traditional scores such as Tokuhashi, Tomita and SINS however external validation is still required. OSRI and NESMS are yet to be directly compared within a population. This study aimed to externally validate NESMS within a U.K. population and compare its prognostic ability with OSRI. 

Methodology

Components for the NESMS and OSRI scores were collected alongside demographic and mortality data for all patients (n=104) referred to our tertiary spinal surgery unit between October 2018 and December 2020, identified via the British Spine Registry and “Referback”.

Results

Similar demographic, comorbidity and proportion of operative patients was achieved in this study compared to the original NESMS validation cohort.

Kaplan-Meier survival analysis showed significant differences in mortality between NESMS groups and OSRI groups at 1-year (p<0.001). Survival curves demonstrated clear differences in mortality between all 4 NESMS scores, however OSRI had substantial overlap between scores but maintained 3 distinct mortality groups (1/2, 3 and 4+) that broadly mirror NESMS. Mortality at 1-year was 46% at NESMS 3 vs. 88% at NESMS 0, compared to 48% as OSRI 1/2 compared to 84% OSRI 4+.

Multivariate logistic regression controlling for confounders identified a C-statistic (discriminative power) of 0.78 for NESMS at 1-year, whilst OSRI had a C-statistic of 0.76.

Conclusion

Similar discriminative power was demonstrated by NESMS in our study population compared to the original validation cohort, however mortality was higher at more favourable NESMS scores with less differentiation between groups.

Elizabeth Ojelade^1,2, Jacob Koris^1,3, Maria Van-Hove^1,4,5, William Gray¹, Tim Briggs^1,2, Mike Hutton^{1 1}Getting It Right First Time, NHS England, London, United Kingdom. ²Royal National OrthopaedicHospital, London, United Kingdom. ³John Radcliffe Hospital, Oxford, United Kingdom. ⁴Greener NHS, NHS England, London, United Kingdom. ⁵Department of Public Health and Sport Sciences, University of Exeter, Exeter, United Kingdom

Abstract

Background

Facet joint injections and medial branch blocks have been used to manage non-specific low back pain despite limited evidence of clinical benefit. Repeated use of these injections over a short timeperiod is a particular concern due to resource use, financial cost and unnecessary carbon emissions. This study was performed to investigate the changing practice in the use of repeated lumbar facet joint injections/medial branch blocks in England over a six-year period.

Methods

Patient data was extracted from the Hospital Episodes Statistics database for the period 1st April 2015 to 31st March 2021 for the index lumbar injection and for repeat lumbar injections performed within one year of the first. The exposure of interest was two injections within 180 days or three within one year. Patients aged < 17 years and where the body site was listed as cervical, thoracic or sacral were excluded.

Results

Data was available for 134,249 patients of which, 8,922 (6.6%) had either two injections within 180 days or three injections within one year. First injections fell from 42,511 in 2015/16 to 13,368 in 2019/20 as did the number of repeat injections: 4018 to 424 for the same period. If all years had the same carbon footprint as 2019/20, 2.8 kilotons of CO2e would have been saved over the six years, enough to power 2,575 average UK homes for one year. The financial cost of injections decreased from £27.6 million in 2015/16 to £7.9 million in 2019/20.

Conclusions

Opioid Requirements During Rehabilitation After Pelvic Fracture

James Zhang¹, Florence Bradshaw¹, Michal Duchniewicz¹, Matija Krkovic^{2 1}University of Cambridge, Cambridge, United Kingdom. ²Addenbrookes Hospital, Cambridge, United Kingdom

Abstract

Aim

Pelvic fractures are highly traumatic and debilitating injuries for patients, with an arduous rehabilitation process. Our study analyses the predictors for opioid requirements in pelvic fractures.

Method

Data was collected from all pelvic fractures treated at a Major Trauma Centre from 2015-2021, including fracture location, demographics, and comorbidities. Opioid prescriptions in the first postinjury year were computed for every individual monthly interval. For each time period, we assessed the overall combined level, and duration of background pain, based off the total “strength” in Morphine Milligram Equivalents (MME), and days with at least one opioid prescribed (“coverage”) respectively. Multivariate regression was performed on the outcomes.

Results

A total of 3137 patients with pelvic fractures were included, with mean 954 MME (95% CI=899-999) in the first year. Patients with pubis fractures showed the greatest level of opioid requirement, requiring mean 1033 MME (95% CI=961-1106) in the first year overall, with significantly higher opioid “coverage” and “strength” requirements across every individual time interval (p<0.05). Ilium fractures had the lowest level of opioid requirements, requiring mean 717 MME (95% CI=565-870) in the first year overall, with lower “strength” and “coverage” every month from month 1 to 6 post injury (p<0.05)

On multivariate analysis, female patients and patients over 60 required higher opioid “coverage” and “strength” in every time interval (p<0.05). Patients with BMI>30 required higher opioid “strength”, but not “coverage”, in every time interval (p<0.05). In comorbidity analysis, patients with connective tissue disease (x1.44), depression (x1.43), diabetes (x1.21), hypertension (x1.19), rheumatological conditions (x1.47) and valvular conditions (x1.46) required higher “strength” of opioids in the first year (p<0.05)

Conclusions

Our study highlights the various injury related, demographic and comorbidity factors that predispose patients to requiring higher strength and coverage of opioids during their rehabilitation from pelvic fractures.

Epidemiology and Incidence of Pelvic Fractures

James Zhang¹, Florence Bradshaw¹, Michal Duchniewicz¹, Matija Krkovic^{2 1}University of Cambridge, Cambridge, United Kingdom. ²Addenbrookes Hospital, Cambridge, United Kingdom

Abstract

Aim

There is a lack of recent UK based literature reporting on the incidence of pelvic fractures, and the demographic associations with fracture locations. Our study reports the incidence and factors associated with pelvic fractures at a major trauma centre over a 7.5-year period.

Method

Data from pelvic fractures treated at a Level 1 trauma centre was collected from January-2015 to June-2022. Fracture location, patient demographics, and operative status were collected and analysed.

Results

A total of 3137 patients with pelvic fractures were included, with an incidence of 78.6/100,000 patients per year. The mean age, BMI and length of hospital admission was 63.0 years old, 25.3 and

20.5 days, respectively, 53% of patients were female

Patients with Pubis fractures had the highest mean age (65.55), whilst those with ilium fractures had the lowest (51.14), both significantly different from the mean (p<0.001). Female patients were more likely to have pubis (60.1%) fractures but less likely to have acetabulum (30.0%) fractures (p<0.01). Patients with acetabular fractures had a higher BMI (p<0.01) and the highest rate of operative fixation (48.5%).

When incidence is plotted against age for each gender, the overall cohort showed a constant incidence for males throughout, and females until the 7th decade of life, with a sharp rise, peaking during the 9th decade of life. This is shared with the pubis fracture subgroup. This contrasts most other orthopaedic fractures, with a peak in younger active males, a distribution shared with ilium, sacrum and acetabulum subgroups of pelvic fractures.

Conclusions

Our study provides insight into the incidence and epidemiology of pelvic fractures in a UK major trauma centre setting, the first study in over 15 years in this context. This contributes to the literature, and allows international comparisons to be conducted, and guidelines and policies to be more informed.

Chinmay Tijare¹, Balint Borbas¹, Temidayo Osunronbi², Thomas Keith¹, Agbolahan Sofela¹, Himanshu Sharma^{1 1}University Hospitals Plymouth, Plymouth, United Kingdom. ²Royal Hallamshire Hospital, Sheffield, United Kingdom

Abstract

Introduction

Neutrophil-lymphocyte ratio (NLR) has previously been utilised as a prognostic tool to predict pain outcomes and complications in multiple fields. However, the prognostic value of NLR has not been evaluated in cervical spinal surgery. This study aimed to determine the association of preoperative NLR with pain outcomes at 12-months and post-operative complications.

Methods

This single-centre single-surgeon retrospective cohort study reviewed 107 patients with degenerative cervical spine disease who underwent elective anterior cervical discectomy and fusion (ACDF) between January 2013 and January 2021. Demographics and preoperative serum biomarkers were collected. The outcomes were postoperative complications within 30-days (yes/no), substantial clinical benefit (SCB) in Visual Analog Scale (VAS) scores for neck and arm pain(≥3.5 points improvement, yes/no), Neck Disability Index (NDI)(≥9.5 points improvement, yes/no) between baseline and 12-months post-operatively. Binary logistic regression was utilised to estimate associations between patient demographics, NLR and outcome measures. P<0.05 was considered a significant. Significant findings were analysed using receiver operating characteristic (ROC) analysis and Youden’s index was used to determine the optimal cut-off values of statistically significant variables.

Results

31 of 107 patients suffered from complications post-operatively. There was no significant association between pre-operative NLR and post-operative complications occurring or SCB in VAS arm scores at 12 months. Reduced preoperative NLR (p=0.019) was a significant predictor of SCB in VAS neck score at 12-months. The optimal cut-off for NLR was ≤2.94 (sensitivity:96.2%, specificity:37.1%). The area under the curve value of 0.687 (p=0.013), which is just below the “acceptable” cut-off 0.7 for prognostic accuracy for 12-months post-operative VAS neck score.

Conclusion 

NLR was not found to be a significant predictor of complications in patients undergoing ACDF. A greater preoperative NLR may be associated with higher levels of neck pain following ACDF. Further studies are needed to investigate this association fully. 

It’s all about quality! Not quantity! – Development of a prototype scoliosis brace strap tensiometer to monitor quality of brace wear.

Matthew Potter¹, Raveen Jayasuriya², Damien Lacroix¹, Ashley Cole^{2 1}University of Sheffield, Sheffield, United Kingdom. ²Sheffield Children's Hospital NHS, Sheffield, United Kingdom

Abstract

Background

Thermal sensors are used in multicentre trials and clinical practice to monitor brace wear time adherence. Such sensors don’t provide data about quality of wear which may be crucial for brace success. Physical activity may be linked to comfort, quality of wear and adherence.

Methods

This experimental study assessed the effect of Velcro strap tightness and activity on measured strap tension on healthy volunteers wearing a CAD/CAM, rigid, full-time, TLSO brace. 

A load cell and microcontroller with a datalogger were utilised to measure strap tension at four different levels of tightness: fully fastened as determined by spinal orthotist, then loosened by 10mm incrementally. At each tightness four activities were performed: standing, lying supine, sitting, and walking. Strap tension was recorded at a 1Hz sampling rate.

Results

Mean strap tension at orthotist determined recommended strap tightness: 150N standing, 67N laying supine, 194N sitting, 132N walking.

The loosening of the strap by 10mm led to a large reduction in measured tension across all activities (34-50%). However, subsequent loosening to 30mm resulted in minimal further decrease in tension. 

Across all strap lengths (fully tight to 30mm loose) when compared to standing position, supine strap tension decreased 55-62% and sitting strap tension increased 29-69%.

Conclusions

The pattern of strap tension associated to physical activity correlates with qualitative work done by our group which concluded that full time braces are best tolerated overnight whilst in the supine position, and least tolerated in the seated position. 

This study highlights the importance of appropriate strap tightness, where even a small 10mm decrease in strap tightness leads to a drastic drop of tension. 

Miniaturisation of this prototype will allow valuable data on brace wear quality to be monitored through a brace trial, and the justification of strap tension indicators, or auto tensioners.

Clinical Outcome of Fixed Versus Adjustable Loop Cortical Suspension Devices in Arthroscopic Anterior Cruciate Ligament Reconstruction

RAMY MOHAMED¹, MOHAMED EL-SHEIKH^{2 1}James Paget Hospital, Great Yarmouth, United Kingdom. ²ALEXANDRIA UNIVERSITY Hospital, Alexandria, Egypt

Abstract

Background  

Anterior cruciate ligament (ACL) reconstruction has remained the gold standard for ACL injuries, especially for young individuals and athletes exposed to high level sporting activities aiming to return to their preinjury level of activity. Cortical suspensory femoral fixation is commonly performed for graft fixation to the femur in anterior cruciate ligament reconstruction using hamstring tendons. 

The aim of this study was to compare the clinical results of using fixed and adjustable loop cortical suspension devices in arthroscopic ACL reconstruction using the Lysholm Knee Scoring Scale and IKDC score after 12 months postoperatively.

Material and Methods

This study included a total of sixty patients who underwent transportal arthroscopic ACL reconstruction using a hamstring tendon autograft from November 2016 to December 2017. For femoral graft fixation, a fixed-length loop device was used in 30 patients (fixed-loop group) and an adjustable-length loop device was used in 30 patients (adjustable-loop group) randomly. For tibial graft fixation, interference screw was used for all patients.

Results

The present study shows that there was no statistically significant difference between the two groups in terms of the Lysholm and IKDC scores with highly statistically significant difference between preoperative and postoperative scores in each group separately.

Conclusion

Both fixed loop and adjustable loop devices in ACL reconstruction provided good clinical outcomes but without significant statistical difference between both groups from the clinical point of view postoperatively using  Lysholm and IKDC score.

SAROJ PATRA AIIMS, Bhubaneswar, India

Abstract

Background  

Anterior cruciate ligament reconstruction surgery is the standard procedure practiced worldwide. For a successful outcome of the surgery, the post-operative rehabilitation protocol has significant importance. But there is no definite consensus for the protocol to be followed. The aim of the study was to compare the effectiveness of early accelerated rehabilitation and delayed conservative rehabilitation protocol in terms of the International Knee Documentation Committee (IKDC) score, post-operative pain, laxity and stiffness at 6 months post-operative period to achieve an optimal outcome.

Methods

Study was conducted at a tertiary health care hospital from April 2019 to April 2020 after approval of the ethical committee and after registration in the clinical trial registry of India. A total 80 patients were analyzed in two comparable groups (early accelerated group and delayed conservative group) after applying strict inclusion and exclusion criteria. 

Results

Knee laxity in the six-month post-operative period was found to be significantly high in the early accelerated group when compared with the delayed conservative group.

The post-operative pain, in terms of VAS score and IKDC score was found to be comparable between the two groups. 

Although, post-operative range of movement is better in the early accelerated group but was not statistically significant. 

Conclusion

Early accelerated rehabilitation protocol was found to be associated with significant knee laxity at six months post-surgery when compared with the delayed 

Implication

This study will guide appropriate rehabilitation following arthroscopic ACL reconstruction.

William Martin¹, Philip Walmsley², George Holland², Sarah Mitchell^{2 1}School of Medicine, University of St Andrews, St Andrews, United Kingdom. ²Department of Trauma and Orthopaedic Surgery, Victoria Hospital, Kirkcaldy, United Kingdom

Abstract

Background

Anterior Cruciate Ligament (ACL) tears are common amongst athletes. Reconstruction is the gold standard of care for ACL tear in the active population. The risk of secondary ACL injury after reconstruction is estimated at up to 31%. Revision reconstruction has substantially worse outcomes and comes at significant cost. There is a lack of consensus regarding the most appropriate objective criteria for a safe return to sport following ACL reconstruction, with most patients being discharged without objective assessment. Implementing a set of objective criteria before return to sport may reduce the incidence of second ACL injury. This review aims to determine the most suitable measurements for a safe return to sport criteria.

Methods

A literature search was conducted on Ovid MEDLINE and EMBASE based on PRISMA guidelines to identify all qualifying articles. Articles were assessed for risk of bias and quality using COCHRANE, CLARITY, and SIGN tools. Qualifying articles were split into three outcomes, with the evidence for each outcome being assessed using the GRADE process. 

Results

Ten articles (n=833) were identified for inclusion in this review. The results of each study were compiled into individual tables summarising study demographics and results. Three forms of objective measurements were identified: Psychological tests, functional tests, and biomechanical analysis. Functional tests, assessing quadriceps strength and single leg hop tests, using a ≥90% EPIC cut-off are currently the most accurate predictors of second injury. Biomechanical analysis is the most sensitive and specific predictor of second injury however, it is limited by high associated costs.

Conclusion

The current evidence suggests psychological tests, functional tests, and biomechanical analysis are all effective predictors of second ACL injury. Employing a return to play test for patients following ACL reconstruction using a combination of the three different tests may reduce the rate of second ACL injury

Home-based rehabilitation following anterior cruciate ligament reconstruction in the Kurdistan region of Iraq: epidemiology and outcomes.

Nardeen Kader¹, Samantha Jones^2,3, Ziyad Serdar⁴, Paul Banaszkiewicz⁵, Deiary Kader^{2,6 1}St George’s University Hospitals NHS Foundation Trust, London, United Kingdom. ²South West London Elective Orthopaedic Centre, London, United Kingdom. ³St George’s University of London, London, United Kingdom. ⁴Shar Teaching Hospital, Sulaymaniyah, Iraq. ⁵Faculty of Health and Life Sciences, Northumbria University, Newcastle, United Kingdom. ⁶University of Kurdistan, Hawler, Iraq

Abstract

Background

Rehabilitation plays a critical role in the recovery from anterior cruciate ligament reconstruction (ACLR) and is usually managed by physiotherapists and rehabilitation specialists. However, in Iraq orthopaedic surgeons are forced to adopt a home-based approach to rehabilitation due to the shortage of such professionals. This study describes the epidemiology and outcomes for patients who underwent an ACLR followed by home-based rehabilitation in the Kurdistan region of Iraq.  

Methods

A retrospective review of patients aged ≥16 years with an ACL rupture who underwent an ACLR under a single surgeon followed by a home-based rehabilitation programme. This was designed for completion at home, consisting of graded stretching, range of motion, and strengthening exercises. Demographics, mechanisms of injury, operative findings, and outcome data (Lysholm scores, Tegner Activity Scale, and revision rates) were collected from 2016 to 2021. Data were analysed using descriptive statistics. 

Results

The cohort consisted of 545 patients (547 knees), 99.6% were male with a mean age of 27.8 years (SD 6.18 years). The mean time from diagnosis to surgery was 40.6 months (SD 40.3). Despite data attrition, Lysholm scores improved over the 15-month follow-up period, matched data showed the most improvement occurred within the first 2 months post-operatively. Post-operative Tegner scores showed an improvement in the level of function but did not reach pre-injury levels by the final follow-up. At the final follow-up, six (1.1%) patients required an ACLR revision. 

Conclusion

Patients who completed a home-based rehabilitation programme in Kurdistan had low revision rates and improved Lysholm scores at 15 months post-operatively. 

Implications

The NHS long-term plan aims to empower patients to manage their own conditions (supported selfmanagement). Thus, further research should investigate the efficacy of home-based rehabilitation for trauma and elective surgery in low to middle-income countries and the developed world.

Francesca Solari¹, Sophie Gasson², Edwin Prashanth Jesudason^{1 1}Ysbyty Gwynedd, Bangor, United Kingdom. ²Cardiff University, Cardiff, United Kingdom

Abstract

Introduction

Current usage of planetary resources is unsustainable. Surgical procedures are particularly resourceintensive, often using vast amounts of single-use consumables, like water. It is well established that initial hand sterilization and maintenance of hand sterility during the surgical list is essential for preventing hospital-acquired infections and associated morbidity and mortality. This study aims to estimate the current daily water usage of two typical hand surgery lists from a District General Hospital in North Wales, to determine potential water savings by switching exclusively to an alcoholbased hand rub for subsequent scrubs, in line with current national guidelines.

Methods

Observational study estimation of water consumption from a temperature controlled manual tap required using a 1 litre volumetric jug where time taken to fill was recorded. Three separate observational samples were taken, and a mean was calculated. This mean determined the amount of water dispensed from the tap in a standard 3 min scrub and subsequent 1 min scrub. Two different theatre schedules were analysed 1. A  trauma list (5 cases) and 2. A higher volume minor elective procedure schedule, (16 cases) in this case a wide-awake local anaesthetic no torniquet (WALANT) carpal tunnel release (CTR). 

Results

Each case had approximately 3 persons scrubbing. 20.57L of water is used for 1 person to scrub for 3 mins and an extra 6.8574L for each subsequent 1 min scrub. Daily water consumption reached 143.99L during the major hand trauma list and 411.4L during a high-volume carpal tunnel release list. Considering water savings possible with an alcohol-based gel; reductions in water use of 57.2% and 70.2% for typical hand trauma and carpal tunnel lists respectively could be achieved. 

Conclusion  

By switching to alcohol-based surgical hand preparation, for subsequent scrubs, water consumption could be reduced by 57.2% for hand trauma lists and 70.2% for high-volume CTR lists. 

A Cost and Water Consumption Analysis of Different Surgical Hand  Disinfection Techniques in an Arthroplasty Unit in Scotland

Xinwei Low, Jun Min Leow, Joshua McIntyre, Ewan Goudie NHS Lothian, Edinburgh, United Kingdom

Abstract

Background

Orthopaedic theatres are resource-intensive in terms of water consumption compared to other parts of the hospital. This could be reduced by using motion-sensor taps or waterless handrubs, which have similar efficacy to traditional scrubbing methods. The aim of this study is to provide a cost and water consumption analysis of various surgical hand disinfection techniques (SHDT). 

Methods

A questionnaire on the preferred method of SHDT were distributed to a group of arthroplasty surgeons in the study centre which runs two arthroplasty lists daily. The average time of SHDT was calculated based on the responses. The amount of water and disinfectant used for each SHDT were measured. The cost and water consumption for each SHDT was calculated based on the number of arthroplasty cases over a two-week period and extrapolated to provide an annual estimate.

Results

Over two weeks there were 46 arthroplasty cases with a total of 183 scrubbing events. There were 14 questionnaire responses. Over two weeks, the total amount of water used was 5,236L and the total cost of SHDT (water and disinfectant included) was £110.21. When using a motion-sensor tap, the total amount of water used is 2,320.5L and the total cost was £105.79. When using a waterefficient SHDT (single 4-minute scrub with motion-sensor tap followed by waterless handrub for subsequent cases), the total amount of water used is 1,092L and the total cost was £45.61. Per annum, using a motion-sensor tap would save 75,791L of water, whilst using a water-efficient SHDT would save 97,744L of water and £1679.60 in cost.

Conclusion

Data from this study can be used to inform hospital management on the potential water savings from using motion-sensor taps and the additional cost savings when using a water-efficient SHDT, which could help reduce the carbon footprint of orthopaedic surgery.

Catrin Morgan, Matthew Smitheman, Branavan Rudran, Reza Mobasheri, Lily Li Imperial College Healthcare NHS Trust, London, United Kingdom

Abstract

Background

The NHS accounts for 4.6% of the UK’s carbon footprint, with operating theatres accounting for   a disproportionate percentage. Theatre waste is segregated into steams for costs and methods of disposal, leading to varying CO2 emissions. These include: orange (infectious), tiger (non-infectious), green (recycling) and clear (domestic). The aims of our study were: 1) to assess the percentage of correct waste segregation and 2) quantify the recyclability of the waste in orthopaedic trauma theatres.

Methods

Data was collected at a Major trauma centre in December 2022. Cycle 1 involved collating data on the type of waste segregation theatre bins. The different waste streams were weighed using digital weighing scales. A waste segregation survey was distributed to all theatre members to ascertain behavioural trends. Following staff education, a further data collection cycle was carried out in March 2023. For each cycle, the cost of waste disposal and CO2 emissions were calculated.

Results

The average waste generated in trauma theatre per day was 42kg. 8% (2/25) of theatre staff members were able to correctly identify all waste streams. In cycle 1, the cost of waste disposal was £0.35 per kg resulting in 0.45 CO2 emissions per kg. 86.9% of waste was placed in the wrong stream which reduced to 12.2% in cycle 2 (p<0.05).  This lead to a 57.1% (£0.15/kg) reduction in the cost of waste disposal and 28.9% (0.32kgCO2e) reduction in CO2 emissions. Only 9% (cycle 1) and 8% (cycle 2) was recyclable.

Conclusions/Findings

Trauma theatre generates a large amount of waste, with only a small proportion being recyclable. Proactive measures focusing on staff education and correct waste stream segregation can lead to a reduction in the carbon footprint and an overall cost saving for the NHS.

Edward Cornish¹, Vladislav Kutuzov¹, Helen Andrews², Amit Kapoor¹, Neil Jain^{1 1}Northern Care Alliance, Manchester, United Kingdom. ²Becton, Dickinson and Company, Wokingham, United Kingdom

Abstract

Background

The environmental impact of surgery is concern that has been raised in recent years. Operating theatres have been found to create up to 230kg of waste per day. There  is a need to reduce surgical waste whilst maintaining patient safety. This observational study assessed the waste generated between two accepted surgical skin preparation techniques.  

Methods

Groups consisted of two consultant surgeons, both performing 5 arthroscopic procedures. Surgical skin preparation was performed with disposable ChloraPrep™ sticks or bottled chlorhexidine solution with dye. The total weight for all items used in both groups was calculated.

Results

The ChloraPrep™   group generated a total of 876g of net waste compared to 1727g in the Chlorhexidine bottled solution  group. Waste per surgical case was 134.6g (SD 14.97) in  ChloraPrep™ group compared to 328.8g (SD 86.09) in the Chlorhexidine bottled solution group. The disposable ChloraPrep™ group  produced significantly less waste than the Chlorhexidine bottled solution group (P <0.0069).

Conclusions

Arthroscopic procedures are common practice in the UK. This study demonstrates the significant difference in waste production between two accepted skin preparation techniques for arthroscopic surgery. Despite small numbers in this study, a wider application of this practice would likely reduce the impact arthroscopic surgery upon the environment, whilst not compromising patient safety.   

Implications

Choice of skin preparation can significantly impact waste production in arthroscopic surgery.

Henry Slade, Thomas Goff Pinderfields Hospital, Wakefield, United Kingdom

Abstract

Background

In 2020 the NHS committed to reaching net zero. Operating theatres and surgical procedures are significant contributors to this carbon footprint. We sought to change practice in a high-volume low complexity/variability procedure to maximise impact and acclimatise as many staff as possible to this step change. We applied the principles from the Intercollegiate Green Theatre Checklist to rationalise our surgical instrumentation usage and tray sterilisation hoping to achieve environmental, social and economic impacts.

Methods

We undertook a pilot study to inform rationalisation of surgical instrumentation and restructuring of trays for cemented hip hemiarthroplasty, introducing a supplementary tray of instruments available dependent on surgeon preference. Following these changes we performed a 3 month audit to monitor staff engagement, staff satisfaction and tray usage. Carbon accounting and economic impact was performed using published equivalent industry numbers.

Results

Restructuring and rationalising our trays allowed reduction from 7 trays per procedure to 3 trays plus the 1 supplementary tray. During our audit period 74 cemented hip hemiarthroplasties were performed with the new core tray opened every time, and the supplementary tray 31 times (42%), observing a downward trend as staff gained familiarity with set up. Orthopaedic theatre staff were satisfied with the restructuring and more than 80% of surgeons had exposure to the new trays.  

In this period we calculated savings of 261kg carbon dioxide equivalent (CO2e) and £7,083 from reduced sterilisation. This could be extrapolated to a total 1044kgCO2e and £28,332 over a calendar year.

Conclusion

We have demonstrated that with the simple intervention of rationalising our tray inventory for a common procedure it is possible to achieve a significant reduction in carbon dioxide, reach a large staff population, and realise cost savings. We hope to apply this methodology to other orthopaedic procedures and inspire other departments to implement similar changes.

Fabian Roberts¹, Tobias Roberts², Yael Gelfer³, Caroline Hing^{3 1}Epsom and St. Hellier Hospitals NHS Trust, Epsom, United Kingdom. ²Croydon University Hospital, London, United Kingdom. ³St. George's Univeristy Hospitals NHS Foundation Trust, London, United Kingdom

Abstract

Background

As fracture clinic services come under increasing pressure, innovative solutions are needed to combat rising demand. AI programmes can be used to diagnosis fractures, but patient perceptions towards its use are uncertain. This study aimed to assess carer attitudes towards the use of artificial intelligence (AI) in management of fractures in paediatric patients. 

Methods

We conducted a cross-sectional survey of carers of paediatric patients presenting to fracture clinic at a tertiary-care centre, combining single-best-answer questions and likert-type questions. We investigated carer perception of clinical review of their child in the Emergency Department (ED); disruption to school to attend fracture clinic and attitudes towards AI.

Results

45% of paediatric fracture patients were seen in the ED within two hours, 29% were seen between 2-4 hours and 26% were seen after 4 hours. 75% were seen by both a nurse and a doctor, 16% were seen only by a nurse, and 9% only by a doctor. Attending fracture clinic, 61% of children had to take time off school for their appointment, whilst 59% of parents had to take time off. 56% agreed that more research is needed to reduce waiting times. With regard to attitudes towards AI, 76% preferred a nurse or doctor to review their child’s radiograph, 64% were happy for an AI programme to diagnose their child’s fracture, and 82% were happy with an AI programme being used as an adjunct to a clinician’s diagnosis. 

Conclusion

Carer perceptions towards the use of AI in this setting are positive. However, they are not yet ready to relinquish human decision making to automated systems. 

Digitalising musculoskeletal injuries management and referral pathway – Introducing a novel IT service solution

Ahmad Al-Sukaini west Suffolk Hospital, Bury St Edmunds, United Kingdom

Abstract

Introduction 

More than 3.5 million patients attend the Emergency Department (ED) with musculoskeletal injuries annually in the UK.  Frontline staff are under pressure, faced with a broad spectrum of conditions, and have limited resources. This has led to longer ED waiting times, variations in patient care practice, and unnecessary follow-up appointments. Digital innovation has played a big role in improving patient care in the NHS. We reveal a novel IT service mobile app solution that will enhance efficiency and patient care.

Methods 

Virtual and face-to-face fracture clinic patients were audited retrospectively. Information on the diagnosis, management, time in ED, patient information leaflet utilisation, and clinical outcome were recorded. ED survey was also conducted to understand the challenges faced by ED staff. IT service solution, Virtual Bones, was designed and developed to tackle all the challenges encountered. The service solution has just been implemented as a pilot service at West Suffolk Hospital.

Results 

Virtual Bones enables specialist clinicians to digitalise and tailor fracture management pathways to enhance efficiency and patient care. The system is accessible via a web viewer and mobile devices, allowing health workers to have the latest guidance available at the point of care. The content is accessed via an interactive digital skeleton, which uses various pedagogical features and an integrated module to locate splints/casts in ED. The system has an integrated QR code generator for patient information leaflets and a fully-equipped content management system coupled with Google Analytics that allows hospital admin users to have full control over the content.

Conclusion

Virtual Bones' innovative modules can support health-worker decision-making and allow them to assess and manage patients in an efficient, effective, and safe manner. It is a promising solution that has the potential to revolutionise the musculoskeletal injuries management pathway and reduce the burden on the NHS.  

ORthopaedic Trauma Hospital Outcomes - Patient Operative Delays (ORTHOPOD) study

Thomas Baldock^1,2, Reece Walker², Thomas Walshaw¹, Hussam Elamin-Ahmed¹, Nicholas Wei¹, Sharon Scott³, Alex Trompeter⁴, William Eardley^{2,5 1}Health Education England North East, Newcastle upon Tyne, United Kingdom. ²Academic Centre for Surgery (ACeS), Middlesborough, United Kingdom. ³Liverpool University Hospitals NHS Foundation Trust, Liverpool, United Kingdom. ⁴St George's University Hospitals NHS Foundation Trust, London, United Kingdom. ⁵Department of Health Sciences (York University), York, United Kingdom

Abstract

This is a multicentre prospective assessment of a proportion of the overall orthopaedic trauma caseload of the United Kingdom. It investigates theatre capacity, cancellations, and time to surgery in a group of hospitals that is representative of the wider population. It identifies barriers to effective practice and will inform system improvements.

Methods

Data capture was by collaborative approach. Patients undergoing procedures from 22/08/22 and operated on before 31/10/22, were included. Arm one captured weekly caseload and theatre capacity. Arm two concerned patient and injury demographics, and time to surgery for specific injury groups.

Results

Data was available from 90 hospitals across 86 Data Access Groups (70 in England, 2 in Wales, 10 in Scotland and 4 in Northern Ireland). After exclusions, 709 weeks of data on theatre capacity and 23 138 operations were analysed. The average number of cases per operating session was 1.73. Only 5.8% of all theatre sessions were dedicated day surgery sessions despite 29% of general trauma patients being eligible for such pathways. 12.3% of patients experienced at least one cancellation.

Delays to surgery were longest in Northern Ireland and shortest in England and Scotland. There was marked variance across all fracture types.  Open fractures and fragility hip fractures, influenced by guidelines and performance renumeration, had short waits, and varied least. 9 hospitals had 40 or more patients waiting for surgery every week whilst 7 had less than five.

Conclusion

There is great variability in operative demand and list provision seen in this study of ninety UK hospitals. There is marked variation in nearly all injuries apart from those associated with performance monitoring. There is no evidence of local network level coordination of care for orthopaedic trauma patients. Day case operating and pathways of care are underused and are an important area for service improvement.

Ali Jarragh¹, Ali Lari¹, Waleed Burhamah¹, Mohammed Alherz¹, Abdulla Nouri¹, Yahia Alshammari¹, Ameer Al-Jasim², Sulaiman AlRefai¹, Naser Alnusif^{1 1}Department of Orthopaedic Surgery, AlRazi Hospital, Al-Shuwaikh, Kuwait. ²College of MedicineUniveristy of Baghdad, Baghdad, Iraq

Abstract

Digital injuries are among the most common presentations to the emergency department. In order to sufficiently examine and manage these injuries, adequate, prompt, and predictable anaesthesia is essential. In this trial, we aim to primarily compare the degree of pain and anaesthesia onset time between the two-injection dorsal block technique (TD) and the single-injection volar subcutaneous block technique (SV). Further, we describe the temporal and anatomical effects of both techniques for an accurate delineation of the anaesthetized regions.

This is a single-centre prospective randomized controlled trial involving patients presenting with isolated wounds to the fingers requiring primary repair under local anaesthesia. Patients were randomized to either the SV or TD blocks. The primary outcome was procedure-related pain (Numerical Rating Scale). Further, we assessed the extent of anaesthesia along with the anaesthesia onset time.

A total of 100 patients were included in the final analysis, 50 on each arm of the study. The median pain score during injection was significantly higher in patients who received TD block than patients who received SV block (median [interquartile range] = 4 [2.25, 5.00] vs. 3.00 [2.00, 4.00], respectively, P = 0.006). However, anaesthesia onset time was not statistically different among the groups (P = 0.39). The extent of anaesthesia was more predictable in the dorsal block compared to the volar block.

The single-injection volar subcutaneous blocks are less painful with a similar anaesthesia onset time. Injuries presenting in the proximal dorsal region may benefit from the two-injection dorsal blocks, given the anatomical differences and timely anaesthesia of the region.

Coronavirus in hip fractures (CHIP) 4 : has vaccination improved mortality outcomes in hip fracture patients?

Aatif Mahmood¹, Fatima Rashid¹, DAvid Hawkes¹, William J Harrison¹, CHIP 4 Collaborative group^{2 1}Countess of Chester Hospital, Chester, United Kingdom. ²multicentre, Multicentre, United Kingdom

Abstract

Aims 

Prior to the availability of vaccines, mortality for hip fracture patients with concomitant COVID-19 infection was three times higher than pre-pandemic rates. The primary aim of this study was to determine the 30-day mortality rate of hip fracture patients in the post-vaccine era.

Methods

A multicentre observational study was carried out at 19 NHS Trusts in England. The study period for the data collection was 1 February 2021 until 28 February 2022, with mortality tracing until 28 March 2022. Data collection included demographic details, data points to calculate the Nottingham Hip Fracture Score, COVID-19 status, 30-day mortality, and vaccination status.

Results

A total of 337 patients tested positive for COVID-19. The overall 30-day mortality in these patients was 7.7%: 5.5% in vaccinated patients and 21.7% in unvaccinated patients. There was no significant difference between post-vaccine mortality compared with pre-pandemic 2019 controls (7.7% vs 5.0%; p = 0.068). Independent risk factors for mortality included unvaccinated status, Abbreviated

Mental Test Score ≤ 6, male sex, age > 80 years, and time to theatre > 36 hours, in decreasing order of effect size.

Conclusion

The vaccination programme has reduced 30-day mortality rates in hip fracture patients with concomitant COVID-19 infection to a level similar to pre-pandemic. Mortality for unvaccinated patients remained high.

Oliver Krahelski¹, Sinthiya Sivarajah², Will Eardley³, Toby Smith⁴, Caroline Hing^{2 1}Epsom and St. Helier Hospital, LONDON, United Kingdom. ²St. George's Hospital, London, United Kingdom. ³James Cook University Hospital, Middlesborough, United Kingdom. ⁴University of York, York, United Kingdom

Abstract

Background

Mobility scooter use as an alternative method of transport is becoming ubiquitous amongst the older population. Currently no evidence exists assessing mobility scooter associated major trauma in the UK at a national level. This study investigates the demographics and injury patterns of mobility scooter users who have sustained traumatic injury requiring hospital admission.

Methods

The Trauma Audit and Research Network (TARN) database was used to collect data concerning injuries associated with mobility scooters. The data was taken from incidents that occurred between February 2014 and November 2020. The data analysed included: patient demographics, injury mechanism and patterns and associated mortality rates.  

Results

1,504 patients were identified of which 61.4% were male. The median age was 76.2 years (IQR 63.5– 84.9). The median injury severity score (ISS) was 9 (IQR 9–17), with major trauma (ISS ≥16) being observed in 29.4% of patients. Injuries to the limb were most common, although injuries to the head were most severe. Vehicle collisions accounted for 65.4% of injuries and were most closely associated with the most severe incidents. The median length of stay in hospital was 12 days, excluding the patients who died. Overall, mortality following injury was 10.6%, but the mortality rate was 15.4% in those aged 75 years and over, and 24.2% in those sustaining major trauma.

Conclusion

As the population ages, injury characteristics of those with both major and non-major trauma changes. Mobility scooter use is prevalent amongst older people, and we provided a detailed analysis of injuries sustained with their use across a national database. The length of stay and the inherent resource use, because of admission following mobility scooter trauma, is considerable. These injuries particularly affect the ‘most elderly’ and carry a considerable mortality burden.

Return to Work Following Intramedullary Nailing of Lower-Limb Long-Bone Fractures in South Africa

Samuel Masterson^1,2, Maritz Laubscher³, Sithombo Maqungo^3,4, Nando Ferreira⁵, Michael Held³, William J. Harrison^6,7, Simon Graham^{2,3,8,9 1}University of Liverpool, Liverpool, United Kingdom. ²Liverpool School of Tropical Medicine, Liverpool, United Kingdom. ³Orthopaedic Research Unit (ORU), Division of Orthopaedic Surgery, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa. ⁴Division of Global Surgery, University of Cape Town, Cape Town, South Africa. ⁵Division of Orthopaedic Surgery, Department of Surgical Sciences, Stellenbosch University, Cape Town, South Africa. ⁶Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, United Kingdom. ⁷Department of Orthopaedic Trauma Surgery, Countess of Chester Hospital, Chester, United Kingdom. ⁸Liverpool Orthopaedic and Trauma Service, Liverpool University Teaching Hospital Trust, Liverpool, United Kingdom. ⁹Oxford Trauma and Emergency Care, Nuffield Department of Orthopaedics, Rheumatology & Musculoskeletal Sciences, Oxford, United Kingdom

Abstract

Background

Injuries are one of the leading causes of global death and disability and commonly have substantial economic implications. The economic impact of injuries is particularly pronounced in low- and middle-income countries, where 90% of injuries occur. In this study, we aimed to assess return-towork rates of individuals who sustained a lower-limb long-bone fracture in South Africa and to identify factors that influence the ability to return to employment.

Methods

This prospective cohort study was conducted across 2 tertiary trauma centers in Cape Town, South Africa. Adults who received intramedullary nail fixation for a lower-limb fracture between September 2017 and December 2018 were recruited and followed for 18 months postoperatively. The participants' return to employment was assessed at 6 and 18 months post-injury. Multivariate logistic regression was used to identify factors that influence post-injury employment.

Results

Of the 194 participants enrolled, 192 completed follow-up. The study population had a median age of 33.0 years, and most of the participants (76.6%) were male. Seventy-five percent of the participants were employed before their injury. At 6 and 18 months post-injury, 34.4% and 56.3% of participants, respectively, were employed. Of those employed pre-injury, 70.1% had returned to work at 18 months. Multivariate regression identified increasing age, unemployment prior to injury, and working in the informal employment sector as factors that impede an individual's likelihood of working 18 months post-injury. For those in employment prior to injury, increasing age was the only factor found to impede the likelihood of returning to work following an injury.

Conclusions  

Mansi Tolia¹, Santosh Baliga², Gareth Medlock^{2 1}University of Aberdeen, Aberdeen, United Kingdom. ²NHS Grampian, Aberdeen, United Kingdom

Abstract

Background

Distal femoral fractures are a common injury with a bimodal distribution; typically high-energy fractures in the young and fragility type fractures in the elderly. Most commonly these are fixed with lateral plates, hence a laterally based incision is favoured. However, for intra-articular fractures access for reduction and fixation can be limited. Also when there is medial based comminution a separate medial incision may be required for medial plating. Alternatively, a midline exposure with proximal extension facilitates both goals. The purpose of this study is to investigate the safety of a midline approach for distal femur fracture fixation.    

Method

Patients were identified from a Trauma database. Inclusion criteria were all patients admitted from 2020-2022, aged over 16 years, fixation using a midline line skin incision with either a lateral or medial parapatellar approach. Data was collected from patient records, operation notes and the Scottish national PACS archive. Data included patient demographics, anatomical approach, fixation method, complications, and time to union.     

Results  

In total, 35 distal femoral fractures underwent a midline approach for fixation. Patient average age was 65 years (range 21-94); 66% were females and 34% were males. Surgical exposure was achieved using a medial in 27 cases and lateral parapatellar in 8. 17 fractures were double-plated, 14 were single-plated and 4 used a combination of nail with a single or double plate. Average healing time was 19 weeks. Of the 35 patients, 4 required revisions due to early metalwork failure and this was done through the same incision. 

Conclusion

The midline approach is safe and has comparable outcomes as lateral based approaches and requires only a single incision in providing access to the distal femoral articular surface as well medial and lateral cortices for plate fixation if required.

Mark Rickman, Dominic Thewlis, Andreas Ladurner, James Bassett, Thomas Nijman University of Adelaide, Adelaide, Australia

Abstract

The protocol was prospectively registered (ACTRN12618001431213). All patients over 60 with an extracapsular proximal femoral fracture were considered for inclusion. Participants were randomised between 3 arms: Single screw device (Gamma Nail, Stryker) dynamic mode at the proximal end, Dual screw device (Intertan, Smith & Nephew) dynamic mode at the proximal end, or Dual screw device locked statically at the proximal end. All nails had a proximal neck shaft angle of

125 degrees, all fractures were compressed. Follow-up was clinical and radiographic at 6 weeks and 6 months. The primary outcome measure was construct failure by 6 months post-surgery, indicated by any of: Device breakage, lag-screw cut-out (LSC), or a change in Tip Apex Distance (TAD) of more than 10mm.

479 patients were included, mean age 84 (range 60 to 101), 71% were female.  95 died before the 6 month follow-up. 131 refused to return for the 6 months follow-up, but were all contacted by telephone. 226 participants had full radiographic follow-up.

There were no differences between groups in terms of age, gender, fracture pattern, reduction achieved at surgery or initial TAD. 

7 of the 226 cases (3.1%) required revision surgery for LSC. No devices fractured.

Including change of TAD over time, the overall failure rate of the Gamma nail was 11.3%, the Intertan unlocked was 9.7%, and the Intertan Locked was 1.4%. The Intertan Locked group showed significantly less proximal sliding, but no sliding was only seen in 38% of cases.

The results presented for the dynamically locked groups are similar to previously published data. The proximally locked group showed statistically and clinically significant different results, with less failures and lower change in TAD. The locking mechanism doesn’t  appear to lock the device fully, but slows collapse. Controlling collapse at the fracture site potentially has significant clinical effects on outcomes.

The impact of NICE treatment guidance on outcomes following severe open tibial fractures

Anjali Shah¹, David Metcalfe¹, Andrew Judge², Xavier Griffin^{3 1}NDORMS, University of Oxford, Oxford, United Kingdom. ²University of Bristol, Bristol, United Kingdom. ³Barts and the London School of Medicine and Dentistry; Queen Mary University of London, London, United Kingdom

Abstract

Background

Clinical services related to open lower limb fractures have changed considerably over the last 15 years. In 2012, dedicated Major Trauma Centres (MTCs) were established together with Regional Trauma Networks across England. In 2016 NICE published guidance for managing complex fractures (NG37). The objective of this study was to assess whether these changes were associated with improved patient outcomes following open tibial fracture. 

Methods

An interrupted time series study was undertaken using data from the Trauma Audit and Research Network (TARN) linked to Hospital Episode Statistics and civil death registrations. All patients admitted to hospital in England with an open tibial fracture during 2012-19 were included. The outcomes were 30-day and 1-year mortality, hospital length of stay, and readmission.

Results

There were 7,796 patients available for analysis. Mortality at 30 days and one year and length of stay in hospital were all significantly increasing until the publication of NICE treatment guidance in 2016 (P<0.01). Following this a decrease in mortality and length of stay was observed. Significant changes in trend occurred for 30-day mortality (-0.3 (-0.51- -0.09) P=0.009), 1-year mortality (-0.038 (-0.63 - 0.013) P=0.004) and mean length of stay (-0.34 (-0.54 - -0.014) P=0.001). Throughout the study period mean time to readmission (days) significantly fell (-15.1 (-16.6 - -13.59) P<0.001).

Conclusions

Publication of NICE guidance on treatment of open tibial fractures was associated with reductions in mortality and length of stay in hospital.

Implications

These data support the value of publication of national guidance on treatment for patients with the most severe lower limb injuries. 

Post Binder Pelvic Radiograph Role in Identifying Bladder Injury Associated with Pelvic Fracture

Aidan Butler, Matthew Dawson, Stella Ruth Smith, Katie Moore, Joseph Alsousou Manchester University NHS Foundation Trust, Manchester, United Kingdom

Abstract

Background

All patients with pelvic trauma undergo a contrasted Computer Tomography (CT) scan followed by post-binder X-ray (PBXR), as per BOAST guidelines. CT cystography is recommended to investigate potential bladder trauma. Contrast filling or extravasating from the bladder on PBXR may indicate the absence or presence of significant bladder perforation. 

Aim

To investigate whether contrast extravasation on an adequately-timed PBXR detects bladder perforation associated with pelvic fractures. 

Methods

Using TARN data, we identified all patients admitted to a level-1 major trauma centre (July 2021December 2022) with pelvic fracture. Patient demographics, injury mechanism, fracture classification, outcomes and complications were extracted. PBXR images were correlated with urological investigations and operative findings.

Results

Of 169 patients with pelvic fracture, 58 underwent a CT-scan followed by PBXR. 3 had confirmed bladder injury. Contrast extravasation was visible on PBXR in all patients with bladder injury, and not in any patient without bladder injury (Chi-square test, p<0.00001). In all patients with bladder injury, urinary catheters were present and time between CT and PBXR ranged from 8-30 hours. 

In patients without bladder injury, 15 (27%) were catheterised and therefore contrast was not visible. Of non-catheterised patients (n=40), 28 (70%) showed contrast filling the bladder. PBXR performed within 10 hours of CT-scan was associated with a significantly higher rate of contrastfilled bladder (90%) than those performed more than 10 hours since CT-scan (10%, p<0.0001). 

Conclusion

Visible contrast extravasation on PBXR correlates strongly with bladder injury associated with pelvic fracture, regardless of catheterisation status. Contrast-filled bladder and absence of contrast extravasation correlates strongly with the absence of bladder injury. 

Elective amputations as a sequelae of lower limb trauma: rationale for amputation and long-term complication rates

Charlotte Brookes, Sara Dardak, Moatisim Qayyum-Bin-Asim, Alice Linden, Alex Trompeter St. George's Hospital, London, United Kingdom

Abstract

Background

Elective lower limb amputation in the context of previous trauma is a complex decision. There is paucity of literature on the rationale for undertaking elective amputation in these patients, as well as their outcomes following amputation, which we aim to address in this study. 

Methods  

Retrospective analysis of a prospectively collected database of all lower limb amputations secondary to trauma from a regional multidisciplinary amputee service in London. Clinical records were consulted for index trauma, date of amputation, evidence of re-operation, infection (superficial or deep), phantom limb pain and neuroma. Amputations were deemed elective if occurring >6weeks post-traumatic injury.

 Results  

69 amputations in 66 patients were analysed. Mean age at index trauma was 38 years, and mean age at time of amputation 45 years. The most prevalent mechanism of injury was RTA (41%), followed by fall from height (28%). Mean time from index trauma to amputation was 77 months (range 3-508 months). Chronic infection and chronic pain were the joint leading causes in proceeding to elective amputation (29%), with non-union and infected non-union accounting for 13% and 10% respectively. Post-amputation rates of phantom limb pain, re-operation and phantom limb pain were 53%, 19% and 12% respectively. Infection was reported at a rate of 33%. Mean follow up from time of amputation was 128 months.

Conclusions

Chronic infection and chronic pain are the most common reasons for proceeding to elective amputation of a previously traumatised lower limb. The rates of re-operation, neuroma and phantom limb pain following elective amputation due to trauma are in keeping with those published for amputations secondary to diabetes or vascular disease. However, we report a higher rate of infection, likely attributable to chronic infection as a leading cause for elective amputation.

Role of distal imaging in pre-operative planning for the management of metastatic disease of the hip: the Liverpool Metabolic Bone Service (LiMBS) experience.

Marieta Franklin, Ladan Yusuf Hassan, Sarah Massey, Saif Ul Islam, Birender Kapoor Liverpool Univeristy Hospitals NHS Foundation Trust, Liverpool, United Kingdom

Abstract

Introduction 

BOA BOOS guidelines recommend long leg radiograph imaging to aid pre-operative planning in patients with proximal femoral MBD(1).  We present our experience of the management of these patients in a Regional Metastatic Unit.

Methods

All cases treated by the LiMBS service from 2013 onwards were reviewed. From the 778 patients, the arthroplasty group were identified and pre-operative imaging was reviewed along with implant choice.

Results

346 patients were treated surgically, 86 patients were treated with hip arthroplasty – 3 bilateral therefore 91 arthroplasties in total. Out of these 27.5% presented as pathological fractures. Primary identified tumour was breast in 24.6% prostate in 18.5%, lung in 15.4%, myeloma in 12.3% and 4.5% gastrointestinal malignancy. Out of the 91, 69 were treated with standard length arthroplasty, 22 (37.9 %) cases using long stems.  8 patients had plate augmentation. 30/91 (32%) of arthroplasty patients had surgical plans altered by pre-operative distal imaging. 86.4% had long leg radiographs.  63.6% had preoperative CT. Those who did not have CT all had long leg radiographs. All patients had clinic follow up till death with Patient Initiated Follow Up (PIFU) - the follow up period for many cases is over 4 years. No cases required revision.  All patients were mobile with no or minimal pain.

Conclusion 

Presence of distal imaging affects decision making in the management of MBD. In our series, distal imaging altered decision making around operative planning in a third of patients.

Multivariate analysis of risk factors for progression to fracture in patients with metastatic bone disease (MBD)

Samantha Downie¹, Alison Stillie², Matthew Moran², Cathie Sudlow¹, Hamish Simpson^{1 1}University of Edinburgh, Edinburgh, United Kingdom. ²NHS Lothian, Edinburgh, United Kingdom

Abstract

Background

It is difficult to predict risk of pathological fracture in patients with bone metastases.  Commonly used scoring systems like Mirels do not incorporate patient-specific variables such as primary cancer type and may overestimate those who need surgery by 20%.  The aim was to identify predictors of fracture at 12 months in patients with long bone metastases managed non-surgically.

Methods

This was a powered retrospective analysis of individuals with a long bone metastasis managed without surgery.  New long bone metastases identified on x-ray or CT imaging were identified from radiology reports and excluded if they presented with a fracture or had prophylactic surgery.  A literature review and pilot study identified 15 potential predictors of fracture (variables of interest) including primary cancer type and radiological appearance. 

Results

2142 patients were analysed and of these 58 sustained a pathological fracture on admission (4%), 7 underwent operative management (0.4%) and 630 did not have metastases in a long bone (40%).  We reviewed data for 571 lesions in 503 patients (45% female, mean age 71 range 17-95 years) managed conservatively.  73% were dead at follow-up (418/571 median survival 6.4 months) and median followup in living patients was 2 years (range 8 months-12 years).

 The 12-month fracture rate was 28% (143/571).  A number of variables were associated with increased risk of fracture including older age (p<0.05), primary diagnosis of lung cancer or lymphoma (p<0.05), lytic radiological appearance (p<0.001) and increasing pain (p<0.05)

Protective factors included sclerotic radiological appearance (p<0.001), primary diagnosis of prostate cancer (p<0.001) and polymetastatic disease (p<0.05).

Conclusion 

Predicting risk of pathological fracture is vital in managing patients with bone metastases to avoid unnecessary surgery.  This study has identified a number of independent predictors of fracture which could be used to generate a novel scoring tool for use in counselling patients for surgery.

David Fellows, Julia Kotowska, Thomas Stevenson, Matthew Baldwin, Duncan Whitwell, Jennifer Brown, Sarah Pratap, Thomas Cosker, Christopher LM Gibbons Oxford University Hospitals, Oxford, United Kingdom

Abstract

Background

Giant cell tumour of bone (GCTB) is a benign condition with metastatic potential. The treatment is surgical and/or chemotherapy (denosumab).

Staging is undertaken before surgery as GCTB may present with distant disease. The common site is the chest and is monitored following treatment (1,2). What is uncertain is the behaviour of distant disease (3,4). The purpose of this review was to assess the incidence and surveillance of chest disease.

Methods

A retrospective audit of Oxford bone tumour registry. The inclusion criteria is patients with diagnosis of

GCTB confirmed histologically. Exclusion criteria is medical records and full imaging were not available/incomplete, or referred for secondary MDT opinion. A total of 84 patients (from 131 histopathology records) were identified.

Results

Pulmonary metastasis was identified in 9 (10.7%) patients, 2 at presentation and 7 (78%) at follow-up between 2 – 44-month period. Two of these were histologically confirmed, 7 radiologically diagnosed.

5 (56%) of patients with chest disease have died (between 1 and 22 months after confirmed chest disease), 4 alive with stable disease

5 (56%) with chest disease had recurrence of local disease requiring further limb/axial surgery.

40 (48%) had denosumab (MDT recommendation). 8 patients (89%) with chest disease were treated with denosumab/chemotherapy (6 before, 2 after chest diagnosis).

Overall local recurrence occurred in 20 patients (24%). 16 (80%) with local/extremity recurrence were treated with denosumab (9 before, 7 after recurrence diagnosis).

Conclusions

GCTB is unpredictable and has metastatic potential both at presentation and follow-up. Chest disease on surveillance may not be stable and progress and requires careful monitoring with PET scan and CT.

Histological review of biopsy, surgical specimen and chest metastasis may indicate metastatic potential and requires formal MDT review. This requires a multi-centre audit of GCTB outcome and chest surveillance.

Operative Surgical Management of Metastatic Renal Cell Carcinoma; Experience from a Tertiary Referral Centre.

Colin McDonald, Robert Ashford, Bone Metastases Team University Hospitals of Leicester, Leicester, United Kingdom

Abstract

Background

Destructive renal bone metastases are best treated by operative surgical management.  We present our experience of surgery for metastatic Renal Cell Carcinoma (RCC) at a tertiary referral centre. 

 Methods

We prospectively reviewed the clinical outcomes of 52 consecutive procedures in 48 patients for the period July 2005 to March 2023.  Surgical procedures were defined as simple fixation (either ORIF or Intramedullary Nailing); augmented fixation, excision or Endoprosthetic Replacement (EPR). 

Results

There were 31 male and 19 female patients. Mean age a time of surgery was 52 years (Range 32 – 84 years).  Five patients underwent multiple procedures - two for bilateral humeral metastases, two for progressive disease and one for multifocal metastases (clavicle / tibia). Nine patients underwent EPR of which two were for progressive disease.  Around half of the patient cohort received adjuvant

Radiotherapy with a similar number undergoing pre-operative Embolization.  34 patients died during the period of the current study with 14 remaining under routine surveillance.  The mean survival was 10 months from date of surgery (range 0-55 months).  

Conclusion 

Adjuvant radiotherapy is popular in the surgical management of bone metastases in RCC. Pre-operative Embolization may provide better surgical outcomes.  Due to RCCs predilection for osteolytic and destructive lesions, EPR remains a viable management option.  Operative management of metastatic RCC is likely to continue to be a key aspect of treatment as the incidence of the phenomenon increases globally.  

Mahlisha Kazemi¹, Rachel Wei Ying Tan¹, Ather Siddiqi¹, Phoebe Hine¹, Khurram Ayub², Harriet BranfordWhite¹, Thomas Cosker¹, Duncan Whitwell^{1 1}Nuffield Orthopaedic Centre, Oxford, United Kingdom. ²John Radcliffe Hospital, Oxford, United Kingdom

Abstract

Background

Resection and reconstruction of pelvic tumours are complex operations with the potential to have significant morbidity. A systematic review of 801 patients reported mean non-oncologic complication rate of 49% and reoperation rate of 37% (1). Identifying risk enables early planning to improve outcomes. 

Objective

To create a scoring system comprised of surgical and medical factors to determine the risk of postoperative intensive care unit (ICU) admission following pelvic resection for tumours.

Method 

An audit was conducted, as a retrospective observational study on 50 adult patients who underwent pelvic resection for a primary or secondary tumour between December 2017 and December 2022. Patients with osteochondroma and those undergoing sacropelvic or retroperitoneal resections were excluded. Data on patients’ age, comorbidities, ASA score, tumour type and grade, resection type, reconstruction, estimated blood loss, operation duration, involvement of other surgical specialities, preoperative treatments, and ICU admission were collected. 

Based on surgical and medical factors assessed, a risk stratification tool, called COMPOSURE (COMbined Pelvic Oxford SURgical Evaluation) was developed.

Results

Morbidity rates were comparable to existing literature with 34 events in 28 patients. Two patients died. Ten patients were admitted to the ICU with only three having a planned admission. Unplanned transfers to the ICU were due to haemodynamic instability (n=3), aspiration pneumonia (n=1), bowel injury (n=1), revascularization (n=1), and suspected urinary obstruction (n=1). 

The pelvic pathway was proposed to optimise perioperative and post-operative support, with a COMPOSURE score cut-off of 5 predicting an increased risk of ICU admission.   

Conclusion

This risk stratification tool with score validation can help with early planning and resource allocation for the appropriate level of patient care following pelvic resection for tumours.