Core Surgical Training (CST) Application- Time and Money Spent Survey

Gregory Hodgson¹, Samantha Jones¹, Irrum Afzal¹, Sarkhell Radha^2,1

¹SWLEOC, London, United Kingdom. ²Mayday Hopsital, Croydon, United Kingdom

Abstract

Portfolios are a crucial component of the Core Surgical Training (CST) application, scored using a points-based system. Points are accrued via courses, conferences and further training. These can be expensive and time consuming, which poses a significant challenge for junior doctors.

An online survey assessed the time and financial impacts of applying for CST. An anonymised multiple-choice questionnaire was distributed to junior doctors across all deaneries in England, Scotland and Northern Ireland. Questions focused on finance, training and time dedicated to the domains of the CST self-assessment guide.

There were 60 respondents: 3 F2’s (5%), 8 F3’s (13%) (one-year post-foundation training), 5 F4’s (8%) (two-years post-foundation training), 20 CT1’s (33%), 17 CT2’s (28%), and 7 ‘other’ (12%).

The mean total application expenditure was £3,865, ranging from under £500 to over £12,500. Those who already secured CST jobs had a mean total spend of £4,000, the largest portion (£1,594) was spent on teaching skills courses. These were values were largely underestimated when compared to the total application spend calculated using the sum of the participants responses to individual domains. Calculated total application cost for applicants successful at their first attempt of gaining a CST job was £5,966, with that of all participants being £5,470.

The total mean study leave was 9 days, ranging from 3 to over 17 days. Doctors who secured a CST job took a mean of 9 days study leave; those successful on their first CST application averaged 10 days. 70% of participants used annual leave or personal time to attend courses or conferences.

This survey demonstrates the personal, financial and time impacts of preparing a CST application. Teaching skills represented the largest expenditure and identifies part of potential gap in pre-CST training, which applicants are covering at their own expense.

Tips and Tricks for Ergonomic Orthopod: Breaking Diversity Barriers with the Right Tools

Saharish Saleem¹, Karen Chui², Kate Atkinson³, Joanna Higgins⁴

¹Basingstoke North Hampshire Hospital, Basingstoke, United Kingdom. ²RNOH, London, United

Kingdom. ³Havering and Redbridge Hospital University, London, United Kingdom. ⁴University

Hospital Dorset, Poole, United Kingdom

Abstract

Background

Only 7% of trauma and orthopaedic (T&O) consultants are women. A perceived barrier is the misconception that the job requires physical strength and to be of tall stature, a myth that neglects the availability of modern tools and technology available to all surgeons. We designed a course based on surgical ergonomics to challenge this belief and promote gender diversity. Our course, 'Tips and Tricks for the Ergonomic Orthopod,' demonstrated how to apply ergonomics in orthopaedic procedures to optimise performance and reduce health risks for surgeons.

Method

Ten consultant surgeons delivered techniques and ergonomics-based training to medical students and pre-registrar doctors on common orthopaedic procedures. Procedures included distal radius fracture reduction; ankle fracture reduction and plaster application; shoulder dislocation reduction; prosthetic hip dislocation reduction; and total hip arthroplasty. The course was attended by 25 students and doctors who were surveyed before and after.

Results

The study included 12 cis-men, 12 cis-women participants and 1 who preferred not to say.

Participants included 9 registrars, 8 senior house officers and 8 medical students. 31% of participants reported they knew someone who didn't pursue T&O due to perceived physical challenges. Of the

25 participants, 77% reported improved confidence in their ability to perform shoulder reduction, 53.8% reported increased confidence for distal radius fracture reduction and 31% recorded increased confidence in ankle fracture reduction and application of plaster.

Conclusion  

Surgical ergonomics training can improve technique, confidence, efficiency and occupational health and safety in medical students and doctors early in their career when performing orthopaedic procedures. It offers an effective solution to diversity challenges and the misconception that performing T&O surgery requires a specific physicality. Further research is needed to understand the effect of surgical ergonomics on preventing musculoskeletal injuries among orthopaedic surgeons.

United Kingdom Pregnancy in OrthoPaedics (UK- POP): A Cross- Sectional  Study of UK Female Orthopaedic Surgeons and their Experiences of Pregnancy

Christina Kontoghiorghe¹, Catrin Morgan², Deborah Eastwood^3,4, Scarlett McNally^{5 , 1}University College London Hospitals NHS Trust, London, United Kingdom. ²Imperial College Healthcare NHS Trust, London, United Kingdom. ³Royal National Orthopaedic Hospital, London, United Kingdom. ⁴Great Ormand Street Hospital, London, United Kingdom. ⁵East Sussex Healthcare NHS Trust, London, United Kingdom

Abstract

Background 

The number of females within the specialty of trauma and orthopaedics (T&O) is increasing. The aim of this study was to identify 1) current attitudes and behaviours of UK female T&O surgeons towards pregnancy, 2) any barriers faced towards pregnancy with a career in orthopaedic surgery and 3) areas for improvement.

Methods

This is a cross-sectional study using an anonymous 13- section web-based survey distributed to female-identifying orthopaedic Trainees, Specialty and Associate Specialist Surgeons (SAS) and Locally Employed Doctors (LED), Fellows and Consultants in the UK. Demographic data was collected as well as closed and open questions with adaptive answering relating to attitudes towards childbearing and experiences of fertility and complications associated with pregnancy. A descriptive data analysis was carried out. 

Results

A total of 226 UK female orthopaedic surgeons responded to the survey. All regions of the UK were represented. Forty-four percent (N=99/226) of respondents had at least one child, whilst 9.3% (N=21) did not want children. Two- thirds (66%, N=149) of respondents delayed childbearing due to a career in orthopaedics and 61.9% (N=140) of respondents had experienced bias from colleagues directed at female orthopaedic surgeons having children during training. Nearly 20% (N=24/121) of respondents required fertility assistance to get pregnant, 28.9% (N=35/121) had experienced a miscarriage and 43.8% (N=53/121) had experienced obstetric complications.

Conclusions

A large proportion of female orthopaedic surgeons have and want children. Orthopaedic surgeons in the UK delay childbearing, have experienced bias and have high rates of infertility and obstetric complications. The information from this study will support female orthopaedic surgeons with decision making, as well as raising awareness for Training Programme Directors (TPDs) and employers and can be used to assist with workforce planning. Further steps are necessary in order to support female orthopaedic surgeons having families.

Major Trauma multi-professional simulation and cadaveric training: “Firefighting” for orthopaedic teams

Aidan Butler, Mariam Gaddah, Amer Shoaib, Ian Tyrell-Marsh, Ananth Ebinesan, Stella Ruth Smith Manchester University NHS Foundation Trust, Manchester, United Kingdom

Abstract

Background

Following the Manchester Arena attack of 2017, a simulation and cadaveric training course was developed for multi-professionals targeting damage control, improving teamwork, decision-making and surgical skills. Engagement with these training methods is associated with improved patient outcomes. We aim to evaluate the efficacy of the orthopaedic version of this course.

Methods:

A three-day multidisciplinary course incorporated lectures, simulation and cadaveric skills training, including a major incident exercise. Attendees included registrar and consultant surgeons, anaesthetists, emergency department consultants and nurses, scrub nurses and operating department practitioners. Pre- and post-course questionnaires assessed perception of confidence in multidisciplinary decision-making and specialty-specific skills, using Likert scales.

Statistical analysis used a two-tailed Mann-Whitney test with a 5% confidence level.

Results

Of 80 attendees, 19 were surgeons. 73% had never attended a damage control simulation or cadaveric course. 93% agreed trauma simulation is a useful tool to improve skill development.

89% agreed/strongly agreed the simulations were appropriate for their level of training and 95% found it useful for their development. 95% agreed/strongly agreed the multi-professional workshop improved their understanding of the multi-professional team roles including their role within the team.

Confidence in skill performance improved significantly in finger thoracostomy (pre-course v postcourse) (20% v 95%, p=0.00132), clam shell thoracostomy (0% v 63%, p<0.00001), pelvic fracture management (67% v 100%, p=0.00036), pelvic external fixation application (27% v 100%, p<0.00001) and vascular injury management (13% v 89%, p<0.00001). Non-significant improvements were observed in intraosseus access (53% v 89%), knee-spanning fixator application (80% v 95%) and fourcompartment fasciotomy (87% v 100%).

Conclusion

This multidisciplinary simulation and cadaveric course improved orthopaedic surgeon knowledge, multi-professional teamwork skills and trauma-related surgical skills. Investigation into the impact on performance in the clinical environment would further characterise the efficacy of this valuable training tool.

The effect of augmented reality on skill acquisition and alignment accuracy in total knee arthroplasty. A double-blinded randomised controlled trial.

Anaiya Kaka¹, Jack Donovan¹, Aishwarya Shah¹, Azedah Yunus², Arpit Patel², James Barnett², Akash Patel^{2 , 1}University College London, London, United Kingdom. ²Royal Free London NHS Foundation Trust, London, United Kingdom

Abstract

Introduction

Demand for total knee arthroplasty (TKA) has surged as average age increases and patient outcomes improve; hence, it is imperative to train registrars to perform them in a safe environment. However, trainee working patterns have changed and with increased focus on patient safety, high-quality alternative methods of teaching are required. The aim of this double-blinded randomised-controlled trial was to assess validity and evaluate the use of augmented reality (AR) for training orthopaedic registrars in TKA.

Method

Seventeen orthopaedic registrars from 9 UK hospitals were randomised to intervention or control groups. The control received a TKA teaching session from an expert while the intervention received training via Microsoft HoloLens, where experts superimposed virtual information over physical objects. Participants then performed a TKA on sawbones and were assessed by 2 orthopaedic consultants using 3 quantitative outcome measures: OSATS scores, TKA-specific checklist, and femoral and tibial mechanical alignment. Qualitative feedback was analysed using a 5-point Likert scale.  

Results

AR was equal to traditional training for teaching technical proficiency, with cohorts scoring equivalently in OSATS (p=0.807) and checklists (p=0.642). The intervention had smaller standard deviation (4.80 versus 6.21), indicating AR teaching was more standardised. The AR group achieved significantly better mechanical alignment, with 66.67% achieving femoral neutral alignment compared to none in the control and 88.89% achieving tibial neutral alignment compared to 75% in the control. Additionally, AR was rated as significantly more realistic (p=0.003) and interactive (p=0.01) than the control.

Conclusion

AR training was found to be equally capable of teaching technical proficiency and significantly more successful in teaching mechanical alignment for TKA to orthopaedic registrars. The results demonstrate face, content, and transfer validity for AR in surgical training. 

Disclosure

Is Trauma and Orthopaedics diminishing in popularity within the Medical School Population due to a reduction in MSK exposure?

Sarah Stapley¹, Fransiska Guerreiro¹, Lucy Bailey¹, Alice Coburn², Robert Gregory^{3, 1}Portsmouth Hospitals University Trust, Portsmouth, United Kingdom. ²British Orthopaedic Association, London, United Kingdom. ³University Hospital of North Durham, Durham, United Kingdom

Abstract

Background

Since COVID, applications to ST3 for Trauma and Orthopaedics have seen a gradual drop off especially from UK trained doctors. Is this the result of reduced exposure to surgical specialties and in particular, MSK during Medical School training?  Is this having an impact on potential surgical career pathways and how might it be rectified moving forwards. 

Method

A national survey of UK Medical Students was undertaken with the assistance of the Medical Schools Council to distribute. It asked how surgical specialties are considered in the student population, the overall exposure during Medical School of MSK and how this has an impact on potential career pathways.

Results

527 responses were received across all 5 years. Differential survey response seems to be due to whether the school’s ELAG lead circulated the survey. Responses were 63% female, 35% male of which 55% white, 45% ethnic background. 36% had already decided upon a career pathway, of which 64% had chosen a surgical specialty. When asked generally which surgical specialty, T&O was the most popular (52%) followed by General Surgery (30%), and Plastic surgery (21%). What stimuli had prompted this choice, the top three responses were clinical attachment, inspiring consultant/trainee, careers materials available via various resources. Factors important in choice were enjoying the job, making a difference to patients and work/life balance. MSK exposure during training was considered inadequate by 50%. Although 59% stated they were confident in assessing the MSK system following training. When asked about accessing additional careers material the top answers were web search/ email/ Instagram. Twitter, WhatsApp and TikTok were rated lower. 

Conclusion

This survey demonstrates that T&O remains a well-liked specialty in the undergraduate population. MSK exposure was acceptable by 44%. Possibly the dip in numbers applying to higher training is just a lull.

Natural Language Processing in Research: Pandora’s Box or a Plethora of Opportunities?

Foad Mohamed¹, Klaas Victor^2,1, Alistair Hunter¹, Marcus Lee¹, Simon Lambert^{1 , 1}University College London Hospitals, London, United Kingdom. ²University Hospitals Leuven, Leuven, Belgium

Abstract

Background

Natural language processing (NLP) platforms have sparked both excitement and concerns in the scientific community about its use in research. There is a lack of quantitative assessments to evaluate the accuracy and potential impact of this tool. This study aims to examine the strengths and weaknesses of ChatGPT and Bard, two natural language processing platforms, in synthesizing orthopaedic literature.

Methods

Twenty-five original abstracts, published in three high-impact factor journals, were randomly selected to cover different orthopaedic subspecialties. ChatGPT and Bard were used to generate 25 abstracts for each original abstract using the title of original paper as a prompt. Ten orthopaedic consultants were asked to determine which abstract(s) were authored by artificial intelligence (AI).

The consultants were blinded to the AI-processing performed by the researchers.

Results

All 50 unique abstracts were assessed by the orthopaedic consultants, with 13 (56.5%) out of 23 AIgenerated abstracts correctly identified. Surprisingly, only 50% of the published abstracts were correctly identified. 31% of AI-generated abstracts were found to have the same qualitative outcome and quantitative size order as their matched original abstract. 26% of AI-generated abstracts had conflicting outcomes compared to their controls.

Conclusions

Our study found that human reviewers struggle to differentiate between NLP-generated and humangenerated information. The positive predictive value for a human reviewer to identify an AIgenerated abstract was only 0.52. Also, 1 in 4 artificial abstracts had conflicting or opposite outcomes to the original papers.

Implication

NLP has the potential to revolutionise a number of areas in scientific research, including editing manuscripts and summarising vast literature, quality assessments in systematic reviews, and performing biostatistics. This study cautions its use in synthesizing novel research due to high rates of factual errors which without technical and editorial framework has the potential to adulterate the scientific literature.

Comparing clinical efficacy of bio similar to original molecule in short course use of neoadjuvant denosumab in giant cell tumour of bone

Ajay Puri, Manish Pruthi, Prakash Nayak , Tata Memorial Centre, Mumbai, India

Abstract

Background

Densosumab is used effectively as a neoadjuvant drug to facilitate treatment of Giant cell tumor in bone in selected cases. The original molecule (OD) , though effective was expensive and it was challenging for patients to pay  "out of pocket". The availability of an affordable generic biosimilar (BD) made it accessible to a larger patient pool. We sought to compare clinical efficacy of OD and BD

Methods

Between January 2019 to December 2021, of 27 patients treated with short course neoadjuvant denosumab, 13 received original molecule (OD) while 14 received biosimilar (BD). The protocol followed was drug delivery at 0,7,15 & 28 days with patients getting more doses during initial study period. All patients received minimum 2 doses of 120mg. Mean duration of treatment in both groups was 5 weeks, with mean number of 3 doses in both groups. We compared initial radiographs to the pre-surgery radiographs (usually after 3-4 weeks from last dose). The development of a sclerotic neocortex (peripheral rimming) and varying degrees of matrix osteosclerosis (intralesional ossification) was assessed by 2 blinded reviewers. Rimming was graded as present or absent while matrix ossification was graded as < or > 50%. 

Results

4 patients received 2 doses, 10 received 3 doses while 14 patients received 4 doses.

Intralesional ossification was <50% in 46% and >50% in 54% of patients receiving OD while it was <50% in 43%  and >50% in 57% of the patients receiving BD. Peripheral rimming was present in 100% of the patients receiving OD while it was in 86% (12 out of 14) patients receiving BD.  

Conclusions

The data from the present study suggests similar efficacy of biosimilar drug as compared to original molecule. This has implications for cost effectiveness and improved access without compromising clinical efficacy in neoadjuvant treatment of denosumab in giant cell tumor of bone. 

Post-traumatic stress disorder among patients with lower limb fractures in South Africa

1Gerald Tan MBBS, MRCS, MSc ²Maritz Laubscher, MBChB, FC Orth(SA), MMed Ortho(UCT), ^2,3Sithombo Maqungo, MBChB, FC Orth(SA), MMed Ortho(UCT), ^2,3Kirsty Berry, MBChB, FC Orth(SA), MMed Ortho(UCT), ⁴Nando Ferreira, PhD, ²Michael Held, FC Orth(SA), MMed (UCT), MD (LMU), PhD (UCT) and ^5,6Simon Matthew Graham, MBChB, MRCS, MSc, FRCS, PhD ¹St Helen's & Knowsley Teaching Hospitals NHS Trust, Prescot, Merseyside, United Kingdom ²Orthopaedic Research Unit (ORU), Division of Orthopaedic Surgery, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa ³Division of Global Surgery, University of Cape Town, South Africa ⁴Division of Orthopaedic Surgery, Department of Surgical Sciences, Stellenbosch University, Cape Town, South Africa ⁵Liverpool Orthopaedic and Trauma Service, Liverpool University Teaching Hospital Trust, Liverpool, United Kingdom ⁶Oxford Trauma and Emergency Care, Nuffield Department of Orthopaedics, Rheumatology & Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom

Abstract

Background  

The risk factors and prevalence that lead to post-traumatic stress disorder (PTSD) in patients with lower limb trauma  are not widely known. The aim of this study is to investigate the prevalence and risk factors of PTSD among patients with lower limb trauma. The study was undertaken in 2 large trauma centres in South Africa which represents a middle income country with a significant lack of research into lower limb trauma.  

Methods

The study was undertaken from September 2017 to December 2018 with a 260 participants with lower limb fractures. Participants were screened using the Primary Care PTSD (PC-PTSD-5) screening tool, which is a gold standard measure to identify patients at risk with PTSD. Within the cohort, high risk participants were assessed with the PTSD checklist (PCL-C) which is a standardized questionnaire scale to indicate PTSD. Data on sociodemographic and clinical characteristics among participants were stratified according to risk groups. 

Results

We found the prevalence of participants at high risk of developing PTSD within the study population was 13.4% and among the high risk groups, 52.9% were deemed PTSD positive. In terms of risk factors, male gender, early infection, delayed union and younger age participants were found to be at higher risk compared to their counterparts. 

Conclusion

The findings of our study suggests that there is a significant role of PTSD screening among patients with lower limb trauma. Early identification of patients at risk of developing PTSD are useful indicators to provide appropriate resources, psychological support and patient education.

Establishing a Consensus on Research Priorities in Orthopaedic Trauma Within South Africa

Simon M Graham^1,2,3, Luke Render⁴, Sithombo Maqungo^3,5, Nando Ferreira⁶, Leonard Charles Marais⁷, Michael Held³, Maritz Laubscher^{3  , 1}Oxford Trauma and Emergency Care, Nuffield Department of Orthopaedics, Rheumatology & Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom. ²Liverpool Orthopaedic and Trauma Service, Liverpool University Teaching Hospital Trust, Liverpool, United Kingdom. ³Orthopaedic Research Unit (ORU), Division of Orthopaedic Surgery, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa. ⁴Liverpool Orthopaedic and Trauma Service, Liverpool University Teaching Hospital Trust, Liverpool, South Africa. ⁵Division of Global Surgery, University of Cape Town, Cape Town, South Africa. ⁶Division of Orthopaedic Surgery, Department of Surgical Sciences, Stellenbosch University, Cape Town, South Africa. ⁷Department of Orthopaedic Surgery, School of Clinical Medicine, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa

Abstract

Authored on behalf of the Orthopaedic Research Collaboration in Africa (ORCA) 

Background

Musculoskeletal (MSK) injuries are one of the leading causes of disability worldwide. Despite improvements in trauma-related morbidity and mortality in high-income countries over recent years, outcomes following MSK injuries in low and middle-income countries, such as South Africa (SA), have not. Despite governmental recognition that this is required, funding and research into this significant health burden are limited within SA. 

This study aims to identify research priorities within MSK trauma care using a consensus-based approach amongst MSK health care practitioners within SA. 

Method

Members from the Orthopaedic Research Collaborative (ORCA), based in SA, collaborated using a two round modified Delphi technique to form a consensus on research priorities within orthopaedic trauma care. Members involved in the process were orthopaedic healthcare practitioners within SA. 

Results

Participants from the ORCA network, working within SA, scored research priorities across two Delphi rounds from low to high priority. We have published the overall top 10 research priorities for this Delphi process. Questions were focused on two broad groups - clinical effectiveness in trauma care and general trauma public health care. Both groups were represented by the top two priorities, with the highest ranked question regarding the overall impact of trauma in SA and the second regarding the clinical treatment of open fractures. 

Conclusion

This study has defined research priorities within orthopaedic trauma in South Africa. Our vision is that by establishing consensus on these research priorities, policy and research funding will be directed into these areas. This should ultimately improve musculoskeletal trauma care across South Africa and its significant health and socioeconomic impacts. 

 Funding

This study was not funded but was supported by AO Alliance and the South African

Orthopaedic Trauma Society

Economic burden and cost-effectiveness of treatments of open tibia fractures in Malawi: results of a nested economic analysis in a multicentre prospective cohort study

Alexander Thomas Schade^1,2, Linda Alinafe Sande¹, Maureen Sabawo³, Nohakhelha Nyamulani⁴, Kamewe Mwafulirwa⁴, Leonard Banza Ngoie⁵, Andrew John Metcalfe⁶, David Lalloo², William Jim Harrison^7,8, Jason Madan⁶, Peter MacPherson^{9  1}Malawi-Liverpool-Wellcome Trust, Blantyre, Malawi. ²Liverpool School of tropical Medicine, Liverpool, United Kingdom. ³Kamuzu University of Health Sciences, Blantyre, Malawi. ⁴Queen Elizabeth Central Hospital, Blantyre, Malawi. ⁵Kamuzu Central Hospital, Lilongwe, Malawi. ⁶Warwick clinical Trials Unit, coventry, United Kingdom. ⁷AO Alliance, davod, Switzerland. ⁸Countess of Chester, Chester, United Kingdom. ⁹University of Glasgow, glasgow, United Kingdom

Abstract  

Background

In high-income countries (HICs), open tibia fractures are expensive injuries to treat and patients still struggle to return to work after one year. In Malawi, we hypothesised that patient would have significant financial loss and struggle to return to work at one year following injury. 

Methods

This economic evaluation study from the societal perspectives with a 1-year time horizon was nested in a multicentre prospective cohort study. Effectiveness was assessed by EQ-5D-3L scores from faceface interviews at 6 weeks, and 3, 6, and 12 months post-injury. Direct treatment costs (including readmission up to one year) were obtained from a prospective micro costing study and staff interviews at tertiary and district hospitals. Indirect costs included household lost productivity and patient transportation. Multilevel regression models investigated associations between costs and QALYs. All costs were reported in 2021 GBP.

Results

287 participants were included in this analysis with the majority (n=170, 59%) working in casual business and 83% (n=238) of participants were in the poorest quintile. Most participants (n=255, 89%) were working prior to injury with a median monthly household income of £36 (21-86) and only 42% (n=112) were working one year after injury with a median monthly household income of £28 (455).

Total societal cost at one year for Gustilo I/II injuries were £657 for a POP in a district hospital, £797 for POP in a central hospital, £718 for a nail in a central hospital. For Gustilo III injuries, external fixator was £1,574, intramedullary nail was £1,663, POP in a district hospital was £1,731 and £2,476 for an amputation. Interventions provided similar incremental cost/QALY.

Conclusion

Participants report significant economic suffering and loss of income following an open tibia fracture in Malawi. Orthopaedic treatments offer similar costs/QALY from a societal perspective therefore function should be prioritised. 

Supramalleolar Osteotomy For Ankle Arthritis  : Medium-Term Results From A Major Referral Centre

Islam Mubark, Seyed Ali University hospitals Birmingham, Birmingham, United Kingdom

Abstract

Background 

Realignment osteotomies are joint preserving operations usually utilized in eccentric ankle arthritis where there is focal overload to one side of the joint in one or more plane. 

Aim 

Report the functional and radiographic outcomes of supramalleolar medial open and closing wedge osteotomies in the management of eccentric varus and valgus ankle arthritis respectively. 

 Methods

 A retrospective case series study from foot and ankle tertiary referral centre including 37 ankles operated on  by a single surgeon between 2010 and 2020 . We assessed the functional outcome of the patients utilizing the AOFAS and MOXFQ score. The radiological parameters measured included  Tibial articular surface angle, and Talar tilt angle.

 Results    

Out of 37 osteotomies, 21 patients had medial opening wedge osteotomy for varus deformity and 16 patients had medial closing wedge osteotomy for valgus deformity. Mean follow-up at the end of the study was 39.5 months (range 23- 56 months). The mean AOFAS has improved from a preoperative mean of 20.84   to a postoperative mean of  56.36  . The MOXFQ decreased from a preoperative mean of 54.53 to a mean of 24.72 post-operatively. All the radiological parameters showed statistically significant improvement. The arthritis progressed in two cases, both had ankle arthrodesis. 

Conclusion  

 Supramalleolar osteotomy is a viable option for patients with asymmetric ankle arthritis with improved functional and radiological outcomes and a good medium-term survival rate.

UK Foot and Ankle Thrombo-Embolism Audit (UK-FATE) – A multicentre prospective study of Venous Thromboembolism in Foot and Ankle Surgery

Jitendra Mangwani¹, Linzy Houchen-Wolloff¹, Lyndon Mason², Karan Malhotra^{3 ,1}University Hospitals of Leicester, Leicester, United Kingdom. ²Liverpool University Hospitals NHS Foundation Trust, Liverpool, United Kingdom. ³Royal National Orthopaedic Hospital, London, United Kingdom

Abstract

Introduction

There is wide variation in the threshold and provision of chemical thromboprophylaxis in the treatment of foot and ankle conditions. One of the difficulties in affecting change in practice in this area is the low incidence of postoperative, symptomatic venous thromboembolism (VTE). Therefore, a large number of patients need to be included in any series for meaningful conclusions to be drawn.

Primary objective

To observe the UK-wide variation in post-operative thromboprophylaxis, and to analyse the 90-day incidence of symptomatic VTE related to:

•       Elective foot/ ankle surgery

•       Trauma foot/ ankle surgery

•       Treatment of Achilles tendon ruptures (operative/ non-operative)

Methods

Multi-centre prospective audit (June 2022-Feb 2023). Primary outcomes were symptomatic VTE following foot/ ankle surgery and Achilles tendon rupture, including VTE related mortality up to 90 days. Secondary outcomes included thromboprophylaxis used, possible confounding variables and influencing factors for VTE.

Results

A total of 12,080 patients were included from 70 UK sites. 48.68% trauma (n=5,880), 3.31% diabetic surgery (n=400) and 48.01% elective surgery (n=5,800). There were 99 VTE events (0.80%). The most common chemical prophylaxis used was Enoxaparin (27.19%),then Dalteparin (20.38%). The diagnoses with significant increase in VTE included Achilles tendon ruptures (OR 14.43, p<.001), Diabetic wound debridement (OR 8.15, p=.004) and malleolar fractures (OR 6.46, p=.011).

Patient factors significantly associated with VTE included cancer (OR 2.32, p=.039), stroke (OR 2.912, p=.020), Asthma/COPD (OR2.35, p=.036), clotting disease (OR 4.21, p=039) and poor compliance with VTE prophylaxis (OR .41, p=.042). There were six cases of Heparin induced thrombo-cytopenia.

Conclusion

This multicentre national study has shown low incidence of VTE in patients undergoing surgical treatment of foot/ ankle conditions in the UK. There is wide variation in the type of chemical thromboprophylaxis used. The study identified Achilles Tendon Rupture and Diabetic foot surgery as diagnoses with increased risk of VTE.

Transformation from “hot” to “cold” elective site operating for primary hip and knee arthroplasty in the UK; a 4 year review of regional outcomes for the enhanced recovery programme (ERP)

Jessica Harvey, Rohit Rambani

Pilgrim Hospital, Boston, United Kingdom

Abstract

Background

The ERP continues to provide an evidence-based, multidisciplinary team (MDT) approach for primary elective hip and knee arthroplasty.   A trust ERP was initiated in 2014 and revised regularly as part of the continuous audit process.  

Specific modifications were the introduction of preload supplements and consideration of individual patient factors.  A bespoke feature of the updated ERP is that the radiograph is performed postoperatively assisted by ongoing spinal analgesia.   This coincided with the trust’s involvement in the 2018 Getting It Right First Time (GIRFT) pilot which transformed operational practice from a “hot” trauma unit to “cold” elective site. 

Method

Patients for elective arthroplasty were consecutively analysed  from 2018 to 2021 during this transition.  Patients suitable for day case procedures were included i.e. without need for level 2 care.  The primary outcome was length of stay (LOS); secondary outcomes were 30-day readmission rate and major postoperative complications.  LOS is presented as the median number of nights/patient/year.

Results

A total of 2462 patients were included with a median age of 71 years.  A total of 1114 hip and 1348 knee replacements were performed.  From 2018-2019 the median LOS was 2 nights which fell to 1 night in 2020-21.  Overall 30 day readmission was 6.8% with orthopaedic admissions accounting for 1.94%.  Between 2018 and 2021, 30-day readmission improved from 7% to 5%.  Median time to 30-day readmission was 8 days post discharge.   Overall 30-day orthopaedicrelated complication rate was 1.95%. 

Conclusion

In conclusion, this MDT-coordinated ERP alongside the GIRFT initiative limiting “hot” site elective operating was effective in halving LOS for patients. Moreover, 30 day readmission rate and major complication rate improved substantially over the 4 years studied.

Implications

Ring-fenced elective operating alongside ERP is effective at reducing patient stay, readmission rate and complications.

The prognostic value of the modified Glasgow Prognostic Score in the management of patients with Chondrosarcoma: a multicentre study

Ofir Ben Gal¹, Sanjay Gupta¹, James Doonan¹, Ashish Mahendra², Naeil lotfi³, Jonathan Stevenson³,Sam McMahon⁴, Rob Pollok⁵, Gavin Baker⁶, David Warnock⁶, Gillian Cribb⁷, Trevor Mwaramba⁸, Kenneth Rankin⁹, Corey D Chan⁹, Ather Siddiqui¹⁰, Tom Cosker^{10  1}Glasgow royal infirmary, Glasgow, United Kingdom. ²GRI, Glasgow, United Kingdom. ³The Royal Orthopaedic Hospital, Birmingham, United Kingdom. ⁴The Royal National Orthopaedic Hospital, Stanmore, United Kingdom. ⁵The Royal National Orthopaedic Hospital, stanmore, United Kingdom. ⁶Musgrave Park Hospital, Belfast, United Kingdom. ⁷The Robert Jones and Agnes Hunt Orthopaedic Hospital, Oswestery, United Kingdom. ⁸The Robert Jones and Agnes Hunt Orthopaedic Hospital, Oswestry, United Kingdom. ⁹The North of England Bone and Soft Tissue Tumour Service, Newcastle, United Kingdom. ¹⁰Oxford Bone and Soft Tissue Tumour, Oxford, United Kingdom

Abstract

Aim

The prognostic role of systemic inflammatory biomarkers in patients with Chondrosarcoma remains unclear and evidence is lacking. mGPS is an inflammation-based prognostic score consisting of preoperative CRP and albumin which is validated in multiple carcinomas, and soft tissue sarcoma,   where its use is recommended. This national multicenter study aimed to investigate the prognostic significance of preoperative systemic inflammatory biomarkers, primarily the mGPS, in the prediction of Chondrosarcoma patient survival.

Method

Patients who underwent an elective resection of primary or secondary chondrosarcoma between January 2006 and December 2020 were identified from prospectively maintained databases of seven collaborating UK bone sarcoma units. Laboratory and clinical data as well as oncologic outcomes were collected from the patient's record with a minimum of 2 years of follow-up.  Data were analyzed using Kaplan Meier survivorship, uni- and multivariate analysis.

Results

A total of 549 patients were included in our study. We found that increased mGPS, tumour grade, size, age, local recurrence, metastasis, and inflammatory markers were significantly associated with reduced overall survival. mGPS was able to stratify the overall survival of patients in all grades of chondrosarcoma, especially when divided into mGPS score 0 versus mGPS 1 & 2.

Conclusion

Our findings indicate that inflammatory markers and mGPS strongly correlate with the survival of chondrosarcoma patients. We recommend its use in the early assessment of chondrosarcoma patients to better stratify prognosis, reinforce decision making and improve clinical outcomes

The rate of delayed and non-union in the occult MRI-detected scaphoid fracture – a multi-centre cohort study

Benjamin Dean1,2, OCCULT SCAPHOID STUDY GROUP3,4,5,6,7,8,9,10,11,12 ¹OUH Hospitals NHS Trust, Oxford, United Kingdom. ²University of Oxford, Oxford, United Kingdom. ³University of Oxford, Oxford`, United Kingdom. ⁴UHB, Birmingham, United Kingdom. ⁵GKT, London, United Kingdom. ⁶Whiston Hospital, Whiston, United Kingdom. ⁷Glasgow Royal Infirmary, Glasgow, United Kingdom. ⁸Wrexham Hospital, Wrexham, United Kingdom. ⁹Barnsley Hospital, Barnsley, United Kingdom. ¹⁰Taunton Hospital, Taunton, United Kingdom. ¹¹South Tees NHS, Middlesbrough, United Kingdom. ¹²Southmead Hospital, Bristol, United Kingdom

Abstract

Introduction There is a lack of published evidence relating to the complication rate in occult scaphoid fractures.  This study reports the rate of delayed union and non-union in a cohort of patients with MRI detected acute scaphoid fractures.

Methods  

This national, multicentre, cohort study at 7 centres in the UK included all patients diagnosed with an acute scaphoid fracture on MRI having presented following wrist trauma and having undergone normal x-rays. Data was gathered retrospectively for a minimum of a 12 months at each centre.  The primary outcome measures were the rate of delayed and non-union, and the rate of acute surgery.  

Results

A total of 1896 patients underwent acute MRI for a suspected scaphoid fracture during the study period, of which 237 patients (12.5%) who were diagnosed with an occult MRI detected scaphoid fracture.  Of the scaphoid fractures, seven patients underwent early surgical fixation (2.9%) and there was a total of 14 cases of delayed or non-union (5.9%). Of the delayed and non-unions, 9 underwent surgery (4%), three healed after further cast treatment (1.3%), one opted for nonsurgical treatment and one failed to attend follow up.   All patients who underwent surgery had united at follow up.  There was one complication of surgery (prominent screw requiring removal).

Conclusions  

The rate of delayed or non-union for occult MRI detected scaphoid fracture is significant at 5.9% with the majority of these patients requiring surgery to achieve union.  This study adds further weight to the considerable evidence base supporting the use of early MRI for these patients.

Total Hip Arthroplasty for Neck of Femur Fracture – Can we better predict patients that will benefit?

Lauren Smith¹, Lee Hoggett², Reinier Van-Mierlo², George McLauchlan², Joshua Patton^{1  1}University of Manchester, Manchester, United Kingdom. ²LTHTR, Preston, United Kingdom

Abstract

Introduction

NICE guidance for the treatment of neck of femur fractures is to offer total hip arthroplasty (THA) to cognitively intact patients who are independent outdoors with no more than the use of a stick. Recent RCT evidence suggests little difference in outcomes between THA and hemiarthroplasty in patients up to 2 years after their index procedure. We report on the relationship of pre-operative frailty scores on post-operative mortality at 2 years in patients undergoing THA for femoral neck fracture.

Materials and Methods

Prospective case series of all femoral neck fractures treated at a major trauma centre with a primary

THA between 2013-2020. Included patients were those ≥65 years of age and who fulfilled the NICE CG-124 criteria for THA. They were excluded if the fracture was pathological or around an existing implant. Pre-operative data was collected on Nottingham Hip Fracture Score (NHFS), Johns Hopkins Frailty Assessment (JHFA), Rockwood Frailty Score (RFS) and Sernbo score. Mortality data was obtained from the primary care mortality database.

Results

333 patients were included. 71% (238) were female. Median age was 83 years (65-93). Overall mortality rate was 28% (92 patients) at a median follow-up of 66 months (24-109). The two-year mortality rate was 8.4% (28). Patients who died within 2 years had no significant difference in Sernbo risk p=0.138. NHFS, JHFA and RFS were all independently significantly different between those alive or dead at two years p=<0.001. Factors most strongly associated with 2-year mortality were JHFA score consistent with frailty (OR 6.914; 95% CI 3.04 to 15.71; p=<0.001) and RFS ≥4 (OR 17.03; 95% CI 2.28 to 127.065; p=0.006). 

Conclusion

Pre-operative frailty scores are strongly predictive of two-year mortality following arthroplasty for neck of femur fracture. We suggest surgeons consider hemiarthroplasty in patients ≥65 with a JHFA consistent with frailty or RFS ≥4.

Direct Anterior Approach or Posterior Approach Total Hip Arthroplasty - Is there a difference in long-term revision rates and 10-year Patient Reported Outcome Measures?

Irrum Afzal, Richard Field

South West London Elective Orthopaedic Centre, London, United Kingdom

Abstract

The Posterior and Lateral approaches are most commonly used for Total Hip Arthroplasty (THA) in the United Kingdom (UK). Fewer than 5% of UK surgeons routinely use the Direct Anterior Approach (DAA). Whether DAA offers long-term clinical benefit is unclear.

We undertook a retrospective analysis of prospectively collected 10-year, multi-surgeon, multicentre implant surveillance study data for matched cohorts of patients whose operations were undertaken by either the DAA or posterior approach. All operations were undertaken using uncemented femoral and acetabular components. The implants were different for the two surgical approaches. We report the pre-operative, and post operative six-month, two-year, five-year and 10year Oxford Hip Score (OHS) and 10-year revision rates. 

 125 patients underwent DAA THA; these patients were matched against those undergoing the posterior approach through propensity score matching for age, gender and body mass index. The 10year revision rate for DAA THA was 3.2% (4/125) and 2.4% (3/125) for posterior THA. The difference in revision rate was not statistically significant. Both DAA and Posterior THA pre-operative OHS were comparable at 19.85 and 19.12 respectively. At the six-month time point, there was an OHS improvement of 20.89 points for DAA and 18.82 points for Posterior THA and this was statistically significant (P-Value <0.001). At the two, five and 10-year time-points the OHS and OHS improvement from the pre-operative review were comparable. At the 10-year time point the mean improvement from pre-op to 10-years post op was 22.78 and 22.98 respectively. There was no statistical difference when comparing the OHS or the OHS mean improvements at the two, five and 10-year point. 

Whilst, there was greater improvement and statistical significance during the initial six month time period, as time went on there was no statistical significant difference between the outcome measures or revision rates for the two approaches. 

Retrospective population-based analysis of the association between approach-specific volume and the complications following Direct Anterior Approach for THR

Elmunzar Bagouri, Daniel Pincus, Bheeshma Ravi Sunnybrook Holland centre, Toronto, Canada

Abstract

Introduction

The DAA is a "muscle-sparing" approach, which can contribute to faster initial recovery. However, it is associated with higher complication rate relative to other conventional approaches. It has been suggested that this complication rate in DAA procedures normalizes with increased surgeon volume.

Aim

The aim of this study is to explore the association between approach-specific surgeon volume and the risk for early surgical complications following DAA THA.

Methodology

This is a retrospective population-based cohort study of adult patients undergoing primary elective THA in Ontario, Canada between April-2016 & March-2021. Data collected included patient demographics, co-morbidities, surgical approach & complications after surgery. Surgeon volume was defined as the number of DAA THA performed by the primary surgeon in the 365 days immediately preceding the index procedure. Restricted cubic splines with three knots were used to visualize the relationship between DAA surgeon volume and the risks for complications following DAA THA. A separate cohort of non-DAA THA patients was defined over the same time period, and splines were generated for complications relative to non-DAA surgeon volume.

Results

There were 9,672 patients (median age 67  years;  Pts received their first primary THA via the direct anterior approach from 53 hospitals by 196 surgeons. 2.5% (242) patients had a major surgical complication (revision, dislocation, infection) within one year of surgery. Results suggested a major reduction in the risk as volume increases, with a plateau after 80-100 cases/year. Over the same time period, the curve for conventional approaches was similar, but with a lower trough and tail.

Conclusion

The results suggest that increased approach-specific surgeon volume is associated with a significant reduction in the risk for complications following DAA THA. However, at higher surgical volumes, the risk for complications after DAA remains higher than that of conventional surgical approaches performed by surgeons with comparable volumes.

Post-Operative Pain Trajectories in Total Hip Arthroplasty: An Analysis of Patient Reported Outcomes

Kareem Omran¹, Daniel Waren², Ran Schwarzkopf^{2 1}University of Cambridge, Cambridge, United Kingdom. ²NYU Langone Orthopedic Hospital, New York City, USA

Abstract

Background

Total hip arthroplasty (THA) is a common procedure to address pain and enhance function in hip disorders such as osteoarthritis. Despite its success, post-operative patient recovery exhibits considerable heterogeneity. This study aimed to investigate whether patients follow distinct pain trajectories following THA, and identify the patient characteristics linked to suboptimal trajectories.

Methods

This retrospective cohort study analysed all THA patients who completed PROMIS pain-intensity questionnaires from 2017-2022, collected preoperatively and over a two-year follow-up. Latent Class Growth Analysis (LCGA) and Growth Mixture Modelling (GMM) modelled the trajectories. Optimal model fit was determined by Bayesian Information Criterion (BIC), Lo-Mendell-Rubin Likelihood Ratio Test (LMR-LRT), posterior probabilities, and entropy values. Multinomial logistic regression measured the association between trajectory groups and patient characteristics.

Results

A piecewise GMM model with 4 distinct trajectories best fit the 1784 eligible patients. Distribution of patients among trajectories was: 6.1% (T1), 88.7% (T2), 3.1% (T3), and 2.1% (T4). T2 was considered the normal trajectory and as reference in the regression model. T1 and T3 showed high initial pain levels; T1 maintained the highest pain scores to 24 months, while T3 experienced recovery similar to the normal trajectory. T4 displayed a consistent, low-pain trajectory.

There was a 10% increase in odds of allocation to T1 per unit of BMI increase (p<.001) and 1% per hour of hospital stay (p=.002). African Americans had a 2.97x increased risk of allocation to T1 (p<.001). There was a 2.81x (p<.001) increased risk of allocation to T3 for current smokers. Conclusion:  

This study identified four distinct pain trajectories following THA, offering insights to refine preoperative counselling and tailor pain-management strategies to patient needs. The findings underscore the importance of addressing risk factors associated with suboptimal pain trajectories preoperatively in at-risk patients and emphasizes the role of individual patient factors in establishing realistic recovery expectations.

Potential carbon savings from changing surgical trends in primary elective total hip arthroplasty in England: A retrospective observational study

Elizabeth Ojelade^1,3Jacob Koris^1,2, , Hasina Begum⁴, Maria Van-Hove^1,4,5, Tim Briggs^1,3, William Gray^1 1Getting It Right First Time, NHS England, London, United Kingdom. ²John Radcliffe Hospital, Oxford, United Kingdom. ³Royal National Orthopaedic Hospital, London, United Kingdom. ⁴Greener NHS, NHS England, London, United Kingdom. ⁵Department of Public Health and Sports Sciences, University of Exeter, Exeter, United Kingdom

Abstract

Background

The National Health Service (NHS) in England has set a target to be net zero for carbon emissions by 2040. The aim of this study was to investigate how changes in key aspects of clinical practice over the last eight years have contributed towards reducing the per-patient carbon footprint of elective total hip arthroplasty (THA) 

Methods

This was a retrospective analysis of administrative data. Data were extracted from the Hospital

Episode Statistics database for all adult (≥17 years), primary, elective THA procedures conducted in England from 1st April 2014 to 31st March 2022. The estimated carbon footprint for key elements of the surgical pathway were calculated based on data from Greener NHS and the Sustainable Healthcare Coalition.

Results

Data were available for 537,441 THA procedures conducted during the study period. The per-patient carbon footprint associated with the primary THA (index) procedure fell by around 25% from 2014/15 to 2021/22. Length of stay was by far the largest contributor to this decline, falling from 169.1 kgCO2e to 117.6 kgCO2e per patient from 2014/15 to 2021/22. Absolute declines in the carbon footprint associated with emergency readmissions, revisions and out-patient attendances were more modest.  If all patients in all years had the 2021/22 average carbon footprint, then carbon equivalent to powering 19,976 UK homes for one year would have been saved.

Conclusions  

Improving per-patient efficiency of surgery is likely to contribute towards meeting the NHS's netzero target whilst also helping to improve patient outcomes, reduce costs and cut waiting lists. 

Disclosure: No funding was received for this study.

Outcomes of the Birmingham Hip Resurfacing at 25 years

Raj Nandra¹, Alistair Mayne², Walid Elnahal², Lesley Brash², Callum McBryde², Ronan Treacy^{2  1}Robert Jones and Agnes Hunt Hospital, Oswestry, United Kingdom. ²Royal Orthopaedic Hospital, Birmingham, United Kingdom

Abstract

Background

The Birmingham Hip Resurfacing (BHR) was introduced in 1997 to address the needs of young active individuals with a hard-wearing metal-on-metal bearing surface, large head size for stability and to allow preservation of the femoral neck. 

The aim of this study was to review the long term survivorship of the BHR at 25 years follow-up.

Methods

The study cohort comprised a consecutive series of 144 resurfacing procedures performed in 130 patients who have been prospectively reviewed since index surgery. The primary outcome measure was hip survivorship at latest follow-up, with failure defined as revision of either component for any reason during the study period, with Kaplan-Meier survivorship analysis performed. Routine followup with serum metal ion levels, radiographs and Oxford Hip Scores was also assessed.

Results

Mean age at index surgery was 52.1 (17-76) years. During the study period 28 patients died (21.5%). The majority of patients were male (93 patients,71.5%). The overall hip survival was 83.50% at 25 years (SE 0.034, 95% CI 0.79 to 0.90). Hip survival was better in male patients 89.5% (95% CI 0.83 to 0.96) compared to females, 66.9% (95% CI 0.51 to 0.83). 

In Cox-regression analysis assessing independent risk factors for revision, female gender (P=0.46, OR 4.800) was more influential than head size (p=0.685) or increasing age (p= 0.710) for risk of revision.

The mean cobalt and chromium levels at last follow-up were 42 nmol/L and 49.5 nmol/L respectively. The mean oxford hip score was 35.

Conclusion

This study demonstrates that metal-on-metal hip resurfacing using the Birmingham Hip provides a durable alternative to total hip replacement, particularly in younger male patients with arthritis, wishing to maintain a high level of function. Overall hip survivorship at long term follow-up is amongst the highest in the published literature.

Systematic Review and Meta-Analysis of Studies Comparing the Rate of Post Operative Periprosthetic Fracture Following Hip Arthroplasty with a Polished Taper Slip Versus Composite Beam Stem.

Jacob Feathers¹, Ahmed Mabrouk², Ansar Mahmood³, Robert West⁴, Hermant Pandit⁵, Jonathan Lamb^{5  1}Mid Yorkshire NHS Trust, Wakefield, United Kingdom. ²Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom. ³University Hospitals Birmingham NHS Trust, Birmingham, United Kingdom. ⁴Leeds Institute of Health Sciences, Leeds, United Kingdom. ⁵Leeds Institute of Rheumatic and Musculoskeletal Medicine, Leeds, United Kingdom

Abstract

Background

Post-operative periprosthetic femoral fractures (POPFF) are a devastating complication of hip arthroplasty. It is associated with increased patient morbidity and mortality. Recent studies demonstrate that cemented polished taper stems (PTS) are associated with a higher incidence of POPFF in comparison to cemented composite beam (CB) stems. Our study aims to estimate the difference in incidence of POPFF following primary hip arthroplasty with PTS versus CB stems in comparative studies.

 Methods

A systematic review of comparative studies, written in English, and published in peer-reviewed journals since the year 2000 to 2021 was conducted using Ovid MEDLINE, EMBASE, Web of Science, and Scopus. The methodology followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Study quality was assessed using the Newcastle-Ottawa scale. Cohorts were classified as high or low risk of POPFF based on patient risk factors. Metanalysis was performed using a random effects model and the relative incidence with 95% confidence intervals was reported.

Results

The overall study quality was good. 913,021 patients from 18 cohorts were included in the metaanalysis. 294,540 patients received a CB stem and 618,481 received a PTS stem. For patients at low risk of POPFF the incidence rate ratio (IRR) was 3.14 (CI: 2.48, 3.98) for the PTS group versus the CB group. For patients at high risk of POPFF the IRR of 9.87 (CI: 3.63, 26.80) for the PTS group versus the CB group.

Conclusions

The risk of POPFF is lower when hip arthroplasty was performed using a CB stem versus a PTS stem. This protective effect was greatest in patients with a higher risk of POPFF. Surgeons should consider the effect of cemented stem choice on the risk of subsequent POPFF, particularly in frail or elderly patients.

Risk of Revision Following Total Hip Replacement Performed Using Computer Guidance and Robotic Systems Versus Conventional Technique: An Analysis of National Joint Registry Data

Muhamed Farhan-Alanie¹, Daniel Gallacher¹, Jakub Kozdryk², Peter Craig³, James Griffin¹, James Mason¹, Peter Wall^1,4, Mark Wilkinson^5,6, Andrew Metcalfe^1,7, Pedro Foguet^{7  1}University of Warwick, Coventry, United Kingdom. ²University Hospital Coventry & Warwickshire, Coventry, United Kingdom. ³Worcestershire Acute Hospitals NHS Trust, Worcester, United Kingdom. ⁴Royal Orthopaedic Hospital, Birmingham, United Kingdom. ⁵University of Sheffield, Sheffield, United Kingdom. ⁶Sheffield Teaching Hospitals NHS Trust, Sheffield, United Kingdom. ⁷University Hospitals Coventry & Warwickshire, Coventry, United Kingdom

Abstract

Background

Compared to conventional surgery, relatively improved accuracy of implant positioning can be achieved in total hip replacement (THR) when computer-guided and robotic systems are used. However, it is not known whether the use of these technologies has translated to improved survival of prosthesis in the real-world. The aim of this study was to compare risk of revision for all-causes and dislocation following primary THR performed using computer guidance or robotic system assistance compared to conventional technique.

Methods

We performed an observational study using NJR data. All adult patients undergoing primary THR for osteoarthritis only between 01/04/2003 to 31/12/2020 were eligible. Exposures were computer guidance and robotic system assistance. Comparison was conventional technique. We generated propensity score weights (PSW), using Sturmer weight trimming, based on the following variables: age (continuous), gender, ASA, side, operation funding, year of surgery, position, approach, bearing, fixation. Outcomes were assessed using Kaplan-Meier analysis and expressed using hazard ratios (HR) and 95% confidence intervals (CI).

Results

For the computer-guided versus conventional analysis, trimmed unadjusted HR for revision for allcauses and dislocation was 0.771 (95%CI 0.573-1.036) p=0.085, and 0.594 (95%CI 0.297-1.190) p=0.142, respectively. When comparing robotic system assisted versus conventional THR, trimmed unadjusted HR for revision for all-causes was 0.480 (95%CI 0.067-3.452) p=0.466. Further Cox Proportional-Hazards covariate adjustment was not required as PSW were stable.

Conclusions

Identification of anterior cruciate ligament fibroblasts and their contribution for knee osteoarthritis progression by single-cell analyses

Ziji Zhang, Zhiwen Li, Shiyong Zhang, Puyi Sheng  Sun Yat-sen University First Affiliated Hospital, Guangzhou, China

Abstract

Background

A better Understanding of the key regulatory cells in the anterior cruciate ligament (ACL), and their role and regulatory mechanisms in knee osteoarthritis (KOA) progression can facilitate the development of targeted treatment strategies for KOA.

Methods

The relationship between ACL degeneration and KOA was first explored using human ACL specimens and mouse models. Next, single-cell RNA sequencing (scRNA-seq) and single-cell detection of transposase accessible and chromatin sequencing (scATAC-seq) data were integrated to reveal the transcriptional and epigenomic landscape of ACL in normal and osteoarthritis (OA) states. 

Results

Six cell populations were identified in the human ACL, among which were inflammation-associated fibroblasts (IAFs). Degeneration of the ACL during OA mechanically alters the knee joint homeostasis and influences the microenvironment by regulating inflammatory- and osteogenic-related factors, thereby contributing to the progression of KOA. Specifically, a IAF subpopulation identified in OA ACL was found to enhance the transcription and secretion of EGER via SOX5 upregulation, with consequent activation of the EGER–EGFR signaling pathway. These molecular events led to the upregulation of downstream inflammatory and osteogenic factors, and the downregulation of the extracellular matrix-associated factor, thereby leading to knee osteoid formation, cartilage degeneration, and OA progression. 

Conclusions 

In summary, this study identifies a novel subpopulation of fibroblasts in the ACL, which confirms the importance of the ACL in knee joint homeostasis and disease. Additionally, the specific mechanism by which these IAFs regulate KOA progression was uncovered, which provides new foundation for the development of targeted treatments for KOA.

Gait Characteristics of Patients with Symptomatic Cartilage Defects of the Knee

Beatrice Timme¹, Gwenllian Tawy^1,2, Mike McNicholas^3,1,4, Leela Biant^1,4

¹University of Manchester, Manchester, United Kingdom. ²International Cartilage Regeneration &

Joint Preservation Society, Zurich, Switzerland. ³Royal Liverpool and Broadgreen University Hospitals,

Liverpool, United Kingdom. ⁴Manchester University NHS Foundation Trust, Manchester, United Kingdom

Abstract

Background  

Little is known about the impact of cartilage defects on knee joint biomechanics. This investigation aimed to determine the gait characteristics of patients with symptomatic articular cartilage lesions of the knee. 

Methods  

Gait analyses were performed at the Regional North-West Joint Preservation Centre.
Anthropometric measurements were obtained, then 16 retroreflective markers representing the Plug-in-Gait biomechanical model were placed on pre-defined anatomical landmarks. Participants walked for two minutes at a self-selected speed on a treadmill.  A 15-camera motion-capture system recorded the data.  Knee kinematics were exported into Matlab to calculate the average kinematics and spatiotemporal parameters per patient across 20 gait cycles. Paired t-tests or Wilcoxon ranked tests were performed to compare both knees (α = 0.05). 

Results

20 patients participated; one of whom has bilateral cartilage defects. Patients walked at an average speed of 3.1±0.8km/h with a cadence of 65.5±15.3 steps/minute. Patients also exhibited equal step lengths (0.470±0.072m/0.471±0.070m: p=0.806). Maximum flexion achieved during swing did not differ between knees (54.3±8.6°/55.5±11.0°:p=0.549). Neither did maximal extension achieved at heel strike (3.1±5.7°/5.4±4.7°:p=0.135). On average, both knees remained in adduction throughout the gait cycle, with the degree of adduction greater in flexion in the operative knee.  However, differences in maximal adduction were not significant (22.4±12.4°/18.7±11.0°:p=0.307). Maximal internal-external rotation patterns were comparable in stance (0.9±7.7°/3.5±9.8°:p=0.322) and swing (7.7±10.9°/9.8±8.3°:p=384). 

Conclusion

Knee kinematics were symmetrical in patients with a cartilage defect of the knee, but increased adduction during flexion in the operative knee may lead to pathological loading across the medial compartment during high flexion activities.  Future work will investigate this further and compare the data to a healthy population. 

James Lind Alliance First Time Soft Tissue Knee Injuries Priority Setting Partnership: Top 10 Research Priorities

Humza Osmani^1,2, Nicolas Nicolaou³, Sanjeev Anand⁴, Andrew Metcalfe^5,6, Stephen McDonnell^{1,2 1}Cambridge University Hospitals NHS Trust, Cambridge, United Kingdom. ²Cambridge University, Cambridge, United Kingdom. ³Sheffield Children's Hospital NHS Trust, Sheffield, United Kingdom. ⁴Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom. ⁵University Hospitals Coventry and Warwickshire NHS Trust, Coventry, United Kingdom. ⁶Warwick Clinical Trials Unit, Coventry, United Kingdom

Abstract

Background  

Soft tissue knee injuries occur in sporting and work related accidents, with the knee the most commonly injured joint in sports. It causes substantial disability, time off work and long-term problems. High-quality randomised controlled trials assessing first time, acute soft tissue knee injuries are further required. Key areas where questions remain, include prevention, diagnosis, treatment, rehabilitation and delivery of care. The James Lind Alliance, in association with the BOA, BASK and BOSTAA , performed a prioritising exercise over a year. 

Methods

The James Lind Alliance methodology was utilised. Firstly, an initial survey invited patients and healthcare professionals to submit any uncertainties regarding soft tissue knee injury prevention, diagnosis, treatment, rehabilitation and delivery of care. Over 1000 questions were received. Seventy-four questions (identifying common concerns) were formulated and checked against best available evidence. An interim survey was then conducted and 27 questions were taken forward to the final workshop (January 2023), where they were discussed, ranked and scored in multiple rounds of prioritisation. This was conducted by healthcare professionals, patients and carers.

Results

The Top 10 will be presented and discussed. It includes questions regarding prevention, diagnosis, treatment and rehabilitation. This reflects the concerns of patients, carers and the wider multidisciplinary team.

Conclusion

This validated process has generated 10 important priorities for future soft tissue knee injury research. These have been submitted to the National Institute for Health and Care Research. All 27 questions in the final workshop have been published. 

Implications

Future priorities for soft tissue knee injury research have been identified and have allocated funding available through the NIHR. This will lead to future high quality research, thus improving patient care & outcomes. 

Disclosures 

Research was funded by the BOA, BASK, BOSTAA and Day 1 Trauma Charity. 

A comparison of the long term periprosthetic fracture rate of cemented and cementless Unicompartmental Knee Replacements: An analysis of 14,122 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

Periprosthetic fractures are serious complications of Unicompartmental Knee Replacement (UKR). There are concerns that the risk of periprosthetic fractures is higher with cementless UKR given it relies on an interference fit for primary stability. There have been no large scale comparative studies. We performed a big data matched study comparing the long term fracture rates of cemented and cementless UKRs.

Methods

14,122 medial mobile bearing UKRs (7,061 cemented and 7,061 cementless) with linked data 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 code M96.6 was used to identify periprosthetic fractures. Cumulative fracture rates to 10 years postoperatively were calculated using Kaplan Meier analysis. Cox regression was used to compare fracture rates. Hazard Ratios (HRs) below 1 indicate a lower risk of fracture in the cementless group. 

Results 

The overall HR during the 10-year study period was 1.06 (CI 0.64-1.77, p=0.79) with no significant differences between the matched groups. The fracture rates were highest during the first three months postoperatively, but then decreased and remained constant between one and 10 years after surgery. The three month periprosthetic fracture rates were similar (p=0.80) being 0.10% in the cemented group and 0.11% in the cementless group.   The one year cumulative fracture rates were 0.2% (CI 0.1-0.3) for cemented and 0.2% (CI 0.1-0.3) for cementless cases. The 10-year cumulative fracture rates were 0.8% (CI 0.2-1.3) and 0.8% (CI 0.3-1.3) respectively. 

Conclusion/Findings 

Periprosthetic fracture rate following UKR surgery is low being approximately 1% at 10-years. There were no significant differences in fracture rates between fixation groups. We surmise that surgeons are aware of the higher theoretical risk of early fracture with cementless components and take care with tibial preparation, which mitigates this risk. 

The effect of surgeon caseload and usage on the patient reported outcome measures following Unicompartmental Knee Replacement. A study of 20,347 knee replacements from the National Joint Registry of England, Wales, Northern Ireland and Isle of Man and Hospital Episode Statistics PROMs 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

Unicompartmental knee replacement (UKR) is an effective treatment option for end stage arthritis and is associated with better patient reported outcome measures (PROMs) but higher revision rates than total knee replacement (TKR). It is currently unknown whether surgeon caseload (number of UKRs performed annually) or usage (number of UKRs as a proportion of knee replacement practice) affect functional outcomes. We studied the effect of caseload and usage on functional outcomes.  

Methods  

20,347 UKRs from the National Joint Registry linked to the Hospital Episode Statistics PROMs database were analysed. Surgeon caseload was divided into; (1) >0 to <5 UKRs/yr, (2) ≥5 to <10 UKRs/yr, (3) ≥10 to <30 UKRs/yr and (4) ≥30 UKRs/yr. Surgeon usage was divided into; (1) >0 to <10%, (2) ≥10 to <30%, (3) ≥30 to <50% and (4) ≥50%. The preoperative, postoperative (six-month) and change in Oxford Knee Score (OKS) after surgery were compared using the Kruskall Wallis Test. The percentage of the possible change (PoPC) was calculated. 

Results

Postoperative OKS significantly increased with caseload (p<0.001). Change in OKS after surgery significantly increased with caseload (p<0.001) with increases of (1) 15.1 (SD 10.1) (2) 16.2 (SD 9.5) (3) 16.4 (SD 9.7) and (4) 17.1 (SD 9.4). PoPC increased with caseload (1) 55.7% (2) 60.9% (3) 60.9% and (4) 65.3%. Postoperative OKS significantly (p<0.001) increased with usage. Change in OKS after surgery also significantly increased with usage (p<0.001) with increases of  (1) 15.3 (SD 9.8) (2) 16.2 (SD 9.7) (3) 17.4 (SD 9.3) and (4) 17.2 (SD 9.4). PoPC increased with usage (1) 57.7% (2) 61.1% (3) 65.7% and (4) 63.7%. There was no significant interaction from fixation. 

Conclusion/Findings  

Higher surgeon caseload and usage were associated with larger improvements in functional outcomes postoperatively. These differences were even larger when assessing the PoPC. 

The association between surgeon grade and risk of revision following knee replacement: an analysis of National Joint Registry data

Tim Fowler, Ashley Blom, Adrian Sayers, Mike Whitehouse Musculoskeletal Research Unit, University of Bristol, Bristol, United Kingdom

Abstract

Background

Knee replacements are performed by surgeons at different stages in training with varying levels of supervision. We used NJR data to investigate the association between surgeon grade, the supervision of trainees, and the risk of revision following total knee replacement (TKR) and unicompartmental knee replacement (UKR) 

Methods

We included 953,081 primary TKRs and 106,206 primary UKRs, performed between 2003 and 2019. Exposures were surgeon grade (consultant or trainee), and whether or not trainees were supervised by a scrubbed consultant. The primary outcome was all-cause revision, and the secondary outcome was the number of procedures revised for the following indications: aseptic loosening, infection, progression of OA, unexplained pain, and instability. Flexible parametric survival models (FPM) were incrementally adjusted for patient, operation, and healthcare setting factors.

Results

Trainees performed 96,544 (10.1%) TKRs and 4,382 (4.1%) UKRs. Trainees achieved comparable outcomes to consultants in terms of the unadjusted cumulative probability of all-cause revision following both TKR and UKR. Adjusted analysis indicated an association between trainee-performed TKR and a small increased risk of early all-cause revision. This effect was not explained by the level of supervision and may be attributable to episodes of revision for aseptic loosening, infection, and progression of OA. There was no association between surgeon grade and the all-cause revision of UKRs in either crude or adjusted models (adjusted HR 1.01, 95% CI 0.90 to 1.13; p=0.88). Trainees achieved comparable all-cause UKR survival to consultants, regardless of the level of scrubbed consultant supervision (supervised: adjusted HR 0.99, 95% CI 0.87 to 1.14; p=0.94; unsupervised: adjusted HR 1.03, 95% CI 0.87 to 1.22; p=0.74).

Conclusion/Implications

Current knee replacement training practices in England and Wales are safe in terms of equivalence of all-cause implant survival between trainee and consultant-performed surgery. However, we have identified areas for potential improvement in trainee outcomes. 

Early tibial component aseptic loosening revision in popular TKR brand

Lokesh Sharoff, Gohar Naqvi, Ryan Wood, Mark Bowditch  East Suffolk and North Essex NHS Foundation Trust, Ipswich, United Kingdom

Abstract

Background  

Recently there has been reported early revision in a certain variant combination of a well-known brand of total knee replacement (TKR). The combination was the high-flex LPS with the standard Option tibia. This has led to the voluntary implant withdrawal of the tibial implant.  Since 2013 we have used the standard option tibia implant but with a different femur component combination – standard option LPS femur. The Unit changed to the standard tibial option component, from the precoat augmentable tibial implant, in 2013 whilst keeping all other variables the same. The Aim of this study is to evaluate the mode of failure and revision rates of this metal-backed tibial baseplate TKR implant and compare it with the surgeon’s NJR (National Joint Registry) data for revisions.   

Methods 

This is a retrospective cohort study obtaining data of revision TKR from the last 9 years – from March 2014 to March 2023 which were revised due to aseptic loosening. Inclusion criteria: Patients who have had revision due to aseptic loosening of this specific implant was considered as the end-point. Study data was compared with NJR data.

Results

The early tibial loosening seen were failing in flexion and varus with cement lucency and debonding beneath the tibial tray posteromedially. There was increased revision rate compared to prior to 2013. 

Conclusions

The change of tibial implant has led to increased early tibial loosening and revision. The mode of failure was the same as those seen in the withdrawn combination/s.

The withdrawn combination represented a relatively small total number of NJR cases. The combination we have presented is a much larger number in the NJR. 

Implications 

Aseptic tibial loosening incidence within the same TKR brand can vary dependent on the combination chosen. 

Evaluation of Comorbidity Scoring Systems in Patients Undergoing Knee Arthroplasty

Alexander Green^1,2, Jonathan Old³, Oday Al-Dadah^{3,4  1}South Tyneside District hospital, Newcastle upon Tyne, United Kingdom. ²Newcastle University, Newcastle upon Tyne, United Kingdom. ³South Tyneside District Hospital, South Shields, United Kingdom. ⁴Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, United Kingdom

Abstract

Background

Aging populations are increasing the demand for knee arthroplasty. Concurrently, the prevalence of medical comorbidities are rising too. The Self-Administered Comorbidity Questionnaire (SCQ) was developed to provide a patient’s assessment of their own co-morbidities whereas the American Society of Anaesthesiologist’s (ASA) grades and the Charlson Comorbidity Index (CCI) utilise clinical evaluation to objectively measure peri-operative morbidity and mortality risk. The primary aim of this study was to compare SCQ scores with ASA grades and CCI scores. The secondary aim was to compare SCQ scores with knee outcome scores.

Methods

A single centre observational study of patients with knee osteoarthritis undergoing elective knee arthroplasty. Pre-operative evaluation included SCQ scores, ASA grades, CCI scores and validated patient reported outcome measures (PROMs) specific to knee surgery.   

Results

A total of 141 patients were included in this study. SCQ scores were directly correlated with ASA grade (rho=0.37, p<0.001), and CCI scores (rho=0.19, p=.047). Individual ASA grades had significantly different SCQ scores (p=0.001). SCQ scores were specifically associated with hypertension, ischaemic heart disease, chronic obstructive pulmonary disease and the total number of comorbidities but ASA and CCI scores were associated with more comorbidities. Overall, SCQ scores were inversely correlated with PROM scores. 

Conclusion

SCQ scores are associated with increasing comorbidity in patients with symptomatic knee osteoarthritis, however ASA grades and CCI scores had stronger and more abundant associations with comorbidities and PROM scores. SCQs may complement but not replace current objective assessments of comorbidity when evaluating peri-operative risk for knee arthroplasty.

Anthropometric Measures of Obesity in Patients with Knee Joint Pathology: Body Surface Area vs. Body Mass Index

Alexander Green^1,2, Sam Crow³, Oday Al-Dadah^{4,5  1}South Tyneside District hospital, South Shields, United Kingdom. ²Newcastle University, Newcastle Upon Tyne, United Kingdom. ³The Medical School, Newcastle University, Newcastle upon Tyne, United Kingdom. ⁴South Tyneside District Hospital, South Shields, United Kingdom. ⁵Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle Upon Tyne, United Kingdom

Abstract

Background

Obesity is commonly quantified using Body Mass Index (BMI). Body Surface Area (BSA) may provide a superior and more anthropometric method of quantifying obesity in patients with musculoskeletal knee disease. This study compares the effect of weight, height, age, and gender on BMI and BSA in a population with orthopaedic knee disease and whether this influenced management.

Methods

Observational study was conducted of patients presenting with musculoskeletal knee disease to a single centre between October 2019 and June 2020.  Associations between BMI, BSA, age, gender, height, weight and the use of operative versus non-operative management were analysed.

Results

A total of 151 patients were included. BSA was strongly correlated to weight (r=0.98, p<0.001) and height (r=0.65, p<0.001) unlike BMI which was correlated to weight (r=0.84, p<0.001) but not height (r=-0.08, p=0.35). BMI and BSA were correlated with one another (r=0.70, p<0.001). Age was inversely correlated with BSA (r=-0.20, p=0.013) but not BMI (r=0.05, p=0.585).  BMI scores were no different between males and females (30.1 vs 30.9, p=0.37), however BSA scores were significantly higher in males than females (2.11 vs 1.91, p<0.001). There were no differences between BSA or BMI scores in those who received operative versus non-operative treatment.  

Conclusion

BSA could be a useful alternative to BMI when considering obesity in patients with musculoskeletal knee pathology. BSA better reflects the effects of height, weight, age and gender than BMI. BSA or BMI alone cannot be used to predict those who are likely to be offered operative versus nonoperative management.

Obviously because it’s a tear it won’t necessarily mend itself.’ A qualitative study of patient experiences and expectations of treatment for a meniscal tear.

Imran Ahmed¹, Chetan Khatri², Fatema Dhaif¹, Nicholas Parson¹, Charles Hutchinson¹, Andrew Price³, Sophie Staniszewska¹, Andrew Metcalfe^{1 1}University of Warwick, Coventry, United Kingdom. ²University of Warwic, Coventry, United Kingdom. ³NDORMS, Oxford, United Kingdom

Abstract

Introduction

Recent research has questioned the role of arthroscopic meniscectomy in patients with a meniscal tear leading to the development of treatment recommendations for these patients. There is a clear need to understand patient perceptions of living with a meniscal tear in order to plan future research and treatment guidelines.

Aims

To explore the experiences and expectations of treatment of young patients with a meniscal tear of the knee  

Methods

Ten participants diagnosed with a meniscal tear were recruited from the METRO cohort study using a purposive sampling strategy. These patients underwent semi-sructured interviews between April and May 2021. Thematic analysis was used to code the transcripts and generate key themes in order to describe the data.  

Results

Themes identified relate to the broad areas of: the effect of symptoms, the experience of the clinical consultation and the experience of the treatment modality undertaken. Meniscal tears have a profound impact on pain and many patients experience effects on their family and financial life in addition to physical symptoms. Participants expected the majority of their management to occur in secondary care and most thought surgery would be a definitive treatment, while the effectiveness of physiotherapy could not be guaranteed as it would not fix the physical tear. 

Conclusion

Patient experience of meniscal tear may not correspond with current available clinical evidence. Clinicians should consider the common misconceptions highlighted in this study when conducting a consultation and pre-empt them to optimally manage patient expectations.

Staged revision of the infected knee arthroplasty and endoprosthesis; retrospective analysis of failure of antibiotic loaded cement spacers after the first stage

Christopher Lodge, Amirul Adlan, Rajpal Nadra, Jasprit Kaur, Lee Jeys, Jonathan Stevenson Birmingham Royal Orthopaedic Hospital, Birmingham, United Kingdom

Abstract

Background

Periprosthetic joint infection (PJI) can prove a challenging complication of any arthroplasty based procedure. We review our use of static spacers utilising antibiotic loaded cement spacers (ABLCs) as a staged management of PJI where segmental bone loss, ligamentous instability or soft tissue defects necessitate a static construct. We review factors that contribute to their failure and techniques to avoid these complications from using ABLCs in this context. 

Methods

Retrospecitve analysis of 94 patients undergoing first-stage revision of an infected knee prosthesis between 2007 – 2020 at a single institution. Radiographs and clinical records were used to analyse and classify causes and incidence of spacer failure. 

Results

Of the 94 cases there were 19 Primary TKRs, 10 revision total knee replacements (Varus-valgus constraint), 20 hinged total knee replacements, 1 arthrodesis (nail), 1 failed spacer (performed elsewhere), 21 distal femoral replacements, 22 proximal tibial replacements. 35 out of 94 (37.2%) had spacer related complications. 26 of the 35 complications (74.3%) were as a result of mechanical failure of the spacer construct. Risk factors for internal failure were a construct where the total intramedullary spacer length was <200% of the central osseous defect (p=0.0085). Proximal or distal intraosseous spacer contact of less than 10% and the requirement of a tibial tubercle osteotomy for tibial component extraction (p=0.0046).      

Conclusion

The failure rate of antibiotic loaded cement spacers with segmental osseous defects is much higher than anticipated. Complications of the spacer significantly increased the time to second stage. The risk of mechanical failure is greatly increased if the spacer is <200% of the size of the segmental defect or if insufficient amount of spacer is inserted into residual bone.

Imageless Robotic Assisted versus Conventional Manual and Navigated Total Knee Arthroplasty: A Propensity Matched Cohort Study

Lena Al-Hilfi¹, Irrum Afzal², Hasan Mercalose¹, Nick Clement³, Vipin Asopa², Deiary Kader², Sarkhell Radha^{2  1}Croydon University Hospital, London, United Kingdom. ²South West London Elective Orthopaedic Centre, London, United Kingdom. ³Royal Infirmary of Edinburgh, Edinburgh, United Kingdom

Abstract

Despite advances in navigated and robotic assisted surgery, there has been no direct comparison. Our study reviewed a matched cohort of patients undergoing conventional, navigated and robotic assisted TKA to identify if there are difference in radiological and clinical outcomes in these techniques. 

In each of the different surgical techniques there were 88 TKA procedures included. Patient cohorts were matched for valgus and varus pre-operative deformity, grade of pre-operative osteoarthritis (OA) and patient demographics, patient reported outcomes and radiographic data were reviewed. 

Mean correction for tibiliofemoral alignment for the robotic assisted TKA (RTKA) was – 3.58 degrees, for the navigated assisted TKA (NTKA) was – 5.00 degrees, for the conventional TKA (CTKA) was – 4.16 degrees. Mean posterior slope was reported as 4.46 degrees, 7.89 degrees and 5.20 degrees respectively. An independent Kruskal-Wallis test comparing the posterior slope showed there was statistical significance (p <0.005) between the different types of surgical techniques. There was no statistical significance between the groups for the OKS and EQ-5D scores, 6 week and 1-year outcome satisfaction.  CTKA had the shortest length of stay, length of operation and lowest readmission rate. There was statistical significance between the groups for the length of operation (P <0.005). There have been no major reported complications in any of the cohorts.

 While technology may offer better short-term results based on literature, our results show CTKA to have the greatest mean improvement in OKS and EQ-5D scores, lowest LOS, lowest length of operation and lowest 30-day re-admission when compared to RTKA and NTKA.

Cementless primary TKA study: Interim results on safety and performance at two- and five-years

Anil Gambhir¹, George Brindley², Gary Hooper³, Benjamin Bloch⁴, Shannon Puloski⁵, James Lesko⁶, Thierry Bernard⁶, Sukhjeet Kaur^{6 1}Wrightington, Wigan and Leigh NHS Trust, Wigan, United Kingdom. ²Texas Tech University Health Science Center, Lubbock, USA. ³University of Otago, Christchurch, New Zealand. ⁴Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom. ⁵Foothill Hospital, CALGARY, Canada. ⁶Depuy Synthes, Warsaw, USA

Abstract

Background

There is increasing interest and utilization of primary cementless TKA. Registries demonstrate high rates of survivorship believed to stem from long term osseointegration. This is an interim report of clinical, radiographic, and survivorship outcomes for a Cementless primary TKA system. 

Methods  

This multi-center prospective post-market study enrolled N=245 cruciate retaining rotating platform

(CRRP) beginning January 2017, and N=253 posterior stabilized rotating platform (PSRP) beginning

April 2018. Evaluation of patient reported outcome measures, independent radiographic review (IRR) of radiolucent lines (RLLs) by size and progressiveness, and adverse events (AEs) were at 6 months, 1, 2 and 5 years post-operatively. Summaries consisted of mean(SD), percentages, and Kaplan-Meier device survivorship (KM).

Results

Age and BMI were 63.1(8.7), 31.9(6.1); 49.8% female, 43.8% had patella resurfaced. 335 subjects had 2-year and 87 had 5-year follow up. At 2-years, significant improvements were observed compared to pre-operative (p-values<0.05) in all domains of KOOS, PKIP total and subscores, EQ-5D3L score and health-state VAS, and Subjective Knee Outcomes pain (rest and activity). RLLs≥1mm were observed in 98 subjects, 16 of whom had RLLs≥2mm, of which 2 were progressive. Of these 98 subjects, 30 had surgical site AEs including two insert exchanges at 6-months and one TKA revision at 4-year; 5 of which occurred in subjects with RLLs≥2mm. Eight subjects underwent femoral/tibial revision (4 aseptic loosening, 2 instability, 1 fracture, 1 mal-alignment; KM was 98.9%[95%CI: 97.3%99.5%] at 2-years and 97.3%[95%CI: 94.2%-98.8% at 5-years]. An additional 5 subjects underwent insert exchange (KM for any revision procedure was 97.9%[95%CI: 96.0%-98.8%] at 2-years and 96.30%[95%CI: 93.2%-98.0%] at 5-years).

Conclusion

This interim report provides evidence to support good patient outcomes and survivorship at 2- and 5-years post-op. The presence of small, non-progressive RLLs were not correlated to clinical outcome.

Do delays in processing influence the ability to perform synovial leukocyte count in investigation of periprosthetic joint infection?

Rathan Jeyapalan, Paul Baker, Simon Jameson, Sindhoo Rangarajan, Igor Kubelka South Tees NHS Foundation Trust, Middlesbrough, United Kingdom

Abstract

Background

Elevated synovial leukocyte count is a minor criteria derived from the musculoskeletal infection society (MSIS) widely used in clinical practice for diagnosis of prosthetic joint infection. There is evidence to suggest analysis within 1 hour, preferentially within 30 minutes, of aspiration reduces the risk of ex vivo cell lysis occurring during prolonged transport. Multiple site working is more common practice and the availability of a lab on site to perform these tests is not always possible. We aimed to assess whether we could safely perform synovial leukocyte counts within our cold site in the diagnosis of prosthetic joint infection. 

Methods

We reviewed all orthopaedic synovial fluid aspirates within the lower limb arthroplasty unit from April 2021 – April 2022 performed at South Tees NHS Foundation Trust. We assessed time from aspirate to the lab. This information was compared with the labs ability to perform a synovial leukocyte count to determine the impact of delays on testing.  

Results

110 patients (63.6% knees and 34.5% hips) were identified. Time from aspirate to lab ranged from <10 mins to 19 hrs. Mean time to processing was 3hrs 30 mins. 61% of all samples had a synovial leukocyte count performed. 67% of patients had a cell differential performed. There was no difference in the ability to perform a synovial leukocyte count between samples processed in < 2hours vs up to 6 hours.

Conclusion/Findings

We conclude that it is safe practice to perform joint aspirates for the work up of periprosthetic joint infections in sites where no laboratory is immediately available as the delay to processing synovial fluid does not alter the ability to perform a synovial leukocyte count. This study will provide evidence to enable the work up of periprosthetic joint infections in cold centres and reduce the delay in diagnosis. 

Patella resurfacing in TKA. A retrospective review of 2231 cases between 2020 and 2021.

Waleed Moussa, Karim Ashmawy, Nishit Shah, Qasim Malik, Naveed Akbar, Bilal Barkatali Salford Royal NHS Foundation Trust, Salford, United Kingdom

Abstract

Introduction 

Recent changes to NICE guidelines (NG157) have suggested that all patients undergoing primary total knee arthroplasty (TKA ) should be offered resurfacing of the patella at the index procedure. Despite these guidelines, there is still on-going debate whether patients with osteoarthritis of the knee would benefit from primary patella resurfacing (PR). The aim of this study is to determine if routine resurfacing of the patellofemoral joint is a cost-effective treatment for all patients . 

Methodology 

 A retrospective cohort analysis was performed investigating patients who underwent a primary TKA at Salford Royal NHS Foundation Trust between 1st January 2010 and 1st March 2021. Case-notes and radiographs were retrieved using the Trust’s EPR software. Degree of osteoarthritic wear of the patello-femoral joint was assessed using the Kellgren-Lawrence grading system.

Results   

A total of 1945 patients underwent a primary TKA over the 10-year period. 1710 patients (87.9%) had an isolated primary total knee arthroplasty without resurfacing of the patella whilst the remaining 235 (12.1%) had primary TKA with concomitant PR at the index procedure. 

All cause revision rates after total knee arthroplasty with primary PR was significantly greater than total knee arthroplasty without patella resurfacing, 2.5% vs 10.2% respectively (p value < 0.001)

1.3% (n=22) of patients underwent a secondary procedure for isolated PR and 1.2% (n=20) of patients had revision surgery with concurrent PR. Only 60% (n=12) of patients who had isolated secondary PR were revised due to documented anterior knee pain as a cause for revision surgery.

Conclusion 

This single centre study demonstrates that the overwhelming majority of patients undergoing primary TKA do not benefit from concurrent resurfacing of the patella. The authors view is that the indications of patella resurfacing should be case specific and from both a biological and health economic perspective, this should not be part of routine treatment. 

Potential carbon savings associated with changing surgical trends in total knee arthroplasty in England: A retrospective observational study using administrative data.

Elizabeth Ojelade^1,3Jacob Koris^1,2, , Hasina Begum⁴, Maria Van-Hove^1,4,5, Tim Briggs^1,3, William Gray^{1 1}Getting It Right First Time, NHS England, London, United Kingdom. ²John Radcliffe Hospital, Oxford, United Kingdom. ³Royal National Orthopaedic Hospital, London, United Kingdom. ⁴Greener NHS, NHS England, London, United Kingdom. ⁵Department of Public Health and Sport Sciences, University of Exeter, Exeter, United Kingdom

Abstract

Background  

Best practice pathways and initiatives such as reducing the post-operative length of stay for common procedures including Total Knee Arthroplasties (TKA), have the potential to not only improve patient outcomes but could also affect carbon emissions. The aim of this study was to estimate the potential reduction in carbon emissions as a result of changing trends in the care of patients undergoing TKA in England.

Methods  

A retrospective analysis of the Hospital Episode Statistics database from 1st April 2013 – 31st March

2022 was performed for all patients aged ≥17 years who underwent an elective primary TKA in England. The carbon footprint for each patient was calculated using carbon factors for multiple steps in the pathway including ipsilateral knee arthroscopies in the year preceding the TKA, the index TKA, revisions of the TKA performed within 180 days of the index procedure, length of hospital stay and emergency readmissions. 

Results

648,461 TKA operations were performed during the study period and over this time, the median length of stay reduced by a day, the number of ipsilateral knee arthroscopies performed within a year of TKA surgery fell as did the number of TKA revisions. This led to an overall reduction in the carbon production associated with TKA surgery with the biggest contributor being the reduced length of stay. If all the patients undergoing TKA surgery over the study period had had the same carbon footprint as the average patient undergoing surgery in 2021/22, 32,427,965.8 kgCO2e (32 kilotons) would have been saved, enough to power 29,508 UK homes.

Conclusions

This study has shown that practices that were primarily introduced to improve patient outcomes in TKA surgery can, as a secondary effect, contribute to a reduction in the carbon footprint associated with the procedure. 

Identifying Research Priorities in Limb Reconstruction Surgery in the United Kingdom

Luke Williams^1,2, Simon Graham^{1,3,4,5,6,7,8}, Luke M Williams¹, Hemant Sharma⁴, Paul Harwood⁵, Dan Perry⁶, Nando Ferreira⁷, Om Lahoti⁸

¹Liverpool Orthopaedic Trauma Service, Liverpool University Teaching Hospital Trust, Liverpool, United Kingdom. ²Severn Postgraduate Medical Education - HEE England, Bristol, United Kingdom. ³Oxford Trauma and Emergency Care, Nuffield Department of Orthopaedics, Rheumatology & Musculoskeletal Sciences, Oxford, United Kingdom. ⁴University of Hull, Hull, United Kingdom. ⁵Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom. ⁶University of Liverpool, Liverpool, United Kingdom. ⁷Stellenbosch University, Cape Town, South Africa. ⁸King’s College Hospital NHS Foundation Trust, London, United Kingdom

Abstract

Introduction 

Limb Reconstruction Surgery (LRS) has a wide range of clinical application within orthopaedic and trauma surgery. We sought a consensus view from LRS practitioners, across the United Kingdom, to help guide research priorities within LRS. Our aim is to guide future clinical research, and assist healthcare practitioners, clinical academics, and funding bodies to identify key research priorities.

Methods  

A modified Delphi technique was used; it involved an initial scoping survey and a 2-round Delphi process to identify the consensus research priorities in both Adult and Paediatric LRS. Participants were asked to rank approved submitted questions according to perceived importance on a 5-point Likert scale, where 1 represented lowest importance and 5 indicating highest importance. Mean scores were calculated to identify a consensus of the top 5 Research priorities for both Adult and Paediatric LRS topics.

Results 

115 participants from across the United Kingdom and overseas working in LRS contributed to the modified Delphi process. Participants ranked and then re-ranked the presented research topics in terms of perceived importance. This ultimately led to identification of the top 5 research priorities for both Adult and Paediatric LRS research topics, based on the collective responses of LRS practitioners. The highest ranked questions in both Adult and Paediatric practice related to how to best assess and record patient-recorded outcome measures (PROMs) in LRS. With other priorities including the effectiveness of specialist LRS physiotherapy, the use of patient psychological support, as well as the use of various operative management strategies for infection and limb length discrepancies.

Conclusion 

We present a consensus-driven research priority study that outlines the key research topics determined by healthcare professionals within LRS in the United Kingdom. These questions will assist funding bodies to prioritise where research funding may be best utilised and help drive future improvement in patient care.

A Surgeon Survey to Identify Instrumentation Improvements for the Oxford Unicompartmental Knee Replacement Procedure

Lachlan Arthur¹, Xiaoyi Min¹, Barbara Marks¹, Coral Milburn-Curtis², Stephen Mellon¹, David Murray^{1 1}Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, Oxford, United Kingdom. ²Green Templeton College, Oxford, United Kingdom

Abstract

Background

The Oxford Unicompartmental Knee Replacement (OUKR) is the most widely used UKR globally. Instrumentation modifications have resulted in significant outcome improvements for OUKR patients over 40 years of use. This study aimed to assess surgeons’ views of the OUKR instrumentation with a survey.

Methods

An anonymous online survey was developed to collect demographic information on OUKR user experience and caseload. Surgeons were also asked to identify instruments that need improvement for each step of the operation and asked what new instruments and/or technology may improve the procedure. The survey was distributed via email and social media. Inclusion criteria was any surgeon that had completed at least one OUKR. 

Results

104 responses from OUKR users (87 orthopaedic consultants and 17 other users) were received. On average, the users had 8.6 years (95%CI=1.4) of OUKR experience and performed 51 OUKRs per year (95%CI=14), which comprised 37% (95%CI=5.3) of their knee replacement caseload. Instruments used for tibial resection (50%), femoral preparation (35%), and tibial keel slot preparation (29%) were identified as requiring improvement by the greatest proportion of surgeons. 62% of surgeons believed technology would improve the OUKR procedure, with robotics and navigation the preferred assistance types.

Conclusions

Based on surgeon feedback, mechanical instruments for OUKR tibial resection to assist the vertical cut, femoral preparation to facilitate accurate drill guide placement, and the tibial keel slot saw and template need to be optimised. The implementation of assistive technology for OUKR should also be investigated.

Fifteen-year prospective longitudinal cohort study of outcomes following single radius total knee arthroplasty: patient reported outcome measures, response attrition and survival.

Chloe Scott^1,2, Gordon Snowden², William Cawley¹, Katrina Bell², Deborah MacDonald¹, Gavin Macpherson², Liam Yapp^1,2, Nick Clement^{1,2 1}University of Edinburgh, Edinburgh, United Kingdom. ²Edinburgh Orthopaedics, Edinburgh, United Kingdom

Abstract

Aims

This prospective study reports longitudinal, within-patient, patient reported outcome measures (PROMs) over a 15-year period following cemented single radius total knee arthroplasty (TKA). Secondary aims included reporting PROMs trajectory, 15-year implant survival and patient attrition from follow-up. 

Patients & Methods

From 2006-2007, 462 consecutive cemented cruciate retaining Triathlon TKAs were implanted in 426 patients (mean age 69 (range 21–89), 290 (62.7%) female). Patient reported outcome measures (Short form (SF)-12, Oxford Knee Scores (OKS), satisfaction) were assessed pre-operatively and at 1, 5, 10 and 15-years. Kaplan-Meier survival and univariate analysis were performed. 

Results

At 15 years, 28 patients were lost to follow-up (6.1%) and 221 patients (51.9%) had died. The mean age of the remaining cohort reduced by 4 years. PROMs response rates among surviving patients were: 1yr 63%; 5yr 72%; 10yr 94%; and 15yr 57%. OKS and SF-12 scores changed significantly over 15 years (p<0.001). The mean improvement in OKS was 18.8 (95% confidence (CI)16.7 to 19.0) at 1 year. OKS peaked at 5-years (median 43)  declining thereafter (p<0.001), though at 15-years it remained 17.5 better than preoperatively. Age and sex did not alter this trajectory. A quarter of patients experienced a clinically significant decline (≥7) in the OKS from 5-10 and from 10-15 years. The SF-12 physical component score displayed a similar trajectory, peaking 1 year (p<0.001). Patient satisfaction was 88% at 1, 5 and 10-years and 94% at 15-years. Fifteen-year Kaplan-Meier survival was 97.6% (95% CI 96.0 to 99.2) for any revision and 98.9% (95%CI 97.9-99.9) for aseptic revision.

Conclusion

Long-term follow-up influences the demographics of the cohort available to complete PROMs. Improvements in PROMs were significant and maintained, with OKS peaking at 5-years, and generic physical health peaking at 1-year. Patient satisfaction remained high at 15 years at which point 2.4% had been revised.

Does Chemical Shift Magnetic Resonance Imaging (MRI) Improve Visualisation Of Pars Interarticularis Defect

Emily Smith¹, Neha Nischal², Jennifer Murphy², Christine Azzopardi², Shahnawaz Haleem², Usama Mahmood², Karthikeyan Iyengar³, Rajesh Botchu^{2 1}Russell Hall Hospital, Birmingham, United Kingdom. ²Royal Orthopaedic Hospital, Birmingham, United Kingdom. ³Southport and Ormskirk Hospital NHS Trust, Southport, United Kingdom

Abstract

Background

A unilateral/bilateral fracture of pars interarticularis (Spondylolysis) is a frequent cause of axial back pain in active young and middle aged persons. Identification by suitable imaging (MRI gold standard) is the first step in management. The aim of this study was to compare the accuracy of chemical shift sequence (MRI) technique to conventional MRI sequences in the detection of pars defects.

Patients and Methods

Conventional T1, T2- and STIR sagittal, axial as well as ‘in’ and ‘out’ phase chemical shift sagittal MRI sequences of 70 consecutive patients referred for low back pain were reviewed. Demographic details, clinical indication and presence/diagnosis of pars defects using a 5- point Likert Scale on both conventional and chemical shift MRI Sequences.  Spearman correlation was used for statistical analysis.  Intraclass correlation coefficient (ICC) was evaluated to assess the intraclass reliability between observers. Data was analysed using DATAtab software (2022).

Results

70 patients (average age - 54.3) years with a female predominance were included. There were 11 pars defects in the cohort. Both in and out phase of chemical shift imaging were able to identify pars defect and intact pars. However, out phase was relatively better in delineating pars defects whilst the ‘in’ phase was superior in identifying an intact pars though this was not statistically significant. There was good intra and interobserver reliability.

Conclusion

Chemical shift MRI sequence is a quicker, complementary technique to assess and analyse pars interarticularis confidently than conventionally utilized MRI sequences in patients being evaluated for axial back pain.  

The outcomes of complex primary INBONE II total ankle replacement

Mehak Kakwani, Aral Jamalfar, Rajesh Kakwani, David Townshend, Aradhyula Murty

Northumbria Healthcare NHS Foundation Trust, Northumberland, United Kingdom

Abstract

Background

The INBONE II prothesis is a third-generation total ankle arthroplasty (TAA), consisting of modular stem components inserted into the tibia and a flat cut talus. The design necessitates more bone excision compared to a resurfacing type of prosthesis. At our institution, the INBONE II was selected for primary cases with anticipated poor bone quality, insufficient tibial bone stock and cases where additional forces were expected at the bone/implant interface. We present the radiological, functional and operative outcomes, including complications, with the INBONE II prosthesis.

Methods

All patients with a primary INBONE II prosthesis operated at our trust, from June 2013 to June 2021, were included. Patient demographics, indications using the Canadian Orthopaedic Foot and Ankle Society (COFAS) ankle arthritis classification system, complications and radiological outcomes were recorded. Functional outcomes reported by the patients included: Manchester-Oxford Foot Questionnaire (MOXFQ), EuroQol-5 Dimension (EQ-5D) and the Visual Analogue Score (VAS).

Results

Total of 70 patients underwent primary INBONE II TAA (M:F 47:23; average age = 71 years; range: 48 to 90 years). Average follow-up is 4.8 years (range 1-8 years). There were 8 cases of unrelated deaths. Overall, there was a statistically significant improvement in the average outcome score (pre/post- operation): 62/29 in MOXFQ, EQ5D Index value of 0.39/0.69, and VAS scores of 26.7/10.0. However, EQ5D VAS score of 69.9/70.5 was not statistically significant (p=0.82). The average improvement in the coronal deformity correction was 9 degrees. No patients have required a subtalar fusion for subtalar pain. Complications included a periprosthetic fracture of the distal tibia and two cases of DAIR procedure. The implant survival was 100% excluding DAIR. Including DAIR, the survivorship was 97.1%.

Conclusion

The INBONE II TAA is a safe and successful procedure for end stage ankle arthritis with deformities around the foot and ankle.

COSMIC feasibility study - Comparing Open Scarfosteotomy and Minimally Invasive Chevron Osteotomy for Hallux Valgus Correction.

Mehak Kakwani, Andrea Pujol Nicolas, Alexandra Griffiths, Nicholas Hutt, David Townshend, Aradhyula Murty Northumbria Healthcare NHS Foundation Trust, Northumberland, United Kingdom

Abstract

Background

Minimally invasive surgery (MIS) has gained popularity for hallux valgus, compared to the traditional scarf osteotomy (OS). Though evidence suggests similar clinical outcomes, there is paucity of randomised controlled studies. This study aimed to assess the feasibility of conducting a randomised controlled trial comparing the patient recorded and clinical outcomes for the surgical management of Hallux Valgus between OS and MIS Chevron Akin (MICA).

Methods

Patients suitable for surgical correction were invited to participate. Post-op rehabilitation was standardised for both groups. Patients completed a validated questionnaire (Manchester Oxford Foot questionnaire and EQ-5D-5L) pre-operatively and post-operatively at 6 months and 1 year. Radiological parameters and range of motion were measure pre-and post-operatively. 

Results

31 patients were recruited between Dec 2017 and June 2022. 17 patients were randomised to MICA (15 female, mean age 51) and 15 to OS (14 female, mean age 51). Both groups had a significant improvement in all MOXFQ parameters at 6m and 12m, as well as radiological parameters. VAS improved for OS (p=0.048) and for MICA (p=0.059) at 6m. There was no significant improvement in EQ-5D in either group at 12 months and, no significant difference in operative time (p=0.53). There was a higher number of complications in the MICA group with 5 removal of metalwork (29.4%) and 2 superficial infections (11.8%) v/s none in the OS group. The dorsiflexion significantly improved in the OS group at 6months (p=0.04). Recruitment rate dipped during COVID. No patients were lost at follow up.

Conclusion

Both surgical options show similar clinical results, but higher complication rates were seen with MICA. A larger study is needed to evaluate further. Challenges to recruitment included surgeon equipoise, patient preference, training requirement and the Covid 19- pandemic which could be mitigated in a larger multicentre study.

Disclosures

BOFAS scientific grant

High rate of loosening of Endolink modular hinge knee replacement in patients under 70 years old

Lucy Reason^1,2, Sam Jonas³, JT Evans¹, KS Eyres¹, AD Toms¹, NS Kalson¹, JRA Phillips^{1 1}Royal Devon University Healthcare Trust, Exeter, United Kingdom. ²University of Exeter, Exeter, United Kingdom. ³Great Western Hospital NHS Trust, Swindon, United Kingdom

Abstract

Introduction

Choosing a hinged implant in the revision knee arthroplasty (rTKA) setting is challenging and limited data on implant performance exists. We present the survivorship and reason for failure in rTKA performed at our institution using the LINK hinge prosthesis, predominantly the cemented modular Endo-Model prosthesis. 

Methodology

260 consecutive revision knee cases performed between 2012 and 2020 were reviewed retrospectively. Mean follow up was 27 months (range 0 to 107). Survivorship was analysed in Stata using a Log Rank test to compare performance in patients stratified according to age (≥80 years old (76 cases), 70-79 years (104 cases) and ≤70 years (80 cases).

 Results

53 patients died and 48/207 (23%) cases in 40 patients underwent re-revision. Reasons for re-revision were aseptic loosening (21), infection (12), instability (4), extensor failure (1), stiffness (1), fracture (1) and other (8). Loosening was seen in the femur (8), tibia (5), and both the femur and tibia (8). Sub-group analysis of patients according to age showed a significantly higher failure rate in younger patients (6 failures (8%) in patients ≥80, 27 failures (26%) in 70–79 and 15 (19%) in ≤70 (p = 0.02). Failure in patients ≤70 was predominantly due to aseptic loosening (8/15).

Conclusion

Here we report a significantly higher rate of LINK hinge prostheses failure in patients <70 undergoing rTKA. Consent should consider the risk of re-revision in this patient group.

The Keel Plays a Role in Periprosthetic Fractures of the Tibial Component in Cementless Unicompartmental Knee Replacement (UKR)

Azmi Rahman¹, David Heath¹, Stephen Mellon¹, David W Murray^{1,2 1}NDORMS, University of Oxford, Oxford, United Kingdom. ²Nuffield Orthopaedic Centre, Oxford University Hospitals, Oxford, United Kingdom

Abstract

Introduction

In cementless UKR, interference fit of the tibial component may reduce the structural integrity of the proximal tibia, increasing the risk of peri-prosthetic fractures. The risk of such fractures is 7 times greater in very small tibias. The mechanical processes underlying these fractures are not understood. This study explores the effect of keel-related features in fracture risk of these very small tibias.

Method

This study compares the effect of keel and slot depth (standard vs 33% smaller vs no keel/slot) and loading position (known range limits: midline, 8mm posterior) on fracture load and path. 3D-printed titanium tibial components were implanted in bone-analogue foam machined to a CT-reconstructed small tibia which experienced a peri-prosthetic fracture. Implantation was performed using surgical instrumentation and technique. Implants were loaded to failure. Load-to-fracture and fracture paths were assessed.

Results

Introducing a standard slot reduces load-to-fracture by 50% (1421N vs 710N, p<0.0001). Press-fitting a standard keel into this slot further reduces load-to-fracture by 40% (710N vs 423N, p=0.0001). A small keel increases load-to-fracture by 60% (683N vs 423N p=0.0004). 

Standard-sized keel resulted in significantly more vertical fractures (standard 8.2° vs shallow 15.5° vs no keel 21°, p<0.0001), consistent with fracture patterns seen clinically. 

There was a difference in load-to-fracture between loading positions with no keel (p=0.0038), but this was absent in standard (p=0.330) and shallow (p=0.635) keels.

Conclusion

Introduction of slot, and insertion of keel, both independently increase the risk of a peri-prosthetic fracture in very small tibias. Fracture lines follow the path of the keel and mask loading position effects, suggesting that these fractures are driven by the keel. A smaller keel significantly reduces the risk of peri-prosthetic fracture, but further assessment is needed to determine viability to fixation.

Implications

Surgeons implanting cementless UKR tibias should avoid oversizing tibial components and slot size.

Interference and Keel Design significantly influence Sagittal Micromotion in Cementless Unicompartmental Knee Replacement (UKR)

Azmi Rahman¹, David Heath¹, Stephen Mellon¹, David Murray^{1,2 1}NDORMS, University of Oxford, Oxford, United Kingdom. ²Nuffield Orthopaedic Centre, Oxford University Hospitals, Oxford, United Kingdom

Abstract

Introduction

In cementless UKR, early post-operative tibial fractures are 7x more common in very small tibias. This fracture risk is reduced when a smaller keel is used. However, a smaller keel may impair primary fixation. This may be compensated by reducing damage to the bone lining the slot during the press-fitting process. A new small, smooth-bottomed keel was designed to explore this. This study assesses the effect of different keel design elements (standard, no-interference, no-keel, small-smooth-bottomed) on sagittal micromotion of the standard tibial component. 

Method

A high-resolution uniplanar Digital Image Correlation setup was developed, and validated to be accurate to 50 micrometres. 3D-printed titanium tibial components were implanted into bone-analogue foam which was machined to a CT-reconstructed small tibia, using surgical instrumentation and technique. Tibias were loaded to 200N axially in physiological loading positions: 8mm posterior to midpoint representing a step-up, and 15mm posterior to midpoint representing a lunge, and corresponding micromotion was calculated. 

Results

In all tests, anterior lift-off was consistently the largest micromotion observed. In ‘step-up’ loading, a standard keel moved more than the no-interference and no-keel variants (340μm-vs-63μm-vs-30μm, p=0.002). However, compared to standard keel, no-interference and no-keel micromotion dramatically increased in ‘lunge’ loading (521μm-vs-826μm-vs-1003μm, p=0.039). The new small-smooth-bottomed keel performed similar or better than the standard in both tests (step-up 125μm-vs-340μm p=0.03, lunge 273μm-vs-521μm p=0.116). Values above are for largest micromotion; if overall micromotion was considered, all differences stated above were significant (largest p=0.006).

Conclusion and Implications

Counter-intuitively, interference increases micromotion in a step-up motion, likely due to implant pivoting around the fixed bone-keel interface. However, the keel is protective during the deeper lunge motion, though there was still substantial implant micromotion. To avoid excess implant micromotion prior to remodelling, patients should be advised against deep knee flexion early post-operatively. A new keel design may mitigate this issue.

Quantitative scoring of Gait Analysis in Ponseti-treated clubfoot patients; a Pilot study in 66 unilateral clubfeet.

Sally Tennant, Christine Douglas, Roisin Delaney, Olivia Mcveigh-Mellor, Matt Thornton  RNOH, Stanmore, United Kingdom

Abstract

Background

The benefit of Gait analysis (GA) in Ponseti-treated clubfeet is ill-defined. Having used GA routinely in our Ponseti patients from age 5, we developed a scoring system using 6 parameters in 66 unilateral clubfeet, comparing with the contra-lateral foot.

Patients & Methods

66 unilateral clubfeet treated in one unit were assessed using 3D instrumented GA (Motek GRAIL treadmill system) at 5 years.

GA was scored out of 6 on; heel strike, second rocker, early heel rise (measures of hindfoot tightness, HFT), dynamic supination (DS), dorsiflexion in swing (DFS), and ankle power (AP), and each graded as either symmetrical with contra-lateral foot (1), asymmetrical within normal range (0.5) or outside normal range (0). 

Results

84% of 44 patients with excellent clinical function scored 6/6 (Median gait score 5.5), with minor asymmetries in HFT and DFS/DS in 18%. 

Patients with dynamic supination (n=17) and Hindfoot tightness only (n=5) had lower median Gait scores (4 and 2.5 respectively). 

Residual HFT and DS were significantly commoner in non-compliant feet.

Mild asymmetry of HFT was commoner without tenotomy.

AP was symmetrical in 73% of those with good function but in only 41% of those with dynamic supination.

Conclusions

GA parameters correlated well with clinical assessment, and illustrated mild asymmetry in HFT and DFS/DS missed clinically, highlighting those who might benefit from closer follow-up.

GA aided management decisions in recurrence, eg highlighting need for tendon transfer in significant HFT, and need for repeat tenotomy with tendon transfer. 

Numerical representation of these 6 gait parameters gives a clear summary allowing easy comparison of function over time and between different clinical groups. 

Higher GA scores and lower HFT and DFS/DS abnormalities in compliant patients provides quantitative evidence of the importance of bracing.

Implementation of open fracture guidelines to improve functional outcomes following an open tibia fracture in Malawi: results of a nested pre-post implementation study

Alexander Thomas Schade^1,2, Maureen Sabawo³, Zahra Jaffry⁴, Nohakhelha Nyamulani⁵, Chiku Mpanga^3,5, Leonard Banza Ngoie⁶, Andrew John Metcalfe⁷, William Jim Harrison^8,9, Nick Sevdalis¹⁰,Andrew Leather¹¹, Peter MacPherson^{12  1}Malawi-Liverpool-Wellcome trust, Blantyre, Malawi. ²Liverpool School of Tropical Medicine, Liverpool, United Kingdom. ³Kamuzu University of Health Sciences, Blantyre, Malawi. ⁴Bart’s Health NHS Trust, london, United Kingdom. ⁵Queen Elizabeth Central Hospital, Blantyre, Malawi. ⁶Kamuzu Central Hospital, Lilongwe, Malawi. ⁷Warwick Clinical Trials Unit, Coventry, United Kingdom. ⁸AO Alliance, Davos, Switzerland. ⁹Countess of Chesterr NHS, Chester, United Kingdom. ¹⁰University of Singapore, Singapore, Singapore. ¹¹King's College London, london, United Kingdom. ¹²University of Glasgow, Glasgow, United Kingdom

Abstract

Introduction

Management standards and guidelines of open fractures in other countries have improved outcomes and complications. We hypothesised that the implementation of locally adapted open fracture guidelines would improve patient functional outcomes following an open tibia fracture in Malawi.

Methods

This pre-post implementation data was nested in a prospective cohort study of adults with open tibia fractures before and after an open fracture quality improvement programme. The primary outcome was a change in function as measured by the Short Musculoskeletal Function Assessment (SMFA) at one-year post-injury before and after the open fracture interventional bundle. Secondary outcomes included clinical process variables, knowledge and implementation outcomes. Multilevel regression models were constructed to investigate associations between SMFA scores, knowledge and implementation domains before and after the open fracture quality improvement programme.

Results

A total of 287 participants were recruited with 160 before and 120 after intervention. Amongst course candidates, open fracture knowledge improved from 65% to 75%. More candidates agree or strongly agreed with all implementation domains one year after (mean: 83%) compared to before the intervention (mean: 76%). There was little difference in the clinical process: definitive fixation within 72hrs (45% before vs 56% after, P-value: 0.14). Before implementation, there was no difference in the SMFA dysfunction score one year after injury (mean: 12, 95% HDI:7.8-20.9) and (mean: 14, 95% HDI:6.7-17.8) after implementation of the guidelines. Major barriers to implementation of open fracture guidelines in Malawi include orthopaedic clinical officer motivation, lack of hospital resources and adequate supervision of clinical officers by orthopaedic surgeons.

Conclusions

Sustained improvement in knowledge and implementation domains did not lead to a change in clinical process or improvement of patient outcomes after implementation of open fracture guidelines. Further research is required to develop interventions that reduce disability from open tibia fractures in resource-limited hospitals in low-income countries.

Orthopaedic Trauma Hospital Outcomes - Patient Operative Delays (ORTHOPOD) Study: The Management of Day-Case Orthopaedic Trauma in the United Kingdom.

Nicholas Wei¹, Thomas Baldock¹, Hussam Elamin-Ahmed¹, Thomas Walshaw¹, Reece Walker¹, Alex Trompeter², William Eardley^{1 1}James Cook University Hospital, Middlesborough, United Kingdom. ²St George's University Hospital, London, United Kingdom

Abstract

Background

Day-case trauma patients (DCTP) are a distinct population subject to variance in outpatient path, are vulnerable to delay and afforded diminished priority when compared to inpatients. Anecdotally, there are concerns over delays in the care of day-case trauma injuries, some with clear national ‘time to surgery’ windows, for example, distal radius and ankle fractures. ORTHOPOD: Day Case Trauma is the first multicentre prospective service evaluation of day-case trauma surgery across four countries. It is an epidemiological assessment of injury burden, patient pathways, theatre capacity, time to surgery and cancellation. 

Methods

Data were prospectively recorded through a collaborative approach. Arm-1 captured weekly daycase trauma list (DCTL) availability. Arm-2 detailed DCTP demographics, route to surgery and cancellation. Patients listed for surgery after 22/08/22 and operated on before 31/10/22 were included. Hand and spine injuries were excluded. 

Results

Data were obtained from 70 hospitals in England, 2 in Wales, 10 in Scotland and 4 in Northern Ireland. 23,138 operative cases and 709 weekly datasets were analysed. DCTP accounted for 29.1% of overall trauma burden and utilised 25.7% of general trauma list capacity. 56.7% were adults aged 18 to 59 and 65.7% had upper limb Injuries. Nationally, median number of DCTLs available per week was 0 (IQR 1). Time to surgery for equivalent injuries, rates of cancellation (13.2% DCTP; 11.9% inpatient) and escalation to elective operating lists (9.1% DCTP; 3.4% inpatient) were higher in DCTPs. Median time to surgery for distal radius and ankle fractures were 3 days and 6 days respectively. Outpatient path to surgery was widely varied. 

Conclusion

There is significant mismatch in DCTP management and resource availability. This includes significant variation in route to surgery. Improving day-case trauma services reduces the burden on trauma lists and this study demonstrates there is considerable scope for day-case trauma pathway development.

AO Type-C Distal Humeral Fractures in the Over Fifties – To Fix or Replace?

James Allen, Sam Vollans, David Limb, Charlotte Tunstall Leeds General Infirmary, Leeds, United Kingdom

Abstract

Background

To compare outcomes between open reduction internal fixation (ORIF), total elbow replacement (TER) and distal humerus hemiarthroplasty (DHH) for AO type-C (AOC) fractures of the distal humerus. 

Methods

We performed a retrospective analysis of acute AOC distal humerus fractures in patients ≥50 years old treated surgically in our Major Trauma Centre between 2016 and 2022. We evaluated the Oxford Elbow Score (OES), Mayo Elbow Performance Score (MEPS), range of movement (ROM), complication rate and re-operation rate. Kruskal-Wallis, Chi-squared and ANOVA statistical analysis were used.

Results

65 patients met the inclusion criteria (22 ORIF, 26 TER and 17 DHH). Mean age was 64.4 (range 5089), 77.1 (Range 62-91) and 61.3 (Range 52-75) for ORIF, TER and DHH respectively. Mean follow-up in months was 11.7, 14.8 and 14.3 for ORIF, TER and DHH respectively. Complication rates were higher in the fixation group (ORIF 54.6%, TER 11.5%, DHH 23.5%, p=0.02). Re-operation rates were higher in the fixation group (ORIF 31.8%, TER 3.9%, DHH 11.8%, p=0.03). Whilst OES and MEPS favoured arthroplasty over fixation, there was no statistically significant difference (OES: ORIF 37.6, TER 41.4, DHH 42.1, p=0.56; MEPS 84.4, TER 86.3, DHH 88.2, p=0.78). There was no statistical difference in ROM between any groups (p=0.38).

Conclusion

Our results have shown that TER is a proven option for older patients with AOC fractures. In the younger patient (<65 years old), DHH offers significantly fewer complications and re-operations compared to ORIF, with trends towards better functional outcomes. Further studies are required to establish the long-term outcomes for these patients and in addition, whether aseptic loosening becomes an issue in younger patients undergoing DHH or TER.

Anatomic total shoulder arthroplasty versus reverse total shoulder arthroplasty in patients aged over 70 with intact rotator cuff: A Systematic review and Meta-analysis

Christos Dragonas¹, George Mamarelis², Cameron Dott², Saima Waseem¹, Abhijit Bajracharya¹, Dimitra Leivadiotou^{1  1}The Princess Alexandra Hospital NHS Trust, Harlow, United Kingdom. ²The Royal London Hospital, Barts Health Trust, London, United Kingdom

Abstract

Background

This systematic review and meta-analysis compared the revision rates, complications and outcomes in anatomic Total Shoulder Arthroplasty (aTSA) and reverse Total Shoulder Arthroplasty (rTSA) performed for primary glenohumeral osteoarthritis in patients aged over 70 years with an intact rotator cuff.

Methods

We performed a systematic literature search identifying comparative studies meeting the above patient criteria and published from January 2010 to May 2022 from 3 databases: MEDLINE, EMBASE, Cochrane Library. We performed the systematic review in accordance with PRISMA guidelines and the study was prospectively registered on PROSPERO.

Results

From the 1798 studies identified from the initial literature search, four met our inclusion criteria. 2731 shoulder arthroplasties (1472 aTSA and 1259 rTSA) were evaluated with a minimum follow-up of two years. A statistically significant lower revision rate was observed in rTSA compared to aTSA (OR 0.50, 95% CI 0.30-0.84, p<0.05). No significant difference was noted between aTSA and rTSA in American Shoulder and Elbow Surgeons (ASES) scores post-operatively (MD: - 3.34, 95% CI: -9.773.09, p = 0.81, I2 = 0 %) and overall complication rate (OR 0.98, 95% CI 0.34-2.86, p=0.97).

Conclusion

Higher revision rates were identified following aTSA in our study population, although admittedly this is within retrospective studies. ATSA displayed equal functional results and post-operative complications compared to rTSA in patients over 70 with intact rotator cuff. Given these similar results a shoulder surgeon must carefully consider each patient individually prior to deciding with them the optimal form of arthroplasty to offer.

Safety of Tranexamic Acid in Surgically Treated Isolated Spine Trauma - a Prospective Observational Study across two UK Major Trauma Centres.

Wajiha Zahra¹, Sandeep Nayar², Ashwin Bhadresha², Vinay Jasani¹, Syed Aftab^{2 1}University Hospital of North Midlands, Stoke-On-Trent, United Kingdom. ²Barts Health NHS Trust, London, United Kingdom

Abstract

Background

Tranexamic acid (TXA) is an anti-fibrinolytic drug that helps to reduce blood loss by inhibiting the plasmin-mediated degradation of fibrin. This is the first study in the United Kingdom looking at the effectiveness of TXA in surgically managed isolated spine trauma. 

The primary aim was to evaluate if TXA is safe to be used in surgery for isolated spine trauma. The secondary aims were to assess whether TXA use impacts the need for perioperative blood transfusion and the incidence of postoperative complications.

Methods

This prospective observational study across two Major Trauma Centres in England looked at all patients aged 17 and above with isolated spine trauma requiring surgical intervention from 1st January 2022 to 31st June 2022. Statistical analysis was performed using SPSS software (version 20.0).

Results

We identified 67 patients. 26 (39%) received TXA, and 41 (61%) did not. Both groups were matched in age, gender, ASA grade, and mechanism of injury. All patients in the TXA group had an open approach with a mean of 5 spinal levels involved and a mean operative time of 203 minutes, compared to 24 patients (58%) in the non-TXA group having an open approach with a mean of 3 spinal levels involved and mean operative time of 159 minutes. In patients that received TXA, blood loss was less than 150ml in 8 patients (31%), 150-300ml in 15 patients (58%) and 300-500ml in 3 patients (11%). There were no cases of thromboembolic events in any patients that received TXA.

Conclusion

Our study shows that TXA is safe for surgically treated isolated spine trauma, and we found no increased risk of blood transfusion or VTE in either group. From this study, it is difficult to assess if TXA effectively reduces blood loss, as most surgeons prefer TXA for open or multilevel cases. 

Oncologists prediction of life expectancy in spinal metastatic cord compression. How accurate is it?

Shahnawaz Haleem, Gurvinder Singh Kainth, Mohammed Junaid Choudri, Simon Hughes, Faizul Hassan, Petr Rehousek Royal Orthopaedics Hospital, Birmingham, United Kingdom

Abstract

Life expectancy and prognosis of a patient with Metastatic Spinal Cord Compression (MSCC) is one of the important determinants in decision making for suitability of surgical intervention. The prognosis provided by an oncologist is based on the tumour biology, its metastasis, predicted response to chemotherapy or radiotherapy and general well-being of the patient. The aim of our study was to compare the predicted oncological prognosis to the actual time of death of the patient with Metastatic Spinal Cord Compression.   

Methods and Materials

A retrospective analysis of MSCC referrals to a tertiary spinal centre in the UK was carried out between June 2019 to February 2020. Demographic data, details of the primary tumour, neurological deficit of the patient and prognosis provided by oncologist were recorded. Patient’s hospital records and General Practitioner records were assessed in June 2022 to determine the patient’s current status. Predicted and actual mortality were compared.

Results

192 patients were included in our study of which, 83 had a recorded oncologist prognosis. Male to female ratio was 52:31 with an average age of 69 years (range 41-92 years). The most common primary tumour was prostate (24.10%) followed by lung (19.28%). The prognosis was correctly provided in 32.53% of patients. 60.24% died earlier than predicted with an average of 265 days earlier (range 8-1644 days). 7.23% of patients outlived their expected prognosis. 

Conclusion

Our study revealed that prognosis of patient in metastatic spine cancer seems to be overstated pragmatically in majority of the patients and this should be kept in mind while assessing and treating patients for surgical intervention.

A pre-operative spinal education (POSE) intervention for spinal-fusion surgery is safe and could reduce hospital length of stay: A prospective cohort study.

Jonathan Lucas, Rebecca Edwards, Jamie Gibson, Escye Mungin-Jenkins, Rashida Pickford, Gareth Jones Guys and St Thomas' NHS Foundation Trust, London, United Kingdom

Abstract

Background

Psychoeducative prehabilitation to optimise surgical outcomes is relatively novel in spinal-fusion surgery. The aim of this prospective cohort study was to determine if a Pre-Operative Spinal Education (POSE) programme, using the rehabilitation treatment specification system (RTSS) reduces anxieties, was safe, and reduced Length of Stay (LOS).

Methods  

POSE was offered to 150 prospective patients over 10-months. Some chose to attend (Attend-POSE) and some did-not-attend (DNA-POSE). A 3rd independent retrospective group of 150 patients (mean age 57.9±14.8years, female 50.6%) received surgery Pre-POSE. POSE consisted of 60min of face to face education with accompanying literature. Across-group, age, sex, median-LOS, perioperative complications, and readmission rates were assessed. 

Results

Sixty-five (43%) patients (age 57.4±18.2years, female 58.8%) attended-POSE, and 85 (57%) DNAPOSE (age 54.9±15.8years, female 65.8%). There were no significant between-group differences in age, sex, surgery-type, complications, or readmission rates. Median LOS was Pre-POSE (5 range 3-7 days), Attend-POSE (3 range 2-5 days), and DNA-POSE (4 range 3-7 days). Pairwise comparisons showed statistically significant differences between Pre-POSE and Attend-POSE LOS (=0.011), but not between any other group comparison. In the Attend-POSE group, there was significant change toward greater surgical preparedness, procedural familiarity, and less anxiety.  POSE did not affect complication or readmission rates meaning its inclusion was safe. 

Conclusion

POSE was associated with a significant reduction in LOS for patients undergoing spinal-fusion surgery. Patients reported being better prepared, more-familiar, and less-anxious about their surgery. 

Implication  

Clinical utility of ultrasonography for the assessment of skeletal maturity based on Sanders' radiological classification in patients with adolescent idiopathic scoliosis

Gonzalo Mariscal, Aranzazu Pedraza, Jose Luis Bas, Fernando Bonilla, Silvia Pérez, Pedro Rubio, Miquel Bovea, Paloma Bas, Teresa Bas La Fe University and Polytechnic Hospital, Valencia, Spain

Abstract

Background

The degree of skeletal maturity is a key factor in the prognosis and treatment of adolescent idiopathic scoliosis (AIS), since its progression is directly related to growth. The Sanders radiographic classification is currently the most widely used to determine the degree of skeletal maturity. However, the development and refinement of ultrasound could lead to a paradigm shift. The objective of this study was to determine the reliability of determining the degree of skeletal maturity by ultrasound, using the Sanders radiographic classification as a reference.

Methods

A reliability study was carried out. The study included patients with AIT between 10 and 16 years of age in the case group. Sanders classification was performed by radiography and ultrasonography on each patient. Each parameter was measured by four investigators by intraclass correlation coefficient. Statistical analysis was performed using IBM SPSS Statistics software.

Results  

A sample of 70 patients was obtained. Surgeon 1 obtained a correlation of 0.89 (p<0.001), surgeon 2 obtained a correlation of 0.72 (p<0.05), surgeon 3 showed a correlation of 0.92 (p<0.001) and finally surgeon 4 showed a correlation of 0.82 (p<0.001). Sanders stage 3 was the stage where the least coincidence was observed in the four surgeons.

Conclusion

Sanders' method of evaluation by hand radiographs can be replaced by ultrasonography to determine skeletal maturity in patients with AIS. A new simple and reliable algorithm has been developed that reduces adverse events in the diagnosis of skeletal maturity.

Comparison of perioperative and midterm clinical outcomes following open or minimally invasive lumbar spinal fusion

Daniel Lewis, Shivan Marya, Silviu Sabou, John Leach Salford Royal Hospital, Manchester, United Kingdom

Abstract

Introduction

Fusion of the lumbar spine is commonly performed for instability with neurological compression and/or deformity. Previous studies comparing techniques of fusion have heterogenous data making interpretation difficult. We present the results of 447 consecutive patients having undergone a TLIF, PLIF or PLF in a single centre with the same pre, intra and post-operative care and data collection.

Method

This study is a retrospective analysis of prospectively collected data between 2011-2018. Surgical techniques included PLIF with either bilateral muscle strip or Wiltse approach, open and minimally invasive TLIF and posterolateral fusion. Patient self-reported outcome measures were determined through use of core outcomes measure index (COMI) questionnaires pre-surgery and at three months, 1 year and 2 years post-surgery. 

Results

Across all procedures, post-operative COMI scores were improved compared to pre-surgery (p<0.001) with the largest decrease in COMI score observed in the first 3 months post-surgery. With the exception of lower COMI scores in the PLIF-Wiltse group at 1 year compared to the the MI-TLIF (p=0.02) and PLF-only groups (p=0.04, Kruskal–Wallis test), there was no significant difference between different procedure groups (p>.05) in patient self-reported outcome measures. Patients undergoing minimally invasive TLIF had a significantly shorter post-surgery stay than patients undergoing open PLIF (p=0.03) and there was no difference in intra-operative dural tear rate or repeat surgery rate between approaches (p>0.05).

Conclusion

There was no sustained difference in clinical outcomes following open vs. minimally invasive techniques at 2 years post-surgery but minimally invasive techniques were associated with a shorter post-surgery stay.

Rationalization of Orthopaedic Surgical Instrument Trays

Shady Hermana, Francesca Solari, Robert Whitham², Cara Hatcher², Oliver Donaldson^{2 1}Ysbyty Gwynedd, Bangor, United Kingdom. ²Yeovil District Hospital, Yeovil, United Kingdom

Abstract

Background 

This study aimed to rationalize surgical instrument trays used in some trauma and orthopedic procedures. Aiming to reduce the environmental burden of surgical tray sterilization and create financial savings. 

Methods 

Surgical instrument trays for several T&O procedures at our trust were assessed, by a senior consultant and scrub nurse individually, judging the utility of each instrument. Trays for hip, knee and shoulder arthroscopy, dynamic hip screw (DHS), rotator cuff repair, shoulder stabilization, total shoulder arthroplasty, and proximal humerus fracture fixation were reviewed. Infrequently used instruments were removed to minimize the number of trays used. 

Results 

The number of surgical instrument trays was rationalized from four to two for DHS, three to one for hip, knee, and shoulder arthroscopy, five to two for rotator cuff repair and shoulder stabilization, three to one for shoulder arthroplasty, and proximal humerus fracture fixation. 15 trays from the selected operations chosen were rationalised down to 6; a 60% reduction. From December 2017 to December 2020 there were 2505 of these operations within our trust. With the rationalisation there was a reduction of trays used from 8355 to 3045 in the three years, a reduction of 63.8%. In one year this is estimated to be a reduction from 2785 to 1015 trays. Based on the sterilization cost of in our trust of £35 per tray, annual savings amounted to about £61,950. Qualitative analysis also showed approval from both surgical and scrub staff regarding the rationalisation and improved ease of use. 

Conclusion 

Rationalising surgical instrument trays in our department yielded significant cost savings; £61,950 per year. There were also significant improvements in sustainability; with reductions of 63.8% in the number of surgical trays used. This is a simple intervention that could be utilised across surgery in general to improve financial and environmental sustainability. 

NHS is at risk of losing elective Total hip and total knee activity due to NHS Payment Scheme for 2023-25.

Gunasekaran Kumar Liverpool University Hospitals NHS Trust, Liverpool, United Kingdom

Abstract

Background

Integrated Care Boards (ICB) manage and arrange secondary care. For the upcoming two fiscal years,

NHS Payment Scheme (NHSPS) has released its payment schedule. IND are on Activity Based Payment (ABP) contracts. NHS are on Aligned Payment and Incentive (API), with caveat, 2019–20 volumes must be met to receive 100% tariff for THR and TKR.

Aim was to evaluate the NHSPS requirements for NHS and Independent (IND) sectors to provide elective THR&TKR and its impact on each sector's capacity to land ICB contracts.

Methods

THR and TKR volumes for NHS and IND for the previous 10 financial years (April 2013 to March 2023) were identified via National Joint Registry (NJR). Using linear regression analysis, regional and national trends in THR and TKR volumes were examined for both NHS and IND. 

Results

NHS THR and TKR trends showed volume stasis or decline and 2022–23 volumes were lower by 35% compared to 2019–20. IND THR and TKR trends were a strong uptrend, and 2022-23 volumes were up by 15%. In 2022-23, IND has overtaken NHS for THR and TKR. Linear regression analyses for England and by region showed that NHS performed significantly worse than IND (p 0.001).

Conclusion

IND has a clear advantage to obtain ICB contracts for THR and TKR. NHS runs the danger of having to care for sicker and more complicated patients, which could lead to worse NJR results for NHS. NHS, already struggling with unprecedented emergency admissions, is at a severe financial disadvantage due to payment disparity and penalty of 75% tariff.  

Implications

Proving financial sustainability of total knee arthroplasty services: valuebased healthcare analysis

John Williams, Grace Poole, Matthew Davies, Matt Gee, Toby Colegate-Stone, Alvin Chen Kings College Hospital, London, United Kingdom

Abstract

Background

Resource limitations in the NHS present a challenge to providing sustainable care for the increasing cohort of patients requiring total knee arthroplasty (TKA). Providing evidence of the clinical and economic value of procedures to patients, clinicians and stakeholders is vital to allow responsible allocation of finite resources. 

The value-based healthcare agenda (VBHA) determines value by comparing the total cost of each intervention against the outcomes which are important to patients and their carers. We have applied this principle to our TKA pathway in order to prove financial sustainability of our service.

Methods

Prospective analysis of clinical outcomes (Oxford Knee Score, EQ-5D-5L & EQ-VAS) for all TKAs performed over a 6-month period was performed. Economic evaluation for each patient pathway was performed from the Patient Level Information Costing System (PLICS) and compared against hospital income per episode (via the NHS Payment by Results scheme).

Results

38 patients were included for analysis. There was an improvement in all PROMS from baseline to 6months post operatively. Total pathway costs and income were plotted against patient reported outcome data, both on a cohort and individual basis. This demonstrates an overall positive picture in relation to value generation from primary TKA.

Conclusion/Findings

This study has shown that it is feasible to apply the VBHA approach to TKA in an NHS setting. This methodology can prove the value of TKA by measuring clinical outcomes which matter to patients against the cost to the healthcare provider.

Implications

This methodology allows clinicians to prove both financial sustainability and clinical value to patients and stakeholders. Whilst not without logistical challenges, this methodology is applicable to other providers and procedures throughout orthopaedics.

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.

Reducing the carbon footprint and cost by correct waste segregation in trauma theatre

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.

Assessing Bone Mineral Density Using Radiographs of the Hand

Natan Silver¹, Harry Burton², David Bodansky², Maxim Horwitz^{2  1}Liverpool University Hospitals Foundation Trust, Liverpool, United Kingdom. ²Chelsea and Westminster hopital, London, United Kingdom

Abstract

Background

Fragility fractures incur significant cost to quality of life and global healthcare systems with an annual financial burden of around  £4.4 billion. Assessing bone health identifies patients at risk of osteoporotic fracture and is critical for preventing such injuries. The current reference-standard for quantifying bone density is dual-energy x-ray absorptiometry (DEXA), which requires referral to an equipped facility. We hypothesise that bone density can be measured with a simpler and more accessible method, using plain radiographs of the hand or wrist, thereby providing a more sustainable modality.

Methods

A retrospective cohort study was undertaken in two UK centres: An inner-city, high

socioeconomic  population and a suburban, low socioeconomic population. Age, gender, date of XR/fracture, date of DEXA, femoral neck t-score, and Second Metacarpal Cortical Percentage (2MCP) were collected. Inclusion Criteria were patients suffering a distal radius fracture between 2020-22 with hand or wrist radiographs and DEXA within 12-months of each other. Exclusion Criteria were inability to assess radiograph and overlying cast material/hardware.

2MCP was calculated using the smartphone app “BoneGauge”, which measures second metacarpal mid-diaphyseal cortical percentage on a true posteroanterior radiograph of the hand or wrist.

Pearson correlation coefficients were calculated to correlate 2MCP with femoral neck t-scores.

Results

188 patients were included (88 inner-city and 100 suburban).

The 2MCP score correlated positively with a t-score at the femoral neck in the inner-city cohort (r2=0.81, p<0.05), suburban cohort (r2=0.82, p<0.05), and pooled cohort (r2=0.81, p<0.05).

2MCP <50% was 100% sensitive and specific for osteoporosis. 2MCP <60% was 94% sensitive and 83% specific for osteopaenia.

Conclusion/Findings

Bone density may be assessed by calculating 2MCP from a simple radiograph of the hand. This takes 30-seconds to complete with no additional cost or training and negligible radiation, making it a more accessible and sustainable solution than traditional methods.

The Scottish Trauma & Orthopaedics Equality Project (STEP) 2: Reporting experience of inclusion within the orthopaedic community

Jennifer Cherry¹, Phil Walmsley¹, Monu Jabbal², Chloe Scott², Deborah Eastwood³, Emily Baird^{4  1}Victoria Hospital, Kirkcaldy, United Kingdom. ²Edinburgh Royal Infirmary, Edinburgh, United Kingdom. ³Great Ormond St Hospital, London, United Kingdom. ⁴Royal Hospital for Children & Young People, Edinburgh, United Kingdom

Abstract

Introduction

The orthopaedic community is making great strides in improving diversity. With changing demographics, there must be increased vigilance against discrimination to ensure a cohesive workforce. The aim of this study is to report the incidence of reported barriers to progression, and experience of exclusion and discrimination.

 Methods

A working group of orthopaedic surgeons from across Scotland investigated the experience of discrimination in the Scottish orthopaedic workforce. A self-administered, electronic questionnaire was developed comprising of direct questions quantifying experiences of discrimination and openended questions prompting more detailed accounts of these experiences. The target participants were all orthopaedic surgeons in Scotland. Data was recorded and analysed by the Client Analyst and Relationship Development (CARD) group: a secure third party which ensured anonymity for all respondents. Thematic analysis was performed on the anonymised personal accounts.

 Results

A total of 353 responses were recorded, which represents 71% of the Scottish orthopaedic workforce. 26% reported discrimination or barriers related to equality and diversity, with 36% related to gender, 33% to race, and 42% to workplace culture.

13% reported being intentionally excluded from clinical or social conversation or collaboration, and 13% reported being unintentionally excluded from clinical or social conversation or collaboration. Themes of exclusion included inappropriate topics of conversation, and reluctance to alter the nature of conversation to reflect changing dynamic of the group. 

Conclusion

This is the most comprehensive national survey to report experience of discrimination in contemporary orthopaedic literature. The majority of respondents did not report any discrimination, however of those who did, issues surrounding gender, race, and workplace culture remain most prevalent. Reports revealed themes of real hurt, frustration, and impact on lives and livelihoods as a result. While diversity in orthopaedics is improving, acknowledging and addressing these issues is essential to improve workplace culture for all.

The Burden of Musculoskeletal Conditions (MSK) in Scotland – findings from the Scottish Burden of Disease (SBoD) study.

Stephen Bridgman^1,2,3, Eilidh Fletcher¹, Ian Grant^{1  1}Public Health Scotland, Edinburgh, United Kingdom. ²NHS Highland, Inverness, United Kingdom. ³University of Aberdeen, Aberdeen, United Kingdom

Abstract

Background 

The SBoD study monitors the contribution of 100+ diseases and injuries to the population health in Scotland, in the context of disability-adjusted life years (DALYs).  The summary measure of DALYs combines the years of life lost (YLL) to early death and the years lived with disability(YLD).   Providing robust estimates of burden is the first step in identifying areas of prevention which could have the biggest impact on health.  Our aim was to estimate the total burden for 2019 and to describe the burden of musculoskeletal conditions(MSK) in Scotland.

Methods

The SBoD 2016 study estimated the burden using routine data and patient-level record linkage. For this update, years lived with disability were estimated using 2016 age-sex-deprivation specific rates, assuming no change in disease prevalence from 2016, but taking account of changes to the population structure.   Years of life lost were calculated from 2019 observed deaths and the application of an  aspirational life table.  

MSK included were low back and neck pain, osteoarthritis, rheumatoid arthritis and ‘other’ MSK conditions (remaining ICD10-Chapter XIII).  

Results

In 2019 the overall burden of disease in Scotland represented 1,732,800 DALYs. MSK contributed 7% (123,185 DALYs) to the total burden of disease in Scotland, but 19% (117,185 YLDs) to the total nonfatal burden.

95% of the total MSK burden comes from those living with a MSK condition and women contributed a higher proportion of the total MSK burden (60%) than men (40%).   

Conclusions

MSK represent nearly 20% of the non-fatal disease burden in Scotland. Females are

disproportionately affected. As these conditions impact on the demand for healthcare and quality of life for those living with the conditions, insights from the SBoD study can be used to help prioritise investment for MSK, and develop actions to prevent and mitigate the burden of disease.

Skin Preparation in arthroscopic surgery – are there environmental savings to be made?

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.

Water Usage During Hand-Scrubbing in Orthopaedic Operating Theatres

Rhody David Raj, Adam T Yasen, Joyce Lam, Dia Eldean Giebaly, Fares S Haddad University College Hospital, London, United Kingdom

Abstract

Background

Water treatment and supply is an energy-intense process that has an impact on climate change, releasing 0.271 grams of carbon dioxide per litre of water. The NHS is a predominant consumer of water in the UK, with orthopaedic operating theatres responsible for a major proportion. This study investigates water usage during pre-operative hand-scrubbing and proposes measures to avoid waste.

Methods

This multicentre observational study assessed water consumption from 100 episodes of handscrubbing utilising continuous-flow taps. 10 taps in four operating theatres across two hospitals were included. Calibrated gradings were added to taps and flow was measured at each setting. For each hand-scrubbing episode, an observer timed the total duration the tap was open and the proportion that hands were in the stream. The calibrated grading to which the tap was set was noted.

Results

The mean flow in 60 seconds when taps were 100% open was 7.5 litres. The mode tap setting was 100% open. The mean total time taps were open was 110 seconds, 39 seconds of which hands were in the stream. Mean consumption was 12.0 litres per hand-scrubbing episode but only 4.2 litres (35%) of this made contact with hands.

Conclusion

The use of continuous-flow taps results in significant water wastage since 65% of water does not make contact with hands. Over 500 million orthopaedic operations are performed yearly in England and Wales, equating to an annual wastage of 12 billion litres on the assumption that three theatre staff scrub per operation. Options to reduce waste include non-continuous-flow mechanisms such as sensor-activated or foot pump-activated taps. Alternatively, alcohol-based hand rubs without water instead of conventional surgical scrubs have similar antiseptic efficacy, consume less time, and reduce paper towel waste from hand-drying. Further comparative research would be useful to guide resource allocation and reduce environmental impact.

The Sustainable Surgical Hand Hub

Amelia Dickinson, Sarah Abbott, Shamim Umarji , St George’s Hospital, London, United Kingdom

Abstract

Background

A Sustainable Surgical Hand Hub has been created at a non-acute community site, Queen Mary’s Hospital. This offers protection of elective recovery from emergency pressures and protects teaching for trainees. This aims to provide safe, efficient, and sustainable care for high volume, low complexity conditions: carpal tunnel syndrome, trigger digit, basal thumb arthritis and De Quervain’s. The carbon footprint has been reduced in two main ways. Firstly, by optimising virtual triage to reduce patient travel. Secondly, by encompassing sustainable measures within theatre for hand hub cases. Following established GIRFT/BSSH pathways, surgery is only offered to patients meeting certain criteria thus standardising care.  

Methods

A “one-stop-clinic” was created for common conditions. Patients are offered PIFU (patient-initiated follow-up) as a safety net. For CTS, face-to-face (F2F) appointments are potentially reduced from five to three (including surgery) and for conditions treated by steroid injection from three to one. There are new modular theatres on site which are ideal for hand surgery. Sustainable measures applied within theatre included: WALANT (Wide Awake Local Anaesthetic No Tourniquet) technique, regional anaesthesia rather than general anaesthesia and rationalisation of surgical sets (reduction in number of items by 60%).    

Results

A total of 6.6kg CO2e per “one-stop” patient is saved. Approximately 2.2kg CO2e is saved in travel for CTS surgery patients. A total of 18kg CO2e is saved per hand case completed via WALANT or local blocks rather than general anaesthesia. Rationalising the surgical sets by 60% saved 66-77g CO2e per instrument. By working more efficiently, appointment waiting times have reduced from 12 to 6 weeks. There are now 44% fewer patients on the waiting list.  

Conclusion

Implementing the new Hand Hub model has reduced the carbon footprint of the service significantly. We hope to expand the sustainable pathways further to services locally and nationwide.  

A prospective study of travel -related carbon reduction by implementation of a digital surgical pathway.

Francesca Haarer, riem johnson, james gibbs, stephen bendall, benedict rogers university hospital susex, brighton, United Kingdom

Abstract

Background

This study aims to quantify achievable reduction in carbon footprint relating to patient travel, by the implementation of a digital surgical pathway in a high-volume low complication (HVLC) elective orthopaedic centre. The patient pathway was redesigned around a web-based platform and the impact prospectively analysed over 6 months.

Methods

All lower limb arthroplasty patients, no exclusions, entered the digital pathway from March

2023. Pre-operative assessments (POA) included a digital health self-assessment (questionnaire) & patient education material. Questionnaire was screened, triaged and validated by pre-operative nurses.

For every stage of the pathway, patient travel mileage and carbon savings are calculated, including cancellations, postponements, and transport. Mileage was calculated from patient postcode and correlated to carbon footprint using UK government data 1 .

Results

To date, 313 patients over 6 weeks have enrolled with no refusals.

After digital triage, the following travel reductions were achieved in pre-operative assessment (POA)

1. Bypass POA. Achieved in 33 patients (10.5%)

Saving: 997.4 miles

2. Telephone-only POA. Achieved in 117 patients (37.4%)

Saving: 5173.4 miles

3. Cancellations. 13 procedures (4%).

Saving: 586.1 miles

4. Postponements. 15 surgeries (4.8%)

Saving: 356.1 miles

1 Source: UK Department for Business, Energy & Industrial Strategy.

The cumulative reduction in pre-operative patient travel was 7113 miles, equating to

1093Kg of CO2 for a 2-passenger petrol car, or 603Kg of CO2 for a medium EV.

Conclusion

This study demonstrated a CO2 reduction of between 0.6-1.09 metric tonnes from patient travel savings alone over 6 weeks, equivalent to 29-52 trees. Annual estimated CO2 reduction is between 4.8-8.7 metric tonnes.

The total potential CO2 reductions from a digital surgical pathway, including paper & other materials, are likely to be greater.

Implications

In line with NHS targets, substantial carbon reductions are achievable by implementing digital clinical pathways.

Disclosure

FH – UHS Trust Doctor, funded by Small Business Research Initiative

Approach for Tibial Plateau Fractures

Thomas Fleming, Thomas Murphy, Alex Torrie, Alexander Dodds, Daniel Engelke, Harminder Gosal, Christopher Curwen, James Pegrum  Gloucestershire Hospitals NHS Foundation Trust, Gloucester, United Kingdom

Abstract

Background

It is well known that a computed tomography (CT) scan improves the classification of tibial plateau fractures (TPF) compared with radiographs. However, it is less clear how this translates into clinical practice. The aim of this study is to establish to what extent a pre-operative CT scan alters the approach, setup and fixation choice in TPF compared to radiographs. 

Methods

50 consecutive TPF with a preoperative CT and radiographic imaging available, were assessed by 4 consultant surgeons. First, anonymised radiographs were classifying according to the column classification and the planned setup, approach, and fixation technique documented. At a 1-month interval, randomised matched CT scans were assessed and the same data collected. A tibial plateau disruption score (TPDS) was derived for all 4 quadrants (no injury=0, split=1, split/depression=2 and depression=3). Radiograph and CT TPDS were assessed using an unpaired T-test.

Results

26 female and 24 male patients, mean age 50.3, were included. Mean TPDS on radiographs and CT scans were 2.77 and 3.17 respectively. A significantly higher CT TPDS, of 0.4 (95%CI 0.10-

0.71)[P=0.0093] was observed, demonstrating that radiographs underestimate the extent of injury. The surgical approach changed in 28.5% of cases, thus influencing a change in the patient setup in theatre in 27% of cases. Identification of fractures within a column changed in 34% of cases. A high intra-observer reliability was observed when surgeons were asked to repeat their assessment in a third round at a further one month interval. 

Conclusion

A pre-operative CT scan has a significant effect on the approach required to fix TPF. This therefore influences the setup of the patient and can justifiably be requested as part of pre-operative planning. 

Long Term Outcomes of a Randomized Control Trial comparing Fibular Nail with Open Reduction and Internal Fixation in Patients with Unstable Ankle Fractures

Nicholas Heinz¹, Kate Bugler¹, Nick Clement^1,2, Xinwei Low¹, Andrew Duckworth^1,2, Tim White^{1  1}Royal Infirmary of Edinburgh, Edinburgh, United Kingdom. ²University of Edinburgh, Edinburgh, United Kingdom

Abstract

Background

Previous randomised control trials have compared open reduction and internal fixation with fibular nail fixation and shown minimal difference at short- and medium-term outcomes. Our aim is to compare the long-term outcomes of fibular nailing and plate fixation for unstable ankle fractures in a cohort of patients under the age of 65 years at a minimum of 10 year follow up.

Methods

Patients from a previously conducted randomized control trial comparing fibular nailing and plate fixation were contacted at a minimum of 10 years post intervention at a single study centre. Short term data were collected prospectively and long term data were collected retrospectively using an electronic patient record software. 

Results

Ninety-nine patients from one trauma centre were included (48 fibular nails and 51 plate fixations). Groups were matched for gender (p=0.579), age (p=0.811), body mass index (BMI)(p=0.925), smoking status (p=0.209), alcohol status (p=0.679) and injury type (p=0.674). Radiographically at an average of 2 years post-injury, there was no statistically significant difference between groups for development of osteoarthritis (p=0.851). Both groups had 1 tibio-talar fusion (2% of both groups) secondary to osteoarthritis with no statistically significant difference in overall re-operation rate between groups identified (p=0.518,). Forty-five percent (n=42) of patients had so far returned patient reported outcome measures at a minimum of 10 years (Fibular nail n=19, plate fixation n=23). No significant difference was found between groups at 10 years for the Olerud and Molander Ankle Score (p=0.990), the Manchester-Oxford Foot Questionnaire (MOXFQ) (p=0.288), Euroqol-5D Index (p=0.828) and Euroqol-5D Visual Analogue Score (p=0.769).

Conclusion

The current study illustrates no difference between fibular nail fixation and plate fixation at a longterm follow up of 10 years in patients under 65 years old, although the study is currently under powered. 

Thoracic sarcomas: demographic, histological and clinical data from a tertiary referral centre

Sarah Saifuddin¹, Solveig Hoppe², Matthew Williams³, Thomas Cosker³, Dionisios Stavroulias⁴, Francesco Di Chiara^{4  1}University Hospitals of North Midlands NHS Trust, Stoke-On-Trent, United Kingdom. ²St Mary's Hospital, Isle of Wight, United Kingdom. ³Nuffield Orthopaedic Centre, Oxford, United Kingdom. ⁴John Radcliffe Hospital, Oxford, United Kingdom

Abstract

Objectives

The diagnosis and evidence-based management of thoracic sarcomas is challenging due to its rarity. Our project aims to investigate the management and outcomes of primary thoracic sarcoma patients under the care of the Oxford Sarcoma Service over a three-year period.

Methods

Data of all thoracic sarcoma patients discussed at the Oxford tertiary centre multidisciplinary meetings from 2017-2019 were collected from the local electronic database.

Results

65 patients met the inclusion criteria. Chondrosarcomas were the most common histological subtype out of the 24 different subtypes recorded. 60% of cases were high-grade. There were 19 sarcomarelated deaths at a mean time of 22.4 months from date of diagnosis. 14 out of 19 deaths occurred in patients with high grade sarcomas (p=0.0586). 78.3% of patients underwent surgical resection, and 35.4% underwent surgical resection alone. Both surgical intervention (p < 0.0001*) and clear marginal status (p = 0.026*) were associated with a statistically significant improvement in survival. Local recurrence was seen in 31.3% of cases, with 93.3% of these in high-grade sarcomas. There was no association between recurrence and marginal status. 8 of the 15 cases with recurrence received surgical intervention for their recurrence.

Conclusion

Primary resection should remain the gold standard for treatment of thoracic sarcomas due to its significant improvement in survival. Variability between outcomes and overall survival is likely multifactorial – diversity of histological subtypes, predominance of high-grade sarcomas, and wide agerange at diagnosis. Prospectively maintained databases and cross-centre collaboration would be beneficial for future study in thoracic sarcomas.

Leiomyosarcoma of trunk wall and extremities: A multicenter data of 619 patients.

Sudhir Kannan^1,2, Ganapathy Periyanagam.³, Nicholas Eastley⁴, Han Hong Chong⁵, Viswanath Jayasankar⁶, Maria Anna Smolle⁷, Sanjay Gupta⁶, Andreas Leithner⁷, Olga Zaikova⁸, Johnothan Stevenson⁴, Prof.Paul Stalley³, Prof.Peter Grimison⁹, Kenneth S Rankin¹, Prof.Robert U Ashford^{10 1}Newcastle University, Newcastle upon Tyne, United Kingdom. ²Health Education England, Newcastle Upon Tyne, United Kingdom. ³Royal Prince Alfred Hospital., Sidney, Australia. ⁴Royal Orthopaedic Hospital, Birmingham, United Kingdom. ⁵Health Education England, Leicester, United Kingdom. ⁶Glasgow Royal Infirmary., Glasgow., United Kingdom. ⁷Medizinische Universität Graz, Graz, Austria. ⁸Oslo University Hospital, Oslo, Norway. ⁹Australia and New Zealand Sarcoma Association, Camperdown, NSW, Australia. ¹⁰University Hospitals Of Leicester, Leicester, United Kingdom

Abstract

Introduction

Leiomyosarcomas are aggressive neoplasms with poorly understood pathogenesis. We aimed to identify the risk factors for local recurrence, metastases, and mortality.

Methods

We present data of 619 patients from centres across the UK, Europe, and Australia who had

Leiomyosarcomas involving the trunk wall and extremities. We included tumours showing pure smooth muscle differentiation, at least focally. Purely cutaneous, retroperitoneal, major vessel, and uterine tumours were excluded. Survival, local recurrence, and metastasis were the outcome measures. 

Results

The median survival was 48 months (IQR 18-102 months). 10.9%(56/513) patients had local recurrence.

More importantly, 66% (37/56) of these local recurrences were within 12 months of diagnosis.

40.4%(216/534) of patients developed metastases. 55%(118/216) of metastasis occurred in less than 12 months. 

Our analysis shows that size greater than(>) 5cm (p-Value 0.001), location deep to the deep fascia (pValue 0.0001), higher mitoses (p-Value 0.0001), higher grade (p-Value 0.0001) had an impact on survival. Further, we found that size > 5 cm( p-Value 0.001) and higher grade (p-Value 0.02) were independently prognostic for survival. 

Our analysis suggested that the deeper location of the tumour (p-Value 0.01) and higher grade ( p-Value 0.04)were predictive of local recurrence. However, none of these factors did not attain statistical significance as independent prognostic factors in the multivariate analysis.

Finally, our analysis suggested that size >5 cm (p-value 0.001), location deep to the deep fascia( p-Value

0.04), and higher grade (p-Value 0.001) were associated with increased risk of metastasis. Further, size (p-Value 0.002) and higher grade (0.001) were independent prognostic factors for predicting the risk of metastasis.  

Conclusion

Update on the Oxford experience of Complex Reconstruction of the Humerus for Tumour following the development of an updated implant.

Indika Wijesinghe, Ryad Nejjari, Varun Senthurajah, Ather Siddiqi, Thomas Cosker Oxford University Hospitals, Oxford, United Kingdom

Abstract

Background

There is currently no consensus with regards to upper limb endoprosthetic reconstruction (EPR) following tumour resection of the proximal humerus. Studies reveal up to 20% revision rate for loosening and between 30% to 80% rate of dislocation.  We reviewed our outcome of a next generation prosthesis (using CadCam technology) which incorporates novel techniques to promote osteointegration & stability to reduce the failure rate. 

Methods

 Patients who underwent upper limb EPR with the new prosthesis were followed up for 24 months to assess clinical and radiological outcome. Osteointegration was measured using the previously described Radiographic On growth Score for Endoprosthesis (ROSE). It measures the number of cortices on orthogonal radiographs showing bone ongrowth and/or osteolysis (scale -4 to +4). 

Results 

43 patients (mean age 60.57+/- 18.04 years) were included in the study. Overall implant survival was

65.1% at 24 months, with CadCam the highest at 83.3%. The dislocation rates for CadCam, Reverse

Shoulder Arthroplasty and Hemiarthroplasty were 16.66%, 40% and 33.33% respectively. CadCam and Hemiarthroplasty recorded the highest Oxford Shoulder Scores at 28 and 29.91 respectively. Among all implants the mean ROSE score increased from -0.55 to 1.30 at 24 months. There were no revisions due to aseptic loosening.  

Conclusion

Early radiological and clinical outcome of the new prosthesis to address instability and aseptic loosening in upper limb EPR is promising. A suggested algorithm for complex reconstruction is presented. All but those with limited life expectancy or medically extremely frail are recommended for CadCam prosthesis for revision upper limb EPR.

Use of 3D-Printed Patient-Specific Technology in Resections of the Malignant Bone Tumours of the Pelvis

Mahlisha Kazemi¹, Rachel Wei Ying Tan¹, Ather Siddiqi¹, Michael Richard², Ilja Asanovic², Thomas Cosker¹, Duncan Whitwell^{1 1}Nuffield Orthopaedic Centre, Oxford, United Kingdom. ²Insight Surgery, Oxford, United Kingdom

Abstract

Background

Obtaining safe oncological margin with function optimised is the primary goal for resection of malignant bone tumours of the pelvis. 3D-printed patient specific resection jigs impact on negative tumour margins and recurrence risk.

Methods

A retrospective review of all patients with pelvic bone tumours and 3D-printed patient-specific resection jigs from December 2018 and March 2023 was conducted. We identified 19 patients from the Oxford University Hospital Sarcoma Service. 

Clinical data including demographics (age, sex), primary diagnosis, surgery-related variables

(pathological margin, reconstruction), use of resection guides, and outcome variables (local recurrence, survival data) were collected.

Results

The patients were followed-up till 14th April 2023. There were five deaths; one on the table from a massive pulmonary embolism, and four due to disease progression. The mean disease-free survival follow-up period postoperatively was 417 days. 89.5% (n=17/19) of the patients had negative margins after resection. Two positive margins were identified, and one local recurrence occurred. 

One intraoperative tumour leakage from cystic soft tissue components was identified, but no further complications followed. One patient with positive bone margin after resection, developed a local recurrence.

Discussion

Primary malignant tumours of the pelvis are rare and heterogenous, recognized as surgically challenging, with close proximity of major neurovascular structures and organs. Our study showed good clearance of bony margins with the use of 3D-printed jigs. Negative tumour margin is the most important prognostic factor. One patient had intraoperative tumour leakage from the cystic soft tissue component, but no further recurrence. The positive bony margin identified was likely due to inaccurate use of the jig intraoperatively. The patient developed local recurrence after 10 months. A known limitation of 3Dprinted jigs is tumour growth during fabrication period.

Conclusion

Using Spatial Patterns to Predict Local Recurrence in Extremity Soft Tissue Sarcoma: A Novel Concept

David Fellows¹, M. Ather Siddiqi¹, Karen Partington¹, Huw Walters¹, Jennifer Brown¹, Jennifer Astley², Tingshan Yan³, Thomas Cosker^{1  1}Oxford University Hospitals, Oxford, United Kingdom. ²University of Oxford, Oxford, United Kingdom. ³Royal Berkshire NHS Foundation Trust, Reading, United Kingdom

Abstract

Background

Tumour related risk factors predicting local recurrence (LR) following surgical resection of soft tissue sarcomas (STS) are well established. There is no anatomical classification for recurred tumours.

Enneking proposed staging based on anatomical orientation of primary tumour. However, there are limitations of using this system in the recurrence setting as anatomy is altered following resection. 

We propose a novel system using spatial patterns to predict local recurrence in STS.

Methods

We analysed all patients with STS recurrence treated at Oxford since 2007. Exclusion criteria was recurred tumours with incomplete scanning or lost to follow-up. 44 patients and 119 recurrences were identified.

We created a spatial grid of 4 anatomical zones (I – IV) of increasing distance from the primary tumour epicentre. The LR site was mapped onto this grid to establish the spatial relationship between the primary and recurred tumour. Known risk factors for LR were assessed alongside our novel classification for each tumour using logistical regression analysis.

Results

79% of patients who died from their STS had type III or IV tumour recurrence. Average LR free survival time after a type I or II recurrence was 16.9 months, after type III or IV recurrence was 10.0 months. 11 patients developed metastases after a minimum of 1 LR, 8 followed a type III or IV.  None of the data analysis was found to be statistically significant (p>0.05)

Conclusion

Our study shows promising trends in developing an anatomical classification for STS recurrence that has potential to predict further LR, metastasis, and mortality. However, due to small data size, none of the data analysis was found to be statistically significant (p>0.05). More data is needed to test our model and we call for a national multi-centre collaboration.